Book Excerpts

Though it rarely occurs to anyone entering the healthcare field that they might experience high levels of conflict and violence, soon after beginning their clinical training, providers are taught to accept a culture of violence. That’s because the culture of healthcare embraces the belief that violence is part of the job.  From one certainly tragic point of view, the people who embrace this notion are absolutely right.  Violence is a day-to-day reality in healthcare.

How bad is the problem?  Among the ranks of risk management professionals, workplace violence is a much talked about issue. But is workplace violence an even larger issue in healthcare? If the federal government’s own statistics, from sources such as the Bureau of Labor Statistics are to be believed, healthcare is the most violent profession.  In fact, people who work in healthcare are at least seven times more likely to be assaulted on the job than average.   That’s higher than any other profession, including law enforcement and corrections.

One of the more prevalent misperceptions is that these grim statistics include numbers of minor assaults, such as shoves or spitting incidents.  Nothing could be further from the truth.  In order to qualify for the government’s statistics, workers must have suffered enough of an injury to miss time from work.  We can place these numbers into an even clearer perspective, by accepting the following reality.  None of these statistics represent all of the so called “minor” assaults, such as slaps, shoves, unwanted sexual touching, spitting, verbal threats, and other assaults that do not result in time off from work.  This represents an even greater number of uncounted assaults, because healthcare workers are notorious for accepting and under-reporting violent incidents. Police officers and prison guards are not so forgiving and rightly so.

In their groundbreaking surveys between 2009 and 2012, the Emergency Nurses Association discovered that half of all emergency department nurses surveyed have been the target of violence and threats on the job. Also, half of those who reported said they had experienced twenty or more violent and/or threatening incidents, during their last three years on the job.  Overall, even according to the government’s statistics, which are limited to assaults resulting in injury, around 20,000 registered nurses are assaulted annually and over 40,000 nursing assistants! Physicians, respiratory therapists, hospital security officers, x-ray technicians, social workers, and many others are also assaulted at unusually high rates.

The loss of quality healthcare workers, due to violence related turnover and the hundreds of millions of dollars lost annually from injuries are devastating.  In a very real way, violence in healthcare has become one of the medical profession’s biggest problems and can no longer be contained as one of its dirty little secrets.

The following story is a blatant example—albeit an all too familiar one—of a level of acceptance that is perhaps unique to healthcare.  While merely engaged in a casual conversation, a law enforcement professional asked a healthcare professional how her day was going. She related that moments earlier she had almost been physically and sexually assaulted. This Nurse Practitioner was able to escape from the situation by having done an appropriate assessment and using some evasive tactics.

After escaping the potentially catastrophic attack, she told the shocked police officer that the police were not contacted and that she simply went to a location where others were present and waited for her attacker to leave the scene.  She did say that she notified her supervisor and documented the incident in the patient’s medical record.  The scariest part of the whole interaction was that not only didn’t she feel the need or the right to access the criminal justice system, but that she did, in fact, report the incident to her employer and no law enforcement action was deemed necessary.

To make things perhaps even worse, due to a general misunderstanding of HIPAA and other laws  governing patient confidentiality, she did not feel that she was able to notify the police.  She also told the officer that all her previous training as a nurse caused her to accept that “these things just happen” and that they must be accepted as “part of the job”.  She also believed that if she were to pursue an investigation of the incident, it was quite possible that she would lose her job.

In her interpretation of her role as a provider, she believed that there was actually no recourse for her as a victim.  In her mind, her position as a provider denied her not only  access to the criminal justice system, but even to a reasonable expectation of safety.  There was no system in place, set by the employer, to protect her from any future occurrence.  Instead, there was a professional culture in place to protect the offender from prosecution.  Obviously, the environment of care in which she was working was compatible with violence; furthermore, her acceptance of risk for violent behavior was an expectation of employment.  But is that reasonable or even uncommon?

Before we even begin to consider our rights under the law, our beliefs should always be subjected to the smell test of reasonable expectation.  It’s time we ask ourselves, would she have adopted the above belief system if she were a waitress or a police officer?  The answer seems obvious, doesn’t it?  Then why is it okay to sexually assault a healthcare provider?  If she asked a peer or her boss, if this was an acceptable risk, perhaps they might have answered yes.  But what if she asked her mother or her husband?  What would any of their perceptions have been?  In all likelihood, they wouldn’t have been as accepting as someone who works in the healthcare field.

This scenario and many like it also begs the question, what if her attacker had just been a visitor or a relative of her patient?  What if he had been a fellow employee or just some courier delivering a package to the clinic?  The relationship between patient and provider is special, but is culpability for violent behavior really just a matter of context?  Do any solid lines exist that no one may cross in the patient-provider relationship?  That blurry line is at the heart of the problem of violence in healthcare.  Providers cannot begin to protect themselves from violence in their profession, if they cannot first agree that they are entitled to their own personal safety and basic human dignity.