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Where We Heal An Informed Discussion on Workplace Violence Prevention in the Healthcare Environment

Healthcare is a unique environment with a variety of challenges.

Navigating this system is complex, as there are many situations unique to the Healthcare environment, including the following:

  • Emergency Departments
  • Forensic Patients
  • Unauthorized Patient Departures (Elopements)
  • Behavioral Health Services
  • Women and Infant Services
  • Pediatric Units
  • Escalated patients or family members/vistors
  • Domestic situations coming into the workplace
  • Disgruntled or terminated employees

An Ordinary Day Can Turn Extraordinary

A patient on a clinical unit has called a nurse into his room. He has not been delivered the food he requested an hour ago. The nurse advises him that, based on his upcoming procedure, he is on food restriction. He starts to shout profanities at the nurse.

What steps should the nurse take to de-escalate the situation?

Keep the patient updated on the status of the procedure(s) and timing of food delivery post procedure.

Use the SLOW De-escalation Method,

  • Set a positive and collaborative tone
  • Listen and acknowledge feelings, emotions, and experiences
  • Observe from an outside perspective
  • Work to find a solution

A patient on a Behavioral Health Unit became upset. He verbalized irrational perceptions of threats to himself. Attempts by the staff to verbally de-escalate the situation failed as the patient rapidly escalated and threw nearby objects. In an effort to gain physical control over the patient, a staff member was struck and bitten.

What steps should be taken following an assault on a staff member?

Best Practices Post-Assault

  • Call for additional assistance. One person should communicate with the patient while all others attempt to remove objects from out of the patient's reach.
  • Attempt to corral the patient into a more vulnerable position.
  • Document and report any aggression and escalation, not limited to injuries.
  • Notify / flag others of the propensity for violence, in order to caution all staff who have further interaction with the patient, such as nutrition and cleaning services.
  • When a staff member has been assaulted, provide access to Occupational Health and Safety Administration/Employee Assistance Program resources. If a fellow patient has been assaulted, provide the patient with access to the patient advocacy resources.

A visitor who was disruptive to the hospital environment was escorted out of the hospital by security. The visitor re-entered the hospital through the loading dock, and waited in the cafeteria for an opportunity to return to the unit where the family member was located. A nurse recognized the visitor.

How might the nurse respond?

When a visitor is escorted out of the hospital for being volatile and disruptive, they should be given written notice of being barred from returning except for emergency medical care (Emergency Medical Treatment And Labor Act).

Document all steps taken to effect the removal of the visitor, to include names of all parties involved, and efforts made to de-escalate the situation. If any criminal conduct occurs, document the notification made to the local police authority.

Policies addressing disruptive visitor conduct will empower the staff, including security, to more effectively maintain control over the environment of care for all patients.

Awareness and Intervention

A situation evolved in a hospital where a physician advised a family member that his loved one was an end-of-life patient. The family member became distraught and stated an intention to remove the patient and transport her to a different hospital. The physician advised that the patient could not be moved.

Over several hours that evening, the family member called the nursing station requesting updates, and threatened to come and forcibly remove the patient, and use a firearm, if necessary. Security and local law enforcement were notified. Hospital Security and police responded to the unit, and local law enforcement officers were sent to the family member's house.

The family member was intercepted at his home by police as he was preparing to place weapons in his vehicle. No one was harmed and the family member voluntarily was taken to a different hospital for behavioral health evaluation.

During this situation, the hospital followed appropriate internal and external notification channels, and effectively prevented a threatening situation from escalating and occurring at their hospital.

Vigilance and External Areas

In June 2011, a patient, upset with his liver-kidney transplant, ambushed and killed his surgeon in an elevator in the parking garage at Florida Hospital Orlando. The patient then shot and killed himself. Prior to the incident, the patient had escalated interactions with the physician on several occasions, however, it is unknown if these interactions were reported to security.

On February 19, 2020, a man entered the employee parking garage and shot and killed his girlfriend, a clerk at Baptist Hospital in Jackson, Mississippi. A security guard who had just arrived and witnessed the assault, attempted to intervene and was killed in the attack.

Incidents occur in parking lots or parking structures because they are accessible, by vehicle or foot, to the assailant and used by the intended victim. Vigilance is crucial in external areas, to include surveillance cameras and patrols by security.

Community of Engagement

Hospitals are a unique environment in which assaults happen routinely. It is important for healthcare leaders to actively promote a community of engagement to effectively reduce the number of assaults experienced by healthcare workers, and to create a safe and caring workplace.

All staff members, from security to physicians, should participate and/or be represented in Workplace Violence Prevention Program goals.