Mitigating Violence in Healthcare Environments

Hospitals and health systems are tasked with controlling costs and cutting budgets while maintaining the highest levels of patient care, safety and privacy which heighten our awareness of the vital role played by security services in the nation’s ever-evolving healthcare landscape. With the unpredictable rise and fall of COVID cases stretching the limits of some hospitals, tensions can escalate and the opportunity for violence can rise. 

Security has proven to be more essential than ever in the health care world as the chaotic, uncertain nature of the coronavirus has created new threats for patients and health care workers within the walls of a hospital.  The hallmarks of an effective workplace violence prevention program include numerous partnerships among a wide variety of stakeholders.  The workplace violence prevention (WPV) team or committee should be a cross-functional and diverse group dedicated to a culture of safety.

Internal partnerships include stakeholders including security, patient safety, nursing, compliance, risk management and human resources.  External partnerships include regulatory, compliance and consulting organizations such as The Joint Commission (TJC) which released new WPV prevention standards along with a free webpage that includes a host of tools to assist healthcare organizations strengthen their culture of safety. 

Creating Safer Workplaces Guide

The American Hospital Association (AHA) and the International Association for Healthcare Security & Safety (IAHSS) collaborated on “Creating Safer Workplaces: A Guide to Mitigating Violence in Health Care Settings.” This new guide is a crucial read for healthcare security leaders as it offers a number of case studies that illustrate how a range of organizations used best practices and individual solutions tailored on the organization’s size, culture and resources.  The report offers a framework to guide leaders in building a culture of safety, mitigating risk, violence intervention and the support of trauma survivors and recommends holding all parties accountable.  Recording metrics and promoting ongoing education and training across the organization are vital.

The IAHSS Council on Guidelines defines WPV as “an act or threat occurring at the workplace that can include any of the following: verbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; harassment; physical assaults or other behaviors of concern involving staff, licensed practitioners, patients, visitors, or others on-site or off-site when related to the healthcare facility.

Hospitals face many challenges in regard to an active assailant/hostile event risk such as providing care to victims of shootings and being prepared in the event an active assailant/hostile event situation occurs at the hospital. In times of crisis, it is imperative that proper protocol is followed to minimize risk to staff, patients and visitors, and to end the situation as safely as possible. It is important for hospitals and healthcare systems to follow FEMA guidelines and identify resource requirements, capability gaps, strengths and potential best practices to easily train hospital staff. All staff need to have the following: 

• Overview of the potential threat of active shooters in hospitals
• Tips about how to prepare a hospital facility to protect against an active shooter threat
• Information on how to recognize a potential shooter
• What to expect from first responders and how to help and preserve life during an active shooter incident
• Outline a plan to quickly recover to help keep the facility open and operational

Security leaders are encouraged to go through industry-specific training, education, and self-development. For healthcare security leaders, , this means staying up-to-date on healthcare security publications, participating as an active member in associations such as the International Association for Healthcare Security and Safety (IAHSS), ASIS International, attending formal healthcare security seminars or educational programs, participating in industry research, and so on. 

Workplace Violence Prevention Compendium

Hospitals and critical access hospitals will find the compendium of resources offered in the JHC’s “Workplace Violence Prevention Compendium of Resources to Support Joint Commission Accredited Hospitals” invaluable. These resources were compiled from a wide variety of sources including national organizations, federal and state agencies, associations, academic institutions, and peer-reviewed publications.

Recommendations to reduce rising violence in hospitals and healthcare systems includes:

• Establishing clear workplace violence policies. (Johns Hopkins University, for example, has established clear policies as part of its “Safe at Hopkins” program, which covers everything from bullying to violence to disrespectful behavior). 

• Enforcing policies consistently. The WPV policies should have clear goals and objectives for preventing workplace violence, be suitable for the size and complexity of operations and be adaptable to specific situations and specific facilities or units. 

• Offering training (particularly non-escalation/de-escalation training). Training should be mandatory and ongoing — not an easy-to-forget, one-time session. 

• Increasing security. In the 2018 ACEP/ENA survey, nearly half of respondents said that hospitals could do more to protect workers by adding security, video surveillance, metal detectors, and visitor screening, especially in the emergency department. 

• Studying your space. Improvements can include better lighting, clear evacuation plans, badge detectors, mirrors (so that no area is hidden), removing potential weapons (such as IV poles, which are now frequently built into beds), and reducing the number of exits and entrances.

• Protect against cyber stalking. Cyberstalking refers to the use of the Internet and other technologies to harass or stalk a healthcare person online.

Emergency Department on Frontlines 

While any part of a hospital could become violent, the emergency department (ED) has the greatest potential for violence. The lack of healthcare resources available at night and on the weekends drive many people to the ED. The ED is the most challenging and stressful area in any hospital where dramatic life-and-death cases come in the front door.

Nurses, physicians, and other medical professionals are on the ED’s front lines and are at an increased risk for workplace violence. 

The American College of Emergency Physicians (ACEP) believes that optimal patient care can be achieved only when patients, healthcare workers and all other persons in the ED are protected against violent acts occurring within the department. As such, ACEP advocates for increased awareness of violence against healthcare workers in the ED and for increased safety measures in all EDs.

The pandemic has taught us several lessons when it comes to hospital safety and security. For example, in addition to heightened access control, it is critical for hospitals to develop mutual aid relationships, consider contracts for emergency security staffing during disasters, and establish appropriate/regulatory “Just-in-Time” training modules for various disaster scenarios. A WPV committee that keeps all of these risk factors at the forefront while updating the group on actions taken is crucial to combating violence.  While a hospital cannot determine the types of patients they treat in their ED, they can establish acceptable behaviors for patients and the visitors who may accompany them by adopting a disruptive patient policy.  With that policy in place, staff and physicians who are experiencing unacceptable behaviors know the exact steps to take as soon as these behaviors escalate.

The root of WPV problems in the healthcare sector is a combination of clinical, environmental and organizational risk factors.  Organizations need to address all three areas when addressing the potential of WPV.  Clinical risk factors may include patients who are under the influence of an impairing substance, in pain or have mental/behavioral health issue or who are custodial.  Environment risk factors may include lack of access control to a high-risk area, lack of safe areas for violent patients, or lack of duress alarms.  Organizational risk factors include inadequate policies and procedures for reporting and managing WPV, inadequate staffing, lack of training and inadequate security. 

# # #

About the Author:  Lisa Terry, CHPA, CPP is Vice President of Vertical Markets-Healthcare at Allied Universal, a leading global security and facility services company with more than 800,000 employees and with revenues of $20 billion. She is the author of "Active Shooter Response Handbook for Healthcare Workers.”  She can be reached at lisa.terry@aus.com.