Discussion: Non-Emergent ER visits
INTRODUCTION

Workplace violence can happen anywhere, at any time, and to anyone. In 2009, there were about 575,000 nonfatal workplace violent crimes committed in the United States (Harrell, 2011). Between 2005 and 2009, approximately 10 percent of the workplace violence victims were employed in the healthcare industry (Harrell, 2011). Research suggests that this rate may be considerably higher since incidents due to the lack of a standard definition of workplace violence, underreporting, and the lack of mandated regulations for workplace violence prevention (Gerberich et al., 2004). Most occurrences are nonfatal, but they are still capable of causing serious injuries and having multiple consequences for the victim and the organization for which they work. The perpetrators are often patients and it is an all-too-common problem in healthcare, which has been tolerated and widely overlooked. Every healthcare facility should consider developing a workplace violence prevention program with strategies focused on managing violent patients to better protect their employees and create a safer environment. This paper reviews how violence from patients can affect healthcare workers and an organization by causing injuries and physical trauma,

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lowering quality of care, and increasing costs. Furthermore, it discusses potential solutions such as prevention training and how a new plan can be implemented to decrease incidents of patient violence against healthcare workers. According to the National Institute for Occupational Safety and Health (2002), workplace violence is defined as any act or threat of violence directed at someone who is at work or on duty. The violent person could be an employee, patient, visitor, or even someone with no legitimate relationship to the employee or organization. Healthcare workers experience a significant amount of workplace violence, especially from the patients they are caring for. Patients are the main source of physical violence in the healthcare setting, which is categorized as Type II violence since it is the recipient of service who becomes violent towards employees (Wax, Pinette, & Cartin, 2016).

Between 2011 and 2013, the average number of workplace assaults were 24,000 per year, of which almost 75% occurred in healthcare settings and data suggests that healthcare workers are four times as likely to have missed days due to workplace violence and injury (Phillips, 2016). Other studies show a growth in the number of injuries from workplace violence for all healthcare workers with workplace violence almost doubled for nurses and nurse assistants between 2012 and 2014 (Gomaa et al., 2015). Of the workplace violence injury reported, 49 percent were specified as being physical, verbal or destruction of property, and 99 percent were physical assaults (Gomaa et al., 2015). Furthermore, from the reports where the perpetrator type was specified, 95 percent of them were identified as patients (Gomaa et al., 2015). In a study done by Crilly, Chaboyer, & Creedy (2004), 70 percent of the emergency department nurses reported a total of 110 violent incidents from patients in a span of just five months. This averages out to about 5 incidents a week (Crilly, Chaboyer, & Creedy, 2004). Another study found the type of verbal violence towards nurses was usually shouting and cursing. While physical violence was typically an employee being grabbed, scratched, or kicked (Speroni, Fitch, Dawson, Dugan, & Atherton, 2015).

Common barriers to patient violence prevention are underreporting and the culture of acceptance. Most violent incidents are not reported by healthcare workers due to the lack of reporting policies at their organization, feeling too busy, assuming that an incident is too minor or unnecessary to report, fear of being judged or blamed, and some have even become accustomed to violence (Gacki-Smith et al., 2009; Gerberich et al., 2004). The culture of acceptance is a further contributor to the lack of reporting on account of many healthcare workers thinking violence is a part of their job and unavoidable. This may be the result of a lack of appropriate procedures, the absence of management support, and feeling like abuse is expected from certain patients. Identifying the risk factors and possible solutions can help break down these barriers.

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LITERATURE REVIEW

There are numerous risk factors associated with patient violence against health care workers in hospitals. Many healthcare workers are vulnerable to becoming victims but nurses are believed to encounter violence the most while on the job (Gerberich et al., 2004). In terms of healthcare settings, long-term care facilities, emergency departments, and psychiatric departments have an increased possibility for violence (Gerberich et al., 2005). Patients typically classified as high risk for violence consist of people who are under the influence of drugs or alcohol, have a history of mental illness, and previous offenders (Crilly et al., 2004; McPhaul, & Lipscomb, 2004). Feelings of stress or not having control stemming from their illness, injury, or fragmented services are also common causes of violent behavior from patients (Gates, 2004). In addition, there are other circumstances that can lead to patients becoming violent towards medical staff. Transporting patients, working when understaffed or alone, long wait times, poor environmental designs, poorly lit areas, inadequate security, and lack of formal training can heighten the risk of violence (McPhaul, & Lipscomb, 2004; OSHA, 2016).

When a healthcare worker becomes a victim of violence it can have both physical and mental consequences. Physical injuries may be minor or severe and are capable of causing temporary or permanent disabilities. Some victims may even struggle with short- and/or long-term psychological trauma, which could cause anxiety, depression, and post-traumatic stress disorder (Gerberich et al., 2004; Texas Department of Insurance, n.d.). These consequences can, in turn, have an impact on job performance, morale, and decrease the quality of care for patients.

The repercussions of violence are capable of going beyond the victim. Often times, the employer or organization will take on the cost of caring for the employee’s injuries, time taken off from work, medical leave, workers’ compensation, increased turnover, and legal action against perpetrators. Each incident bears its own distinct costs that may be astronomical. For example, one organization’s annual cost for nurses who experienced workplace violence was $78,924 for treatment and $15,232 compensation for lost wages, which added up to $94,156 (Speroni et al., 2015). The national costs for workplace violence in hospitals are estimated to be $234.2 million for staff turnover, $42.3 million in medical care and lost wages compensation for employee victims, and $90.7 million for disability and absenteeism (Van Den Bos, Creten, Davenport, & Roberts, 2017).

Despite its economic burden, there are no federal laws that directly apply to violence against healthcare workers. However, with increasing recognition, some states have passed laws regarding assaults against healthcare workers. In 2013, Texas made it a felony to assault healthcare workers providing care in the emergency department (Houston Chronicle, 2013). Other states that have implemented policies pertaining to violence against healthcare workers include Delaware and New York. Delaware made assaulting emergency personnel a felony

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in the second-degree (Emergency Nurses Association, 2016) while New York has legislation making the assault of all registered and licensed practical nurses on duty a felony (The New York State Senate, 2010).

In addition to state initiatives, some change has occurred within organizations. For example, Mission Health, a hospital system based in Asheville, North Carolina, formed a Behavioral Emergency Response Team to help prevent assaults against employees in one of their hospitals (Stempniak, 2017). In its implementation process, Mission Health used data analysis and continuous improvement to assist with designing the team and procedures used for each at-risk unit. When a patient’s behavior escalates and staff members are unable to ameliorate or stop the event a call is made to the hospital operator. At that time, the operator sends a “Code BERT” to initiate the 24-hour response team’s arrival within 15 minutes. A behavioral health clinician is made available to guide any necessary verbal de- escalations, medication is administered by a primary nurse (as needed), the team debriefs everyone, and house supervisors proceed to round on the patient daily (Stempniak, 2017).

In the first year of the program, approximately 75 percent of the nurses surveyed from Mission Health reported feeling safer in the workplace and more comfortable caring for patients with behavioral health emergencies. Moreover, there was a reduction in the number of missed days due to injuries, as well as the number of reportable assaults since 2013. These were the only nationally benchmarked statistics connected to workplace violence. In light of its success, Mission Health plans to expand this initiative throughout its facilities and are researching more ways to reduce assaults in their emergency departments. Its chief quality officer advises that it is important for organizations to utilize reliable data, however, they should not get overwhelmed by the numbers. Instead, hospitals may want to consider testing a strategy, make improvements, re-test, and then repeat (Stempniak, 2017).