Violence in hospitals has been reported in the news with increasing frequency. It no longer occurs just in the emergency departments, but is happening in waiting areas and patient treatment rooms, particularly in critical care, psychiatric and geriatric units.
The US Department of Labor, Bureau of Labor Statistics (BLS) showed that 48 percent of all non-fatal injuries from workplace assaults and violent acts occurred in healthcare and social services settings, the majority of which occur in the emergency department. However, other areas of the hospital are not immune.
There are different acts of violence that occur: patient against staff, family against staff, public against patient, domestic issues with family members of staff, disgruntled staff or staff as perpetrators of violence towards patients. According to the Department of Justice data, nurses are most likely to be assaulted among healthcare workers. They are 57 percent more likely to be assaulted than are physicians.
More than half of emergency nurses say they’ve been “spat on”, “hit”, “pushed or shoved”, “scratched” or “kicked” while on the job according to a national online survey by the Emergency Nurses Association titled Violence against Nurses Working in US Emergency Departments. According to the survey of 3,465 emergency nurses, one in four reported that they had been assaulted more than 20 times in the past three years; one in five nurses had been verbally abused more than 200 times during the same period.
Nearly one-third of violent acts against nurses are committed by family members of patients, visitors and other healthcare providers, including physicians. Perpetrators are commonly impaired males (fortunately pediatric emergency departments report the lowest amount of violence).
The highest incidents of violence occur during night shifts and on weekends. Common causes of assault by family members of patients are anger-related regarding staff enforcement of hospital policies, concern related to the patient’s situation or condition, long wait times or the healthcare system, physicians or nurses, in general.
Why the escalation of violence?
Hospitals are vulnerable to the stresses of the modern world. Many patients and visitors are intoxicated, under the influence of drugs or brought in by police as victims or perpetrators of violence. The economic downturn, unemployment, loss of medical insurance, crime and increased substance abuse also serve to fuel a feeling of hopelessness and anger among some individuals that may result in them expressing their frustrations or concerns aggressively. Violence is not isolated to the poor and urban areas: it is an equal opportunity aggressor.
The increase in hospital violence may also be a reflection of an increasingly violent society. There is more reported domestic abuse, easier access to firearms, an increase in gang activity and more use of drugs and alcohol. Add to that inadequate hospital staffing due to financial constraints, inadequate training of staff, more unemployment, less insurance, increased usage of emergency departments as primary care, longer wait times in unpleasant waiting conditions and increased use of emergency departments for psychiatric treatment and clearance and it is easy to see why violence in all types of healthcare settings is on the rise.
The Joint Commission weighs in
The Joint Commission has studied the factors that lead to violence in healthcare through analysis of sentinel events. According to its data, between 1995 and 2010, hospitals and healthcare facilities experienced 256 assaults, rapes or homicides with 110 of those occurring since 2007.
- Among many local reasons and individual institutional factors, the Joint Commission lists some of the main reasons for the increase:
- Lack of appropriate or updated policies and procedures.
- Inconsistent implementation of policies and procedures.
- Inconsistent use of screening and monitoring tools.
- Human resources issues: lack of provision of appropriate education and competencies.
- Physical environment: high risk areas are often easily accessible to the public leaving them highly vulnerable to adverse events. There are also basic physical deficits in the environment and in regards to security safeguards.
- Assessment: inadequate identification of high risk patients, lack of psychiatric assessment tools and inadequate specially trained staff to monitor and assess the patients can lead to unidentified high risk patients. Inadequate psychiatric resources lead to increased use of emergency departments.
- Communication: a deficit in communication between patients, caregivers and family members is usually noted to be one of the main reasons for adverse events. Lack of appropriate communication can also contribute to disgruntled workers and staff eruptions.
Proactively addressing the problem
To prevent violence in healthcare facilities, The Joint Commission’s Sentinel Event Alert newsletter issue #45 suggests that facilities take a series of 13 specific steps, including the following:
1. Work with the security department to audit your facility’s risk of violence. Evaluate environmental and administrative controls throughout the campus, review records and statistics of crime rates in the area surrounding the healthcare facility and survey employees on their perceptions of risk.
2. Identify strengths and weaknesses and make improvements to the facility’s violence-prevention program—the Healthcare Risk Control system (HRC) issue on Violence in Healthcare Facilities includes a self-assessment questionnaire that can help.
3. Take extra security precautions in the emergency department, especially if the facility is in an area with a high crime rate or gang activity. These precautions can include posting uniformed security officers and limiting or screening visitors for weapons or conducting bag checks.
4. Work with the HR department to make sure it thoroughly pre-screens job applicants and establishes and follows procedures for conducting background checks of prospective employees and staff. For clinical staff, the HR department also verifies the clinician’s record with appropriate boards of registration. If an organization has access to the National Practitioner Databank or the Healthcare Integrity and Protection Databank, check the clinician’s information, which includes professional competence and conduct.
5. Confirm that the HR department ensures that procedures for disciplining and firing employees minimize the chance of provoking a violent reaction.
6. Require appropriate staff members to undergo training in responding to patients’ family members who are agitated and potentially violent. Include education on procedures for notifying supervisors and security staff.
7. Ensure that procedures for responding to incidents of workplace violence (eg, notifying department managers or security, activating codes) are in place and that employees receive instruction on these procedures.
8. Encourage employees and other staff to report incidents of violent activity and any perceived threats of violence.
9. Educate supervisors that all reports of suspicious behavior or threats by another employee must be treated seriously and thoroughly investigated. Train supervisors to recognize when an employee or patient may be experiencing behaviors related to domestic violence issues.
10. Ensure that counseling programs for employees who become victims of workplace crime or violence are in place. Should an act of violence occur at your facility—whether assault, rape, homicide or a lesser offense—follow-up with appropriate response that includes:
a. Reporting the crime to appropriate law enforcement officers.
b. Recommending counseling and other support to patients and visitors to your facility who were affected by the violent act.
c. Reviewing the event and making changes to prevent future
This list and other information can be found on the Joint Commission website at
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About Barbara J. Youngberg
Barbara J. Youngberg has more than 25 years of experience in the healthcare industry focused on legal regulatory issues, risk management and patient safety concerns and internal operations in academic medical centers and complex teaching hospitals. She has joined Beecher Carlson as a consultant to the national healthcare practice. She currently works as a visiting professor and director faculty of the online programs at the Beazley Institute for Health Law and Policy at the Loyola University College of Law in Chicago. She can be contacted at: firstname.lastname@example.org
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