Tuesday, March 27, 2012

Increasing Violence or Increased Reporting?

Security Technology Executive tells us hospitals are experiencing an epidemic of workplace violence...

What does that mean?  As Marleah Blades assembled her wide-ranging article she interviewed a variety of well-known security practitioners in the hospital security field, Bonnie Michelman, David Gibbs, and Bryan Warren.  As is frequently the case, the underlying studies tell a more complete, interesting, and useful story than the article referring to them.

The Joint Commission

“The Joint Commission’s Sentinel Event Database, which tracks unexpected events resulting in death or serious injury, shows that 2011 had the second-highest reported rate of criminal events since the database’s inception in 1995.”

What is a “sentinel event?” According to The Joint Commission “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.”

What is the statistical significance of sentinel events? The Joint Commission cautions the its readers “The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.”

The Joint Commission’s "Criminal Events" category is titled “Assault/Rape/Homicide.”  As the following Emergency Nurses Association study shows the term ‘assault’ may represent a wide variety of acts. Homicide is unambiguous. One would think the emotion-laden term “rape,” as commonly understood, would be used very carefully. In its Assault/Rape/Homicide category The Joint Commission tells us “Rape defined as un-consented sexual contact.”  The phrase “sexual assault” would seem to be a more accurate description of such behavior.

The Joint Commission recorded 49 Criminal Events in 2011, surpassing the previous high of 45 set in 2008. It has recorded 311 Criminal Events between 1995 and 2011.

Emergency Nurses Association (ENA)

“The Emergency Department Violence Surveillance Study released by the Emergency Nurses Association in Nov. 2011 found that of more than 6,500 emergency department nurses surveyed, 54.5 percent had experienced physical violence and/or verbal abuse at work at some point in the previous seven days.”

The "and/or" is very important to this story.  The details from that survey actually report slightly higher numbers. Of 6,543 nurses responding to the survey 12% had experienced physical violence in the past seven days. Of those nurses experiencing violence 62.2% encountered it more than once in the previous week. Of those nurses experiencing violence 13.4% suffered an injury. The most common act of physical violence was being grabbed/pulled (48.3%), slapped/punched (41.3%), spit on (35.8%), pushed/shoved/thrown (27.6%), or kicked (25.8%). The most common injury sustained by a nurse was bruise/contusion/blunt trauma (60.0%), abrasion/scratch (51.4%), sprain/strain/spasm (20.8%), and exposure to bodily fluids (20%).

In the previous seven days 53.7% were subjected to verbal abuse. Common forms of verbal abuse took the form of being sworn/cursed at (89%), yelled/shouted at (89%), called names (68.2%), threatened with legal action (51.8%), harassed with sexual language/innuendos (22.7%), and threatened with physical violence/weapons (19.8%).

Not quite half of ED nurses who responded to this survey (45.5%) experienced no violence in the previous seven days.

International Association For Healthcare Security & Safety (IAHSS)

“Workplace violence is part of an epidemic in healthcare now, and line staff — regardless of what unit they work in — must have at least a basic knowledge of how to recognize potential warning signs and how to react appropriately when an incident occurs.” – Bryan Warren, Senior Manager of Corporate Security at Carolinas Healthcare System and president of IAHSS.

We're told the IAHSS 2010 crime and security trends survey referred to in the article states "reported that in four categories — sexual assault, robbery, aggravated assault, and simple assault — violent crime in hospitals increased by 200 percent from 2004-2009."  It's behind a membership wall (anyone out there have a copy they can share?) so we can't see their data, but there are some statistical clues we can draw from the very detailed analysis of the Emergency Nurses Association survey data.

In the Emergency Department the patient is the perpetrator of 97.8% of physical violence and 92.3% of the verbal abuse.

Events occur in the patient’s room 82% of the time.

The verbal abuse or violence occurs while triaging the patient (40.2%), restraining/subduing the patient (34.8%), or performing an invasive procedure on the patient (29.4%).

When the verbal abuse or violence occurred many patients were under the influence of alcohol (55.7%), under the influence of illicit/prescription drugs (46.8%), or a psychiatric patient (45.2%).

Perpetrators of physical violence were lucid 73.1% of the time (or not lucid a quarter of the time).

This is what the phrase "Workplace Violence" means in the health care setting.  Violence in hospitals is committed almost exclusively by patients, usually while receiving care in their rooms.  They are frequently intoxicated, medicated, or being treated for psychiatric disorders (they are not even lucid 26.9% of the time).  Much of the verbal abuse and/or violent behavior occurs while the patient is being assessed, while they are being restrained (already violent), or when they experience discomfort during an invasive procedure.  These risk factors have been well-understood by OSHA for some time now.  I submit these events have little to do with security hardware budgets; they have everything to do with the complex issues arising out of professional staff levels, working conditions, concerns about patients' rights, the number of psychiatric beds, and the cost of medical care.

Under-reporting of harassment, bullying, verbal threats, and simple assault by employees is a serious concern, so efforts to increase management awareness of these issues is important to those of us responsible for providing a positive and productive work environment.  For better or (mostly) worse the phrase "workplace violence" has become synonymous for workplace mass murder.  Using the phrase when you mean anything else, simply because everyone pricks up their ears when you say it, is unseemly and unprofessional.

We need to be careful with our data collection, interpretation, and communication.  When we survey populations we can expect those with negative experiences to respond more than those who are not troubled. When employee awareness and incident reporting program kicks in we can expect to hear from team members who never said anything about being uncomfortable or fearful at work before.  Increased reporting is not the same increased violence.


Emergency Department Violence Surveillance Study, November 2011

Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers

The Joint Commission - Sentinel Event

The Workplace Violence Epidemic

Summary Data of Sentinel Events Reviewed by The Joint Commission

Sentinel Event Data Event Type by Year 1995-2011, pg. 7.