Jessica Rosing, R.N., has been punched, kicked and threatened, but she never reported those incidents to supervisors, figuring they were just part of the job.
Often, she reasoned, patients were not in control of their actions, or there was a justifiable reason for their aggression. But when a patient violently yanked Rosing’s arm and threatened to stab her with a syringe about a year ago, her views began to change.
“I’ve been trying to advocate to my co-workers that, regardless of the circumstances, getting punched in the face is getting punched in the face, and that’s something that we shouldn’t be tolerating,” she says.
So, too, has the attitude shifted at the 15-hospital, Milwaukee-based Aurora Health Care system where she works, and it’s shifting at hospitals across the country. Violence appears to be on the rise in the health care setting, fueled by myriad issues, many unrelated to mental health. Those include emergency room wait times, domestic disputes, an opioid epidemic that’s bringing desperate patients to hospitals for drugs or addiction treatment, and by a general a shortage of beds for behavioral health.
Violent crimes taking place in such institutions have risen from two such events per 100 beds in 2012 to almost three in 2015, according to the Joint Commission. About 50 percent of all workplace assaults occur in the health care setting, according to the Bureau of Labor Statistics.
To address the problem, Aurora Health Care put together a systemwide steering committee about a year ago, on which Rosing participated. Leaders found violence to be grossly underreported at Aurora and elsewhere in the field, says Mary Beth Kingston, R.N., executive vice president and chief nursing officer of the Wisconsin system. With that in mind, Aurora piloted a call center and urged employees at its behavioral health hospital to report any incident, whether verbal or physical. Eventually, Aurora may have those reports skip the call center middleman and go directly to loss prevention or the employee health division. Without solid data, says Kingston, “we’re not able then to identify where we need to put our resources. We just don’t have an idea of the scope of the issue, and it makes developing strategies to address it much harder.”
In just the first three weeks of the pilot, Aurora saw more reported incidents than in all of 2015, which Kingston believes is a sign of progress. She’d like to see a consistent, user-friendly system spread to other hospitals in the system, and is eyeing further remedies to document and respond to such violence. Already, they are training gatekeepers who answer phones to de-escalate touchy situations, along with placing red flags in the electronic health records of patients to warn employees of a patient’s history of violence.
Kingston says hospitals must embrace a “systems approach” to addressing assaults in their organizations, not just doing so in a reactive fashion at local sites.
“Across the country, we really do need to work with all of our providers and folks in health care to change the mindset and say, ‘Yes, we’re caring for people at a very vulnerable time, but no, we want to put systems in place so that we all can see that this really isn’t part of our job,’ and ask ourselves how we can prevent such violence. That’s where we’re at,” she says.
Executive Corner: A BERT response from start to finish
In a December American Hospital Association webinar, experts from Mission Health in Asheville, N.C., detailed how they have deployed a Behavioral Emergency Response Team to move upstream and prevent staff assaults before a situation escalates. The intervention was developed through a process of data analysis and continuous improvement. Sonya Grack, R.N., senior vice president of patient safety net services and behavior health, emphasized that there is likely no end point to these efforts. “You can never get complacent in this work. It’s a constant quest,” she says. Here are the nine steps in the initiation of the BERT team:
- Patient behavior escalates.
- Staff on the floor attempt to de-escalate the situation.
- Patient behavior continues or escalates.
- Code BERT is activated by calling hospital operator; team is paged overhead.
- Team arrives to floor within 15 minutes, with security arriving sooner.
- Verbal de-escalation is led by a behavioral health clinician.
- Medications are obtained and administered by a primary nurse, as needed.
- The team debriefs.
- House supervisors continue to round on patient daily.
Adding up
Mission Health, in Asheville, N.C., has found that violence prevention is in the numbers. The seven-hospital system had been working to solve this “major national issue” for years, but a call from its board and leadership to begin benchmarking and tracking violence-related data helped to crystallize those efforts, says Chris DeRienzo, M.D., chief quality officer for the health system.
Fueled by support from its governing body, Mission Health formed a multidisciplinary assault-reduction team, incorporating all hospital staff affected by this issue — nursing, psychiatry, security, quality improvement, risk management, etc. The team began meeting monthly to review data on assaults and started looking for opportunities to prevent violence and improve staff safety, DeRienzo says. They came up with approaches specifically tailored to each part of the health system that was prone to attack, including the medical-surgical unit, the ED, psychiatric units and its regional hospitals.
For instance, Mission Health’s med-surg unit began utilizing what it calls a Behavioral Emergency Response Team. With it, a single phone call to the hospital operator sends a “Code BERT,” which activates a multidisciplinary team of professionals at any time of day, 24/7, to respond to any potential or actual violent situation. First deployed in the 760-bed flagship Mission Hospital in Asheville, the health system is now working to spread the BERT concept across its enterprise, DeRienzo says. In concert with those efforts, they’ve eyed other strategies to decrease assaults in the ED: training staff to recognize the early signs of escalating behavior, using crisis intervention and prevention techniques, providing medications in a more consistent manner so that patients don’t grow agitated waiting for them, and ensuring that security and behavioral health specialists are consistently available during crises.
DeRienzo cautions that having reliable data for a hospital’s board and leadership teams to act upon is crucial, but organizations must not get bogged down by the numbers. He encourages hospitals to try a strategy, evolve it, perform iteration and try again.
“You can only spend so much time getting your data right, and then you have to take action. I think it’s important for groups to be mindful that they’re taking action on data that are as good as they can get, but that they don’t land in analysis paralysis and never try an intervention,” he says.
As one early sign of success, DeRienzo notes that within the first year of the Code BERT program, about 75 percent of the nearly 300 nurses surveyed feel safer on the job. An equal percentage say they’re comfortable working with patients who are experiencing a behavioral health emergency. Since 2013, Mission Health also has seen a drop in the number of days employees are absent because of injury, as well as the total number of reportable cases of assault — the only two nationally benchmarked stats tied to workplace assaults.
Leaders at the North Carolina system believe violence perpetrated on hospital staff constitutes a “burning platform” that should fuel the field to aggressively track and decrease violent incidents. In an article written for Hospitals & Health Networks in March, Mission Health CEO Ronald Paulus, M.D., underscored the need for centralized assault-related databases or registries to help hospitals and policymakers understand the issue. Stats tracked by those repositories might include the number of staff calls for immediate intervention each month or the number of assaults on staff and incidents with injury per month.
DeRienzo believes such data will enable health care providers to address and eliminate workplace violence in the same way that data-driven solutions helped to reduce patient falls or central line-associated bloodstream infections. Fifteen years ago, CLABSIs were seen as one of the inevitabilities of health care, but today they’re entirely preventable. DeRienzo says the field must view assaults similarly, regardless of the myriad unpredictable factors that may cause them.
“Once you have something that can be preventable, then zero is a realistic option,” he says. “I’m not saying it’s realistic tomorrow. I’m not saying it’s realistic in three months or nine months or 12 months, but once you have the data and you can begin driving interventions based on that data, then, yes, I firmly believe that, as with any construct across the quality and safety universe, zero is the ultimate goal.”
Big picture prevention
From a national perspective, the American Hospital Association has pegged workplace violence as a key concern in 2017. In a letter to the Occupational Safety and Health Administration in April following a request for comments, the AHA echoed the need for data and sharing best practices to help mitigate workplace violence.
As part of its yearlong Hospitals Against Violence initiative, the association recently hosted a series of webinars tied to the issue, AHA General Counsel Melinda Reid Hatton wrote in the letter to Dorothy Dougherty, OSHA’s deputy assistant secretary of labor and health. The webinars cover a range of topics, including how to prepare for an active shooter and risk-mitigation strategies to avoid assaults in the hospital’s corridors. Up next, the AHA’s American Organization of Nurse Executives has collaborated in recent months with the International Association for Healthcare Security and Safety, with plans to host an upcoming webchat on June 13.
Two years ago, AONE, alongside the Emergency Nurses Association, released a list of eight guiding principles to help mitigate violence in the workplace. Extending from that original work, AONE is now planning an updated version, “Mitigating Workplace Violence 2.0,” that looks outside of the nursing sphere by incorporating security to gain further perspective on the approach, says CEO Maureen Swick, R.N. Her hope is to give nurse executives real examples of health facility safety assessments that they could implement in their own organizations, as well as de-escalation training techniques from a security standpoint.
“It’s really to broaden the scope and have a more inclusive, interprofessional look at workplace violence, especially with the experts,” says Swick, who is also the chief nursing officer of the AHA. “Security [personnel] are folks who are intimately involved in the safety of our health care organizations, and have done some tremendous work on training, on de-escalation and on preventing violence in the workplace. So, we want to make sure that we capture that in [expanding] the work that was originally done.”
The need for such broadening of the scope of anti-violence work within the hospital has been one of the major findings for the Washington State Hospital Association. The group recently released its own toolkit following an extensive literature review and gap analyses at member hospitals.
One key takeaway for Lucia Austin-Gil, senior director of patient safety at WSHA, is the need to integrate the work of security, patient safety and employee health experts who typically all report to different members of the C-suite. The toolkit notes that the current decentralization of safety functions “can make efforts to establish a single organizational focus on safety very difficult and is a main point of frustration with professionals addressing the risk of aggressive behavior in health care.”
The WSHA released its draft toolkit in the spring with an aggressive goal of reducing violent incidents by 20 percent before winter.
Boards and executives alike, on a widespread geographical scale, are frustrated by this issue, Austin-Gil says, but momentum seems to be building toward a solution.
“This problem is not new, clearly, but because of the increase in rates and the impact on not only patient outcomes, but staff morale, we’re hearing from the front line all the way up to the C-suite and board level, that there’s an urgent need for support around this topic,” she says. “Some CEOs sound, quite frankly, exasperated because it’s so complex and multifaceted, but we have come together and committed to starting somewhere.”
7 steps to prepare for a gunman 
Active-shooter situations may occur in hospitals much less frequently than physical assaults, but the outcome is much more devastating, says Kevin Tuohey, board president-elect of the International Association for Healthcare Security and Safety. In a January webchat hosted by the American Society for Healthcare Engineering of the American Hospital Association, Tuohey spelled out seven steps hospitals can take to prepare for an active shooter. According to ASHE, about 95 percent of hospitals have a plan in place, and Tuohey believes awareness is building that hospitals are no longer immune from mass shootings. “While hospitals have always been looked at as places of refuge, as places that were really safe, I think in the last 10 years that’s changed, and I think that they are no longer exempt,” he says.
Visit AHA.org/hav to find webinars on both “4 Universal Precautions to Shift a Hospital’s Culture” and the Behavioral Emergency Response Team approach to preventing staff assaults, plus additional resources.
- STEP 1 | Assess risks and vulnerabilities.
- STEP 2 | Determine prevention and response actions.
- STEP 3 | Reduce workplace violence.
- STEP 4 | Plan mock drill exercises and training.
- STEP 5 | Collaborate with outside law enforcement.
- STEP 6 | Build communication and crisis awareness among staff.
- STEP 7 | Debrief and recover from an incident.
Don’t lose sight of lateral violence
While recent attention in the field has focused on violence inflicted on hospital staff by patients or their families, experts say that it is important not to lose sight of lateral violence in the workplace, which can come in the form of bullying, general incivility among colleagues or, in some cases, physical altercations between staff members. Some — like Lisa Wolf, R.N., and director of the Emergency Nurses Association’s research institute — believe that lateral violence can contribute to, or exacerbate, other violent incidents perpetrated by patients.
Wolf speculates that new nurses are the most vulnerable to both bullying by colleagues and attacks by patients — and that the two behaviors are linked. Rookie nurses may be given complex patients beyond the nurses’ experience level with no support from more seasoned staff and be forced to work long hours. New nurses also may feel too intimidated to report incidents.
If a nurse is not given information about a potentially violent patient or not supported in the care of such a patient, the likelihood of an incident occurring is much greater. “External violence, when we think of workplace violence, may actually be facilitated and encouraged by nurses’ own workplace bullying behaviors,” Wolf says.
Wolf has preliminary data demonstrating the connection and plans to test the theory in future research. In recent literature, the American Nurses Association, the Occupational Safety and Health Administration and others have mentioned the connection between bullying and violence, along with patient and nurse safety. Bullying, as defined by the ANA, is “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient.”
OSHA offered mitigation strategies to help prevent bullying and violence in its 2015 guide “Preventing Workplace Violence: A Road Map for Healthcare Facilities.” St. John Medical Center, Tulsa, Okla., which is part of Ascension Health, has an incident-reporting system that allows a worker to bypass supervisors who might be perpetrating the abuse.
Bullying often can arise from “clinical hierarchies,” i.e., the long-tenured surgeon who yells at an assistant to remind him to wash his hands. St. John has engaged its physicians in designing anti-bullying strategies led by Chief Medical Officer John Forrest, M.D., who has a zero-tolerance policy toward such behavior.
Forrest believes it’s crucial to take seriously all bullying complaints and to respond immediately before tensions fester. More recently, St. John began expediting responses to such complaints with a newly installed electronic reporting system. The medical center also hopes to break down clinical hierarchies and foster collaboration with physician-nurse rounding.
“You have to continually maintain the culture of an open, free line of communication,” Forrest says. “I try very hard to show my face around every nook and cranny of the medical center about once a week so that people know you’re there and approachable. With these sorts of issues, you’ve got to create an environment in which communication goes in both directions, and it’s not just a one-way street.”
