Trained and Ready

May 15, 2013
Dealing with workplace violence in the healthcare environment means having the policies, procedures and training in place to respond quickly and effectively

Sifting through the reams of data available on workplace violence, it becomes clear that the issue has been on the radar of healthcare executives for more than a decade.

Back in 1998, the Occupational Safety and Health Administration (OSHA) reported that “more assaults occur in the healthcare and social services industries than in any other.” And while the statistics say healthcare workers are no longer the top target for workplace violence, it is clear they remain on the front lines. “It’s prevalent and it’s escalating,” says Anthony Potter, senior director of public safety administration for Novant Health, which operates 13 hospitals in Virginia and the Carolinas.

What are the major contributing factors to violence in the healthcare environment? Among the many factors, the number-one issue, according to Potter, is the economy. “We are dealing with a far greater percentage of our population that’s under economic stress, and this is always a trigger for workplace violence and also for domestic violence, which can spring over into the workplace.”

Other contributing factors include long waits in the emergency room, overcrowding of hospitals and the lack of beds and rooms available at any given time, along with intoxicated patients. But luckily for healthcare security executives like Potter, the problem of workplace violence is so universal, so widespread and frankly, so mature, that strategies to deal with it have evolved greatly over the years.

For Potter and Novant Health in particular, the key to curbing workplace violence lies mostly in the hands of the security officers on the front lines on a day-to-day basis.

The Scope of the Problem
The Labor Department defines workplace violence as “any threat or act of physical violence, harassment, intimidation, or other threatening disruptive workplace behavior.” The impact of non-fatal instances of workplace violence is significant, with the FBI estimating in 2011 that occurrences of workplace violence “cost the American workforce approximately $36 billion per year.” The FBI separates workplace violence into four categories based on victim-perpetrator relationship:

• Crime: when a perpetrator who has no connection to the organization attempts a criminal act, such as a robbery;

• Customer or patient: Most common in the healthcare environment, the act is perpetrated by an a patient or other outsider to an organization;

• Worker on worker; or

• Domestic violence.

According to the 1998 OSHA stats, the averagerate of assaults against health workers was more than four times greater than that for the rest of the private sector.

When thinking about workplace violence in the healthcare setting, the obvious circumstance involves the emergency room, for a variety of reasons. Potter points out that the current economic climate has many emergency room visitors treating the unit as their family doctor — thus creating instant problems with wait times and bed/doctor availability.

But to boil it down to its simplest term, a trip to the emergency room is easily one of the highest-stress situations a person can experience. “There’s always stress involved when someone comes to a hospital, because unlike nearly any other place, they don’t want to be here,” Potter says. “As a result, the tension level is high to begin with.”

Several studies indicate that violence often takes place during times of high activity and interaction with patients, such as at meal times, during visiting hours and patient transportation. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking or tobacco or alcohol use.

But Potter says a particular aspect of the workplace violence and assault problem has gone beyond the emergency room doors, and into the behavioral health areas of the facilities, which lately have taken on a much more prominent role: “We’ve had a tremendous increase in the number of behavioral health patients because many states are just closing their mental health facilities,” Potter explains. “There’s basically no other place for them to go — they may sit here for up to 10 days just waiting for a bed in a state mental health facility. That’s just terrible, but it’s a reflection of the times and the finances being experienced on a state level.

“In 10 years, we’ve had two officers injured that required medical attention when dealing with crimes,” Potter continues. “We’ve had 27 officers over that same period of time injured as a result of a physical confrontation with a behavioral health patient. With those patients, you can’t use handcuffs, batons, or any of the police methods, which go against regulations.”

While 27 major incidents involving injury seems like a large number, it is because of a combination of training, technology and deterrence that the number isn’t dramatically higher. Potter, a former police chief and commissioner who has been heading up healthcare security departments since 1990, has spearheaded that effort for Novant Health.

Steps to Prevention
In most workplaces where risk factors can be identified, the risk of assault can be prevented or minimized if employers take appropriate precautions. According to OSHA, one of the best protections employers can offer is to establish a zero-tolerance policy toward workplace violence covering workers, patients, visitors, contractors, and anyone else who may come in contact with healthcare personnel.

“I have a simple view (regarding workplace violence), and it’s reflected in our corporate policy,” Potter says. “It’s a zero-tolerance thing with us, and we take every step possible to prevent it. When something does happen, we immediately move on it and take whatever steps are necessary to deal with it.”

OSHA stresses that a well written and implemented Workplace Violence Prevention Program, combined with technology and training, can reduce violence in workplaces. This can be a separate workplace violence prevention program or can be incorporated into an injury and illness prevention program, employee handbook, or manual of standard operating procedures.

Typical policies include a ban on weapons; stationing security and/or police officers in high-risk areas within the facility; and nighttime parking lot escorts, as the lots tend to be a hotbed of violence. Design considerations include creating waiting areas to accommodate and assist visitors and patients who may have a delay in service; enclosed nurses’ stations; deep service counters or bullet-resistant and shatterproof glass enclosures in reception areas; and to arrange furniture and objects to minimize their use as weapons.

Beyond policy and design, there is technology. Most hospitals use a combination of video surveillance, access control, visitor management and panic/duress alarm technologies. Some facilities have found success in using walk-through metal detectors, especially in the emergency departments. Potter says that while his hospitals do not use the airport-style walk-throughs, his officers carry hand-held portable metal detectors that he says are about the size of a small flashlight.

Training is the Key
At Novant Health, basic training for the majority of employees — particularly those who work in emergency departments, behavioral health and public safety — is the Crisis Prevention Institute’s non-violent crisis intervention course. “For the most part, we restrict our physical intervention when dealing with patients to the techniques taught in that course,” Potter says.
For the hospital’s in-house security force, training is job one, and it has been paying dividends.

“Our new officers go through 160 hours of police academy-style training, which is unique to us — most hospitals don’t do that,” Potter says. “That’s the first four weeks of employment, and the last two hours of every day is physical training on how to respond to and deal with a whole range of confrontation situations.

“When I first got here, the officers didn’t have any training,” he continues. “Like every hospital, our budget is under a microscope, but the one thing administration has never asked us to do is cut back on training, because they see the results.”

Those results are a marked decrease in incidents of workplace violence at Novant hospitals, including its largest, Forsyth Medical Center in Winston-Salem, N.C., where Potter is headquartered. The training is not only focused on physical training, but also on how to lower the tension levels and respond in non-violent ways.

Novant security officers do not carry firearms — the only people on the campus who do are police officers. Instead, the security officers carry ASP Batons — extendable metal batons that were made popular by law enforcement agencies such as the Secret Service — along with OC spray. But the batons and spray, much like tasers and other non-lethal forms of defense, are most effective as a deterrent. “Our officers started carrying the ASP Baton in 2003, and the first time anyone was actually hit with one was in April of 2012, which goes back to the training and using force as a last resort,” Potter says. “The baton is a deterrent, and it’s a very effective tool.”

The 360-officer force at Novant is trained to identify potential violent activity through the analysis of human traits like body language and speech. They are keying on verbally expressed anger and frustration, threatening gestures, signs of drug or alcohol use and the presence of a weapon.

In the case of an incident, the goal is clear — to reduce the level of tension and confrontation. “When our officers respond, they are the problem-solvers,” Potter says. “People call us and they expect us to take care of the situation, and the vast majority of them don’t involve physical confrontation.”

The bottom line is that wherever it ranks on the latest Bureau of Labor Statistics or FBI study, workplace violence is going to be a major issue for healthcare organizations — from the emergency rooms, to psychiatric wards, to general waiting areas. The key is for an effective, well-trained response. “Before I came here, our officers didn’t carry anything, and it took quite a bit of time for us to convince administration to allow (non-lethal forms of defense),” Potter says. “The fact that we have used them so seldom reinforces the fact that training is what it’s all about.”

About the Author

Paul Rothman | Editor-in-Chief/Security Business

Paul Rothman is Editor-in-Chief of Security Business magazine. Email him your comments and questions at [email protected]. Access the current issue, full archives and apply for a free subscription at