Promoting a Nonviolent Health Care Culture

1. Promoting a Nonviolent Health Care Culture A Train the Trainer Program Module 1

2. Promoting a Nonviolent Health Care Culture • VIDEO--Violence from disruptive behavior through homicide.

3. Purpose of Training • Educate attendees about disruptive behavior through extreme forms of violence • JC sentinel events #40 and #45 • OSHA standards • Increased employee satisfaction and person/family satisfaction • Safer working environment • Best practice

4. Objectives • Define violence • Recognize the different types of violence • Discuss local and national statistics related to workplace violence • Explain current research and trends in evidence based practice to promote a non-violent workplace • Define culture and identify a need to shift paradigms • Define assessment of person, situation, environment, self, and co-workers • Discuss the assessment of person, situation, environment, self, and co-workers • Define and discuss therapeutic communication and therapeutic relationship • Explain the crisis cycle • Demonstrate protective stance, blocks and releases

5. Regulatory Requirements

6. Joint Commission • Sentinel event #40- Behaviors that undermine a culture of safety- addresses disruptive behavior amongst staff. • Reveals that this behavior fosters medical errors, poor patient satisfaction, increase in cost of care, adverse outcomes, and attrition of professional staff. • These behaviors are not rare and occur across all disciplines.

7. JC Sentinel Event #40 • LD 03.01.01 EP 4- Code of conduct in place that defines acceptable and disruptive and inappropriate behaviors. EP 5- Process for managing disruptive and inappropriate behaviors. • Other suggestions- reporting process, surveillance system, skills-based training for leaders.

8. JC Sentinel Event #45 • Preventing violence in the healthcare setting- addresses assault, rape and homicide to patients and visitors by staff, visitors, other patients and intruders. • Significant increase in reports since 2004 • 62% problems with policy and procedures • 60% HR related factors • 58% Flawed assessments • 53% Communication failures • 36% Physical Environment • RI 01.06.03- patient’s right to be free from neglect, exploitation, verbal, mental, physical and sexual abuse.

9. OSHA Section 5 (a)(1) • Each employer --  (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.

10. Definitions

11. Exercise • What is your definition of violence? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12. What exactly is violence? • Webster’s dictionary violence • 1.a:exertion of physical force so as to injure or abuse b: an instance of violent treatment or procedure • 2: injury by or as if by distortion, infringement, or profanation: outrage • 3 a: intense, turbulent, or furious and often destructive action or force Does this belong in the workplace? No standardized definition for workplace violence. This leads to confusion, many sub-categories, and underreporting of events.

13. Other Definitions/forms of violence • Verbal violence-Using violent and offensive words and/or threatening violence • Nonverbal violence-Using violent and offensive gestures, postures, facial expressions • Disruptive Conduct- Creating a hostile or intimidating work environment. This conduct includes, but is not limited to • Intimidation • Bullying • Physically touching someone • Throwing objects • Writing threatening notes • Non-constructive criticism • Use of inappropriate language, gestures

14. Definitions • Intimidation- behaviors or threats that imply loss of future opportunity, worsening abuse, or compromise of education, abuse of power through threats or coercion. • Stalking-repeated persistent following with no legitimate reason and with the intention of harming, or to arouse anxiety or fear of harm in the person being followed. May also take the form of harassing telephone calls, computer communications, letter-writing, and texting. • Assault- Intentionally, knowingly, or recklessly causing physical harm. • Mobbing-A number of workers who unfairly gang up on a manager, peer, or subordinate, tormenting the person in usually non-violent ways.

15. Definitions • Involuntary Manslaughter-occurs where there is no intention to kill or cause serious injury but death is due to recklessness or criminal negligence. • Voluntary Manslaughter-is the killing of a human being in which the offender had no prior intent to kill and acted during "the heat of passion", under circumstances that would cause a reasonable person to become emotionally or mentally disturbed. • Homicide-the killing of a human being by another human being.

16. Types of Violence

17. 4 types of workplace violence • Criminal- the person committing act of violence has no relationship with employer or the workplace. Most common is robbery- 85% • Customer/Client- the person committing act of violence is a client and is dissatisfied with a product/service-3% • Employee on employee- one employee is being violent towards another-7% • Domestic violence- home violence spills over into the workplace-5%

18. Employee on Employee Violence • Vertical violence- Supervisor is using covert or overt violence towards employee • Horizontal violence- Also known as lateral violence, peer(s) is using covert or overt violence towards employee • Covert forms of violence-psychological harassment. Ex. eye rolling, changing assignments without informing the person, gossiping, isolating, withholding information, intimidation, excessive criticism, and denial of access to opportunity • Overt forms of violence-verbal abuse, shoving, hitting, slapping, kicking and throwing objects

19. Bullying Behaviors • http://www.bing.com/videos/watch/video/bullying-at-work/263dd594ad8a5207568d263dd594ad8a5207568d-306029265671?q=bullying%20videos%20at%20work&FORM=VIRE5

20. Bullying in the workplace • Bullying-Workplace Bullying is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms: • Verbal abuse • Offensive conduct/behaviors (including nonverbal) which are threatening, humiliating, or intimidating • Work interference — sabotage — which prevents work from getting done

21. Bullying VS. Harassment Bullying Harassment • almost always psychological • frequently linked to a staged attack on competent and popular individuals • usually perpetrated behind closed doors • Covert nature • A target of this type of abuse may not realize it for weeks or months, until great damage is done. • shows its face through trivial untrue criticisms of under-performance • repeated, deliberate, disrespectful behavior with the intent of hurting someone else. • strong intrusive component including physical contact such as invading physical space, including personal possessions and damage to possessions. • overt nature • A target of workplace harassment knows he or she is being harassed immediately. • unwanted conduct that violates people's dignity or creates an intimidating, hostile, degrading, humiliating or offensive environment

22. Case Example Discuss examples of violence in the workplace.

23. Effects of Violence in the Workplace The damaging effects of workplace violence are far-reaching and may include: • Deterioration in the quality of care delivered- as many as 70% of preventable errors result from poor communication • Deterioration in the quality of staff relations- oppression theory • Low staff morale • Increased stress levels and stress-related illnesses • Feelings of shock, disbelief, shame, guilt, anger, fear, and powerlessness • Depression and self-blame, loss of self-confidence • Sleeplessness and loss of appetite • Lower levels of job satisfaction • Increased costs to employers and the health system • Increased absenteeism and sick leave • Poor performance and lost productivity • Loss of creative problem-solving capacity • Attrition of staff

24. Risk Factors • Staffing patterns • Stress, tension, and frustrations • Lack of training to recognize or cope with bullying • Shift work and demanding workloads • Lack of reporting system or punishment against perpetrators • Working alone • Poor management skills and policies

25. Attributes • Clash of personalities between perpetrator and victim • Workplace relationships • Appearance or disability • Success or achievement / jealously • Culture of tolerance or acceptance of violence • Race, gender, religion, and sexual orientation

26. Statistics

27. How often does workplace violence occur? • More assaults occur in healthcare and social services industries than any other • National Institute Occupational safety and health (NIOSH) reports that 3 people are murdered per day on the job • One million employees are assaulted per year • One thousand are murdered per year • 111,000 incidents costs 6.3million dollars • Estimated that ½ of the cases go unreported

28. ISMP Survey • during the past year, 88% of respondents encountered condescending language or voice intonation (21% often); 87% encountered impatience with questions (19% often); and 79% encountered a reluctance or refusal to answer questions or phone calls (14% often). Almost half of the respondents reported more explicit forms of intimidation during the past year, such as being subjected to strong verbal abuse (48%) or threatening body language (43%). Incredibly, 4% of respondents even reported physical abuse.

29. Cost • Difficult to determine but has been estimated to cost hospital organizations up to $4 billion/year

30. Awareness- Why Now? • Raised to public awareness in 1986 after a series of postal shootings • #1 myth and why remains a problem is that most people feel “That could never happen to me” • Workplace interaction last piece to the puzzle in errors on the job • Shift in healthcare culture from a patriarch approach to a team approach

31. Research

32. What does the Research Tell Us? • No standardized definitions makes benchmarking and comparative research difficult • Inconsistent legal and protective measures • Belief that violence is “part of the work” • Not including all acts of violence as acts of violence • No standardized way of reporting the incidents • Little research related to intervention evaluation

33. Barriers • Denial- doesn’t happen at “my” hospital • Employers don’t see the connection of work place violence and turnover • No laws or regulations that address all types of violence • No set policy or procedure • Lack of reporting and follow up • Lack of awareness • Lack of communication/training • Lack of resources • Inadequate data

34. Key players in Workplace Prevention • Management is the first key player to workplace violence prevention. • Management must be committed to the Violence Prevention Program, or the program will fail. • Management needs to have a commitment or statement letter indicating that violence of any form will not be tolerated. • Management should also support: -medical and psychological follow-up for employees that are victims of violence -ensure safety of employees and persons -provide security officers with authority and adequate resources to keep facility safe -encourage all employees to report violent incidents -inform employees there will be no retaliation for reporting violence

35. Employee Involvement • Employees must be included in the planning or the program will not succeed • Employees should be encouraged to report all incidents of violence and lack of reporting needs to be addressed • Employees need to understand importance of report is to identify, address, and correct security problems.

36. Evidence Based Research- Employer’s role • Adopting a workplace violence policy and prevention program and communicating the policy and program to employees. • Providing regular training in preventive measures for all new/current employees, supervisors, and managers. • Supporting, not punishing, victims of workplace or domestic violence. • Adopting and practicing fair and consistent disciplinary procedures. •Fostering a climate of trust and respect among workers and between employees and management. •When necessary, seeking advice and assistance from outside resources, including threat-assessment psychologists, psychiatrists and other professionals, social service agencies, and law enforcement.

37. Evidenced Based Research- Employee’s role • Accept and adhere to an employer’s preventive policies and practices. • Become aware of and report violent or threatening behavior by coworkers or other warning signs. •Follow procedures established by the workplace violence prevention program, including those for reporting incidents.

38. Break Out Session • Create an outline for your ideal Workplace Violence Plan

39. What should be included in Workplace Violence Plan? • The plan should describe all part of the violence prevention program. The plan should include: • State clear goals for preventing violence • Adapt and state a zero tolerance for violence with consequences • Identify an employee reporting protocol • Encourage employees to keep records of violence and emphasize no retaliation against employee making report • Identify role of security and/or police

40. Laws in Existence or Being Requested • States that have requested violence prevention programs, better reporting system or increase research: California, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Washington, West Virginia • States with laws that increase or strengthen penalties for offenders: Alabama, Arizona, Colorado, Hawaii, Illinois, Massachusetts, Nevada, New York, North Carolina, New Mexico

41. Laws Pertinent to Tristate Area • HB 154 reintroduced as it never made it to a vote. • Rep. Denise Driehaus and Rep. Stephen Slesnick are seeking increased penalty for those assaulting healthcare workers. • Requesting that offenders be charged with a fourth degree felony, 6-18 months in jail, $5,000 fine. • Currently charged as assault with up to 6 months in jail and fine up to $1,000.

42. Sample Cases • Raess v. Doescher, Indiana Supreme Court (2008) • $325,000 award for assault to a perfusionist related to workplace violence • Physician stormed at perfusionist with “clenched fists, piercing eyes, beet-red face, popping veins, and screaming and swearing at him” • Physician did not hit the perfusionist but did state “you’re finished, you’re history”

43. Raess v. Doescher • Court rejected a challenge to expert testimony about workplace bullying • Decision of the case received national attention because media characterized it as a successful workplace bullying claim • No new tort laws or creation of new legal claims as result of case to help pave the way for future plaintiffs.

44. Hollomon v. Keadle, Arkansas Supreme Court (1996) • Hollomon was a female employee of Dr. Keadle • Dr. Keadle would frequently degrade Hollomon with obscene language and comments such as “women who work outside of the home are whores and prostitutes.” • Hollomon also reported that Dr. Keadle informed her that he was “connected with the mob and carried a gun.”

45. Hollomon v. Keadle • Hollomon left on her own free will and filed an intentional infliction of emotional distress case against Keadle citing that working for him caused her to suffer from “stomach problems, loss of sleep, loss of self-esteem, anxiety attacks and embarrassment.” • Court ruled for Keadle citing Hollomon for not making Keadle aware of her peculiar vulnerability to emotional distress.

46. Snyder v. Truck, Ohio Court of Appeals (1993) • Dr. Turk was performing a gall-bladder operation and became upset when a nurse, Snyder, was making mistakes and complicating a difficult procedure. • Turk became increasingly frustrated when Snyder handed him the wrong instrument. He then grabbed Snyder by the shoulder and pulled her face down toward the surgical opening and stated “Can’t you see where I’m working? I’m working in a hole. I need long instruments.”

47. Snyder v. Turk • Judge ruled at trial that Turk had not established the elements of intentional infliction of emotional distress and had not established the elements of battery • The appeals court agreed that there was no emotional distress but did support the battery claims

48. Role of Worker’s Compensation • Workers’ compensation prevents workers from bringing individual lawsuits against their employers for intentional harm at work. • WC is designed to replace personal injury lawsuits as a means of compensating employees for injuries suffered on the job.

49. Culture and Paradigm Shift

50. Culture