Every day, workers in hospitals, psychiatric facilities, nursing homes and other settings face the threat of violence.
Physical assaults, from shoves to bites to punches, can and do beset health care professionals as they treat patients.
Yet, health care professionals interviewed by Lehigh Valley Business feel awareness of the risk is lacking. And they believe that training in how to handle workplace assaults needs to be a bigger part of the health care landscape.
“Nurses will say ‘this is just part of the job,’” said Robert McDonald, a professor of health care systems engineering at Lehigh University and former administrator at the Mayo Clinic in Minnesota. “Doctors are often reluctant to speak about it. Administrators don’t always want to open the lid on this because it might cause fear among workers and patients, as well. The culture is that this is just part of the job and you deal with it. There is a lot more that could be done to prevent these situations if it were openly talked about.”
Workplace assaults are more common in health care than in the general workforce, according to the Occupational Safety and Health Administration, an arm of the U.S. Department of Labor.
Health care accounts for nearly as many violent workplace injuries as all other industries combined. Between 2002 and 2013, incidents of serious workplace violence were four times more common in health care than in any other industry, OSHA reports.
Dr. Jeffery Zlotnick, a primary care physician who practices in Reading, first encountered violence in the health care arena while working as an orderly during medical school.
“I was working with a patient who was high on crack,” he said. “I was attacked and kicked, there were verbal threats.”
Drug abuse is one cause of violence in patients. Health care workers also may get caught in the middle of domestic abuse situations or gang violence. Or patients may lash out simply because they are frustrated, sick and in pain.
“It’s the nature of the work,” said Dr. Raja Abbas, psychiatrist and founder of Ethos Clinic, a mental health clinic with campuses in Bethlehem, Emmaus and Lehighton. “A lot of patients come into a health care facility with uncertain conditions. Some have not been taking needed medications. They may have been in a setting without structure. They may have delirium. All these factors contribute to a greater chance that a patient will be violent and aggressive.”
Some health care workers are at greater risk than others. About half of emergency medical technicians report having been assaulted on the job, according to Harris Interactive, a market research firm in Rochester, New York. That compares to 30 percent for nurses reporting physical abuse at work, according to a January 2015 study in the Journal of Emergency Nursing.
“EMTs are the first person to respond to someone who is agitated,” said Abbas. “They are dealing with drug abuse and overdoses, and other stressful situations where a person may become violent.”
As a psychiatrist, Abbas also has experienced workplace assault. “I was with a psychotic/paranoid patient,” he said, “when she got agitated and claimed I was working with the government. She pushed me.”
Abbas said a secondary concern of assaults is bloodborne diseases that can be transmitted from patient to caregiver during an incident.
“If a patient spits in a nurse’s eye, this can cause infection,” he said. “There have been bad infections as a result of bites and scratches. Any injury or assault should be treated seriously.”
From awareness to training
Despite anecdotal and statistical evidence of high rates of workplace violence in health care, professionals argue that awareness remains low.
“Incidents are dramatically underreported,” said McDonald, the Lehigh University professor. “These things aren’t talked about and there are not many consistent systems for reporting physical or verbal assaults. The view is that the less said, the better.”
Zlotnick said health care workers themselves reinforce the code of silence because they want to take care of people and do their jobs.
Many learn how to handle volatile patients simply by watching more seasoned doctors and nurses handle them, he said.
Zlotnick recommends that medical schools and nursing schools put more emphasis on training.
“It’s desperately needed. I received zero training for these situations in medical school. I was totally unprepared. Emergency rooms can be like war zones,” he said
Better record-keeping also might help.“Many patients are repeat offenders, especially in the emergency department,” he said. “There are lots of people who get their primary care in the ER. A patient may have a history of assaulting workers in the ER. Being prepared can help a lot.”
Other measures could include the use of metal detectors, additional security personnel and the installation of panic buttons in examining rooms, McDonald said.
Recommendations, not mandates
Currently, OSHA recommends implementing a comprehensive workplace violence program in all health care facilities, but there are no legal mandates.
Lawmakers are working to change that.
In 2018, the HealthCare Workplace Violence Prevention Act was introduced in the U.S. House of Representatives. If passed, it would require the Department of Labor to mandate workplace violence prevention programs for all health care employers.
In the Lehigh Valley, KidsPeace, a psychiatric hospital in Orefield serving the mental health needs of children and their families, has implemented its own workplace violence prevention program, in order to protect both staff and patients.
“Safety is key in our field of providing psychiatric services,” said Robert Martin, director of communications for KidsPeace. “It is part of our model of care. Clients and staff need to feel safe in order to provide a therapeutic environment for the clients.”
KidsPeace has a three-step program to address workplace assaults: de-escalation, protection, and consistent training.
“With de-escalation we look for ways to keep a situation from flaring up,” said Martin. “We use a system called ‘ukeru,’ from the Japanese word for receive, that involves training staff to interact with clients who might be escalating.”
The KidsPeace staff make stuffed pads available for agitated clients to vent their frustration on. The pads are there to take the place of making violent physical contact with another person, or an object that may harm the client.
“Comfort rooms” with soft furniture are also available. They offer a refuge where potentially aggressive clients to go and feel safer.
“Safety is never ‘done,’” said Martin, “we are continually looking for new evidence based strategies to keep clients and staff safe. We are always looking to get better.”
“Everyone in health care faces safety concerns,” Martin continued. “These are emotional situations where folks are experiencing crisis and trauma. The personal safety of all involved must be considered.”