Violence in Health Care Settings on Rise

By Bridget M. Kuehn, The Journal of The American Medical Association

In October 2006, Chicago dermatologist David Cornbleet, MD, was found stabbed to death in his downtown office. The assailant, according to media accounts, was a former patient, who later confessed that he had returned to Cornbleet’s office 4 years after his first visit and attacked the physician because he believed that the Accutane Cornbleet had prescribed caused impotence and other medical problems.

The case highlights the vulnerability of clinicians who may encounter patients who are agitated or distressed. In fact, many clinicians reported being threatened or attacked in a few recent surveys of clinicians working in hospital or private practice settings.

Clinicians are not the only ones at risk. In recent years, increasing numbers of patients and visitors at health care facilities have also fallen victim to violent crimes, including assault, rape, and homicide, according to a report released in June by the Joint Commission. Yet too often, clinicians and health care facilities neglect to take steps that may prevent such violence. New recommendations from the Joint Commission and other experts call for detailed safety plans and an aggressive response to reports of violence.

FACILITY SAFETY
Surveys of clinicians and surveillance by the Joint Commission indicate that violence at health care facilities remains a pressing concern. A Sentinel Event Alert issued June 3 by the Joint Commission noted increases in reports of homicides, rapes, and other assaults against patients or visitors by staff, visitors, patients, or intruders at US health care facilities since 2004. The agency has received 256 such reports since 1995, and its experts believe that such events are under reported. In recent years, the number of those reports was 36 in 2007, 41 in 2008, and 33 in 2009 (the latest data available).

Factors cited as contributing to such events include weaknesses in leadership’s development or implementation of policies (noted in 62% of events); problems, such as inadequate staff training or assessment (60%); inadequate patient assessment (58%), such as poor patient observation protocols or lack of psychiatric assessment; communication failures among staff and with patients and their families (53%); and deficiencies in the physical safety of the environment or in security procedures (36%).

The alert notes the challenges in securing a hospital, which is open to the public 24 hours a day. These difficulties are particularly great in high-traffic or high-stress areas such as emergency departments. Additionally, the alert emphasizes the potential for violence by members of the health care staff itself: “The stressful environment together with failure to recognize and respond to warning signs such as behavioral changes, mental health issues, personal crises, drug or alcohol use, and disciplinary action or termination can elevate the risk of a staff member becoming violent toward a patient.”

Clinicians may also frequently be the targets of assaults, according to data from the Bureau of Justice Statistics’ most recent Violence in the Workplace report. The report, which tracks incidents that took place between 1993 and 1999, found that violence against physicians occurred at a rate of 16.2 per 1000, while the rate among nurses was 21.9 per 1000; the rate among mental health care professionals was 68.2 per 1000 (compared with a total rate of 12.6 per 1000 among workers in all professions).

“Violence is often a reaction to passivity, helplessness, fear, and humiliation,” said Robert I. Simon, MD, clinical professor of psychiatry at the Georgetown School of Medicine in Washington, DC. In an interview, he listed examples of factors that might trigger a confrontation: patients may be afraid, they may be undergoing intrusive or painful procedures, or they or their family members may perceive a lack of empathy from clinicians. Some individuals may be volatile because of paranoia unrelated to the care they are receiving or have received.

Clinicians working in the high intensity environment of the emergency department may be particularly vulnerable. Susan Kansagra, MD, MBA, director in the office of the commissioner at the New York City Health Department, explained in an interview that emergency department clinicians often treat patients with conditions that may make them less able to deal appropriately with stress, such as substance abuse, mental illness, or demen- tia. In addition, factors such as long wait times or a patient’s feeling of loss of control may increase stress.

A recent survey of 5695 staff members at 69 US emergency departments (3518 surveys from 65 sites were ultimately analyzed) found that a quarter of emergency department staff feel safe only sometimes, rarely, or never (Kansagra SM et al. Acad Emerg Med. 2008;15[12]:1268-1274). Key informants from the participating departments, who were interviewed by the study authors, reported 3461 physical attacks—on average, 11 attacks per department—during a 5-year period. One in 5 of these key informants also reported that guns and knives were found in the department on a daily or weekly basis. Additionally, nurses were one-fifth as likely as other clinical staff to report that they felt safe “most of the time” or “always.”

Despite the safety concerns of staff, the departments often did not implement some common safety precautions. For example, only 14% of the key informants reported use of metal detectors to screen for weapons and fewer than half of the departments had a training program to prepare staff to handle violent situations, although the American College of Emergency Physicians recommends such programs.

VIOLENCE AGAINST NURSES
A survey of 3465 members of the Emergency Nurses Association seems to confirm that violence against nurses is alarmingly common (Gacki-Smith J et al. J Nurs Adm. 2009;39[7-8]:340-349). About one-quarter of the nurses reported that they had experienced physical violence more than 20 times in the past 3 years, and nearly 1 in 5 reported experiencing verbal abuse more than 200 times during the same period.

While violent or abusive incidents may be more common in busy hospital settings, physicians may also face threats in their offices.

A recent Canadian survey suggested that primary care clinicians are frequently targeted. More than 3802 members of the College of Family Physicians of Canada were randomly selected to be surveyed, but only 20% (774) responded (Miedema B et al. Can Fam Physician. 2010;56[3]:e101-e108). Of those respondents, 97.9% had experienced a minor incident of abuse such as disrespectful behavior or verbal threats; 75.1% reported at least 1 major abuse incident, such as physical aggression, destructive behavior, or sexual harassment; and 39.2% reported at least 1 severe incident of abuse, such as an assault, an attempted assault, a sexual assault, or stalking. The authors said that given the low response rate, physicians who had experienced abuse may have been overrepresented. However, they noted that even if none of the nonrespondents had experienced abuse, minor abuse would have affected at least 1 in 5 physicians, and severe abuse at least 1 in 12.

ONLINE THREATS
Clinicians are also grappling with online threats to their safety or reputation, said Simon. He noted that a tremendous amount of personal information, including home addresses and information about family members, can be found online and used to threaten, harass, or harm a clinician. For example, he noted a case in which a disgruntled patient sent pornography to the mother-in-law of a psychiatrist in the psychiatrist’s name.

“Someone could hurt you terribly without even laying a hand on you, by really besmirching your reputation,” he said.

In some cases, Internet postings may be warning signs. The patient who reportedly confessed to killing Cornbleet had posted numerous complaints about the adverse effects he experienced and had complained about Cornbleet in online patient forums, according to news accounts.

Simon noted that it may be difficult to remove all personal information from the Internet. However, he encouraged physicians to periodically search for online postings about themselves and to take action if any appear to represent a threat.

Preventing such violence requires a proactive approach. The Joint Commission alert recommended several steps health care facilities can take to curb violence, including the following:

- Evaluate the risk of violence at the facility and identify weaknesses in existing prevention programs.
- Enhance emergency department security, for example, by adding security officers or limiting or screening visitors.
- Thoroughly prescreen job applicants for criminal history and professional competency.
- Require training for staff on responding to agitated or violent individuals.
- Establish procedures for reporting incidents and train staff on how to report.
- Report crimes to the appropriate authorities.

Kansagra acknowledged that preventing violence in the emergency department may be challenging, but she said there are steps supervisors and administrators can take. For example, they can provide staff with training that helps them recognize when a patient or visitor is becoming agitated and implement techniques to defuse the situation. They should also ensure adequate staffing and consider changes to patient flow or the design of patient care areas to ensure that staff who are working with patients are visible to other staff members. Additionally, it is crucial that facilities encourage clinicians to report incidents, ensure that those who do report do not face reprisals, and address issues that these reports reveal.

“Supervisors can set the culture and tone for their staff, ensuring that violence should not be considered normal and should not be accepted,” Kansagra said.

Simon also encouraged physicians to develop a safety plan for their practices, incorporating such features as a panic button in examination rooms or a second door to facilitate escape from an aggressive patient. He emphasized that all clinicians and staff in the practice must be familiar with the plan and prepared to implement it.

“There should be a safety plan like a fire plan,” Simon said. “It’s a rare event [an assault in a practice setting], but an always-present threat.”