January 24, 2025

Where is the line? Navigating the brave new world of workplace violence

Increasingly, health care professionals find that they must protect themselves from harm, even as they care for their patients.

(photo by Erin O. Smith) (photo by Erin O. Smith)

The patient was admitted to the emergency department in the middle of the night, inebriated and belligerent. Well-known to the ED staff, he had been talking about harming himself.

He wanted to leave but was detained under an emergency order until a psychiatric evaluation could be conducted. A staff member — a “sitter” — was assigned to watch him.

At some point the patient got out of bed, verbally abused the sitter with racial slurs, and took a swing at him. Alerted by the commotion, other staff rushed into the room to defuse the situation.

This is not an isolated incident, said Jeremy Boyd, MD, associate professor of Emergency Medicine at Vanderbilt University Medical Center. Increasingly, health care professionals find that they must protect themselves from harm, even as they care for their patients.

The story related by Boyd kicked off a frank discussion of workplace violence hosted on Jan. 15 by “Bedside Matters,” a monthly online forum for front-line health care providers at VUMC organized by Walter Merrill, MD, professor of Cardiac Surgery.

VUMC’s Workplace Violence Prevention Committee, which was established at the height of the COVID-19 pandemic, has developed policies meant to equip employees with tools to prevent, respond to, and report incidents ranging from verbal abuse and threats to property damage and physical assault.

Yet although the pandemic has abated, workplace violence in health care has not. During the forum, participants discussed several possible remedies including administrative discharge — discharging a patient whose behaviors threaten the safety of staff or other patients.

However, “Where is the line of medically treat versus administratively discharge?” asked Alison Coyne, RN, a clinical education facilitator. Administrative discharge is not appropriate for violent patients who are also critically ill or injured.

In these cases, providing more training to staff may be helpful.

Bring in reinforcements, early

Jim Kendall, LCSW, CEAP, manager of VUMC’s Work/Life Connections-EAP (Employee Assistance Program), returned to Boyd’s opening example of the patient provoking his sitter.

“We need to make sure we’ve empowered that sitter to be able to say, ‘Hey guys, I need to be relieved from this,’” Kendall said. “Sometimes it’s a tag team … somebody else who comes in and diffuses it for a few minutes.

“You guys in the ED are under tremendous pressure at all points in time,” he added. “You don’t have a lot of relief.”

Shawn Perry, RN, CCRN, who works in the Cardiac Stepdown Unit, recommended that sitters spend no longer than an hour with each patient before being relieved, and no more than two hours in a row, sitting with different patients. Of course, the ability to do that will depend on the availability of staff, he said.

“There’s sometimes an opportunity of utilizing case managers and social workers to have those bedside conversations,” added Amanda McKinney, LCSW, ACM-SW.

“That sometimes can help de-escalate,” McKinney said. “Not all the time. It is not an easy answer, but I think that there are more things that could be implemented earlier on to help provide that support to the nursing staff.”

Know your patient, and know yourself

At Monroe Carell Jr. Children’s Hospital at Vanderbilt, family members fill out a form, called a behavioral “passport,” that indicates how best to communicate with patients who may be on the autism spectrum or who are nonverbal.

“Who communicates for them?” said Cara Clancy, MEd, CCLS, a behavioral health child life specialist at Monroe Carell. “Sometimes it’s a parent or caregiver. They can act like a translator when it’s not necessarily specific language but gestures and facial expressions and knowing what those mean.”

Caregivers also need to be aware that the way they normally communicate may annoy patients who are already on edge, Perry said.

Follow the plan, and be creative

Jade McClure, RN, clinical staff leader in the Vanderbilt Interdisciplinary Care Program, once took care of a man with post-traumatic stress disorder who had a reputation for being a “difficult” patient.

“We made a care plan for him, how you should say things to him,” she said. “I did nothing different than what that care plan said to do, as well as thinking outside the box sometimes. Sometimes you’ve just got to get creative with what you’re doing.”

The man responded positively, and gratefully. He nominated McClure for a DAISY Award, which honors nurses for their skillful and compassionate care.

“I cherish it,” she said.