Workplace violence in trauma centers: an American Trauma Society Position Statement

Summary

In 1966, the National Academy of Sciences and National Research Council published ‘Accidental Death and Disability: the Neglected Disease of Modern Society’ which served as a national call to action to address the apparent public apathy towards the devastating and unnecessary toll that injury was taking on America. This white paper recommended the establishment of a National Trauma Association to drive public demand for injury prevention and mitigation. The American Association for the Surgery of Trauma heeding that call, founded the American Trauma Society (ATS) in 1968. Since its founding and with a mission of ‘Save Lives. Improve Care. Empowering Survivors’, the ATS has had a 56-year legacy of service to improve trauma care by providing professional and public education, advocacy for injury and violence prevention, and attending to the unique needs of trauma survivors and their families.

As a focus of the ATS’s advocacy efforts, the ATS’s Legislative and Policy Committee (LPC) formulates the organization’s legislative goals and strategy by reviewing proposed legislation and regulations that may favorably or adversely affect trauma professionals, and disseminating key information as position statements to the membership and public for edification and/or action. In accordance with this effort, the ATS has partnered with the Trauma Surgery and Acute Care Open to publish these important collaborative endeavors.

For this inaugural publication of an ATS position statement, the topic we chose is workplace violence (WPV) in trauma centers. A work group of the ATS’s LPC reviewed current literature gathered from a variety of organizational and agency sources addressing safety and protection of healthcare providers from WPV including federal and state legislative and regulatory initiatives. Based on the work groups review, we provide eight recommendations regarding the prevention, mitigation, or handling of WPV. We also review and discuss best practices and risk mitigation strategies, providing a listing of them in an accompanying appendix.

The American Trauma Society endorses several specific measures to support and protect trauma center personnel from workplace violence

Trauma centers should

• Advocate for Congress to pass the ‘Workplace Violence Prevention for Health Care and Social Service Workers Act’^{1 2} and H.R. 2584, the ‘Safety from Violence for Healthcare Employees Act (SAVE Act)’³ in the current session.

• Petition local and state jurisdictions for increased criminal penalties for threatening and/or assaulting any healthcare worker.

• Work to ensure that regulatory agencies implement and enforce legal mandates to support workplace safety for all types of healthcare workers.⁴

• Institute a policy of zero tolerance for workplace violence (WPV) that clearly conveys the message that all threats or incidents of violence towards trauma center personnel will be investigated.^{5 6}

• Offer ongoing training for trauma center staff on workplace safety.^{5 6}

• Promote a culture of safety and non-violence through periodic workplace inspections and staff surveys.^{5 6}

• Work collaboratively to promote a culture focused on accountability to proactively minimize exposure to hazards in the workplace.^{7 8}

• Support research on the epidemiology of WPV in trauma centers.⁹

Background

According to the Occupational Safety and Health Administration (OSHA), ‘workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide’.¹⁰ The Bureau of Labor Statistics reports that healthcare workers are five times more likely to suffer a workplace violence (WPV) injury than the general working population and they accounted for 73% of all non-fatal workplace injuries and illnesses due to violence in 2018.¹¹ In 2019, US hospitals recorded 221 400 work-related injuries and illnesses and a rate of 5.5 work-related injuries and illnesses for every 100 full-time employees. This is almost twice the prevalence for private industry as a whole.¹² Hospital safety directors report that aggression against staff escalated as the COVID-19 pandemic intensified in 2020¹³ with 44% of nurses reporting they experienced physical violence during that period.¹⁴ The WHO estimates that up to 38% of healthcare workers experience physical violence during their careers.¹⁵

Nearly 50% of emergency physicians say they’ve been assaulted, and 70% of emergency nurses report being hit or kicked on the job.¹⁶ One prominent healthcare performance improvement company estimates that ‘more than two nursing personnel were assaulted every hour in Q2 2022. That equates to roughly 57 assaults per day, 1739 assaults per month and 5217 assaults per quarter’.¹⁷

The National Institute for Occupational Safety and Health classifies WPV into four basic types.¹⁸ The most common type to affect healthcare workers involves a patient, family member, or visitor that becomes violent while receiving services. Others include actions of a criminal nature, verbal abuse, threats and violence from a coworker, and interpersonal violence of a domestic nature can also occur in healthcare settings. Intentional workplace injury inflicted by another person, although not isolated to healthcare workers, can include gun violence, stabbing, cutting, slashing, piercing, hitting, kicking, beating, shoving, strangulation, arson, rape and sexual assault, intimidation, threats, and verbal assault.¹⁹

Evidence on the epidemiology of WPV specific to trauma centers compared with the overall healthcare workforce in the current literature is very limited. For example, the categorization of trauma centers is not specified in studies related to violence occurring in emergency departments. Further studies would be beneficial to analyze if trauma center personnel are at greater risk for WPV.⁹

Recent accreditation and regulatory efforts

According to the American Nurses Association, nearly 40 states have laws that establish or increase penalties for assaults on healthcare workers.²⁰

In 2021, the Joint Commission (TJC) added WPV prevention criteria to their standards for several areas of evaluation. The ‘R³ Report’ is a publication by TJC that provides the rationale and references used in the development of new requirements and applies to all TJC-accredited hospitals and critical access hospitals. This report addresses worksite analysis, data collection, education and training, in addition to a culture of safety and quality.⁷

In November 2022, the Centers for Medicare and Medicaid Services issued QSO-23–04-Hospitals, a memorandum under the Emergency Preparedness Conditions of Participation, to require hospitals to educate and train staff to identify patients at risk of harm to self or others, develop mitigation strategies, and enact policies and procedures to protect both the workforce and patients.²¹

In 2023, OSHA developed a regulatory framework to demonstrate the provisions that a proposed rule could include and notified the Small Business Administration Office of Advocacy of its intent to initiate procedures under the Small Business Regulatory Enforcement Fairness Act (SBREFA.) In February and May 2023, OSHA reopened Docket No. OSHA-2016–0014 to allow for the submission of documents and comments related to WPV in healthcare. However, OSHA’s authority to implement meaningful rules is lessened by the Regulatory Flexibility Act, which requires OSHA to consider significant regulatory alternatives that achieve its statutory objectives while minimizing any significant economic impact on small entities. The SBREFA Panel efforts towards a potential standard to address Prevention of Workplace Violence in Healthcare and Social Assistance sectors concluded on May 1, 2023. The Agency’s Issues Document, Preliminary Interim Regulatory Flexibility Analysis, the SBREFA final report, and draft regulatory framework can be accessed at https://www.osha.gov/workplace-violence/sbrefa.

Current federal legislative efforts

The ‘Workplace Violence Prevention for Health Care and Social Service Workers Act’ would require the Department of Labor, through OSHA, to issue a new national standard requiring healthcare and social service sector employers to develop and implement WPV prevention plans to better protect their workers and respond appropriately to WPV incidents. In 2022, the bill passed Congress with bipartisan support in the House of Representatives but stalled in the Senate. It has been reintroduced in the 118th Congress as H.R. 2663/S. 1176.^{1 2}

In a related proposal, H.R. 2584, the ‘Safety from Violence for Healthcare Employees Act (SAVE Act)’ is modeled after the federal statute protecting aircraft and airport workers and would make it a federal crime to assault or intimidate a hospital employee and as a result interfere with the ability of that employee to perform their duties. Enhanced penalties would apply to acts that involve dangerous weapons, result in bodily injury, or are committed during an emergency declaration. The bill also would establish a federal grant program at the Department of Justice to augment hospitals’ efforts to reduce violence, by funding violence prevention training programs, coordinating with state and local law enforcement, and securing physical plant improvements, such as metal detectors and panic buttons.³

Impacts of WPV on the healthcare workforce

The risks to the healthcare workforce can be broadly categorized into three main areas: psychosocial, financial cost, and physical injury. The psychological effects of WPV on the healthcare workforce include demoralization and increase in anxiety, sleep disorders, burnout, and secondary traumatic stress.²² The severity of consequences generated from WPV are related to the levels of stress experienced.²³ Healthcare workers who repeatedly experience aggression present with higher levels of depression, insomnia, generalized fear or other emotional sequelae that may lead to post-traumatic stress disorder or burnout.²⁴ It has been reported that burnout affects almost 50% of emergency department healthcare workers.²⁵

There are both individual and system impacts of WPV due to expenses incurred for added security measures, lost wages, and legal and medical bills. In addition, there are the indirect costs of decreased productivity and staff turnover. The costs associated with non-fatal WPV in healthcare settings have been estimated to range from $109 000 per year for indemnity and treatment among injured nurses to over $330 000 per year in a single hospital system.²⁶ There are costs associated with staff turnover. It has been estimated that it may cost a hospital between $500 000 to $1000 000 to replace a single physician.²⁷ There are more indirect costs related to the negative impact that burnout has on productivity. One meta-analysis reported that there is a 30% reduction in work effort for each 1-point increase in burnout as measured by a 7-point scale.^{28 29}

The negative impact on workforce productivity and retention that results in staffing shortages also impacts the ability of patients to access quality care. WPV is associated with decreased job satisfaction and poor patient care outcomes, and negatively influences worker commitment to healthcare organizations. Such widespread violence may ultimately affect the delivery of care as more healthcare workers abandon their professions.²⁸

Best practices/risk mitigation

Risk mitigation falls under three primary categories: environmental considerations, administrative considerations, and individual considerations. Environmental strategies may include alarm systems, security devices such as metal detectors and cameras, workspace designs, securing access to ‘Staff Only’ areas and exits. Administrative interventions may include establishing a commitment to and culture of safety that encourages incident reporting, enforcing zero tolerance policies, ensuring proper staffing and education, responding to safety reporting occurrences, and supporting debriefings, and drills. Trauma centers should develop clear policies defining those behaviors classifiable as instances of WPV based on local, state, and federal statutes. These policies should also define the reporting process and consequences of infractions should they occur.

As to individual considerations, trauma center personnel can help to mitigate risk for personal harm by maintaining situational awareness, participating in safety training, practicing effective communication with patients and supporting coworkers. Trauma centers should provide staff training, focusing on WPV recognition, reporting, and protective measures (eg, de-escalation training, self-defense training, and active shooter simulations, etc). This effort should be framed such that safety for the individual as well as the team is prioritized.

Several professional organizations offer resources and tool kits to promote safety and accountability in healthcare. For example, the American Hospital Association published ‘Creating Safer Workplaces: A guide to mitigating violence in health care settings’ in 2021.⁵ In 2022, the American Organization for Nursing Leadership and the Emergency Nurses Association jointly released and updated ‘Guiding Principles on Mitigating Violence in the Workplace’.⁶ An expanded sampling of trauma center risk mitigation strategies is included as table 1 to this position statement.^{5 6 30 31}

Table 1. Trauma center risk mitigation strategies.

Environmental considerations	Emergency signaling, alarms, and monitoring systems Security devices such as metal detectors to prevent armed persons from entering the hospital Security devices such as cameras and good lighting in hallways Security escorts to low-traffic and high-risk areas including parking lots at night Waiting areas to accommodate and assist visitors and patients who may have a delay in service Triage area and other public areas designed to minimize the risk of assault Enclosed staff areas and nurses’ stations Deep service counters or bullet-resistant and shatterproof glass enclosures in reception areas Arranging furniture and other objects to minimize their use as weapons Secured staff only rest areas Evacuation exits
Administrative considerations	Management commitment, including the endorsement and visible involvement of top leadership Clearly defined workplace expectations that convey a culture of respect at all levels including intolerance for incivility and bullying among coworkers Zero tolerance policies (including prominent signage for hospital visitors addressing violence, supporting staff in the removal of perpetrators of unruly behavior from hospital property, and the willingness to support legal action for violations) Disruptive and violent patient behavior policy and agreements Emergency communication systems Proper staffing Workplace analysis and violence prevention plans Hazard identification and remediation Event reporting systems and data analysis Analysis and improvement of operational factors that cause patient delays Prevent unrestricted movement of the public in clinical areas Post incident debriefings Employee assistance programs Collaboration and relationships with local law enforcement Violence risk assessment tools Information sharing among healthcare organizations Safety stand-downs Drills and exercises
Individual considerations	Situational awareness Take the initiative to seek education and training Improve skills related to situational awareness and de-escalation techniques Communication with patients and family members about long waits Provide support to coworkers that are verbally or physically assaulted and encourage incident reporting

The American Trauma Society (ATS) membership supported the development of this position statement which was subsequently approved by the ATS Board of Directors. Be advised that our recommendations strive to be evidence-based when possible but are non-binding. Any given healthcare entity, facility, or trauma center must interpret the issue within the current context of their capabilities and may therefore vary in their capacity to adopt aspects or recommendations of any ATS Position Statement.