Violence in healthcare facilities significantly challenges patients, providers, support staff, visitors, and first responders. The most recent data in 2016 from the Occupational Safety and Health Administration (OSHA) estimates that nearly 75% of about 25,000 workplace assaults reported annually happen in healthcare settings. More recent survey data published in 2022 by the International Association for Healthcare Security & Safety (IAHSS) found increased violent crime in healthcare facilities from 1.4 per 100 beds in 2019 to 2.5 incidents in 2021. Simple assaults rose from 10.9 incidents per 100 beds in 2019 to 17.7 in 2022. Violence directed at staff by non-employees accounted for 73% of aggravated assaults and 86% of simple assaults. Anecdotal evidence suggests that the problem only increased during the COVID-19 pandemic and extended off campus, as community members verbally and physically attacked healthcare providers because they were angry about social distancing, vaccination mandates, restricted visitation policies, and other disease prevention protocols and strategies.
Responding to healthcare workplace violence can be particularly challenging for local law enforcement, who may not be familiar with the facility layout, staff, or established procedures. This unfamiliarity can potentially lead to a delay in response or worse. Once the incident is over, the crime scene must be secured and thoroughly investigated, temporarily removing a significant amount of workspace and requiring staff to suspend or relocate critical medical services. Many healthcare facilities have solid relationships with local law enforcement, but this still seems to be the exception, not the rule.
There is some “good” news. While violent incidents are increasing, victimized healthcare workers are likelier to report them than dismiss maltreatment as “part of the job.” In the May 2023 issue of the Domestic Preparedness Journal, certified protection professional Kevin Jones provided a comprehensive overview of workplace violence and listed robust prevention and preparedness suggestions. Recent incidents have demonstrated the need for improved collaboration and joint exercises between healthcare facility emergency management and security and local law enforcement to solidify relationships and guarantee the best response possible. This article provides a snapshot of healthcare-specific information and tools designed to protect staff, patients, and others in what was traditionally one of the safest locations in a community.
Workplace Violence in Healthcare Facilities: A Snapshot of the Problem
Patients and visitors bringing weapons to healthcare facilities is a challenge, particularly for emergency department (ED) staff, where time is of the essence, and interpersonal conflict (e.g., domestic disputes, gang activity) may carry over into the facility. Staff at the Cleveland Clinic (which has been using metal detectors since 2016) confiscated 30,000 weapons (e.g., knives, box cutters, and guns) from patients and visitors in 2018 alone in its Northeast Ohio region. In a 2018 study by Omar et al. from Oakland University’s William Beaumont School of Medicine, more than 70% of respondents reported experiencing any form of violence, nearly three-quarters had personally witnessed assaults during their shifts, and close to 22% frequently felt afraid of becoming a victim of violence. In addition, a 2022 report by the IAHSS Foundation found that EDs are among the highest-risk areas for workplace violence, with most ED nurses stating they have been hit or kicked while on duty.
- 21 were staff members (10 were shot by a patient, five by a visitor, four by a family member, and two by a current or former staff member); and
- 18 were patients (15 were shot by a family member, two by a visitor, and one by another patient).
Nearly 30% of the shootings were murder/suicides (the report notes these were primarily mercy killings that resulted in the deaths of the patient and the shooter, typically a significant other). Another 2012 study published in the Annals of Emergency Medicine noted reasons for hospital-related shootings, including settling a “grudge,” attempting suicide, “euthanizing an ill relative,” and prisoner escape (11%). The same study found that nearly one-third of these shootings occurred in the ED area, followed by the parking lot and patient rooms.
However, these statistics only represent reported incidents. The bulk of workplace violence incidents occur in the emergency department and inpatient psychiatric settings (The Joint Commission, 2021). However, violence committed against healthcare workers is not limited to hospitals. It can happen in outpatient clinics, patient transport, in-home health settings, and pharmacies (one international literature review found that 65% of pharmacists included in these studies had experienced some form of workplace violence).
Security in healthcare facilities varies widely. Larger systems may have their own security forces. Others may employ local law enforcement officers (some working overtime). Not all healthcare facility officers carry guns, but they may carry handcuffs, batons, pepper spray, or conducted electrical weapons (e.g., tasers). Levels and the nature of training vary, too, as does the amount of formal collaboration between hospital security, emergency management, and local law enforcement.
Finally, workplace violence is expensive – in addition to treating physical injuries (e.g., concussions and lacerations), there are costs associated with the negative mental health effects survivors may experience (e.g., missing work or taking time off to seek behavioral healthcare). The healthcare field also just witnessed “The Great Resignation” (due, in part, to workplace violence and burnout) and must now invest heavily in recruitment and retention strategies, including workplace safety programs.
As Jones noted in his May 2023 article, there are “warning signs and pre-incident indicators” of violent incidents that trained staff are more likely to notice and report. In the healthcare workplace, The Joint Commission notes that risk factors can include:
- Patients with various forms of mental illness;
- Patients in police custody;
- Stressful conditions (e.g., long wait times, crowding, being given bad health-related news);
- Lack of policies and training related to de-escalation;
- Gang activity;
- Domestic disputes among patients or visitors;
- The presence of weapons;
- Understaffing (including on-site security or mental health personnel and providers);
- Poor environmental design (e.g., lighting and factors that affect visibility in hallways, rooms, parking lots, and other areas);
- No access to emergency communication; and
- Unrestricted public access to healthcare facilities.
Risk factors can vary by location, too. Working in homes with limited space and skilled nursing facilities can present unique challenges to healthcare providers.
Legislative and Standards Changes
Updates to Federal Legislation
In 2023, OSHA convened a Small Business Advisory Review Panel to begin work on developing a new Prevention of Workplace Violence in Healthcare and Social Assistance standard. According to the press release and related fact sheet, topics OSHA is considering include:
- A programmatic approach to workplace violence prevention,
- Workplace violence hazard assessments,
- Workplace violence control measures,
- Preventive training,
- Violent incident investigations and recordkeeping,
- Anti-retaliatory provisions, and
- Approaches that avoid stigmatization of healthcare patients and social assistance clients.
Updates to State Legislation
Many states have recently passed new laws or established or increased penalties for assaulting healthcare workers. The American Nurses Association notes there is variation in these laws. In some states, the penalties only apply in specific settings (e.g., ED personnel, mental health personnel, and public health personnel). Laws protecting staff vary, too. Maryland, for example, is the only state not to require healthcare staff to put their full names on their name badges (thus making it harder for patients to target staff via social media or in person at their home addresses).
Updates in Standards
Due to a “high incidence of workplace violence,” The Joint Commission released in January 2022 new workplace violence requirements for accredited facilities. These requirements focus on managing safety and security risks, collecting information to monitor environmental conditions, participating in ongoing education and training, and creating a culture of safety and quality. Before the update, The Joint Commission released a Compendium of Resources that includes information and links to resources hospital staff can incorporate when implementing these standards.
Steps Healthcare Facilities Can Take to Prevent Workplace Violence
As changes continue from a federal and state perspective, it is essential to note that there are several steps healthcare emergency managers can take to prevent, respond to, and recover from workplace violence incidents. First, healthcare facilities and systems must have a workplace safety and violence prevention and reporting program. Staff should be familiar with and comfortable knowing the definition of an incident and how to report it. Data collection could enable more tailored programs and policies.
Jones mentioned the importance of having threat assessment teams and protocols. In healthcare, security, social work, risk management, and nursing administration staff could collaborate on creating threat protocols:
- Forms like the Violence Reduction Protocol Treatment Plan and the Brøset Violence Checklist can be a good starting point.
- Providing staff with panic buttons and mobile applications can help monitor situations and notify security if, for example, an employee does not confirm receipt of a message.
- De-escalation training (for all facility employees) can teach staff how to interact with agitated patients, coworkers, and visitors.
- Making adjustments to the physical layout of facility areas (e.g., improving lighting and sight lines, using metal detectors or signage that implies they are in use, using sloped desks that are more difficult to jump over, providing additional egress points for staff) can create a more resilient workspace.
And finally, working with facility security and local law enforcement is crucial to building relationships when things are calm and ensuring the safest, best response possible. Routine visits and regular exercises can help first responders learn the layout of a facility and adjust healthcare staff expectations of the role of law enforcement during and after an incident (e.g., temporarily closing parts of the facility for evidence collection). Giving officers access to live camera footage can help them rapidly locate threats and victims. Stashing go-kits for law enforcement near the ED entrance can improve overall response time and help protect patients and staff while ensuring operations quickly return to normal.
To help healthcare planners prepare their facilities to mitigate, respond to, and recover from an armed assailant situation, the U.S. Department of Health and Human Services’ Administration for Strategic Preparedness and Response’s Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) released a comprehensive On-Campus Healthcare Facility Armed Assailant Planning Considerations document (with assistance from IAHSS, The Joint Commission, and other subject matter experts). This document can be used as a checklist and includes links to free resources to help with workplace safety planning efforts. In conjunction with a top-down approach to workplace safety, tools like this help ensure healthcare facilities remain as safe and resilient as possible.
Corina Solé Brito
Corina Solé Brito, MA, has had the honor of working with first responders for nearly three decades. As a senior manager with the Police Executive Research Forum, she co-authored guides on preparing the law enforcement system for a public health emergency. She helped conduct case studies on four departments at various stages of pandemic planning. She served as the communications manager for the Substance Abuse and Mental Health Services Administration Disaster Technical Assistance Center, where she developed materials for disaster responders and survivors. Since its inception, she has managed communications for the U.S. Department of Health and Human Services’ Administration for Strategic Preparedness and Response’s Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) project. Currently, she serves as the ICF International’s deputy program manager.