Continuing Education Activity

Workplace violence is vastly understudied in the healthcare industry. Workplace violence includes physical, verbal, and psychological abuse. As many as one in 5 healthcare workers encounter physical abuse, and verbal abuse is even more common. Workplace violence has significant institutional and personal repercussions affecting the quality of care. This activity describes the etiology, consequences, evaluation, management, and significance of workplace violence and explores current approaches for reducing the problem.

Objectives:

• Describe types of workplace violence and their risk factors.
• Identify the repercussions of workplace violence and what steps toward improvement have been taken.
• Explain the challenges in reporting workplace violence and how it contributes to incidence.
• Examine approaches to promoting a safe practice environment.

Introduction

Workplace violence in the healthcare system is vastly understudied. While there is no universal definition of workplace violence (WPV), the National Institute for Occupational Safety and Health defines WPV as “an act or threat of violence on a spectrum that ranges from verbal abuse to physical and even lethal assault towards persons at work or on duty.”[1]

Differing methods of categorizing WPV are found. One means of dividing WPV is based on the nature of the aggression. Violence may be physical, verbal, or psychological.[2][3] Examples of psychological violence include sexual harassment, bullying, and intimidation. In the professional environment, verbal abuse was shown to be the most common form of violence.[4][5][2]

Another means of classifying WPV is based on associated intent.[3]

• Type I refers to acts of violence, usually with criminal intent, without any legitimate professional relationship with the organization or its employees. These are generally associated with crime, such as thievery or terrorism.
• Type II WPV refers to violence by patients, former patients, or their visitors.
• Type III is violence by colleagues and staff.
• Type IV is similar to Type I but replaces the criminal association with a personal one with an employee.

Etiology

WPV in the hospital, especially the ED, may be related to organizational, employee, and patient risk factors. The type of work done in the emergency department is implicitly high risk. Emergencies are unpredictable, potentially fatal, and necessitate unparalleled access to immediate treatment. Care is provided regardless of background, insurance status, or other discriminatory impediments. The 24-hour availability makes the ED the "front door" and possibly a bottleneck to definitive inpatient care.[6][7] Large influxes of patients can create an overcrowded environment with long wait times. 

Patient-centered factors that may affect the risk for WPV include the acuity and severity of the illness, intoxication or drugs, and cognitive impairment. The clinical expectation of the patient may differ from the results they receive. The delivery of bad news may not go well. Social influences such as socioeconomic status, health literacy, and education level strongly influence expectations and the risk of ED violence.[8] Urban hospitals may have an increased risk of gang violence between rival patients or involving hospital staff.[9]

Lastly, employees themselves may unintentionally increase the incidence of WPV. The ED's stressful, fast-paced, and chaotic environment can cause healthcare providers to miss cues, move too quickly to sedation or restraints, and inadvertently heighten aggressive tendencies. Opportunities to de-escalate potentially violent patients may be overlooked or poorly performed.[10]  

Type III violence is more prevalent in institutions and departments with a history of abuse. Cultures of incivility fester in an "abuse begets abuse" mentality.[11][12] Inherent differences in power dynamics cause incognizance, fear, acceptance, and a culture of silence. There may be naivete about what constitutes abuse, and roughly half of the resident physicians know the proper protocol for reporting toxic behavior.[13][14] 

Many resident physicians find reporting ineffective and would rather tolerate abuse than confront it, fearing retaliation.[15] Others fear the act of reporting would magnify the attention of the abuser.[16]

Epidemiology

WPV is four times more likely to occur at the hospital than in any other setting.[17] Nearly twenty percent of healthcare professionals have experienced physical abuse. The prevalence is greater in tertiary facilities and urban environments.[18] 

WPV is also more likely to occur in psychiatric wards and emergency departments (ED).[17] Males are more likely than females to be violent and aggressive, especially between the hours of 16:00 and 04:00. One in every 5 people brings a weapon to the ED, regardless of gender.[8] The risk of experiencing physical violence in the ED also extends to the patient’s partner (2.67X) and sibling (1.52X), not just the patient. Advancing age is a risk factor. Patients aged 65 or older were also 1.47 times more likely to become violent.

The literature on Type III violence is somewhat sparse.[19][20][21] Similar to Type II WPV, verbal abuse is most common. In one healthcare study, nurses were the most common victims and the most common perpetrators of violence when compared to physicians, patient care associates, and other health professionals. Seventy-five percent of perpetrators were female and 60% were employed full-time; they had an average age of 45 years and an average tenure of 11.7 years.[3] 

WPV among physicians is also common, especially in teaching hospitals. Regardless of gender, verbal abuse and bullying is the most common cause of Type III violence.[22] For female clinicians, sexual harassment is also common. Multiple studies have described type III violence in the hospital perpetrated by physicians in higher positions of power; Bonafons et al found the occurrence to be high as 90%.[23][24] First-year residents have the highest risk of being abused as they have more senior colleagues to contend with.

Pathophysiology

Repercussions

The damage of WPV in the healthcare industry causes both institutional and individual repercussions. Failure to address it can cause a spiral of worsening. The ramifications of violence extend beyond physical injury to healthcare workers. Wirth et al. found that physical violence correlated directly with PTSD and inversely with patient compassion, while verbal abuse correlated more with negative emotions such as anger, depression, anxiety, guilt, humiliation, and helplessness.[25] Both resulted in higher stress perception, low job satisfaction, absenteeism, and even self-medication.[2][3][26] 

This also resulted in higher attrition rates and turnover for nursing and auxiliary staff. For physicians, it produces higher rates of psychological distress and promotes a culture of incivility that may be especially prevalent in teaching institutions.[27]

Resident physicians may be particularly vulnerable. Resident physicians function as both a clinician and an apprentice. This places them in the unique position of simultaneously falling victim to Type II and Type III violence. Higher rates of burnout, emotional exhaustion, cynicism, or depersonalization lead to erosion of self-confidence, fear of procedures, and deterrence of future candidates.[28][29]

Type III WPV has the propensity to self-perpetuate. Consciously, residents may feel compelled to contribute to the WPV of their colleagues to draw the spotlight away from themselves or to avoid retribution in performance evaluations or ingratiation.[22] Subconsciously, they may assimilate abusive behavior into their future career.[12] Some justify verbal abuse as a "drill sergeant" approach to competency or a "rite of passage," but it decreases eagerness to work and learn.[15]

To reduce the incidence of WPV in the healthcare field, especially the ED, patterns of addressable factors must be identified. Unfortunately, the repository of literature from the past two decades is small.[17][30][31][32] Much of the research has focused on the willingness to report WPV. One review shows 69% of staff have never reported their own WPV.[8] Several studies have investigated the cause of failure to report. Common themes in failure to report are trivialization and incognizance. 

Trivialization

Trivialization is common, especially in the ED.[32] Healthcare providers may see WPV as a "part of the job." [31] Clinicians and staff excuse the abuse by blaming the behavior on the illness or altered capacity of the patient and employ empathy by comparing the magnitude of abuse as inconsequential to the severity of the patient's illness.[8]

Another study found clinicians minimalized the abuse as an ordinary and emotionally cathartic byproduct of the patient's illness. Reporting violence is perceived as taboo, reflecting the clinician's incompetence. Faulty reasoning concludes if the patient were properly treated, they or their visitors would not be violent. In some cases, an ineffective legal system may be used as an excuse to doubt real repercussions.[31] Because the names of plaintiffs are published, healthcare workers may fear the risk of retaliation. As a result, a culture of learned acceptance prevails.[32][33][34]

Incognizance

Incognizance is the lack of understanding of what constitutes workplace violence. Unless clearly egregious, there are disagreements in the literature about what constitutes reportable violence.[33][34] Some believe the absence of physical injury means no WPV has occurred, but violence does not require physical injury.[17] 

If workers recognize WPV, many are unfamiliar with the reporting process. Nurses and patient care technicians are likelier to report to their supervisor or the charge nurse than to file a report or formal complaint. Many find reporting too time-consuming or difficult, especially in a chaotically busy work environment.[33]

Cost

A workplace's institutional, personal, and societal costs may be direct or indirect. Direct cost includes the cost of care. Indirect costs can include lost productivity, wages, legal costs, staff attrition, understaffing, and diminished capacity to care for patients.[8]

History and Physical

Identifying patient-specific risk factors helps to avoid WPV.[17][10]

• Triage flagging systems are a preliminary approach to identifying patients at greater risk of committing WPV. Risk assessment tools such as Staring Tone Anxiety Mumbling Pacing (STAMP), Violence Risk Screen Decision Support in Triage (VRSDSiT), the Alert System, and Broset Violence Checklist (BVC) may be useful in quick recognition of behavioral patterns associated with risk WPV.[29][35]
• Behavioral cues include anxiety, agitation, restlessness, a sense of entitlement or dissatisfaction, glaring, staring, or an angry or otherwise inappropriate tone of voice.
• Signs of criminal intent or drug-seeking behavior may be subtle but raise concern.
• Arrival via law enforcement officers.
• Male gender, age <30 or >65, or parental relationship to the patient are well-documented demographic risk factors.
• Historical predictors include mental illness, medication noncompliance, substance abuse, and documentation of previous aggressive behavior.

Evaluation

Literature has shown that having precautionary action plans for WPV generally decreases the rate and severity of WPV over time. However, risk assessment tools have still been underdeveloped. Screening instruments such as STAMP, VRSDSiT, Alert System, and the BVC all function to assess specific patient behaviors and estimate the probability of violence.[17][29] 

Alert systems utilize mental status, behavioral, and orientation criteria to flag patients for potential WPV. Risk is highest if they have at least three of the following: shouting or demanding tone, are drunk or under the influence, confused or hallucinating, withdrawn, agitated, suspicious, or otherwise have an alteration in mental status.

Flagging at-risk patients shows high predictive value. The Behavior of Concerns Chart (BVC) has the highest predicted validity for WPV, especially in the ED. Senz et al was the first study to apply the BVC in the ED setting, intending to provide a standard for both communication and shared understanding amongst administrative, physician, nursing, and security staff.[35] 

This guideline may significantly reduce unplanned WPV and mechanical restraint usage. Its adoption has also improved the perception of organizational support and cognizance of WPV.

Treatment / Management

Management of the workplace focuses on prevention and de-escalation, with flight or fight as a last resort.[32][25] Several steps may be taken to help diffuse risk when an at-risk situation is identified.

• De-escalation may be applied as early as triage.
• Safe assessment rooms (SARs) have been shown to improve acutely agitated management, with most patients calming down within twenty minutes.
• Opportunities to diffuse tension, such as taking the patient to an available room earlier, should be seized.
• Staff should be trained in de-escalation. Risk is reduced when patients are approached calmly and efforts are made to connect.
• Efforts should be made to listen to the patient, acknowledge their concerns, and respectfully direct them to a goal; this process can be repeated as often as necessary to achieve the required results.
• Aggression management teams can be used if needed, and their presence can be enough to de-escalate further.
• Physical restraints, as an adjunct to chemical restraints, should also be used as a last resort.

Pearls and Other Issues

Pearls and Pitfalls

Pearls and pitfalls are noted at environmental, organizational, and individual levels.

Environment

Pearl

Environment-based policies prioritize preventative measures through deterrence.[32][25] Effective preventive measures include enhanced visibility through improved lighting, transparent doors, and CCTVs. Security of the environment may be improved with door locks, secured furniture, and weapons screening such as metal detectors. Studies have shown environmental preventive measures decrease the incidence of Type I WPV and produce a 50% reduction in the number of weapons brought to the ED. 

Pitfall

Despite the use of preventive environmental policies, there is no decrease in the incidence of Type II WPV, which is inherently contextual and impulsive, dynamic rather than planned. Even without weapons, patients may still use their hands. Visibility and physical barriers are not impediments to verbal abuse.

Organizational

Pearl

Institutions may curtail WPV by developing policies centered on prevention and recovery.[32] Precautionary directives include screening protocols and educational guidelines. At a minimum, the most basic policies include "Zero Tolerance" and buddy system approaches. More progressive policies prioritize better work practices through clear communication, staffing expansion, and pre-shift briefing.[10][32][25]

Effective staff training should focus on the following themes.

• Risk analysis and warning signal detection.
• De-escalation.
• Restraints, evasion, and break-away techniques.

Other beneficial topics include event reporting and the incorporation of simulated drills. There was no difference in the effectiveness of online, live, and hybrid formats. Regular training seminars improve staff confidence, and those who feel prepared for WPV have a lower burnout risk.

Pitfall

Zero-tolerance policies are intended to counter the perceived normalization of WPV as an occupational hazard. Despite their adoption, there is no significant decrease in WPV incidence overall, though it does reduce physical violence.

Enforcement may be hampered by confusion and legal incongruency.[36] Even if morally acceptable to shirk the duty to care over WPV concerns, in the ED with EMTALA, there is a legal responsibility to provide care.

Screening applications may have limited applicability.

• They only work for Type II WPV and physical forms of Type I and only work for short durations.
• Screening tools are also wholly user dependent and are influenced by the operator's current state of mind.
• False-positive screens lead to misuse or misallocation of resources.
• Inappropriate use of resources can stimulate, contribute to, or inadvertently escalate violent behavior.
• Inter-organizational data sharing deficit limits cross-institutional intervention and subsequent policy generation.

Individual

Pearl

Despite improved awareness, instituting a workplace violence training program does not automatically equate to a decrease in WPV.[2][10] The effectiveness of prevention programs is predicated on employee participation and administrative staff commitment.[30] The management staff is often overwhelmed by the volume of responsibility.[28] Even with training, many staff members still feel unprepared. The skill level in self-awareness and the ability to connect with agitated patients are variable. Connecting with patients who have altered capacity is potentially impossible.[32]

Pitfall

Training experience does not equate to proficiency. There is no concrete evidence to show de-escalation training has any clinical benefit. The application of learned techniques is challenging to replicate in practice. Regardless, more pressure may be placed on those who have completed training—especially if they are adept. Paradoxically, employees who have undergone training have double the likelihood of encountering WPV.[2] This may increase the risk of burnout, attrition, and turnover.[28]

Enhancing Healthcare Team Outcomes

Early identification of at-risk situations and de-escalation is crucial to prevent and manage aggression. Multiple screening tools are available to facilitate an interprofessional team-based approach to WPV among physicians, nurses, auxiliary staff, and security. Resources such as aggression management teams, environmental interventions, and policy implementation should be used judiciously to prevent further escalation of aggression. Documentation of violent incidents should be met with action and impunity. Appropriate interventions may improve patient outcomes and enhance team performance.