Workers in a great variety of industries and occupations face the serious problem of workplace violence. A basic definition of workplace violence is any physical assault or threat that a worker experiences associated with his or her job. The perpetrator of such violence may be a stranger, a client/patient, a co-worker, or an intimate partner. The probability of a worker experiencing workplace violence at the hands of one of these classes of perpetrators varies by industry and occupation.
Today, workplace violence is one of the most dangerous occupational hazards facing health care workers, particularly in the behavioral health setting.1 This is in part because of the lack of attention to the prevalence and severity of workers' injuries from work-related violence, the failure to recognize violence as a public health problem amenable to an occupational health approach to prevention, and the view that many people hold that violence toward those working with or in the presence of people with cognitive impairment, mental illness, or a tendency toward violent acts “is part of the job.”2 The risk of workplace violence arises from the exposure to individual clients, their family members, and visitors, who sometimes are violent, in combination with a lack of sufficiently strong violence prevention programs. Violence toward physicians, nurses, health care aides, and other employees working in behavioral health is a major public health problem. Aside from the risks of physical harm, overall health and wellness can be greatly affected, leading to negative emotional and psychological consequences such as burnout, anxiety, and decreased productivity. Fortunately, occupational and organizational psychiatry provides an approach to prevent or minimize staff assaults and their severity.
Workplace Violence—Magnitude of the Problem and Risk Factors
The Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health define workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site or during the course of work. It ranges from threats and verbal abuse to physical assaults and even homicide.3 As with most occupational injuries and illness, less severe injuries are underreported, so the best data by industry exist for homicides, followed by OSHA recordable incidents via the United States Bureau of Labor Statistics Annual Survey of Occupational Injuries and Illnesses and data from the Department of Justice's National Crime Victimization Survey (NCVS).5
In 2014, the incidence rate of violence-related injuries in the health care and social assistance sector was more than 3 times the rate in all of private industry (14.4 vs 4 per 10,000 workers).1 The rate among high-risk settings within the overall sector was 181.1 per 10,000 workers for psychiatric and substance abuse hospitals, 78 per 10,000 within residential mental health facilities, and 34.8 per 10,000 in nursing and residential facilities, respectively.4 According to the NCVS, mental health workers experienced the highest rate of workplace violence in the health care sector, with 20.5 assaults per 1,000 workers compared with a rate of 6.5 per 1,000 workers among health care workers across all medical settings.5
The true impact of workplace violence is often underestimated because of the failure to include the emotional and psychological consequences of assaults and threats of assault regardless of whether a physical injury was sustained. The emotional consequences of workplace violence include anxiety, depression, insomnia, stress-related disorders, and loss of self-confidence.6 A cross-sectional study of employees of a large Midwest health care organization found that approximately 78% of health care employees experienced at least one adverse symptom in response to work-related violence, whereas 20% of those physically assaulted and 25% of victims of nonphysical violence experienced five or more troublesome symptoms.7 A cross-sectional study of physicians from nine tertiary hospitals in four Chinese provinces found that workplace violence was positively correlated with turnover intention and job burnout and was negatively associated with job satisfaction and social support.8 The frequency of posttraumatic stress disorder (PTSD) following workplace violence mirrors that of other traumatic life events. Caldwell9 found that of staff members who reported experiencing an assault, 61% of the clinical staff and 28% of the nonclinical staff reported symptoms of PTSD. Ten percent of clinical staff and 7% of nonclinical staff met the diagnostic criteria for PTSD.9
Published studies of surveyed psychiatric nurses showed that, on average, 77% reported experiencing physical violence during the previous year.10 A seminal study entitled “Trends, Victims, and Injuries in Injurious Patient Assaults on Adult, Geriatric and Child/Adolescent Psychiatric Units in US Hospitals, 2007–2013” examined the National Database of Nursing Quality Indicator data from 614 psychiatric units across 345 hospitals.11 The author found that during the 16.3 million patient days studied, nearly three-quarters of the 14,877 injurious assaults by patients involved injury only to hospital staff; by contrast, one-fifth resulted in injury only to patients.11
In most behavioral health settings, a clinical approach, focused on individual patient behavior and treatment is the primary strategy for managing patient behavior and violence prevention. The clinical management of potentially violent patients/clients is critically important, but insufficient to prevent workplace violence. Such an approach rarely examines groups of patients and how they interact with staff and the environment to understand system-level risks. For example, when tracking incidents of patient-on-staff assault it is critically important to evaluate where, when, and how incidents occur at a population level to identify trends in risk factors for assault that extend beyond the individual patient's behavior at the time of the assault. It is equally important to ask why the incidents are occurring, when and where they cluster, and examine system-level factors such as staffing levels, procedures for handling patients, environmental design, as well as reviewing the clinical profile of the patient. Given the unpredictable nature of human behavior, it is especially important to assess environmental risk factors, which are often easier to modify than changing patient (or staff) behavior.12
Professional associations representing behavioral health professions have issued position statements and conducted research on the problem of workplace violence. The American Psychiatric Nurses Association (APNA) created a workplace violence task force13 and published a comprehensive position paper in 2008 addressing issues surrounding workplace violence.14 In 2011, the APNA conducted a survey among its members to elicit information about individual concerns regarding workplace violence.11 More than 300 members responded and highlighted the lack of violence prevention policies in various mental health organizations. When asked about the presence of a zero-tolerance policy within their institution, more than 63% of survey respondents stated one existed in their workplace, but many admitted it was neither enforced nor supported by the administration. Others indicated skepticism about such a policy, citing it as ineffective, unrealistic, and difficult to enforce. Although more than 59% of the respondents reported that a culture of violence is not actually condoned, 72% of those who commented said that in practice, violence is often expected and tolerated. Most felt that there has been little movement toward addressing the problem.13
Preventing Workplace Violence
Health care workplaces can be made safer for workers, patients, and visitors alike through the development and implementation of a comprehensive workplace violence prevention program (WVPP) that includes strong employee involvement, comprehensive and ongoing risk analyses, use of engineering and administrative controls such as security alarm systems, adequate staffing and training, and ongoing evaluation.15
In 1996, OSHA published “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers.”16 In 2015, OSHA updated and published a revised set of guidelines to delineate hazard control measures across settings.3 Both the 1996 and 2015 federal guidelines describe a comprehensive WVPP that provides a framework for addressing the hazard via the basic elements of a health and safety program. A WVPP is synonymous with a health and safety management system focused on the risk of workplace violence.
The program must have as its foundation strong management commitment and worker involvement. These foundational elements then support the other program elements, namely, comprehensive risk analysis, effective control of hazards, training, recordkeeping, and regular program evaluation. Worker involvement is important in any comprehensive illness and injury prevention program, but particularly in developing a WVPP. Frontline health care workers are skilled in recognizing patients who may have risks for violence. Additionally, those workers are key in identifying prevention strategies that are effective, and that do not have unintended negative consequences, either to staff or patient safety or to patient care.
Evidence from a recently published, randomized, controlled intervention study demonstrated that a data-driven, worksite-based intervention based on the OSHA guidelines was effective in decreasing risks of patient-to-worker violence-related injuries by 60%, 24 months after the intervention.17 Using guidelines such as those from OSHA16 can be a helpful framework to build institutional programs. However, health care institutions must take the onus and commit to improvements, invest resources, develop strategies, and implement solutions to address workplace violence in ways that fit their practice patterns and settings.
A Practical Organizational Approach to Addressing Workplace Violence in the Psychiatric Emergency Services Setting
Emergency departments (ED) are particularly prone to violence, as workers face a high risk of injuries from assaults by patients or their family members. In response to incidents with workplace violence, the ED at Northwestern Memorial Hospital in Chicago, IL, developed a WVPP through the creation of a multidisciplinary task force designated with improving safety and mitigating violence. This ED Safety Task Force at Northwestern Memorial Hospital is comprised of emergency and psychiatry physicians, nurses, pharmacists, security, and other care staff, and is united under the vision: “Patients first, always starts with safety first.” The goal of the task force is to create practical, sustainable, ED-specific safety solutions. As workplace violence is so prominent in both psychiatric patient care areas and EDs, a key area identified for improvement was in our interactions with psychiatric patients in the ED.
Although the response to workplace violence can sometimes be reactionary and focus on the individual patient and incident, the ED Safety Task Force sought to reevaluate the problem from a systems-based approach. To organize and develop interventions, the factors that affect staff and patient safety were grouped into three main systems-based categories: education of staff, the physical environment, and departmental processes and procedures.
Although many providers of psychiatric emergency care have some experience in this domain, opportunity often exists to improve staff education on ways to improve safety and prevent violence. Education on verbal de-escalation was a high priority for the task force. First, an educational blog post and infographic on verbal de-escalation was developed and disseminated online and within the department. In addition, multidisciplinary simulation training accompanied by online educational materials is currently in development. Pharmacologic intervention for patients who are acutely agitated is also an important part of patient care and safety. A clinical care guideline for the use of anxiolysis medications was developed and based on best evidence, and it stratifies treatment based on the level of patient agitation. Treating patients early in their course with oral medications and using parenteral medications with rapid onset when necessary were two areas that were emphasized in the guideline. Last, a safety orientation guide was developed and posted on the Intranet, which included maps of duress alarm buttons within the department to serve as a reference when questions about their locations inevitably would arise.
It is critical to optimize the physical environment for patient and staff safety. We evaluated the two main spaces in which psychiatric patients are treated in our department and found opportunities for improvement. In our main psychiatric interview room, it was confirmed that the main door is double hinged to swing in both directions, improving emergency egress when needed. In addition, a camera was placed, and a window is in the process of being installed to allow improved visualization into the room. In a second area where patients who are acutely agitated are mainly seen, it was recognized that a second interview space needed to be created. An isolation room with multiple points of egress now doubles as the interview room, and headwall equipment and a hanging overhead light were removed to mitigate use of these items as weapons or for self-harm. We also created an area to cohort patients who require direct observation, which includes half-height partitions and curtains, allowing these patients to be collectively monitored.
The processes by which patients under psychiatric care are treated encompass many aspects. Health information technology is one factor that can be leveraged to assist safety, and a behavioral flag was implemented in the electronic medical record to alert staff to patients who have violent tendencies. Adequate staffing is another important aspect of care. With fewer available community resources for these patients, our ED has experienced a major increase in the volume of psychiatric patients. Our psychiatric emergency services added additional staffing to address the volume increase. Optimizing communication and the procedures for care and safety is necessary along the entire encounter. Whereas most attention was previously given to the acute treatment phase and point of provider interaction, it was identified that early and later phases in the ED course were also important areas to address. For example, improving the time to initial provider contact can prevent escalation of the patient who is agitated and allow more prompt treatment. One component of this included improving the efficiency of patient searches for items that could be used for harm, which was accomplished through improved security staffing and the use of metal detector wands. It was also noted that the length of stay for our patients under psychiatric care is much higher than medical patients, sometimes in the manner of days, due to the lack of availability of inpatient psychiatric hospital capacity in the region. To better care for patients staying for longer-term care, we implemented daily multidisciplinary rounds including emergency and psychiatry physicians and pharmacists.
Because this program is new, the impact of the interventions is yet unclear; however, there is anecdotal consensus that the ED is safer and providing higher quality of care for patients. As data from our incident reporting system become available, we plan to use this information to evaluate its effect. We plan on reviewing data 1 year prior to and 1 year after implementation of the safety task force, specifically reviewing data that are entered into the system under the category of “Abuse/Assault.” In addition, we will attempt to subcategorize the data into physical versus verbal assault.
Workplace violence, the physical assault or threat by any person, stranger, patient, coworker, or intimate partner occurring at or associated with a person's job, is a pervasive epidemic that continues to plague a wide variety of industries, including health care. Mental health workers, both clinical and nonclinical, are especially at risk, as a culture that does not condone violence has come to accept it as a regular part of the workplace dynamic. Although strides have been made to decrease workplace violence using zero tolerance policies focused on individual patient behavior and treatment, there is still more work to be done.
- US Department of Labor, Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work, 2014. http://www.bls.gov/news.release/archives/osh2_11192015.pdf. Accessed October 16, 2019.
- Lipscomb J, London M. Not Part of the Job: How to Take a Stand Against Violence in the Work Setting. Silver Spring, MD: American Nurses Association; 2015.
- Occupational Safety and Health Administration. Guidelines for preventing workplace violence for heatlhcare and social service workers (OSHA 3148-04R 2015). Washington, DC: US Department of Labor; 2015.
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- Occupational Safety and Health Administration. Preventing workplace violence: a road map for healthcare facilities. https://www.osha.gov/Publications/OSHA3827.pdf.
- Occupational Safety and Health Administration. Guidelines for preventing workplace violence for health care and social service workers (OSHA 3148). Washington, DC: US Department of Labor; 1996.
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