"It's really an astounding number when you look at it. Unfortunately, it's the caregivers that bear the brunt of that," said Gordon Snow, chief security officer for the Cleveland Clinic. "There are so many different issues that you're trying to protect against or address, everything from verbal assault to an active shooter."
Hospital systems say protecting workers is a balance of preventing violence, de-escalating tense situations and communicating clearly with patients on safety standards and care.
The Cleveland Clinic has an enterprise workplace violence steering committee that develops safety standards for the system. The committee includes members from various disciplines, including victim advocates, and looks at how the system can meet OSHA standards and address other safety issues, Snow said.
Healthcare workers and safety personnel train in violence prevention and de-escalation but that still won't address some events.
The Cleveland Clinic has 170 police officers on staff and 350 contracted security officers, as well as hospital safety officers, who wear a different type of uniform, in its behavioral health units. All officers go through a hospital safety training school.
"We're always looking for what we call a Code Violet situation," Snow said.
Those are violent situations. Sometimes there's a distraught patient or family member. Or there's someone seeking medications they can't have. Or someone is distressed by visitor restrictions, especially during the pandemic.
There are panic alarms that healthcare workers can use when a situation becomes violent, and the system has metal detectors in all of its emergency departments in Northeast Ohio.
"Patient safety and workplace safety are inextricably intertwined. You can't have one without the other," said Mary Beth Kingston, chief nursing officer at Advocate Aurora Health. "If someone doesn't feel safe at work, they can't perform."
At Advocate Aurora, workplace safety is part of the health system's overall safety program because, while a threat, workplace violence is only one of the dangers healthcare workers face.
"The business case is, I think, pretty clear. It costs more to not have a strong workplace violence prevention program than it does not to invest in that. It's an investment that pays off," Kingston said.
Workplace violence can lead to higher turnover, which is costly; worker's compensation claims; lost productivity; and a hit to the system's reputation, Kingston said.
Advocate Aurora offers online violence prevention and workplace safety training programs for workers, but direct-care providers also receive more extensive in-person training. However, the infection prevention protocols made necessary by the pandemic have hindered some of the in-person training opportunities, Kingston said.
"In all transparency, we lost a little bit of ground in the past year," she said.
During the pandemic, workers at screening sites, where visitors and patients are checked for COVID-19 symptoms, have experienced aggression from individuals upset about mask policies or other issues, Kingston said.
The system makes reporting instances of physical violence, aggression and threats a priority. It reviews those cases and determines if there was a medical, medication or behavioral health issue involved. Cases that involve a patient are noted in the patient's medical record to help those providing care in the future avoid another violent event.
"We review the trends, and we learn from those instances," Kingston said.
Each year, and more often as needed, the public safety team reviews all facilities and units for risk to make sure the design of the space is optimized for worker safety, Kingston said. For example, Kingston once worked in an emergency department where the exit was only accessible by passing patients. That site ended up installing a back exit and making sure all new EDs had accessible exits for workers.
"Hospitals want to be open and welcoming but the violence that's in society has definitely spilled over to every aspect of healthcare," Kingston said.
Dr. Henry Pitzele, president of the Illinois chapter of the American College of Emergency Physicians and an emergency physician at a VA Hospital in Chicago, said part of deterring violence comes down to "depth of personnel.''
"Security and policing personnel in the emergency room 24/7 is something you would think everyone should have," he said. "Well, it is not."
A national effort
The U.S. House of Representatives recently passed a bill, H.R. 1195, that will create a minimum standard for health employers' plans to combat violence against their workers. Lawmakers approved basing the standard on voluntary guidelines created by the Occupational Safety and Health Administration in 2015. Under the bill, employers would need to create training programs, investigation procedures and track violent incidents against workers, with more specific regulations coming through OSHA rulemaking over the next three years.
"Employers have not taken the action they need to prevent workplace violence from happening," said Jane Thomason, an industrial hygienist with nurses' union National Nurses United.
Thomason said nurses have seen employers pull back on workplace safety measures, such as having adequate staff, during the pandemic, and historically fail to safely design patient care units to prevent nurses from getting trapped and fail to put alarm systems in place.
The American Hospital Association said it appreciates Congress addressing the issue but wants to make sure any standards set aren't "overly burdensome for hospitals and other employers."
"Addressing workplace violence is an issue that hospitals and health systems have focused on within their facilities and in the communities they serve. Ensuring the safety of our No. 1 asset, the men and women who care for patients in our facilities, is our top priority," an AHA spokesperson said.
To that end, the CEOs from 10 hospital systems created a CEO Coalition this year to create a new safety standard for healthcare workers as the pandemic has highlighted the risks and inequities in the industry.
Some healthcare systems have had to change their approach to safety during the pandemic so they could to better address the communities they care for.
"We had yearly training for the behavioral event response team and regular response team events, but the increase in our pediatric population demonstrating emotional trauma was overwhelming," said Tammy Sinkfield-Morey, nurse supervisor at Gillette's Childrens' Specialty Care, a not-for-profit hospital in St. Paul, Minn. "They were completely different from the patients Gillette usually sees."
Predominantly white staff did not know how to help Black or Brown patients feeling trauma and pain following the police killing of George Floyd and continued police brutality within the community. This lack of preparation and understanding led to dangerous interactions for staff as well as patients, Sinkfield-Morey said. With the support of Regions Hospital administrators, Sinkfield-Morey now runs monthly gatherings for co-workers, who feel disconnected from the urban communities they serve, to discuss diversity and safety training.
"Until we get to a more relational way of understanding patients, we will not be able to create a safe space for patients or staff," said Sinkfield-Morey.
McDonald, of University of Minnesota's Community Healthcare Center, says she also sees remedies to workplace violence through community building between providers and patients. She explains that it was the center's partnership with the American Indian Movement, which patrolled the area overnight, that kept healthcare workers and the facility safe from violence during protests in Minneapolis.
McDonald attributes these "transformational and not transactional" relationships to supporting diverse staff in leadership roles. She says this structure helps build that understanding of patients and creates a safe space for workers to report violent or traumatic incidents.
Robert Pearl, who spent 14 years of his career as a police officer responding to calls from University of Kentucky Good Samaritan Hospital, says he saw care facilities and local police tasked with keeping them safe growing more disconnected from their community toward the end of his career in July 2017.
"I have gotten up there and there were nurses bleeding and getting spit on," said Pearl. "It was getting a whole lot more physical."