The story below is from our July/August 2019 issue. For the full issue Subscribe today, view our FREE interactive digital edition or download our FREE iOS app!
Whether initiated by patients, visitors or medical professionals, violence in hospitals has come under special scrutiny as they strive to become safer places for everyone.
One of the most significant problems hospitals—including those in the Roanoke Valley—have to face today is violence on their premises.
Locally, hospitals are not just facing the violence epidemic, they are attacking it.
“That [violence] happens at all [at Carilion] is startling,” says Carilion CEO and President Nancy Agee, even though its hospitals have 75,000 admissions a year and 500 adult patients a day are being served. Emergency deals with 250 people a day “who are in rough places.”
The violence comes in a variety of forms, and one hospital executive calls it, “an epidemic nobody talks about. It’s been getting worse. This has not happened overnight.” Actually, there’s a lot of talk about it, both inside and outside hospitals.
The Virginia legislature recently passed a bill that would increase criminal penalties for those harming or threatening to harm medical professionals engaged in their duties.
“Many health care workers simply dismiss such events as a routine part of the job,” says James Cole, president of the Virginia Hospital Center, a 394-bed not-for-profit, teaching facility offering comprehensive health care in Arlington. “In a way, there is a certain nobility to that response from health care workers who prioritize the needs of distressed patients over personal concerns. However, prioritizing patients doesn’t mean we should ignore the physical and emotional well-being of health care workers who devote themselves to caring for patients in their hour of need.”
The epidemic looks like this:
In one recent 10-year period, incidents of serious violence in hospitals were four times more common than in private industry, according to Occupational Safety and Health Administration (OSHA). One study concluded that “78 percent of participants experienced at least one act of workplace violence in the last 12 months, with 75 percent reporting verbal threats and 21 percent reporting physical assaults.”
Disturbing statistics abound about the prevalence of violence in medical facilities, but the surveys show that just 30 percent of nurses and 26 percent of physicians report violence.
One long-time Roanoke Valley RN, who has worked in several hospitals and units, including the emergency room and intensive care and asked that her name not be used, says that some of the verbal and physical violence that used to be present is rare now.
“Colleagues used rude language, threw pens, called nurses ‘stupid.’ It doesn’t happen so much now.” Patients, she says, “hit, slap, bite” and that “is sometimes tolerated.” She says that “a nursing assistant I worked with had a patient try to stab her with an ink pen in the neck. The patient was a schizophrenic and what we see so often is the victim being blamed. ‘She shouldn’t have had a pen in her pocket,’ or ‘why let the patient get that close?’
“I think the biggest problem,” says the nurse, “is that there’s just not enough staff” to handle difficult situations. Still, “nurses are much better educated now and there is security in hospitals.”
Management Consultant Sandy Smith, who works with hospitals (including Carilion), says the costs of hospital violence are significant.
“Violence that involves a staff member, whether from a patient, visitor, or another employee, has a significant impact on the operations of the hospital. Workplace violence leads to increased staff turnover, medical care, lost productivity and a host of other issues for injured employees. Many studies on this issue focus on a single hospital system or clinic to illustrate the experiences of limited events. … National in-facility violence costs of $428.5 million a year, including $234.2 million for staff turnover, $42.3 million in medical care and indemnity [compensation for lost wages made to employees who were injured on the job] for employee victims of violence, and $90.7 million in disability and absenteeism costs.”
Carilion has gone so far as to create the Carilion Clinic Center for Simulation, Research and Patient Safety. It deals with a variety of medical issues, including safety.
Agee says Carilion is also one of many hospitals aspiring to #HospitalsAgainstViolence, which “invites hospitals to stand with communities against violence.” The result of considerable discussion and education is “there is true awareness. … Every hospital is a small city … and it is not different inside from what we see in general society. [We are taking care of] people during one of the most traumatic times in their lives.”
“People come in at their most vulnerable times,” says Carilion Chief Medical Officer Patrice Weiss. “We see stress from family members that results in stress for the care team.”
Nancy May, Vice President of Marketing and Public Relations at LewisGale Regional Health System, agrees: “When people need emergency or hospital care for a serious or life-threatening illness or injury, it is one of the most vulnerable times in their lives,” she says via email. “Understandably, it is an emotional time for patients and their family members.”
“The majority of situations in which patients become combative or agitated are due to their health condition, confusion or anxiety. Sometimes family members can also become emotional or angry when questioning the care of their loved ones.”
May says opioid and other drug use “has also resulted in events that require intervention of additional staff or security personnel. All employees go through new-employee orientation that includes a session on security and how to deal with escalated situations.”
Chief Operating Officer and President of Carilion Medical Center Steve Arner points out that Carilion employs 40 security officers and 50 police officers. There are 500 security cameras covering two million square feet “to create a safety environment.” There is a lot of one-on-one training at Carilion and Arner says there are 60 events a year dealing with patient combative injuries.
“We are purposeful in our culture,” says Weiss. Employees sign a code of conduct on how to treat patients and each other. “There is team support. This is not a hierarchy. … We don’t tolerate abusive employees.”
That tolerance “has a very low threshold,” says Agee. “That’s our culture. We try to make it pervasive.”
Employees and patients are encouraged to file reports about misbehavior or errors, says Weiss. The reports can be anonymous “and there is no fear of retribution.”
There are “relaxation” rooms where stressed employees can sit in a massage chair and simply take a break. There is a staff-only chapel. Carilion has reduced “overhead” announcements, creating a quieter atmosphere. “People need a break after a tough case,” says Weiss.
The Schwartz Rounds program, used by 440 hospitals, is a quarterly lunchtime gathering where employees (excluding management) “talk about issues and how things feel.” It is popular, says Weiss. “If we took it away, we’d hear about it.”
At LewisGale, May says training and investment in infrastructure are important aspects of decreasing violence.
“Health care staff who work in the most vulnerable areas are required to go through Crisis Prevention Intervention training that teaches them to de-escalate situations before they turn into physical assault situations,” May says. “Our security team also receives additional, in-depth criminal justice training. One example is ‘Verbal Judo,’ in which officers are trained to use verbal versus physical force to take control of a situation that has already escalated.”
“We have also made significant investments with environmental design to ensure the safety of our patients, staff and visitors. One significant investment is the addition of LED exterior lighting and emergency phone systems in our parking areas.”
Arner says the vital job “is to evaluate potential problems, to remove problems. It’s a pretty elaborate process.”
“We are devoted to making [Carilion] a safe and nurturing environment to provide health and healing,” says Agee, who is president of the National Hospital Association. “This is not one and done. We want people to feel safe.”
Catawba Hospital: A Safe Bed for All
Catawba Hospital in Roanoke County has special challenges, since it focuses on mental health and some of its patients are, by definition, high risk. “The patient population has changed here since 2014 on the heels of the [Virginia State Senator] Creigh Deeds incident,” says Catawba Facilities Director Mitch Mitchell. Deeds’ son attacked him with a knife, then committed suicide after being refused admittance to a mental health facility, leading to legislation changing commitment laws.
“The goal,” says Mitchell, “is that nobody goes without a bed. The state hospital is a last resort. We assess. Others may exclude [some patients], and they come to us.”
That means, says Director of Quality and Risk Management Jarvis Griffin, “They need to be stabilized; they may not be coherent.” And some may tend toward violence. The patients at Catawba carry what would generally be considered higher risk than at other facilities.
“Substance abuse is higher [among those at Catawba] and rates of violence are high even when they are not intoxicated,” says Mitchell. “We deal with dementia, delirium and mental instability. We are robust about human rights; we are human rights advocates. We have a hotline for complaints and we encourage patients to report concerns. Staff-to-staff violence is not much of a problem. We have a strong workplace violence policy.”
The policies can be blunt. “If you see something wrong, you have to say something. In surgery, we have a ‘stand down’ policy where we stop and listen. There is a requirement to report safety concerns,” says Griffin. The goal, he says, is zero harm, zero violence.
Catawba has a public safety department where “everybody is trained in therapeutic options,” says Mitchell. Intervention emphasizes de-escalation without physical interference when possible. Mitchell says hospital professionals in the Roanoke Valley often train together for the safety of their facilities, and Blue Ridge Behavioral Healthcare is “the gatekeeper for the state” in this area, Mitchell says.
Catawba is “different from most psychiatric facilities in the state in that we are a geriatric unit” with 60 geriatric beds and 50 adult beds with a median stay of 20 days. The goal is to teach patients to “live in the community.”
“We’re getting there,” says Mitchell. “But I don’t think we will have done enough until there are no incidents of aggression.”
That sentiment seems to be shared throughout the Roanoke Valley.
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