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Run, Duck, Hide? Workplace Violence and Healthcare Workers

Elizabeth Hofheinz, M.P.H., M.Ed. • Fri, October 6th, 2017

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Hurricanes…lessons are being learned and we seem to be getting better at handling them. Earthquake response? We have concrete plans for those. Violence in a healthcare environment? Anyone?

Pharmacy tech—not typically considered a dangerous profession—unless you are trapped under a desk while a gunman roams the halls. And the title “physician” has always been surrounded by an aura of safety. Societal norms have shifted, however, and now with a rise in active shooter situations, it appears difficult to define “safe workplace.”

Paul Tornetta, M.D., traumatologist, chief and chair of the Department of Orthopaedic Surgery at Boston Medical Center and Boston University School of Medicine and past president of the Orthopaedic Trauma Association (OTA), is of the firm opinion that hospitals lack preparation when confronting violence and/or an active shooter situation.

Along with Michael Bosse, M.D. and Bryan Warren, M.B.A., C.H.P.A., CPO-I, Dr. Tornetta has published work entitled, “Workplace Violence and Active Shooter Considerations for Health-Care Workers.” The article appears in the August 16, 2017 edition of The Journal of Bone and Joint Surgery.

Dr. Tornetta commented to OTW, “The unfortunate fact is that we are seeing a rise in violence in healthcare environments, both in hospitals and clinics. Looking at the big picture, the time pressures involved aren’t helping reduce tension.”

“In general, healthcare providers do their utmost to communicate with—and be available to—patients and their families. However, this kind of personal attention is getting squeezed and providers are finding it difficult to do in this new era of constant charting and declining reimbursements. With such a hurried pace, it’s a bit harder to verify that the patients and their families understand the plan and that all their questions are answered.”

And acute situations, says Dr. Tornetta, can be even worse. “You may have family members rushing their loved one in for emergency surgery. In such a situation it is hard to communicate with the family when you are trying to save their loved one’s life.”

“Even in clinic…if a patient has a significant problem and patient-provider communication is not clear then things can escalate quickly. The patient or family may not understand the plan or the associated risks and then something goes wrong and people are angry.”

“In a clinic setting, the focus should be on preparation and de-escalation. Families are not going to be rational in certain situations, so it is best to be prepared for a worst case scenario, i.e., be ready to evacuate examination and waiting rooms.”

Then there are the stressed souls that show up in the emergency department (ED). “Some patients are belligerent and irrational because they are injured—others are under the influence of medications or alcohol. In many instances they are not sufficiently lucid to be calmed down and actually require sedation.”

OTA Training

If all of this sounds a bit overwhelming, take heart, says Dr. Tornetta…the OTA offers mass casualty training on a regular basis. “Doctors are already busy envisioning ‘what if’ clinical or surgical situations, such as malignant hyperthermia. To have to do that with safety issues isn’t usually the first thing on our minds. Frankly, as a profession we tend not take these matters as seriously as we should. The primary mindset shift is to realize that it can happen to you…you can find yourself in a violent situation while at work. Think about it this way: you prepare for a life-threatening situation in the OR, thus protecting one patient. In a workplace violence situation, there are even more lives at risk. We are just not doing enough drills.”

“I recently took part in a panel discussion where it became clear that many people don’t understand their respective roles in these types of situations. Drills teach us that the first priority is to get out of the way of danger and if that isn’t possible, then hide. Only in the worse possible scenarios would it be recommended to take things into your own hands. Responding to a violent workplace situation is, of course, vastly different from answering ‘what would you do’ questions on paper. That is why healthcare facilities need an ongoing program of drills.”

Asked if he were head of a commission to address violence in healthcare environments, Dr. Tornetta said he would advocate for national funding to train employees. “Once something receives the support of funding, people are more amenable to training. We need to develop large scale, consistent training programs that could be rolled out by content experts in every city and state.”

Hiring the Outside Expert

What else would Dr. Tornetta do? Hire someone like Bryan Warren.

Bryan Warren, M.B.A., C.H.P.A., C.P.O. I, director of Corporate Security at Carolinas HealthCare System and a 28-year veteran of healthcare security, says that with the upsurge in active shooter and workplace violence situations, his work is garnering more attention.

“For the past five years I have been doing a significant amount of education on this topic; the statistics are outrageous, with 70-74% of assaults on the job happening in healthcare. And it would be incorrect to think that these are all related to the ED or behavioral health—you have a fair amount of these occurring in nursing homes.”

When Bryan Warren walks into a facility, what lets him know that they are or are not prepared? “How easily can I gain access into a facility,” he says. “If it’s 3am and someone can just walk in any door then that is not a good sign.”

“You must have sufficient access control—an after-hours visitor should only report through the ED. That alone goes long way in preventing workplace violence. In addition, I look for indicators of security counter measures such as a uniformed presence, cameras, etc.”

Employees who sign on the dotted line have received some reassurance of safety, says Warren. “The Occupational Safety and Health Administration (OSHA) deems that hospitals must provide a safe working environment for employees. That is rather nebulous, however, and a lot of hospitals have been fined in the last couple of years for not taking sufficient steps to protect employees.”

“It is important to understand that workplace violence occurs because, with the exception of having a baby, people who are at a hospital probably don’t want to be there. In such a situation there doesn’t have to be malicious intent…a lot of this is spontaneous.”

“We know that healthcare providers’ coping mechanisms are already being stretched, but it is imperative that you keep an eye out for warning signs and know how to react, including recognizing the signs that someone is agitated and is getting ‘amped up.’ In such instances, you should not touch the person nor invade his or her space.”

Signs of Trouble

“Often, clinical personnel have a natural urge to want to reach out and touch someone, but if the person is exhibiting physical warning signs of violence, then you should not invade this individual’s personal space. You are busy and want to get the job done, but pause…is the person shaking? Do they have a thousand yard stare? Healthcare workers move from crisis to crisis, but sometimes slowing down is part of your job.”

So what else can providers look for?

Bryan Warren says, “Heavy breathing, nervous pacing, fidgeting, lack of verbal expression—all signs that someone needs to be handled carefully. When humans get emotional or anxious the speech centers of the brain aren’t working as well as usual…you may see clenched teeth and/or balled up fists as well. The good news is that when someone is yelling and pointing and generally trying to intimidate you, it means the person is still somewhat cognizant. Frankly, it’s the quiet one that just suddenly leaps on you that you have to worry about.

“Hot Spots” in the Hospital

So what to do in order to be prepared…and to not feel hopeless?

“First,” says Warren, “Identify your high risk areas that have highest risk patient population. These ‘hot spots’ are often the ED, behavioral health, labor and delivery, and pediatrics. When a child is sick and the family is no longer together you get a lot of tension in the air. And of course if someone comes in to remove the child from the parent’s custody then that is a pressure cooker situation.”

“Second, all employees must go through a reasonable amount of training. This should include an initial orientation on the basics of conflict resolution and how to deal with upset patients, as well as an annual refresher course based upon their specific work area and patient populations that they serve. For example, those that work in a behavioral health setting should concentrate on signs of mental crisis and physical indicators of impending violence, while those that work in an emergency department might focus more on signs of criminal activity and the potential for weapons or other contraband on patients.”

“Regardless of the learning model used (face to face, computer based, etc.), such training should be done at least annually to make certain that staff understand the importance of the issue and what their roles are should an event occur.”

“Third, you should assess the physical environment and determine what improvements need to be made. Perhaps there are issues with access control, alarms, or the ability to lock down quickly.”

So what if you are in the operating room (OR) and hear shots fired? “The upside is that an OR is typically harder to reach, i.e., there is a certain amount of additional security before someone can get in. Generally speaking, however, ORs are notoriously hard to secure because they are sterile areas. Security can’t don special gear to walk through there on patrols. Many hospitals have badge readers on doors but sometimes people override them because staff members are in scrubs and don’t want to have to handle their badges.”

And, says Warren, there is no literature about what to do with patients. “What if someone does make it to the OR? You can’t just leave an anesthetized patient on the table. Ideally, we could develop a technology such that we could lock down an area and shelter in place. Things are different in a surgical suite, however, because it is hard to retrofit them with the appropriate hardware. Some places do have wireless duress buttons that also provide lockdown…so even if card readers fail the doors lock automatically.”

If We Can’t Protect the Doctors, We Can’t Protect the Patients

When asked about metal detectors Bryan Warren is less than enthusiastic. “I have seen too many instances where it becomes ‘security theater’ where it looks like something is being done, but it is not. These systems are very labor intensive—they need to be on every door—and after the honeymoon period then they are often gradually put out of use. And the fact that they might drive down a hospital’s patient satisfaction scores doesn’t sit well with everyone.”

Zooming in on a physician’s thinking, Bryan Warren notes, “There is a crisis mentality in your typical ED. If a trauma surgeon is trying to save lives in succession then there isn’t much room for strategic thinking. This is why a security assessment is needed…to say, ‘What if six months from now we have a patient surge event involving gunshot victims, suspects, family members and the press descend on this hospital?’ We need to convince doctors that it is critical to get involved in a multidimensional approach. And it’s important to let security professionals do what we know how to do. We wouldn’t dream of advising them on surgery…they shouldn’t have to decide how to secure a building. We should all work together and support one another when security resources are needed and requested from the organization’s administration.”

Bryan Warren’s parting advice to physicians: “If we can’t protect you, you can’t protect your patients.”

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