NQP Action Team to Prevent Healthcare Workplace Violence

With 71% of all nonfatal workplace violence occurring in healthcare settings, healthcare workers are four times more likely to experience violence at work compared to those in the private industry (e.g., construction, retail, manufacturing).1

Workplace violence, as defined by the National Institute for Occupational Safety and Health (NIOSH), is “any physical assault, threatening behavior, or verbal abuse directed towards persons at work or on duty.”2 In healthcare, this violence can stem from encounters between staff and patients and/or their families; aggression or harassment from co-workers; or the intrusion of community violence, such as domestic violence, into the workplace. Workplace violence comes at a high cost for healthcare workers, healthcare organizations, and patients. Healthcare workers may experience physical and emotional harm, stress-related illnesses, and burnout. Organizations may face direct costs in the form of litigation expenses, medical expenses, and worker compensation, in addition to indirect costs related to low staff morale, employee absenteeism, training and re-training, and negative impacts to an organization’s reputation. 3,4,5,6 Patients also feel the impacts of violence, as when healthcare workplace violence occurs, it means the safety of the worker is at stake and thus the quality of care for the patient may be diminished.

Despite the significant impact healthcare workplace violence has on healthcare workers and organizations, workplace violence often goes unreported,7 prevention initiatives and research are broadly underfunded,8 and evidence-based solutions are unrecognized by patients, healthcare workers, leaders, and policymakers.9

The healthcare industry faces unique challenges that contribute to the persistence of healthcare workplace violence, including the overwhelming perception that violence is simply “part of the job” and that patient safety comes before a healthcare workers’ own safety, which may result in a conflicted care provider.10 These contributing factors have led to a culture where workplace violence goes unrecognized or is misunderstood by many healthcare workers and leaders, and where approximately half of both physical and non-physical violence incident go unreported.11 In certain settings, such as behavioral health units, long-term care facilities, and emergency departments, the rate of underreporting can be even higher.12 Current reporting efforts by healthcare workers are often thwarted by the limited and cumbersome incident reporting processes, the absence of workforce education and support, and a belief that reporting will not result in effective system changes to stop future violent acts.13 Underreporting and lack of awareness of what acts constitute workplace violence prevents healthcare workers and organizations from understanding the true magnitude of the problem, and leads to uncertainty around how to implement meaningful interventions to create safer workspaces.14

To amplify the need for change and improve the safety of the healthcare workforce, the National Quality Forum (NQF) convened the National Quality PartnersTM (NQP) Action Team to Prevent Healthcare Workplace Violence in October 2019.

The NQP Action Team brought together 28 of NQF’s member organizations, representing health systems, patient advocacy organizations, federal agencies, payers, professional societies, quality improvement, measurement and research organizations, and home and community- based services. The goal of the NQP Action Team was to identify and coalesce around action-oriented strategies that support a shared vision to prevent, report, and root out healthcare workplace violence.

The NQP Action Team to Prevent Healthcare Workplace Violence encourages diverse stakeholders, including patients, healthcare workers and leaders, researchers, policymakers, and community members across and beyond healthcare to work together to remove barriers to reporting workplace violence events and encourage the application of innovative and collaborative solutions to prevent and root out healthcare workplace violence across the nation.

The NQP Action Team to Prevent Healthcare Workplace Violence identified the following set of priority challenges for stakeholders to address;

• Limited integration between patient safety and worker safety culture to support reporting, collecting data,and intervening against violence with action-oriented strategies;

• Inconsistent definitions and standards for what is considered violence and what should be reported complicate reporting processes, data collection, and data analysis;

• Limited reporting and data collection infrastructure make reporting harder, inhibiting the ability for data analytics to drive prompt interventions and meaningful systems changes;

• Lack of understanding or awareness of healthcare workplace violence prevalence, reporting infrastructure, and interventions from employees, patients, senior leaders, board members, and external stakeholders complicates and reduces a healthcare workplace safety program’s success;

• Competing priorities limit the time, resources, and funding an organization can allocate to advocating for change, creating education programs, and supporting initiatives that protect healthcare workers;

• Insufficient funding and research at the nationaland organizational level for evidence-based practices, training, innovative interventions, and follow-up activities; and,

• Limited mechanisms to support accountability for following strategies, policies, and legislation that discourage violence.

Healthcare workplace violence prevention programs should be multifaceted and all-encompassing in their approach to measure, intervene, and prevent workplace violence. Prevention programs should be a byproduct of multidisciplinary, multistakeholder design that includes the voices of patients and their visitors, healthcare workers, and leaders of the organization.

To prevent, report, and root out healthcare workplace violence, the NQP Action Team has identified four key strategies that healthcare organizations, community stakeholders, and other leaders in healthcare can take:

1. STANDARDIZE DEFINITIONS AND DATA COLLECTION

• Develop and standardize a universal definition for workplace violence that captures verbal, emotional, and physical assaults

• Implement simple, comprehensive internal reporting systems that allow for actionable interventions and follow-up at the health system level

• Create a national reporting repository that allows for benchmarking and data analysis across systems, states, and regions

2. ANALYZE AND SHARE DATA

• Share stories and data to cultivate and raise awareness of the need for a culture of safety that includes healthcare worker safety and the value of reporting incidents of workplace violence

• Engage patients, families, and caregivers to understand and analyze the root causes for responses or actions that are perceived as violence by the healthcare worker, and co-design solutions and preventative interventions that include the voice of patients, families, and caregivers

• Use data to inform follow-up activities and interventions, and close the loop to communicate how reported incidents, or near misses, resulted in system-level changes

• Invest in research to understand data, trends, contributing factors, and effective solutions to prevent healthcare workplace violence

3. INVEST IN SAFETY

• Support evidence-based research to advance policies, legislation, and voluntary accreditation as levers to drive investment of resources

• Engage quality committees and improvementteams with representation from patients, families, employees, and other key stakeholders (e.g., law enforcement, security, and community partners)to review incidents, identify follow-up actions, and develop administrative processes and controls (i.e., changes to the way healthcare workers perform jobs or tasks) to support system-based solutions

• Encourage and facilitate violence prevention through engineering controls (i.e., physical changes to the workplace), such as by implementing crime prevention through environmental design (CPTED),15 signage and access control, and assessments to identify site-specific solutions

• Recognize that healthcare workers practice across the care continuum, and incorporate safety efforts and initiatives in wide-ranging settings such as patients’ homes, group homes, community agencies, and long-term care facilities

4. COLLABORATE AND SCALE EFFORTS

• Identify and engage stakeholders within and across the care continuum to share lessons learned, best practices, and innovative solutions

• Educate the community, local police, district attorneys, and policymakers on the extent and impact of healthcare workplace violence

• Communicate with and engage internal security departments and external law enforcement as partners in the violence prevention program

• Collaborate with the community, advocacy groups, and leaders to raise awareness, identify opportunities for partnership, and promote closed-loop communication to prevent and address incidents

Strong leadership, an organizational commitment to workplace safety, incident reporting, data collection, and transparency are key to fostering an organization that prioritizes the safety of its healthcare workforce and promotes a culture of safety. Standardizing definitions and data collection, analyzing and sharing the data, investing in safety, and collaborating and scaling efforts are critical actions to prevent violence in healthcare settings and prioritize the safety of this important workforce. A culture of safety must extend to those who work in healthcare, and concerted efforts must be made to understand, address, and prevent the incidents of violence that are occurring in healthcare today. Healthcare stakeholders and organizations must promote the safety of patients while simultaneously strengthening and supporting the safety of its workforce by committing to a culture focused on prevention, response, and follow-up.

NQP ACTION TEAM TO PREVENT HEALTHCARE WORKPLACE VIOLENCE

NQF gratefully acknowledges the members of the NQP Action Team to Prevent Healthcare Workplace Violence for their participation and contributions to this important work.

CO-CHAIRS

American Association for Physician LeadershipPeter Angood

Cleveland Clinic Lutheran HospitalJanet Schuster

ACTION TEAM MEMBERS

American College of Emergency PhysiciansJeffrey Davis

American Nurses AssociationLiz Stokes

American Psychiatric Nurses AssociationJeannine Loucks

American Society of Health- System PharmacistsAnna Legreid Dopp

American Urological AssociationEugene Rhee

Centers for Medicare and Medicaid ServicesMichelle Schreiber

Centers for Disease Control and PreventionDaniel Hartley

City of HopeJean-Luc Bourgeois

Emergency Nurses AssociationGordon Gillespie

Encompass Health CorporationLynne Lee

Geisinger Health SystemHeather Lewis

Greater New York Hospital AssociationJenna Mandel-Ricci

Health Resources and Services AdministrationMichael Weaver

Homewatch CareGivers, LLCJennifer Ramona

Humana Inc.Laura Kinney

Intermountain HealthcareDave Miner

MHA Keystone Center for Patient Safety & QualityBrittany Bogan

Partners Behavioral Health ManagementRenee Colson

Patient & Family Centered Care Partners, Inc.Dorothy Winningham

Patient & Family Centered Care Partners, Inc.Jan Sladewski

Scripps HealthChris Van Gorder

The Joint CommissionBarbara Braun

Trinity HealthDiane Moritz

Veterans Health AdministrationLynn Van Male

Virginia Mason Medical CenterCharleen Tachibana

ENDNOTES

1 Occupational Safety and Health Administration (OSHA). Workplace Violence Prevention and Related Goals: The Big Picture. Washington, DC: OSHA; 2015 https://www.osha.gov/Publications/OSHA3828.pdf . Last accessed February 2020.

2 National Institute for Occupational Safety and Health (NIOSH). Occupational violence website. https://www.cdc.gov/niosh/ topics/violence/default.html. Last accessed February 2020.

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4 Katie Harris. Stopping Violence in Healthcare Presentation. Oregon Association of Hospitals and Health Systems. http://www.wsha.org/wp-content/uploads/Wednesday\_Centennial\_830-930\_Katie\_Harris.pdf . Last accessed February 2020.

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7 Arnetz JE, Hamblin L, Ager J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015;63(5):200-210.

8 Blando J, Ridenour M, Hartley D, et al. Barriers to Effective Implementation of Programs for the Prevention of Workplace Violence in Hospitals. Online J Issues Nurs. 2015;20(1):5.

9 OSHA. Workplace Violence Prevention and Related Goals: The Big Picture. Washington, DC: OSHA; 2015 https://www.osha . gov/Publications/OSHA3828.pdf. Last accessed February 2020.

10 American Nurses Association (ANA). Reporting Incidents of Workplace Violence Issue Brief. Silver Spring, MD; ANA; 2019. https://www.nursingworld.org/~4a4076/globalassets/practiceandpolicy/work-environment/endnurseabuse/endabuse-issue- brief-final.pdf. Last accessed February 2020.

11 Findorff MJ, McGovern PM, Wall MM, et al. Reporting violence to a health care employer: a cross-sectional study. Workplace health & safety. 2005;53(9):399-406.

12 The Joint Commission. Sentinel Event Alert: Physical and Verbal Violence Against Health Care Workers. Oakbrook Terrace, IL; The Joint Commission; 2018. www.jointcommission.org/sea_issue_59/. Last accessed February 2020.

13 ANA. Reporting Incidents of Workplace Violence Issue Brief. Silver Spring, MD; ANA; 2019. https://www.nursingworld . org/~4a4076/globalassets/practiceandpolicy/work-environment/endnurseabuse/endabuse-issue-brief-final.pdf. Last accessed February 2020.

14 Arnetz JE, Hamblin L, Ager J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015;63(5):200-210.

15 Cozens P, Love T. A Review and Current Status of Crime Prevention through Environmental Design (CPTED). Journal of Planning Literature. 2015;30(4):393-412.