Study: Violence against pediatric health care workers largely unreported
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Key takeaways:
- 73% of violent incidents went unreported at two institutions.
- In one pediatric setting, most violent events were associated with guardians or visitors.
Health care-associated violence in pediatrics often goes unreported and mostly involves people other than the patient, according to findings from two studies published in Pediatrics.
In one, Mark Waltzman, MD, an emergency medicine physician at Boston Children’s Hospital, and colleagues created an AI tool to search nurses’ notes for unreported incidents of verbal and physical violence against nurses at a pediatric tertiary care center and a community-based hospital in 2019.
They defined health care-associated violence as “an intentional action by a patient or caregiver in the setting of care delivery with potential to cause harm or insult, to self or to others,” and focused on nursing notes because there is evidence that nurses are “most often the victims” of health care-associated assault.
Waltzman and colleagues trained a natural language processing (NLP) model using nearly 71,000 notes on more than 4,200 patients who were treated at the tertiary care center, then validated the model using more than 19,300 notes involving more than 2,800 patients treated at the community hospital in 2022.
According to the researchers, the model had a 96.8% (95% CI, 90.6%-100%) sensitivity and 47.1% (95% CI, 39.6%-54.6%) specificity when compared with a manual review of notes conducted by a nurse and physician.
The researchers identified 31 episodes of health care-associated violence at the community hospital from July to December 2022, including 26 that were reportable according to hospital criteria. However, 73% of the incidents went unreported, according to the study.
“NLP-assisted review is a feasible method for surveillance of under-reported [health care-associated violence] episodes, with implementation and usability that can be achieved even at a low information technology-resourced hospital setting,” Waltzman and colleagues wrote.
‘Rise in documented violence’
A study by Adrienne G. DePorre, MD, FAAP, co-director of clinical operations in hospital medicine at Children’s Mercy Kansas City, and colleagues examined the issue of patient and visitor-associated violence in a children’s health system.
“Our team wanted a better understanding of the violent events occurring in our own system, which will directly inform efforts to improve safety for everyone and are likely generalizable to pediatric systems across the country,” DePorre told Healio.
DePorre and colleagues reviewed violent events reported at their hospital from 2017 to 2021 and found that they increased over time in nearly every location except the ED.
Among 1,727 violent events included in the study, 87% involved intimidation, threatening behavior or verbal abuse, and 12.2% involved physical violence, according to DePorre and colleagues. Most of the violence — 64.2% — was perpetrated by people other than patients. Patients were responsible for 28.8% of overall violence but 66.2% of physical violence.
“Our results confirmed what my colleagues and I across the country have been feeling: There has been a rise in documented violence towards health care workers,” DePorre said. “Likely unique to the pediatric population our hospital serves, we found that most violent events are not actually associated with patients, but rather guardians/visitors. We also found that violent events were clustered around individuals or families, and there are some groups/individuals that have recurring violence.”
DePorre said pediatricians and providers “need more support,” and that more research into what triggers these episodes is also needed.
“Prevention and de-escalation techniques need to be widely taught, and behavioral expectations and consequences for violent behaviors need to be clearly communicated in health care settings,” DePorre said. “Having specialized supports for children, such as individualized behavior plans developed on arrival to the hospital or prior to seeing scheduled healthcare visits, can be helpful in reducing patient-related aggression.”
‘How could it not affect patient care?’
In editorial the accompanied the study by Waltzman and colleagues, Philip O. Ozuah, MD, PhD, president and CEO of Montefiore Medicine in New York, said it was not surprising that 73% of physical and verbal violence against nurses went unreported.
“I do not think I ever reported any of my own experiences with violence, yet there were plenty,” Ozuah wrote. “I remember once being threatened by a family who had to wait a long time for care, and then being told by them that they were going to go home and get a
gun. That was an empty threat, fortunately.”
The behavior “remains an issue today for health care workers of every kind,” Ozuah continued, bringing up a statistic that 89% of respondents said violence had harmed patient care.
“How could it not affect patient care?” Ozuah wrote. “Beyond the immediate shock, fear, and anger, a violent episode can make you more guarded with patients, less friendly, and more cautious, none of which are helpful when it comes to forging a strong therapeutic bond. At the institutional level, it is bad for morale and contributes to burnout.”
The primary issue, Ozuah said, is balancing “being warm and welcoming with an appropriate level of safety and security,” after which he detailed Montefiore’s own de-escalation protocol.
“The details described here, in the Waltzman et al paper, and in the many other papers about violence in health care settings, offer a decidedly grim picture of hospital life,” Ozuah wrote. “But facing difficult truths is what we do in medicine. We face them and we deal with them.”
For more information:
Adrienne G. DePorre, MD, can be reached at adeporre@cmh.edu.
References:
- DePorre AG, et al. Pediatrics. 2024;doi:10.1542/peds.2023-065041.
- Ozuah PO, et al. Pediatrics. 2024;doi:10.1542/peds.2024-066108.
- Waltzman M, et al. Pediatrics. 2024;doi:10.1542/peds.2023- 063059.
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