Public health professionals are calling for better accountability, hospital cultures of safety and national policies to protect health care workers from violence in the workplace.

Case in point: Health care workers at California facilities experienced an average of 26 violent incidents per day from July 2017 to June 2020, according to research presented by psychiatric nurse Rachel Odes, also a doctoral student at the University of California-San Francisco, during a Tuesday APHA Annual Meeting session on “Workplace Violence in the Frontlines of Health Care.”

The analysis showed that 94% of the incidents at inpatient psychiatric hospitals involved physical injury, compared to only 19% at skilled nursing facilities within a larger hospital system. The remaining incidents may have been verbal insults or threats, Odes said. At community general hospitals, 21% of the incidents involved physical injury.

The majority of all incidents were perpetrated by patients (94%), family members (2%) and others (4%). The most likely location for a physical injury was in the behavioral health unit.

The data are from a new violent incident reporting system general acute care and psychiatric hospitals in California are required to use as part of legislation passed in 2014. The legislation also requires all health care facilities in the state to develop violence prevention plans, use incidence logs internally and train all staff members in violence prevention.

“I think the biggest asset here is the contribution to the epidemiology of this problem,” Odes said. “Measurement has historically been challenging. We know there is a lot of underreporting in existing government data.”

#EndNurseAbuse Campaign
Calling more attention to violence against health care workers is also critical, said presenter Ruth Francis, senior policy adviser at the American Nurses Association.

In 2015, ANA issued a position statement on incivility, bullying and workplace violence. However, by 2017, rates of violence against nurses had not decreased. ANA surveys showed that one in four nurses had been physically or verbally assaulted, but only 20% to 60% of incidents were reported. The association encourages a zero-tolerance policy to protect nurses.

It also created the hashtag #EndNurseAbuse and a related awareness campaign, and a panel of experts developed an issue brief showing why nurses didn’t report abuse. Reasons included lack of support, no formal policy, fear of reprisal and lack of action after reporting previous incidents. The association has created several resources to help, including a brochure that nurses can stash in their scrubs that outlines the steps for reporting a violent incident.

Stronger federal policies are also needed to prevent and respond to workplace violence. Currently, the U.S. Occupational Safety and Health Administration has developed comprehensive guidelines for employers, but they are voluntary, Francis said.

“The guidelines are useful and a good starting place, but we have found that the best strategy is something that is enforceable,” she told attendees.

OSHA started the process to develop standards in 2016, but not much has happened since, Francis reported. The U.S. House of Representatives passed a bill in 2019 requiring OSHA to act, but the companion bill in the Senate is still sitting in committee. Francis said the Centers for Medicare and Medicaid Services can play a more proactive role as well through provider conditions of participation and by creating violence prevention performance measures.

Being proactive and developing a culture of safety can make a difference and prevent violent situations, Francis said.

For example, ANA worked with a large U.S. health care system after a behavioral health patient attacked and severely injured several nurses. Within a month, the hospital system created a group called SCREAM to review and investigate incidents. They debrief staff; flag charts of patients who are repeat offenders and considered high risk; train staff on how to report and on de-escalation and self-defense techniques; track incidents in coordination with their technology staff; involve security in planning; and allow staff to “tap out” and be relieved on a shift. Six months later, Francis said, the facility had had zero violent incidents.