How to Prevent Violence Against Healthcare Workers

In part 2 of this Instagram Live clip, Jeremy Faust, MD, editor-in-chief of MedPage Today, talks violence in healthcare with Steven Haywood, MD, an emergency medicine physician, and Sarah Warren, RN, executive director and co-founder of Don’t Clock Out. Haywood and Warren discuss ways to prevent violence against healthcare workers and how staff can support each other. Watch part 1 here.

The following is a transcript of their remarks:

Faust: Why is this problem increasing? And it’s not just reporting. Why do you think this is actually an increasing problem?

Warren: Like every issue that I tackle within healthcare, I think they’re symptoms of a much larger problem. Healthcare workers and patients are having to navigate a system that is not designed for safe, high-quality care, and that is extremely frustrating. So not only are we faced with the deeply human issues of our communities, we’re also faced with the reality that they are not receiving the care that they deserve because of circumstances outside of our control and outside of their control.

All of that culminates in the emergency room. It starts there, and then it continues as the inpatient treatment goes forward and patients are met with medical bills, medical debt, insurance denials, new diagnoses — it is a lot on a person, on an individual.

Then when you have that compounded across patients that we care for, and then we’re vicariously absorbing that as well, as people — that’s a lot of trauma.

The other point to this is that healthcare workers are often not fully trained in trauma-informed care. We are working in deeply human settings and faced with trauma, and we’re not able to provide our patients with the care that they deserve. With that trauma-informed lens, that could maybe add a layer of cushion and protection and help prevent emotions to rise to the level that they do.

I am of the belief that criminalization and further pushing patients into this prison industrial complex — I don’t think that benefits us in the long-term. I also think about the consequences of healthcare workers navigating their patients being criminalized after incidents that they experience, as well as the harm and injury already occurring. How do we prevent it from happening in the first place? Because an injury or a traumatic event like that is going to be with you forever. It’s going to impact whether or not you continue working in healthcare.

And to me, criminalizing patients is not really a solution that’s going to prevent this from happening. I believe this because the state that I worked in as a nurse at the bedside where my incident occurred is Florida, and Florida has a state law that makes assaulting a healthcare worker a felony. That didn’t stop me from being strangled by my patient.

Faust: That’s really important because you don’t want to fight fire with fire — not that we’re going to literally hit anyone back — but the idea of taking an injury that’s in one direction and saying, “Alright, let’s throw the book at these people and put them in jail,” like that solves any problems.

There is this argument that goes way beyond our expertise: is the punitive system a good preventative system where people are like, “Oh, if I do that, I’m going to go to jail. So I shouldn’t do it.” It doesn’t always work. In this case, obviously it doesn’t — or it’s unlikely to.

So how can we identify a high-risk patient and prevent an event that hasn’t happened yet? It’s impossible, right? Or is it? Are there other ways to identify [them]? What are the interventions that can make it so that someone doesn’t have to worry about walking into a room with their stethoscope?

Haywood: It’s tough. Again, absolutely primary prevention would be phenomenal.

First of all, our society needs to be aware that this is unacceptable. I understand you’re seeing me at the worst moment of your life. I understand that your family member is sick, and I understand that my ER is understaffed, and I understand that there are some delays in care, and I understand that increases your frustration, but to turn that into violence, to turn that into threats, is completely unacceptable.

The SAVE Act that Sarah mentioned is supported by the American College of Emergency Physicians [ACEP], which essentially turns this into a federal penalty, similar to if you assault an airline employee or something of that nature. That’s one way that ACEP supports communicating that this is unacceptable.

And then in-house, you have to have well-trained security staff. I’m not security. I’m a big guy, I’m 6’2″, I fill out my frame, but I’m not security and I’m not trained to resolve violent issues. You’ve got to have that staff so that I can focus on taking care of my patient, providing care, and I have that support behind me in case things do escalate.

Faust: Yeah, it’s really important.

I do kind of wonder, Steve, you mentioned something before about whether we’re in a way victims of our calling, which is that we do want to provide care to everyone who comes in. Unlike if you go to a restaurant and make a scene, you can be banned from that place forever. We are always going to be there for our patients no matter what. It’s our mandate and it’s our moral. That’s what we want to do.

But I sometimes wonder if the reason this has become a problem is that a small subset of patients, just a small subset, sense that they can get away with it or something. Is that part of it?

Warren: It is definitely part of it. I think in medicine and healthcare in general, we tend to put ourselves in that bubble of self-sacrifice. That does reflect on how we are exploited in the workplace, how we are overextended in the workplace, and also potentially how some small subsets of patients do treat us as clinicians or providers.

To me, safe staffing legislation is something that could really help prevent workplace violence, just from having more people in the healthcare space to support each other. When I had that experience, we had maybe three security officers in the whole hospital, and on night shift there were maybe two or one, and they were always in the emergency room. So when you called a code gray, it was going to take 15 minutes for them to get there and we had already handled it. But we didn’t have that support. It’s like they might as well have not been there.

Other things like no-tolerance policies, I think, are important. Metal detectors, de-escalation training, panic buttons, and then the root cause analysis. Why is this happening? With standards like the OSHA [Occupational Safety and Health Administration] standards, that means that these incidents have to be documented. They have to be reported. Your reimbursement is affected if you’re not taking care of your healthcare workers.

I’m of the belief that there should be no incentive to care for your healthcare workers and make sure your patients and healthcare workers are safe. You shouldn’t be paid to protect staff, it should be something that is a priority regardless. The fact that not every hospital in this country has metal detectors tells me that we are not a priority, not only healthcare workers, but patients as well — especially because we have open carry laws popping up in different states. And like you said, it’s not if, it’s when. We’re the ones finding weapons, we’re the ones having to navigate that. That just adds to our trauma.

This is what we receive through Don’t Clock Out, these are the insights that we’re seeing. These healthcare workers are having to navigate so much, they feel so much pressure, and it’s just not sustainable at the end of the day. So, I’m so grateful for this discussion.

Faust: In terms of onboarding students or junior members of the practice, Steve, are there resources that you’re aware of for getting people aware of this before it happens? Are there standards for this in onboarding or just in general training?

Haywood: In medical school we’re taught, especially on our psychiatry rotation, to never put the patient between you and the door. Be cautious about different ways that a patient could assault you. For my residents, as Sarah mentioned, we pull a lot of firearms off of patients, and so we had to have a special training day from our residents to make sure that everyone was able to safely handle a firearm and get that firearm out of somewhere where it could cause harm to staff. We have training modules that are completed.

Honestly, it’s so integrated into medical education. It just reinforces the fact that this has become the status quo. That’s so completely unacceptable that the status quo in healthcare is, “Hey, here’s what to do if you’re assaulted, here’s how to prevent assault.” It’s important that we have those trainings. It’s important we do whatever we can to assure staff safety, but we need to make sure that we are not putting blame on healthcare workers.

Our first response when somebody’s assaulted is, what could you have done differently to not get punched in the face? It’s going to happen. There’s no way that we can prevent it.

I’m all about giving my residents and giving my nurses all the resources possible to protect themselves, but at the end of the day, it is completely unacceptable and it’s never the victim’s fault.

Faust: If there’s one thing that we could tell either patients or administrators or anyone listening how we can get this to be better, what would that one thing be?

Warren: We spoke to over 100 legislators with Impact in Healthcare about a month ago. We spoke to White House, Congress, Health and Human Services, and what was jarring to this group of healthcare professionals who have worked in the last 3 years who have experienced workplace violence, who this legislation impacts directly, is that the way that we framed our conversations with them — because we have no special interests other than getting healthcare workers safe and getting patients safe — is that our experiences and the way that we frame them and our truths were news to the people in charge.

That did not make sense to me. That did not make sense to the 30 healthcare workers who were there. And it made us feel almost nihilistic, like, “Wow, we have to live on Capitol Hill to be able to impact change.” That shouldn’t be the reality.

We should be telling our stories through social media, telling our stories through this platform, speaking up when this happens in our workplace, not only to ourselves, but to our colleagues. Reporting, documenting, putting things on paper, and also reporting these incidents to the bodies that you can report them to and getting reviews of your facility if something egregious happens, talking to the press if you have to.

That, I believe, is how we move the needle forward, because we are past the point of no return. We are past the point of waiting, because the more we wait, the more healthcare workers are harmed as well as patients in this process.

Haywood: Yeah, I agree with Sarah. This has to be a priority, and the way we make it a priority is by telling our story.

What I tell people is, “I want you to imagine for a minute that you are worried about someone. You want to help that person. You go to that person, you put a blood pressure cuff on their arm, you put EKGs on their chest, you put your stethoscope on, you’re listening for breath sounds. Is that a crackle? Is that a wheeze? And out of nowhere you get a full-force fist to the side of your face.” That is what our staff is experiencing.

We need those emotional stories, because I can say, “Hey, workplace violence is an issue. Hey, violence is on the rise,” and it doesn’t make that emotional connection. Tell your stories.

When somebody can then imagine going to the next room and you see a big strong individual and you’re expected to go in there and listen again. And the whole time you’re thinking not, “Is this a crackle? Is this a wheeze?” But, “Is a fist coming to the side of my head?” Which leads to guilt, because you feel like you’re neglecting other patients. It just leads to this vicious cycle.

We have to tell our stories because this has to be a priority. We need to communicate with our lawmakers, with our colleagues, with our administration, how unacceptable it is. And the best way to do that is with these true, emotional stories of what we’ve had to endure.

If you want to get involved with advocacy, legislation, Sarah is involved in a lot of great programs and we also have the vehicle through the American College of Emergency Physicians to affect that change. So please reach out to me if you’re interested in getting more involved in this topic.