Be Safe, Not Sorry

Assaults, beatings, shootings, deaths.

Violent acts, unfortunately, have become part of everyday life, spreading from large cities to quiet, rural areas once thought to be immune. We read about violence in the newspaper and hear reports on radio and TV with such frequency that it may seem easy to become indifferent. But don't.

You may be surprised to learn that the Occupational Safety & Health Administration (OSHA) reports that more assaults occur in the healthcare and social services industries than in any other. OSHA attributes the high rate of incidents to the prevalence of handguns, the increasing number of mentally ill patients, low staffing levels, and isolated work conditions during exams.

For example, one 1994 study (the most recent statistic posted by OSHA) reported violent deaths among the following healthcare workers while on the job: 26 physicians, 27 pharmacists, 18 registered nurses, and 17 nurse's aides.

Those working in psychiatric settings are at greater risk with an average of 16 assaults per 100 workers, compared to 8.3 assaults per 100 workers in all other studied areas.

Acting out

Violence in physician offices often stems from frustrated patients, staff, or others who can wander into the practice at any time. Tim Dimoff of Sacs Consulting and Investigative Services in Cleveland blames today's "serve me now" society for violence by frustrated patients and their family members.

"As physicians bring on more and more patients, it is harder to get an appointment, and when patients do [get into the practice], they face an assembly line attitude," he says. "Employees may get caught in the middle of doctor-patient relationships. Most confrontations start as verbal assaults but may escalate into a physical attack, grabbing someone, or throwing something," he adds.

Lynn McClure, of McClure Associates, an occupational consulting firm in Mesa, Ariz., explains that patients may become violent if they feel they are not recuperating fast enough, if their physician is not available, or in some cases, if they are mentally unstable.

The OSHA data supports this, noting the increasing prevalence of mentally ill patients who have the right to refuse medication and who cannot be hospitalized involuntarily - until they pose a threat to themselves or others.

Still, violence caused by patients occurs more often in hospitals than in outpatient settings. OSHA notes the increasing use of hospitals as temporary holding cells for potentially violent criminals, such as drug dealers or users who have been injured, and availability of drugs at hospitals and clinics, making them likely robbery targets.

Staff stresses

Patients aren't the only ones who pose a potential threat. Workplace stresses can lead medical-office staff members to reach the boiling point, too. McClure has studied violence by employees in her book Risky Business: Employee Violence in the Workplace, and she names some common high-risk behaviors to watch for, including acting out in anger, failure to take responsibility for one's behavior, passive-aggressive behavior, being rigid and controlling, drug or alcohol abuse, and withdrawal.

McClure blames some of this behavior on stress stemming from dealing with patients' personal problems - as well as staffing shortages. Staff members, too, may not be able to resist the availability of drugs in the office setting, which may contribute to an existing habit and affect an employee's judgment. "You should be aware of the potential risks when you hire staff, train them in dealing with anger and stress, and be open to hearing about employee problems," McClure recommends.

Planning ahead and putting policies in place may help you avoid the potential for violence in your practice. "It's when it actually happens that physicians begin to take notice," says Debbie Sandler, a partner in the Philadelphia-based law firm, White and Williams. "Most only have informal policies; physicians would rather practice medicine than be a businessperson. Still, there are reasonable steps for an employer to take to make sure an employee is not a threat, such as obtaining references and checking them out, rather than engaging in 20/20 hindsight."

She notes that a patient or another employee who is injured by a medical staff member can file suit for negligent hiring - failure to check an employee's files, which could have put the employer on notice about potential problems; or negligent supervision - not taking steps to prevent potential violence despite evident warning signs. "Figuring out what to do is shaky ground for an employer," Sandler says.

Take charge

Scary as this all sounds, there are some little things a physician can do to make the office a much safer place. Simply being aware that violence is a possibility is a good start. Widespread ignorance about the issue makes physician offices even more vulnerable, Sandler notes. Preventive measures are rare because no physician believes it will happen to his or her practice.

Dimoff adds that it is the physician's responsibility to provide a safe environment and to develop procedures for preventing and handling violence. "Physicians thought they were immune because their offices are where people go for help, but visiting the doctor is not always a pleasant experience," he says.

Dimoff suggests taking such steps as installing a panic button at the front desk and training employees to use it; making sure that no employee is left alone; preventing access to examination rooms from the lobby; and encouraging employees to respond to dangerous situations by calling the police.

Women's Health Connecticut in Avon, Conn., has seen first-hand how such preventive actions can help. Violence is not a common occurrence in his practice, says Mark DeFrancesco, MD, chief medical officer of the 140-physician practice. Nevertheless, Women's Health has had two incidents - both involving irate husbands - that were deflected by cool-headed nurses.

One man was upset by what he considered a lack of attention to his wife, a patient at the practice, and threatened to go to the office with a gun. The police were dispatched to his home.

Another patient's husband was upset about his depressed wife and requested confidential information about her condition that a nurse refused to provide. He responded by threatening to kill her. The nurse called the wife and found that the husband did indeed have a gun. Again, the police interceded.

"The best advice for defusing violence," DeFrancesco says, "is to be prepared for it." He leans on employee training as a primary source of dealing with potential violence - teaching staff how to handle irate phone calls or visitors at the registration desk, or how to proceed in case of an emergency. "Training helps to not only prevent a dangerous situation but also teaches employees how to better serve the customer," he says.

As in the case of the depressed wife, he explains, employees need to know what they can legally divulge without betraying confidentiality. "Physicians need to be aware that violence can be a potential danger and plan ahead," he notes.

DeFrancesco acknowledges that violence is increasingly common in healthcare, thanks to economic pressure in doctors' offices - fewer raises, more patients, increased work loads - and patients' increasing discontent with the medical system.

Women's Health Connecticut has initiated a program to reinforce compliance with various rules and regulations. It includes sexual harassment training for all supervisory personnel; a written document spelling out employees' rights and benefits; and instructions on how to report violations of the law or any unethical behavior to an employee's supervisor or to a compliance officer without fear of retaliation. For DeFrancesco and other physicians, it's a solid start - and one more vital than ever in today's violence-prone society.

Mari Edlin can be reached at editor@physicianspractice.com.

This article originally appeared in the September/October 2001 issue of Physicians Practice.