How to reduce workplace violence

Stephanie Ross had only been on the job for about three months when she lost her life.

The recent college graduate was stabbed to death in December of 2012 by a patient while working as a social service coordinator with Integra Health Management.

As part of her job, Ross visited clients in their Florida homes and coordinated case management, even transporting patients to appointments in her car. But Ross had previously reported in her case notes that the client she was seeing that day made her uncomfortable. He had a severe mental illness and violent criminal history. He ultimately stabbed the young case worker in the front yard of his home.

Ross' case isn't an isolated incident. According to the U.S. Department of Labor Bureau of Labor Statistics, 271 of the 4,679 fatal work injuries recorded in 2014 across all industries were workplace homicides. The rate of injuries and illnesses from violence is more than three times higher in healthcare than the violence rate for all private industries.

The incident in Florida not only cost Ross her life, it also resulted in two serious citations for Integra and penalties totaling more than $10,000 for failing to protect her from workplace violence.

"It's the nature of the industry perhaps that there is more tension and a higher likelihood that people are going to not react very well to certain circumstances," says Mikki Holmes, national workplace violence coordinator for the Occupational Safety and Health Administration (OSHA).

 So, what can behavioral healthcare facilities do to protect themselves and their employees from seemingly random acts of violence?

Experts say while it's not always possible to predict incidents of violence, it is possible to establish policies and procedures that foster safety and are aimed at reducing violence in the workplace.

"There really needs to be some careful thought and preparation in identifying what the risks are and then doing some preparedness training, because many of these situations are very difficult to anticipate," says Sean F. Conaboy, MSW, MPA, a broker and risk manager for the behavioral healthcare practice at NSM Insurance Group.

Obviously, law enforcement must be called for any emergent, potentially dangerous situation, but there are processes that can happen proactively, separate from an emergent situation, that can help treatment center operators lay some groundwork for worker safety.

Dispelling denial

Experts agree that the first step for behavioral healthcare organizations, regardless of the practice setting, is acknowledging that they aren't immune from the threat of violence. Denial is all too common.

"People don't think it's going to happen to them,” Conaboy says. “They don't think they have those kind of patients, or they think they have good rapport built with them, or that they have therapeutic alliance."

H. Steven Moffic, MD, Behavioral Healthcare blogger, who retired from the clinical practice of psychiatry, says treatment professionals are often faced with a difficult paradox. One of the best things to do to prevent violence is for a therapist to show patients that he or she cares for the patient and isn't just simply doing a job. However, that feeling of camaraderie can also make it more likely that behavioral healthcare specialists will downplay the risk of violence to themselves.

"The most important thing for mental health facilities is to accept that the risk is there," Moffic says.  "So once you do that, at least your  guard can be up and when you do that, then you do certain things to make the organization safer."

Establishing safety

Every practice setting is different, but there are several universal strategies behavioral healthcare providers can employ to minimize risks and establish a safe environment for patients and staff. Experts caution that preventing potential violence should begin before a patient even enters the door.

For example, Moffic says, the best indicator of future behavior is often past behavior, so a glimpse into a patient's background to discover past violence can be one way to decide whether the patient is a fit for a given facility.

“If they are calling for an appointment, ask them respectfully,” he says. “But many times, the referral call comes from elsewhere, so ask that referral source, too. And if possible, review any records before actually accepting the patient. For a walk-in, do a careful screening, never alone, and in the safest area possible.”

Certain types of diagnoses, he says, might be more prone to violence such as paranoid schizophrenia, post-traumatic stress disorder, or narcissistic or sociopathic personality disorders.

"For patients with those conditions, you almost always have to be on alert, but the key there is whether they are following treatment or not," he says, adding that those who have stopped treatment are at a higher risk to become violent.

Another important aspect of violence prevention is assessing the population and the environment in order to establish policies and procedures that can help prevent violent attacks. For instance, Conaboy says organizations that consistently work with the corrections populations might be more at risk for violence than others.

"That group of people has a much higher propensity for overt violence than some of the other treatment populations, such as those in self-pay, private drug and alcohol treatment centers in Malibu," he says.

Organizations need to consider what kind of local emergency resources are available if violence occurs, and how staff is expected to react. An evacuation plan and an alert system are considerations.

To help employers prepare, OSHA recommends creating a written workplace violence prevention program. The program should include the following aspects:

• A violence policy statement that clearly identifies the responsibilities of all staff and states that violence will not be tolerated and will be fully investigated;
• Implementation of a real-time system for staff to log in and out;
• A hazard, threat and security assessment including an employee survey to identify risks;
• Training and education program for all staff;
• A system for reporting and investigating incidents;
• Built-in periodic review periods;
• Employee involvement and feedback when creating the violence prevention plan; and
• A safety committee with direct care staff.

Practice to Prepare

Conaboy says all organizations, whether they are inpatient, outpatient or community-based, should also practice their response in the event of violence.

"It's much like fire drills have become. If you practice some things and know what to do in the event of the unforeseen emergency, you at least are prepared and can minimize what the potential damage could be," he says.

Practicing for potential violent attacks is just one aspect of a training and education program for staff members. According to a guidelines created by OSHA, training programs should also include discussion of the location and operation of alarm systems, early warning signs or behaviors that may indicate potential violence, and strategies to diffuse volatile behaviors.

Experts say organizations can also think about ways to improve their physical surroundings like adding security officers onsite or requiring people go through a metal detector when they arrive. Remember visitors can pose a potential safety threat in a facility as well.

Inpatient

The inpatient environment gives an employer the most control over the setting, according to Conaboy. Organizations have the greatest level of control in inpatient settings because patients are often restricted from leaving  the facility, and staff members are able to provide constant evaluation and assessment.

For this reason, communication between staff in inpatient settings is critical. Assess how many communication opportunities staff have with one another, whether its during rounds or with written documentation. 

"This stuff gets overlooked just because of staffing patterns. Is there enough staff to pay attention to this stuff? Do they have the time and the patience to address it?” Conaboy says.

Holmes says another aspect of the inpatient setting is the ability to ensure that staff have easy exit from rooms, or if they are concerned about potentially being chased, that they have a safe place to go.

Outpatient

In practice settings where patients are coming and going, providers have less control over the physical environment.

Once again, communication is key and shouldn't be restricted to just those staff members treating a patient. For instance, if someone is having difficulty paying their bills and has been told by financial staff that they won't be allowed to continue treatment, that's information that should be communicated to therapists.

Safety can also be achieved in numbers.

"So, in the private practice realm, let alone in the clinic setting, you shouldn’t see potentially dangerous patients alone. Have some sort of safety around you," Moffic says.

There should be a way to signal staff outside the room if a situation is escalating or additional help is necessary. If a facility can't afford security staff, employees may want to take self-defense classes to learn strategies to defuse physical altercations. And obviously, staff will need to know to call law enforcement for any situation that seems truly dangerous. The prevalence of mobile phones can make this an instinctive process, however, it’s a good rule of thumb to be sure every staff member knows the facility’s address by heart to direct law enforcement quickly.

Moffic also recommends other practical tips such as placing the behavioral healthcare provider's chair between the patient and the door, so that there is a clear exit path, or not wearing ties or scarfs, which could be used as makeshift weapons.

Community

Providers have the least amount of control in situations where team members are going out into the community to deliver services.

"That's probably the most volatile," Conaboy says.

In these scenarios, experts recommend that employees use a buddy system. Some teams have even added community police officers to the team to enhance safety.

It's also critical for employees to assess their surroundings and identify possible exits and potential weapons as soon as they enter the patient's home.

In the case of Integra, OSHA says, the company made several key errors. While the company had a buddy system in place, it wasn't enforced. Ross was only provided with minimal training before going out into the field.

"They had done no background checks on any of the clients that they were asking people to go out and serve," Holmes says.

They also failed to provide Ross with a reliable way to summon for help.

"OSHA believed that they could have materially reduced the likelihood of the hazard if they had better trained their employees and had protocols in place of what to do in situations when employees felt threatened," Holmes says.

Jill Sederstrom is a freelance writer based in Kansas.