Protecting Heath Care Workers from Being Targets of Violence

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00;00;01;03 - 00;00;40;16
Tom Haederle
Sometimes you hear a fact so startling that you ask yourself, can that really be true? Here is such a fact. And yes, it's true. A health care worker has a higher chance of being exposed to violence than a prison guard or a police officer. Stunning, but accurate. And the question is, what can be done about it? Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;40;19 - 00;01;08;06
Tom Haederle
I'm Tom Haederle with AHA Communications. A survey of 1000 caregivers in April of 2022 found that 92% had directly experienced or witnessed workplace violence. The problem has been growing exponentially for years and prompted the AHA to create #HAVhope Day, a National Day of Awareness to highlight how America's hospitals and health systems combat violence in their workplaces and communities.

00;01;08;09 - 00;01;26;09
Tom Haederle
In today's podcast, Laura Castellanos, associate director of Hospitals Against Violence with AHA explores some of the ways health care leaders are tackling the problem of workplace aggression. Her guest is Dr. Ronald Paulus, president and CEO of Mirabel Health. Let's join them.

00;01;26;11 - 00;01;58;01
Laura Castellanos
Since the pandemic, the prevalence of workplace violence in health care has grown. Begging the question what can we do to mitigate it? I am Laura Castellanos associate director of Hospitals Against Violence for the AHA. It is very timely that I'm joined by Dr. Ronald Paulus, Ron is a strategic advisor for Commure StrongLine and former president and CEO of Mission Health, as well as former chief administrative officer and CIO for Geisinger Health System.

00;01;58;03 - 00;02;21;27
Laura Castellanos
Today, we will discuss the unfortunate growth of workplace violence in health care, including its financial, organizational and clinical consequences. Mitigating violence and investing in workplace safety initiatives and have an exponential impact on caregivers, patients and health care organizations. Ron, I'm glad to be back with you.

00;02;21;29 - 00;02;23;29
Ronald Paulus
My pleasure. Thanks for having me.

00;02;24;02 - 00;02;35;05
Laura Castellanos
So let's get started with today's discussion about learning about your health care background, your organization, and how you support AHA member hospitals and health systems.

00;02;35;07 - 00;03;10;00
Ronald Paulus
Well, again, it's a pleasure to be here. And you gave a good chunk of my background. Thanks for doing that. Today I'm here because I have a relentless passion to help keep health care team members safe, and I continue that work as an advisor to Commure Strongline. Strongline is a solution that enables each individual staff member to have a personal panic button that connects through low energy Bluetooth to a Wi-Fi network and can send alerts to PROXIMO, colleagues, security subscribers and so forth.

00;03;10;01 - 00;03;12;07
Ronald Paulus
So that's what the solution does.

00;03;12;10 - 00;03;27;20
Laura Castellanos
But definitely passionate about this topic. For years I've talked about it. And you know to set the stage for today's topic, let's talk about how workplace violence is impacting hospitals and health systems. Give me your take on that.

00;03;27;23 - 00;03;58;05
Ronald Paulus
Yeah. So I wish I had a better take. You know, last year was a year that spotlighted the insidious undercurrent and dire consequences of workplace violence in health care. And it honestly, it pains me to share that the numbers are truly staggering. A thousand caregivers were surveyed about their experience with workplace violence during April in 2022, and 92% of those surveyed caregivers shared that they had either directly experienced or witnessed workplace violence.

00;03;58;07 - 00;04;22;29
Ronald Paulus
Laura That's stunning. And the sad reality is that health care workers are nearly five times more likely to be the victim of workplace violence than those working in other industries. Tragedy in Atlanta is just one of a myriad of examples. Think about this, Laura. A health care worker has a higher chance of being exposed to violence than a prison guard or a police officer.

00;04;23;02 - 00;04;51;13
Ronald Paulus
And I know a lot of people don't think this is a really big issue, or maybe they think it only happens within behavioral health units or emergency departments. But real world data from Strongline customers tell us from tens of thousands of caregivers that more than 60% of all incidents happen outside of those areas. And those include hallways, cafeterias, ambulatory centers, billing offices and more ... essentially everywhere and anywhere.

00;04;51;15 - 00;05;14;14
Ronald Paulus
So not surprising given that reality, the health and well-being of our workforce, the exact people who we depend upon to take care of us when we're at our most vulnerable point of being ill is declining. And the surgeon general recently issued an advisory on health care workforce burnout citing unsafe conditions is one factor. That's the reality of where we are.

00;05;14;17 - 00;05;36;24
Laura Castellanos
It is a dire reality. And thank you for for setting that stage. So let's start breaking it down. And I think an important topic to cover is the cost, right? The cost of this violence on our hospitals and health system. Our caregivers, our patients pretty much overall the health system. So what can you share with us about the cost of this violence?

00;05;36;26 - 00;05;57;13
Ronald Paulus
I'm so glad you asked that question, Laura, because it's exactly the right one to ask. So often we focus on what is the cost of our investments to mitigate workplace violence. And we know it's our first priority in a professional and ethical obligation as leaders to keep our patients and team members safe. And without a doubt, that is singularly important.

00;05;57;15 - 00;06;20;29
Ronald Paulus
But the reality is that the hidden but very real costs of workplace violence are hiding in plain sight. And my experience is that most hospitals have no idea what their true costs of workplace violence are. And that's because they don't have the data to track incidents or severity. They're often unaware of the downstream costs. They just don't realize how pervasive the issue is.

00;06;21;01 - 00;06;49;16
Ronald Paulus
I say that without judgment because the person I'm describing was me. I was clueless about this issue when I first became the CEO of Mission Health in North Carolina, although I'd experience workplace violence personally as a clinician. It just wasn't top of mind. And that was until my world changed. When I was the CEO at Mission, I would routinely do focus groups with nurses and other caregivers, and at the end of the session I would always ask, Hey, what else is on your mind that we haven't spoken about?

00;06;49;19 - 00;07;09;04
Ronald Paulus
And then back to back focus groups, a nurse said, We don't feel safe at work. And I was shocked. And frankly, I was ashamed. And I used those feelings to push me to develop a deep understanding of this issue, to make all the evidence based interventions that I could. And that's what ultimately led me to where I am today.

00;07;09;06 - 00;07;32;21
Ronald Paulus
But getting to the core of your question. Workplace violence costs are multifactorial, starting with staff. A recent McKinsey survey found that a safe work environment was literally the number one most cited factor influencing nurses decisions about whether to stay or leave their job. And that same study found that one out of every three nurses actually intends to leave their role within the next three years.

00;07;32;24 - 00;07;58;05
Ronald Paulus
That alone tells us that the safeness of our work environment is paramount. Nationally, average workplace turnover is about 20%, with vacancy rates stuck in the 15% range. Another recent study by Epic Research found that there's been a 56% increase in shifts filled by nurses with less than one year of experience. These are nurses who are new to our industry and new to their jobs and who need extra support.

00;07;58;08 - 00;08;23;20
Ronald Paulus
So given all the investments that we make in recruiting and hiring and training and supporting, we need to have confidence that these team members will ultimately choose to stay in that role. And if they don't, the cost to replace just one nurse averages more than $50,000. Traveler nurses cost an extra $150,000 on average per year. And something else that people don't really appreciate:

00;08;23;22 - 00;08;53;13
Ronald Paulus
Days lost from work due to workplace violence are huge. Up to 13% of all non vacation days relate directly to workplace violence. And it doesn't stop there. Typical workplace violence OSHA fines exceed $100,000. And jury awards - when an organization is found guilty of not taking appropriate steps to keep team members safe average more than $3 million. So when people are thinking about making an investment to create a safer workplace.

00;08;53;15 - 00;09;07;24
Ronald Paulus
Framing it as simply, you know, yet another new expense when my budget is already tied is both inaccurate and counterproductive. The reality is it's a strategic investment with a highly positive ROI.

00;09;07;27 - 00;09;32;27
Laura Castellanos
Well, you definitely shared some staggering statistics, and thank you for sharing your story, your perspective, and obviously what drives this passion. You know, you even expand it to talk about the impact it has on the workforce. So let's talk about what are some ways that hospitals and health systems are currently investing in their workforce safety initiatives, keeping their workforce safe?

00;09;32;29 - 00;09;36;14
Laura Castellanos
And what evidence supports these strategies?

00;09;36;16 - 00;10;01;17
Ronald Paulus
Yeah, I've spent more than a decade trying to understand the answer to that question, and I hope I've contributed to some of what's out there. As you know, the AHA, you all have several tools available to support hospitals, including your toolkit for mitigating workplace violence and your guide for developing a workplace violence program. And so I want to applaud that work and encourage everyone to review those materials.

00;10;01;19 - 00;10;28;02
Ronald Paulus
And in January of this last year, The Joint Commission announced new standards across three domains that should help guide interventions. One, The Joint Commission says around environment of care that you have to initially assess your physical environment, looking for difficult areas to visualize staff and unlock entries and that kind of thing. Importantly, use data to guide where the highest risks are and where exposures occur and to whom.

00;10;28;05 - 00;11;00;05
Ronald Paulus
Now, this is exactly what we did in patient safety. So every health system needs to track incidents and rates of workplace violence occurrence. IHHSS has put forward a detailed framework for doing this. But just as a practical example, at mission, we use a workplace violence scale that began with unwanted verbal contact, progressed to verbal abuse and to unwanted physical touching on to physical assault, then to physical assault with injury, and finally to physical assault with injury and time lost from work.

00;11;00;08 - 00;11;25;25
Ronald Paulus
But whatever scale you choose, you need to strongly and repetitively encourage and reward reporting, because despite the statistics that I shared, 70% of all incidents go unreported. From a human resource perspective, The Joint Commission says that you should regularly survey your staff about their perceptions of safety, both as a baseline measure and across time and violence prevention, training and de-escalation is essential.

00;11;25;27 - 00;11;47;25
Ronald Paulus
At the time of hire and annually at least thereafter, per The Joint Commission standards. And let me be clear about something this training isn't like watch a PowerPoint and check the box kind of exercise. It needs to include de-escalation roleplaying and trauma informed care education, at least for the most vulnerable workers. So that's where the data map and should guide your interventions.

00;11;47;28 - 00;12;13;16
Ronald Paulus
And because staff need to practice and experience what de-escalation feels like to be comfortable doing it when it counts, they have to do that role play. Another intervention is behavioral emergency response teams. These are dedicated professionals that parallel our rapid response teams for medical escalations. We created one of the first in the nation at Michigan when I was there, and we did an AJ webinar on that very topic.

00;12;13;18 - 00;12;51;09
Ronald Paulus
These are now a best practice for behavioral escalations. From a leadership perspective, you need to develop an interdisciplinary committee specifically focused on workplace violence. That should include a broad swath of stakeholders from your clinical security admin, ambulatory, offsite operations, and this leadership focus and accountability is the secret sauce. It's exactly what it took for the patient safety movement to finally pick up steam and with the right leadership, we bring together the tools, techniques, technologies that will reduce this epidemic to a more manageable level.

00;12;51;11 - 00;13;20;02
Laura Castellanos
Let me do a quick follow up on your last comment about the patient safety movement. And I know you and I have talked about how workplace and workforce safety should truly be part of this larger framework of quality and safety because we've learned so much. Can you just share your insights as to how we can begin to leverage systems to learn from other systems to create safety?

00;13;20;04 - 00;13;47;14
Ronald Paulus
Yeah, you know, just harkening back to that patient safety moment, we can't repeat how long it took us to get our act together. It was more than a decade from the publication of "To Err is Human," which you'll recall flagged that as a health care profession, we killed at least 100,000 people per year. But it took a long time and it wasn't a total value-based purchasing took a foothold that things really began to accelerate.

00;13;47;16 - 00;14;11;29
Ronald Paulus
And the good news here, relative to the intersection between safety for patients and for staff is that they're correlated. So I feel like with so many of these statistics that I've been giving, I might be depressing everyone. So let me give you some good information. What we know is when the workplace is safe for team members, both patients and staff do better.

00;14;12;02 - 00;14;40;28
Ronald Paulus
Data from Press Ganey show that when staff do feel safe, patient outcomes improve and they're more engaged. So specifically, feeling safe is correlated with a 22% higher CMS hospital quality star rating, a 52% lower rate of nurse perceived mis-care. That's a key marker for patient safety and a 27% higher job enjoyment. So these are tied together and it starts with collecting the data.

00;14;41;01 - 00;14;49;00
Ronald Paulus
It starts with encouraging reporting, just like I did with patient safety. And we can make a difference if we focus on those things.

00;14;49;02 - 00;15;13;22
Laura Castellanos
Well, thank you so much for sharing. So let's give a message to how hospital leaders and executives -  as you mentioned, it's the secret sauce, right? So how can they collaborate to mitigate this violence and most importantly, support their workforce? We know that through the pandemic and through everything that has been escalating our workforce needs more support.

00;15;13;27 - 00;15;14;07
Ronald Paulus
Yes.

00;15;14;09 - 00;15;17;26
Laura Castellanos
What message do you have for leaders and executives?

00;15;17;28 - 00;15;46;25
Ronald Paulus
Yeah, I'm going to repeat that. I think that leadership focus and accountability around this topic is the secret sauce. This is not something that can't be managed and controlled and mitigated. You know, we used to think that surgical wound infections and retained sponges and all this stuff was just part of the process. It doesn't have to be. Leadership needs to bring together the tools, techniques and technologies to reduce and seek to eliminate this totally unacceptable epidemic.

00;15;46;28 - 00;16;12;10
Ronald Paulus
That's a repeat of what I was saying. In this fight to stop workplace violence, every one of us has a role to play. And measurable progress can be achieved if we get collaborative buy in from across the organization. Leaders have to set the tone around its importance, the need for reporting, the investments that are made in and tools and technologies to keep people safe.

00;16;12;17 - 00;16;38;01
Ronald Paulus
And they need to view and articulate those as what they are. Investments with a return on investment that manifest in both better patient outcomes and staff outcomes in addition to a measurable financial return. So as leaders, keeping our patients and team members safe must be our number one priority. And I know that we can collectively make a difference and turn this tide as an industry together.

00;16;38;01 - 00;16;57;06
Ronald Paulus
We've done it before. We did it with patient safety, no matter how long it took. We did it with COVID. And I'm 100% confident that we can do this again. So this is the time to stand up, acknowledge the problem, and apply what we know how to do to make an impact for our team members and our patients.

00;16;57;08 - 00;17;01;00
Ronald Paulus
It's not just the right thing to do. It's the right investment to make.

00;17;01;02 - 00;17;23;28
Laura Castellanos
Well, I applaud your efforts and your passion for this work. And please do know you're making an impact. I appreciate you sharing your insights. Definitely learned a lot. And what a packed podcast. There's so much information and what you share, and I'm sure we'll be able to share more with our listeners. So Ron, thank you so much for joining the podcast and sharing your takeaways with other AHA listeners.

00;17;24;03 - 00;17;34;06
Laura Castellanos
So for our listeners, if you'd like to learn more, please visit AHA.org/HAV. Thanks for listening.