What is Workplace Violence in Healthcare?
Workplace violence in the healthcare field is often not studied enough. Workplace violence, as defined by the National Institute for Occupational Safety and Health, refers to any action or threat that stretches from verbal abuse to physical assault and even deadly attacks against individuals at work or on duty.
Workplace violence can be categorized in various ways. One such method is by the type of aggression. The violent act can be physical, verbal, or psychological. Psychological violence can take the form of sexual harassment, bullying, or intimidation. It’s noted that in professional surroundings, verbal abuse tends to be the most common form of violence.
Workplace violence can also be categorized based on the intent behind it:
- Type I – involves acts of violence, generally with a criminal intent, by people who have no legitimate professional ties to the organization or its employees. This type often relates to crimes like theft or terrorism.
- Type II – refers to violence carried out by patients, ex-patients, or their visitors.
- Type III – involves violence between colleagues and staff members.
- Type IV – is similar to Type I but the person committing violence has a personal relationship with an employee.
What Causes Workplace Violence in Healthcare?
Workplace violence (WPV) in hospitals, particularly the emergency department (ED), could be linked to organizational, staff, and patient factors. The nature of work in the ED is inherently risky. Emergency situations are uncertain, possibly life-threatening, and require immediate treatment. This care is offered to all patients regardless of background, insurance, or other barriers. The ED is open around the clock, making it the hospital’s gateway and potential bottleneck for patient care. A large number of patients arriving at the ED can cause overcrowding and long wait times.
Certain patient-related factors could increase the risk of violence in the ED. These might include the urgency and severity of the patient’s illness, whether they’re under the influence of alcohol or drugs, and if they have cognitive impairments. When a patient’s medical results do not meet their expectations, the risk of violence could increase. Additionally, delivering bad news might not be well-received. Other influences such as socioeconomic status, health literacy, and educational level can also affect risk levels. Hospitals in urban areas may face an increased risk of gang-related violence involving patients or hospital staff.
Healthcare staff themselves might unintentionally contribute to workplace violence. The chaotic and high-stress environment of the ED could lead healthcare providers to overlook cues, resort hastily to sedation or restraints, and unintentionally provoke aggressiveness. Chances to calm down potentially violent patients might be missed or not well executed.
Violence in the workplace, specifically referred to here as “Type III Violence”, is more common in departments or institutions with a history of mistreatment. These environments might create a cycle where abusive behavior encourages more abuse. Unequal power dynamics within these places can lead to misunderstanding, fear, acceptance, and silence. People might not understand what constitutes abuse, and many resident doctors aren’t aware of the correct procedure for reporting harmful behavior.
Many young doctors might find reporting ineffective and may choose to put up with misbehavior rather than confronting it due to fear of backlash. Others worry that reporting might increase the abuser’s attention on them.
Risk Factors and Frequency for Workplace Violence in Healthcare
Workplace violence (WPV) is a common issue in hospitals, seen four times more than in any other setting. Nearly one fifth of healthcare professionals report experiencing physical abuse, with higher instances in tertiary facilities and urban areas. Particular risk areas include psychiatric wards and emergency departments with increased risk seen in males and during specific hours (between 4pm and 4am). Despite gender, one in every five people visiting an emergency department carries a weapon. Not just the patients, but also their partners and siblings at the emergency department face the risk of violence. Older patients, particularly those aged 65 and above, are more likely to exhibit violent behavior.
Insights about Type III violence, another form of WPV, are limited but it is known that verbal abuse is the most common form. Nurses are often the victims of violence, but can also be the perpetrators. When incidents were compared, 75% of the offenders were female, worked full-time, were around 45 years old and had an average job tenure of about 12 years.
- Workplace violence is common among physicians too, particularly in teaching hospitals.
- Verbal abuse and bullying are the top causes for Type III violence, irrespective of the gender.
- Female clinicians often face sexual harassment.
- Incidents of type III violence perpetrated by physicians in higher positions have been reported. In one instance, it was as high as 90%.
- First-year residents have the highest risk of being mistreated as they work with more senior colleagues.
Signs and Symptoms of Workplace Violence in Healthcare
Being able to identify patient-specific risk factors can help in preventing workplace violence. There are various methods and tools that can help in recognizing patients who are more likely to commit such acts.
- Triage flagging systems mark out high-risk patients. Tools like Staring Tone Anxiety Mumbling Pacing (STAMP), Violence Risk Screen Decision Support in Triage (VRSDSiT), the Alert System, and Broset Violence Checklist (BVC) are effective in quickly identifying behavior patterns linked to workplace violence risk.
- Certain behavioral clues can be a signal as well, such as feeling agitated, restless, entitled or dissatisfied, glaring or staring, or using an angry or otherwise inappropriate tone of voice.
- Subtle signs of criminal behavior or drug-seeking tendencies should also alarm.
Other factors to take into consideration include arrival via law enforcement, the patient’s gender, age, and relationship to the parent if the patient is a minor. Known factors from the patient’s history like mental illness, refusal to take medication, substance abuse, and recorded instances of previous aggressive behavior also matter.
Testing for Workplace Violence in Healthcare
Research shows that having a plan in place to prevent workplace violence (WPV) can reduce the number and seriousness of such incidents over time. However, there is still room for improvement in developing tools to assess the risk of WPV. Certain screening tools, like STAMP, VRSDSiT, Alert System, and the BVC, are used to interpret specific behaviors of patients and predict the likelihood of violence.
The Alert System uses various criteria related to a patient’s mental state, behavior, and awareness to identify those who might become violent. Patients are seen as a higher risk if they show at least three of the following behaviors: yelling or speaking in a demanding tone, appearing drunk or under the influence, seeming confused or hallucinating, acting withdrawn or agitated, appearing suspicious, or showing any other changes in their mental state.
Identifying these at-risk patients has shown to be valuable in predicting WPV. The Behavior of Concerns Chart (BVC), in particular, is very effective in predicting WPV, especially in the Emergency Department (ED). The BVC was first applied in an ED setting by Senz et al, with the intention of creating a common standard for communication and understanding among administrators, doctors, nurses, and security staff.
The use of these guidelines can significantly decrease unexpected WPV incidents and also reduce the use of physical restraints. It has been found that adopting these guidelines has also enhanced the perceived level of organizational support and awareness of WPV.
Treatment Options for Workplace Violence in Healthcare
In the workplace, managing potential conflict or threats is centered on prevention and calming the situation, with escape or confrontation only used as a final option. There are several measures that can be employed when any potential threat is noted.
The process of calming things down, or de-escalation, can be started even at the point when a client first approaches for assistance or service.
Secure spaces for evaluation, termed Safe Assessment Rooms (SARs), can be highly effective for managing people who are extremely upset, as most of them become calmer within approximately twenty minutes in these environments.
It’s also beneficial to take measures that defuse stress as early as possible – for example, if a private room is available, guiding the troubled individual to this place sooner rather than later can be effective.
Training staff in techniques to defuse tense situations also can be extremely beneficial. When staff approach patients in a calm manner, attempting to form a connection, it can significantly lessen the risk of tension escalating.
Listening to the upset person, acknowledging their worries constructively, and delicately guiding them toward a solution is another beneficial technique – this process may need to be repeated frequently to achieve the desired outcome.
If needed, specialized teams experienced in managing aggressive behavior can be brought in. Sometimes, just the presence of these teams can alleviate tension. If all else fails, physical restraints could be used, but only in combination with tranquilizing medicine as a last resort.
