Hospital security chiefs weigh in on the contributing factors and what can be done to stop it
Late last month, 45-year-old physician Henry Michael Bello walked into Bronx-Lebanon Hospital Center in New York where he used to work and opened fire with an assault rifle, killing a fellow doctor and wounding six other people. Following the shooting spree, police say Bello, who was reportedly forced to resign from his post at the hospital in 2015, tried to set himself on fire but later turned the gun on himself after the self-immolation attempt failed. The shooting was but one extreme example of the numerous workplace violence threats that workers in healthcare facilities across the country face every day.
According to the Occupational Safety and Health Administration (OSHA), from 2002 to 2013, the rate of serious workplace violence incidents, which are defined as those requiring days off for an injured worker to recover, were more than four times greater in healthcare than private industry on average. The most recent statistics compiled by the International Association for Healthcare Security and Safety (IAHSS) also paint a grim picture with regards to the rate at which incidents of violence are occurring in hospitals.
The “2017 Healthcare Crime Survey,” which analyzed the responses of security professionals at 222 U.S. hospitals, found that "Workplace Violence Type 2" assaults, which are acts of violence committed against hospital staff by patients and visitors, accounted for 89 percent of all assaults and aggravated assaults at hospitals from 2012 to 2016. Drilling down even further, the study found that hospitals suffered 1.4 Type 2 assaults and 0.7 Type 2 aggravated assaults for every 100 employees on staff last year.
By their very nature, hospitals and other healthcare facilities inherently contain many of the combustible elements that can result in outbursts of violence. With the exception of the birth of a child, the vast majority of people seeking treatment at a hospital are not there because they want to be, friends and relatives of patients are under a great amount of stress being concerned about the welfare of their loved ones, and there are a number of other elements – mental health conditions, narcotics addiction, etc. – that can also play a factor in someone’s propensity for violent behavior.
However, nearly everyone agrees that workplace violence in the healthcare environment is not a new phenomenon but rather doctors, nurses and other staff are now more likely to report it.
“One reason that you’re seeing more or hearing about more incidents of violence is people are now reporting things that they didn’t report as much before,” says Bonnie Michelman, executive director of police, security and outside services at Massachusetts General Hospital. “Oftentimes it was suggested that clinicians should just ‘suck it up’ or ‘sweep it under the rug’ and people are not doing that anymore. People are now often reporting any time there is a threat or incident of stalking or of intimidation or harassment. Those may be effecting actual statistics, it may not be actual violence but rather the threshold or tolerance for violence that has gone down, which is a very good thing.”
Combating the Problem
The first thing that hospitals need to do to combat the issue, according to Bryan Warren, director of corporate security for Carolinas HealthCare System and past president of the IAHSS, is to recognize the fact that there are outsized problems with workplace violence in healthcare and make a commitment to address it, which starts with education.
“We need to do a better job of helping the average healthcare worker – be they clinical or non-clinical – understand what workplace violence is, define it for them, tell them what the warning signs are, and then let them know what their role is when they witness those types of events,” Warren says. “I think that is probably the most critical part of it.”
Martin Green, manager of security, telecommunications and emergency preparedness for Baycrest Health Sciences in Toronto and the current president of the IAHSS, agrees that training is key along with continually reviewing security policies and procedures.
“Security managers must work with their law enforcement, human resource, health and safety and union partners, to develop a policy of ‘zero tolerance’ on workplace violence," Green says. "This policy needs to be clearly and conspicuously posted to inform the public. Facilities should actively prosecute those individuals that violate this policy. The public must come to understand that acts of violence or aggression in a healthcare setting will not be tolerated.”
In addition to training staff and regularly updating policies and procedures, healthcare security executives say that having the proper mix of integrated technology solutions and incorporating sound security strategies into the overall design of the facility can also go a long way in mitigating workplace violence.
“The kinds of access control, CCTV and alarm systems and software that exist for hospitals are incredibly innovative and incredibly valuable to better security for a hospital. They are not a be all end all, but they are a tool,” Michelman says. “Emergency departments are now constructed with security in mind, as are a lot of high-risk areas in hospitals, so architectural considerations for security in hospitals is more prevalent and more important than ever before.”
Contributing Factors to Violence
While much of the combative behavior exhibited by patients, visitors and others can be attributed to some of the aforementioned factors, there is also a myriad of other reasons percolating underneath the surface that could help explain why workplace violence in healthcare has reached epidemic proportions.
Healthcare security professionals theorize that perhaps a general shift in the culture towards more aggressive behavior, coupled with drug and alcohol abuse and a lack of resources necessary to properly treat the mentally ill may all be playing some role in the problem.
“I think, in general, society just seems to be more aggressive and people seem to lack the coping mechanisms that they once had,” Warren says. “I’m certainly no expert on that, but it just seems like people don’t have the same connections with friends and family that they used to and that, in turn, is driving some of the behaviors. You’ve obviously got criminal behavior, but you’ve also got a huge drug issue with the opioid epidemic. You also have behavioral health issues and, unfortunately, we’re seeing more and more behavioral health patients being helped for longer and longer periods in emergency departments and not getting the treatment they need because we don’t have the resources to provide them with psychiatric services in a timely manner.”
Green agrees that these are likely contributing factors to violence in hospitals and also believes that a bent towards more aggressive behavior in society is also to blame. “Sometimes I think that it has become somewhat culturally acceptable to exhibit negative and aggressive behavior,” he says. “Social media sites are full of examples of negative behavior caught on cellphone video and uploaded apparently for people’s amusement. Videos often show people standing, watching and laughing while people are behaving in a violent or aggressive manner.”
Sometimes an illness or disorder that a person suffers from, such as advanced Dementia or Alzheimer’s, or even the effects of medication can make someone act violently, albeit not willfully. “Most of the things we see in hospitals are not incidents of serious violence but some form of conflict," Michelman adds. "It’s agitation, verbal aggression, threats, maybe some bullying as well as assaults that may not be willful – people coming out of anesthesia, people with Dementia, etc. – so you’ve got a lot of incidents where people are not wanting to do bad things. There are certainly occasions where violence with intent takes place in our hospitals.”
Mitigating the Internal Threat
As evidenced by the statistics, the threat that patients and visitors pose to healthcare workers is far greater than that from disgruntled employees; however, as the Bronx-Lebanon shooting shows, hospitals are not immune from these types of incidents either. According to Michelman, one thing that hospitals cannot afford to do is simply brush off threats and other types of aggressive behaviors, whether they be exhibited by patients and visitors or by doctors, nurses and other staff members.
“I think the first part is understanding the risk – if someone has made a threat or there is concern that a person could commit inappropriate behavior – and making sure you’ve done everything you can to be proactive to alert people, safeguard particular areas, talk to local police if that’s appropriate and even get the person psychiatric help if that’s deemed necessary,” she says. “Obviously there is no formula for every event. Unfortunately, there are times where there are situations in healthcare and every other industry when there is an unforeseeable incident and that’s the hardest part – when there is no way to have seen something coming. Certainly what you can’t do is turn your head if somebody has made a threat or if somebody feels they are at risk or that someone else is at risk. It’s very important to get an interdisciplinary group of staff at the table to deal with the risk at hand. This can include risk management, human resources, EAP, psychiatry and relevant clinical staff.”
In conjunction with training everyday staff members, Warren says that management and HR officials also need to be taught how to recognize the potential signs of workplace violence and how to respond appropriately. “Just because it is a rare event doesn’t mean it can never happen and so we have to be prepared not only for the external threat from patients and visitors, but also from the internal threat posed by co-workers, vendors or students – because at a lot of hospitals, if there is an institution of higher learning attached to the facility, there are all kinds of students coming and going," Warren explains. "They are in the hospital working closely with other clinical staff, so we need to do a parallel education for those managers, supervisors and human resources professionals on these things and the steps to take, especially when it comes to threat assessment. I think that is one thing a lot of facilities probably don’t do well because they don’t have to do it often and it is a perishable skill.”
Green says it is not uncommon for HR and other departments to be “insular” when handling employee termination or discipline; however, he feels it is paramount that security be involved in dealing with these types of situations. “It is essential that these sensitive terminations are handled properly to ensure that access cards, ID cards, keys, pagers, cellphones, laptop computers and other hospital property are retrieved and that remote access to email and other IT Systems are terminated,” he says. “In high-risk terminations, it is also very important that security staff and other impacted staff are made aware that an individual has been terminated and that they should not be allowed to return to the facility.”
Rules and Regulations Evolve
There has been a push in recent years in many states to not only increase the penalties for those found guilty of committing acts of violence against healthcare workers, but to also require hospitals to beef-up their workplace violence mitigation training. According to the American Nurses Association, a number of states, including Connecticut, Illinois, Maryland, Minnesota, New Jersey and Oregon all require private hospitals to provide employer-run workplace violence programs.
Last October, California became the most recent state to join this group as the state’s Division of Occupational Safety and Health approved a rule that requires hospitals, as well as other healthcare providers, to perform security assessments that also incorporate feedback from workers and subsequently develop a plan to help mitigate the identified risks.
Warren says that while headway is being made in state legislatures to stiffen penalties against violent offenders, he believes more could be done to create greater standards for the healthcare industry as whole when it comes to workplace violence mitigation. “Our genuine hope is that OSHA or perhaps some of the accreditation agencies, such as the Joint Commission, DNV or CIHQ, can work closely together to create some standards so that there are actually consequences if acute care facilities and healthcare providers don’t meet a certain minimal level of training and education,” he says.
Similar to the way the federal government has passed laws severely penalizing those persons who disrupt the operations of airplane, Green thinks comparable legislation should be enacted to protect healthcare workers.
“When the people realize that violence will not be tolerated and that there are significant penalties if they act with violence in a healthcare facility, it will make a difference,” he adds. The government of Australia has taken the lead in this by enacting laws with tough penalties. According to Australian law, ‘offenders who assault health practitioners in hospitals or anywhere that they are providing or supporting care will face up to six months jail, double the penalty for a common assault.’ “We can do the same. We must do the same.”
In the end, Green says there is not a panacea to solving the workplace violence pandemic in healthcare but that it will take a combination of different solutions. “There isn’t a single solution that will reduce violence in healthcare. It is a combination of all of them,” he says. “It is important that hospitals provide and maintain a comprehensive security program so that patients, visitors and staff feel safe and persons looking to commit violent acts know that they are being monitored.”
Joel Griffin is the Editor-in-Chief of SecurityInfoWatch.com and a veteran security journalist. You can reach him at [email protected].
