Nurses face an increasingly dangerous and unpredictable environment. We’re frequently placed in situations where we might become victims of workplace violence—sometimes at the hands of the patients we care for. A study led by the Occupational Safety and Health Administration found that between 2002 and 2013 incidents of serious workplace violence were four times more common in healthcare than in private industry. The American Nurses Association (ANA) conducted a survey in 2019 with sobering results. Of the over 5,000 nurses surveyed, one in four had been physically assaulted by a patient, and 59% said that they’d been verbally assaulted.

Healthcare organizations have a duty to prevent violence within their facilities and properly investigate when it occurs. The following guide can help hospital and healthcare administrators protect staff and enhance the overall perception of personal safety.

Workplace violence policy

Implementing a workplace violence program requires the endorsement of executive-level leadership. Then an interprofessional team that includes risk management, legal, nursing administration, security, and occupational health services should be formed to address workplace violence prevention and response and work with human resources (HR) to develop clear and concise policies that reflect zero tolerance for patient and visitor violence (including harassment, bullying, and coercion) against staff members. The policies should state that those who commit physical violence against staff will be prosecuted to the fullest extent of the law.

The International Association for Healthcare Security and Safety (IAHSS) violent patient/patient visitor management guideline recommends using the electronic health record to flag disruptive behavior, such as verbal threats, abusive language, physical violence, and possession of weapons or illegal substances. The IAHSS also suggests establishing behavioral expectations with those individuals, which includes restricted visitor access or care termination if disruptive behavior continues. The organization’s legal and risk management teams should be consulted before instituting a termination of services plan in response to patient-generated violence.

After the policies are established, the interprofessional team presents them to executive leadership for approval. Leadership commitment is critical to ensuring the necessary culture change to combat this complex issue.

The next step is pursuing a charter for creating a formal workplace violence committee.

Workplace violence committee

The mission of the workplace violence committee is to investigate events, identify root causes, recognize trends, and provide victim support. To help ensure comprehensive incident examination, the committee should include department directors and representatives from HR, risk management, legal, nursing administration, security, and occupational health services. The committee should meet at least monthly to review incident reports, but the charter should establish that emergency meetings may be necessary to review significant events.

At routine meetings, the committee should review reported incident details but also look for trends to help members understand where violent events are occurring and their severity. The committee should discuss root causes, training deficiencies, personnel shortages, and other factors that may have contributed to the events. At the conclusion of each quarter, the committee can review all violent event reports by location, severity, and type to identify trends that will be crucial in determining resource allocation. Quarterly findings should be communicated to executive leadership to strengthen ownership and support of the workplace violence program.

Concise reporting mechanisms

Reporting is one of the most important actions taken after a workplace violence incident. Encourage staff to report all threats and acts of violence (including intimate partner violence, which might spill over into the workplace) regardless of severity and without fear of retaliation. Nurses already spend an exorbitant amount of time charting, so the reporting mechanism should be concise, as well as centrally monitored and evaluated. (See Keep reporting simple.)

After an incident is reported, an immediate email notification should be sent to a subcommittee that includes the security manager, risk manager, and occupational health manager. The subcommittee will determine if immediate intervention is warranted. If the event is serious or resulted in significant injury, members may be called in for an emergency meeting.

Investigation

The security manager or other appropriate committee member should conduct initial investigations within 48 hours of events that don’t warrant an immediate response. Using discreet interview techniques, the investigator should speak with the reporting employee and any witnesses to obtain facts about the event, including what led up to it and contributing patient factors (for example, behavioral health admission, drug/alcohol intoxication, and length of stay) and employee factors (for example, fatigue, de-escalation training, and staff-patient ratios). The investigator should document the findings in a security report and present it to the workplace violence committee without judgments or opinions.

Department directors and managers are responsible for providing support to employees who’ve experienced violence on the job. When an incident occurs, the leader to whom it’s reported should speak immediately with the affected employee to determine if medical care is needed (victims with visible wounds or prolonged pain should be encouraged to seek medical care), consult with the nursing supervisor and administrator on call when an injury occurs, and refer the employee to the employee assistance program, chaplain services, ethics and compliance department, and HR as appropriate. In addition, the employee’s leader (charge nurse, manager, or director) and the workplace violence committee should follow up to ensure services have been provided and that the employee is being supported.

Increased stress levels and emotional tension can last well after a violent incident. To ensure the employee’s well-being, the manager should provide ongoing support and follow up for at least 2 weeks (longer if needed). This step demonstrates the administration’s commitment to keeping staff safe.

Depending on the severity of the event and state law, law enforcement may need to be called to open a criminal investigation. In these cases, everyone involved should cooperate with the police and provide as much information as possible. The organization’s legal team and risk management leader can help ensure that organization records release policies are followed. The workplace violence team should record the law enforcement case number and the responding police officer’s name for future reference and share it with the affected employee. Continued follow up with the employee, including legal advice and advocacy from the risk management team, throughout the criminal investigation and prosecution will demonstrate commitment to staff.

Ongoing support

The success of the workplace violence program doesn’t rely on the participation of clinical staff alone. Support from security, facilities engineering, and environmental services can help create a comprehensive program with widespread involvement. Developing a process to address workplace violence won’t happen overnight; frontline staff engagement and education about new policies and reporting expectations will take time. In addition, the workplace violence committee must be given enough time to compile information so it can avoid making snap decisions that won’t be sustainable or in the organization’s best interests.

Duty to protect

Healthcare leaders have a duty to protect staff on the job. Hospital administrators must take a lead role in preventing workplace violence and properly handling these difficult situations when they occur. Garnering executive support, properly investigating events, following through on findings, and providing ongoing assistance are effective methods of combatting this issue.

The authors work at St. David’s Medical Center in Austin, Texas. John M. Demming is the manager of safety, security and emergency management, and Lynn O’Neill is the chief nursing officer.

References

American Nurses Association. ANA applauds passage of workplace violence prevention legislation. November 21, 2019. nursingworld.org/news/news-releases/2019-news-releases/ana-applauds-passage-of-workplace-violence-prevention-legislation/

International Association for Healthcare Security & Safety. 05. Services–Patient: 03.Violent Patient/Patient Visitor Management. 2018. jointcommission.org/-/media/tjc/documents/resources/workplace-violence/0503_violent_patient_management.pdf

Occupational Safety and Health Administration. Workplace Violence in Healthcare: Understanding the Challenge. December 2015. osha.gov/Publications/OSHA3826.pdf