Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Breaking the cycle of violence in hospitals: the role of trauma-informed care

Jenica W. Cimino, Lyza Hiltner, RN, Katie E. Raffel, MD
Policy
November 7, 2022
77 Shares
Share
Tweet
Share

“We use a punishment mindset that exacerbates the trauma (people have already suffered). We have to change that.”
– Bryan Stevenson, Director of the Equal Justice Initiative

 In the months preceding the COVID-19 pandemic, our quality improvement team was discussing the safety of providers and staff on a weekly basis. This was not in the context of a communicable disease or sufficient personal protective equipment but instead related to another insidious health care exposure and threat: workplace violence.

Consider CW, a 55-year-old female with altered mental status who arrived from the emergency department at midnight with suspected sepsis. When the nurse performed her admission assessment, the patient yelled profanities and gripped her ponytail, not letting go until another nurse came to assist. The patient attempted to depart, and security was called to return her to the room. There had been an “FYI alert” in the patient’s chart, which mentioned her physical violence toward staff with no further explanation or customized care plan.

According to the Occupational Safety and Health Administration (OSHA), hospitals are one of the most dangerous places to work. Our institution logged 363 violent incidents in fiscal year 2019, with 91 percent of occurrences in the inpatient setting. In a recent poll of emergency physicians, almost half of the respondents reported having been physically assaulted, and most of the assaults had occurred within the previous year. OSHA reported that 13 percent of missed workdays by nurses in 2019 were due to workplace violence. Even more troubling, workplace violence often is considered a part of the job.

During the 2019-2020 academic year, our improvement team discovered a sense of vulnerability among providers—stories of patients propelling hot coffee and sharp utensils at them, chokeholds, sexual innuendo, and racist slurs. Workplace violence was eroding morale, contributing to burnout, and threatening their sense of safety.

 Though the health care sector is among the most susceptible industries to violence in the United States, workplace violence prevention and response protocols are vague at best. The Joint Commission has not developed clear policies regarding workplace violence. OSHA has provided guidelines to reduce the risk of workplace violence, though it lacks a patient-centered focus. As a result, workplace violence efforts have included low-impact, stigmatizing, and traumatizing interventions: security at entrances (sign-in procedures; visitor passes; badge entry), FYI alerts regarding violence, and security officers to respond to aggressive behavior.

Institutions must consider patient-centered ways to prevent episodes of violence through the practice of trauma-informed care (TIC). Nearly one-quarter of patients have a history of trauma and are often re-traumatized by the invasive and authoritarian nature of health care. TIC offers a framework for providing medical care and serves as a vehicle for systems and culture change that creates physical and psychological safety for both providers and patients. It emphasizes trauma prevalence and impact, recognition of symptoms, and response to trauma history, and prevention of re-traumatization.

In the case of CW, the assistant unit director sat with her on several occasions. She discovered that the patient had experienced homelessness, substance use disorder and had suffered multiple violent assaults. The patient found the lack of control over the day, multiple providers, and limited privacy challenging. She felt like she was “back on the streets, fighting for her life.” The patient, husband, and team collaborated on a care plan to contact her family right away when she felt triggered, allow them to visit without restrictions, and minimize the number of staff responding to her.

All instances of violence may not be preventable, but early recognition and intervention are critical. Behavioral Emergency Response Teams (BERTs) are staff well-trained in non-violent intervention techniques to manage disruptive behaviors from patients suffering from untreated mental illness, poverty, violence, and/or a lifetime of maltreatment. In a pilot on a medical-surgical unit, a BERT responded to 17 behavioral emergencies. The number of assaults decreased from 10 (pre) to 1 (post); security intervention decreased from 14 to 1; and restraint use decreased from 8 to 1. Nurses rated the BERT as supportive and effective. In another study, the BERT improved safety for patients and staff and enhanced staff satisfaction.

By the summer of 2020, groups across our health system convened through an educational program in TIC, Trauma Transformed. Executive leaders had weekly interdisciplinary meetings that included psychiatry and security representatives to create systems change. The task force developed a pilot with a psychiatric nurse on three Medicine units. The nurse rounds on patients with a history of violence and engages our TIC-trained security team selectively. We are tracking a range of metrics, including demographics, patient and provider satisfaction, calls to security, WPV events, and safety attendant usage. We also plan to review FYI flags for bias and amend them appropriately.

 CW healed safely in part due to her team’s trauma-informed approach. She is one patient among countless others with a trauma history who have experienced the cycle of violence perpetuated within our hospital system. It is imperative that health systems revise and clarify their approach to workplace violence by acknowledging the re-traumatization of patients as a core cause. The first steps may be to train providers in TIC, create less authoritarian/invasive care processes (maximize patient autonomy, enhance continuity, minimize unnecessary interruptions) and establish a BERT. Work in this area must incorporate the patient perspective, engage providers across disciplines, and include unbiased and rigorous data collection. Prioritizing the well-being of providers through enhanced safety for our patients with trauma represents the leadership that our health care institutions need.

Jenica W. Cimino is a program manager and quality improvement specialist. Lyza Hiltner is a nurse and palliative care consultant. Katie E. Raffel is an internal medicine physician.

Image credit: Shutterstock.com

Prev

Big Joe: living proof of a surgeon's fallibility

November 7, 2022 Kevin 0
…
Next

A doctor's journey through constraints and creativity in the ER [PODCAST]

November 7, 2022 Kevin 0
…

Tagged as: Hospital-Based Medicine

Post navigation

< Previous Post
Big Joe: living proof of a surgeon's fallibility
Next Post >
A doctor's journey through constraints and creativity in the ER [PODCAST]

Related Posts

  • The epidemic of violence against health care workers

    Marlene Harris-Taylor
  • Gun and health care workplace violence: Dr. Lindley Dodson’s tragic death

    Sheryl Yanger, MD
  • It’s time to invest in trauma-informed ACEs interventions

    Vida Sandoval
  • How social media can help or hurt your health care career

    Health eCareers
  • Improving access to care in rural America: Keeping rural hospitals in the game

    Richard Watson, MD
  • Why health care replaced physician care

    Michael Weiss, MD

More in Policy

  • Pediatricians grapple with guns in America, from Band-Aids to bullets

    Tasia Isbell, MD, MPH
  • Health care wins, losses, and lessons

    Robert Pearl, MD
  • Maximizing care amidst provider shortages: the power of measurement-based care

    Tom Zaubler, MD
  • Unveiling excessive medical billing and greed

    Amol Saxena, DPM, MPH
  • Chronic health issues and homelessness

    Michele Luckenbaugh
  • The impact of certificate of need laws on rural health care

    Jaimie Cavanaugh, JD and Daryl James
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • 1 in 5 doctors will become disabled. Are you prepared?

      Amarish Dave, DO | Finance
    • The art of pediatrics: Connecting through observation

      Alexander Rakowsky, MD | Conditions
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
  • Recent Posts

    • The art of pediatrics: Connecting through observation

      Alexander Rakowsky, MD | Conditions
    • Assertiveness in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Practicing medicine with conviction

      Arthur Lazarus, MD, MBA | Physician
    • The power of memory in shaping human identity

      Emily F. Peters and Sandeep Jauhar, MD, PhD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 1 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • FDA Relents, Approves Novel Antidepressant After Many Rejections
  • OSHA Comes in for Both Praise and Harsh Criticism at House Hearing
  • New Insight Into Hyperglycemia Risk With PI3K Inhibitor for Breast Cancer
  • Oktoberfest Doctor: Not the Wurst Job You Could Have
  • Blue Shield of California Has Fix for MA Enrollees Worried About Co-Pays

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • 1 in 5 doctors will become disabled. Are you prepared?

      Amarish Dave, DO | Finance
    • The art of pediatrics: Connecting through observation

      Alexander Rakowsky, MD | Conditions
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
  • Recent Posts

    • The art of pediatrics: Connecting through observation

      Alexander Rakowsky, MD | Conditions
    • Assertiveness in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Practicing medicine with conviction

      Arthur Lazarus, MD, MBA | Physician
    • The power of memory in shaping human identity

      Emily F. Peters and Sandeep Jauhar, MD, PhD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Breaking the cycle of violence in hospitals: the role of trauma-informed care
1 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...