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Never had I seen a loaded gun at the workplace that wasn’t strapped into the holster of a guard or police officer, much less one that was recently fired. That all changed one summer night while working a late shift at the hospital when I was summoned to respond to a code blue.
I wasn’t prepared for what I saw: A man in his late sixties with a self-inflicted gunshot wound, blood pooling around his head. The minutes that followed were an eternity of lifesaving efforts that ultimately failed. Sharing the news with his devastated family was one of the most emotionally difficult challenges I have ever faced. Death certainly wasn’t new to me, but until that point, I had not yet encountered this type of trauma. A hospital is the last place I would ever want to see an unlocked gun—mere steps from me, my team, staff, guards and visitors, and those who need to heal.
Healthcare professionals around the country face constant threats in the workplace. These may range from verbal abuse to physical acts of violence. A patient who harasses a nurse, for instance, with racial slurs and expletives can cause real harm, damaging that person’s ability to do the job—a situation made even worse by the patient’s subsequent refusal to receive necessary care. When an attempt is made to approach the patient, the nurse is rebuffed with fists. None of this is new or surprising. Too often it is written off as patient delirium or the result of intoxication and we are expected to move on. The animus behind patients’ unruly behavior is discounted, in nearly every instance they are the sick and we are to help them, never mind the threats or the violence. It’s an old and dated logic that we simply must abide the danger. After all, this is what doctors, nurses, and staff in hospitals signed up for. Correct?
No.
That violence in the workplace has been tolerated for years doesn’t mean it has to continue.
When it comes to protecting the health and safety of workers, the country is divided on myriad levels, and intractable conflicts persist. Everything from gun control measures to the use of metal detectors to screen for weapons in facilities and schools continues to separate and rive communities. With the ratcheting-up of rhetoric comes the threat of real violence, and a concomitant escalation of fear. We read about shootings every day, and wonder—no, tremble—about how many go unreported. We are certainly well aware that number is growing, and the response by now is familiar—more and more, we become psychically numbed to the reality, defined by and fraught with unresolved tension. This intolerable situation is met with an array of responses, many of them ideologically opposed, that impede our efforts to achieve solutions. Without the necessary remedial steps taken, violence proliferates. Yet, despite the intransigence around this issue and despite the ongoing threats to well-being, healthcare workers continue to show up, risking their lives in understaffed teams on a front line replete with unpredictable hazards. Such is the nature of our practice.
What needs to change?
First and foremost, a well-maintained workforce is critical for patient care. More than three years of pandemic surges have resulted in droves of health workers leaving the field. This is due to staffing shortages, stressed work conditions, and the challenges of unknown and unfamiliar disease processes that, taken together, frequently lead to burnout. Hospitals and administrators now face a pivotal question: How do we sustain and retain our workers? Our primary focus always must be to protect and safeguard the workforce. Without such a top-down directive and a mechanism to support it, at some crucial point, the healthcare system will collapse. These aren’t just jobs and professional careers; people’s lives are at stake, and that means all of us.
Fundamentally, if one does not feel safe at work, nothing else matters. Compensation, location, collegiality, and workload all pale in comparison with personal safety. As we have seen with COVID and its permutations, an ample supply of personal protective equipment is vital when treating patients: gowns, gloves, and N95 masks, in addition to face shields and goggles in some cases. Add to this the numerous metal detectors, armed guards, and stringent visitation rules for the sorely needed optics and barriers to potential workplace threats, all of which help bolster a sense of physical safety. I commend the healthcare systems that continue to implement these safeguards.
Our efforts must focus on psychological safety as well. Again, what more can be done?
A workplace should not only be safe for its workers but also should feel safe, particularly on a hospital front line. This requires timely and accurate communication, support, validation, and above all reassurance. It is natural, after a sentinel event—that is, a patient safety event that results in death, permanent harm, or severe temporary harm—to establish new safety protocols. Resources are directed to address the need until the next competing priority. Before long, policies are adjusted as new needs arise and when attention is diverted, resources get split. It’s a bit like receiving immediate support after a death in the family, when one is surrounded by love and care, the focus suddenly moves to the next person who has suffered a loss and needs that same support. The difference in the workplace is the ongoing nature of imminent threats.
In a hospital, a sentinel event can be just as debilitating to staff and care providers as to the patient. The workplace no longer feels safe. The emotional toll such events may produce is exacerbated by the cycle of nonstop reactivity: in essence, we are putting a Band-Aid over a serious wound as a salve until the next grievous injury. Psychologically, that puts us in an unsafe space.
In the absence of routine messaging, a worker who experiences a threat to safety can feel isolated in that moment. That sense of aloneness—where the silence can be deafening—may easily turn to fear. Our leaders need to be on the lookout for telltale signs of emotional detachment: uncommunicative states, disjointed focus, or the person appears withdrawn. Reassuring our workers that they are not alone, by keeping open communication, greatly helps to relieve anxiety. A responsive, well-functioning healthcare team should be in constant touch. Also key is to assure our staff that any threat—an abusive patient, for example, who lashes out with hateful or personal remarks—will not be tolerated and will be duly addressed. We all need compassion and support at such times, and team leaders need to be mindful. Acknowledging in person or sending a text in response to every reported incident is an important first step. Our workers should know that we have their backs. Frequent reminders to each of our staff that their safety comes first are recommended.
Listening too is important. The hospital front line is where solutions exist, with expertise and perspective from the trenches. Policies and protocols decided at the uppermost levels come with risks if administrators are in any way detached from the daily goings-on of our workers. As we saw with the pandemic, issues evolve quickly and the nature of a threat can rapidly morph; at that point, communications up and down the line at each level need to be strong. When safety becomes an issue, psychological well-being is also at stake. Every voice must be heard if a team is to function, and reassuring staff with validation and support in the midst of a violent incident or dangerous event can further fortify their feeling of safety.
I’ve found that being receptive to a colleague’s concern first by listening and then following through with a text or in-person exchange can help ameliorate resentments or incipient doubts about leadership, particularly during moments of critical stress. In this case, no issue is too small. Whether expletives were used, epithets hurled, or worse, a physical assault by a patient, I have learned to acknowledge and treat seriously all incidents reported to me by colleagues and staff, even if I don’t have a ready fix. We work on solutions together. Any skip or delay in responding can too easily result in a loss of trust. When one is feeling alone and vulnerable after a violent event, long-standing relationships are questioned.
Intentional messaging therefore is essential to sustain and retain our healthcare workforce, most especially in moments of crisis and stress. Workers need to feel safe as they do their jobs, and when that threshold of personal security is breached, they must be able to rely on our support. That includes revising institutional policies and norms that have proved ineffective when new threats emerge. We must adapt. Communicating those changes to all of our staff, acknowledging pitfalls, understanding their concerns, and listening for solutions are vital to maintaining a shared sense of safety. We need to trust those in the trenches. Our lives, after all, depend on it.
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