Workplace violence prevention policy and procedures

The policy would identify for staff how to respond in a violent situation, including what to do and whom to call. The Joint Commission accreditation standards for healthcare organizations mandate certain steps for organizations to take that will better identify and mitigate workplace violence.^[4] The steps include having a written plan to manage the safety of patients and others who enter the organization’s facilities.

There are multiple ways that healthcare organizations can work to prepare staff to deal with patients or visitors who become aggressive or violent. A policy and procedure might encompass part of the organization’s code system. It is not uncommon for healthcare facilities to have a variety of codes that alert staff to the nature of the situation. A Code Gray is commonly used to inform staff there is a violent patient or visitor in the specific area of the code. There may also be a Code Silver that alerts staff there is a situation involving a weapon and/or a hostage. Some organizations might have an additional code that signals there is simply an unsafe situation. Any of these situations could involve a violent patient or visitor, but it is important that staff are aware of the most appropriate code to use so that an appropriate response can be initiated.

Flagging the patient’s file

There is also the circumstance where a patient or visitor might be flagged because of escalating aggressive behavior over time. If a patient is unsatisfied with the care they are provided and makes a complaint to the clinic staff, that is not so unusual. But if the patient, on subsequent visits, demonstrates increasing aggression, there might be a need to take steps to prepare staff for when that patient will be coming in for a service. The same may be true for family members or others who attended visits with the patient.

The organization might also consider a policy for flagging the patient’s medical record in some manner so that staff can be alerted if the patient or their visitor has been a concern in the past. This will allow staff to be on the lookout for any inappropriate behavior and be prepared to deal with any issues that might arise. However, the organization will also need to be aware of any privacy concerns regarding how much information is shared in the flag as well as being aware of any potential discrimination issues that could arise from such a flag. This is a challenging balance. If the patient is not satisfied with the care being given, that may be something the patient relations department can address to help de-escalate a situation. But dealing with a patient who does not appear to be satisfied no matter what is done may need more drastic measures.

The Health Insurance Portability and Accountability Act’s Privacy Rule permits the use or disclosure of protected health information for “treatment, payment, or health care operations.”^[5] Specifically, under the definition of healthcare operations, the rule states information may be used for “business management and general administrative activities.”^[6] A key activity for business management would be to keep staff, patients, and visitors safe as reflected in The Joint Commission’s accreditation standards. It is this author’s position that a flag could be included in the patient’s record that alerts staff of the potential for aggressive and/or violent behavior. As to the details of what would be included in such a flag, the minimum necessary provisions of the Privacy Rule would still need to be considered.

The organization would also need to be aware of any issues associated with other state and federal laws regarding the confidentiality of the patient’s information. For example, if the patient is being seen for a substance use disorder and the records are covered by the Substance Abuse and Mental Health Services Administration regulations, there may be limitations on the information that can be included in the flag without patient consent. State laws may also have additional protections for certain behavioral health and other sensitive information.

Other considerations for any policy regarding placing a flag on the patient’s record might include a list of factors that would trigger placing the flag on a patient’s file. The organization might also consider having an independent review of the recommendation to place a flag on the file to help ensure it is based on factors that are as objective as possible and not simply the result of a single staff member’s disagreement with the patient. This will help avoid instances where the issue might not be the patient or visitor but the staff member and their subjective interpretation of the patient’s or visitor’s actions. For example, a criterion might be that the patient or visitor has demonstrated the behavior with multiple staff members and not just one unless the interaction with the one staff member was witnessed and was egregious. This may also help avoid any allegation of discrimination by the patient.

Providing training

A policy is only as good at the awareness of it, so training staff is a critical step. Organizations will also need to look at what training is being provided to staff. The staff should have training on recognizing the warning signs for when a situation might become violent. If staff recognize the warning signs, there may be interventions that can be initiated to help avoid a more serious outcome. Staff may also need training to look at the entire situation to identify the stressors that may be contributing to the individual’s particular behavior. Being in a healthcare environment, many patients and visitors may feel that much of what is occurring is beyond their control. It also will most likely involve them or a loved one being ill. Doing something helps them feel like they have some control and may be the outlet for their frustration. For some people, it may, unfortunately, be exhibiting aggressive or violent behavior.

Staff may also need to be trained on whom to call rather than attempting to handle the situation. Healthcare providers in general are individuals interested in helping people. However, a clinic nurse or a pediatric physician might not be the best person to help de-escalate a situation with an aggressive or violent parent. That might take someone specifically trained in those skills. Helping staff understand when they need to bring in support may be critical to avoiding personal injury or property damage.

Another component of training staff is making sure they know the most appropriate steps. In an active shooter situation, the Department of Homeland Security recommends one of these three steps:^[7]

1. Evacuate the area if it is safe to do so.

2. If evacuation is not possible, then find a hiding place. If there are multiple people, don’t all hide in a cluster.

3. If the shooter must be confronted, use any available tool or resource to try to provide protection and disable the shooter.

Staff should also be trained on how to respond when law enforcement is involved. If there is a violent individual and staff is evacuating or being rescued by law enforcement, making sure they understand to keep their hands in view so that the law enforcement won’t mistake them for the aggressor can help them avoid a potential negative interaction with law enforcement. This also allows law enforcement to focus on the active shooter faster.

Review physical controls

According to the Occupational Safety and Health Administration, there may also be physical controls to help identify, avoid, or control aggressive or violent behavior.^[8] Doing a routine walk-through of the environment may help identify changes that could better support preventing violence. Being particularly aware of areas that might be more prone to violent outbursts is important. These areas might include the emergency department, a psychiatric unit, geriatric units, or admission areas. These might be areas where the organization might want to consider installing panic buttons to allow staff to alert the appropriate responders without raising the suspicion of the individual. Helping ensure that there are no significant physical barriers that prevent staff from seeing what is occurring in the workspace or installing mirrors to see around a corner are also considerations.