CNOs Tap Into Nurse-Led Tech to Combat Workplace Violence

Violence is on the rise, but so is technology that can turn the tide, as long as those on the frontlines lead the way. 

It’s a sobering reality across healthcare: Workplace violence is on the rise.

And nurses, who are at the heart of care, are at especially high risk. In a 2022 National Nurses United survey, nearly half of hospital-based respondents reported an increase in workplace violence, a 57% increase from the rate reported in their previous survey in late 2021.

“The examples, what people describe—years ago, you would never have heard of these kinds of incidents,” says Bonnie Clipper, DNP, MA, MBA, RN, CENP, FACHE, FAAN, founder and CEO of Innovation Advantage, a healthcare innovation consultancy specializing in virtual nursing care delivery models. She recalls being in a hospital earlier this month when a patient who had just given birth punched a nurse following a communication breakdown over discharge plans.

It's an alarming escalation of a longstanding issue.

“Healthcare in general is an emotionally intense kind of field,” says Sharon Pappas, PhD, RN, NEA-BC, FAAN, chief nurse executive at Emory Healthcare in Atlanta, who co-chaired the American Organization for Nursing Leadership committee on evidence-based approaches to combatting workplace violence in 2014. “So even prior to the pandemic, it was something that of course we were concerned about.”

The pandemic brought with it a host of new challenges, like visitation restrictions that ratcheted up stress during an already fraught time.

“It predisposed us to more emotional reactions by family members, and maybe even patients themselves, because they were among strangers,” Pappas explains.

Beyond rising violence, nurses’ workplace expectations are evolving. Younger nurses tend to be “less tolerant of bad behavior,” Clipper says.

“I don’t think they’re wrong," she says. "We have to figure out how to make it comfortable and safe for everyone. Being a healthcare professional doesn’t mean we have to tolerate violence.”

That figuring out needs to happen fast—and at scale—to avoid sweeping loss.

“If we don't protect healthcare professionals, our numbers, turnover, is only going to accelerate,” Clipper says.

Nursing-Focused Tech Can Help

Two-thirds of U.S. chief nursing officers are already interested in, researching, or deploying a virtual nursing care model, Clipper says. And the involved solutions provide strong bones for safety strategy. For example, patient rooms wired with cameras, speakers, microphones, and more offer extra eyes and ears attuned to threats.

“We're on the precipice, and we’re starting to use some of those things to help us,” Clipper says.

And yet, the current crisis calls for even swifter uptake.

“We really have to have more of a sense of urgency in adopting these technology solutions that are going to help us not only provide better patient care, but also protect our caregivers more,” she says.

Beyond just-in-time tools like wired rooms and badge alert buttons, technologies with emerging safety applications run the gamut in terms of size, complexity, and point of intervention. AI solutions, while still baking, show potential for predicting and preempting behavioral risks, while virtual reality can make de-escalation training more resonant. Seamless incident reporting, meanwhile, can incentivize uptake and produce more insights to shape prevention strategies.  

But before beelining to the latest innovation, consider the broader strategic context to avoid doing more harm than good, nurse executives and experts advise.

Some considerations Clipper addresses with her virtual nursing clients include:

• What’s the real, underlying problem that needs to be solved?
• What’s the model going to look like in the organization?
• What are the specific use cases?
• How are nurses being brought in to help identify solutions?

Then, design with humans in mind. That means tapping diverse disciplines—security who respond to threats, AI and data experts who can explore predictive applications, and, of course, nurses who are at the fore, Clipper says.

“They're the ones that have to be involved to say, ‘Hey, here was the trigger of this event,’ or ‘there was no warning whatsoever, and here’s what happened,.’” she says. And on the other end of the spectrum, they can share ideas for “proactively identifying precipitating events to predict and thus avoid violence in the first place."

Pappas agrees with the importance of an interdisciplinary approach.

Emory convened a group to probe workplace safety performance and implement structures to facilitate daily discussion on incidents and improvement opportunities.

“That's how you learn, and that’s how you get better and get safer,” Pappas says.

The health system named two co-chairs, a chief nurse and an operations leader, who in turn recruited a behavioral health expert to help guide the effort.

The diverse representation was intentional.

“This isn’t something that you do top down,” Pappas says. “We wanted to get people as connected and oriented toward the first line of workers as we possibly could.”

It’s working. The two inaugural co-chairs are still at the helm today, and Emory’s foresight to form the group “prepared us very well for the increase in some of those workplace safety issues that occurred during and following the pandemic,” Pappas says.

Keep An Eye On AI

With sound safety strategies and decision-making frameworks in place, nurse executives can explore specific technology applications.

Using AI during the intake process, for example, could help identify factors like diseases, conditions, substance use disorder or withdrawl, traumatic events, and family dynamics that could make patients more prone to violence, Clipper says.

It could also preempt fallible decision-making in charged situations, she says, like when the person being violent is a patient who needs care, and their behavior is the result of an underlying condition.

“If we have ways to identify, predict, and prevent, that's way easier for us to deal with than the more subjective, moral, and value-based conversations that nurses struggle with such as 'Do you press charges?' or 'Do you issue a criminal trespass warrant?'” she adds.

Of course, there are risks in relying on hyped, fast-evolving technology for weighty predictions.

“We don't want to bake in bias into our algorithms or into our predictive systems that might inaccurately identify someone that may potentially be at higher risk to behave poorly,” Clipper says. “We have to make sure that we're building these systems in a way that’s equitable."

Make Training Safe (And Sticky)

Technology can also enhance training on how to recognize and respond to violence. VR, for example, can produce realistic, scalable simulations for high-stakes skills like de-escalation and crisis prevention, Clipper says.

Plus, she adds, “the beauty of VR is that’s a failure-safe environment.”

Earlier this year, UT Southwestern Medical Center and UT Dallas designed a VR training tool that places clinicians inside a virtual hospital exam room and presents a series of realistic patient encounters so they can practice proven de-escalation tactics in a real-feeling environment, complete with a headset, vest, and gloves that mimic the sensation of being touched (or hit).

Given this capability, VR is a useful—and increasingly popular—tool for improving problem solving and “muscle memory,” Clipper says.

“When you go through those scenarios, you get to test over and over again what you should do, what you should say, how that works,” she says.

Technology can also make training more accessible and consumable in the course of a busy day.

“It's important that we look at training and newer ways that are more bite-sized as opposed to a three-day class,” Pappas says. “Technology can help with that by [creating] little vignettes, something you can access on your cellphone.”

Meet the Moment

With virtual nursing on the rise, many CNOs already have tools in place or in the works that they can weave into their safety strategy.

Such solutions range from simple, Clipper explains, such as a tablet that allows a virtual nurse to admit, discharge, or educate a patient, to sweeping: a room wired with cameras, speakers, microphones, and even sensor-enabled ambient computer vision and sound.

In the high-tech setups, the devices can act as an occasional or ongoing “extra set of eyes and ears observing what's going on or listening for things that might trigger someone’s interest,” she says.

One organization on Clipper’s radar has developed a safe phrase, “something along the lines of ‘there’s birthday cake in the breakroom,’” that “perks up” the virtual nursing system and prompts “no questions asked” action like a security visit.

It can “expedite that time it typically takes to get someone into the room to further investigate and check it out,” she explains.

Create a Strong Reporting Culture

Emory has found great success, Pappas says, using tech to improve ease of incident reporting so “you have information that you can use to understand it better and actually start to devise strategies to make the workplace safer.”

They’ve integrated reporting with their EHR to automate as much of the process as possible.

“If you can make reporting really easy, people are more prone to do it,” she explains.

As a result, Emory has seen tremendous, across-the-board improvement in levels of reporting thanks to their targeted interventions.

“We were able to detect, by operating unit, that we were having increases at just about every site in the amount of reporting that they do,” Pappas says.

It’s additional information they use daily to make the workplace better, which in turn fuels more reporting, she explains.

“The positive feedback system has helped us to continue to increase reporting and to improve safety,” she says.

To synthesize and act on findings, Emory has implemented a five-tiered huddle system, which runs from the frontlines all the way to operating unit leadership. Every day, the top tier comes together to share what they’ve learned from their own tiered huddles.

“It’s made people say, ‘Wow, if we report it, that means that people are going to talk about it, and I get a chance to improve this,’” Pappas says.

Know That Tech Alone Can’t Save You

An “aha moment” in Emory’s stepped-up reporting came from an unexpected setting: ambulatory clinics.

“The stakes aren’t quite as high [because] the patients aren't quite as sick,” Pappas explains.

And yet, their reporting revealed that some patients experiencing long wait times “would exhibit behaviors that threaten the staff,” she says. “It just was a real surprise to us.”

So they tapped their strong professional governance network, clinical nurses and other caregivers who come together on a regular basis to review competencies and patient outcomes, to review the safety reporting and help devise a response. Following these time-tested decision-making and discussion frameworks produced “some of our best interventions.”

Those interventions included targeted de-escalation training for staff in areas where patients had been demonstrating aggressive behaviors and lots of “very good discussions” about applying low- and high-tech solutions strategically, especially in high-risk areas like the emergency department.

Based on group deliberation, Pappas says, Emory installed metal detectors at certain—but not all—key entrances. They also explored the idea of placing alert buttons on badges but decided to instead voice needs and check on each other rather than introducing and keeping track of another new gadget.

“The key there is just involving the people that it impacts and getting the best direction from them about how to use devices and systems to improve safety,” Pappas says.

It's a testament to technology’s ability to augment but not replace human ingenuity and camaraderie. Safety is “everyone's job,” Pappas says. That means success comes from a shared responsibility and commitment to “take care of each other.”