Strategies to Mitigate Healthcare Workplace Violence Threats

Years ago there were only a handful of professions in which employees left for work thinking “am I going to make it back home safe today?” The military, law enforcement, firefighters, miners and many other high-risk careers came with known hazards and everyday dangers and it was just part of the territory. You knew the risks you faced when you signed up. It’s not that simple any longer. With the continuing issues of workplace violence and active assailant events, it’s not uncommon for teachers, salespersons, and even clergy to ask the question “Am I going to make it home safe?” This is particularly true for those in the healthcare industry. 

Workplace violence in healthcare is currently more the rule rather than the exception with workplace violence-related injuries requiring days off from work at an estimated rate at least four times higher than the rate for private-sector workers overall ¹. Healthcare facilities can no longer be considered safe havens, and have far surpassed other places of business in the US as the leader in incidents of workplace violence against workers. This is not surprising when you think about the daily issues that healthcare workers face. No one wants to come to the hospital, and if you are there (with a few exceptions such as a new birth) then you or your family or friends are probably having a bad day. This results in a lot of emotional turmoil much of the time, especially in areas such as emergency departments and behavioral health units where unpredictability is commonplace. Add to this volatile mix the presence of opioids and other drugs, the presence of forensic patients (those subjects in protective legal custody requiring a law enforcement presence) and treatment of the victims of crime related activity (gang shootings, domestic violence cases, etc.) and the stage is set for dangerous situations to erupt.

 Healthcare leaders continue to struggle with this issue, and many professional healthcare advocacy groups have made concerted efforts to better control this epidemic as it not only threatens healthcare workers but also negatively impacts the ability of healthcare facilities to provide quality patient care. The American Hospital Association (AHA) as well as the Emergency Nurses Association (ENA) are just two of the many professional healthcare associations that are working diligently to address this growing issue in our country through the “Hospital Against Violence” campaign and a national day of awareness regarding workplace violence in healthcare which was inaugurated on June 9, 2017 ². While these efforts are certainly important for the safety of staff and clients, there is also a significant financial incentive involved.  In July of 2017, the AHA issued a groundbreaking report ³ that compiled the actual costs of workplace violence to healthcare providers as well as to communities. Some of their findings included:

• It estimated that proactive and reactive violence response efforts cost U.S. hospitals and health systems approx. $2.7 billion in 2016.
• It also estimated national in-facility violence costs of $428.5 million, including $234.2 million for staff turnover, $42.3 million in medical care and indemnity (compensation for lost wages made to employees who were injured on the job) for employee victims of violence, and $90.7 million in disability and absenteeism costs. 
• The report also indicated an annual cost of $17,500 per hospital on workplace violence prevention plan development.

Preparing Your Organization for Workplace Violence

Two critical components of any workplace violence prevention plan are staff training and physical environment design. In designing a workplace training program for employees, regardless of industry, one should consider a multi-tiered approach, in which the basics of workplace violence are discussed in a Tier 1 program (defining workplace violence, its sources, and current trends). For example, such a program in healthcare should be tailored to speak to the unique challenges posed when it comes to workplace violence prevention, such as:

• The receipt of a poor prognosis, imposing of physical limitations or providing other “bad news” to emotionally unstable patients or those without sufficient coping mechanisms when such information is shared.
• Dealing with patients and clients that suffer from behavioral disorders or are under the influence of alcohol, medications or controlled substances.
• The denial of narcotics or other controlled substance prescription demands or refusal to categorize a client’s diagnosis based upon their request due to disability claims, insurance reimbursement or other illegitimate purposes.
• Misplaced blame for financial situation resulting from charges incurred from medical treatment and/or related services (labs, X-ray, etc.).
• Refusal to follow medical advice which results in exacerbation of initial injury or condition resulting in additional issues mentioned above (physical limitations, medication needs, financial impacts, etc.).

In the second phase of a three-tiered training program, the lessons from the previous Tier 1 presentation should be reinforced and specific techniques on how to de-escalate potentially violent behavior and how workers can recognize verbal and physical queues that people tend to display prior to initiating physical aggression. When faced with escalating behavior, there will typically be additional physical warning signs manifested by the subject as part of their "fight or flight" response to the encounter. In these situations, staff should be trained to not only recognize these behaviors but also how to appropriately react to them once such behaviors manifest themselves.

Building upon the Tier 1 and Tier 2 programs, the Tier 3 program examines the top of the workplace violence spectrum, that of the active assailant or mass casualty incident. According to the FBI, an active shooter is defined as an individual(s) actively engaged in or attempting to kill people in a populated area⁴. There are several best practices that are suggested by the FBI and the Department of Homeland Security when it comes to responding to an active assailant or mass casualty incident. These include being aware of your environment and any possible danger signs, taking note of the two nearest exits in any facility you visit or work in and knowing the "Run, Hide, Fight " process⁵.

• If you’re in an office, stay there and secure the door using whatever means necessary, including barricading any doors with furniture or office equipment.
• If you’re in a hallway, get into a room and secure the door. Silence cell phones or any other devices that might give away your location and close all blinds and curtains, turn off the lights and move away from the door. Remain quiet.
• Remember, there is a difference between Cover and Concealment. Cover provides some protection from bullets (such as a heavy desk) while Concealment simply hides you from the shooters direct line of sight.
• As a last resort, employees should be trained that when the assailant is at close range and if they cannot escape or shelter in place, they might try to incapacitate him/her by whatever means necessary, including the use of improvised weapons such as fire extinguishers which can be used to blind and disorient the shooter at a distance or used as an impact weapon at close range. This topic can be controversial based on how it is presented, and organizations need to determine their own educational programs content based upon the totality of circumstances and the needs of their staff.

Above all, those involved in an active shooter or mass casualty incident should seek to escape first and always contact law enforcement via 911 when it is safe to do so.

The design process for a secure physical environment has many components, including consideration of perimeter security measures such as appropriate access controls, doors and windows that can resist forced entry attempts, and visitors’ screening processes. Internal controls like an effective mass notification system for all staff, identification of “safe rooms” for workers to shelter in place until law enforcement arrives on the scene. The Department of Homeland Security’s updated “Options for Consideration” video series⁶ offers detailed information on how to create your own Emergency Operations Plan as well as how to determine appropriate physical security countermeasures with the assistance of a qualified security professional that can provide an assessment and make recommendations based upon best practices, industry standards and applicable regulatory requirements.

Regulatory Guidance

Speaking of regulatory compliance, regardless of your industry or business, all organizations within the U.S. (based upon its number of employees) should pay particular attention to the Occupational Safety and Health Administration’s (OSHA) General Duty Clause. This General Duty Clause states, in part, that "... employers are required to provide their employees with a place of employment that "is free from recognizable hazards that are causing or likely to cause death or serious harm to employees" ⁷.  OSHA also advises that " An employer that has experienced acts of workplace violence, or becomes aware of threats, intimidation, or other indicators showing that the potential for violence in the workplace exists, would be on notice of the risk of workplace violence and should implement a workplace violence prevention program combined with engineering controls, administrative controls, and training" ⁸. OSHA has made an example of a number of organizations in the U.S. over the past several years issuing multiple citations for failing to provide a safe work environment for staff due to known hazards of workplace violence under the provisions of the General Duty Clause.  Considering that the fines for OSHA violations begin at $12,934 per violation for those deemed as “Serious” or
“Other-Than-Serious”, plus an additional $12,934 per day past the abatement date, or $129,336 per violation for those considered “Willful” or ‘”Repeated” (a ten-fold increase), all businesses should take the tangible and intangible costs of a workplace violence incident into consideration when determining how to proceed with the mitigation planning process⁹.

Summary

Workplace violence is a traumatic event that is occurring with increasing frequency in many organizations across the country.  Mitigation measures must be undertaken to minimize the risk of such events, including the education of staff as to their role when such events occur and the proper physical safeguards that should be in place to provide a reasonably safe work environment. A multidisciplinary threat assessment teams should also be considered with a focus on developing plans to minimize the risk of violent incidents.  Such a team, with the support of the organization's leadership, should include local law enforcement, security, human resources, legal, risk management, and of course representation from the employees that work at the facility.  Through a well-defined threat assessment process, such teams may be able to mitigate workplace violence incidents before they reach a critical stage. In many instances of workplace violence, employees suspected or had knowledge of an existing problem, so the best strategy to prevent workplace violence is to develop a security culture that supports respect, open communication, and employee involvement.

About the Author:  Bryan Warren, MBA, CHPA, CPO-I is President and chief consultant at War-Sec Security and has over 28 years in the healthcare security, safety and emergency management fields. He has conducted healthcare security assessments and training workshops across the United States, Canada and Australia and has served on a number of national task forces including the U.S. Centers for Disease Control and Department of Health and Human Services Office of Infrastructure Protection.

References

1. United States Government Accountability Office. Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence, 2016. Web. 10 January 2018.  http://www.gao.gov/assets/680/675858.pdf

2. American Hospital Association. HAVHOPE, A National Day of Awareness Campaign, May 2017. Web. 10 January 2018. http://www.aha.org/advocacy-issues/violence/havhopephotos.shtml

3. American Hospital Association. Cost of Community Violence to Hospitals and Health Systems, 2917. Web. 10 January 2018. http://www.aha.org/content/17/community-violence-report.pdf

4. United States Department of Justice - Federal Bureau of Investigation. FBI Study on Active Shooter Incidents in the US, 2014. Web. 10 January 2018. https://www.fbi.gov/news/stories/2014/september/fbi-releases-study-on-active-shooter-incidents

5. United States Department of Homeland Security. Active Shooter Preparedness. Web. 10 January 2018.  https://www.dhs.gov/active-shooter-preparedness

6. United States Department of Homeland Security. Active Shooter Preparedness. Web. 10 January 2018.  https://www.dhs.gov/active-shooter-workshop-participant

7. United States Department of Labor Occupational Safety and Health Administration. Workplace Violence Enforcement Standards, 2018. Web. 10 January 2018. https://www.osha.gov/SLTC/workplaceviolence/standards.html

8. Ibid.

9.  United States Department of Labor Occupational Safety and Health Administration. OSHA Penalties. 2018. Web. 10 January 2018. https://www.osha.gov/penalties/