Ethical responses to violence toward health care workers

Violence toward health care workers—from threats and discriminatory comments to physical assault—is increasing; up to 38% of health care workers have experienced physical violence at work, with nurses being disproportionately affected.1-4 The American Medical Association and the American Nurses Association have both issued position papers calling for coordinated responses among hospitals, health systems, and independent practices.5, 6 We discuss ethical tensions triggered by violent patient behavior, outline factors influencing different health care worker approaches to those tensions, and highlight four major components of the ethical management of violence in hospitals. Rising rates of violence in hospitals create tension among multiple important ethical values. Clinicians must decide which values are preeminent and how to develop plans for resolution that balance multiple competing values equitably.7 Figure 1 depicts ethical values relevant to the management of patient violence and how they pertain to individual or communal interests and promote more or less toleration of such patient behaviors. When the patient's life is in danger, clinicians should attempt to provide necessary care while ensuring health care worker safety. However, clinically stable adult patients can accept the consequence of their choice to be violent, including delay or even loss of needed clinical care. In patients with decision-making capacity, clinicians can attempt to connect, negotiate, and provide care conditioned on whether the patient decides to behave less violently. By contrast, if a violent patient lacks decision-making capacity, such as from severe intoxication, and thus cannot make a coherent decision to behave less violently, clinicians can use sedation to enable life-saving care. Intermediate impairments in decision-making capacity require individualized responses. While dedication to compassionate care prompts clinicians to provide care even when patients are violent, protection of workplace safety is also a core clinician duty.7 The preservation of a safe hospital environment and thus the protection of health care workers from trauma and burnout can outweigh a violent patient's nonurgent interests. Since violence toward health care workers exists along a spectrum, so too should the assertiveness of health care worker responses to ensure workplace safety. Physical violence might trigger discontinuation of nonurgent clinical care, whereas less severe behavior, such as mild repeated verbal abuse, can elicit less stringent consequences. Such consequences are not retribution for violent behavior but rather a means of promoting workplace safety by reinforcing behavioral expectations. Violent patient behavior can be stressful and alienating for health care workers and thus exacerbate burnout and attrition. Racism and other forms of patient bias can drive violence against health care workers and thus impede institutional diversity, equity, and inclusion efforts by disproportionately affecting employees from historically marginalized populations. Thus, effective institutional responses can lessen the risk of health care worker alienation if affected workers feel their colleagues stood up for them and prioritized their well-being. Equity considerations also extend to patients, since clinician bias may inform their perceptions of threats from patients or affect the aggressiveness of their management of patient violence.8, 9 Clinician style and institutional hierarchy also influence the management of violent patient behavior. Clinicians with a collaborative style that prioritizes adaptation of the clinical environment to patient needs may be more tolerant, as suggested by values depicted in Figure 1, such as “Respect for patient autonomy” and “Prioritization of patient needs over clinician interests.” Through nonresponsiveness, this clinician style risks undermining workplace safety. Clinicians with a more authoritarian approach may respond to violent patient behavior with imposition of institutional consequences, such as removal of hospital visitation or other privileges or discharge from the hospital. If implemented too aggressively, this clinician style undermines workplace safety by exacerbating the patient's sense of powerlessness that may have fueled violent behavior in the first place. Clinicians should learn to mitigate the risks of their preferred style. A clinician with a more collaborative style might mitigate the temptation not to respond to patient violence by weighing the duty to support affected colleagues, for example, whereas a clinician with a more authoritative style may benefit from de-escalation training. Health care, regrettably, remains hierarchical. Physicians may be more tolerant of health care violence than nurses and other clinicians due to lower personal risk or less frequent exposure to patient violence. Similarly, established staff nurses may have more institutional status and, therefore, some insulation from violence compared with nurses with shorter tenure, less institutional influence, and more time at the bedside. The shared duty to protect equitable access to a safe and respectful workplace must be an institutional priority, nonetheless. The ethical response to violent behavior in hospitals must be addressed both at the individual and system levels. The latter can be accomplished by involving patients, direct care clinicians, support staff, administration, behavioral intervention staff, security personnel, and legal representatives. Clinical ethicists can help teams balance the ethical tensions to develop plans of response to patient violence, including trauma-informed care, de-escalation skills building, team responses to violent behavior, and leadership accountability. Trauma-informed care is a model of behavior management and organizational change based on the recognition that trauma often informs patient and clinician behavior, and that both groups perform better when the environment does not exacerbate trauma responses.10 Trauma-informed care encourages clinicians to be open and curious about patient stories and how they may shape violence or other challenging behaviors. This understanding may mitigate the risk that clinician bias informs perceptions of or responses to patient violence. A trauma-informed approach also recognizes that health care can be traumatic, despite health care workers' best intentions.11, 12 A trauma-informed care approach can respond to, and prevent, violent patient behavior by identifying what in the current clinical environment or the patient's prior life might have triggered patient violence. This method gives patients a sense of respect, safety, and control to the greatest extent possible in the clinical environment. For instance, a team managing a patient assault on a nurse can convey nonviolent behavioral expectations and inquire about what triggered the violent episode. Trauma-informed care also involves support for any relevant underlying mental health concerns. At an individual level, nurses and other health care workers exposed to the risk of violence can be empowered to protect themselves while preserving therapeutic alliance via training in de-escalation communications. These are communications that can prevent the transition from high emotion to violence and/or respond to violence itself. Prevention ranges from displaying institutional behavioral guidelines prominently to utilization of stress toys and calming videos for use with agitated patients. Responses to violence can include team huddles to ensure consistent management of patients at risk of violence to door closure followed by prompt involvement of security when patients seem likely to become violent.13 Employees within the health care system should all receive basic training and education in role-appropriate communication and de-escalation strategies.14-16 Beyond individual responses to violent patient behavior, health care teams must be able to engage in active bystander training to promote a safe and respectful workplace environment. Health care teams can benefit from quick debriefings after difficult encounters to connect those who need it with support and potentially to broader institutional interventions. Many institutions have created behavioral response teams led by skilled mental health professionals to help de-escalate clinical situations with the potential for aggression or violence. Beyond guiding difficult bedside decisions about the management of patient violence, behavior response teams can also help lead the institution's overall response to the risk of violence toward health care workers. This can include avoiding zero-tolerance policies, developing policies around the uses and moral downsides of behavioral health contracts, and advocating for needed preventive resources such as de-escalation training, antibias training, or physical interventions like metal detectors.17 Individual training and team responses to violence should be complemented by institutional support that may range from creating behavior response teams to demonstrating visible leadership involvement. This accountability is especially important when individual clinical situations require extensive experience or managerial latitude due to the complexity of competing needs. Diversity, equity, inclusion, and belonging training should be implemented alongside these efforts, so that appropriate supports are provided to any health care worker groups who are disproportionately affected by workplace violence. Clinicians confronting patient violence should balance ethical values in tension, like respect for patient autonomy and protection of workplace safety, layering in relevant context such as clinical urgency and severity and patient decision-making capacity. Individualized management of each instance of violent patient behavior should utilize the principles of trauma-informed care, health care worker training in de-escalation communications, and a team-based response supported by visible leadership engagement. The authors declare no conflict of interest. This work had no separate funding and did not require human subjects research review or patient consent. The authors have no conflicts of interest to declare. There are no primary data to share nor materials reproduced from other sources.