Violence In Healthcare

This post is not intended to be an indictment of any particular entity, organization, people or persons. It is merely an observation of what I have seen, experienced, and understand in regards to violence on healthcare providers.

Further this post will very likely, and by likely I mean it absolutely will not change anything. As I've grown older, I am far more knowledgable of institutional inertia than ever before. However that doesn't mean I shouldn't say the quiet part out loud. At least with that, I know I took the road less traveled. I took the time to make the covert more overt.

First the problem! Admittedly, I was not truly aware of the violence that occurs in hospitals and other medical facilities on providers until I worked in an ER in my given profession as a paramedic. Until then I had been on a truck for 30 years. And now working in an ED I have seen and experienced more violence in one year working in an ER than I did in 30 years on a truck. Thats not hyperbole, thats a fact.

Oddly I have found something else I never expected in the healthcare setting and this can also be extrapolated to most fixed medical facilities. They are a much more permissive environment for violence than I could honestly ever imagined! Despite the zero tolerance signs and despite the hype if you will, actual violence on providers takes a back seat to institutional training and doctrine.

Now it bares mentioning here most every HR and admin person will not believe that, nor will they entertain that notion, but it is in fact true! This was a complete shock to me! However I can guarantee any medical provider that does patient care who reads this will agree. Because I've had those conversations! They've experienced violence and most just accept it. And the ones who don't, many actually, leave the profession.

Don't take my word for it. Let me throw out a few statistics to bolster my point. Directly from the AHA, the American Hospital Association, these key findings.

The Burden of Violence to U.S. Hospitals:

A Comprehensive Assessment of Financial Costs and Other Impacts of Workplace and Community Violence

KEY FINDINGS:

• Violence, including workplace (in-facility) and community violence, abuse, and threatening behavior, is a significant public health issue affecting the U.S. health system and communities.

• This incidence of violence has significantly increased in the U.S. over the past decade, with rising rates of assault, homicide, suicide, and firearm violence, which were further exacerbated during the COVID-19 pandemic.

• This study sought to estimate the financial costs and other impacts associated with workplace and community violence.

• Hospitals experience substantial financial impacts from violence.

o The total annual financial cost of violence to hospitals in 2023 is

estimated at $18.27 billion U.S. dollars (USD).

o Pre-event costs associated with violence in the community and within facilities are estimated at $3.62 billion (USD), primarily for prevention measures.

o Post-event costs for healthcare,work loss costs,case management, staffing, and infrastructure repair are estimated at $14.65 billion (USD).

o The largest contributor to total annual costs came from post-event health care expenses to treat violent injuries.

• Additional impacts, like public perception, staff recruitment and retention, legal concerns, job satisfaction, and psychological harm to health care workers, are significant but difficult to quantify due to limited data.

If you'd like to read the full report you can simply search violence in healthcare. You'll find it's a much greater issue than most, even those working in healthcare, would imagine. Also I found it interesting that the AHA used the phrase, “the burden of violence.” I suppose one could say it's a burden, however that makes it seem more like something that is shouldered as a part of the job as opposed to any other descriptor.

Again, just searching the term will bring up a lot of articles all saying the same thing and most all have the same response to this problem which is education and training. What's most interesting about this is the same approach has been taken for sometime now and yet violence on healthcare providers continues to rise every year. Why?

I'll state the obvious here. Hospitals, healthcare facilities, doctors offices, etc allow the violent behavior to get much further. They are much more a permissive environment for violence and health care providers are routinely told to only the use the approved training! Now I'm not talking about the elderly dementia patient. Though they can and do become violent. But often it's short lived and/ or controllable. I'm talking about a patient, family member, friend of patient, who is younger and much more capable of real violence. Further, once the patient has been controlled, a much more meager approach is taken to keep the patient from becoming violent again. A least more meager than the protocols we had on the truck!

Again, neither of these are the case in my experience in EMS of 30 years on the truck. We looked for pre event indicators and we were more aggressive with chemical and physical restraint. By aggressive, I mean controlling the patient without using striking! Think 5mg of Versed on the truck versus 2mg Ativan and 25mg of benadryl in a medical facility! And if you're concerned about an airway issue or decreased respirations, there are medications and adjuncts for that eventuality. Paramedics live in both a basic and advanced airway schema and they aren't prone to let a patient stop breathing.

I've seen 2mg of Ativan and 25mg of Benadryl take a prolonged onset time while several providers are trying to hold a violent patient. Why?!

Before I continue and if you aren't familiar with my background. I built a defensive tactics program for Austin Travis Co EMS in Austin, Tx. I was able to export that program to Williamson Co EMS, Austin's neighboring EMS system, as well as to Haywood Co EMS in Western NC. And parts of the program especially the deescalation aspects to a group of Stand Alone ERs in Austin and Houston, and a small Surgical Hospital in Austin. I also took my program to Austin Parks at their request as well as Austin Fire Dept.

The training I provided is moral, ethical, and legal and has a heavy emphasis on pre event indicators and deescalation. The physical portion is about controlling the violent patient. My contention is a patient cannot be treated until they are under control, that force must parallel the danger, and that the patient goes from being a patient to an assailant, and back to a patient, so force must be titrated to effect to bring the violent patient under control and treat them safely and appropriately. My training does NOT advocate, nor teach striking. Nor have I invented any new super ninja tricks. My program is built from years of my own personal training jiu jitsu, wrestling and other pieces that gain and maintain control of the violent patient, or you can simply disengage safely. Again the biggest part of what I teach is recognizing the warning signs and deescalation.

Now I'm not saying hire me and you worries are over. Nor is this an advert for my training. What I am saying is I understand violence and I understand healthcare. What I don't understand is why so many facilities across the nation choose to provide ineffectual check the box training, and let providers fend for themselves. Again I refer you to the escalating violence issue despite the training provided for years now.

Well it's not completely true that I don't understand. I understand that facilities are more concerned about litigation and optics from the violent patient point of view than they are for the provider who got assaulted. You can ask any nurse, doctor, or healthcare provider whose been assaulted and most will say admin was less than helpful. And thats putting it mildly. I also understand that our current narratives in society are that of empowering the violent since they are the post modern victims of society when the actual victims of the violence just shrug and expect no support or simply leave the profession they've spent a lot years of education, time, and money on. Not to mention rocking the boat at the organization they currently work where the assault occurred.

There are a few programs hospitals employ to train their people and I have taken one of these. CPI to be exact and there are some aspects of CPI I think are valid-ish! The parts concerning someone who is anxious or in crisis aren't bad. And CPI has some reasonable responses to this. Where it falls woefully short is when actual violence occurs, when things become kinetic it is entirely ineffectual. I would posit that I could be a violent patient with no training, only ill intent and the tactics CPI teaches would not allow a provider to control me and in fact the provider would be more apt to become injured using CPI physical tactics. Now thats certainly just my opinion but I am willing to back that up with anyone who feels that CPI provides them the ability to both protect themselves and bring a truly violent patient under control safely, effectively, and efficiently. More especially given the tenor of once a year training in unrealistic scenarios. I would welcome a chance to test my theory quite honestly.

As I stated in the beginning of this post my opinion won't make any kind of difference. The issues keeping healthcare from any real change in its security posture will always be there and honestly it's the same issue with most organizations. If it's important to the company they'll budget for it, if its not, they won't. And more often than not litigation and optics, as well as patient satisfaction rates are much more important than healthcare providers being assaulted.

As of this writing two nurses not too long ago were murdered in the parking lots of their respective hospitals. One in Houston and one in Alabama. This isn't anything new to the nursing community. Whether it's in hospital or on the grounds. This is unacceptable yet I doubt any more security will be forthcoming. There may be for a time and then the hulabaloo dies down and admin will say what every person whose ever paid for security eventually says, nothing else has happened so why are we paying you?! They don't see what was prevented from having security, they only see the money they're paying.

I don't like to point out a problem without offering a solution so if I were in charge of a hospital and its security. These are the things I would seek to implement.

First training that is effectual and standardized, and most importantly pressure tested. Not all providers are built to be effective in this. Have specific staff that are willing to take the training and respond to events and be allowed to use that training. Being allowed to utilize effective training is a big key here.

Have an after action on each event and document them. Not as a punitive device but for learning purposes.

Have a security force for the facility that are sworn police officers such as Company Police. I have nothing against security guards however a sworn LEO is better trained, has arrest powers, and has more authority.

Provide a roving security patrol in the parking lots especially after dark. Criminals are smart, they understand patterns of life just as much as security professionals. Maybe not to the same degree but they understand someone walking alone to their car in the dark after a long 12 hour shift is an enticing target.

And lastly for admin, don't send mixed signals when an event occurs. Get the story and make sure it follows the TTPs. If not, reeducate, if so do not simply say I'm sorry that happened and what could you have done better. I can assure you when a patient has become an actual assailant and punching you in the face and you then control the patient safely and effectively despite being punched and do it with no emotional vitriol and physical control while not raising your voice, the last thing you want to hear is what could you have done better. Theres no better way to tell an employee who handled a situation well that you only care about possible litigation and if the check the box training was followed.

And lastly, press charges. But I also feel that's up to the person being attacked. And in my opinion, the facility should press charges on behalf of the assaulted employee. I also realize that this will inspire fret and condemnation from HR and Admin. Although I would venture to guess that an HR or Admin person who was similarly assaulted in the street, or even in facility would be inclined to press charges because it was them who was assaulted, not just some employee.

Again these are just my thoughts on the subject and I think we all know that nothing will change within healthcare as far a violence on providers. The violence will continue to rise. Healthcare already has the highest rate of violence among allprofessions, including law enforcement. And most if not all healthcare facilities think its a bad optic to press charges. I can tell you it's much worse optic to your employees. You know, the ones who provide the medical care.

One other caveat. This post isn't a shot towards any one facility or person. This is a literal healthcare epidemic. Violence on providers isn't going away, in fact it gets worse every year. And it will continue to do so because if we always do what we've always done, we'll get what we always got. But I would remiss if I didn't at least say my peace on it! I have no illusions that things will change, but I am great at tilting at windmills!

Anyway here endth the rant! W