Safety in healthcare settings has always been a top priority in our daily workspace, be it against infection, occupational injury, or attacks against healthcare staff and patients. Yet there has been a marked increase of violence against healthcare workers since the beginning of the pandemic. The American Hospital Association (AHA) reports that healthcare workers suffer more workplace violence and injury than workers in any other environment. The AHA also states that 44% of nurses have reported an increase in physical violence since the pandemic and 68% have reported an increase in verbal abuse. Those unfamiliar with day-to-day experiences in healthcare settings may be shocked to learn that violent altercations are so common. According to the American College of Emergency Physicians, 80% of emergency physicians acknowledge that these episodes have also taken a toll on patients and patient care. In the high stress environment of the emergency department, 50% of physicians said that patients have been physically harmed, while 47% have stated they’d personally been assaulted at work. 

Of course, our work in the ICU also takes place in a high stress environment. Each day we deal with conditions that can be highly stressful for our patients and visitors. Brain death, permanent disability, prolonged hospitalization—all of these can trigger verbal outbursts and violence in some of our visitors. We must therefore work with our administration to develop policies and training to create a welcoming and restorative environment for both our patients and caregivers.

Safety starts with open discussions between staff and administration prior to a major violent event.  Preparation and training can rapidly defuse a potential violent encounter, and general training should start at the time of a new employee’s orientation. Reviewing how to deal with violent outbursts should be a part of every healthcare worker’s training. These reviews should cover scenarios on how to secure your areas, call for help, evacuate an area, and deal with violence, ideally with annual in-service programs that are available both online and in person. Active shooter exercises should also be organized on a regular basis with hospital security and local law enforcement. 

Because a facility’s entrance is the first bastion of safety, the number of entrances that can be used by the public should be controlled. This checkpoint is where we can screen for individuals who are intoxicated, attempt to bring weapons, are not on the visitation list for a specific patient, or have any other reason to be barred from entry. Security measures can range from the obvious (e.g., metal detectors) to more discreet security personnel that can serve as “ambassadors.” Because an overly aggressive security presence can be off-putting to patients and visitors, hospitals should aim instead for measures that are relatively inconspicuous. Ambassadors can welcome visitors and direct them to elevators, clinics, labs, and units while issuing visitor passes and maintaining a log of who is in the building. Entry to the ICU should be controlled with a locked door that can be opened by unit staff to allow visitors in. Closed circuit video cameras are also a key part of perimeter security, both as a screening system and as a recording device that can be used to later identify an individual who was violent at the bedside. Importantly, facilities should have safe areas for staff and patients to be able to retreat to, such as a medication or store room fitted with bullet proof glass and staff lounges and locker rooms equipped with bolted doors. 

In cases of violence, communication is key, and an important skill to learn is the ability to de-escalate a situation. Programs should be created that train all staff in a given department to learn to recognize signs of agitation and potential violence. Even though it may be a struggle to ensure this topic is given sufficient priority in an ICU environment that is constantly filled with so many different emergencies and critical issues, safety should never be neglected. After all, when staff are not safe, patients are not safe. Such programs can also help staff feel supported and address issues related to burnout that remain rampant.

Finally, know what to do if the unthinkable occurs—an active shooter in your hospital. Staff should learn the public safety mantra: run, hide, fight. You may not always be able to find an escape route on your unit, so make sure you know your secure hiding spots, such as the rooms mentioned above. Take action only as a last resort, and only if your life is in imminent danger—try to incapacitate the shooter, find a makeshift weapon and act aggressively, or yell and throw items. Remember that an active shooter can be an employee, patient, or visitor. Always be alert for people acting suspiciously, such as those who appear nervous when you ask simple questions or exhibit signs of at-risk behavior such as:

• Depression and withdrawal
• Repeated violations of your facility’s policies
• Explosive outbursts of anger
• Talk of severe financial problems or previous incidents of violence

Report your concerns to the public safety team, and remember—if you see something, say something.