March 12, 2021

The Road to a Safer Workplace

COVID-19 can add to challenges for nursing caregivers


Across the United States, violence at work has been on the rise for years, and experts acknowledge that healthcare workers are disproportionately in the crosshairs.


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According to the Centers for Disease Control and Prevention, 73% of the 20,790 people injured in workplace violence incidents in 2018 were healthcare workers. A 2020 article in Occupational Health & Safety reported that 21% of nurses and nursing students had reported being physically assaulted on the job.

And that was before the COVID-19 pandemic added new stressors. The data has yet to be finalized on how the pandemic has affected violence in healthcare, but there are plenty of instances of nurses having to enforce mask regulation and visitation guidelines.

“One of our goals to really look at what we have been seeing with COVID-19-related workplace violence,” says Janet Schuster, RN DNP, RN, MBA, NEA-BC, CPHQ, HACP, Chief Nursing Officer at Lutheran Hospital. “The limited visitation can cause some patients to feel more anxious, and when they become more anxious, they can become more aggressive. And the person they may react to is a caregiver.”

Schuster is a co-chair of Cleveland Clinic’s Workplace Violence Committee and says the health system prioritizes a safe and healthy workplace. Crisis response training, improved communication and increased police presence and security measures are among important tools that have been put in place over the years.

In addition to ensuring that the hospital is compliant with state and national safety standards, the Workplace Violence Committee encourages caregivers to report activity. Benchmarking incidents so that the problem be can analyzed, year over year – and thus, be more fully understood and prevented – is an essential step.

Delivering excellent care has many challenges, but working amid the potential for violence shouldn’t be one of them. “For me, this is an extremely important topic,” Schuster says.


Schuster is in good company with her passion for improvement. When Cleveland Clinic formed its Workplace Violence Steering Committee in 2018, the goal was to have a working group of 25 members, including Schuster and co-chairs Stephen Meldon, MD, and Ashley Withrow, Cleveland Clinic Victim Advocate. Soon there was a long list of people who wanted to be part of the solution.

Factors contributing to the escalation

Increased workplace violence isn’t limited to the health industry, but factors unique to healthcare can make hospitals and caregivers especially vulnerable. The digital age may be a contributor. On the one hand, medical information is more readily available to all. On the other hand, a Google search can set people up for unrealistic outcomes.

“Patients read more, they see more, so they may come in expecting a certain outcome,” Schuster says. “Or they may be expecting a certain diagnosis, and they may not get that diagnosis.” The problem is exacerbated by the mental-health challenges of the pandemic itself, during which reports of depression, anxiety and suicide have increased.

The problem extends beyond clinical settings to offices, homes and anywhere nurses or therapists bring the care to patients, but certain environments are common targets.

“If you look at the higher numbers of folks that are being impacted, they tend to be emergency department nurses and physicians,” Schuster says. “Behavioral Health also is an area where there is a potential for workplace violence due to the nature of the patient population. So those folks are particularly vulnerable.”

In recent years, Cleveland Clinic has increased security measures, from adding police and metal detectors to confiscating weapons.

Welle de-escalation training (formerly NAPPI) is important, too, as a tool to empower caregivers to bring empathy to a tense situation and keep it from getting out of control.


Nurse assistant Daryl Galloway recently used his de-escalation training when a patient became agitated just before undergoing treatment. The care team had been setting up for the procedure when the patient leaped out of bed, screaming and pulling out all monitoring devices. Galloway used a hands-on de-escalation technique to guide the patient back to bed. He also showed another caregiver how to safely intervene. The team had used a panic button to call for help, the situation was under control by the time support arrived.

“Since becoming a NAPPI instructor in 2007, I have found that many times in chaotic situations, the calmer mind prevails,” Galloway says. “Some people can be less patient and tolerant of others. It is up to us as caregivers to model behavior that we want to receive. We need to respond to behavior rather than react to it.”

Mitigating risk during the pandemic and beyond

Communication is key to reducing any escalated potential for violence during COVID-19, Schuster says. The hospital conveys information about COVID-related restrictions on its website and at entrances. It also posts notices informing visitors that there are criminal penalties for threatening or assaulting healthcare workers.

In the end, though, Schuster says, more information is needed to establish metrics for improvement, although there are a few tools that hint at progress.

Schuster compared results of a caregiver engagement survey of more than 12,000 Cleveland Clinic nurses to nationwide surveys of registered nurses, and noticed that Cleveland Clinic registered about 4% percent higher in categories pertaining to feeling safe at work. “So I think we’re doing a good job,” she says.

Continuous improvement is always the goal. So is continuous education. It’s important for nurses and other caregivers to understand the importance of speaking up.

Schuster says. “You can be having a verbal conversation and somebody can be very verbally aggressive to you,” Schuster says. “That is a type of workplace violence, and it can have a widespread effect. We have a responsibility to create the safest care environment for our patients and each other.”

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