Safety Culture & Virtue 4: Violence (9 mins)

What is the intersection between safety and security? This episode shares some of my adventures at the bedside and explores opportunities to strengthen safety culture with best practices in security.

Key Points:

-Violence is prevalent

-TJC on violence in healthcare

-Safety and Security

References:

-The Joint Commission (May 15, 2024). 2023 Sentinel Event Data Annual Report. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/may-15-2024/now-available-2023-sentinel-event-data-annual-report.

-Markovitz, S.; Grimes, C. (Sept. 1, 2022). Violence Against Healthcare Workers Is At An All-Time High: Here’s How Workplaces Can Keep Them Safe. Forbes. https://www.forbes.com/sites/coronavirusfrontlines/2022/09/01/violence-against-healthcare-workers-is-at-an-all-time-high-heres-how-workplaces-can-keep-them-safe/.

Transcript

Nurses are on the frontline of violence. And patients, already vulnerable from disease and disability, are at particular risk to the volatile environment of a healthcare organization. The current attention given to reducing and mitigating violence in healthcare and preventing patient and staff assault is completely warranted.

Let me explain. Thankfully, I was never a victim of assault, despite working in some pretty dangerous situations. But one of my colleagues was brutally murdered. She was a cheerful grad student who wore colorful headbands and made everyone around her feel like the world was a better place because she was in it. It was profoundly jarring to get report from her one day and hold a memorial service just a few days later. 

Other experiences included a prisoner escape with a gun who was tackled by a nurse, and or a jumper that climbed the roof of nearby building on display before frightened patients and their families – thankfully, the jumper came down safely and everyone was okay. Another time, the unit was in a state of stress because a colleague feared that their relative had been kidnapped in Mexico by the cartel because they took a long time at the dentist. Another time, we had a suspicious visitor frequenting the newborn nursery, but our former marine turned security guard noticed and stopped it. 

We cared for patients who were cartel and Texas Syndicate prison gang members, many of whom sported tattoo teardrops extending down the length of their bodies to mark their personal record of kills. There were patients who were victims of trafficking and kids who had been abused by coyotes crossing the border. One man had drugs smuggled into the hospital and immediately had a very noisy bad trip. Other times, domestic disputes were carried into the facility and required a call to the police. We’ve had a lot of colorful experiences, but we always did our best to take care of each other and do our best for our patients, regardless of their past. You’ve never seen gratitude until you’ve offered a sandwich and apple juice to a prisoner who can’t sleep at night.

 One reason that I could work in this environment without experiencing harm from the violence around me is because my coworkers watched over each other. Well, that and a lot of prayer. But we each took personal responsibility for the safety of the team and watched for signs that someone might need help. If anyone on the team was in a bind, the team rallied. We ran into the fire rather than away because we wouldn’t leave each other exposed.

On my first day of work at one institution, my trainer told me, “Don’t ever go in a room alone with that doctor. He felt up a nurse that looked just like you, and she had to leave when she reported it. That’s how it goes, the nurse has to leave because the doctor is more difficult to replace. But we’ll watch out for you, ‘cause we want you to stay. The other guys and I, we always follow him when he rounds. But if we’re not around, get out of the room when he comes in and don’t let him shut the door.” While I did pause and question my life choices after that, I found that I generally felt safe at work because I was never alone. I believed I could trust my team to show up in an emergency. That team mentality was so strong on the nursing team, and we really did watch out for each other: whether it was a potential physical risk, or even an emotional risk because we would reassign patients that might cause personal distress to a nurse. I have heard from friends that the herd mentality is not present among physicians and allied health teams, which is unfortunate, because it is the saving grace of the nursing team.

But I’ll never forget the the night a patient directly threatened me. He asked which entrance I used when I came and left work. He wanted to know which car I drove, what time did I usually come in to work, and what days did I work. Obviously, I said nothing, but he discharged a few hours before my shift ended, which meant he was free to go where he wanted and wait for me to exit the building. I don’t mess around with that sort of threat, so I reported it, and I determined I would call for a security escort to my car. There was no lighting in the lot, the hospital was in a shady part of town, it was late at night, and there were no emergency alarms to call for help if something went wrong. When I asked for an escort to my car, the security guard implied that I was being over-dramatic. I was floored. Thankfully nothing happened, but from that point forward my husband drove me to work and picked me up.

No healthcare organization should ever become comfortable with a baseline level of violence. Staff should not risk their lives just to go to work. While we can’t control everything, we can work to manage obvious threats. And even though we certainly cannot change the entire community around us, we can learn to deliver care in imperfect circumstances just like the healthcare heroes of history (because dangerous places need healthcare too). 

Did you know that The Joint Commission’s 2023 annual report highlighted how acts of violence had risen dramatically, representing 8% of the approximately 1,400 sentinel events in 2023?[1] The risk is increasing; so should our attention to mitigating that risk.

The humanitarian heroes of the past formed protective guidelines for patients and civilian health workers based on a clear ethical framework. This reality hints at why security implementation is one of the assessments for a virtuous safety culture. If we don’t protect our own team’s safety, then we can hardly argue that we are protecting patients effectively. That’s why the Geneva Conventions themselves specifically require humane treatment for all persons in enemy hands, without any adverse distinction. This is a moral good, but it is also intensely practical because it would be impossible in a chaotic environment to judge whether safety is deserved by a person. It’s far better to apply best practices for safety to all persons than to occupy precious clinical attention to extensive moral questioning. It is part of the ethics of healthcare to provide evidence-based, compassionate care to all patients, regardless of their legal status, criminal record, demographics, or physical or mental state, and healthcare workers are meant to be outside the conflict.

But clearly, there are a lot of legitimate physical threats to caregivers. What can be done to protect people in a place that is fraught with tense emotions? Well, Forbes published an article describing practical security methods to keep everyone in the hospital safe, including metal detectors, cameras, panic buttons, safety badges, improved lighting, and limiting traffic.[2] They talked about scheduling and virtual visits and the role that telehealth can play in reducing the potential for violence in healthcare. These are great ideas because they are practical, system interventions with evidence to support their use.

Personally, I can say that I saw a difference at my workplace when we hired an off-duty police officer to remain in the ER at all times. There was a measurable reduction in the incidence of violence. We also had active shooter training, and we were taught negotiation tactics in case we answered the phone when a bomb threat was called in. These practical interventions not only increased our physical safety awareness and prepared us for difficult situations, but it also demonstrated that the organization valued our safety and was willing to invest in it.

So today’s assessment is to call security and ask for an escort to your car. If a security guard shows up promptly with a professional attitude and asks about any perceived threats, then give yourself a point. If they make you wait more than 15 minutes, fail to ask why you requested additional safety measures, or otherwise act unprofessional, it’s time to elevate your institution’s security at the administrative level. Update your policies for various threats and do a thorough review of security items like lighting, traffic, incident response, and video surveillance. Ask staff if they know about safety measures and set aside time for some security-related drills.

[1] The Joint Commission (May 15, 2024). 2023 Sentinel Event Data Annual Report. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/may-15-2024/now-available-2023-sentinel-event-data-annual-report.
[2] Markovitz, S.; Grimes, C. (Sept. 1, 2022). Violence Against Healthcare Workers Is At An All-Time High: Here’s How Workplaces Can Keep Them Safe. Forbes. https://www.forbes.com/sites/coronavirusfrontlines/2022/09/01/violence-against-healthcare-workers-is-at-an-all-time-high-heres-how-workplaces-can-keep-them-safe/.