High profile and widely reported violent acts occurring in hospitals have elevated public and employee awareness about security and safety in hospitals and healthcare in general (e.g. CBS News, 2014). The Bureau of Labor Statistics (BLS) recently reported that healthcare workers had more than twice the incidence of injuries with days away from work resulting from violence compared to the overall workforce (BLS, 2015). Among healthcare and social assistance workers in the public sector the incidence of injuries requiring time away from work was more than 20 times that of the overall workforce (BLS, 2015). Nine states have passed regulations requiring workplace violence prevention measures in hospitals (GAO, 2016). In the Spring of 2016, the Occupational Safety and Health Administration (OSHA) published a pre-rule stage request for information titled “Preventing Workplace Violence in Healthcare”. Labor organizations also petitioned the U.S. Department of Labor for a federal OSHA Workplace Violence Prevention Standard for the healthcare and social assistance industries.

In 2008, New Jersey passed the Workplace Violence Prevention (WVP) in Healthcare Facilities Act (2008) and promulgated regulations in 2011 (NJ Workplace Violence Prevention in Healthcare Facilities, 2011). These regulations include specifications for a WVP program that encompasses training, a written policy, incident reporting, violence risk assessment, and worker participation.

The training requirements specifically stated in the regulations require the following:

The policy specifications of the regulations require:

Reporting and Assessment elements of the regulations require:

Worker participation is encouraged through the regulatory requirement that at least 50% of the workplace violence prevention committee contain direct patient care staff and that the annual violence assessment walk-through surveys be conducted with at least one direct patient care staff member.

Violence and fear can significantly affect the operations of a hospital. If a hospital experiences violent incidents and does not respond effectively, the quality of care decreases, employee turnover rises, and fewer people will seek care at the facility by choosing to go to a competing hospital instead (Jackson et al. 2002, Hegney et al. 2010, Gates et al. 2011, McNamara et al. 1997, Meyer et al. 1997, Mattox et al. 2000, The Joint Commission, 2012). Despite these consequences, many hospital executives undervalue their security programs and view these programs as overhead, often citing budget limitations and a need for a customer friendly atmosphere as significant barriers to implementing a comprehensive security program (Blando et al; 2014).

Research has also suggested that the crime rate in the community surrounding the hospital may not be the most important predictor of injury among staff from violence, but rather the comprehensiveness of the security program may be a more important predictor of employee risk (Blando et al., 2012). In other words, data suggests that the implementation of a strong security program reduces the risk of injury to employees from violence, perhaps more than any other single factor (Blando et al., 2012). Employees at hospitals located in communities with low crime rates may still be at significant risk because of the stressful situations encountered in providing healthcare.

For example, we abstracted a case in a low crime community of an elderly security guard who had his neck fractured during an incident identified as workplace violence on the OSHA log, which was reviewed as part of the Blando et al. (2012) survey. During the review of the OSHA log for this survey, the hospital CEO provided great detail of this particular incident because he felt this was necessary and it was recorded by the survey team as an independent case report in an effort to capture all the details that were reported (Blando, 2005 unpublished case report). This altercation between brothers occurred because one brother did not notify the other that their father had a heart attack. The security guard was not trained to de-escalate these types of situations and was not able to prevent the physical violence causing his injury (Blando, 2005 unpublished case report). The hospital CEO struggled with this event and kept stating during our discussion of the OSHA log data that “they just didn’t think they really needed security because it is so beautiful and peaceful in our town”.

This paper is a summary of information collected from interviews conducted with 35 individuals representing the safety and security departments of 52 New Jersey hospitals. Details are provided in Blando et al. (2017). In summary, participants were recruited from a sample of 93 New Jersey hospitals including general acute care, trauma and psychiatric hospitals. A semi-structured face-to-face interview was used that focused on the security director’s opinion, beliefs, background, and their implementation of the WPV program. The semi-structured interview was pilot tested and validated and interviews were conducted by trained staff. SPSS (IBM Corporation, Armonk, New York) was used to compute descriptive statistics such as frequencies, percentages, and standard deviations after the data was coded by the project investigators.

This project was approved by the Institutional Review Boards (IRB) of Old Dominion University, University of North Carolina-Chapel Hill, and the National Institute for Occupational Safety and Health (NIOSH) and verbal informed consent was obtained prior to the conduct of all interviews. The overall goal of the project was to describe hospital experiences with the New Jersey Violence Prevention in Health Care Facilities Act and to learn of effective and innovative ideas that have been implemented in hospitals. This report is subjective in nature and subject to personal bias due to the opinions and beliefs of survey participants and is not intended to serve as definitive evidence. Readers are encouraged to critically evaluate the information presented in this summary.

This project collected data on the opinions, expertise, and experiences of those implementing programs in the “real world”. As such, the Chairperson of the workplace violence prevention (WVP) committee (or their designee, often the Security Director) completed a face-to-face interview with a member of the research team. Interviews were conducted between August 2012 and July 2014, which is after the NJ regulations were officially in effect and compliance was legally required. The person interviewed, either the WVP committee chair or their designee, was the person with the functional knowledge of the WVP program. This means that the interviewee was the person responsible for overseeing the WVP program and also managing the functions of the program. The average time in their current position among the survey participants was eight years, ranging from one to 28 years. They had served as WVP Committee chairperson on average for four years. In many cases, the WVP committee existed before the regulations became officially effective because some hospitals created their committees in anticipation of their compliance requirements. Twelve individuals were responsible for more than one hospital in their healthcare system.

Table one demonstrates that almost half (49%) of those interviewed reported that they had been previously employed in law enforcement, either as command staff or officers. Other employment history background included positions in Hospital Administration/Management (31%), Security (20%) and/or Patient Care/Healthcare (14%). Three individuals (9%) held an advanced degree including an MBA and/or PhD. Having a background in law enforcement was also the most frequent response when asked to describe their background in security and developing security programs, while 17% reported relying on “on the job training” or having no background in security or developing security programs.

The most commonly reported organization of the security services in participating hospitals was an in-house team managed by the Security Department (75%) (Table 2). Few hospitals (10%) in this survey reported contracting their security services to a private agency. The number of security officers varied by hospital size and location with a range of 4-200 officers. More than half (56%) of the hospitals in this survey had 50 or more security officers, and often included both part-time and full-time officers.

Sixteen security directors were asked their opinion about the quality of in-house and contract security guards. Most (n=14) felt that in-house security staff performed better than contract security services, while two were ambivalent. One security director suggested that budget and administrative needs should be factored into the final decision about the organization of the security program. Another noted that healthcare systems that consisted of multiple hospitals had enhanced flexibility because they had a pool of security officers from which to draw upon when unexpected needs arose. Officers could be pulled from one facility to another with short notice, which provides flexibility to ensure proper staffing of hospitals.

During the interviews, six security directors discussed their facility’s policies on physical contact between guards and patients/visitors. During these discussions about “hands on” approaches only one security director reported having explicit policies that prohibited physical contact between guards and patients/visitors. Three security directors who participated in the interviews indicated that former police officers were, in their view, not necessarily the best guards because they felt these retired officers had difficulty making the distinction between law enforcement and the more customer-centered approach required in hospital security departments. However, two security directors strongly indicated that retired police officers are the best option when possible.

Many security departments are actively involved with preparations and planning for an active shooter scenario. Security directors in our study were very mixed in their attitudes and beliefs regarding the presence of guns among security officers patrolling the facility. One security director felt this was necessary, three had no opinion but were considering allowing firearms among security staff, and four felt this was dangerous. Those security directors who explicitly objected to guns being present in the hospital cited the potential for escalation to deadly force and the potential for an officer to lose control of their weapon during an altercation. One interviewee, who was a retired police officer that carried a gun, told a story where he was involved in a physical incident in their emergency department where he did not feel confident that he could retain control of his gun in the holster beneath his jacket. In the security setting the guard’s goals are not simply rule enforcement but also to assist the medical team in restraining combative patients and as such this can potentially leave the guard in possession of a gun vulnerable to loss of control.

The NJ regulations require that every applicable healthcare facility has a workplace violence prevention committee that has half the committee composed of staff with direct patient contact and meets at a minimum every quarter. Fifty (96%) of the hospitals surveyed in New Jersey had a Violence Prevention Committee. Eight of the 35 (23%) interviewees had WVP committees with less than 50% of members having clinical duties. The frequency of meetings for these committees varied. Forty percent of the hospitals had committees that met 6 times or more per year and another 34% held meetings quarterly, while 26% met less than the quarterly requirement of the regulations (Table 4).

Security directors identified a variety of sources used by the committee to develop their hospital’s workplace violence prevention plan. The most frequently cited sources included the 2011 NJ Violence Prevention in Health Care Facilities Regulations (89%), Occupational Safety and Health Administration (OSHA, 2004; 2015) Guidelines for Security and Safety of Health Care Workers (54%), the Joint Commission (JCAHO, 2012) Standards (33%), New Jersey Hospital Association (NJHA) (14%), and the National Institute for Occupational Safety and Health (NIOSH) (10%) (Table 4). Respondents also used peer input (17%) and relied on professional journals (12%) and internet resources (8%).

The security directors surveyed in this project reported several program elements that they felt were particularly effective in preventing workplace violence. As such, many of our security directors emphasized these elements in the security program at their healthcare facility. Trending and following violent event data was reported as an important aspect of an effective violence prevention program. It was clear to our participating security directors that effective reporting is a precursor to awareness and enables early detection of potential problems. In addition, several security directors indicated that report writing and documentation of investigations involving violent incidents was crucial for security guards. Discussion of violent events in post-event debriefing were also reported as extremely helpful by 17% of our security directors because this de-briefing allows for a detailed assessment of the causes and consequences of an event. This also allows for the effective development of interventions to prevent similar events from occurring in the future. Interestingly, cameras or surveillance systems were not frequently mentioned as helpful features for violence prevention but six security directors suggested that they are useful for documentation purposes.

Security directors also reported some aspects of their programs that they felt were very helpful and innovative. For instance, several facilities had developed the ability for secure remote video feeds so that supervisors can view cameras and situations in realtime when not on site. One facility utilized this remote access feature to eliminate the need for a guard in the command center at a satellite location, as the video feed went directly to the command center at the flagship hospital. Another facility utilized secure remote access cameras to reduce costs associated with “one-on-one” patient observers. Using the cameras allowed one patient observer staff member to simultaneously view multiple patients, thereby reducing the number of staff needed for “one-on-one” observation. However, patient confidentiality was a factor they had to carefully consider. Several security directors also indicated that their practice of checking hospital registrations before giving visitor badges was very useful to allow better access control among visitors. Security officers quickly checked to determine if the person a visitor was requesting to see was actually in the hospital, where they were located, and if there were restrictions or restraining orders before giving visitor passes.

Many hospitals and security programs that were the focus of this survey are taking important steps in the prevention of workplace violence. Despite the fact that every security director would like a larger budget and more resources, cost was not identified as a primary barrier to implementation of the workplace violence prevention program or training. While significant progress has been made, additional efforts are necessary and should result in continuous improvement that will protect healthcare employees, patients and visitors, and the healthcare organization. Several interesting approaches highlighted in this report may be of interest to workplace violence prevention committees and security directors as they work on furthering the goal of a safer and healthier workplace.