Patient code of conduct report provides insight on communicating and enforcing workplace violence policies

by Liz Boehm
Executive Strategist, Human-Centered Research

Workplace violence (WPV) in healthcare settings has escalated to untenable levels in recent years.1 According to a Press Ganey report released in April 2024, there has been 5% year-over-year increase in violence against nursing personnel – rising to an average of 1.89 incidents per hour.2 And in a 2022 American College of Emergency Physicians survey of 2,712 emergency physicians, 24% reported multiple physical assaults weekly, and 85% reported increased violence over the previous five years.3

The situation has become so problematic that in 2022 The Joint Commission issued new and revised standards for WPV prevention to help protect healthcare team members.4 In addition, health systems in various states have lobbied to pass legislation that criminalizes assault against healthcare team members,5 and the American Hospital Association has called for federal legislation to prevent WPV.6

One foundation of reducing WPV is setting, then communicating clear expectations for patients, visitors and employees about appropriate and acceptable behavior. It is important to outline fair consequences for behavioral violations and acting consistently to enforce standards. As WPV escalates, and as the definition of care team safety expands to include incidents of verbal assault, racism and other inappropriate conduct, clear patient codes of conduct are critical to setting shared expectations and communicating consequences.

Hospitals and health systems across the country have been updating their patient codes of conduct to reflect evolving understandings of "violent" behaviors. In late 2022, Mass General Brigham was the first health system to proactively publish and promote its updated patient code of conduct to all patients, stating that it would turn away patients exhibiting violent or offensive behavior.7 In 2023, the Massachusetts Hospital Association members issued its United Code of Conduct Principles to help create consistency across the state. Connecticut Hospital Association quickly followed suit.8

While patient codes of conduct are not new, we wanted to capture a broad view of how they are evolving, how they are perceived by health system leaders, and how, if at all, they affect team member safety and wellbeing. From fall 2023 through spring of 2024, the Heart of Safety Coalition fielded a survey asking healthcare professionals responsible for, or familiar with, their organization's patient code of conduct to share details about the contents, distribution, consequences and impact of their policies.

Our hope is that this report will help empower healthcare leaders to create, communicate and enforce patient codes of conduct that foster safe working and healing environments for team members, patients and visitors.

References

1. Lim MC, Jeffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures. Ann Med Surg (Lond). 2022 May 13;78:103727. doi:10.1016tj.amsu.2022.103727. PMCID: PMC9206999

2. Press Ganey. eBook: Safety in Healthcare 2024. https://info.pressganey.com/e-books-research/safety-2024  

3. Rotenstein LS, Brown R, Sinsky C. et al. The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19. J Gen Intern Med. 2023 Jun;38(8):1920-1927. https://pubmed.ncbi.nlm.nih.gov/36959522/ 

4. Arnetz JE. The Joint Commission's New and Revised Workplace Violence Prevention Standards for Hospitals: A Major Step Forward Toward Improved Quality and Safety. Jt Comm J Qual Patient Saf 2022
Apr;48(4):241-245. Epub 2022 Feb 5. doi:10.1016tj.jcjg:.2022.02.001. PMID: 35193809

5.Ninan RJ, Cohen IG, Adashi EY. State Approaches to Stopping Violence Against Health Care Workers. JAMA. 2024;331(10):825-826. doi:10.lO0ltjama.2024.1140

6. Fact Sheet: Health Care Workplace Violence and Intimidation, and the Need for a Federal Legislative Response. American Hospital Association, American Hospital Association. https://www.aha.org/fact-sheets/2022-06-07-fact-sheet-workplace-violence-and-intimidation-and-need-federal-legislative   

7. Muoio D. Mass General Brigham turning away offensive, violent patients under new 'Patient Code of Conduct'. Fierce Healthcare. Published November 8, 2022. https://www.fiercehealthcare.com/providers/mass-general-brigham-turning-away-offensive-violent-patients-under-new-patient-code 

8. Carbajal E. Connecticut Hospital Association adopts Patient Code of Conduct. Becker's Hospital Review. Published October 23, 2022. https://www.beckershospitalreview.com/hospital-physician-relationships/connecticut-hospital-association-adopts-patient-code-of-conduct.html 

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