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March 15, 2017

Health care violence is a growing problem—but people disagree about how to solve it

Daily Briefing

    Workplace violence has become more common in health care settings in recent years, but stakeholders lack a consensus on how to address the issue, Elizabeth Whitman reports for Modern Healthcare.

    A difficult measure

    According to Whitman, workplace violence in health care is not well measured. One survey published in 2015 estimated that only 19 percent of such incidents are recorded.

    Further, inconsistency in the way researchers classify workplace violence incidents makes it difficult to quantify the problem, Whitman writes. The Government Accountability Office last year estimated that the number of nonfatal violent incidents that occurred in health care settings in 2011 ranged from 22,250 to 80,710.

    According to Whitman, health care workers, and particularly direct care providers, face a higher risk of workplace violence than workers in other industries. Data from the Bureau of Labor Statistics show that more than half of all the workplace violence incidents reported to the agency in 2014 occurred in the health care industry.

    In addition, a 2014 survey by the American Nurses Association (ANA) found that about half of nurses and nursing students reported they had been verbally abused, and more than 20 percent reported that they had been physically assaulted. According to Whitman, physicians, particularly emergency medicine doctors, also frequently are targets of aggression.

    Such incidents can have financial effects for hospitals, Whitman reports. For instance, one hospital spent about $79,000 on medical treatment and $15,000 on indemnity in one year for 30 nurses who were injured as a result of workplace violence, according to Whitman.

    Understaffing and workplace violence

    Workplace violence can drive providers to leave health care, and the subsequent staffing shortages can add to the potential for future violent incidents, Whitman writes. According to nurse advocacy groups, the risk of workplace violence increases when nurse-to-patient ratios drop below a critical level.

    That said, evidence showing a direct correlation between staffing levels and workplace violence is sparse, according Gordon Gillespie, a nurse and associate professor at the University of Cincinnati's College of Nursing. Still, Gillespie said he has seen that violence is most likely to occur when staffing levels are low, adding that patients sometimes turn to violence to get nurses' attention.

    Further, it is more difficult for staff to detect impending violent incidents as they become more overworked, Whitman writes. ANA President Pam Cipriano said, "It is the time that (nurses) are spending with (patients) that's allowing them to assess the degree to which the behavior they're seeing could be problematic." She added, "If there's not sufficient staffing, that's a missed opportunity to catch something before it's a problem."

    Moreover, fewer staff means there are fewer people available to respond when violence does occur, Whitman writes.

    Lack of national guidance

    While there is widespread acknowledgment that violence in health care workplaces is a growing issue, there is little agreement on the best way to respond, Whitman writes.  And according to Gillespie, a lack of national standards makes it difficult to address the issue.

    The Occupational Safety and Health Administration (OSHA) since 1996 has offered voluntary guidelines on workplace violence for health care and social services workers. The latest edition of the guidelines, which were last updated in 2015, states that "a written program for workplace violence prevention, incorporated into an organization's overall safety and health program, offers an effective approach to reduce or eliminate the risk of violence in the workplace."

    However, OSHA cannot enforce the guidelines or require employers to implement workplace violence prevention programs, Whitman writes. OSHA can cite employers for workplace violence under its general duty clause, which requires employers to provide a hazard-free workplace, but

    OSHA must meet a high burden of proof to issue such citations.

    To address the issue, OSHA in January began the rulemaking process to create standards intended to protect health care workers from violence, Whitman writes. OSHA is soliciting stakeholder input on the matter until next month. According to Whitman, OSHA still is in the "early stages of a process that ordinarily takes five to seven years."

    Meanwhile, several states have passed laws that require employers to develop programs to protect their employees from violence in the workplace, Whitman reports. Such laws vary significantly from state to state. For example, New Jersey's law encompasses the health care sector, while Maine's only includes hospitals.

    In addition, some stakeholders have called for regulations that would set a mandated nurse-to-patient ratio. However, some industry stakeholders have argued that nurse-to-patient ratios increase costs without improving care and impose rigid requirements on providers.

    So far, only California has set such standards, Whitman reports.

    How one hospital addressed the issue

    Some hospitals have taken their own initiative to address workplace violence, such as through technology and awareness initiatives, Whitman writes.

    For instance, the ED at New Jersey-based Valley Hospital had its nursing staff complete a survey about workplace safety, then required all ED staff to complete an online evacuation training. The hospital's ED also developed a team responsible for de-escalating risky situations without physical force and offered frontline staffers the option of wearing a badge that could be used to notify security and the charge nurse in instances when they felt threatened.

    According to ANA, the hospital after implementing the policies saw the number of workplace injuries decline in 2014 and 2015. However, that number increased slightly in 2016 (Whitman, Modern Healthcare, 3/11).

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