When an epidemic of violence against health care workers meets a pandemic

“Sir, please calm down,” she says nervously, glancing around to see if anyone had noticed their interaction.

“No, I will not calm down. Where is your boss? You don’t know what you are doing!”

He gets up and starts walking towards her, continuing to raise his voice, and comes to a stop less than six inches from her face.

“You listen to me. If you don’t get me what I need, you and this entire clinic will be sorry. I can promise you that!”

Interactions like the above are becoming more prevalent in health care settings. The Occupational Safety and Health Administration (OSHA) defines workplace violence as “violent acts, including physical assaults and threats of assault directed toward persons at work or on duty.” At last count, the health care sector continues to lead other industries in the incidence of non-fatal workplace violence. Let’s consider the following facts:

Health care workers suffer workplace injuries that require taking time off work at a rate of 4x that of other industry workers.
It is widely accepted that health care workers underreport incidents of violence at their workplace by ~50 percent.
In 2016 OSHA reported in ~24,000 workplace assaults in health care every year between 2010 and 2013…or ~ 65 assaults per day.
Health care workers comprise 13 percent of the workforce but suffer from ~60 percent of all workplace violence incidents.

Prior to the COVID-19 pandemic, the incidence of violence in the workplace was already on the rise across several sectors. As the pandemic continues, its effects on individuals in general and society at large have added fuel to the fire that is workplace violence.

At baseline, the threat of violence against health care workers is elevated. Factors in health care that increase this risk include the high levels of stress and anxiety in the working environment (especially the emergency room (ER), operating room, or intensive care unit (ICU) practice settings), elevated feelings of loss of control by patients and their families during the course of illness, inadequate hospital staffing, and patients with pre-existing mental health conditions or dementia (i.e., the ER, nursing homes, or inpatient wards). When these risk factors are combined with a lack of regulatory protection and robust violence prevention programs, the results are predictable.

The COVID-19 pandemic has exacerbated factors that cause violence in the workplace. At no time in recent history will you find clinical health care workers under this degree of stress. Physicians and nurses are operating under high alert in hospitals and clinics while facing COVID deniers and abusive treatment (name-calling such as “disease spreaders”) in their day-to-day life. Due to social distancing measures, shutdowns, and resultant economic fallout, patients are experiencing significant psychological and financial burdens. The politicization of the pandemic has elevated the level of difficulty for all parties.

This combination of clinical and societal strain increases the likelihood of overly (and overtly) aggressive or unpredictable reactions to day to day encounters.

Health care organizations routinely advertise their patient safety protocols via email newsletters or “Number of Days Since Last Fall” graphics on the wards or the intensive care units. Few of those same organizations have comprehensive disruptive patient/worker safety programs (with the notable exception of the Veteran Affairs Health Care System’s Disruptive Behavior Reporting System and the Beth Israel Deaconess Medical Center’s Don’t Worry Alone programs). The lack of organized response leaves health care workers feeling isolated or worse, fearing retribution should they report or take action to protect themselves. Further complicating the issue is the culture of health care that prioritizes martyrdom and self-sacrifice for the benefit of the patient, our “do no harm” mentality, and internal rationalization of violence against health care workers as “part of the job.”

The cost of not addressing this epidemic of violence against health care workers is high for all stakeholders. Institutions suffer a loss of worker trust and increased cost of recruitment; workers suffer from higher rates of burnout, caregiver fatigue, and chronic pain; patients suffer from decreased quality of care that may manifest as increased risk of a medication error, increased infection risk, and decreased staff expertise.

A key step to a solution is an understanding of the scope and complexity of this critical issue. Accurate data can be gathered via electronic, mandatory, anonymous reporting systems on a national, institutional, and/or organizational levels. Because OSHA has not provided mandates or standards for workplace safety as it relates to violence against health care workers, it is up to health care organizations to develop and implement their own, adapted to each organization’s unique culture and work environment.

Health care worker safety and high quality, safe patient care and are two sides of the same coin: To ignore one in favor of the other would be to our collective peril.