Keeping Staff and Patients Safe From Workplace Violence
A Conversation With Anne Gross, PhD, RN, FAAN
The statistics are chilling. According to estimates from the U.S. Bureau of Labor Statistics, workers in the fields of health care and social services are five times more likely to suffer from a workplace violence injury than workers overall.1 The Bureau statistics show that the rate of injuries from violent attacks against medical professionals grew by 63% from 2011 to 2018,1 and, in 2020, 76% of all workplace violence injuries were inflicted on health-care workers.2 In addition, a survey, in 2022, by National Nurses United found that nearly half (48%) of the more than 2,500 respondents reported a small or significant increase in workplace violence, a nearly 57% increase from the previous year’s surveys.3
And these statistics likely do not reflect the actual number of incidents of workplace violence in the health-care industry because of a lack of nationally standardized measurement systems for reporting all types of workplace violence that occur, according to The Joint Commission,4 a nonprofit organization that accredits more than 22,000 health-care organizations and programs in the United States. It is this worsening trend in violence in health-care settings that prompted The Joint Commission to require accredited hospitals to implement new and revised requirements for workplace violence prevention.4
Earlier this year, in the Journal of Clinical Oncology,5 Noelle K. LoConte, MD, Associate Professor in the Division of Hematology, Medical Oncology, and Palliative Care, in the Department of Medicine, at the University of Wisconsin School of Medicine and Public Health, recounted her own terrifying experience of workplace violence. She told a patient she had been treating for about 3 years that her cancer had recurred and was incurable. “I want to kill you,” responded the patient. “I want to blow your face off. You should never have become a doctor.”
“I was sure I was about to be killed,” wrote Dr. LoConte. “I was certain she had a gun in those bags.”
Understanding What Constitutes Workplace Violence
According to The Joint Commission, workplace violence is defined as “an act or threat occurring at the workplace,” including the following:
- Verbal, nonverbal, written, or physical aggression
- Threatening, intimidating, harassing, or humiliating words or actions
- Sexual harassment
- Physical assaults
- Other behaviors of concern involving staff, licensed practitioners, patients, or visitors
To learn how oncology centers are stepping up their security protocols to ensure clinicians, patients, caregivers, and other hospital visitors remain safe from workplace violence, The ASCO Post talked with Anne Gross, PhD, RN, FAAN, Senior Vice President, Patient Care Services and Chief Nursing Officer at Dana-Farber Cancer Institute, Boston.
Anne Gross, PhD, RN, FAAN
Preventing Workplace Violence
Many hospitals now have safety flag alerts on their electronic health records system to warn staff of patients who have been aggressive in the past. Please talk about the security precautions Dana-Farber Cancer Institute has in place to protect staff from aggressive patients and hospital visitors.
Over the past 6 years, we have taken an institution-wide approach to the issue of workplace safety, including incorporating flagging alerts into our electronic health records, which guides where a patient with a history of aggression or potentially disruptive or aggressive behavior is examined to ensure clinician safety. The clinical staff is made aware of the alert, and we post plainclothes security in the area in case there is any sign of disruption or violence. Whenever there is a real or potential threat, a report is filed, and a team of medical and security experts review the report and develop a plan for how to manage the patient in the future.
We have formed an interdisciplinary violence prevention working group that includes psychosocial clinicians, security, and human resources staff to think through every aspect of how we can continue to keep our environment safe. We conduct annual violence prevention training for all staff, including active shooter training, how to remove yourself from a potentially dangerous situation, and how and where to report acts of workplace violence.
We have a very low threshold for any situation that we consider constitutes workplace violence. This includes any behavior—physical or verbal—that leaves another individual feeling uncomfortable, unsafe, or threatened in any way.
We have also developed a situational AVADE (Awareness-Vigilance-Avoidance-Defense-Escape; properauthorities.com) approach to preventing, avoiding, de-escalating, and mitigating violence and aggression in the hospital setting. We have installed more than 1,000 panic buttons throughout the Dana-Farber campuses, which send alerts directly to our security office. In addition to the panic buttons, all desktop computers have safety icons that send messages to our security staff when clicked, generating an immediate response.
Of course, we have zero tolerance for weapons on our various campuses. Weapons of any kind are confiscated from patients when they check in and placed in a safe until their clinical visit is completed. We have not installed metal detectors.
Responding to Threats
How do you respond to specific threats against physicians and nurses?
Fortunately, we do not have many specific threats made toward our clinicians. What we mostly deal with is disruptive behavior where emotions are high, and there is a need to de-escalate the situation. Our training helps staff de-escalate these situations and call additional staff when necessary to help reduce tensions and resolve the problem.
When there is an actual violent situation or threat from a patient or a loved one, our team of clinicians and staff from Patient Family Relations and security review the threat; the treating physician, usually along with Patient Family Relations staff or security staff, will speak directly to the person making the threat. If the behavior continues, we will discharge a patient if necessary. The bottom line is that as a hospital, we must have an institution-wide approach in response to this difficult societal issue.
De-escalating Aggressive Situations
What are some tips on how front-line and telephone staff members can de-escalate a disruptive or potentially violent situation?
We use an approach we call STOP—Stay in control, Take a step back, Observe what is going on around you, and Proceed mindfully—to help front-line staff. STOP includes seven steps to help staff stay in control of an aggressive encounter:
1. Stay calm, manage your own responses with empathy and positive regard.
2. Ask clearly, “How can I help you today?”
3. Listen to the patient and validate the problem. For example, “Yes, it is frustrating to have to wait on the phone for an appointment for so long. I can imagine I might feel distressed as well.”
4. Explain to the patient what is possible, be concise, and do not respond to threats.
5. Set limits and assert yourself if the patient becomes abusive, uses vulgar language, or is demanding. For example, say, “I understand that you are upset, but if you continue to yell and swear, I’ll have to end this conversation.”
6. Report the encounter to a supervisor and file an incident report.
7. Debrief the encounter with a supervisor and colleagues and consider what went well and how the situation could be improved in the future.
DISCLOSURE: Dr. Gross reported no conflicts of interest.
1. U.S. Bureau of Labor Statistics: Injuries, Illnesses, and Fatalities—Fact Sheet, Workplace Violence in Healthcare, 2018. April 2020. Available at www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm#:~:text=Workplace%20violence%20due%20to%20intentional%20injuries%20by%20other,cases%20requiring%20days%20away%20from%20work%20in%202018. Accessed June 26, 2023.
2. U.S. Bureau of Labor Statistics: Injuries, Illnesses, and Fatalities. Table R4: Number of nonfatal occupational injuries and illnesses involving days away from work by industry and selected events or exposures leading to injury or illness, private industry, 2020. Available at www.bls.gov/iif/nonfatal-injuries-and-illnesses-tables/case-and-demographic-characteristics-table-r4-2020.htm. Accessed June 26, 2023.
3. National Nurses United: National nurse survey reveals significant increases in unsafe staffing, workplace violence, and moral distress. April 14, 2022. Available at www.nationalnursesunited.org/press/survey-reveals-increases-in-unsafe-staffing-workplace-violence-moral-distress. Accessed June 26, 2023.
4. The Joint Commission: New Requirements for Preventing Workplace Violence. The Source, volume 19, issue 10, October 2021. Available at www.jointcommission.org/-/media/tjc/documents/resources/workplace-violence/ts_10_2021_preventing-workplace-violence.pdf. Accessed June 26, 2023.
5. LoConte NK: I want to kill you. J Clin Oncol 41:2859-2861, 2023.