Stephanie Ross had only been on the job for about three months when she lost her life.
The recent college graduate was stabbed to death in December of 2012 by a patient while working as a social service coordinator with Integra Health Management.
As part of her job, Ross visited clients in their Florida homes and coordinated case management, even transporting patients to appointments in her car. But Ross had previously reported in her case notes that the client she was seeing that day made her uncomfortable. He had a severe mental illness and violent criminal history. He ultimately stabbed the young case worker in the front yard of his home.
Ross' case isn't an isolated incident. According to the U.S. Department of Labor Bureau of Labor Statistics, 271 of the 4,679 fatal work injuries recorded in 2014 across all industries were workplace homicides. The rate of injuries and illnesses from violence is more than three times higher in healthcare than the violence rate for all private industries.
The incident in Florida not only cost Ross her life, it also resulted in two serious citations for Integra and penalties totaling more than $10,000 for failing to protect her from workplace violence.
"It's the nature of the industry perhaps that there is more tension and a higher likelihood that people are going to not react very well to certain circumstances," says Mikki Holmes, national workplace violence coordinator for the Occupational Safety and Health Administration (OSHA).
So, what can behavioral healthcare facilities do to protect themselves and their employees from seemingly random acts of violence?
Experts say while it's not always possible to predict incidents of violence, it is possible to establish policies and procedures that foster safety and are aimed at reducing violence in the workplace.
"There really needs to be some careful thought and preparation in identifying what the risks are and then doing some preparedness training, because many of these situations are very difficult to anticipate," says Sean F. Conaboy, MSW, MPA, a broker and risk manager for the behavioral healthcare practice at NSM Insurance Group.
Obviously, law enforcement must be called for any emergent, potentially dangerous situation, but there are processes that can happen proactively, separate from an emergent situation, that can help treatment center operators lay some groundwork for worker safety.
Experts agree that the first step for behavioral healthcare organizations, regardless of the practice setting, is acknowledging that they aren't immune from the threat of violence. Denial is all too common.
"People don't think it's going to happen to them,” Conaboy says. “They don't think they have those kind of patients, or they think they have good rapport built with them, or that they have therapeutic alliance."
H. Steven Moffic, MD, Behavioral Healthcare blogger, who retired from the clinical practice of psychiatry, says treatment professionals are often faced with a difficult paradox. One of the best things to do to prevent violence is for a therapist to show patients that he or she cares for the patient and isn't just simply doing a job. However, that feeling of camaraderie can also make it more likely that behavioral healthcare specialists will downplay the risk of violence to themselves.
"The most important thing for mental health facilities is to accept that the risk is there," Moffic says. "So once you do that, at least your guard can be up and when you do that, then you do certain things to make the organization safer."
Every practice setting is different, but there are several universal strategies behavioral healthcare providers can employ to minimize risks and establish a safe environment for patients and staff. Experts caution that preventing potential violence should begin before a patient even enters the door.
For example, Moffic says, the best indicator of future behavior is often past behavior, so a glimpse into a patient's background to discover past violence can be one way to decide whether the patient is a fit for a given facility.
“If they are calling for an appointment, ask them respectfully,” he says. “But many times, the referral call comes from elsewhere, so ask that referral source, too. And if possible, review any records before actually accepting the patient. For a walk-in, do a careful screening, never alone, and in the safest area possible.”
Certain types of diagnoses, he says, might be more prone to violence such as paranoid schizophrenia, post-traumatic stress disorder, or narcissistic or sociopathic personality disorders.
"For patients with those conditions, you almost always have to be on alert, but the key there is whether they are following treatment or not," he says, adding that those who have stopped treatment are at a higher risk to become violent.
Another important aspect of violence prevention is assessing the population and the environment in order to establish policies and procedures that can help prevent violent attacks. For instance, Conaboy says organizations that consistently work with the corrections populations might be more at risk for violence than others.
"That group of people has a much higher propensity for overt violence than some of the other treatment populations, such as those in self-pay, private drug and alcohol treatment centers in Malibu," he says.
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