Violence inside the walls of America’s hospitals 

By Tim Johnsen, FACHE

[Warning: I open this article on the issue of violence in the healthcare setting with a true story of workplace assault that occurred in one of the hospitals that I served as COO.  Please feel free to scroll down to the section entitled “An Epidemic of Violence” to read the rest of the article without reading the details of the story.]

It was a busy day like any other in one of my health system’s emergency rooms.  An adult male patient in his mid-30s came in with abdominal pain that appeared severe.  He exhibited no unusual behavior in the triage process other than seeming “intense,” which the triage nurse attributed to his apparent pain.  After triage, he was placed in a room with glass doors and walls and a privacy curtain. 

A relatively new nurse who had worked in the ER since she graduated just a little over two years prior to this day was assigned to do his initial evaluation.  Before leaving the room, she told the patient that the physician would likely order lab work, and that she would be back in a few minutes to draw the blood for his lab work.  She asked him to get into a gown since he would be getting x-rays as well.

When the nurse re-entered the room a few minutes later, the patient, who had moved to the side of the door to be hidden from view of the hallway, immediately attacked her, first covering her mouth so she couldn’t scream.  Her tray of lab work supplies hit the floor, but not loudly enough to be heard in a busy ER.  The man quickly slid the door and privacy curtain shut.  In a matter of seconds, he had slipped behind her, his left hand strong and firmly across her mouth, and his right hand around her with such force that it broke her collar bone, his hand now in her scrub pants. 

By any definition, he had sexually assaulted her all within a matter of 15 seconds.  He was physically much larger than her, and she was easily overtaken by his strength, her fear and shock paralyzing her.

There were very little, if any, signs that he would become violent.  There was no escalating aggressive behavior in other ER staff members’ interactions with him.  In the critical incident debriefings that followed, each person who had interacted with him insisted that they never saw this coming.

Several resources were immediately provided for the nurse, including evaluation and treatment for her physical injuries and emotional trauma evidenced by a changed demeanor that no one had ever seen from her.  We connected her with a counselor, offered to assist her in filing criminal charges, and gave her all the time off she needed.

She never came back.  When a colleague ran into her over a year later, she indicated that she had left the nursing profession altogether.

An Epidemic of Violence

Tragic events like this one that occurred in one of my own hospitals are increasingly common.  From 2011 to 2018, the rate of nonfatal workplace violence against healthcare workers grew by 63%, according to a 2018 study by the U.S. Bureau of Labor Statistics.  This same study found that healthcare workers are five times more likely to experience workplace violence than workers in other industries combined.

The rise of violence has impacted frontline staff particularly.  According to Press Ganey, two nursing personnel were assaulted every hour in 2022.  Nearly half of nurses report experiencing physical violence, and 68% report experiencing verbal abuse, stated a study released by the American Association of Occupational Health Nurses.  Because these statistics are based only on incidents that were reported, experts believe this number may be even higher. 

There are many medical or traumatic conditions that cause patients to lash out at healthcare workers (e.g. head injuries, dementia, total brain injury patients, acute intoxication, use of recreational drugs, many behavioral health diagnoses).  These kinds of conditions are known and violence is expected on some level, and risk mitigation practices have long been in place in facilities that serve patients with these issues.  I believe those of us leading acute care hospitals can learn from these practices.

However, the rise in intentional harm against healthcare workers in recent years, as in the tragic situation I described above, is often unrelated to a medical diagnosis. 

The rise of violence against healthcare professionals is alarming, and sadly, in our current healthcare climate, I believe it’s not an issue of if a healthcare organization will experience a violent incident, but when.  As employers and leaders in acute care hospitals and behavioral health settings, we can and must continue to take action to mitigate risk to our frontline staff.

Three areas deserve our particular focus and investment:

Area 1: Preventative Tactics and Risk Mitigation

Work with local law enforcement. 

Safe hospitals are essential for safe communities, and are a place where local police and hospital leadership can naturally collaborate.  Invite local law enforcement or the FBI to cooperate with your security team to do a walk-through of your physical plant, citing areas of risk.  Then gather a team to prioritize the list of actions needed in the physical environment and work through it item by item. 

Ask local police to evaluate crime statistics for your facility’s surrounding area to deepen your understanding of the risks particular to your area.  You might also consider setting aside a room for them to do their paperwork after responding to a safety issue and fill it with food and energy drinks, or consider building a police sub-station in your ER waiting area. 

Bottom line: Do whatever it takes to have a great relationship with local law enforcement.

Deploy basic prevention tactics. 

Ensure there is adequate lighting in parking lots.  Install emergency call stations in remote areas outside the facility.  Re-design any areas in the facility where staff could be trapped or cornered.  Add security cameras or fencing where necessary.  Employ visible deterrents such as security vehicles rounding frequently in parking lots.  At the front entrance, consider the use of police dogs, weapon screening, metal detectors, or signage.  Screen all visitors and require them to wear badges while in the building, and limit access to the building at night when there are fewer layers of security resources available.

Identify high-risk areas within your facility (ERs, ambulance personnel, ICUs, and labor and delivery are most frequent areas of violence inside hospitals), and start there.  Establish patient rights, responsibilities, and code of conduct, and post them in all patient areas.

Area 2: Staff Training and Awareness

Offer regular access to continuing safety education. 

Conduct simulations where well-trained personnel present escalating scenarios and then evaluate staff members’ reactions.  Very elaborate healthcare-specific modules and systems are now available on the market.  We just purchased two for our health system. 

At a minimum, all employees should undergo active shooter training, situational awareness training, and de-escalation training to keep themselves and their patients safe in a potentially violent situation.  Offer optional self-defense classes.  Conduct regular safety fairs to educate and re-educate employees. 

Invest in technology and training. 

We have silent duress alarms on the badge of every staff member and provider, and these devices have been fantastic.  They use geofenced alarming technology to alert security and all staff in a department, citing that a panic button has been activated and provides exact location of the staff member activating it.  It is important that this is a silent alarm that can be subtly activated as a patient or visitor begins to show signs of escalating aggressive or unwanted behavior rather than a loud alarm that could trigger or intensify violent behavior. 

Alternatively, you could utilize a “CODE 10” or some other unknown code for overhead pages to alert staff to an incident where violence is occurring, I also recommend placing security cameras in as many areas as you can.  Though these are most commonly not monitored in real time, they are an effective visible deterrent and footage can be used to reconstruct incidents and place timelines in a violent event.

Ensure all employees are trained in reporting processes, procedures, and policies. 

In a survey conducted last year by National Nurses United, only about 1 in 3 nurses (31.7 percent) reported that their employer provides a clear way to report incidents.  We have to do better.  Without a clear process, violent incidents will go unreported, and our employees suffer the consequences.

Encourage frontline staff participation on workplace violence committees or workgroups to ensure their lived experiences are informing the best practices implemented.  Empower employees to “trust their gut” and pay attention to their instincts as a health care worker, urging them to bring someone with them if they have any concern at all that a patient or visitor may be at risk for violence.

Area 3: Preparation, Policy, and Advocacy

Develop internal safety policies to respond to escalating or violent situations. 

The moment of crisis is too late to be making decisions about how to respond.  Workplace violence plans must be carefully thought through before a violent situation occurs, with all stakeholders having a voice in the creation of these policies.  Responding effectively in a crisis requires that leaders determine security staff roles based on individual abilities and training, as well as an organization’s philosophies and policies for the use (or non-use) of weapons, tasers, and firearms. 

Clear procedures for the aftermath of incidents are also necessary, including incident reports and ongoing communication with local law enforcement and media.  As part of emergency management planning, create a “first eight hours” checklist of what to do following an active shooter or other violent event.

Additionally, leadership and governing boards should conduct an annual safety/risk assessment plan review.  These bodies must also ensure that financial resources are allocated appropriately to continue to prioritize safety in the workplace. 

Prepare for a rapid, effective victim response. 

Experiencing workplace violence can be traumatic.  Develop on-site response teams who are best trained to communicate with the victim in the immediate post-event time frame.  If a trial becomes necessary, provide legal advice and support through the filing of charges, going to court, filing police reports, and writing affidavits.  For ongoing care and support, design an employee assistance program to support those who have experienced violence of any kind in the workplace. 

Report every incident. 

I believe it is essential to the long-term safety of our healthcare employees and patients to strongly encourage reporting of every violent incident.  This allows trends to be identified and mitigated.  Develop a regular pattern of positive interaction with local police, state police, and local district or prosecuting attorneys’ offices, and advocate on behalf of the victims that the strictest charges be filed in attacks on healthcare workers.

Empower employees to take action to feel safe at work. 

Encourage and equip employees to do what is necessary to feel safe while at work.  For example, give healthcare workers the option to request security escorts in and out of parking garages and lots with no hesitation or delay.  Create an expectation that staff must document a violent patient’s behavior in the electronic medical record so that in the event of a future visit from this patient, staff are aware that they have a violent history.

Create an open and ongoing conversation about whether employees feel safe in the workplace.  Constantly reinforce that staff have a voice in their concerns.  Communicate frequently what you are doing and have done to reduce incidence of violence, whether in tiered huddles, town-halls, or whatever mechanisms you communicate with your employees.  Give easy ways for workers to offer honest feedback without fear of retribution, and create structures to make sure leadership will follow through on responding to those concerns. 

A crucial part of employees feeling safe at work is knowing that the hospital administration has their back in an escalating or violent situation.  If a patient who has been admitted to the hospital is showing signs of aggression, expect senior leaders, along with security, to visit with patient and set limits and expectations.

Advocate at local, state and federal levels for resources and attention to this epidemic of violence. 

Engage with lawmakers to educate them about the issue of violence against healthcare workers and encourage them to allocate resources and pass laws that will promote safety in our communities’ hospitals.  

Currently, the American Hospital Associate is supporting the Safety from Violence for Healthcare Employees Act (H.R. 2584/S. 2768), also called the SAVE Act.  This is a bipartisan, bicameral legislation that would provide federal protections from workplace violence for health care workers, making battery against health care worker a federal felony.

There’s more work to be done.

In the well-known Maslow’s hierarchy of needs, “safety and security” is named as the basic foundation for personal well-being.  Yet our healthcare workers who are tasked with promoting the well-being of their patients are not being afforded this basic human need in their own workplace. 

The nurse whose story I shared at the beginning of this article lived through a horrific situation no one should experience.  We failed her that day, losing a good nurse from the profession and likely causing life-long trauma to her. 

We as hospital leaders must do everything we can to ensure the work environment is as safe as it can be.  It is imperative that we invest in preventative measures; train, equip, and listen to our staff; and consistently offer a coordinated and quick response to violence in order to move our hospitals toward being a place of safety and healing for patients and employees alike.

Resources and references for this article can be found here.