Combating Workplace Violence in the Healthcare Office Practice

Workplace violence has devastating consequences in ambulatory healthcare settings. It affects staff morale and safety, business operations, and even the quality of patient care. Incidents of workplace violence in healthcare settings are on the rise, with office practices facing unique challenges due to limited resources, personnel, and infrastructure. Given this environment, it is critical that ambulatory settings combat the prevalence of workplace violence in a manner that focuses on prevention, deterrence, and remediation.

Defining Workplace Violence

The Occupational Safety and Health Administration defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite. It ranges from threats and verbal abuse to physical assaults and even homicide.”¹ The workplace includes any location, either permanent or temporary, where an employee performs work-related duties.

Workplace violence manifests in a variety of forms, from physical to psychological trauma. Physical altercations may include inappropriate touching, beatings, use of weapons, and loss of life. Psychological trauma may result from threats, intimidation, or harassment. Workplace violence can also carry over to a healthcare worker’s personal life—through social media and personal texts and calls, and by following the employee to locations outside of the workplace.

Although certain states—such as California, Connecticut, New York, Oregon, and Washington—have passed workplace violence laws specific to healthcare settings, the only current national law addressing workplace violence is Section 5(a)(1) of the Occupational Safety and Health Act of 1970, a law requiring employers to provide a work environment that is free from recognized hazards that are causing or likely to cause death or serious bodily injury. Check your state laws for any specific requirements.

How Is Workplace Violence Perpetrated?

Healthcare practitioners are four times more likely to encounter workplace violence than are other professions.² Workplace violence might be inflicted by coworkers, patients, patient affiliates (for example, a spouse or a parent), or unaffiliated third parties. The most common aggressors are patients toward staff.

Underlying factors inherent in the healthcare setting can contribute to the risk of violence. Contributing factors include a patient’s or family’s confusion or frustration about a medical diagnosis, treatment options, or outcome; substance dependency; or a history of violence, psychiatric disorders, chronic pain, cancer, or similar long-term conditions. COVID-19 has exacerbated the frequency of violent encounters targeting healthcare workers.

Certain types of settings experience higher rates of workplace violence. These settings include behavioral health, substance abuse rehabilitation, pain management, urgent care, community clinics, orthopedics, end-of-life/palliative care, family medicine, neurology, oncology, and cardiology.³

Repercussions of Workplace Violence

Workplace violence is a leading cause of career dissatisfaction and burnout in the healthcare workforce, and it contributes to high staff turnover. Victims of workplace violence can suffer mental fatigue, physical or emotional injury, prolonged leaves of absence, reduced levels of happiness, decreased focus and awareness, job dissatisfaction, and absenteeism.

Office practices may not have compliance departments, leaving it to practice leadership to develop a workplace violence response plan (“response plan”). Despite the rise in workplace violence, many offices forego implementing policies because leadership’s limited time is diverted to more pressing matters.

Implementing a Comprehensive Response Plan

An effective response plan includes early threat detection strategies, heightened security measures, a threat notification and reporting system, active threat response protocol, staff training, and periodic plan updates.

Detection: For patients, family, or visitors who are recognized as being potentially problematic, early identification (during exchanges that do not involve patient care) may include adding tagging or a note in the patient’s record (in a place that is not within the clinical notes or in any section of the record that could be transferred to an outside practitioner or entity).

Security measures: Heightened security measures may include hiring security guards, installing alarm systems and cameras in public areas, and adding self-locking doors and safe rooms within the premises. Exits should be clearly marked, and mirrors may be installed in blind corners. Other security measures include secure parking areas, staff ID badges for entry, and arranging exam rooms to provide staff with unencumbered exit paths.

Threat notification: Consider implementing code words, headsets, silent alarms, or personal alarm devices that can be easily activated if prompt assistance is needed, including summoning law enforcement.

Threat response: Create a strategized response to various types of threats (e.g., contact a point person for de-escalation, shelter-in-place, or follow evacuation plans).

De-escalation techniques are effective ways to regain control of a situation or maintain the status quo until first responders arrive. Key components include remaining empathetic and nonjudgmental toward a perpetrator; maintaining physical separation; communicating in a calm, nonthreatening manner; and maintaining nonthreatening body language. Identifying with an aggressor’s emotions and motivations may help to build rapport.

Following an incident, the office practice can offer staff such remedial assistance as therapy or paid time off. Interviewing victims and witnesses will help determine how the threat occurred and whether protocols should be updated.

Staff training: De-escalation training provides staff members with tools to employ if they cannot safely remove themselves from a threat. Hold annual simulations and training to ensure that staff uniformly understands all response plan procedures. Creating an environment that encourages threat reporting will send a message to staff members that their opinions and safety matter. Annual reviews of the plan can incorporate updates as required by law or office needs.

Scenarios

During a routine appointment, a patient informed staff that he was an avid gun collector and would “hate to have to use one” if his scheduled procedure failed. In this situation, an adequate response may involve employing de-escalation tactics to safely terminate the appointment and escort the patient from the premises. It may be appropriate to dismiss the patient from the practice.

In another scenario, an off-duty staff member called the office and made bomb threats using a voice synthesizer, terrorizing fellow staff members. The practice postponed all appointments, vacated the premises, and called authorities—who confirmed that the premises were secure. After an investigation, the practice terminated the staff member and instituted safety protocols, such as locking entrance doors and installing security cameras at points of entry.

Conclusion

The best way for healthcare practitioners in ambulatory settings to deter and remediate workplace violence is to implement a comprehensive response plan. Implementing a response plan may be required by state law, and it also increases staff safety and morale, reduces the potential financial effects of workplace violence, and increases the quality of care to patients.