Healthcare workplace violence, gender, societal norms and technology

Healthcare workplaces can do a lot more with technology to help manage incidences of violence, but without systemic changes to what remain accepted norms within healthcare workplaces, the problem is likely to keep getting worse.

Although accurate data is hard to obtain, it is apparent that for some years now, violence in healthcare workplaces has been on the rise, and that covid has put that problem on steroids.

Setting aside that our federal government has still not seen fit to create some form of standardised system of data collection and analysis across the country for this significant issue, there are some fairly big challenges to accurately mapping incidences of violence in our healthcare workplaces.

According to Dr Michael Chataway, a chief investigator for QUT Centre for Justice, methods used to examine occupational violence need to consider the dynamic nature of workplaces and the roles performed within them in order to identify the context – and role specific circumstances – that increase the risks and opportunities for violence in the healthcare workplace to occur.

“Understanding the steps and actions of individuals who perpetrate violence against healthcare workers, along with their reasons and intentions for committing these crimes, may provide an opportunity to identify strategies for preventing or disrupting this type of violence,” he said in a paper he wrote in a briefing paper on the topic recently.

The huge variation in how statistics are recorded between our states gives us some sense of just how small a handle we have on the problem across Australia.

The Victorian Crime Statistics Agency recorded 335 assaults on healthcare premises in 2015 and 539 in 2019, while the NSW Bureau of Crime Statistics and Research recorded 361 violent incidents in hospitals in 2015 and 521 in 2019. But, in Queensland, where the Department of Health oversees the issue and asks for much more fine-tuned reporting, there were 3,719 cases reported in 2016 and 5,514 cases by 2019.

If you assumed that the NSW and Victoria had been measuring the same way across their states – and you extrapolate across Australia using population and health institution concentration – then you come up with the figure that in 2019, just prior to covid causing a significant escalation of the problem, there were 31,998 incidents of violence in healthcare workplaces across Australia.

But we know that it is very likely that this would be a significantly under-reported figure.

A systematic literature review conducted in 2019 across developed countries indicates that in any given year, 62% of healthcare workers report exposure to healthcare workplace violence, 42.5% reported exposure to non-physical violence and 24.4% reported experiencing physical violence. Verbal abuse (57.6%) was the most common form of non physical violence, followed by threats (33.2%) and sexual harassment (12.4%).

42.5% (95% CI 38.9% to 46.0%) reported exposure to non-physical violence, and 24.4% (95% CI 22.4% to 26.4%) reported experiencing physical violence in the past year. Verbal abuse (57.6%; 95% CI 51.8% to 63.4%) was the most common form of non-physical violence, followed by threats (33.2%; 95% CI 27.5% to 38.9%) and sexual harassment (12.4%; 95% CI 10.6% to 14.2%).

Why, with such a high and rapidly increasing incident rate (and even then, likely under-reported), do we still not understand what is going on, and is there anything we can do about it?

In terms of understanding much better what is going on, and in terms of making an immediate safety impact at the point of care, there is much available and emerging in terms of technology that can help make a difference, if it is applied in the right way.

According to David Williams, country manager for Ascom, which is a major solutions provider to the sector around safety and security platforms for healthcare workplaces, the starting point for any workplace is a system that provides appropriate “contextual protection” for staff.

“Solutions differ facility to facility based on the type of work done, the physical characteristics of the facility, whether the work is all done on campus, or whether members of the caring cohort travel off campus as well as work on campus. Each client, each potential opportunity where this technology will be employed, may well need to be different”.

But, Williams says, even when such systems are in place, often institutions will have a set up that isn’t able to log event data in a systematic and standardised manner, and this is a major issue.

“A key component of any system is that you have to able to log the data,” said Williams.

“That is not just for immediate events but for trend analysis. If, for example, you are able to collate a known number of events in a given location, then you should be able to drill into that data and understand what is happening at that location. Is there a set time or range of times that duress events are likely to occur?”

Ascom and several of its competitors have an increasingly sophisticated platform offering for institutions to solve the above issues. Some of these have been incorporated into hospitals overseas for many years now, but have only been installed in limited respects in Australia due to the state of digital health infrastructure in hospitals until the last few years, but also due to budgeting priorities of state governments.

Although at the end of the day, Williams key job is sales, he is at pains to point out that the technology that his company sells is only as good as the response from the institution using it.

“That response has to be broader than merely, ‘we send help when an event happens’.

“It’s how do we trap the data? How do we analyse the data? How do we use the data to inform better policy, better design, better training, all of those elements? And then how do we consolidate the data into bigger data sets at a state level, at a federal level, at a local health district level, so on.”

So, the technology is mostly there to potentially bring about improvement via better collection and analyses of the data around what is going on and how to fix it.

But even in new and large hospital builds today, the specification of sophisticated communication and safety platforms for staff, to a level now commonly seen in some overseas institutions, is just not there in Australia yet.

What looks short at this point of time is the will on the part of all our governments to co-ordinate around what can be done, and to develop a plan that would include some sort of standardisation between the states and the major institutions on approaching the problem.

CEO at Australian College of Nursing (ACN), adjunct professor Kylie Ward, sees the essential problem as simple, but complex.

Much of issue around recognition and response at the policy level is mired in societal attitudes on gender and violence, and an historical view around nursing, that “it goes with the job”, she told Wild Health at its recent violence in the healthcare workplace webinar.

“There’s such vulnerability around what we do as nurses,” she said.

Nurses don’t beat their chests and they don’t do the job for the financial gain or the accolades. We have the sacredness of privacy and confidentiality so that people know they can trust us for that, so we don’t show up to the world all those little things that make a difference to the experience: providing nursing care.

“But that also comes at a cost that we forget to say what we need to do when our experience isn’t honoured.”

“We live in a society that tolerates violence against women, so the nursing profession is going to experience occupational violence.

“For many years, nurses just took a lot of this as part of our job, people not coping. And sometimes when those boundaries are blurred, you take it on yourself, rather than thinking, I’m worth not tolerating this.

“There’s been a history of tolerance that has to stop.

In an effort to alter this dynamic at the highest levels of government the ACN has established a Nurses and Violence taskforce which has recently made submissions to the federal health minister, Greg Hunt.

But there remains a classic Catch 22 in the problem.

To get the data – the sort of shocking data that anecdotally people like Kylie Ward are seeing within the profession of nursing – which can be used to force a more cohesive response from policy makers, the policy makers may have to agree on some sort of national standard for collecting, analysing and reporting data.

But the erratic data coming form regions and states suggests that the issue is more complex and nuanced than a simple black and white scenario. It may be difficult to standardise this data collecting, analysing, and reporting nationally.

However, without the data, Ward fears we might remain stuck with the “it just goes with the job” societal paradigm, even though everyone says the situation was getting worse before covid and now is much worse again.

According to Ward, nurses now experience more occupational violence than police officers and prison guards.

“Why is it okay to continue with such a situation?”, she asks.

“Governments and employers, need to be creating psychologically safe workplaces which have a zero-tolerance approach to any occupational violence.”

Jackson Heilberg, a registered nurse who developed video series on violence in nursing for his blog, which recently went viral on social media (and even made it to network TV as a story), told Wild Health in the webinar that a national standardised data set requiring every health service – including private and public hospitals, aged care facilities and even primary care groups – to report on a minimum set of incident data, would go a long way to starting to address the problem.

Heilberg, who has experienced several incidences of violence himself as a practising nurse, suspects the problem is seriously under-reported and such an initiative would likely put policy makers in a position where they would have to respond.

“I wonder though if such a prospect might scare the policy people,” he told Wild Health.

Some of this article was based on comments made by experts during an Ascom sponsored video on how hospitals can prevent workplace violence, which you can watch here: