Workplace violence prevention: Supporting inpatient behavioral health bedside staff

By Daniele Klebern
Vizient, PI Program Manager

Unfortunately, the healthcare workforce is disproportionately impacted by workplace violence. This problem is more prevalent since the COVID-19 pandemic, with a 35% increase in reported violent incidents over the past several years. These incidents can cause physical and emotional impacts on workers, with consequences that can be both acute and chronic, including serious physical injury, temporary or permanent disability, psychological trauma or even death. There also are productivity and workplace-related consequences as workplace violence can lead to low morale, a lack of trust in management/leadership, loss of team cohesiveness, and perceptions that the workplace environment is hostile or dangerous.

Who's most at risk?

When taking a closer look at which areas within healthcare organizations are most susceptible to violent incidents, 5 to 15% of staff working in inpatient psychiatric units experience physical assault. The estimated percentage of RNs and LPNs experiencing violence or physical assault from 2020 to 2021 was 57.1%, followed closely by correctional facilities and detention centers at 55.8%.

Despite carrying a higher rate of violent incidents, only about one-third of patient safety events involving psychiatric patients are actually recorded by staff in hospitals' reporting systems. A study published in the Joint Commission Journal on Quality and Patient Safety studied 40 Veteran Hospital Association hospitals to determine how many behavioral incidents made it into their reporting system. It was discovered that only 37.4% of safety events had been reported.

Inaccurate harm score assignments

When reviewing the reports that do make it into the system, a point of interest is the harm score assigned to each report. The harm score, developed by the Agency for Healthcare Research and Quality, is used in hospitals across the U.S. to assess harm resulting from adverse events. However, human bias in the application of harm scores is a persistent problem. The high frequency of safety events experienced by the reporter also can be a factor. For example, if a healthcare worker has witnessed multiple safety events consistently during their shifts, they may become desensitized and assign a lower harm score.

The Vizient Patient Safety Organization team examined event reports submitted to its reporting system from inpatient behavioral health units. They searched for event reports that received a harm score of "no harm" to identify whether there were signs of harm that would contradict this scoring. The team determined that there was indeed evidence that some scores were incorrectly categorized and should have been filed indicating signs of harm. Examples of misrepresented "no harm" reports included: "Patient was agitated and kicked the RN in the back," "Resident hit peer in the hallway" and "Patient became agitated and hit the RN in the chest."

The American Nurses Association cites a variety of reasons why staff may not report harm after a violent incident:

• A hospital culture that considers workplace violence as "part of the job"
• Perception that violent incidents are routine
• A lack of agreement on the definition of violence (i.e., "Does this include verbal assault?")
• Fear of being accused of inadequate performance
• Lack of awareness of the reporting system
• A belief that reports will have no impact on the culture or climate
• A belief that the incident was not serious enough to report
• Not reporting unintentional violence
• Lack of manager and employer support
• A fear of reporting supervisory workplace violence

Supporting staff with interventions

Healthcare organizations and safety leaders are navigating this complex issue with interventions to increase support for staff and provide resources for healing after a violent event, as well as clarity around what workplace violence means and how to respond to it. These interventions are aimed at encouraging staff to report these incidents and preventing a culture that considers violent incidents in the workplace as routine. Some examples of interventions that have been successful in creating a support system and strong safety culture in healthcare organizations across the country include:

• Crisis Prevention Institute (CPI) workplace violence training: CPI's workplace violence prevention trainings reinforce an organization's commitment to supporting staff in times of crisis and encourage a continued focus on reducing violent incidents by giving staff the resources they need to respond. For example, staff at Oaklawn Psychiatric Center use regular shift changes to discuss important topics around workplace violence and keep it top of mind. Oaklawn's crisis prevention training includes the CPI COPING model, a systematic framework for workplace violence prevention that outlines six steps to follow after an emotional or physical crisis.
• Case review training: A study conducted at Taipei Veterans General Hospital explored the efficacy of violence prevention training courses in improving workplace violence awareness and reducing the number of violent incidents. The elements of the program include an introduction to workplace violence, simulation-based training, real case review, videotaped simulations of real scenarios, coping strategies and discussion. The researchers discovered that this form of training greatly increased confidence and preparedness among staff. An example of this in practice is the University of Kansas Health System's violence prevention courses as part of their "De-escalation Wednesdays" program, a virtual program also open to other organizations, where staff congregate one Wednesday a month to review case studies, refresh basic de-escalation skills and discuss their experiences.
• Healing circles: These provide an opportunity to heal and alleviate suffering through connection with peers in the workplace who need a safe space to discuss their concerns, trauma and experiences. Stormont Vail Health has implemented "restorative circles" for hospital staff to come together and discuss their experiences, which have created a community to establish deep connections. Stormont has used these meetings to connect with new employees and help them feel supported and more open to reporting workplace violence.
• Mutual respect policy: "Zero tolerance" policies establish that blame be solely placed on the aggressor in a violent situation, but it neglects the role of the healthcare worker and can make patients feel defensive as soon as they walk through the door. Mutual respect policies however establish the necessity for both parties to respect one another and prevent harm. A successful mutual respect policy describes both patient and caregiver rights and responsibilities and drives home the need for both parties to actively listen and respect one another.
• Post-incident team analysis: The Centers for Disease Control and Prevention recommends conducting post-incident team analysis after any violent incident to discuss the power dynamics from the perspective of the staff and patient, de-escalation techniques used and the bedside staff's expectations for follow-up and support post-incident. Holding frequent "debrief" huddles to discuss an incident with involved staff provides them a safe space to share what happened, their feelings and concerns.

Successfully implementing these interventions requires buy-in and support from hospital and safety leaders along with a continued commitment by the organization to create a strong safety culture in inpatient psychiatric units and beyond. By providing these resources for staff and demonstrating dedication to creating a safe work environment, healthcare organizations can prevent the negative consequences of workplace violence and create a healing environment for staff and patients.

Learn more about Vizient's Patient Safety Organization.

Explore Vizient recommendations focused on mitigating common risks, identifying national guidelines and utilizing existing resources to ensure preparedness for an active shooter event at healthcare organizations.

To evaluate your workplace safety and get more information, contact Diana Scott at diana.scott@vizientinc.com.