W

ork-related injuries have long been considered the main threat to healthcare worker safety. Indeed, the United States Department of Labor says job-related sprains and strains, bruises and contusions, cuts and lacerations, and fractures accounted for nearly two-thirds of the 1.3 million cases of days away from work in 2003. So maybe it is not surprising that nursing aides, orderlies, and attendants rank at the top of the occupational injury list—right alongside laborers, material movers, and tractor-trailer truck drivers.¹
       But these painful injuries seem tame compared to purposeful violence, a new healthcare worker issue that has taken hold. The benchmark research for this problem, a 1999 Bureau of Labor Statistics study, estimated that 2,637 non-fatal assaults took place on hospital workers that year, at a rate of 8.3 assaults per 10,000 workers, compared to an average of just 2 assaults per 10,000 workers for all private-sector industries.¹
       The National Institute for Occupational Safety and Health (NIOSH) says it is possible to prevent or reduce healthcare worker exposure to violence and other hazards (eg, needle injuries, trunk strains, latex allergy, and stress). But prevention is not working—in reality, things are getting worse. Healthcare workers are experiencing increasing numbers of occupational injuries and illnesses, and NIOSH says occupational injury to healthcare workers has risen over the past decade. Compare that to 2 of the most traditionally hazardous industries, agriculture and construction—which are safer today than they were a decade ago —and the significance of the problem becomes clear.² Although anyone working in healthcare may become a victim of violence, says the institute, nurses and aides who have the most direct contact with patients are at higher risk. Others who need to take extra care include emergency response personnel and hospital safety officers.

Factors for Violence

       Many factors play into making a facility violence-prone. These include the availability of drugs or money in the pharmacy area (though robbery is not a major factor in healthcare violence) and the fact that healthcare personnel must work evening shifts at facilities in high-crime areas. Add the overall prevalence of firearms, low staffing levels, high turnover rates, and stress, and it is a gumbo of trouble—even before factoring in the violent, confused, and/or mentally unstable patients many facilities care for. Violence often takes place during times of high activity and interaction with patients, such as at mealtimes and during visiting hours and patient transportation. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or tobacco or alcohol use. They most likely occur in psychiatric wards, emergency rooms, waiting rooms, and geriatric units.
       Vital to addressing healthcare violence is finding a new approach to ensure greater staff safety. The old way (ie, watching each others’ backs, literally) can still work when there are adequate personnel present or facilities are designed with safety in mind. But that is not always the case. Even new facilities are likely built with economies of scale in mind, meaning they are big. And that makes security and surveillance much more difficult.

Keeping Healthcare Staff Secure

       The potential for harm can influence staffing. It is hard enough to attract healthcare staff under prime conditions; it is further complicated when they feel they might be threatened. Says Ed Halliwell, facilities and projects manager for Toronto’s Sherbourne Health Centre: “Our ability to provide the kind of security measures that make staff feel safe can be a real drawing card for recruitment.” Halliwell is in the midst of dealing with the trend toward increased healthcare worker abuse. In the past, he typically saw about one violent incident a year. But before 2006 was half over, he had already encountered 2 of them. And while that is an unfortunate statistic, some wonder how the facility managed to keep the numbers so low for so long, given its diverse and challenging clientele.
       Sherbourne Health Centre is located in and serves downtown, southeast Toronto. It is an area with a wide variety of communities, including Toronto’s gay and lesbian village, apartment complexes that house large numbers of immigrants, and a variety of shelters and services for homeless people. Many persons in the area live in poverty. About 20 counselors and 6 doctors provide primary healthcare, counselling, support, outreach, health promotion, and education programs.
       A significant number of Sherbourne’s clients suffer from substance abuse and mental-health issues. For others, a lack of English language skills or problems understanding or accessing healthcare can lead to frustration. “Most are calm when they come in seeking our services, but some are not,” says Halliwell. “We’ve had incidents where their counseling session escalates, or they’re not satisfied that they’re being seen quickly enough and they’ve cornered the nurse or healthcare provider, demanding attention.” In other workplaces with a high degree of public contact, such as taxicabs and convenience stories, violence most often relates to robbery. But violence in hospitals usually results from patients (and occasionally their family members) feeling frustrated, vulnerable, and out of control.
       Halliwell knows the center needs to be vigilant about staff safety. Currently, workers use a combination of audible and electronic signals to summon help. For example, workers who sense a potentially tense counseling session in progress will pass by the counselor’s door with a seemingly innocuous question like, “Wanna go for coffee?” that is actually code for, “Are you all right?” The response, also in code, will signal either all is clear or there is a problem. The center also uses remote transmitters—sort of a combination of a remote garage door opener and a panic button—located in each of the facility’s existing counseling rooms. When it is activated, a receiving device in the security area notes the signal’s source, and help can be dispatched. However, Halliwell says it is not an ideal situation. “If the caregiver can’t reach the button or if he or she is in a different part of the building when a problem occurs,” he says, “this system doesn’t help.”
       To that end, Halliwell is trying to curb violence by examining beefed-up, high-tech personal alarm systems that tell security a staffer’s having a problem and pinpoint the distress call’s exact location.
       “We need something that says, ‘I’m here, I’m not happy with the situation I’m in, and I need help’,” he says. One system he is considering, the RoamAlert^® system from VeriChip Corporation, uses strategically placed radio frequency sensors to pick up signals from small wireless tags carried by staff members. The system automatically updates the location of each individual as he or she moves around the facility, so that in an emergency the individual can be located down to a specific room. A panic button on the front of the tag enables staff to call for help whenever needed.
       Although application in a setting like Sherbourne to protect staff is relatively new, the underlying technology has widespread use in the long-term care setting to protect wander-prone residents. Halliwell says it could even have applications for objects.
       “We could tag some of our valuable pieces of equipment and trigger the system so an alarm goes off if equipment is removed without permission.”

Other Approaches to Promote Safety

       There are other ways to make healthcare workplaces safer, and NIOSH has several suggestions. Start by providing better visibility and good lighting, especially in areas of high risk, such as the pharmacy area or in isolated treatment areas. Implement safety measures like metal detectors to deter handguns inside the facility. Control access to work areas, and provide training for staff in recognizing and managing hostile and assault-prone behavior. Increase staffing in areas where assaults by patients are likely (eg, emergency departments), and increase worker safety during arrival and departure by encouraging car pools and providing security escorts and shuttle service to and from parking lots and public transportation. NIOSH also suggests making patients clearly aware of zero-tolerance policies for violence. Awareness will not always stop irrationality. But if patients realize they are jeopardizing their access to care, they might think twice.
       With regard to security, NIOSH supports the idea of technology devices, such as panic buttons, beepers, surveillance cameras, alarm systems, 2-way mirrors, card-key access systems, security guards, and curved mirrors at hallway intersections or concealed areas. But Halliwell says it is time to take those measures up a notch. Sherbourne Health Centre now operates 12 hours a day, but that will increase to 18 when some construction projects are finished. Eventually, Halliwell expects the facility to be open around the clock, if the current demand for services continues. “That,” he says, “is even more reason why we need a secure environment.”