Underreporting: The Deficiency in your Healthcare Workplace Violence Program

I’ve conducted security and workplace violence vulnerability assessments of hundreds of healthcare facilities across the US including twenty-two following shooting incidents, interviewed thousands of healthcare employees and reviewed dozens of workplace violence plans and programs.? Perhaps the most common deficiency I’ve encountered in healthcare workplace violence safety programs is a lack of consistent reporting of incidents of threats or violence followed by inadequate training.?

????????? Too often front-line employees fail to report threatening, assaultive or other problematic incidents.? How can the administration then manage and improve their workplace violence security and safety efforts if they don’t know what is actually happening?? The excuses to not report are many.? Employees often tell me they don’t report because, “I get threatened and abused all the time,” “It’s just part of the job,” “I don’t have the time to complete a report,” “I thought someone else reported it,” “Nobody will do anything about it, anyway,” “Management doesn’t care,” “I can handle it,” “I didn’t know I was supposed to report that,” “The report is too cumbersome and time-consuming,” or “It wasn’t really serious enough to report – this happens all the time.”?

The Extent of the Problem and Related Considerations

????????? We’ve heard the disturbing statistics.? Healthcare workers are five times more likely to experience workplace violence (WPV) than those working in any other industry.? Compared to other healthcare workers, nurses are two times more likely to experience nonfatal assaults.? Studies have found that 80% of nurses do not feel safe in their workplace, 82% of ED nurses had been physically assaulted within one year and 25% of psychiatric nurses experienced disabling injuries from patient assaults.? It has been found that nurses who experience violence are more likely to experience low job satisfaction and burnout, as well as an increased incidence of medical errors.?

????????? A recent study published in the ACHE Journal of Healthcare Management found that:

·?????? Employee productivity is expected to decline up to 50% in the first 6 to 18 weeks following an incident of violence while turnover can increase 30% to 40%

·?????? The incidence of violence in healthcare rose steadily from 2011 to 2020

·?????? Organizational factors that contribute to increased violence include the availability of necessary supplies and equipment, long waiting times and staff shortages

In my and my clients’ experience, I have further found that:

·?????? Workplace violence incidents spiked during the Covid Pandemic and haven’t declined much since

·?????? Over the last decade, and much amplified by the recent Pandemic, healthcare facilities and their staff have been facing more confrontational, aggressive, entitled and threatening behavior.

·?????? Younger employees are more likely to be injured on the job than more seasoned workers.? Most nursing schools don’t teach de-escalation and workplace violence safety, so it falls to us to guide these newer employees

·?????? One incident of violence sends long-lasting ripples of fear, worry and discontent through the entire organization

·?????? Emergency departments are seeing much higher admittance of behavioral health patients and may not be adequately trained and equipped for that population

·?????? Protection measures and training are often lacking for the employees who are the first to be encountered by the public, including Registration/Patient Access, Guest Services/Greeters, Receptionists and Triage

·?????? Physical Security programs are too often underfunded, misunderstood, misfocused or more reactive than preventive

·?????? Workplace violence prevention and response training is too often quick annual on-line “check the box” programs that few take seriously and may not relate to the real risks

·?????? In my experience, most, but not all, serious acts of violence showed some early warning indicators that may not have been properly recognized, reported or managed

·?????? When I interview employees who had experienced shooting incidents in healthcare, I most often hear, “We never thought it would happen here” along with issues regarding poor communications during and after the incident – “We couldn’t hear the announcements, they forgot us, we didn’t know what to do, etc.”

So What Can We Do To Improve WPV Reporting?

Culture?? Most healthcare systems take pride regarding their values and mission which often include qualities such as respect, compassion, safety and integrity.? A respectful and caring workplace is also a safer workplace.? Truly living the values every day and positively engaging with every person directly supports good security and safety.

While there will always be inherent risk in opening your doors to the public, harm and bad behavior can be mitigated by fostering a culture of care and respect in every contact we have with the public, from the first website visit and admitting paperwork, to arriving at the facility and interacting with positively engaging staff and to safely responding to and mitigating the worst situations.? ?

And a key part of driving that culture will be consistent and thorough employee reporting so that leadership can monitor progress and assure continuous improvement.

Ownership and the Safety Team??? Possibly the least costly, most powerful and most often neglected safety and security measure is fostering a sense of awareness, ownership, engagement and involvement by all employees.? Every employee should know they are part of the Security and Safety Team and have responsibilities as members.?

Indications that not all employees are acting and seeing themselves as members of the Safety Team could include allowing others into restricted areas on their card swipes, not wearing identification, under or not reporting, propping doors or escalating, rather than de-escalating, conflicts.? Often employees tell me, “Security or safety isn’t my job.? That’s why we have the guards.”

Especially front-line, public-facing, employees should be regularly reminded that is also their duty to be protective of themselves, their fellow employees and patients.? Violence is often intimate and at bedside where situational awareness and positioning go a long way. Some systems have even instituted disciplinary procedures for non-compliance.

Policies and Procedures? ?Like most employee-based objectives and processes, WPV-related policies and procedures should clearly state reporting requirements and expectations for all employees including the duty to report, how and to whom to report, repercussions for not reporting and alternate reporting channels, along with conflict resolution and safe procedures during emergencies.? ?

Assessments ??So, how do you know whether your Workplace Violence Program addresses your true risks and vulnerabilities and meets applicable industry standards and best practices?? How do you determine whether your employees buy into the program and are reporting? ??What are the hindrances to reporting?? How do you know what their concerns are and whether they feel safe on the job??

The Joint Commission Workplace Violence Standard was effective in January of 2022.? Among other requirements, the Standard requires an annual WPV Worksite Analysis.? The facility should then take actions to mitigate or resolve the workplace violence safety and security risks based upon findings from the analysis.

While the WPV Worksite Analysis can most often be conducted by in-house staff, it is advisable to periodically commission an objective, qualified and independent assessment of the prevention, mitigation, response and recovery aspects of your workplace violence program.

The Reporting Mechanism? There are several commonly used and powerful patient safety reporting systems that extract valuable data which drives reviews, planning, reports, education, root cause analyses and budgets.?? But, again, if the data isn’t going in the resultant products are of questionable value.

While most of these reporting products attempt to be easy to use with drop-down menus walking the reporting employee through the process, I often hear that the process is still time-consuming, too lengthy and sometimes a disincentive to reporting.? Clinical staff are very busy nowadays, and it can be challenging to find a half hour to complete a report.?

Perhaps there could be an abbreviated reporting tool for aggressive, threatening and confrontational incidents that doesn’t need to touch on the many features related to patient safety.

Simulations and Training?? ??Perhaps the most impactful component of a WPV program is training, especially of employees who work with the public, on concepts of WPV, recognizing signs of potential violence, conflict resolution and de-escalation techniques, reporting and safely responding to threats and violence. I often see higher risk employees (e.g. Emergency, Behavioral Health, Security, Nursing Managers) receiving more in-depth training while most employees take a relatively quick annual on-line training module.?

WPV training considerations include:

·?????? Who are the first employees encountered by the public when entering your facilities?? Typically those include Registration/Patient Access, Guest Services, Receptionists, Retail Pharmacy, Triage, Volunteers, etc.? And yet, when I talk with those employees, typically they received little or no WPV training. Additionally, they often have no escape route, no way to communicate duress and don’t understand their right to remove themselves when under duress or threat

·?????? Nurses often tell me they are not by nature confrontational and that even applying? trained de-escalation techniques sometimes feel confrontational and uncomfortable.? They therefore ask for scenario simulations in a controlled and friendly environment where they can gain a bit of “muscle memory” when the real event happens.

. Training should include personal protection including the power of numbers, situational awareness, positioning and when to request escort

·?????? WPV training, including the duty to report and safely managing conflict, should begin at new employee orientation and be a part of all following training and communications.? This is when we begin to set the culture and build that Safety and Security Team.

Dick Sem, CPP, President of Sem Security Management based in Burlington, Wisconsin, has decades’ of security and workplace violence management leadership experience.?He serves large and small healthcare systems across North America in almost every state performing comprehensive security and violence management assessments, targeted assessments (of ED, Security Department/Program, Workplace Violence Program, Accessibility, Outlying Facilities, Home Health, Elder Care, etc.), Workplace Violence Worksite Analyses, development of related policies and plans, expert witness service and training.

Dick Sem, CPP – Sem Security Management – [email protected]

262-862-6786