The Safe Haven That’s Not So Safe

The New York Times and This American Life recently collaborated to publish two harrowing accounts of Alan Pean, a hospital patient in Houston, Texas.  Pean went to the hospital seeking medical attention during a manic episode and was held overnight.  When he became delusional, singing and dancing naked in his room, the nurse called for security.  The two off-duty policemen who responded proceeded to shock Pean with a Taser, shoot him in the chest, and handcuff him—all inside the patient’s hospital room.  The bullet missed Pean’s heart by millimeters, and after intensive treatment, he survived to tell the tale.

While Pean’s story and others like it raise serious questions about patient safety, they also have major implications for healthcare worker safety.  A doctor from the hospital where Pean was shot told This American Life that hospital staff is regularly “abused” and is in “just as much danger as cops on the street.”  Though his observations are anecdotal, recent data confirms that hospitals are some of the most dangerous workplaces across the country.  OSHA reports that incidents of serious workplace violence, for which a worker requires time off to recover, are four times as common in the healthcare industry than in private industry on average.  (Patients perpetrated 80% of those assaults.)  And it’s getting worse.  Violent crime in hospitals increased by 40% from 2012 to 2014 and was mostly directed at employees.

So what is being done to keep our healthcare workers safe from these increasingly commonplace attacks?  Two common responses have been to hire armed guards and to pass laws criminalizing assaults on healthcare workers.  Unfortunately these are quick fixes that both suffer from acute flaws. This post will examine each one in turn.

Guns in Hospitals

Many hospitals have concluded that armed guards are the solution to workplace violence.  In fact, more than half the hospitals surveyed in a national study reported having security guards who carry guns.  But such a solution is, at best, overly simplistic.  Many mental health workers actually object to the presence of guns—and for good reasons.  According to a pioneering study by Johns Hopkins, 23% of shootings in hospitals from 2000 to 2011 involved perpetrators taking guns from armed officers, leading to greater danger for patients and workers.  Though better training could potentially alleviate this danger, there are other problems with having weapons in a setting that is meant to provide a safe haven for the sick.  Having weapons in a hospital may “exacerbate delusions” of psychotic and paranoid patients, leading to a greater potential for violence against workers.  Moreover, there are many other, non-lethal ways to restrain patients.

Health Worker Assault and Battery Laws

Many are aware that there are strong legal protections for on-duty police officers.  (A stark consequence of such laws is that Pean has been charged with committing felony assault against the officers who shot him.)  However, it is less commonly known that all but six states and the District of Columbia specifically criminalize assaults on healthcare workers and mandate increased penalties for the assailants.  For example, in Florida, an ordinary battery would result in a conviction of a first-degree misdemeanor, but the same crime would result in a third-degree felony if perpetrated against an emergency medical worker.

Legal protections for assaulted medical workers are generally popular politically.  For example, Texas HB 705 passed unanimously in the state House and Senate.  Unions of medical professionals have enthusiastically supported these laws because they send a message to potential assailants and bring awareness to the problem.  But some unions also advocate for more comprehensive legislation that includes preventative measures, reflecting the fact that assault laws alone are insufficient to combat violence against healthcare workers.  In fact, assault laws suffer from three main flaws.

First, these laws are unlikely to act as a deterrent to violence because many of the assaults take place in the psychiatric ward.  Patients experiencing mental distress, like Pean, are unlikely to be thinking rationally enough to be deterred from assaulting a healthcare worker by the threat of a more severe punishment.  Similarly, patients whose judgment is impaired by drugs or alcohol will be unlikely to be deterred by such laws.  (Some also point out that the laws may be unjustly punishing symptoms of mental illness and addiction.)

Second, enforcement of these laws depends on health workers reporting the instances of abuse.  In order to ensure reporting, hospitals must overcome what the Research Director of the Emergency Nurses Association (ENA) described as a “top-to-bottom cultural assumption that violence is part of the job.”  Other recent studies found that 30-50% of violent incidents that do not result in time away from work are not reported due to a “lack of a reporting policy, lack of faith in the reporting system, and fear of retaliation.”

Third, these laws only take effect after there has already been an incident of workplace violence.  They do not address the need for training of medical personnel in dealing with potentially violent patients.  Unsurprisingly, including training provisions in these bills makes it more difficult to get them passed.

Safer Alternatives

In order to keep healthcare workers safe, hospitals need to make systemic changes to prevent workplace violence—not just penalize it.  AFSCME recommends increasing staffing levels, installing an intercom system, having a secure nurses’ station, and providing anger diffusion training.  Scientific American also recommends using electronic databases to flag potentially violent patients ahead of time and accordingly adapt their treatment.  Relatedly, the ENA found that hospitals that institute mandatory violence reporting policies have half the rate of workplace violence of those that do not.

The good news is that prevention programs can be affordable and cost-effective.  For example, the CDC provides a Workplace Violence Prevention training course for nurses that is available for free online.  Moreover, Scientific American points out that any cost born by hospitals in implementing the programs is minimal, compared to the amount hospitals lose in worker-compensation lawsuits and from workers needing time off due to workplace injuries.

Overall, armed guards and laws punishing assailants of healthcare workers are inadequate mechanisms to keep workers safe.  While they may raise awareness about workplace violence, ultimately, they are shortsighted solutions that may undermine effective medical care.  And, tragically, patients and workers will probably continue to experience hospital violence until more comprehensive and preventative programs are established.