Preventing Patient Assault of Health Care Providers

1. Preventing Patient Assault of Health Care Providers Julie Hoerner, MA, BSN, RN, CEN Director, Emergency and Trauma Services Kootenai Health

2. Kootenai Health • 254 beds • Community - owned • 350,000 people • 10 northern counties • 2,350 employees • 48,000 ED visits • Magnet Designation

3. Situation

4. Objectives • Identify high risk environments associated with an increased risk of health provider assault • Discuss strategies that health care delivery sites can take to prevent assault of healthcare providers

5. Situation:Workplace Violence Defined • “acts of violence (including physical assaults and threats of assaults) directed toward persons at work or on duty” (National Institute for Occupational Safety and Health, 2002)

6. Situation:Workplace violence defined …”includes physical and psychological violence, abuse, mobbing or bullying, racial harassment or sexual harassment.” (International Council of Nurses, 2000)

7. Situation:Types of workplace violence • Type 1 - criminals, no connection • Type 2 - directed at employees by customers, clients, patients, etc • Type 3 - directed at employees by a coworker • Type 4 – non-employee, personal relationship to employee

8. Workplace violence touches all of us……..

9. Background:The magnitude of the problem The Healthcare sector leads all other industries in incidence of nonfatal workplace assaults. (McPhaul & Lipscomb 2004)

10. Background:Risk Factors • Volatile people • Drug/Alcohol Use • Understaffed (including Security staffing) • Transporting patients • Long waits for service • Overcrowded, uncomfortable waiting rooms • Denial of service • Inadequate design • Lack of staff training • Access to firearms • Unrestricted movement of the public (NIOSH 2002)

11. Background:At highest risk • Critical Care areas • Behavioral Health • Home Health • Emergency Dept. ENA ,2011

12. Background:Failure to report • Part of the job • Lack of policies and procedures • Reporting too complex • Nothing happens when its reported • Reporter will be blamed for the incident • Some patients can’t be held responsible for actions

13. Assessment:The short-term consequences ENA 2011

14. Assessment: The long-term consequences low morale Patient safety issues decreased productivity STRESS absenteeism financial loss TURNOVER family turmoil decreased trust in management

15. Assessment :What say we? • “All nursing personnel have the right to work in a healthy working environment free from abusive behavior…” (ANA 20110) • “the facility has the responsibility to establish & promote a safe work environment & strive to use best practice models” (AORN 2011) • “violence in the workplace is a pressing occupational concern for all registered nurses…..”(APNA 2008) • “Healthcare organizations must take preventative measures to circumvent workplace violence & ensure the safety of all healthcare workers, their patients and visitors. (ENA 2010)

16. Assessment :What say we? • “Violence undermines the healing mission of the healthcare organization….and interferes with the ability of the healthcare team to optimally contribute to positive patient outcomes”(AACN 2004) • “TJC’s Environment of Care Standards require healthcare facilities to address and maintain a written plan describing how an institution provides for the security of patients, staff and visitors” (TJC Sentinel Event Alert Issue 45; 2010)

17. Recommendations • Management Commitment & • Employee Involvement • Worksite Analysis • Hazard Prevention and Control • Safety and Health Training • Recordkeeping & program • Evaluation

18. Recommendation: Management commitment “Nurses who perceived their hospital administration and ED management as being committed to workplace violence control were less likely to have experienced workplace violence” (ENA , 2011)

19. Recommendation:Employee Involvement • Understand WPV prevention program • Report WPV incidents immediately • Participate in safety and health committees • Participate in continuing education & training

20. Recommendation:Worksite Analysis • A step by step commonsense look at the workplace to find existing or potential hazards for WPV: -threat assessment -records analysis and tracking -screening surveys -security analysis

21. Recommendation:Hazard Prevention and Control Determine risk reduction interventions, practices, policies and implement: -Environment -Work practices -Policies

22. Recommendation:Safety and Health Training • Workplace Violence Plan • Self-protection • Crisis recognition, intervention and de-escalation techniques

23. Recommendation:Record Keeping & Program Evaluation “The presence of reporting policies (especially zero-tolerance policies) is associated with a lower odds of physical violence and verbal abuse” (ENA , 2011)

24. Recommendations: Other helpful tools www.ena.org

25. CDCWorkplace Violence Prevention for Nurses www.cdc.gov/niosh/topics/violence/training_nurses.html

26. And….what about metal detectors??

27. Metal Detectors….. • Public and staff perceive it creates a safer ED environment (Meyer et al 1997; Mattox et al 2000) • Decreased contraband without negative perceptions by visitors AND decreased unauthorized smoking! (Rustin 2007) • Increased number of weapons confiscated on the front end, but did not decrease the number of assaults (Rankins and Hendly 1999)

28. Recommendation:Legislation The American Nurse’s Association – Encourages individual states to enact laws to protect our nursing workforce against workplace violence. (ANA, 2006)

29. Recommendation: Legislation • WORKPLACE VIOLENCE LAWS ME WA MT ND VT NH MN OR NY MA WI ID SD CT RI MI WY PA NJ IA NE OH MD NV DE IN IL wv UT VA CO CA MO KS KY NC TN SC OK AR AZ NM GA AL MS AK TX LA FL (21 states) Enacted/ adopted: AL, AZ, CA , CO, CT, IL, ME, NE, NV, NJ, NM, NY, NC, OH, OK, OR, TN, VT, VA, WA and WV. HI passed a resolution. * laws vary – generally, approaches are either comprehensive programs or establish / increase penalties for assaults on nurses/healthcare personnel. Laws excluding nurses are not reflected . HI ANA June 2013

30. No easy answer…… • Crisis intervention • Workplace safety policies • Psychiatry • Weapons • Political Debate • Stereotyping • Bullying VIOLENCE AT WORK: IT’S NOT PART OF THE JOB

31. Resources • ENA Workplace violence toolkit – www.ena.org • Workplace Violence prevention for Nurses, CDC course WB1865-NIOSH Pub No. 2013-155 www.cdc.gov/niosh/topics/violence/training_nurses.html • Florida Hospital Association workplace violence toolkit www.fha.org/health-care-issues/emergency-preparedness/workplace-violence-toolkit.aspx • OSHA. Guidelines for preventing workplace violence for healthcare and social service workers. www.osha.gov/publications/OSHA3148/osha3148.html

32. Thank you! • Jacqueline Bassett, Mary Georgi-Doore, Mary Ramsrud, Lori Schneider, Kathleen Wang • Emergency Nurses’ Association • CDC jhoerner@kmc.org

33. American Association of Critical Care Nurses. (2004). Position statement: workplace violence prevention. www.aacn.org/WD/Practice/Docs/Workplace_Violence.pdf American Nurses Association. (2011). Workplace violence. Retrieved from Nursing World: http://www.nursingworkd.org/MainMenuCategories/WorkplaceSafety/worieplaceviolence American Psychiatric Nurses Association. (2008). Workplace violence: APNA 2008 position statement. Http://www.apna.org/14a/pages/index.cfm?pageid=3786 Association of periOperative Registered Nurses. (2011, November 28). Position statement workplace safety. http://www.aorn.org/search.aspx?searchtext=workplace%20safety.pdf Emergency Nurses’ Association. ENA Workplace violence toolkit. http://www.ena.org/practice-research/Practice/ViolenceToolKit/Documents/toolkitpg1.htm Gacki-Smith, Jennifer, et al. (2009, July/August). Violence against nurses working in US emergency departments. JONA, v 39, No 7/8 pp 340-349 Harrell,E. (2011). Workplace Violence, 1993-2009 (NCJ233231). Retrieved from Bureau of Justice statistics. http://www.bjs.gov/content/puv/pdf/wv09.pdf Mattox, EA, et al. Metal detectors in the pediatric emergency department: patron attitudes and national prevalence. PediatrEmerg Care. 2000 Jun; 16(3): 163-5 McPhaul, Kathleen M, and Lipcomb, Jane A. (2004, September). Workplace violence in health care: Recognized, but not regulated. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPerodicals?OJIN/Tableofcontent Meyer T, et al. Attitudes toward the use of a metal detector in an urban emergency department. Ann Emerg Med. 1997 May; 29(5); 621-4

34. National Institute for Occupational Safety and Health. (2002, April). Violence and occupational hazards in hospitals. Retrieved from Centers for Disease Control and Prevention. http://www.cdc.gov.niosh/docs/2002-101 Occupational Safety and Health Administration. (2004). Guidelines for preventing workplace violence for health care and social service workers. http://www.osha.gov/Publications/OSHA3148/osha3148.html Rankins RC, Hendey GW. Effects of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999 Jun; 33(6); 676-9 Rustin, TA. Reducing contraband in a psychiatric hospital thought the use of a metal detector. Tex Med. 2007 May; 103(5); 51-6. The Joint Commission. (June 3, 2010). Sentinel event alert: Prevention violence in the health care setting. http://www.jointcommission.org/sentinel_event_alert_issue_45_preventing_violence_in_the_health_care_setting Walsh, Jill, et al. (2011, November). Emergency Department Violence Surveillance Study. http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf