How health care and social service workers are pushed beyond the call of duty
Virtually all types of health care professionals have been victims.”1 Published in The Joint Commission’s Sentinel Event Alert in 2018, this highlights a truth that is hard for much of the public to imagine about the everyday lives of those working in health care and social service environments.
“I’ve been bitten, kicked, punched, pushed, pinched, shoved, scratched, and spat upon,” says Lisa Tenney, RN, of the Maryland Emergency Nurses Association. “I have been bullied and called very ugly names. I’ve had my life, the life of my unborn child, and of my other family members threatened, requiring security escort to my car.”2 Such violence has been documented in health care and social service environments for many years. Yet, when it comes to workplace violence in the media, news coverage more frequently highlights violence inside white-collar office buildings in the national news. However, workers in health care and social service environments are exposed to violence on a regular basis to a point that they are potentially forced to treat it as just a “part of the job” in order to continue working in their profession.
The National Institute for Occupational Safety and Health (NIOSH), a federal agency that is a part of the CDC, defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”3 The U.S. Department of Labor defines workplace violence a bit more broadly as “an action (verbal, written, or physical aggression) which is intended to control or cause, or is capable of causing, death or serious bodily injury to oneself or others, or damage to property. Workplace violence includes abusive behavior toward authority, intimidating or harassing behavior, and threats.”4
Health care professionals may feel that it is their responsibility to “do no harm” to patients, which may prevent such professionals from attempting to protect or defend themselves from an attack.
Reporting Workplace Violence
Most incidents of workplace violence in health care and social service settings have been reported to be verbal in nature, but physical acts of violence—such as assault, battery, domestic violence, stalking, and sexual harassment—have been reported as well.5 A survey from 2014 that looked at incidents of hospital crime showed that 75 percent of aggravated assaults and 93 percent of all assaults against health care workers were at the hands of patients or visitors.6 This highlights how the majority of crimes in health care settings are not worker against worker, but rather patient/visitor against worker.7
Incidents of workplace violence across all categories are also generally underreported.8 Workers in health care and social services can be uncertain what exactly is considered violence, partially due to the belief or understanding that the individuals who attacked them should not be held accountable for their actions based on conditions that are affecting their mental state.9 Furthermore, health care professionals may feel that it is their responsibility to “do no harm” to patients, which may prevent such professionals from attempting to protect or defend themselves from an attack. It is also possible that health care professionals may not want to report an incident due to a desire not to further stigmatize individuals who may have a mental illness or impairment of some kind.10 Whatever the reason may be for underreporting, it is estimated that only 30 percent of nurses report incidents of workplace violence,11 and among physicians in emergency departments, the estimated rate of reporting is as low as 26 percent.12
This pattern of underreporting may be due in part to the idea that violence is “part of the job.” And, as can be seen from the statistics, in some ways, it is. The Occupational Safety and Health Administration (OSHA) approximates that of the nearly 25,000 workplace assaults that are reported annually, 75 percent occurred in health care and social service settings.13 Furthermore, workers in health care settings are four times more likely to be victims of workplace violence than workers in private industry.14 This issue is clearly more prevalent in health care and social services than any other field, making it a somewhat unique problem for health care and social service workers to need to learn to manage.
OSHA suggests that a workplace violence prevention program has the potential to fit into a broader safety and health management system that can help a facility enhance employee and patient safety, improve the quality of patient care, and promote constructive labor-management relations.
Contributing to the problem is the way that workplace injuries have been reported within health care organizations. There exists various databases where health care workers may report injuries, but these various avenues lack a clear focus, which makes things difficult when professionals seeking a solution attempt to have a strong understanding of the scope of the issue. For the same reasons, it is difficult to track whether efforts made to mitigate or prevent workplace violence are effective. OSHA has made attempts to improve tracking efforts by creating one Injury Tracking Application, which is a secure website where covered employers are requested to submit workplace injury and illness information. In May 2016, OSHA published the rule “Improve Tracking of Workplace Injuries and Illnesses,” with an effective date that was extended to Dec. 1, 2017.15 The agency issued a public Request for Information on the extent and nature of workplace violence in the industry, as well as the effectiveness and feasibility of methods used to prevent such violence. The comment period closed on April 6, 2017.16
Yet, legally, employers are also required to provide a place of employment that is “free from recognized hazards that are causing or are likely to cause death or serious harm,” under the General Duty Clause, Section 5(a)(1) of the Occupational Safety and Health Act of 1970.17 For this reason, the willingness of employers to report data to OSHA that does not comply with this clause could potentially be limited.
The most common characteristics presented by perpetrators of workplace violence are altered mental states associated with dementia, delirium, substance intoxication, or decompensated mental illness.18 Increasingly, hospitals are providing care for potentially violent individuals.19 It is also important to note that there is no conclusive evidence that links workplace violence to any demographic groups20 or with correlations between urban versus suburban or rural emergency departments;21 such assumptions can lead to discriminatory behavior against patients.22 Also, despite the attention paid by the media to shootings in health care settings, such incidents are quite rare compared to other kinds of violence, such as verbal abuse or assaults that do not involve a firearm.23 Furthermore, there is a need to recognize verbal assault as a form of workplace violence that cannot be overlooked, since verbal assault is a risk factor for battery.24 According to the “broken windows” principle, apathy toward less physical types of assault, such as verbal abuse, creates an environment that is conducive to allowing more serious, physical crimes to take place.25
Workplace Violence Comes at a High Cost
Beyond just the harm done to employees’ physical, emotional, and mental health, any instance of workplace violence against an employee that forces that individual to seek medical treatment or miss work means that workers’ compensation insurance typically needs to pay the cost. For example, one hospital system had 30 nurses who required treatment for violent injuries in a particular year, at a total cost of $94,156 ($78,924 for treatment and $15,232 for lost wages).26 If an organization self-insures (as some large healthcare organizations do), it will bear the full cost. If an organization does not self-insure, its claim experience can still affect insurance premiums. Violence can also lead to other less obvious costs. For example:27
- Caregiver fatigue, injury, and stress are tied to a higher risk of medication errors and patient infections28
- Studies have found higher patient satisfaction levels in hospitals where fewer nurses are dissatisfied or burned out29
- Injuries and stress are common factors that drive some caregivers to leave the profession. The estimated cost of replacing a nurse is $27,000 to $103,000.30 This cost includes separation, recruiting, hiring, orientation, and training. Some estimates also account for lost productivity while a replacement is hired and trained
Actions Suggested by OSHA and The Joint Commission
In terms of actions to take, The Joint Commission suggests that health care organizations are encouraged to address this growing problem by looking beyond solutions that only increase security, as this solution has been pursued in the past without providing an effective remedy. OSHA suggests that a workplace violence prevention program has the potential to fit into a broader safety and health management system that can help a facility enhance employee and patient safety, improve the quality of patient care, and promote constructive labor-management relations. The following components are suggested to be the most effective ways to pursue a solution from within a health care or social service organization:31
- Management commitment and worker participation: Provide appropriate follow-up and support to victims, witnesses and others affected by workplace violence, including psychological counseling and trauma-informed care, if necessary.
- Worksite analysis and hazard identification: Review each case of workplace violence to determine contributing factors. Analyze data related to workplace violence and worksite conditions to determine priority situations for intervention.
- Hazard prevention and control: Develop quality improvement initiatives to reduce incidents of workplace violence.
- Safety and health training: Clearly define workplace violence and put systems into place across the organization that enable staff to report workplace violence instances, including verbal abuse.
- Recordkeeping and program evaluation: Recognizing that data come from several sources, capture, track and trend all reports of workplace violence—including verbal abuse and attempted assaults when no physical harm occurred
Workplace Violence Prevention Resources
- OSHA’s Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers describe the five components of an effective workplace violence prevention program, with extensive examples. See www.osha.gov/Publications/osha3148.pdf.
- Preventing Workplace Violence: A Road Map for Healthcare Facilities expands on OSHA’s guidelines by presenting case studies and successful strategies from a variety of healthcare facilities. See www.osha.gov/Publications/OSHA3827.pdf.
- Workplace Violence Prevention and Related Goals: The Big Picture explains how you can achieve synergies between workplace violence prevention, broader safety and health objectives, accreditation, and a “culture of safety.” See www.osha.gov/Publications/OSHA3828.pdf.
Source: Occupational Safety and Health Administration (OSHA)
1. The Joint Commission. Physical and verbal violence against health care workers. Sentinel Event Alert, 2018;59.
2. Enough is enough: OSHA to issue regulation on violence. Case Management Advisor, 2017;28(9):43- 5.
3. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health (NIOSH). Violence in the workplace. DHHS (NIOSH) Publication Number 96-100, Current Intelligence Bulletin 57. Atlanta, GA: DOL, July 1996.
4. U.S. Department of Labor. DOL Workplace Violence Program — Appendices. Definitions. Washington, D.C.: DOL, no date.
5. Rugala EA and Isaacs AR, eds. Workplace violence: Issues in response. Quantico, VA: Critical Incident Response Group, National Center for the Analysis of Violent Crime, FBI Academy, 2003.
6. Vellani KH. The 2014 IHSSF crime survey. Journal of Healthcare Protection Management, 2014;30(2):28-35.
7. Howard J. State and local regulatory approaches to preventing workplace violence. Occupational Medicine, 1996;11(2):293-301.
8. Arnetz, JE, et al. Underreporting of workplace violence comparison of self-report and actual documentation of hospital incidents. Workplace Health & Safety, 2015;63(5):200-10.
9. Privitera M, et al. Violence toward mental health staff and safety in the work environment. Occupational Medicine (London), 2005;55(6):480-6.
10. Occupational Safety and Health Administration (OSHA). 2015. Workplace violence in Healthcare. No. 3828.
11. Speroni KG, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing, 2014;40(3):218-28.
12. Behnam M, et al. Violence in the emergency department: A national survey of emergency medicine residents and attending physicians. Journal of Emergency Medicine, 2011;40(5):565-79.
13. Occupational Safety and Health Administration. Guidelines for preventing workplace violence for healthcare and social service workers (OSHA, 3148- 04R). Washington, DC: OSHA, 2015.
14. Security Industry Association and International Association of Healthcare Security and Safety Foundation. Mitigating the risk of workplace violence in health care settings. Silver Spring, MD: Security Industry Association, August 2017.
15. Occupational Safety and Health Administration. New Safety and Health Resources, July 1 to Sept. 30, 2017. OSHA Compliance Assistance Resources. Electronic Submission of Injury and Illness Records to OSHA. Washington, D.C.: OSHA, 2017.
16. Occupational Safety and Health Administration. OSHA 3169 Publication: Recordkeeping. Washington, D.C.: OSHA, 2001.
17. U.S. Department of Labor. Occupational Health and Safety Administration. Workplace Violence. Enforcement. Washington, D.C.: OSHA, no date.
18. Pompeii L, et al. Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (type II) on hospital workers: A review of the literature and existing occupational injury data. Journal of Safety Research, 2013;44(Feb):57-64.
19. Security Industry Association and International Association of Healthcare Security and Safety Foundation. Mitigating the risk of workplace violence in health care settings. Silver Spring, MD: Security Industry Assocation, August 2017.
20. Gates D, et al. Occupational and demographic factors associated with violence in the emergency department. Advanced Emergency Nursing Journal, 2011;33(4):303-13.
21. Kowalenko T, et al. Prospective study of violence against ED workers. American Journal of Emergency Medicine, 2013;31(1):197-205.
22. Phillips JP. Workplace violence against health care workers in the United States. New England Journal of Medicine, 2016;374(17):1661-9.
23. Blair JP and Schweit KW. A study of active shooter incidents in the United States between 2000-2013. Washington, DC: Texas State University and Federal Bureau of Investigation, Department of Justice, 2014.
24. Lanza ML, et al. Non-physical violence: a risk factor for physical violence in health care settings. AAOHN Journal, 2006;54(9):397-402.
25. Kelling GL and Wilson JQ. Broken windows: The police and neighborhood safety. Atlantic Monthly, March 1982;249(3):29-38.
26. Speroni, K.G., Fitch, T., Dawson, E., Dugan, L., and Atherton, M. 2014. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing. 40(3): 218–228.
27. Occupational Safety and Health Administration (OSHA). 2015. Workplace violence in Healthcare. No. 3828.
28. Rogers, A.E., Hwang, W.T., and Scott, L.D. 2004. The effects of work breaks on staff nurse performance. Journal of Nursing Administration. 34(11): 512–519.
29. McHugh, M.D., Kutney-Lee, A., Cimiotti, J.P., Sloane, D.M., and Aiken, L.H. 2011. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs. 30(2): 202–210.
30. Li, Y., and Jones, C.B. 2012. A literature review of nursing turnover costs. Journal of Nursing Management. 21(3): 405–418. (Dollar amounts presented here are adjusted to 2013 prices.)
31. The Joint Commission. Physical and verbal violence against health care workers. Sentinel Event Alert, 2018;59.