On Friday, an individual allegedly entered the lobby of a state psychiatric hospital in Concord, New Hampshire killing a security guard. A state trooper on duty assigned to the facility subsequently shot and killed the gunmen.
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In early September, a nurse at Inspira Medical Center in Vineland, New Jersey was nearly injured after a patient shot and killed himself, prompting a lockdown inside the hospital. The incident left healthcare workers, visitors, and patients filled with terror.
The ongoing and escalating violence in and around hospitals in the U.S. is a clear and present danger to hospital staff and visitors. This pandemic of violence represents a public health emergency that demands the attention of our elected leaders.
Over the last few years, the media had been filled with stories of assaults, stabbings, and other violent events including mass shootings at hospitals, clinics, and other healthcare facilities. For many of us, this has been a great surprise since we have always believed health care facilities are oases of peace and caring.
Since the pandemic, there has been a marked increase in violence against healthcare workers. The American Hospital Association (AHA) reports that healthcare workers suffer more workplace violence and injury than any other environment.
The AHA also states that 44% of nurses report an increase in physical violence since the pandemic and a majority (68%) report an increase in verbal abuse. Those unfamiliar with daily events in healthcare institutions may be shocked to learn that violent altercations are so common.
According to the American College of Emergency Physicians (ACEP) approximately 80 percent of physicians believe that ED violence has impacted patient care and safety. In this high stress environment, 50% said that patients have been physically harmed, and 47% of emergency physicians have stated they have personally been assaulted at work.
In fact, an April 2022 survey by National Nurses United revealed more than a 100 percent increase in workplace violence compared to a prior survey of nurses in March 2021. The net effects of workplace violence and emotional trauma are major risk factors for burnout, and moral distress and injury.
The health care environment in health care is, of course, also a high stress environment. Every day, professionals deal with conditions that can be highly stressful to patients and visitors. Major trauma, cardiac arrest, brain death, and the other major illness elicit strong emotional responses and can act as triggers that lead to violence among and between patients, visitors and even staff.
Safety starts with having open discussions between staff, visitors, patients and hospital administration prior to the occurrence of a major violent event. Preparation and training can rapidly diffuse a potential violent encounter. But it’s equally important that such preparatory training begin at orientation and onboarding of new staff. A comprehensive preparation on how to deal with violent outbursts and agitated patients should be a part of every healthcare worker’s training. Scenarios on how to secure patient and personal areas, call for help, evacuate an area and deal with violence should be covered repeatedly in annual in-service programs both online and in-person. Active shooter exercises should also be done on a regular basis with security and local law enforcement.
The main hospital entrance and entrance to the emergency department (ED) are the two primary areas that create vulnerability in safety and security in any healthcare facility. That said, side entrances can also be problematic, making it essential to limit the number of entrances that can be used by the public. The main and ED entrances allow staff to filter individuals who are intoxicated, not on any visitation list for specific patients, or other individuals who should not be there. The public must be prepared to go through security check points and screenings much like TSA screenings at U.S. airports. Security can range from the obvious (metal detectors) to more covert approaches by security teams serving as “greeters” or as “ambassadors”.
Because an overly aggressive security presence can be off-putting to patients and visitors, the goal is to instill measures that are invisible. Staff with security training can welcome visitors, and direct them to elevators, clinics, labs and various units within the hospital itself.
It’s imperative to issue “passes”, or ideally take digital photos and maintain a log as to who is in the building at all times. Entry to the intensive care unit (ICU) should also be controlled with a locked door that can only be opened by unit staff to allow visitors in. Closed circuit video cameras are also a key part of “perimeter security” both as a screening system, but also as a recording device that can be used to later identify an individual that was violent at the bedside.
The facility should also have “safe areas” for staff, visitors and patients. A medication or storeroom fitted with bullet-proof glass and a door bolt as well as staff lounges and locker rooms are areas that can be made secure.
Communication is paramount; having a nonverbal set of cues known to staff, along with “panic buttons” that connect to 911 and local police departments are strongly advised.
In preparation for a violent threat, it’s vital for staff to practice de-escalation techniques—ideally by simulation or virtual or augmented reality-based modules—but also by viewing and participating in interactive online tutorials. In this regard, it’s important to train every team member of every department to learn to recognize signs of agitation and potential violence among patients and visitors.
This can be challenging because emergency departments, ICUs and even staff on regular hospital floors deal with an ongoing spectrum of patent-related medical and surgical emergencies and critical issues. Not only violence, but episodes of incivility, rudeness and making disparaging remarks can lead to moral injury and burnout among healthcare workers. Preemptively dealing with these threats is an important factor that may help to prevent staff burnout.
In fact, the impact of verbal insults and harassment by patients and visitors leading to occupational distress has impacted nearly 24 percent of physicians, according to a JAMA study last year. Importantly, recent research further demonstrates that insults, threats and episodes of rude behaviors can adversely impact delivery of clinical care and success of procedures necessary to diagnose and treat patients. What’s clear is that when staff are not safe, patients are not safe.
But, knowing what to do if the unthinkable occurs—such as an active shooter in your hospital—has to be part of the mindset of every healthcare worker, patient, visitor and hospital administrator. Staff should learn the public safety mantra: “run, hide, fight.” Because it may not be possible to find an escape route in every area of the hospital while under lockdown, it can be lifesaving to learn and identify secure hiding places, such as a medication room or a staff locker room that was described earlier.
Violence in and around hospitals may not only place patients, but also innocent bystanders and visitors at risk for injury and death. A recent shooting outside University of Alabama (UAB) Hospital over the Labor Day weekend is case in point: as victims of a shooting pulled up in an SUV, other bystanders’ lives were placed at risk as gunshots—intended for the victims already in the SUV— rang out in front of the hospital entrance. And, yet another shooting at the tail end of the Labor Day weekend inside a hospital in Mississippi related to domestic violence, and now classified as a murder-suicide among 90-year-old spouses, further illustrates the imminent risk to all patients and staff.
The epidemic of violence in the U.S. and spilling in and around our nation’s hospitals continues with no end in sight. It doesn’t have to be this way. We hope that with care, training, and caution we can make health facilities safe again.
Importantly, this ongoing pandemic of violence across U.S. society at large needs to be addressed by our leaders. Without their guidance, leadership and attention, addressing the crisis will be quite challenging. Local grassroots efforts to draw attention to this pandemic of violence will be crucial.
We must restore respect and safety and help our health care professionals as they care for us and our families; hospitals need to remain as sanctuaries that heal, devoid of the epidemic that has permeated every aspect of our society.
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