At the conclusion of this activity, participants will be able to achieve the following:
- Identify and discuss the most common type of healthcare workplace violence and the reasons for it.
- Understand the difference between a zero-tolerance policy versus an intolerance policy of violence management.
- Discuss seven strategies that can prevent, manage and/or respond to violence.
Author: Monica Cooke, BSN, MA, RN, PMH-BC, CPHQ, CPHRM, DFASHRM, Quality Plus Solutions.
Article Content Last Updated: This content was updated as of November 28, 2022.
Accreditation Statement: HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. This enduring article has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Society of New Jersey (MSNJ) and Health Research Education and Trust of New Jersey (HRET) in joint providership with MDAdvantage Insurance Company. HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.
AMA Credit Designation Statement: HRET designates this enduring activity for 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, there are no relevant financial relationships to disclose. No commercial funding has been accepted for the activity. This article was peer reviewed in accordance with the MDAdvisor Guidelines for Peer Review.
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“Workers in the healthcare and social service sectors experience the most violence of any industry.”
You have probably noticed that people are generally nastier, more agitated and more anxious today than in pre-pandemic days. The consequence of this tension has been an increase in violent incidences in healthcare work settings. According to the Bureau of Labor Statistics, workers in the healthcare and social service sectors experience the most violence of any industry. Even pre-pandemic, a 2018 analysis found that healthcare and social service workers were five times as likely to experience workplace violence than workers overall, and that healthcare workers, specifically, made up 73 percent of all nonfatal workplace injuries and illness due to violence.1 While complete data specific to the pandemic are not yet available, widespread reporting2 and early evidence3 clearly indicate that the pandemic has exacerbated violence against healthcare workers. For example, a survey of registered nurses completed in August 2021 found that 44 percent experienced physical violence and 68 percent experienced verbal abuse between February and June 2020.4
The issue of healthcare workplace violence is complex and multi-faceted. This article will focus on the prevention, management, and response to healthcare violence specifically with customers/clients/patients, which, according to the 2021 Healthcare Crime Survey, accounted for 73 percent of aggravated assaults and 86 percent of simple assaults against healthcare workers.5
Seven Strategies For Risk Mitigation
Risk mitigation in response to the dangers of aggression and violence in the healthcare industry is not a call for “zero tolerance.” Although that term sounds strong and effective, it is not the solution, given the varying degrees of fragility, mental stability and vulnerability in our business. We cannot say that everyone gets the same punishment for aggressive behavior, regardless of the etiology.
Zero tolerance does not allow us to use discretion in managing a situation. For instance, if you have a zero-tolerance policy that states that if patients yell at you, you will discharge them from the practice, there’s no room for discussion. That same consequence would apply to both a little old lady who is yelling because she’s demented and to a 55-year-old, 250-pound man screaming in your face because he’s been waiting too long to see the provider.
In the healthcare industry, we have to have an established policy that allows us to figure out what caused the outburst and then what we need to do with that patient to make sure the behavior does not happen again. This is a policy, not of zero tolerance, but of intolerance.
The following seven strategies of risk mitigation will help you establish a consistent and firm intolerance policy in your practice.
Strategy 1: Establish a Culture of Intolerance
The healthcare industry does not have an established culture of intolerance, unlike other industries. We all know that there are expected rules of behavior at an airport, for example. We can’t yell; we can’t threaten; we can’t physically act out. If we do, there will be several TSA agents escorting us out the door. In a restaurant, we know we must wear a shirt and shoes if we want to be served. Each culture has its own expectations. But in the healthcare environment, there are no clearly defined rules of conduct.
We, as an industry, must do a better job of educating our patients and the community about the level of violence in healthcare and the consequences of inappropriate or threatening behavior.
Educate Patients on the Intolerance Policy. The culture of intolerance begins at the door of your practice. Just as many organizations post signs that reflect their culture and the lack of tolerance for disruption, so can your medical practice. For example, a sign such as the one in Figure 1 one educates patients, welcomes them, and invites them to be part of creating a safe space for everyone.
When you decide to institute a culture of intolerance, it is important to communicate that change to your patients. Some practices mail letters to all patients; others give written notice to patients during the office visit. These letters should come from the provider or owner of the practice and educate the patient about the rate of healthcare violence along with an explanation of the new practice protocols being put into place to keep everyone safe. This letter should also contain a patient code of conduct that is expected during office visits.
Strategy 2: Meet Patients’ Needs
Employees of the medical practice have a key role in maintaining a safe environment with a policy of intolerance. Unfortunately, many practices have inadequate employee acquisition, supervision and retention practices along with inadequate training on how to prevent or manage conflict—especially with people who are anxious about medical issues and those with mental health and substance use issues.
Inappropriate attitudes of the staff cause a fair amount of aggressive behavior in patients. To mitigate the risk of aggression, we need to present a consistent attitude of dignified respect and to take a “non-escalating” approach. This is our first line of prevention.
Greet patients. No doubt this scene is familiar to you: You arrive at a doctor’s office and stand at the front desk waiting to be acknowledged. You wait while the staff ignores you. You wait and wait and wait. They keep typing, filing, shuffling folders. You wait. This lack of greeting creates an immediate state of tension and frustration—the groundwork for aggression. Even busy staff can be trained to look up immediately when a patient enters, make eye contact, say hello with a smile, and give a simple directive to sign in.
Minimize waits and apologize up front for any delays. Delays happen in the medical field, but failing to communicate that fact is a common reason that patients get angry. Train your staff to give estimated wait times and regular updates. Apologize for delays and then give options: Do you want to reschedule or do you want to wait? This respects the patients’ time and proactively intercepts the possible angry outburst over waiting too long.
Provide diversions. Anything that distracts people from their medical worries and from the annoyance of waiting is going to help keep anxiety and agitation down. Have a TV or music in the waiting room; allow cell phone, iPad, and computer use; provide magazines; offer coffee or water and snacks.
Offer integrated services. All healthcare settings should have brochures offering information and resources for substance use and mental health issues such as depression, alcohol use, anxiety, bipolar disorder, PTSD and many of the other challenges that people are dealing with, particularly since the COVID pandemic. If a patient does not need the help directly, they may know someone who does and may take the information to pass it along. You can get these resources for free from local, state and federal mental health organizations such as the Substance Abuse and Mental Health Services organization at www.samhsa.gov.
Strategy 3: Assess Patients for Aggression Potential
We must remember that approximately one quarter of the people we treat every day have some form of mental illness or substance use issues.6 There are evidence-based tools to actually predict aggression in our population that would allow for early and proactive intervention. In other words, don’t wait until a situation has exploded. Follow the protocol as soon as the anxiety and the agitation are seen or observed by staff.
Routinely observe patient behavior. All staff should observe and assess patients for signs of anxiety and agitation, both in the waiting room and the examining room. They’re standing. They’re fidgeting. They’re pacing. They’re walking in and out of the room. They’re obviously nervous. This behavior calls for first-step interventions. Talk to them. Tell them why the schedule is running late. Give them something to distract them. Provide verbal assurance that they are in good hands.
Utilize behavioral health clinicians. In an ideal world, medical providers integrate behavioral health resources into the practice. In this setup, when you identify a patient who could use a behavioral assessment, you can quickly refer them to somebody within the practice who can see them in a timely fashion. This would remove the burden of dealing with behavioral health issues from the shoulders of the office physician and staff.
Flag the EMR. After an aggressive, threatening, hostile or violent event, be sure to flag the patient’s electronic medical record so that every provider, every nurse, every tech, everyone who’s working with the patient knows that there’s the potential for aggression. The practice should have a written procedure for how the flag gets initiated and for how it is taken off the medical record.
Strategy 4: Create a Patient/Provider Agreement
Because the healthcare community rarely has an established protocol for responding to angry, demanding, loud and/or threatening behaviors, it is not surprising that the response to these behaviors is weak. Too often, as compassionate healthcare providers, we try to understand the cause of the outburst and make allowances for mental health and substance use factors. We do not make it immediately clear that such behavior is not tolerated.
Naming the behavior for what it is, regardless of the circumstance surrounding it, is vital to creating a safe working environment. It is aggression. It is not acceptable. When it occurs, it has to be addressed and managed. A patient/provider agreement is a vehicle for doing this in a way that meets the specific needs of specific patients (see Figure 2).
The provider and the practice manager should initiate this agreement with the patient—not the nurse, not the receptionist. The agreement should not be delivered as a form to read and sign. It is created through dialogue when the provider and the practice manager sit down with the patient and say, “Look, we’re having difficulty. We want to keep treating you, but your aggressive behavior is making it difficult for us to treat you safely.” The expectations for behavior and the consequences if they are not followed should be outlined. “Going forward, this is what you can expect from us and this is what we’re going to expect from you. If you cannot follow these rules of behavior, then we need to figure out what the next step will be in our provider/patient relationship.”
Be sure to add this conversation and the agreement to the patient’s medical record. Give the patient a copy of the signed agreement. Document their words and their responses to whatever your interventions will be. Note if they disagree or refuse to sign the agreement. Note the exact words they use if they refuse intervention or counseling. Flag the record for aggression.
Strategy 5: Debrief Staff Following Acts of Aggression
In order to consistently stop office aggression, it is vital to routinely review every act of aggression by patients. After a disruptive event, your team needs to get together for five minutes and go over what happened. Identify what the patient was doing before they escalated. What was our response? What could we have done better? What do we need to do now with this patient? (See Figure 3 for sample Event Debriefing Worksheet.)
This discussion will help everyone in the office learn something new about either this patient or about how to better manage aggression in the future. The discussion should be routine, constructive and non-blaming. In this way, the debriefing will help you identify opportunities for improvement.
Strategy 6: Create a Safe Office
No matter how proactive you are in preparing your staff and patients to accept your policy of intolerance, you still need to be prepared for the worst. For this reason, it is important to conduct an office risk assessment for potential dangers or hazards.
Walk around. Take a fresh look at your office setup, thinking about safety. Look closely at where things are, look where things are easy to grab. Look at the glass at the reception desk; make sure it’s safety glass or plexiglass so that nobody will get harmed in case it’s damaged.
Look at the furniture layout. Do staff have immediate egress out of treatment rooms or are they backed up against a wall. If they are, re-arrange the room, if you can, so providers and staff are near the door. If the furniture can’t be rearranged, at least practice situational awareness by moving to stand near a door whenever possible.
Install panic buttons. Banks have panic buttons, why not your office? Contact your local law enforcement officials to find out if you can have a one-touch button installed that would directly alert police to a dangerous situation. Given the number of people who enter your office every day bringing mental health and substance use issues with them, being able to quickly ask for help is vital.
Secure entrance to back office/treatment areas. Can an irate patient leave the waiting room and barge into your back area where your treatment rooms and offices are located? If so, it is wise to secure that entrance. Only identified and supervised patients would then have access to providers, staff and medical equipment.
Limit sharing of staff information. The personal information of your staff should be protected. For example, if your staff wears name tags, display first names only. If you list staff names on your website, use first names only. If you post on social media, do not identify staff members by name. In today’s world of digital interconnectedness, it is too easy for a disgruntled patient to track down a staff worker off-site. Of course, provider names are known to patients, but limiting staff information gives your employees an additional level of protection.
Secure wall hangings. Interestingly, when patients get angry and look around for something to throw, they often go for things on the wall. Make sure that all wall hangings are secured, particularly if it’s encased in glass, and consider reframing pictures with plexiglass.
Secure the office environment. Most practices do a good job of securing syringes, needles and sample medication. You might go one step further and remove needle boxes from treatment rooms. You can now have portable, disposable needle boxes that can be brought into the room and brought out of the room and secured. Of course, secure prescription pads, especially if you now write scrips electronically and have old pads that may still be lying around. Also, encourage you patients to pay with credit cards so you can reduce the amount of cash in the office that temps robbery.
Identify a safe room for staff. Given the recent number of active shooter events, it’s become apparent that the staff need an area where they can move to safety if somebody comes in the front door with a weapon. Disaster preparedness is important in this modern world.
Build good working relationships with local law enforcement. Like healthcare providers, police want to help people in distress, so they too may hesitate to arrest someone with a mental health issue who is acting aggressively in your office. We need to educate local law enforcement personnel and work collaboratively with them to enforce the policy of intolerance.
Invite officers into your practice. Show them the intolerance policy you have given to all your patients. Explain that you will be calling 911 if a patient becomes aggressive, violent or threatening. Explain that, when necessary, you plan to press charges and/or obtain restraining orders and work with law enforcement to keep your staff and patients safe. Consider asking officers to look around your office for safety or security issues. Ask if you can be trained in how to conduct security drills. Creating a partnership with local law enforcement officials will help you get the word out in your community that aggressive or violent actions will not be tolerated in your practice.
Strategy 7: Prepare for Termination of Care
Termination of care is the step of last resort for serious aggression or violence. You protect your liabilities by taking every step possible before termination to address the problem and reduce the danger. Discuss the provider-patient agreement. Thoroughly document all conversations and hostile events. If the patient came to you as a referral from another physician, you can advise that physician that you are sending the patient back to them, and the patient will need a new provider. You might refer the patient out to an integrated clinic that can better handle the mental health and physical needs of the patient.
Bottomline is Prevention
The best strategy to mitigate the risk of violence and the need to terminate a patient is to prevent the escalation of aggression right from the beginning. Do not tolerate even minor instances of aggression. Do not make excuses for the patient who yells at your staff. Do not look the other way. Ever.
Know, in advance, exactly how you will handle the most common complaints from your patients. Be sure your staff feels comfortable making this statement: “I cannot continue to speak with you if you continue to raise your voice. I want to resolve this with you, but we have to be able to talk calmly.”
And, as a provider, do not hesitate to clearly state: “This is the treatment plan, and this is the best practice. It’s all evidence-based medicine. If you don’t agree with it, maybe you should investigate other providers who may be willing to do what you are asking.”
A policy of intolerance requires the provider and staff to relate a firm and consistent message. You will find that most patients respond positively to firm limits and will be grateful that you have procedures in place to keep them safe—as well as healthy.
- Addressing Workplace Violence in Healthcare Settings | Medical Group Management Association
- Advocacy Toolkit: Addressing Rising Workplace Violence Against Physicians and Health Care Workers | American College of Physicians
- Fact Sheet: Workplace Violence in Healthcare | U.S. Bureau of Labor Statistics
- Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers | Occupational Health & Safety Administration
- The Persistent Pandemic of Violence Against Health Care Workers | The American Journal of Managed Care
- Preventing Workplace Violence in Healthcare | American Association of Critical-Care Nurses
- Promoting Policy Standards for Workplace Violence Prevention and Management | American College of Physicians