Growing the Health Revenue Cycle by Decreasing Workplace Violence

Florence Nightingale once said, “Ignite the mind’s spark to rise the sun in you” (Hawes, 2023). This course seeks to do just that by presenting advanced concepts in healthcare administration that can help aspiring healthcare personnel grow in their expertise.

The most significant element affecting the Healthcare Revenue Cycle (HRC) in recent years has been the COVID-19 pandemic (Manolis et al., 2021). Additionally, managers and aspiring clinical personnel in the community have raised concerns regarding substance abuse, mental health, stress, trauma, and other Workplace Violence (WVP) factors that contribute to adverse incidents (Chen et al., 2022; Doran et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Elman et al., 2020; Farooqi et al. 2022; Foxworth et al., 2021; Gee et al., 2022; Hagerty & Williams, 2022; Hill et al., 2021; Kone et al., 2022; Manolis et al., 2021; Thienprayoon et al., 2022; Ward et al., 2022; Wilensky, 2022). In the current healthcare climate, adverse conditions resulting from surviving the COVID-19 pandemic are prevalent in the United States of America (USA) and beyond. Studies note some of the harmful effects of being exposed to this kind of stress, trauma, mental health concerns, substance abuse, WPV, loss of appetite, ulcers, mental disorders, migraines, difficulty in sleeping, emotional instability, disruption of social and family life, and the increased use of cigarettes, alcohol, and drugs. Understanding stress in the healthcare workplace could prevent a harmful, dangerous, or violent situation from erupting.

This course presents the ongoing effects of the global pandemic on the healthcare system and administration, the scope of those effects, and recommendations to mitigate the risk of WPV in an attempt to remedy the healthcare revenue cycle. Concepts in healthcare administration and the healthcare revenue cycle can help aspiring healthcare personnel grow in their expertise.

Addressing stress, trauma, mental health issues, substance abuse issues, and WPV in the frontline workforce improves the healthcare revenue cycle (HRC). Research demonstrates that the COVID-19 pandemic was a significant factor for stress, mental health concerns, substance abuse difficulties, WPV, and workplace burnout (Chen et al., 2022; Doran et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Elman et al., 2020; Farooqi et al. 2022; Foxworth et al., 2021; Gee et al., 2022; Hagerty & Williams, 2022; Hill et al., 2021; Kone et al., 2022; Manolis et al., 2021; Thienprayoon et al., 2022; Ward et al., 2022; Wilensky, 2022). The physical, psychological, psychiatric, and neurotrauma associated with the COVID-19 infection itself, has been associated with an increased risk of adverse events between patients and other individuals, such as personnel (Chen et al., 2022; Doran et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Elman et al., 2020; Farooqi et al. 2022; Foxworth et al., 2021; Gee et al., 2022; Hagerty & Williams, 2022; Hill et al., 2021; Kone et al., 2022; Manolis et al., 2021; Thienprayoon et al., 2022; Ward et al., 2022; Wilensky, 2022). Patients with COVID-19, which “causes confusion and impaired judgment, are more likely to become violent than a patient with normal mentation. Neurologic conditions, seizures, hypoglycemia, or dementia may cause confusion and impaired judgment. Watch for signals associated with impending violence (Wilensky, 2022)." Research also notes that in recent decades, jobs in healthcare “...served as an important stabilizing force to the economy… with employment in health care continuing to grow during that time, although at a slower pace than before the economic downturn…the forces in play during the COVID-19 pandemic–driven slowdown and recession have affected the demand for health care and, consequently, the willingness of hospitals, health care systems, and clinician group practices to continue employing health care workers at pre-pandemic levels (Wilensky, 2022).” It is important to note that, although some issues with the HRC existed before COVID-19, the HRC essentially fell apart as the stress put upon the frontline community began to propagate through the industry (Wilensky, 2022).

The factors related to COVID-19 and the efficiency of the HRC are (Wilensky, 2022):

1. The effect of job loss in health care has not been distributed equally by area or sex
   1. By March 2021, men had mostly recovered from their job loss
   2. This was not true for women, particularly those working in nursing and residential care facilities
2. Even among healthcare workers who kept their jobs, 31% have said they have considered leaving, and 19% have said they have thought about leaving the healthcare field completely
   1. Many have cited burnout and poor pay relative to working conditions as the primary reasons for considering leaving their jobs or the entire healthcare field
3. At least some of the individuals who have left health care specifically or the labor force entirely may have done so temporarily to reconsider their work expectations or professional experiences, and they may reenter the healthcare workforce at some future point
4. Models of care that have been dominant in the past will likely give way to new approaches to providing health care that come with unique workforce needs

The HRC is affected by the ongoing issues of stress, mental health issues, substance abuse, trauma, and WPV through the loss of frontline workers, increased absences due to injury or disease, and the financial burden of providing risk mitigation steps.

For example, one significant action that can be taken from this course and implemented in your everyday practice is establishing recruiting and mitigation programs that help female practitioners in nursing and residential care facilities to be able to recover from the COVID-19 pandemic and return to the workforce (Wilensky, 2022). Increasing WPV following the COVID-19 pandemic is particularly concerning and can devastate a healthcare entity’s HRC (Wilensky, 2022).

Ward et al. (2022) sought to characterize the experience of harassment and threats against public health officials as a manifestation of WPV incidence rates during the COVID-19 pandemic. Media content and a national survey of USA local health departments (LHDs) from March 2020 to January 2021 were utilized to compare media-portrayed experiences, survey-reported experiences, and publicly reported position departures.

The main findings demonstrate:

1. In healthcare settings, such as emergency departments, nonphysical WPV perpetrated by patients has been associated with reduced job satisfaction and burnout
2. Among public health officials who resigned during the pandemic, many indicated that their expertise had been marginalized and disregarded
   1. They identified multiple public health issues as co-occurring with the pandemic, including extreme weather events, an influx of vaping-related injuries, and calls to action on long-standing social inequities
3. All these emergent issues demanded public health expertise, yet public health officials believed their responses to these needs were underappreciated, criticized in personal attacks, and further constrained by forces beyond their control
4. Across media accounts, public health officials described grappling with colliding identities as neighbors, parents, healthcare providers, and protectors
   1. They described confusion and frustration with their sudden shift from being a trusted friend and public servant to being the face of an imperfect response or the leader of an attack on personal liberties
   2. Some described the conflict between the aspiration of their mission and the reality of their limited capacities
   3. They described overwhelming professional demands, inadequate infrastructure, and fatigue alongside worry for their families and grief for their losses
5. The authors (Ward et al., 2022) recommend training leaders to respond to political conflict, improving colleague support networks, providing trauma-informed worker support, investing in long-term public health staffing and infrastructure, and establishing WPV reporting systems and legal protections

Patients who have experienced significant mental health concerns, psychiatric and neurological trauma, and extreme situations are at an increased risk for an adverse event. These risk factors can have deleterious effects on the HRC (Wilensky, 2022). Since 2020, these effects have devastated many healthcare entities and departments. Winchester & Winchester (2016) presented research that directly linked the impact of neurotrauma, psychiatric dysfunction, and other encephalitic effects on patients in primary, secondary, rehabilitation, and long-term care (LTC) communities. In contrast, Manolis et al., 2021 demonstrate that the COVID-19 virus produces several neurological and neuropsychiatric problems. These neurological and neuropsychiatric manifestations can include “olfactory and gustatory impairments, encephalopathy and delirium, stroke and neuromuscular complications, stress reactions, and psychoses… moreover, the psychosocial impact of the pandemic and its indirect effects on neuropsychiatric health in noninfected individuals in the general public and among health care workers are similarly far-ranging (Manolis et al., 2021).” 

Overall, the immune response to COVID-19 affects neurological and psychiatric function. The virus can deteriorate neuronal tissue, and the encephalopathy associated with this class of viruses has been known for decades (Manolis et al., 2021). A large meta-analysis of 72 studies comprising 3,559 patients with suspected or confirmed SARS coronavirus, Middle East respiratory syndrome (MERS) coronavirus, or SARS-CoV-2, indicated that during the acute illness, common neuropsychiatric symptoms included confusion, depressed mood, anxiety, impaired memory, and insomnia (Manolis et al., 2021). Moreover, results indicated that there was a high rate of delirium, particularly in intensive care unit (ICU) patients (65%−69%)... olfactory (35.7%−85.6%) and gustatory (33.3%−88.8%) disorders, especially in mild cases; Guillain-Barré syndrome (GBS) and acute inflammation of the brain, spinal cord, and meninges (Manolis et al., 2021).” Researchers also note a prevalence of (Manolis et al., 2021): 

1. Depression
2. Anxiety
3. Sleeping disturbances
4. Stroke
5. Ischemic stroke
6. Intracerebral hemorrhage
7. CNS vasculitis
8. Unspecified encephalopathy
9. Encephalitis
10. Both neurological and neuropsychiatric health are affected by SARS-CoV-2 infection

One of the most harmful components of the clash between COVID-19 and the HRC has been the impact on patient capture and employee retention. This is a complex relationship affecting both the patient side of the HRC and the provider side (Chen et al., 2022; Doran et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Elman et al., 2020; Farooqi et al. 2022; Foxworth et al., 2021; Gee et al., 2022; Hagerty & Williams, 2022; Hill et al., 2021; Kone et al., 2022; Manolis et al., 2021; Thienprayoon et al., 2022; Ward et al., 2022; Wilensky, 2022).

Data shows that “The COVID-19 pandemic has also had a significant impact on the mental health of many individuals in the general population as a result of loss of loved ones, fear of calamity or death, financial hardships, social isolation resulting from government-mandated quarantine and social distancing requirements, and major disruptions of daily life and social connectedness (Manolis et al., 2021).” Additionally, health professionals have experienced higher levels of adverse psychological effects of the COVID-19 pandemic, with emotional trauma associated with the provision of care in conditions analogous to combat experiences, sometimes exceeding psychological tolerances and the capacity for adapting or coping (Manolis et al., 2021).”

OSHA-focused and related healthcare administrative materials have discussed the pre-pandemic rates of healthcare workforce burnout and provided some tips for mitigating that risk. Disaster response and the detrimental effects of the repeated surges of critically ill patients have been examined extensively, concluding that those experiences drove clinicians to experience an extended period of disillusionment (Gee et al., 2022). This includes secondary traumatic stress, cumulative grief, and moral distress. Below, a summary of this time series is presented in list form (Gee et al. 2022):

1. Pre-disaster
   1. Warning and threats
   2. Decreased emotional states
2. Impact
3. Heroic Phase
   1. Actions and work duties
   2. Increased emotional states, particularly solidarity and empowerment
   3. Increased community cohesion
4. Begin to take inventory of the crisis
5. Disillusionment Phase
   1. Triggering events: Since 2020, the “triggering events” have been COVID-19-specific events
   2. Emotional lows for frontline workers
6. Reconstruction and A New Beginning
   1. Anniversaries of the crisis (e.g., one year)
   2. Reactions to the Crisis
   3. Working through the grief stages
   4. Setbacks
   5. Increased emotional states, particularly empowerment

Data shows that current frontline workers and healthcare staff are in an “extended Disillusionment Phase” and hope to advance to a place where the community can begin “Reconstruction” and “A New Beginning” (Gee et al., 2022). Healthcare workforce burnout can have devastating consequences.

Furthermore, there is an increased risk for Post-Traumatic Stress Disorders (PTSD)  among frontline and healthcare workers following exposure to hazardous and life-threatening situations while treating patients suffering from COVID-19 (D’Alessandro et al., 2021; Manolis et al., 2021; Ward et al., 2022; Wilensky, 2022).

As the clinical community attempts to rebalance the HRC of USA Federal, State, Military, and Tribal health systems, honesty about the functional health state of the USA and the frontline workforce is essential to success. Early reports suggest that the pandemic conditions have created experiences of moral incongruence, wherein the lived experiences of healthcare workers go against their values or morals(Hagerty & Williams, 2022). Specifically, individuals have reported:

1. The combination of the high volume of COVID-19 patients needing acute care and the relative lack of adequate resources to treat these patients have created scenarios in which healthcare workers have been forced to decide which patients should receive critical care at the expense of other patients with equal levels of need
2. Data indicate that some workers felt they were required to decide who lives and who dies, which is an experience that has been associated with moral injury 

Research suggests that moral injury comprises three factors (Hagerty & Williams, 2022):

1. Transgressions–self (e.g., killing an innocent civilian in the line of duty)
2. Transgressions–others (e.g., witnessing acts of disproportionate violence)
3. Betrayal (e.g., an officer or fellow service member deciding on a situation that results in unsafe conditions or loss of life)

Among the three factors of moral injury that many frontline workers have felt during COVID-19, studies note that both “betrayal” and “transgressions–others” involve actions of others, but “betrayal” is differentiated in that it consists of a violation of trust by institutions or people that a person depends on for survival (Hagerty & Williams, 2022). In the HRC, if the healthcare and frontline personnel feel significant moral injury during or after their duties, this would directly affect the “Performance” and “Risk Mitigation” components. Understanding the literature, specific action plans and mitigation protocols can be implemented to improve the HRC.

Moral injury is a complex construct, and capturing the nuances of moral injury is important for understanding the possible psychological consequences of morally incongruent experiences(Hagerty & Williams, 2022). “Dehumanization is a driving force behind the psychological injury resulting from moral incongruence in the context of the pandemic. The pandemic most frequently threatened basic human motivations at the foundational level of safety and security relative to other higher-order needs (Hagerty & Williams, 2022).” Restoring safety begins with empowerment and moving beyond disillusionment. To accomplish this, the healthcare, public health, and frontline workforce must start taking back the power they feel was stolen from them by the ongoing pandemic (Gee et al., 2022; Hagerty & Williams, 2022; Manolis et al., 2021; Ward et al., 2022; Wilensky, 2022). This can be accomplished by establishing setting-specific, population-specific, and culturally relevant materials that can become action points in their everyday setting.

It is important to understand key concepts related to the Military Health System (MHS) of the USA as it directly relates to mitigating the effects of stress, mental health issues, substance abuse, PTSD, and WPV since the onset of the COVID-19 pandemic:

1. USA-based settings that are private, for-profit, investor-owned, or network-owned have unique considerations that a Charge Nurse, Rehabilitation Manager, or other administrative clinicians may need to consider
2. The MHS has an additional task that other settings do not in that they must maintain a certain level of “medical readiness” for the USA’s most patriotic citizens
3. Labeled the Walker Dip, combat casualty care competency increases over the duration of the conflict and decreases during interwar periods
4. The 2017 National Defense Authorization Act centralized health care administration to the Defense Health Agency
   1. The Defense Health Agency has recognized the readiness imperative and need for the expansion of trauma and emergency medical and surgical capabilities
   2. The need for requirements unique to the military highlights the importance of maintaining training programs in the MTFs as opposed to civilian institutions
   3. In addition, training must include all members of the uniformed health care team because the differences in the scope of practice of licensed and non-licensed providers have limited skills maintenance in the civilian sector
5. In the USA, state-based military personnel are known as the National Guard
   1. Each state supplies its funding, and each National Guard is a separate Army militia based in each state of the Union
6. The Army National Guard was established early in the history of the USA
   1. The oldest Army National Guard units are the 101st Engineer Battalion, the 101st Field Artillery Regiment, the 181st Infantry Regiment, and the 182nd Infantry Regiment, all of the Massachusetts Army National Guard
   2. These four units are the descendants of the original three militia regiments organized by colonial Massachusetts legislation on December 13, 1636, and share the distinction of being the oldest units in the U.S. military
7. There are some important points to note when contracting or working as active-duty personnel in an MHS facility
   1. In many cases, females and female dependents of active-duty service members pay out of pocket or additional costs for contraceptive access or reproductive services
   2. The emphasis on women’s health in MHS has been lacking and is a major area where civilian contractors can provide additional education and remedy to an underserved population 

Research into MHS personnel documented clinical outcomes, functional burden, and complications just one month into the pandemic at 9 MHS sites across the USA (Richard et al., 2021). In the first month post-symptom onset, there were 212 hospitalizations, 80% requiring oxygen, 20 ICU admissions, and 10 deaths (Richard et al., 2021). Hospitalizations based on race, age, and weight were also noted. There were found to be increased hospitalizations of Asians, Blacks, and Hispanics compared to non-Hispanic whites. Increased hospitalization rates also occurred in age ranges of 45 to 64 and those over 65, as well as people with BMI>30. 2% of respondents reported needing supplemental oxygen, and 30% had not returned to normal daily activities one month after symptoms onset (Richard et al., 2021). Overall, studies conclude that the MHS is at an increased risk of burnout, moral injury, moral distress, moral incongruence, and exposure to the myriad of factors contributing to WPV incidents on the frontline of the COVID-19 response (Chen et al., 2022; De Boer et al. 2021; Farooqi et al. 2022; Gee et al., 2022; Lara-Reyna et al., 2020; Williams, 2022; Manolis et al., 2021; Richard et al., 2021; Ward et al., 2022; Wilensky, 2022).

Including MHS-related material is important because MHS staff must maintain a certain level of medical readiness. Further, studies note the risk factors for suicide or other deleterious consequences that can occur from stress, workplace dissatisfaction, moral injury, moral distress, moral incongruence, and other PTSD-related factors among MHS staff are similar to those found in other frontline workers.

The risk for issues related to mental health, substance abuse, stress, and anxiety increases further when evaluating the veteran population of the USA. Doran et al. (2022) showed that the odds of death by suicide did not change during the first year of the COVID-19 pandemic, while the odds of making a suicide attempt declined. The data from Doran et al. (2022) was mixed and showed that overall, the risk of suicide during the initial phase of the pandemic did not increase from the already alarming rates. However, when the data was stratified, data did show that more isolated Veterans during the pandemic period evaluated had an increased risk of suicide (Doran et al., 2022).

Additional MHS personnel were recently allocated to many private and Tribal health systems (U.S. Army North, 2022). The Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services (DHHS) have worked with MHS to deploy approximately 220 military medical personnel in ten teams to eight states and the Navajo Nation (U.S. Army North, 2022).

The Army has stated, “As our support to FEMA and the whole-of-government response to the pandemic expands due to a surge in hospitalizations, we are committed to working alongside our civilian medical partners to assist hard-hit states and communities in need… Whether military or civilian, we are in this fight together” (U.S. Army North, 2022). In 2022 and 2023, the MHS deployed “...a 20-person team from the U.S. Army will support Henry Ford Wyandotte Hospital in Wyandotte...This team joins four other teams in Dearborn, Grand Rapids, Saginaw, and Muskegon...The military medical personnel includes nurses, respiratory therapists, and medical doctors…U.S. Army North, under U.S. Northern Command’s oversight, provides an operational command of the teams  (U.S. Army North, 2022).”

An adult male patient, Tommy, presents to a medical facility that provides care to private citizens, military personnel through the MHS, and federally recognized citizens of the local Ojibway, Ottawa, and Potawatomi Tribal Nations through HIS partnerships. Tommy was admitted for breathing complications secondary to smoking-related lung damage and secondary injuries incident to COVID-19 illness. Tommy had been admitted three weeks prior, at which time he was diagnosed with COVID-19. The pertinent past medical history of this patient includes a diagnosis of lumbar hemiplegia with reduced mobility sustained in a traumatic injury five years ago. Since this traumatic injury, he has required the use of assistive devices for ambulation. He is a federally recognized Tribal member with private insurance through his remote computer software job.

Since being admitted, Tommy has received immunological interventions and has been assessed for Respiratory Therapy (RT), Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) to treat the incidental COVID-19-related impairments in conjunction with the ongoing comorbid diagnoses per medical necessity.

To improve Tommy’s low morale, the interdisciplinary team approved occasional computer work in an upright and seated position, using assistive devices. It is intended to improve Tommy’s quality of life while battling the infection. To facilitate this accommodation, the inpatient personnel must assist Tommy into a seated position and then provide oxygen support. This ambulatory accommodation has happened once or twice per week. It has been ongoing since his admission, but it is anticipated that he is close to being discharged following improvements to his sustained blood-oxygenation levels and improved ambulatory capacity. Typically, Tommy received RT and PT in the morning and was provided his lunch upright and seated. Then, he proceeded to work on his laptop in that seated position.

One day, during his transfer from a seated position back into his bed into a reclining position, Tommy became agitated and started violently yelling at the nurse practitioner. Tommy was agitated, isolated, and anxious and could not provide the calm demeanor that may have mitigated the risk in this situation. The incident resulted in a WPV report. At the same time, the patient’s Tribal Elder (a grandfather) had entered the room to assist Tommy but escalated the incident. This resulted in minor injuries to Tommy, the Elder, and the MHS Nurse Practitioner involved in the transfer.

It was ultimately determined that Tommy did not receive a complete set of nutritional values at lunchtime, resulting in decreased electrolyte balances that increased his fall risk. Delays in the coordination of the PT and RT following the morning’s therapy evaluations caused this patient to have an unusually low blood-oxygenation level and other orthostatic-related issues during the ambulation from the reclining position to the seated position.

This facility contracted with local SLPs, OTs, and PTs to provide services supported under consolidated billing practices. The healthcare setting also provided continuous onsite RT, nursing, and other emergency and primary care services during the COVID-19 pandemic, sustaining its HRC. Before the incident, significant personnel burnout, widespread infection, ongoing personnel shortages, supply shortages, and longer wait times resulted in a set of factors contributing to burnout. The issues with the nursing staff, the coordination of PT and RT, and the increased confusion and electrolyte loss contributed to a maladaptive event involving a physical and vocal altercation between the patient and the staff. The nurse practitioner was directly involved in transferring the patient and administering medical interventions; then, while providing service and accommodations, the patient suffered minor injuries that necessitated treatment. The Nurse Practitioner is also clinically privileged in the MHS at this facility, further complicating administrative staff's reporting and risk management procedures.

Table 1 illustrates the risk associated with this case and demonstrates a vital tool in risk management that many Administrators utilize.

Table 1. Risk Assessment for Case Study 1 

Green = Compliant; Yellow = Low Threat; Orange = Mild Threat; Red = Negligent; Black = Absent

In 2020, the MHS and the Department of Defense (DoD) reaffirmed their positions on military workplace violence prevention (U.S. Department of Defense, 2020). “This instruction establishes DoD policy and assigns responsibilities for workplace violence prevention and response policy regarding DoD civilian personnel by the authority in DoD Directive 5124.02 and Secretary of Defense Memorandum... This instruction applies to OSD, the Military Departments, the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the Department of Defense, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD (referred to collectively in this instruction as the “DoD Components”)... It is DoD policy that: (a) DoD Components work with employees to maintain a work environment free from violence, threats of violence, harassment, intimidation, and other disruptive behavior; (b) All employees are responsible for promoting a safe work environment,” (DoD, 2014).

Further, “Operational readiness is critical to maintaining our warfighting capability. Disruptive or malicious behavior can interfere with the mission and must be recognized and dealt with expeditiously…Violent incidents in the workplace are relatively rare; however, they do occur and may cause injury or death. Often, when these unfortunate incidents occur, management initially focuses on continuity of operations; however, preparing for and mitigating the impact these incidents have on our workforce is equally important (Hogue, 2022).”

Related to the case study presented, a savvy Healthcare Administrator will communicate with the MHS oversight channels to ensure the adequate remedy and training of the MHS Nurse Practitioner involved in the incident (Hogue, 2022; DoD, 2023). This step may affect the payment and reimbursement of costs related to treating the minor injuries suffered by the nurse practitioner during the incident, and additional communication may be required to ensure proper accounting and HRC documentation with the facility’s accounting staff.

Reporting procedures are similar for MHS staff and privately clinically privileged staff at the fictional healthcare entity in case study 1. Specifically, “These procedures provide basic parameters for establishing and promoting workplace violence prevention programs within DoD and properly investigating and addressing events” (DoD, 2014):

1. All supervisors must immediately report threats of workplace violence to their management and appropriate military or civilian authorities as determined by local threat reporting protocol
2. Appropriate authorities may include security or safety organizations, employee assistance programs (EAPs), or others as determined locally
3. Information regarding an incident or threat of workplace violence, including but not limited to names of involved parties, witnesses, reports and investigations of allegations, and findings of workplace violence, will be treated by applicable laws and regulations
   1. Statements and reports may be used as evidence in administrative, civil, and criminal proceedings

The following lists the appropriate locations for reporting adverse incidents for MHS and VA personnel in civilian and military locations:

1. Workplace Violence Prevention and Operations Security, which are both available in Total Workforce Management System (TWMS; U.S. Navy TWMS, 2023)
2. DoD Office of Inspector General Hotline (DoD, 2023)
3. Prevention Plan of Action 2.0, 2022-2024 (Defense Equal Opportunity Management Institute, 2023)
4. DoD Instruction 1020.03 w/Chg 2 - Harassment Prevention and Response in the Armed Forces (Defense Equal Opportunity Management Institute, 2023)
5. DoD Instruction 6400.11 - DoD Integrated Primary Prevention Policy for Prevention Workforce and Leaders (Defense Equal Opportunity Management Institute, 2023)
6. DoD Directive 7050.06 w/ Change 1 - Military Whistleblower Protection (Defense Equal Opportunity Management Institute, 2023)
7. VA Disruptive Behavior Guidebook (Veterans Affairs, 2021)
   1. Workplace Violence Prevention Program (WVPP)
   2. Office of Mental Health and Suicide Prevention (11MHSP)
   3. US Veterans Health Administration (VHA)

Once risk mitigation steps are implemented, the literature demonstrates that there is a phase of “Reconstruction” and “A New Beginning” that can be expected (Gee et al., 2022). Data suggest that there can be post-traumatic growth (PTG) in the community (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Doran et al., 2022; Elman et al., 2020; Farooqi et al. 2022; Gee et al., 2022; Lara-Reyna et al., 2020; McGuire et al., 2021; Williams, 2022; Manolis et al., 2021; Richard et al., 2021; Ruggeri et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Wood et al., 2022).

A previously discussed literature demonstrates the widespread knowledge of Moral Incongruence, Moral Distress, Moral Injury, Stress, and PTSD-related factors that frontline healthcare workers must endure in the ongoing COVID-19 pandemic (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Doran et al., 2022; Elman et al., 2020; Farooqi et al. 2022; Gee et al., 2022; Hagerty & Williams, 2022; Lara-Reyna, 2020; McGuire et al., 2021; Williams, 2022; Manolis et al., 2021; Richard et al., 2021; Ruggeri et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Wood et al., 2022). However, very little research has focused on treating COVID-19-related moral injury in healthcare workers (D’Alessandro et al., 2021). In the case study described, the MHS and nursing staff may have experienced moral incongruence and moral injury due to the clash of patient rights with providing quality care. Conclusions from D’Alessandro et al. (2021) provide new lessons and similarly define Moral Injury to that found by Hagerty & Williams (2022). Moral injury is a psychological response that may arise when one transgresses, witnesses another transgress deeply held moral values, or feels that an individual or institution that must provide care has failed to do so (D’Alessandro et al., 2021).

Tribal health systems have discussed every consideration so far, as well as the additional burden of requiring culturally specific care to be provided. Without those considerations, WPV and other adverse events can arise. In the presence of an ongoing COVID-19 pandemic that has decimated Tribal health systems, the burden to implement effective change grows (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Doran et al., 2022; Elman et al., 2020; Farooqi et al. 2022; Gee et al., 2022; Lara-Rayna et al., 2020; McGuire et al., 2021; Williams, 2022; Manolis et al., 2021; Richard et al., 2021; Ruggeri et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Wood et al., 2022). “New and original data to examine both partisan and systemic inequities that have fueled the spread of COVID-19 in Native America… Native nations have experienced disproportionate effects from prior health epidemics and pandemics, and in 2020, Native communities have seen greater rates of infection, hospitalization, and death from COVID-19 (Foxworth et al., 2021).” Additionally, Foxworth et al. (2021) introduce specific policy guidelines that are vital to growth in Tribal health systems of the USA:

1. Reducing funding restrictions
   1. The current distribution of funds to Native nations is often restricted to specific programs, narrow categories, and specific timeframes for spending
   2. Native nations need unrestricted funds to manage distribution and spending according to their community and population needs
      1. For example, time restrictions on federal CARES funding for Native nations may make the spending of federal dollars difficult because of their remote locations, lack of current administrative capabilities, and general shortages of supplies throughout the country
2. Provide Broadband Internet Access and Services
   1. An estimated 35% of individuals living on tribal lands are without broadband services
   2. The lack of services further exacerbates the education and health gap, prohibits access to telehealth, and obstructs the acquisition of basic information on the COVID-19 pandemic
   3. Prioritize PPE and other life-saving equipment for Tribal Nations
      1. Limited funding for Indian Health Services (IHS) by the U.S. government has endangered Native peoples
      2. During the early days of the pandemic, IHS reported having a limited number of ICU beds and reported having only eighty-one ventilators across the country
      3. Tribes were also disadvantaged in trying to purchase PPE, and some PPE sent to Native communities was not medical grade or was sent the wrong equipment
      4. The federal government must prioritize lifesaving equipment for Native nations and consider funding a separate stockpile for Native nations
   4. Investment in Infrastructure (Foxworth et al., 2021)
      1. The lack of healthy water, plumbing, electricity, broadband, and other kinds of infrastructure remains a perennial challenge that affects the health of Native people
         1. Many tribal lands also lack safe roads and public transportation, making access to resources, care, and emergency services nearly impossible
         2. The federal government must prioritize investment in meaningful infrastructure for Native nations
3. Federal legislation affirming Tribal Governments’ powers to regulate non-members on Tribal Lands
   1. When nonmembers endanger public health and safety on tribal lands, tribal governments can do very little to stop them
   2. Federal legislation could undo case law’s limits
   3. Tribes need the authority to require everyone to comply with tribal health and safety standards while on tribal lands

These three main takeaways from Foxworth et al. (2021) can be powerful tools when combined with topics previously discussed regarding working in IHS-based or Tribal-owned healthcare facilities.

The LTC community was hit particularly hard during the COVID-19 pandemic. Inpatient and outpatient facilities had some of the first patients to become infected, perish, and then endure significant disruptions to supply chains and personnel to provide services (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al., 2021; Doran et al., 2022; Elman et al., 2020; Feingold et al. 2022; Farooqi et al. 2022; Gee et al., 2022; Lara-Reyna, et al., 2020; Manolis et al., 2021; McGuire et al., 2021; OSHA, 2023ab; Odes et al., 2022; Richard et al., 2021; Ruggeri et al., 2022; Thienprayoon et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Williams, 2022; Wood et al., 2022). Clinical personnel who provided many inpatient and outpatient services that were transferred to either a hybrid or completely telehealth format during the COVID-19 pandemic crisis will find that certain reimbursements for those services will continue throughout 2023 and beyond.

The administration has continued many policies that took effect in 2020 for speech, physical, and occupational therapy. This extension of telehealth services can be a benefit and a curse in the LTC community (American Speech and Hearing Association, 2023). Isolation can exacerbate many forms of cognitive and neurological impairment (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Doran et al., 2022; Elman et al., 2020; Feingold et al. 2022; Farooqi et al. 2022; Gee et al., 2022; Lara-Rayna et al., 2020; Manolis et al., 2021; McGuire et al., 2021; OSHA, 2023ab; Odes et al., 2022; Richard et al., 2021; Ruggeri et al., 2022; Thienprayoon et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Williams, 2022; Wood et al., 2022). However, the reduced interaction can decrease the likelihood of an adverse incident and mitigate risk. It is key to grow your understanding of managerial, administrative, and other executive-level considerations in LTC.

There is so much potential for growth in this area that many find they can carve out a career they are proud of and feel good about!

Before discussing mitigating risk, it is essential to understand how the HRC broke down during the COVID-19 pandemic and how it was worsened by the extensive levels of trauma, mental health concerns, substance abuse, and WPV (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Doran et al., 2022; Elman et al., 2020; Feingold et al. 2022; Farooqi et al. 2022; Gee et al., 2022; Lara-Rayna et al., 2020; Manolis et al., 2021; McGuire et al., 2021; OSHA, 2023ab; Odes et al., 2022; Richard et al., 2021; Ruggeri et al., 2022; Thienprayoon et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Williams, 2022; Wood et al., 2022).

1. Medicare is one of the largest sources of public health insurance, serving older people, people with disabilities, and those with end-stage-renal-disease
   1. Managed by the Center for Medicare and Medicaid Services (CMS), another division within the DHHS, Medicare offers coverage for hospital care, post-discharge nursing care, hospice care, outpatient services, and prescription drugs
2. Medicaid, the third-largest source of health insurance in the country, provides coverage for low-income adults, children, older people, and individuals with disabilities
   1. This program is also the largest long-term care provider for older Americans and individuals with disabilities
3. SNFs that provide services (e.g., nursing, PT, occupational therapy, and SLP services) to Medicare beneficiaries are paid under a prospective payment system through Part A of the Medicare benefit
4. If a patient requires services based on their clinical characteristics, Medicare requires SNFs to provide them regardless of whether the services are covered under Part A or Part B of the program
5. Laws require a reduction in payments to hospitals that incur excessive Medicare readmissions within 30 days of discharge
   1. Readmission can be to the same or another hospital and is related to the medical condition for which the patient was previously hospitalized
   2. CMS includes the following six condition/procedure-specific 30-day risk-standardized unplanned readmission measures in the program: AMI, COPD, HF, Pneumonia, CABG Surgery & THA/TKA
      1. COVID-19 is an extremely harmful virus to the respiratory and neurological systems, which can be devastating in the LTC community
      2. COPD and pneumonia are already prevalent in the LTC community
   3. Medicare counts the readmission of patients who return to a hospital within 30 days, even if that hospital did not originally treat them. In those cases, the penalty is applied to the first hospital

There may be situations where a series of factors contributed to an adverse incident that must be reported and a remedy provided, but no specific “assailant” or “aggressor” was identified. In truth, in the frontline experience, many clinicians and other personnel encounter incidents of trauma, WPV, and other adverse incidents that are culminated by factors that contribute to risk. Still, there is no clear aggressor and no clear “victim.” The healthcare administrator must be able to mitigate the risk of these types of incidents and those where a clear “aggressor” and a clear “victim” can be identified. In more complicated scenarios, the rehabilitation manager, charge nurse, and Administrator in a facility may have to take the “bird's eye view” of the risks and remedies necessary to facilitate change in their building. Recent research (Alonso-Lana, 2020) discusses how “the COVID-19 pandemic forced Memory Clinics and other providers to implement necessary measures of social distancing and self-isolation… [that] may have contributed to feelings of loneliness and behavioral changes in patients with cognitive impairment (Alonso-Lana, 2020).”  Alonso-Lana (2020) also noted:

1. The COVID-19 pandemic further exacerbated the vulnerability of elderly patients with cognitive impairment, especially those who depend on family or caregivers for their daily care
   1. This is due to the increased morbidity and mortality caused by the infection but also to the indirect effects of the pandemic on the healthcare system that they depend on
   2. Medical resources have been diverted away from patients with chronic conditions, such as dementia, to attend to COVID-19 cases. People with dementia are at risk of discontinuing their treatment during the lockdown, especially those who depend on external help for reminders or assistance
2. COVID-19 has had a dramatic impact on long-term care facilities, where rates of infection and mortality have been very high
   1. The community was forced to socially distance and cancel cognitive stimulation programs, which may have contributed to loneliness, behavioral symptoms, and worsening of cognition in patients with dementia
   2. COVID-19 has impacted the functioning of Memory Clinics, research programs, and clinical trials in the Alzheimer’s field, triggering the implementation of telemedicine
   3. COVID-19 survivors should be periodically evaluated with comprehensive cognitive and neuropsychiatric assessments, and specific mental health and cognitive rehabilitation programs should be provided for those suffering long-term cognitive and psychiatric sequelae

The detailed clinical pathology documented in Alonso-Lana (2020) empowers healthcare staff in LTC to affect change in their patients and communities.

Here, we have emphasized perspectives from all views:

1. The managerial and administrative personnel in the frontline healthcare community
2. The therapist: speech, physical, occupational, and respiratory
3. The primary and emergency clinical and professional staff: physician, nursing, support, and discharge personnel
4. The public health official and regulatory body ensuring consistency and quality of care
5. The patient, caregiver, Powers of Attorney, and other appropriate individuals 

Sample generic organizational checklists based on the present literature review will be provided at the end of this course to be adapted by you and other professionals and personalized to your settings and buildings.

Elder Mistreatment Has Become A Major Concern Since 2020. Due to the COVID-19 crisis, trauma, mental health concerns, PTSD, anxiety, and WPV, elder mistreatment incident rates have risen (Elman et al., 2020). To evaluate the intersection of WPV risk factors in LTC, dementia populations, and the rise in elder mistreatment, data from New York City at the peak of the pandemic will be discussed. This research involves a critical investigation into the “... profound impact [of COVID-19] on the organizations from many sectors that typically respond to protect and serve victims of elder mistreatment (Elman et al., 2020).” Elder Mistreatment is an ongoing problem in the LTC community, and interactions between patients and staff can contribute to WPV (Elman et al., 2020).

Factors that contribute to elder mistreatment and increase the risk of WPV and adverse medical incidents include (Elman et al., 2020):

1. Older adults are disproportionately affected and more likely to die in incidents of natural disasters
2. Family violence, including child abuse and intimate partner violence among younger adults, increases in the aftermath of these disasters
3. Many of the issues involve displacement from living environments, movement to shelters, and repairing/rebuilding and return
   1. Much of the elder mistreatment surrounding disasters is described anecdotally and, in the limited literature available
   2. Elder mistreatment can include abandonment of functionally or cognitively impaired older adults unable to leave nursing homes or other living environments, neglect and theft while in shelters, and fraud by contractors and others overseeing repairs/rebuilding and return
4. The consequences of elder mistreatment are potentially devastating

Clinical personnel can identify elder mistreatment at any level and provide a safe space for patients or visitors to report that mistreatment (Elman et al., 2020).

Frontline healthcare workers, similar to others already discussed, endure significant hardships that contribute to at-risk conditions. Frontline healthcare workers reported that they “...felt isolated and alone were at an increased risk for adverse mental health outcomes... feeling isolated and alone was a risk factor for reporting symptoms of anxiety, depression, PTSD, and especially suicidal ideation… 53% felt disconnected from their family and friends because of their workload… and…did not feel supported by their organization or felt unappreciated at work had a higher risk for reporting symptoms of suicidal ideation (Kone et al., 2022).” This investigation provides information on steps that were taken to manage and mitigate risk factors (Kone et al., 2022):

1. Social support has a mediating role in abating symptoms of anxiety and other mental health conditions and is a strong predictor of resiliency for people who have been exposed to stressors, including COVID-19
2. Frontline workers who felt supported by their organizational leadership, colleagues, friends, and families have fewer mental health outcomes
3. Workers offered organizational support such as the ability to take time off, flexible work schedules, and training to prevent stress or burnout were less likely to report symptoms of mental health conditions
4. Respondents who reported improved physical activity and exercise as a coping mechanism were less likely to report symptoms of anxiety, depression, PTSD, and suicidal ideation
5. Respondents experienced a dose-dependent response to stressors: the more stressors they experienced, the more likely they were to report symptoms of anxiety, depression, PTSD, and suicidal ideation

Additional research provides terminology and wording easily translatable for administrative healthcare personnel. Thienprayoon et al. (2022) note the terms ”Compassion” and “Organizational Compassion” in an attempt to quantify the effect of different approaches in risk mitigation and management. Compassion is recognized by scholars, spiritual leaders, healthcare researchers, and patients as a salient ameliorator of suffering that transcends cultures, patient populations, specialties, and healthcare sectors… Further, the response to burnout and HCW suffering has largely placed the onus of change on the person. Still, it has become clear that HCW suffering must be approached and tackled as a systems issue at the level of the organization and the individual healthcare unit (Thienprayoon et al., 2022). Approaching healthcare risk management, mitigation, and prevention from an organizational compassion perspective may yield significant results in your everyday settings (Thienprayoon et al., 2022). Thienprayoon et al. (2022) go on to further note, “Critically, part of the “hidden curriculum” of medicine is the culture of silence and stigma in acknowledging the distress engendered by healthcare workers.” They note the mounting evidence that growth and a possible respite from these stressors and other factors may be possible with a more organizational perspective on delivering compassion to the workforce. Specifically:

1. Compassion and burnout exist at opposite ends of the spectrum of human experience: whereas burnout includes emotional exhaustion, depersonalization, and low professional accomplishment, compassion means emotional engagement, connecting with another’s humanity, and a neurally-mediated sense of reward from helping
2. Compassion consists of recognizing suffering, emotionally connecting with the distress of the person suffering, and acting to lessen or alleviate the suffering
   1. The key feature of compassion that distinguishes it from similar states (e.g., kindness, empathy, or sympathy) is that it arises specifically in response to suffering and requires not simply a desire to act but action aimed at relieving suffering
   2. Compassion is, by its very definition, ideally suited to prevent and alleviate individual and collective suffering directly
   3. Organizational compassion in healthcare is demonstrating leadership behaviors (e.g., rewarding compassionate acts by employees) that help to result in a climate in which compassionate responses arise when suffering happens
3. While interventions to mitigate burnout have been described, these efforts don’t always directly and compassionately prevent HCW suffering
   1. Sources of avoidable suffering must be targeted at the systems level, whereas the harm caused by sources of inherent or unavoidable suffering must be minimized
4. Frontline healthcare workforce suffering must be confronted as the safety emergency arises
   1. Preventing HCW suffering—and the burnout it engenders— is a far better strategy than waiting to treat it after it becomes a problem
5. Patients also need and deserve the most compassionate care that skilled frontline healthcare personnel can provide
6. Only when organizational leaders systematically acknowledge, prevent, and mitigate the myriad factors that contribute to workforce suffering can communities build the truly sustainable workforce that the USA desires and deserves
7. More compassionate workplace relationships lead to individual and organizational benefits, including enhanced employee trust and commitment to the organization, better perceptions of leadership effectiveness, and improved organizational performance
8. Hospitals that embody these “compassion practices” are more likely to have higher ratings and a higher likelihood of patients recommending them to others
9. Tools to measure both workers' suffering and experiences of compassion must be developed, tested, validated, and disseminated
10. After experiences of compassion at work have been measured, the community can evaluate how those experiences relate to other workforce outcomes and develop responsive interventions to improve those outcomes at scale

Consistent evidence exists that compassionate-focused interventions at the department, setting, local, public, Academic, State, Federal, Military, and Tribal levels can have an impact on mitigating, managing, and possibly preventing risk factors in frontline healthcare workers contributing to adverse events and WPV (Chen et al., 2022; D’Alessandro et al., 2021; De Boer et al. 2021; Doran et al., 2022; Elman et al., 2020; Farooqi et al. 2022; Gee et al., 2022; Lara-Rayna et al., 2020; McGuire et al., 2021; Williams, 2022; Manolis et al., 2021; Richard et al., 2021; Ruggeri et al., 2022; Thienprayoon et al., 2022; Tizenberg et al., 2021; Ward et al., 2022; Wilensky, 2022; Wood et al., 2022).

A major roadblock for healthcare personnel is access to adequate reporting procedures. Understanding reporting practices in healthcare and related administrative laws and guidelines is important as several laws empower the healthcare worker. Details on reporting guidelines for aspiring managerial and administrative frontline healthcare workers and five additional state laws that are important to know (Odes et al., 2022; OSHA, 2023):

1. California:(State Health and Safety Code and SB-1299) In 1993, California became the first state to require healthcare facilities to develop and maintain a violence prevention program. Subsequent state laws incorporated elements of the initial California state law. Currently, California is working on updating state requirements. California .
   1. Who is covered: General acute care, acute psychiatric, and certain other types of hospitals.
   2. Penalties for perpetrators: Yes. California’s law requires a designated committee to develop a safety plan, which must be updated based on findings from an annual facility assessment. This plan should consider physical layout, staffing, security personnel, policy and training related to appropriate responses, and coordination with local law enforcement. Facilities must track incidents of violent behavior and evaluate trends. Affected employees and collective bargaining agents must be engaged in worksite analysis. Safety and health training is required.
2. Washington (Title 49, Chapter 49.19).
   1. Who is covered: Hospitals, home health, hospice, home care agencies, community mental health programs, and evaluation and treatment facilities.
   2. Penalties for perpetrators: Yes. Washington’s law requires facilities to perform hazard assessments, record reviews, and develop a violence prevention plan. Training must be provided regularly to all affected employees identified in the violence prevention plan and must occur within 90 days of an employee’s start date. Records must be available for incidents occurring during the last five years.
3. Oregon (2013 ORS, Vol. 14, Chapter 654).
   1. Who is covered: Hospitals, ambulatory surgical centers, and home healthcare services.
   2. Penalties for perpetrators: No. Oregon’s law requires periodic hazard assessments and record reviews, which must feed into a violence prevention plan. The plan must consider the physical attributes of the facility, staffing, personnel policies, first-aid and emergency procedures, reporting of violent acts, and employee education and training. Employees have the right not to treat a patient who has assaulted them if the employer denies the employee’s request to have a second employee present. An employee in home healthcare may refuse to treat a patient unless the employer provides the employee with a two-way communication device. Training must occur within 90 days of an employee’s start date and is provided as needed after that. Records must be kept for five years.
4. Illinois (405 ILCS 90/).
   1. Who is covered: Mental health and developmental disability facilities.
   2. Penalties for perpetrators: Yes. Illinois law requires a violence prevention plan to be implemented based on findings from a risk assessment and record review. The plan must be reviewed at least once every three years. It must consider the facility’s physical layout, personnel policies, first-aid and emergency procedures, reporting of violent acts, and employee education and training. All affected employees must be trained within 90 days of their start date and receive periodic refresher training. The facility must keep records of WPV incidents.
5. New York (Labor Law Article 2).
   1. Who is covered: Public facilities with at least 20 full-time permanent employees, including state-run healthcare and social service facilities.
   2. Penalties for perpetrators: Yes. New York’s law requires a risk assessment of the workplace, which includes consideration of hazards such as working late, working alone, and exchanging money. Each facility must have a violence prevention plan that addresses the identified hazards. Employees must complete training at the start of employment and annually after that. Each facility must have a system for reporting incidents. Strong requirements for employee involvement have served as a model for other states’ laws.
6. Maine (Sec. 1. 22 MRSA §1832).
   1. Who is covered: Hospitals.
   2. Penalties for perpetrators: No. Maine’s law requires a safety and security plan to be implemented annually, and hospitals must have a process to receive and record incidents or threats of violent behavior.
7. Connecticut (Public Act No. 11-175).
   1. Who is covered: Hospitals, long-term and residential care, behavioral health, outpatient and ambulatory care, home care, and other facilities with 50 or more full- or part-time employees.
   2. Penalties for perpetrators: Yes. Connecticut’s law requires a workplace safety committee with equal representation among management and employees. The committee must meet quarterly, conduct an annual risk assessment, and implement a violence prevention plan. An employee has the right to request accompaniment when caring for a patient who previously assaulted them, or they may ask to be reassigned. Employers must keep detailed incident records and report assaults to authorities within 24 hours (with some exceptions).
8. New Jersey (P.L. 2007, Chapter 236).
   1. Who is covered: Hospitals and nursing homes.
   2. Penalties for perpetrators: Yes. New Jersey’s law requires a violence prevention committee to conduct an annual risk assessment and develop a prevention plan. At least half of the committee must be direct caregivers. The assessment must consider the facility’s layout, the crime rate in surrounding areas, lighting in surrounding areas, communication and alarm devices, and staffing; it must include a records review and a review of existing policies. The plan must specify risk reduction strategies and establish a post-incident response system. Employees must receive annual training in identifying precipitating factors of violence and appropriate responses. Records of violent events must be kept for five years.
9. Maryland (Senate Bill 483).
   1. Who is covered: Hospitals, state residential facilities, and nursing homes licensed for 45 beds or more.
   2. Penalties for perpetrators: No. Maryland’s law requires each facility to conduct an annual assessment and have a workplace safety committee. Hospitals and state residential facilities’ committees must have equal representation among management and employees; their employees must receive regular training and have a system for reporting, responding to, and tracking incidents.

1. Note how your coworkers behave. If a colleague’s demeanor or behavior has changed, notify your manager
2. If a patient has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for this patient
3. Let security know if you feel threatened or find or suspect that the patient is carrying a weapon
4. Notify your nursing supervisor, manager, and hospital security or police if you suspect a patient will be violent
5. Keep your patient informed
6. Help relieve the patient’s tension and anxiety by keeping them informed about when examinations/treatments will be performed and what is going on
7. Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor
8. Be vigilant throughout the encounter
9. Do not isolate yourself from a potentially violent person
10. Plan your exit
11. Watch your surroundings
12. Always keep an open path for exiting
13. Do not let the potentially violent person stand between you and the door
14. When you are with an upset patient or coworker, avoid areas of the room that do not have an accessible exit
15. If you are going to an isolated part of your facility, let others know where you are and when you expect to return
16. Consider asking for an escort
17. Observe your surroundings and note anyone not wearing a staff ID lingering where they should not be
18. Ask politely if you can help and notify security if you are not satisfied with the answer
19. Call security and provide a full description if you would rather not approach someone
20. Evaluate the way you wear equipment to ensure it cannot be used as a weapon against you
21. Carry your stethoscope in a pocket and use an ID badge necklace with a breakaway feature
22. If you wear a necktie, opt for a clip-on style. If your hair is long, wear it in a way that is not easy to pull, and do not wear dangling jewelry
23. Do not ignore the agitated person or avoid them
24. Do not threaten or demand obedience
25. Do not argue or become defensive or judgmental
26. Do not laugh, move suddenly, make threatening gestures, or invade their personal space
27. Do not try to handle a dangerous situation alone
28. Call the security or initiate your facility's violence prevention protocol
29. Remove yourself from the situation
30. Report any violent incidents to your management
31. Present a calm, caring attitude
32. Do not match the threats
33. Do not give orders
34. Acknowledge the person's feelings (for example, "I know you are frustrated”)
35. Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly)

The patient, Ms. Donna, is a female long-term care facility resident. She has a history of child-onset diabetes mellitus and the onset of end-stage renal disease (ESRD). She has also been recently diagnosed with metabolically and nephrological-driven Alzheimer’s disease (AD). A physician and a nurse practitioner lead her interdisciplinary team, consisting of PT, OT, and RT, who are contracted personnel. The team coordinated meals, ambulation, peripheral ulcerations, and edema care. By making appropriate referrals, the interdisciplinary team coordinated Ms. Donna’s care to reduce the swelling, improve circulation, restore the patient's epidermal barrier protection, regulate excretory functions, and re-establish metabolic and endocrine balance. This patient likely has gastrointestinal reflux and dysphagia, as these comorbidities are associated with chronic metabolic and renal imbalances that are common in this type of AD clinical case profile. While uncertain, Ms. Donna may have had aspiration, aspiration pneumonia, or aspiration pneumonitis in her patient history.

Ms. Donna has recently been exposed to the COVID-19 virus. She has been hospitalized more than once and received multiple rounds of immunological interventions despite having received the minimum standard vaccinations for COVID-19, as well as boosters. She occasionally requires supplemental oxygen delivery via a mask or nasal cannula. The presence of viral exposure, isolation, and the reduced care considerations common during the COVID-19 pandemic exacerbated Ms. Donna’s health status.

Ms. Donna was receiving an intravenous injection as part of her ESRD management. The LTC nursing staff administered the injection. Although the nurse is attending to the patient’s needs, the provider has also suffered greatly during the COVID-19 pandemic and works in less-than-perfect conditions for various COVID-19-related reasons. In the process of receiving the intravenous injection, Ms. Donna becomes agitated, and the delivery of the medication goes awry. In the process, Ms. Donna is bruised significantly, the equipment has been damaged, and there is bodily injury to the LTC nursing staff.

Her agitation is consistent with an AD diagnosis as well as the encephalopathic and neuropsychiatric consequences of surviving COVID-19.

The table below demonstrates a generic form of a risk management assessment. The table is color-coded and demonstrates the intersection of risk factors contributing to the adverse events described in this case study (OSHA, 2023ab; Odes et al., 2022; Wood et al., 2022).

Table 2. Risk Assessment for Case Study: Ms. Donna 

Green = Compliant; Yellow = Low Threat; Orange = Mild Threat; Red = Negligent; Black = Absent

The table demonstrates that the risk assessment for case study 2 ranges from mild threats to definitive negligent classification.

After identifying risk, it is critical to establish a method for assessment, management, and future prevention. Below, the Center for Disease Control (CDC) has provided some tips for management and other administrative staff to utilize to mitigate risk in the everyday clinical setting (CDC, 2023a).  There are six  types assessment that the CDC recommends. These include organizational assessment, workplace analysis, identifying environmental risk factors for violence, assessing the influence of day-to-day work practices on occurrence of violence, post incident response, and assessing employee and supervisor training and record keeping.  Here we will go through those in a little more detail.

Missy is a 12-year-old female patient with a previous history of pediatric-onset Asthma, Asthma-related respiratory distress, and cardiopulmonary debilitation following a COVID-19 diagnosis with recent hospitalization. Missy was discharged from the hospital to her home, and it was recommended that she complete outpatient RT and PT for pulmonary muscular function exercises to increase oxygenation, upper thoracic strengthening, and light cardiovascular exercise to improve endurance. She is referred to a multidisciplinary outpatient rehabilitation facility that cares for patients of all ages. She is covered through Medicaid. She receives two hours of RT and PT three times a week. Her mom regularly drops her off, and Missy attends the therapy sessions alone before her mom picks her up.

On the day of the incident, the patient was interacting with a male Physical Therapy Assistant (PTA) in his early 20s, taking Missy through interventions consistent with the supervising PT’s orders. This included pectoralis stretching and scapulothoracic strengthening to improve thoracic muscular function. Before the exercises could be completed, the patient became agitated and attacked the PTA. The PTA maintained control and followed protocol to de-escalate the situation.

Upon further interview, the patient revealed that she felt she was receiving unwanted touching. Risk mitigation steps were taken, and an assessment was conducted. During the interview, the PTA expressed that he does not believe any unwanted touching occurred but feels moral incongruence. Therefore, the PTA sought a remedy to the situation involving administrative intervention to ensure that he maintained trust with his patient. Soon after, the patient’s mother returned and participated in the administrative review process. The mom and Missy were understandably upset, but slowly, Missy began to calm down. The PT, Rehabilitation Manager, and Outpatient Healthcare Administrator went through the risk mitigation process to maintain the quality of care and established a remedy that the PTA, the patient, and her family agreed upon. Table 3 below demonstrates the risk assessment for case study 3.

Table 3. Risk Assessment for Case Study 3: Missy

Green = Compliant; Yellow = Low Threat; Orange = Mild Threat; Red = Negligent; Black = Absent

Table 3 illustrates that the risk is quite low in case study three. However, due to the moral incongruence, moral distress, and moral injury of the pediatric Medicaid beneficiary and the PT Assistant, risk mitigation procedures and remedies were appropriate and tailored to this situation. Tailoring the protocols to be specific to the current case scenario ensures that this situation does not repeat in the future and mitigates the risk of other-related scenarios from occurring.

This course provided concepts in healthcare administration to help aspiring healthcare personnel grow in their expertise, as well as foundational concepts in healthcare, business, ethics, administration and management, risk mitigation, and prevention. This course provided a framework to address the breadth and scope of effects a healthcare frontline workforce has endured throughout the COVID-19 pandemic. It now must facilitate the recovery of the HRC. This course provided clinical personnel with applications in safety and everyday practice that can be useful. The literature has demonstrated a series of factors contributing to adverse incidents in the frontline healthcare community primarily driven by COVID-19-related exacerbation of underlying risks. Risk mitigation tools and tips have been provided and conclusively demonstrate the need for healthcare administrative concept utilization in the successful remedy of the HRC following the COVID-19 pandemic.

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