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Hopkins Medicine Magazine - Cautionary Tales

Hopkins Medicine magazine, Winter 2011

Cautionary Tales

Traditionally considered sanctuaries of healing, hospitals are not always the safest place for people who work there.

By: Linell Smith
Date: February 18, 2011


illustration of doctor. EKG on left, caution tape on right
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NOTHING MATTERED ANYMORE, he told the Hopkins doctor. His child was dying, suffering the final stages of incurable cancer. Meanwhile he was drowning in grief, anger, and the hopelessness of a future without her. As the young father entered the hospital room, he told the pediatric fellow at his side that he was determined to end his daughter’s misery as well as his own.

Barbara Duffy recalls assuring him that the medical team was controlling the young girl’s pain. When the father showed her his handgun, however, the conversation became a crucial negotiation. Listening to his despair, suggesting alternatives, the physician gradually guided him to an emotional place where he was able to put his weapon aside and get the psychiatric help he needed.

“I read this situation as a distraught dad who couldn’t go on,” she says. “It never crossed my mind that he might hurt me.”

This was in the 1980s, long before the tragedies of Columbine, Virginia Tech, and Fort Hood, long before hospital security forces were trained to respond to situations ranging from terrorist attacks to the panic of pandemic flu. Only 25 years ago, Barbara Duffy could not conceive of a world where, on September 16, 2010, Paul Warren Pardus would shoot and wound the Hopkins physician who was taking care of his 84-year-old mother before killing his mother and himself in her hospital room.

In recent years, however, shootings at medical centers across the country have cast doubt on the sanctity of hospitals as islands of safety. In the past two years, health care workers have been shot at hospitals in Long Beach, CA, Columbus, GA., and Danbury, CT.

Although statistics show that such attacks are rare, these and other less fatal forms of workplace violence have focused more scrutiny on hospitals and other health care facilities, including nursing homes and psychiatric hospitals. Consider the following:

•    Health care workers are almost four times as likely as the other American workers in private industry to be assaulted on the job, usually by patients or family members, according to a 2009 study by the U.S. Bureau of Labor Statistics.

•    Every week, 1 in 10 of the nurses who work in emergency departments falls prey to physical violence, according to a national survey by the Emergency Nurses Association, while more than half reported experiencing verbal or physical abuse at work in the last seven days.

•    Nearly half of the incidents of assault, rape, or homicide voluntarily reported since 1995 to the Joint Commission, an organization that accredits the nation’s hospitals on a voluntary basis, have occurred in the past three years.

According to the U.S. Bureau of Labor Statistics, health care and social assistance workers suffered 48 percent of all reported nonfatal assaults in private industry that resulted in lost workdays in 2009. But some say such figures underestimate the extent of the problem: University of Maryland workplace violence prevention researchers Kate McPhaul and Jane Lipscomb, for instance, maintain that only one of every five assaults on health care staff is reported.

Last year, the Joint Commission issued a “sentinel event alert” recommending that hospitals and other health care settings devise policies and plans to better protect their staff and improve the general “culture of safety.”

“Our basic focus has always been on the safety of patients, but it’s difficult to have a secure environment for patients if you don’t provide it for everyone,” says Paul Schyve, the Joint Commission’s senior vice president of health care improvement.

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“Historically, if a patient was giving you a hard time, you’d chalk it up to the fact that they’re not feeling well. But when staff started complaining that they were afraid patients could hurt them, and nurse burnout began to increase, we had to do something.”

—Joann Ioannou, assistant director of medical nursing, Johns Hopkins

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The Hopkins risk assessment team is still reviewing the September 16 shooting and therefore could not discuss the case or any specific security procedures it may suggest. Regulatory bodies that looked into the incident, however, concluded that Hopkins did all it could to appropriately handle the situation and to minimize harm to staff and patients.

Prior to the incident, the hospital already had round-the-clock security and on-demand legal counseling for staff members as well as longstanding policies to restrict visitors deemed abusive and threatening. In the Emergency Department, a place at greater risk for violent behavior, security staff also conducted searches and “wanded” patients and visitors with metal detectors if the situation merited.

Other general safety measures now under consideration here include documenting patients and family members who are disruptive or may have shown abusive behavior in the past, and designating specially trained counselors to respond promptly to worrisome or hostile situations.

“We’re at the stage of improving how to recognize abusive behavior in patients and families and how to set limits,” says Meg Garrett, head of risk assessment and senior counsel for the Johns Hopkins Health System’s legal department.

The task is particularly daunting for a multigenerational workforce with different perspectives on what the relationship between patients and their health care providers should be.

“The whole idea that physicians and nurses no longer need to accept what a patient offers as behavior is pretty new,” says pediatrician Duffy, now in private practice. “It used to be that you just had to put up with it, disengage as fast as you could, and be polite. We were trained that patients [in pediatrics, the term “patients” also refers to parents/caretakers] had a right to be wherever they were emotionally, and that no matter what they said, you treated them with respect.”

In those days, however, medical staff could take their personal safety more or less for granted. When Duffy was a fellow at Hopkins, no one thought to brief her on how to deal with patients with weapons.

“They didn’t have security at the door, and no one searched anybody or their backpacks when they came in. We wore ID cards, but I don’t think they activated anything. It was a much more trusting world,” she says. “The question now is: How do you make Hopkins a place that patients want to come to and at the same time make it safe for people who work there?”

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AS CHAIR OF THE DEPARTMENT of Emergency Medicine, Gabe Kelen is ever mindful of the risk of society’s violence spilling into the hospital. Shortly after the September 16 shooting, he and his colleague, Christina Catlett, set out to determine the extent of armed violence by reviewing news reports of shootings at other medical centers. Their findings were published as commentary in December in the Journal of the American Medical Association.

In one sense, the news is good for Hopkins: Not only are hospital shootings rare, they do not appear to occur more frequently in high-crime areas. At least half of the incidents were what Kelen calls “grudge shootings that happen in society at large.” He and Catlett found no trend of patients or their families seeking deadly revenge because of medical treatment.

“Health facility shootings have tended to be random, at smaller centers, and unrelated to local violence,” they write. “To underscore, the shooter at our institution was 50 years old, lived out of state (with his mother), had no criminal background, held a responsible job, and had a license to carry a gun in his home state.”

Due to the rareness of shootings in health care facilities and the difficulty of preventing “determined shooters,” Kelen concludes that hospitals should focus violence prevention on other assaults to which certain areas and departments—such as ICUs, psychiatry, EDs and geriatrics— are particularly vulnerable because of the type of patients they treat. Many patients exhibiting abusive behaviors may be “disinhibited” as a result of their medical condition, alcohol, drugs, or a combination. Mental illness and dementia can also provoke violent behavior.

“There are mean people, and then there are people whose disease makes them look mean,” Kelen points out. “Most assaults are verbal. The next most common thing is someone who is flailing away and you happen to get in the way. The third is that someone actually takes a swipe at you.”

Diane Gurney, 2010 president of the Emergency Nurses Association, refers to the ED as “the surge protector” for the hospital, and for health care in general.

“We’re more crowded than ever, and many patients are waiting,” she says. “They come into the ED in crisis, and after an hour of waiting, they get loud and abusive and demanding.”

A study published last year by the Emergency Nurses’ Association suggests that nurses often bear the brunt of such anger and frustration. The survey of 3,211 ED nurses from around the country reports that as many as 13 percent experienced physical violence on the job each week, while 55 percent reported verbal or physical abuse during the past seven days. Almost half of the nurses who were harmed physically noted that no action was taken against the perpetrator as a result of the violence, and 74 percent said the hospital never responded to them about their experiences as victims.

Virtually all incidents of physical abuse (97 percent) were inflicted by patients and their family members, and most (80 percent) took place in patients’ rooms. Nurses were most likely to encounter physical violence when triaging a patient, restraining or subduing a patient, or performing an invasive procedure.

“I’ve been slapped, I’ve been spit at, I’ve been urinated on,” says Gurney, now a retired nurse educator in Massachusetts. “In the beginning, you’re shocked until your colleagues say, ‘That happened to me, too. It’s part of the job.’ Unless you’re so hurt that you miss work for a couple of days, you don’t tend to report it.”

She hopes the study will illuminate the plight of frontline staff and encourage hospitals to enact policies of zero tolerance toward violence. Only 8 percent of ED nurses in hospitals with such policies experienced physical assaults, she says, compared to 18 percent in hospitals without them.

In the 1990s, Hopkins medical and legal staff devised a behavior contract to deal with competent patients who behave inappropriately. Essentially, these patients must agree to improve their conduct and comply with medical orders in order to remain in the hospital.

Joann Ioannou, now assistant director of medical nursing, helped implement the contract when she was working with certain HIV/AIDS patients who were belligerent toward staff.

“Historically, if a patient was giving you a hard time, you’d chalk it up to the fact that they’re not feeling well,” Ioannou says. “But when staff started complaining that they were afraid patients could hurt them, and nurse burnout began to increase, we had to do something.”

The document is now used throughout the hospital, including the ED. According to the national nurses’ survey, physical violence rates in the EDs of large urban areas are higher (13.4 percent) than in rural areas (8.3 percent).

“While there are isolated cases of violence, there are many, many more cases of people who rely on us as their provider of emergency resort,” says Adil Haider, a trauma surgeon at Hopkins. “The number of patients who are very thankful for what we do dwarfs the others. And if a patient is acting out, you must remember they are sick and may not typically be like that.”

Kelen says the Hopkins ED is quick to enforce the hospital’s policy toward inappropriate behavior. “If you’re mentally competent and you want to act like a doorknob, you’re going to be shown the door,” he says. “And you’ll be potentially restricted from coming back into the hospital through other entrances. If somebody gets out of hand, we have a very low threshold for the next step. We have a fabulous security staff whom we often summon to difficult situations. That show of force is sometimes all that’s needed.”

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ALSO POISONING THE CULTURE OF SAFETY are employees who intimidate, bully, and belittle their own co-workers. Such behavior may be overlooked, experts say, until it builds into venomous verbal or physical abuse.

Michelle Carlstrom, senior director of Hopkins’ Office of Work, Life and Engagement, says the hospital and health care organization see more worker-to-worker violence than any other part of Hopkins. The number of violent episodes occurring at the medical school and Hopkins Hospital has increased steadily and is on track to hit a record 72 incidents this year.

Behavior meriting investigation includes physical violence or hostility stemming from verbal threats, harassment, and bullying. There is also a category for intimate partner violence. All cases are reviewed by the hospital’s risk assessment team, a group representing the legal, security, and human resources departments as well as the Faculty and Staff Assistance Program.

After an incident is reported, team members “triage” the situation to decide whether it merits a full workplace violence evaluation or if it should be handled administratively.

“Imagine we get a report on someone who walks away from a conversation saying, ‘I’m going to get her, I’m going to kick her ass.’ It’s likely this person has already said something like this a bunch of times but has never been told not to,” Carlstrom says. “So is there a legitimate threat here?

“If we’re told that she’s never spoken like this before, the incident will probably be handled administratively. If we find out that everyone’s afraid of her and has been for a long time, we’ll recommend her for a risk assessment evaluation that may bring up more information.”

Last year, 68 percent of the employees assessed as safety risks were women; one predictor of trouble is whether a person already has a history of acting violently. Carlstrom says that loss—such as a relationship or job—may provoke violence or exacerbate existing passive-aggressive behavior.

“We’re talking about employees who might wander around murmuring comments or threats about particular people,” she says. “It’s never quite clear whether to take them seriously. It can go on for years before that person finally goes too far.”

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“Many of the shootings at hospitals in 2010 involved intimate partners or former partners, so I think it’s important to recognize that personal issues often spill over into the workplace.”

—Andre Simons, manager of the threat assessment program, FBI’s behavioral analysis unit

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Part of the problem, she says, is that supervisors and managers often avoid speaking to workers about their behavior because they don’t consider this part of their jobs.

“They may think, ‘My problem is the person who can’t do the work.’ They need reinforcement that someone’s behavior is as great a part of job performance as completing tasks,” she says. “When supervisors don’t know how to manage bad behavior, they often refer people to FASAP. The tricky part is that these people have often behaved like this over a long, long period of time.”

University of Maryland nurse researcher Kate McPhaul, who received her master’s degree in public health from Hopkins’ Bloomberg School of Public Health, says unpublished data from a study of public-sector workplaces show that health care facilities have a higher incidence of employee incivility, intimidation, and bullying.

“Although all public-sector agencies are working under tight budgets and stresses, the nature of the work is different,” she says. “We hypothesize that stress in health care facilities is simply higher because it involves human beings and not tax forms.

“Often management is not prioritizing civility, or it is sending inconsistent messages. And there continues to be this ethos among health care workers of, ‘It is what it is. Nothing can be done about this behavior. And if I do kick it upstairs, it’s going to look as if I’m not doing as much as I can.’”

Recognizing the problem, the Joint Commission now requires that hospitals have a code of conduct defining disruptive behavior as well as a process to manage it.

“Often supervisory personnel don’t know how to respond to intimidating behavior,” Schyve says. “They may just shrug it off and ignore it. So even though something has been reported, nothing really happens because people literally don’t know what to do.

“In some situations, the appropriate response may be to simply increase vigilance, where other situations might escalate and lead to harm. But if people haven’t talked and thought through various situations ahead of time, it can lead to ineffective response—or no response.”

That further jeopardizes safety, he says, by discouraging staff from expressing concerns about inappropriate behavior.

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HOW DOES ONE PREDICT whether an irascible patient or co-worker will become violent? When contemplating who might be at risk for committing such extreme acts as shootings, risk assessors should look at behavior rather than at characteristics such as gender or race, says Andre Simons, manager of the threat assessment program at the Federal Bureau of Investigation’s behavioral analysis unit.

“There is no useful demographic profile that accurately describes an active shooter,” he says. “Hospital safety professionals should remain vigilant to all potential threats.”

Simons co-authored a 2010 study that looked at homicidal violence occurring at American universities and colleges over the past century. In about a third of the cases, people who knew the perpetrators observed changes in their personality or performance, disciplinary problems, depressed mood, suicidal thoughts or increased isolation, nonspecific threats of violence, odd or bizarre behavior, and an interest in weapons prior to the attacks.

Roughly a third of the assaults studied were related to an intimate relationship, either current or past. The next most common reason for an attack was as retaliation for a specific action. Such appears to be partially the case in a fatal incident of workplace violence that occurred on New Year’s Day at Bethesda’s Suburban Hospital, part of the Johns Hopkins Health System. An engineer in the hospital’s plant operations department was stabbed to death in a basement boiler room, allegedly by a member of his staff. The accused assailant, who police said has a history of violent behavior, had been disciplined recently on several occasions.

“Many of the shootings at hospitals in 2010 involved intimate partners or former partners, so I think it’s important to recognize that personal issues often spill over into the workplace,” Simons says.

Triggering events in the lives of perpetrators included the loss of either a personal relationship or job in the weeks or months preceding the violence and experiencing professional humiliation. Researchers also found that “bystanders” commonly observed troubling behavior but failed to report it.

Simons says that a multidisciplinary threat assessment team, similar to the one at Hopkins, can provide greater insight into all aspects of offenders’ lives and devise better strategies for reducing the risk they present.

Kate McPhaul is helping to develop violence prevention education and training material for the website of the National Institute for Occupational Safety and Health. The free online program for health care workers will present evidence-based methods for dealing with violent situations.

Meanwhile, she says a work climate with responsive managers and supportive co-workers can reduce verbal and physical violence.

“If you’re functioning at a normal stress level, and your boss likes you and you like your boss and your co-workers help one another out, that really makes a difference,” she says. “Those are the kinds of things we’re looking at to prevent violence as well as determining how much security is adequate.”

Identifying patients and families who may become violent is difficult, risk assessors say, because not much is usually known about their past histories and there is less opportunity to observe them over time. It’s also common for people to act in unpredictable, sometimes frightening, ways when facing the loss of a loved one.

“Even the most stable of families will show a lot of emotions if they hear devastating news,” says pediatrician Duffy. “No one is prepared for the news that their 3-year-old has leukemia or that the new father who is only 23 now has brain damage from a car crash. No one is prepared for those things.”

“Some people crumple to the floor, others will collapse on top of their loved ones, sobbing and hugging them. You see people yell. You see them punch walls. Some will go out and drink excessively. The challenge is to figure out who’s at risk for doing harm to others while still respecting their right to these emotions.”

Kelen believes staff should be better attuned to the nuances of such situations.

“It’s perceiving the difference between the distraught person who says, ‘I can’t stand to see my daughter suffer,’ and the angry person who says, ‘You’re not curing my daughter! Why aren’t you doing more?’

“As an institution, and in our own departments, we need to grapple with how to improve this kind of training,” he says.

“Understanding who might go off, and figuring out potential responses, is clearly one of the most important things we can do.”

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