By Jenica W. Cimino, Lyza Hiltner, RN & Katie E. Raffel, MD

“We use a punishment mindset that exacerbates the trauma (people have already suffered). We have to change that.”

– Bryan Stevenson, Director of the Equal Justice Initiative

In the months preceding the COVID-19 pandemic, our quality improvement team was discussing the safety of providers and staff on a weekly basis. This was not in the context of a communicable disease or sufficient personal protective equipment but instead related to another insidious health care exposure and threat: workplace violence. Consider CW, a 55-year-old female with altered mental status who arrived from the emergency department at midnight with suspected sepsis. When the nurse performed her admission assessment, the patient yelled profanities and gripped her ponytail, not letting go until another nurse came to assist. The patient attempted to depart, and security was called to return her to the room. There had been an “FYI alert” in the patient’s chart, which mentioned her physical violence toward staff with no further explanation or customized care plan.

According to the Occupational Safety and Health Administration (OSHA), hospitals are one of the most dangerous places to work. Our institution logged 363 violent incidents in fiscal year 2019, with 91 percent of occurrences in the inpatient setting. In a recent poll of emergency physicians, almost half of the respondents reported having been physically assaulted, and most of the assaults had occurred within the previous year. OSHA reported that 13 percent of missed workdays by nurses in 2019 were due to workplace violence. Even more troubling, workplace violence often is considered a part of the job.

During the 2019-2020 academic year, our improvement team discovered a sense of vulnerability among providers—stories of patients propelling hot coffee and sharp utensils at them, chokeholds, sexual innuendo, and racist slurs. Workplace violence was eroding morale, contributing to burnout, and threatening their sense of safety.

Though the health care sector is among the most susceptible industries to violence in the United States, workplace violence prevention and response protocols are vague at best. The Joint Commission has not developed clear policies regarding workplace violence. OSHA has provided guidelines to reduce the risk of workplace violence, though it lacks a patient-centered focus. As a result, workplace violence efforts have included low-impact, stigmatizing, and traumatizing interventions: security at entrances (sign-in procedures; visitor passes; badge entry), FYI alerts regarding violence, and security officers to respond to aggressive behavior.

Institutions must consider patient-centered ways to prevent episodes of violence through the practice of trauma-informed care (TIC). Nearly one-quarter of patients have a history of trauma and are often re-traumatized by the invasive and authoritarian nature of health care. TIC offers a framework for providing medical care and serves as a vehicle for systems and culture change that creates physical and psychological safety for both providers and patients. It emphasizes trauma prevalence and impact, recognition of symptoms, and response to trauma history, and prevention of re-traumatization.

In the case of CW, the assistant unit director sat with her on several occasions. She discovered that the patient had experienced homelessness, substance use disorder and had suffered multiple violent assaults. The patient found the lack of control over the day, multiple providers, and limited privacy challenging. She felt like she was “back on the streets, fighting for her life.” The patient, husband, and team collaborated on a care plan to contact her family right away when she felt triggered, allow them to visit without restrictions, and minimize the number of staff responding to her.

All instances of violence may not be preventable, but early recognition and intervention are critical. Behavioral Emergency Response Teams (BERTs) are staff well-trained in non-violent intervention techniques to manage disruptive behaviors from patients suffering from untreated mental illness, poverty, violence, and/or a lifetime of maltreatment. In a pilot on a medical-surgical unit, a BERT responded to 17 behavioral emergencies. The number of assaults decreased from 10 (pre) to 1 (post); security intervention decreased from 14 to 1; and restraint use decreased from 8 to 1. Nurses rated the BERT as supportive and effective. In another study, the BERT improved safety for patients and staff and enhanced staff satisfaction.

By the summer of 2020, groups across our health system convened through an educational program in TIC, Trauma Transformed. Executive leaders had weekly interdisciplinary meetings that included psychiatry and security representatives to create systems change. The task force developed a pilot with a psychiatric nurse on three Medicine units. The nurse rounds on patients with a history of violence and engages our TIC-trained security team selectively. We are tracking a range of metrics, including demographics, patient and provider satisfaction, calls to security, WPV events, and safety attendant usage. We also plan to review FYI flags for bias and amend them appropriately.

CW healed safely in part due to her team’s trauma-informed approach. She is one patient among countless others with a trauma history who have experienced the cycle of violence perpetuated within our hospital system. It is imperative that health systems revise and clarify their approach to workplace violence by acknowledging the re-traumatization of patients as a core cause. The first steps may be to train providers in TIC, create less authoritarian/invasive care processes (maximize patient autonomy, enhance continuity, minimize unnecessary interruptions) and establish a BERT. Work in this area must incorporate the patient perspective, engage providers across disciplines, and include unbiased and rigorous data collection. Prioritizing the well-being of providers through enhanced safety for our patients with trauma represents the leadership that our health care institutions need.

Jenica W. Cimino is a program manager and quality improvement specialist. Lyza Hiltner is a nurse and palliative care consultant. Katie E. Raffel is an internal medicine physician.