Dying to help: when violence in healthcare drives away the lifesavers

Healthcare workplace violence

Healthcare settings in the U.S experience some of the highest levels of workplace violence in the country, with a staggering number of incidents occurring daily: on average, 57 nurses are assaulted every day across the country – equivalent to two nurses every hour, according to a Press Ganey analysis using data from 2022.i

This particularly high incidence in the sector is, perhaps unsurprisingly, one of the reasons cited by nurses choosing to leave the profession; in fact, the Journal of Occupational Health estimates that workplace violence causes almost a fifth (17.2%) of nurses to leave their job every year.ii

The motivations for such attacks are varied and complex, and there are a myriad of contributing factors which make healthcare settings higher risk environments for armed assailant incidents than others, including – but not limited to:

• High levels of stress and emotion amongst patients, staff and visitors;
• High volumes of people in a confined space;
• Ease of entering the premises or ward unnoticed;
• Concentration of already vulnerable people;
• Ease of access to medical equipment which can be easily utilized as a weapon;
• Dangerous situations being brought into the setting, such as domestic or gang violence;
• Higher staff turnover rates meaning lower familiarity with safety procedures; and Immobility of some patients

What is the impact of such attacks?

These events have far ranging implications which go beyond the direct impact on the victims – and when an active assailant incident occurs, the impact on employees, patients, and all others present is hard to overstate.

It goes without saying that reduced morale and high levels of workplace stress not only impact the lives of employees, but can impair the quality of care patients are receiving. Furthermore, responding to an incident, or the threat of an incident, inevitably results in resources being pulled from other areas, further impacting the delivery of healthcare services to those who need it most. As well as the quality of patient care, the mental wellbeing of employees and, ultimately, elevated staff turnover are also at stake.

The exposure to liability for harm suffered by non-employees, including patients and visitors in the case of such an event should not be underestimated. Workers’ Compensation coverage may not cover healthcare workers who are utilized as an independent contractor and traditional general liability cover may include exclusions or incur significant delays to confirm coverage.

Who is liable?

The "General Duty clause" in federal employment law states that it is the employer’s obligation to maintain a workplace free from injurious and harmful hazards.

Moreover, the April 2021 Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195) and companion bill (S. 4182) in May 11, 2022 requires the Occupational Safety and Health Administration (OSHA) to develop enforceable standards to protect employees from violent incidents in the workplace.

All of this will increasingly result in employers within the healthcare sector being held liable when these duties and standards of care are not met. The waters become muddied when it’s not only staff but patients themselves who are the victims of such attacks on hospital premises – as was the case last summer, when four people were shot and killed at a hospital is Tulsa, including a patient.iii “They stood in the way and [the suspect] gunned them down,” the media were later told.

Is enough being done?

Regulators are paying attention to this growing threat: at the end of last year, the Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS) warned hospitals that they must protect their employees and patients from increased violence at healthcare facilities, and stated that hospital staff should follow a set of standards of practice for patient security.iv

Some hospitals have gone a step further, such as Mass General Brigham (MGB), who decided to cancel non-emergency care for those who violate its new “Patient Code of Conduct.”v The Code states that words or actions that are disrespectful, racist, discriminatory, hostile, or harassing are not welcome at the facility, and that non-emergency care will be cancelled if is breached. The hospital claimed that the policy was a direct response to a “national rise in violence and hostile behavior at healthcare facilities.”

Such steps only address a small part of the problem though, with the unique challenges posed by a healthcare environment going far beyond the behavior of its patients.

How we can help

Total immunity from risk is impossible, but effective risk management can significantly reduce it, while reinforcing commitment to the highest standards of safety and quality of care . A ‘best practices’ Violence Protection Program should include the following:

• Violence Protection Program Framework and Team
• Risk Assessment
• Program Framework Document
• Policies (weapons, bullying, hostile workplace, sexual harassment)
• Procedures (Background checks, Performance reviews, Terminations)
• Plans (Critical Incident Response, Security, Crisis Management, Crisis Communications)
• Training (Threat Management Team, Critical Incident Response, Behavioral
• Awareness, Anonymous Reporting.
• Active Assailant Drills
• Maintenance
• Open-Source Intelligence Monitoring
• Risk Transfer- Insurance.

An appropriate and holistic duty of care includes preventative measures as well as support, care and rehabilitation for those affected – all of which require dedicated resources in time, personnel, and money.

With appropriate preventative measures being paramount, the nature and speed of the response during an occurrence of violence in a healthcare setting is crucial. If handled well, the response can limit the threat to health or life, the distress caused, and additionally the risk of serious emotional, reputational and financial damage.

Relying solely on General Liability simply isn’t enough to reduce the risk of such incidents or help minimize their impact when they do happen. In fact, most now agree that protection against third party liability, physical damage and business interruption losses via affirmative and specialized coverage is vital for healthcare settings today.

The information set forth in this document is intended as general risk management information. It is made available with the understanding that Beazley does not render legal services or advice. It should not be construed or relied upon as legal advice and is not intended as a substitute for consultation with counsel. Beazley has not examined and/ or had access to any particular circumstances, needs, contracts and/or operations of any party having access to this document. There may be specific issues under applicable law, or related to the particular circumstances of your contracts or operations, for which you may wish the assistance of counsel. Although reasonable care has been taken in preparing the information set forth in this document, Beazley accepts no responsibility for any errors it may contain or for any losses allegedly attributable to this information.