Unfortunately, these fears of violence are not unfounded, and in healthcare, it can be more than coworkers who become violent.

In Minnesota in 2014, a 68-year-old hospital patient attacked a team of nurses with a bar from the side of his bed. In Chicago in 2018, a hospital shooting left two innocent healthcare workers and a law enforcement officer dead, heightening healthcare leaders’ already existing fears about violence in the healing environment.

In general, 9% of American workers are aware of an assault or violent act in their workplace, and 18% experienced some sort of threat or verbal intimidation in the past year.

In hospitals, however, according to a 2016 study published in the New England Journal of Medicine, 80% of emergency department workers will personally experience violence in their careers and all emergency room nurses (100%) reported verbal assault in the past year, with 82.1% reporting a physical assault in the same timeframe. Not to mention that from 2002 to 2013, incidents of serious workplace violence were four times more common in healthcare than any other industry.

Workplace violence includes “any act or threat of physical violence, harassment, intimidation or other threatening disruptive behavior that occurs at the worksite.”

With nearly 2 million American workers reporting that they have been victims of workplace violence each year, the time to act for the safety and security of our employees is now. Here are 10 steps to follow to protect healthcare organizations’ patients, staff and visitors against workplace violence:

1. Commitment from executive leadership: The foundation of workplace violence programs has to begin at the top with executive leadership. When the program is outwardly important to the leadership team, staff will follow their example. This includes not only financial support of the program but visibility through rounds and team meetings and explicitly following the guidelines in the program (such as always wearing an identification badge in a visible location on their body).

The Joint Commission (TJC) recently updated an alert that highlighted the top six “contributing casual factors” or failures by healthcare facilities, which contributed to violent incidents in recent years. At the top of the list: 62% of events were partially due to leadership.

2. Establish a crisis management team: Healthcare facilities should be prepared for any type of workplace violence by establishing a management team that can provide guidance and leadership in a time of crisis. This should be a multi-disciplinary team that includes administrators, clinicians, behavioral health specialists, human resources professionals, staff representatives, and local law enforcement. The team should receive formal training to understand, assess, and provide guidance for near misses, bullying, assault, active shooter events and more.
3. Implement a notification plan: Vital to success is making sure all staff are aware of the workplace violence reduction program and how to activate the plan. If and when a situation arises, don’t delay in letting people know what is going on. Ideally, they should already be briefed on what they should do during a violent incident, particularly when they may only have seconds to protect themselves. Use simple, plain language and, when appropriate, multi-lingual messaging. This will ensure all those present in the facility are aware and understand what to do in the case of a violent emergency.

A misconception is that plain language messaging could cause panic. However, decades of research show that during an emergency, people do not panic from messaging, but rather freeze due to a lack of information on what is happening and guidance on what to do during the incident.

6.  Incorporate workplace violence plans into your emergency operations plan: The Emergency Operations Plan contains the base plan for how facilities manage all hazards. This includes communications, resources and assets, safety and security, staff responsibilities, patient and clinical support activities, and utilities. While most workplace violence incidents will not require the establishment of a formal hospital command center, those that do should be able to seamlessly integrate with the incident command team.
7. Train staff: One failure of workplace violence programs is to only train a handful of staff to recognize and react to events. Our patients and visitors interact with a variety of personnel, including greeters, registration clerks, food service workers, and facilities maintenance staff. With each encounter, those staffs have the ability to not only recognize and report a potential workplace violence incident but also ensure they are not the cause of the escalation. Multiple levels of training from awareness to response should be conducted and become an annual competency check among the workforce.
8. Define terms: “Lockdown,” “shelter-in-place” and “barricade” alone are not confusing terms, but when encompassed in the same plan, they can be confusing if not differentiating. “Lockdown,” for example can mean nobody is allowed into the facility; nobody is allowed out of the facility, or nobody is allowed in or out of the facility. Hospital campuses typically include multiple buildings. In fact, 40% of all hospital-based shootings occurred outside of hospital buildings, according to research by the Johns Hopkins University of Medicine.

What’s more, the term “active shooter” is defined as people or persons with firearms attempting to cause mass casualties. It is not a suspicious person, someone with other types of weapons or someone with a suspicious object, all of which require different reactions and responses. Proper terminology is critical to communicating the situation.

9.  Practice techniques: Regular practice with de-escalation and restraint techniques and barricade and escape/evacuation procedures is crucial. In the most severe workplace violence incidents, such as an active shooter event, staff in the “hot zone” will need to evacuate immediately and head to a safe area or gathering point. Practicing these routes can help save lives.
10.  Establish local collaboration: Help other local healthcare facilities and public safety agencies help you during a violent event. Relevant information they’ll need may include incident command phone numbers, points of contact and campus layout. When it comes to a workplace violence emergency, it’s “all hands on deck.” Having information ready and easily accessible during an emergency can help the appropriate organizations’ teams act quickly when every second counts.
11. Evaluate efficiency: Data collection, including number and types of workplace violence incidents, types of injuries and outcomes are important to understand the success (or failure) of your program. Staff must have confidence in the program to report all incidents, including near misses, and each incident should be reviewed to discuss the efficiency of the current plan. Was the issue mitigated successfully? Were there any unforeseen barriers? Are workplace violence incidents and injuries decreasing?

The crisis management team should evaluate the plan and make updates or corrections as necessary. This will ensure the plan is always improving and continuing to put safety first.

10. Sustain the process: It’s great to implement a plan but tougher to maintain it. Training, incident review, and feedback from staff will help to keep the program successful.

Training shouldn’t be limited to one approach, however. Ensure all relevant audiences know their role and what’s expected of them through periodic orientations, training videos, newsletters, and exercises. The crisis management team should hold monthly meetings to review incidents and make adjustments to the plan as needed.

Planning and procedures are crucial to diminishing workplace violence. However, it’s equally important that they are effective and relevant. Not only will these steps diminish violence against healthcare workers, they will also help to ensure any crisis situation is handled properly. Protecting patients, staff, and visitors against violence can be stressful, but no one needs to go it alone.