Health care workplace violence is an underreported, ubiquitous, and persistent problem that has been tolerated and largely ignored. According to the Joint Commission, a major accrediting body for health care organizations, institutions that were once considered to be safe havens are now confronting “steadily increasing rates of crime, including violent crimes such as assault, rape, and homicide.” Although metal detectors may theoretically mitigate violence in the health care workplace, there is no concrete evidence to support this expectation.
Violence against health care professionals in the workplace is underreported and understudied. Additional data are needed to understand steps that might be taken to reduce the risk. A new Review Article summarizes.
Table 1. Types of Workplace Violence.
• Which one of the four categories of workplace violence is most common in the health care setting?
Experts have classified workplace violence into four types on the basis of the relationship between the perpetrator and the workplace itself (Table 1). Most common to the health care setting is a situation in which the perpetrator has a legitimate relationship with the business and becomes violent while being served by the business (categorized as a type II assault). The highest number of such assaults in U.S. workplaces each year are directed against health care workers. These episodes are characterized by either verbal or physical assaults perpetrated by patients and visitors against providers.
• Are there evidence-based approaches to preventing health care workplace violence?
Most studies on workplace violence have been designed to quantify the problem, and few have described research on experimental methods to prevent such violence. The most recent critical review of the literature in 2000 identified 137 studies that described strategies to reduce workplace violence. Of these studies, 41 suggested specific interventions, but none provided empirical data showing whether or how such strategies worked. Only 9 studies, all of which were health care–related, reported data on interventions. Even so, the conclusion of the 9-study review was that each of the studies used weak methods, had inconclusive results, and used flawed experimental designs. A review of nursing literature had similar conclusions: all the studies showed that after training, nurses had increased confidence and knowledge about risk factors, but no change was seen in the incidence of violence perpetrated by patients. There is a lack of high-quality research, and existing training does not appear to reduce rates of workplace violence.
Morning Report Questions
Q: Are certain health care workers or certain health care settings particularly vulnerable to workplace violence?
A: Certain hospital environments are more prone to type II workplace violence than are other settings. The emergency department and psychiatric wards are the most violent, and well-studied, hospital environments. Since rates of assault correlate with patient-contact time, nurses and nursing aides are victimized at the highest rates. Emergency department nurses reported the highest rates, with 100% reporting verbal assault and 82.1% reporting physical assault during the previous year. Physicians are also frequent targets of type II workplace violence; approximately one quarter of emergency medicine physicians reported being targets of physical assault in the previous year. All employees who work in inpatient psychiatric environments are at higher risk for targeted violence than are other health care workers. Rates of workplace violence against physicians in psychiatric settings may be even higher than those in emergency department settings, with 40% of psychiatrists reporting physical assault in one study.
Q: What is known about perpetrators of health care workplace violence, and what are some potential solutions?
A: The characteristic that is most common among perpetrators of workplace violence is altered mental status associated with dementia, delirium, substance intoxication, or decompensated mental illness. In some studies, researchers have postulated that patients with a previous history of violence are at increased risk for committing violence toward staff members; however, this association remains unproven. Among strategies for individual workers that have been proposed to reduce workplace violence are training in aggression de-escalation techniques and training in self-defense. Recommendations for target hardening of infrastructure include the installation of fences, security cameras, and metal detectors and the hiring of guards. Perhaps most important are recommendations that health care organizations revise their policies in order to improve staffing levels during busy periods to reduce crowding and wait times, decrease worker turnover, and provide adequate security and mental health personnel on site. The importance of recognizing verbal assault as a form of workplace violence cannot be overlooked, since verbal assault has been shown to be a risk factor for battery. The “broken windows” principle, a criminal-justice theory that apathy toward low-level crimes creates a neighborhood conducive to more serious crime, also applies to workplace violence. When verbal abuse and low-level battery are tolerated, more serious forms of violence are invited.