‘An Unrecognized Problem Cannot Be Addressed’: ICL Offers Strategies to Mitigate Workplace Violence

The threat of workplace violence has emerged as a pressing concern in healthcare, demanding collective attention and sparking discourse. The field of orthopaedics has reached a critical juncture where the intersection of patient care, professional collaboration, and personal safety requires a nuanced exploration.

During the AAOS 2024 Annual Meeting, the Instructional Course Lecture (ICL) titled “Workplace Violence in the Healthcare Setting: What We Can Do to Protect Our Patients and Ourselves” served as a platform for orthopaedic and healthcare safety experts to delve into the multifaceted dimensions of workplace violence, address challenges, and explore strategies for keeping both patients and healthcare providers safe. The panel included Alfonso Mejia, MD, MPH, FAAOS, past chair of the AAOS Board of Councilors and vice head of the Department of Orthopaedic Surgery at the University of Illinois Chicago; Julie B. Samora, MD, PhD, MPH, FAAOS, pediatric hand and upper-extremity surgeon at Nationwide Children’s Hospital and member of the AAOS Committee on Healthcare Safety; and Patrick Siemsen, MA, police chief within the south suburbs of Chicago.

Recognizing the workplace violence epidemic
“An unrecognized problem cannot be addressed,” Dr. Mejia said. Violence against healthcare workers is a situation that is increasing in severity and must be “addressed head-on” to provide a safer environment for patients, physicians, and staff. He stressed that steps to mitigate workplace violence include recognition, education, and preparation.

Seventy-five percent of all non-fatal workplace violence occurs in healthcare settings, Dr. Mejia noted, and the cost of this violence for physicians and staff can include burnout, stress-related illness, emotional and physical harm. The cost of violence is not limited to the individual alone. For institutions, workplace violence is associated with increases in litigation, medical expenses, workers’ compensation costs, and training and re-training costs from staff attrition.

The two settings that have the highest rates of healthcare workplace violence are emergency departments and psychiatric units. “The locations of violence nationally tend to be in acute settings, and it’s part of the problem,” Dr. Mejia explained. “Emergency departments are particularly at risk,” as “it’s hard to control entry” in these settings, he said.

Despite the already staggering statistics on healthcare workplace violence, it is actually under-reported at many institutions. “Some people see it as part of the job. Some put patient safety before healthcare worker safety,” Dr. Mejia said. Under-reporting only compounds the problem: “If we don’t know what is happening in what numbers, we cannot implement meaningful interventions to create a safer environment,” he added.

Workplace violence “must be defined, measured, and tracked in healthcare settings,” Dr. Mejia advised, though there are various definitions as to what is considered workplace violence. “The important thing is to pick one [definition] so your institution or your place of work has defined it, and that way they can track it and see how often it’s happening and what the nature of events are,” he recommended. Next, it is important to “train your staff to recognize [it]. In order to recognize it, all practice members must understand what constitutes workplace violence, and this includes verbal and written threats, accident, intimidation, and verbal hostility or abuse,” he stressed.

Integrating leadership oversight
Dr. Samora discussed how leadership at the local, regional, and national levels can mitigate violence in the healthcare setting. “It’s important to have a holistic approach to workplace violence, which we see is only increasing,” she said.

A holistic approach in the workplace offers enhanced employee safety, improved patient care, regulatory compliance, operational and financial benefits, and enhanced reputation. However, drawbacks such as initial implementation costs, resource allocation, and cultural resistance should be considered. Dr. Samora outlined the key components of a holistic approach: risk assessment, policy development, staff training, physical security measures, and adequate support systems for affected staff.

“Training is critical,” Dr. Samora emphasized. “Every single human being that works in healthcare should be trained on workplace violence.” She encouraged physicians to be “on the forefront” of training and to focus not only on the recognition of violence but also prevention.

Mitigating workplace violence on an organizational level involves fostering a “culture of safety,” Dr. Samora said, and establishing a threat-management process with a dedicated team involving human resources, security, managers, employee health, and legal departments. Implementing administrative and physical systems, such as access control, mass notification, and ongoing incident review, is crucial. Additionally, providing a straightforward reporting mechanism for all instances of workplace violence ensures a proactive and responsive approach.

Tracking incidents on an organizational level should be systematic, akin to quality metrics, to identify trends. Implementing a continuous program, rather than a one-time effort, is crucial for sustained effectiveness. Additionally, integrating the employee health department into the team responsible for evaluating injury reports helps identify and address trends in a comprehensive manner.

Organizations can mitigate workplace violence by implementing measures such as screening patients with a history of violence, restricting patient access to specific hospital areas, and installing metal detectors for enhanced security. However, Dr. Samora stressed, “We want to be safe for not only our staff but also other patients in the area. We also want to make sure that we don’t dehumanize patients in any way, so site-specific risk analysis can really help to ensure any interventions are balancing safety but also empathy and efficiency.”

Threat assessment
To round out the discussion was Chief Siemsen, a veteran and police chief with more than 30 years of experience. He has extensive experience with risk and threat assessment while working on a SWAT team responding to critical incidents and active shooter hostage barricades. Much of Chief Siemsen’s work has been in threat assessment in the public education sector. He noted “a lot of parallels” between addressing threats in education and healthcare facilities.

Threat assessment involves identifying warning signs and risk factors that indicate the potential for violent behavior and strategies to respond to them. Put simply: “Threat assessment is a tool that can be used to remediate and identify problems,” he said.

Unfortunately, according to Chief Siemsen, “The biggest problem ends up being people. They don’t ever think it’s going to happen to them. They do not understand why someone would come into their organization and cause harm. It’s a dichotomy in thinking.”

Chief Siemsen outlined several threat-assessment models, defined standards for mitigating and responding to threats of violence, and reviewed actions—or rather, inactions—that cause threat assessments to fail. He said that these failures happen not just because individuals “don’t want to do it, or they don’t have the time to do it, or they can’t do it,” but rather because of the lack of “real litigation” attached to addressing threats before they become violence. “There’s a thing called ‘vicarious liability,’” he explained. Vicarious liability means, according to Chief Siemsen, that “you should have known it was egregious enough that you should have taken action. This is the importance of reporting and understanding the threat-assessment model.”

The best practice to prevent workplace violence, according to Chief Siemsen, is an amalgamation of clear communication, thorough training of current staff, onboarding of new security staff, discipline and vigilance, and environmental design. However, he said, “These strategies, local policies, mitigation, safety, security, the hardening of the targets—all of that does no good” if one does not maintain fidelity of the procedures designed to prevent violence against patients, staff, and fellow physicians.

Cailin Conner is the associate editor of AAOS Now. She can be reached at cconner@aaos.org.