 In a diverse session, our first speaker in the afternoon will be Dr. Sarah Scarlett. Dr. Scarlett is a resident, a surgical resident in general surgery at the University of North Carolina Health Care in Chapel Hill. Sarah holds a master's degree in public health from the University of North Carolina. She was awarded the American College of Surgeons at McLean Center, Surgical Ethics Fellowship in 2017-18, and prior to this she was an active member of the Hospital Ethics Committee at the University of North Carolina. Dr. Scarlett's interests in ethics were inspired by her clinical work as a trainee and her personal interactions with the healthcare system. Early in her training, she became an advocate for improving the communication practices of surgeon trainees regarding critical illness and of life care and high-stakes decision-making. Her specific areas of interest include the integration of the health system with the criminal justice system, which has led her to work on the ethics of healthcare for incarcerated patients. She's also quite interested in ethics education for surgical trainees. Today, Dr. Scarlett will be speaking to us on the topic workplace violence in healthcare, just part of the job. Please join me in giving a warm welcome to Sarah Scarlett. Today, I'll be talking about a topic that I find to be incredibly complex, and that's violence in the healthcare workplace. At least in my field, among individuals who provide trauma care, we often think of how to address interpersonal violence that exists within communities, namely how to identify, treat, and prevent it. Far less, we think of violence as something that can occur within the seemingly safe walls of our hospitals. But it can. And importantly, just as we can experience violence as clinicians, we too can perpetuate it. Before I go any further, I'd like to acknowledge that speaking about violence can be stressful or distressing, and just please be mindful of this as you listen to my talk. I started getting interested in this topic based on my work on the hospital ethics committee at UNC. And during my time working on the committee, we noticed an uptick in consults related to safety threats and violence against healthcare workers. And we were asked to weigh in on challenging decisions, like one of the consults that I featured here. This is a 31-year-old woman with a chronic medical condition, and she was cared for by the same medical team for the majority of her life. And she had recently struggled to afford the cost of her healthcare. And she applied for disability benefits, but was ultimately rejected, and this was an incredibly stressful time for her. She blamed her physician for this, and tensions began to rise. And it started off with some comments in clinic, and then she ultimately called the clinic and threatened to kill her doctor. And this medical team was incredibly distressed, because they wanted to care for this woman. They've been caring for her for a very long time. They tried to develop workarounds and avoided formal reporting mechanisms for this behavior, and ultimately trying to shield the physician from even knowing about this threat, and trying to transfer her care to another physician. And that's when we got involved. In the United States, with the exception of law enforcement officials, we healthcare workers are more likely than any other professional to experience violence in the workplace. This is important, because violence effects are well-being, and that of our patients can lead to injuries, missed workdays, attrition, burnout, decreased productivity, and poor quality healthcare. Oftentimes, violent patients have vulnerabilities. So like many of you, in thinking about your areas of interest, I too went to the literature to see how has the medical community defined workplace violence. And I found this excellent paper from JAMA in 1892 called Assaults Upon Medical Men. The profession is pretty well-disciplined to expect to hear of assaults on medical men by insane persons or patients, but for them to be assailed by persons in normal mental condition is fortunately a decidedly rare occurrence. An incident of this latter kind, however, is said to have transpired at Chattanooga, Tennessee on February 24th, and this is actually an incident in which two parents threatened a physician after their child had a poor outcome. The author goes on to say, at the same time, no physician, however conscientious or careful, can tell what day or hour he may not be made the object of some undeserved attack, malicious accusation, blackmail, or suit for damages. For sufferance is the badge of all our race, and all of which may give a glimpse of the possible conditions that may surprise the practitioner almost any day that will be encountered as a rule, patiently and silently. Because dignity, silence, and patience are the lessons inculcated in the school of medical experience. And it's interesting that this paper is written in this way because many of the accounts of workplace violence and how we perceive it as clinicians, there's a pervasive attitude that it is simply part of the job. And in reading this, I wonder, might this indicate perhaps the origin of this attitude? So the World Health Organization defines violence in this way. The intentional use of physical force or power threatened or actual against oneself, another person, or group, or community. OSHA, the Occupational Health and Safety Administration, defines violence like this. Violent acts, including physical assaults and threats of assault, directed at persons at work or on duty. And there's some important distinctions in these definitions. They have an emphasis on physical violence rather than verbal abuse, which is at least studied by people who, in the literature and workplace violence. And then there's an emphasis on intentionality in the World Health Organization definition, but not an OSHA's definition. One more important thing to note with thinking about workplace violence is it's stratified into many different types in terms of who the perpetrators and victims are. And the literature suggests that greater than 90% of the incidents are type 2 incidents, where a perpetrator is a customer or patient, could also be a family member. And for the purpose of this talk, I'll mainly be focusing on this type of violence. And then there's one more important aspect of this to note, which is, did the patient or the person who committed the violent act mean to do it in a criminal way? In the context of the law, the mens rea, or the guilty mind, refers to criminal intent, which must be present for an individual to be convicted of a crime. But in our work, we often encounter violence in the context of illness that can alter one's state of mind. And that may actually alter how we think about it and respond to it. Our patients may have altered capacity or disordered thinking. Are they truly capable of violence or crime? Violence can present as medical or mental illness. An acutely psychotic patient could end up striking a staff member. Things like pain and anxiety can lead to regression of behaviors and cause people to behave violently. And there are important consequences of recognizing whether a behavior or medicalizing a behavior versus criminalizing a behavior. Medicalization is known as defining a problem in medical terms, using medical language to describe it, and adopting a medical framework to understand it, and using medical interventions to treat it. And it has important consequences, at least partial absolution of moral culpability for the condition, at least partial decriminalization, a preference for a therapeutic response over a punitive one, a tendency for optimism regarding the effectiveness of its treatments, and an increased legitimacy for the medical profession's role in controlling deviance. Now I'll shift gears a little bit and talk about epidemiology of workplace violence. This is probably the largest study on workplace violence out of 5,385 interdisciplinary staff at six US hospitals. Almost 40% reported at least one episode of violence during the year preceding the survey. And this is a survey of nurses in an emergency room that found that uniformly they had experienced at least one episode of verbal violence, and many of them had experienced physical assault. And while much of the literature focuses on nurses and aides and people who provide direct patient care, some of it does focus on physicians as well. This is a study of emergency room physicians across the US and found that of trainees and attending, 78% had experienced workplace violence during the past year. It's important to note how healthcare workers compare to other professions. On this graph it shows the violent incidents based in a year, and on the Y-access cases per 10,000 full-time employees. And what you can see is we're the green line. The experience of violent injuries is far higher than other professional sectors, including retail, construction, and manufacturing. This is from the 2017 healthcare prime report looking at 222 American hospitals, and the rates of certain types of violent crime based on per hundred beds. And what you can see is that the rates of assault and violent crime are about 10 per 100 beds. Thinking about a place like my own hospital with 900 beds, that's a whole lot of incidents. People who work with patients who have a history of violence who are under the influence of drugs or mentally ill have a higher risk of experiencing violence. Reports of assault are proportional to contact time, so people like nurses and aides experience the highest rates of violence. Women, people who are small, people with less experience, and maybe even those delivering bad news are at higher risk of experiencing violence. But there's a lot that we don't know. Most of the research involves high-risk settings like psychiatric wards and emergency rooms. There's a lack of consensus regarding terminology, and I hope that I've convinced you that there's some important distinctions to be made in these definitions of violence. And under-reporting and reporting outside the formal mechanisms is quite common, which may be due to varying perceptions about whether or not violence is part of the job. Something else that's really important to note, as I said, is that violent patients often have significant medical needs, and they can have vulnerabilities. This has been described as a patient care paradox, or a simultaneous need to protect this population while incurring direct threats to personal safety. Violence on behalf of patients or family members can result in poor quality care. Staff might not want to dedicate time to spend with these patients if they're scared of them, and they don't have the tools to help treat them. Restraints are often used, chemical and physical, or even discharge or transfer, in response to violence. And restraints can cause harm. Discharge can eliminate access to care. And restricting family access in the setting of trespassing, which is done at my hospital, can influence support that patients receive, and even bedside care. And so we wanted to know at my hospital what was the experience of workplace violence among our staff. In 2017, we added four supplemental questions to the AHRQ hospital survey on patient safety, and the participants who responded were all staff at two of our largest hospitals within the UNC Health System. And we compared reports of violence in this survey to actual reports that the hospital was aware of in our patient occurrence reporting system. This is who completed the survey. I was largely completed by nurses, but you can see there's good representation from many of the healthcare disciplines. Physicians made up about 10% of the respondents. And these are our findings. So the first thing we looked at was physical violence on behalf of a patient, regardless of mental status or medical history. And of the 3,000, 3,500 people who responded to our survey, almost a third of them had experienced at least one episode of physical violence. We asked respondents about verbal abuse, specifically on behalf of patients or their family members or visitors. And we found that about half of all respondents reported at least one episode of verbal abuse from a patient. And 33% reported verbal abuse from a non-patient. We wanted to know if these behaviors occurred in isolation, or if experiencing one type of violence put you at risk of experiencing another type of violence. And then surprisingly, we found this to be true. Experiencing any type of violence, verbal violence on behalf of a patient or a visitor or physical violence was associated with experiencing other types of violence. And 17% of the people who responded had experienced all three types of violence. And this is unsurprising and well-described in other literature, such as the literature on intimate partner violence that suggests that violent incidents tend to escalate. This is the staff who experienced physical violence stratified by position on the x-axis. There's prevalence, and on the y-axis, it's the position. What we found was that therapists who are reporting the highest rates of violence followed by patient aids and nurses, which is not surprising given that increased contact time. And I will say in this population, the number of therapists who responded to the survey was lower, so that is a little bit skewed. If your staff who experienced verbal abuse on behalf of patients, again, therapists, nurses, and aids were experiencing the highest rates of violence, but people throughout the hospital, throughout multiple disciplines were experiencing these behaviors. And here's verbal abuse experienced on behalf or perpetuated by non-patient visitors. And what we found is that something didn't really add up. 2011 people reported experiencing violence, and during that time, there were only 356 calls to hospital police, and 45 assaults or incidents reported to our patient occurrence reporting system. Not to say that every episode or incident of violence warranted a call to the police, but the mechanism by which the hospital is seeing these incidents, there's a discrepancy here. And so we looked at the literature. This is from a study examining why people didn't report episodes of workplace violence. Common reasons were that the event wasn't serious enough. The individual wasn't physically harmed or there wasn't an intent to harm. We just said it's simply part of the job. So thinking about an ideal response to violence, it ought to clearly define the institution in regards to violent behaviors. It should involve prevention, identification, response and employee support, and drawn input from people from diverse backgrounds, including patient representatives. And it shouldn't be purely punitive, but rather focus on boundary setting and prevention. And there are many aspects of this response, but they include things like clinical care, changing structural design, hospital policies and procedures, and as a last resort involving the criminal justice system. I think this was really important in the context of the doctor-patient relationship, because the last thing any of us would want would be to seeing us colluding somehow with law enforcement. This is a poster from the NHS and their campaign to reduce workplace violence. So this work has left us with very important questions. Have we normalized violence in the healthcare workplace? It has our emphasis on patient autonomy and that patient as customer attitudes somehow increased our tolerance of certain behaviors. How can we balance our duty to care for people who are violent or care for patients whose families may be behaving violently with our duty to protect each other? And when, if ever, is it appropriate to terminate the doctor-patient relationship? And then thinking about violence as medical and mental illness, did the intentionality of these events matter? Or should it influence reporting? So in conclusion, data suggests a large proportion of US healthcare workers experience violence. Accurate estimates are very difficult to achieve and we mostly have data from high-risk settings. They're important nuances related to identifying and labeling violence in healthcare related to intentionality, criminal intent, and thinking of violence as medical and mental illness. Violent patients have vulnerabilities and are often in great need of medical care. And it is my opinion that it is our institutional and personal duty to develop ways to care for patients such as this and also protect ourselves. And any response to violence ideally should focus on prevention rather than a punitive approach. I'd like to thank my many mentors at UNC and here at the McLean Center and for inviting me to give this talk. Thank you. I have a quick question because I actually have been in positions where I've been violently attacked and I'm a pretty gentle person as a clinician. Does your UNC program include in the training program two things, one is how to de-escalate violence and bystander response? So our program is very early and I think there is a huge need for training of individuals and how to respond to these behaviors. I think of my own field and how often as a trauma surgeon or in caring for trauma patients, I'm expected to be able to respond to violence that happens to people before they get to the hospital. But I don't really have any training or not in the standard fashion of how to de-escalate, how to respond, who to call, when to call. And I think this is incredibly important and one of my future projects will involve the training program for physician trainees. Well, I would give you some advice, which is that I worked in emergency rooms for 30 years and never was trained how to deal with violence except in psych settings where it's given the hell doll. But where I did learn was in very large, long-term care settings that were also secondary hospitals. And it was a very detailed and annual review of how to work on de-escalation, what bystanders should do. So you might wanna go to people who work with demented patients and psych patients as opposed to people who work ER because you just call the police when you're in the ER, right, so. Yes, I'm curious if you're familiar with the case of, I think it was about a year or two ago, a nurse who I think it was in Colorado refused to give personal information about a prisoner that was in custody at the time and receiving care and the police ended up basically forcibly arresting her. Because in Utah, it was bubbles, yeah. I don't know if you had any thoughts on that or it's sort of similar to workplace violence, but from the people who we should sort of trust the most. So how to answer that or the specific comment, I think it's a little bit different than the issue that I'm interested here. I think that the notion of seeing physicians and clinicians don't wanna be seen as colluding with law enforcement. And in that circumstance, that nurse was trying to advocate for a patient who wasn't able to consent to a blood draw and was being asked by law enforcement to do it anyways. And she ultimately stood up to that and was arrested. There are policies that are at some places trying to prevent that issue, but I think it's very important that we separate ourselves from law enforcement officials. Hi, Steve Genheim, I work at a state hospital in Wisconsin. Violence is, we have a lot of training, I think it's good training, but violence is common enough at something we think about every day. It would be hard to go to a unit and not find a staff who hasn't been physically assaulted. I was assaulted twice, including going to emergency room and getting stitches. Verbal abuse is probably a daily occurrence. There are staff who've been disabled, but it's a relatively, I don't wanna say common, but it's far from rare. It's something that we just live with. And I guess it's part of the workplace on inpatient psychiatry. It's different than outpatient psychiatry, which I did for years, but patients can be very, very violent and feel they have little to lose and not always psychotic when they're violent. Sometimes it's very significant personality disorders and there may be 15 or 20 staff that respond. We have lots of techniques for restraining people humanely, but patients can be very violent. I think that's right and I think it's up to us to develop ways to mitigate violence and still care for people. Hey, Sarah, thanks for that talk. My name is Hannah. I just had a quick question for you. How did you define for the surveyors that you'd made through your, the data that you showed, what verbal abuse means? Like, what was that? How is that defined? Yeah, many examples are provided on yelling, screaming, physical, or threats of physical violence and we gave, we provided examples of the physical.