FEATURE
were arguing with each other in the hallway and, when
I stepped in to intervene, a full can of Coke – thrown by
the patient behind me – brushed past my ear.”
Even if police witnessed the event, he said, there was
little to do about it. “I told the patient not to do that
again or I’d have her arrested, but she was a psychiatric
patient there under an involuntary hold who was going to
be placed into a psychiatric facility. She wasn’t someone I
could actually have arrested.”
Patients with diminished mental states also often
lash out in acute-care environments, Dr. Phillips noted.
“Being in an unfamiliar environment, or being touched
by unfamiliar people, can make people with Alzheimer
disease or dementia agitated. Often they don’t intend to
cause harm, but they’ll act out of secondary fear.”
Patients on the Edge
“Violence occurs on all types of units,” said Dr. Arnetz.
“We know that doctors and nurses in the emergency
department and psychiatric units or any unit that sees
many elderly patients who may have cognitive issues,
have greater risks for being the victims of violence, but, to
be honest, no one is at low risk.”
The OSHA guidelines continue: “Pain, devastating
prognoses, unfamiliar surroundings, mind- and mood-
altering medications and drugs, and disease progression
can also cause agitation and violent behaviors.” In other
words, what many patients encounter when visiting a
hospital or clinic.
“Other than for the delivery of a child or a check-up,
people are visiting a health-care provider because things
aren’t going well,” Ralph Nerette, the director of security
at Dana-Farber Cancer Institute in Boston, told ASH
Clinical News. “They usually are coming here with stress-
ors beyond their health issues, so I think it’s reasonable to
expect an increase in incidents of conflict in these settings
compared with other workplaces.
“When we have to deliver bad news to a family, there
is a lot of emotion involved, and there are many examples
of medical providers who have been the target of that
emotion,” he added. This is such a well-recognized aspect
of being a health-care provider, “that we teach people
about where to stand and how to ensure access to the
door should you need to get out of a room.”
Although hematologists spend little time on the front
line of health-care violence, they also report challenges
dealing with threatening patients. Earlier this year, ASH
Clinical News Associate Editor Alice Ma, MD, recounted
an unnerving experience with a patient with hemophilia
and a long list of grievances that were voiced aggressively
enough that Dr. Ma’s staff felt she needed to be protected
(“Not What I Signed up For,” March 2018).
“We need to change
the employee’s
mindset from
‘violence is a part of
the job’ to ‘violence is
a problem that needs
to be managed.’”
—JUDY ARNETZ, PhD
“The patient was upset about the copay for his
monthly narcotics, the winter weather, the poor heat and
insulation in his girlfriend’s apartment, his unemploy-
ment, and his lack of disability insurance – for which he
apparently blames me,” she wrote. “He also has an anger
management issue and depression, and he’s been fired
from work for assaulting people who ‘got in his face.’”
With the assistance of center staff and security – and
a plan to transition the patient to another hemophilia
center – the situation resolved without violence.
Readers responded to Dr. Ma’s article with their own
experiences treating potentially violent patients, shining a
light on the emotional toll that it can take on patients and
providers.
“[The psychosocial components of patients’ lives]
greatly impact their clinical care. Each patient is dealing
with poverty, depression, poor coping mechanisms, lack
of social support, perpetual stigmatization, and undi-
agnosed or mismanaged neurocognitive deficits,” wrote
Laura M. De Castro, MD, a sickle cell disease specialist
from the University of Pittsburgh Medical Center. “What
really keeps me up at night is the reality that, while we are
providing the best and most comprehensive medical care
for these unfortunate patients, some people feel that their
needs are unmet, even when multidisciplinary teams are
available at most outpatient clinics. We the providers (in-
cluding the care managers, social workers, pain special-
ists, and psychiatrists on these teams) can sometimes feel
impotent to help them.”
“While I, too, have experienced a small share of
threatening situations from patient families, I have found
that, in most instances, the best defense is not a strong
offense,” wrote Sidharth Mahapatra, MD, PhD, from
the University of Nebraska Medical Center. “Rather, true
engagement with the individual and a show of sincerity
have gone further than defensive tactics.”
Under-Regulated and Overlooked?
In addition to being understudied, violence in health-
care workplaces also is underregulated. The OSHA
“Guidelines for Preventing Workplace Violence for
Healthcare and Social Service Workers” are just that –
guidelines, not rules. 4
“The only law that legally binds us to workplace
violence prevention is called the General Duty Clause,
which goes back to the original U.S. Occupational Safety
and Health Act of 1970,” Dr. Arnetz explained. The clause
states: “Each employer shall furnish to each of his employ-
ees employment and a place of employment which are free
from recognized hazards that are causing or are likely to
cause death or serious physical harm to his employees.” 7
“OSHA has been trying to push standards under the
General Duty Clause, but there is no specific OSHA regu-
lation addressing workplace violence that is an express
requirement under the law,” said Nathaniel M. Glasser,
a health-care labor and employment lawyer at Epstein
Becker & Green, P.C., in Washington, DC.
The General Duty Clause is reserved for OSHA
inspections that involve a violation for which there are
no applicable safety or health standards. To warrant a
violation, inspectors must find that the employer failed to
keep the workplace free of a hazard to which its employ-
ees were exposed; there also must be a feasible method to
correct the hazard. In the health-care setting, when the
“hazard” might be a patient with a long-term illness or a
mental-health issue, this is easier said than done.
“The fact that there is no national standard for a
workplace hazard that is so well-recognized is pretty
astonishing,” Dr. Arnetz added. “The steps OSHA recom-
mends are commonsense actions, but there should be
data behind those recommendations. Yet we don’t even
SIDEBAR 1
Health-Care Workplace Violence by
the Numbers
Workers in health-care and social assistance settings
had a higher annual incidence of intentional injury by
another person than workers in any other settings:
All private
industries All state
industries Private
health care
and social
assistance State
health care
and social
assistance
2012 4 15.1 35.8 147.1
2013 4.2 16.2 35.3 146
2014 4 14.4 32.1 135.2
Health-care settings even outranked the police
protection or correctional institution settings:
Incidence of Intentional Injury per 10,000 Full-Time Workers
Hospitals 97.4
Nursing and residential care facilities 116.8
Police protection 8.7
Correctional institutions 37.2
0
20
40
60
80
100
120
Number of Injuries
Patients are the most common perpetrators of
health-care workplace violence.
Source of Health-Care Worker Injuries
Student 3%
Coworker 3%
Other person (not specified) 1%
Assailant/suspect/inmate 1%
Other client
or customer
12%
Patient
80%
Nurses are most commonly the victims of violent
injuries that resulted in days away from work, with
psychiatric aides having the highest rate:
Injuries per 10,000 Full-Time Employees
Psychiatric aides 590
Nursing assistants 55
Registered nurses 14
0
100
200
300
400
500
600
Number of Injuries
Sources: OSHA, Bureau of Labor Statistics.
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