Responding to Violence in Healthcare

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Responding to Violence in Healthcare

Violence in healthcare settings—especially in hospital emergency departments—is on the rise. A well-trained security team working in concert with the medical team can help manage this increasing violence.

The problem. In February 2017, The Joint Commission, a healthcare accreditation organization, reported, "Anyone in a health care facility can become a victim of violence. Since January 2010, The Joint Commission has received 201 reports from its accredited organizations of violent criminal events. Excluding the 16 reports of shootings…the database includes 118 reports of rape, 32 reports of homicide, 28 reports of physical assault, and seven reports of sexual assault." More than half of the incidents were patient-on-patient violence; six of the physical assaults were patient-on-staff violence.​ 

While healthcare workers make up less than 10 percent of the U.S. workforce, there are nearly as many violent injuries in the healthcare industry as in all other industries combined, Alexia Fernández Campbell reported in a December 2016 article in The Atlantic. She also cited a 2015 study, where 76 percent of nurses at a private hospital system in Virginia said they had experienced physical or verbal abuse from patients in the previous year. 

According to The Joint Commission, "A recent Occupational Safety and Health Administration report on workplace violence in healthcare highlights the magnitude of the problem: while 21 percent of registered nurses and nursing students reported being physically assaulted, more than 50 percent were verbally abused…in a 12-month period. In addition, 12 percent of emergency nurses experienced physical violence, and 59 percent experienced verbal abuse during a seven-day period." 

The California Division of Occupational Safety and Health adopted standards requiring hospitals to establish workplace violence prevention plans to protect healthcare workers and other facility personnel from aggressive and violent behavior. To identify risks, to report them, and to annually evaluate them are normal safety requirements in at least 16 U.S. states. 

Joint Commission standard EM.02.02.05, EP 3 calls for hospitals to clearly explain how personnel are to respond to violence in their management plans. Specifically, "The Emergency Operations Plan describes how the hospital will coordinate security activities with community security agencies." Hospitals are to include preparation for emergencies such as an active shooter situation. 

Training. When the incident rate of aggression is high, the security team can be trained to use advanced confrontation techniques which enable them to manage the most aggressive patients. Of course, security officers work under the supervision of medical staff, and they should use only defensive techniques to control patients. 

Training for de-escalation and other responses to aggressive behavior is provided by such companies as Crisis Prevention Institute, MOAB Training International, and AVADE. It is important for the trainer to address the healthcare facility's security management plan during the sessions. 

Security officers can learn verbal judo and simple defensive techniques in as little as four hours; however, those working in high-incident areas will benefit from longer training sessions. Costs usually include a student workbook, the trainer's fee, and the student's wage. 

At one facility where more than 20 patient watches occur each day, the staff is subject to potential violence. The immediate availability of highly trained security specialists helps to keep the area as safe as possible. The security team finds weapons, places aggressive patients into restraints (on medical authority), and occasionally assists police with responses to violence in the hospital. 

The training of the security specialists at that facility focuses on use of the AVADE (Awareness Vigilance Avoidance Defense Escape/ Environment) defensive techniques. This training shows how a 120-pound person can quickly take down an attacker weighing more than 250 pounds. Size of the security officer is not as important as the quality of the training. 

Proper training can not only improve the security response but also help prevent injuries to security, staff, and patients. When medical staff observe a demonstration of a physical response by a well-trained security officer, confidence in the whole security team is enhanced. 

Securitas has five area trainers who provide de-escalation training and emergency department response team training at a large healthcare system. In class, the trainers address the safety issues of the environment, position of staff, responses to aggressive behavior, and restraints. After such training, the medical staff and the security staff work much more efficiently together. Additionally, the trainers provide security awareness training for all staff for normal security issues such as identity theft, safety in parking lots, and other personal safety issues. 

Response. Techniques for responses to aggression usually address early identification of violence or escalation of violence so that efforts to de-escalate could prevent a crisis, such as an assault. Security teams working in the emergency department are in position to identify the escalation of unacceptable behavior. When intervention is needed, the security team and medical personnel should work together as a response team. 

Typical incidents to which security may respond are: a person with a severe behavioral health disorder who becomes combative; a dementia patient who walks away from healthcare, is lost, and does not communicate coherently; and a drug seeker who threatens medical staff when specific drugs are not prescribed. All of these examples may result in injury to the medical staff if physical intervention does not occur promptly. Security officers may attempt to de-escalate and control the patient so that the medical staff are safe to continue their work. 

In one situation, police responded to de-escalate a behavioral health patient. When the situation appeared to be safe, the officer left the facility. While walking out of the building, the patient attacked the officer and removed his weapon. The security supervisor quickly took hold of the patient and removed the weapon from the patient. With the help of other security officers, the supervisor controlled that person until the police arrived, and arrested the assailant. This is just one of many examples in which the security staff, using physical skills authorized by post orders, successfully responded to an incident. 

Fortunately, in most incidents where the security team responds to assist medical staff, the situations are resolved satisfactorily through verbal persuasion, and the aggressive person is escorted away. Security will conduct an investigation, record the details of the incident, and make notifications as required by policy. In those rare situations that demand a police  response, the security team manages the situation and provides police information. 

One key for success is that the security team understands the medical protocols and that the medical team understands the security protocols. In other words, they must work as a team to keep the environment safe. In a monthlong study at one hospital, there were 59 CODE Gray calls—requests for security response to an aggressive person. In 30 of those instances, physical restraints were applied on request of medical staff. 

Early reporting of an escalating situation and early involvement of the security team is critical for reducing risks. The security team can manage the aggressive persons, de-escalate them if needed, and move them either back to medical care or away from the conflict area if the medical team has completed any treatment. The security response helps to reduce risks to medical staff, helps to keep them safe, and saves them time from working with potentially aggressive persons. And finally, the security team reports back to the medical team after situations are resolved. 

Teamwork and proper training help a security team to manage critical incidents of aggressive behavior that occur almost daily in healthcare. 

Lee Cloney, CPP, is region director of training and development for Securitas Security Services USA. He is a Certified Healthcare Protection Administrator (CHPA) and serves on the ASIS Foundation Board of Trustees.​