In the first part of this series, experts and clinicians shared data and stories related to violence in oncology settings, with several clinicians describing specific threats from patients and other concerning encounters.
Experts agree there is no one simple solution to the problem of workplace violence in healthcare, but some actions can help prevent and limit these dangerous situations.
Leadership Must Be Involved “Not Just When Something Happens”
According to David Corbin, CPP, CHPA, owner and principal consultant at Dynamic Security Strategies, LLC, a security consulting firm in Salem, Massachusetts, the first step in establishing a workplace violence prevention and mitigation program is an assessment to determine the historical prevalence of violence at a given hospital or clinic.
However, that assessment alone won’t tell the tale, because much workplace violence goes unreported. That’s why it is also important to assess “the culture of the facility as it relates to workplace violence,” explained Mike Dunning, CHPA, CEM, owner and principal consultant of the Healthcare Security Consulting Group, LLC, in Atlanta. Dunning’s group learns about workplace culture by interviewing staff members, he said.
“Is it something that's just accepted as part of the job? Is it something that people are told ‘don't report,’ or is it something that's freely and openly talked about and discussed?”
The next step in establishing a workplace violence and mitigation program is to get hospital leadership involved and to ensure “that they're engaged in it, and not just when something happens, but at all times,” Corbin said.
According to Corbin, institutions should also identify a Safety from Violence Officer, ideally an experienced clinician, who helps to lead the mitigation program. “The people who are most well equipped to deal with the clinical issues that lead to violence are clinicians,” Corbin explained. Institutions should also set up a multidisciplinary workplace violence and mitigation committee, including nursing staff.
Prevention Requires More Than Just Online Classes
De-escalation training is another key tool. “It should be available to everybody and should be mandated for everybody to take,” Corbin explained. Some organizations have a safety and de-escalation module that employees can complete online. However, faculty and staff members who work directly with patients need more in-person training, including instruction in verbal de-escalation techniques, as well as how to stay safe during a confrontation.
For people at highest risk, training should also include how to restrain someone and protect against a physical attack, “basically self-defense,” Corbin said.
Several established de-escalation training programs are available from MOAB, AVADE Workplace Violence Prevention, the Crisis Prevention Institute, and others. Any training program selected “should have a trauma-informed piece, because that does play into acts of violence and people's propensity to act out,” he added.
Dunning also emphasized the importance of in-person de-escalation trainings. “You just can't teach people how to change people's behavior by being on a computer,” he said. Even when de-escalation courses are taught in-person, it can still be difficult for people to take a short class and apply it every day in the workplace. “Even if it's instructor-led, if the core principles of that course are not being followed and taught and reinforced, then it was worthless training,” he said.
Most de-escalation training programs start with a scenario in which someone is angry and on the verge of committing assault, Dunning explained. That approach misses what he views as the most important aspect of the training: recognizing escalating behavior before it reaches that stage. “We have to be able to recognize those signs, those clues, of them escalating before the chair flies through the air, before the punch is thrown,” Dunning said.
Tracking Red-Flag Patients
In addition to de-escalation training programs, it’s also key to have a threat assessment and management process. Corbin advocates using a structured professional judgment tool, such as Historical Clinical Risk Management-20 (HCR-20), to systematically evaluate a patient’s risk for committing violence. HCR-20 is a paper manual for assessing violence risk, accompanied by ratings sheets for evaluating individuals in terms of risk factors.
This is not something to use with every patient, just those who have committed previous violence or raise red flags, Corbin noted. If the patient does present a risk for violence, then institutions can develop a safety plan. “Otherwise, clinicians are left sort of using their own professional judgment, using gut instincts or just using guesswork to understand whether a patient might be violent," he said.
It’s also important to track progress in addressing problems identified during the workplace violence assessment and to maintain the program, Corbin notes. He advocates doing mini-refresher trainings to keep staff members on their toes and asking them what they would do in a given situation. Institutions can use such micro-trainings either as confirmation that people know what they’re doing or as teachable moments, he said.
“Workplace violence is a dynamic and persistent threat. And it's not going away anytime soon,” Corbin said.
Amanda Castillon, RN, says that she had not received de-escalation training at Hendrick Medical Center, where she worked as a traveling nurse when a patient’s husband threatened to shoot her, as detailed in our previous story. She has since participated in de-escalation trainings, including Handle With Care and MOAB at other facilities where she has worked.
“The biggest takeaway from those trainings is just listening to the patient,” Castillon said. “With a lot of patients, it's just they feel unheard by the medical profession in general,” she continued.
Long-Lasting Ramifications of Violence in Oncology
The Joint Commission accredits about 80% of US hospitals. Starting in 2022, they now require accredited institutions to have violence prevention programs that include risk evaluations, systems for monitoring and reporting violence, and training for hospital leadership, staff, and health practitioners upon hiring, annually, and whenever changes to the workplace violence policies occur.
A survey of hospital security leaders across the United States commissioned by the International Association for Healthcare Security and Safety (IAHSS) Foundation asked hospital security leaders whether their institutions had threat management teams. Of the 227 respondents, 211 answered this question, and 57% said that they had these teams.
Noelle LoConte, MD, a medical oncologist at the University of Wisconsin (UW) Carbone Cancer Center, described an incident during which a patient threatened to shoot her both in a recent Journal of Clinical Oncology essay and in our previous story.
UW and other institutions utilize behavioral emergency response teams (BERTs). “BERTs include a specially trained nurse, an emergency department technician, and security,” UW Health spokesperson Sara Benzel said. Employees can page BERT “when a patient or visitor is having a behavioral crisis such as self-harm, extreme agitation, yelling or screaming, or being disruptive or threatening, and staff need assistance in de-escalating the situation and providing support,” she added.
“Employees can also call security directly if there is a threat of violence, per the Workplace Violence Reporting and Investigation policy,” Benzel said, adding that it is possible to report a past threat even if BERT was not called.
Dr. LoConte did not make such a report after the violence she faced several years ago. She said that, although she knew that BERT was available, she did not want to risk alerting the angry patient. At the time, she was not aware that it was possible to make an after-the-fact report. She now knows that she can report incidents of patient violence at UW, even after the threat has passed, using a safety reporting system that is embedded in the electronic medical record.
“The formal name for this report in the electronic medical record is a behavior safety alert. These are very visible to staff and display as a pop-up alert to staff as soon as they open the patient’s chart,” Benzel explained.
“That report goes through a review process that looks into the behavior, as well as strategies that staff can use with that patient. It often includes detailed plans on how staff can interact in a standard way with a particular patient or visitor.” The list of patients who have behavior safety alerts is reviewed twice a year to make sure that they are still needed, Benzel added.
Even with the best resources available, and even when worst-case scenarios don’t come to pass, the ramifications of violence in oncology workplaces can be long-lasting.
After Dr. LoConte’s patient made threats on her life, she worked with a therapist for a year. In 2023, she encountered another angry patient and was “right back in that room with that patient that threatened to kill me.” She felt herself dissociating from her body and watching the scene as if from a bird’s eye view, which she said that she later recognized as a response to trauma.
“It was just surprising to me that this thing that had happened, I think in 2017, 2018, something like that, could still be affecting me in 2023,” she said.
