Workplace Violence

Violence in Health Care: What Nurse Managers Need to Know ¹

About 10% to 15% of the violence in the United States occurs in the workplace. Health care workers in particular face dramatically higher risks for nonfatal assault. Nonviolent crisis interventions and a detailed violence management and prevention plan prepare nurse managers for any situation.

Approximately 25 million people every year are victimized by fear and violence in the workplace. A conservative cost estimate of this violence is $4.3 billion annually or $250,000 per incident. This does not include hidden expenses from the emotional pain victims, witnesses and families suffer: depression, isolation and anxiety. In 1992, homicide became the leading cause of death in the workplace for women and the second leading cause of death for all workers. During the past decade, violence in the workplace has become a major cause for lost work time, lost productivity, occupational injury and even death.

According to the Bureau of Labor Statistics Census of Fatal Occupational Injuries, health care providers are at a 16 times greater risk for violence than other workers. Almost two-thirds of non-fatal assaults occurred in service industries, i.e., nursing homes, hospitals and establishments providing residential and other social services. Nonfatal assaults in health care institutions were primarily carried out against nursing staff.

Workplace violence can range in intensity from verbal threats, assaults and destruction of property, to threats of physical violence, actual physical violence and even homicide.

The circumstances of workplace violence also may vary and may include robbery-associated violence; violence by disgruntled clients, customers, patients, inmates, etc.; violence by co-workers, employees or employers; and domestic violence that finds its way into the workplace.

In many cases, violence in the workplace is never reported. Employees may believe that reporting will not benefit them, or they may fear that employers will perceive assaults as the result of employee negligence or poor job performance.

OSHA Guidelines

The Occupational Safety and Health Administration (OSHA) has identified health care settings as workplaces at a heightened risk for violence. In March 1996, OSHA issued Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers (3148-1996).

A number of key factors in the health care environment correlate with the increased risk of violence in health care, including:

1. The 24-hour open door policies for patient access.
2. The decrease in available treatment for the mentally ill and substance abuse patients resulting in the increasing number of acute and chronically mentally ill being released from hospitals.
3. The availability of drugs and money in hospital settings.
4. The prevalence of weapons among patients.
5. The current cost-cutting focus and widespread downsizing within the health care industry.
6. Working alone during the night or in early morning hours.
7. Traditional staffing-patterns—often low staffing levels at times of increased activity.
8. Circumstantial factors such as unrestricted movement of the public in health care settings, presence of gang members, drug or alcohol abuse, trauma patients, distraught family members, long waiting and the inability to obtain care.

These guidelines identify the core elements of a violence prevention program including (1) management commitment and employee involvement, (2) worksite analysis, (3) hazard prevention and control, (4) training and education and (5) record keeping and program evaluation. In addition to OSHA regulations, the Joint Commission Comprehensive Accreditation Manual for Hospitals addresses safety and security concerns regarding patients, visitors, employees and personal property.

The OHSA guidelines recommend a "zero" or "no" tolerance policy regarding violence in the workplace. Efforts must be made to minimize and eliminate violence and severity of injuries resulting from violent behavior. Any policy should support and encourage the reporting of all violence so that violent events can be followed up and that employees exposed to violence are provided appropriate medical care and counseling.

Training and Education

Nurse managers should seek management’s commitment to prevent violence. This involves working with management to identify violence, monitor violent events and determine if current interventions are effective. A written violence management and prevention plan should include monitoring and evaluation, training, incident follow-up, crisis counseling (debriefing) and prevention measures. It should establish policy and procedures and define violence.

An appropriate staffing plan is essential: a sufficient number, the right composition and enough experienced nurses. Staff should wear identification badges, adhere to visiting hours and monitor patient mobility. All staff must be trained in basic violence prevention and they must know the current emergency response procedures. Training should include didactic instruction and hands-on techniques. Nonviolent crisis interventions include: verbal intervention skills, self-protection skills and physical interventions. Verbal interventions include setting limits, verbal de-escalation of a crisis and the step-by-step management of individuals with weapons. Physical interventions include techniques for executing holds, takedowns and carries. Instruction levels should be based on the level of risk for violence in the employee work area.

Prevention and Intervention Strategies

Every employee should understand the concept of "Universal Precautions for Violence", i.e., that violence should be expected but can be avoided or mitigated through preparation. Staff should be instructed to limit physical interventions in workplace incidents whenever possible, unless there are adequate numbers of staff or emergency response teams and security personnel available. Frequent training also can improve the likelihood of avoiding assault.

Training programs should include all employees, including supervisors and managers. New and reassigned employees should receive an initial orientation prior to be assigned their job duties. Visiting staff, such as physicians, should receive the same training as permanent staff. Effective training programs should involve role-playing, simulations, and drills. Topics may include Management of Assaultive Behavior; Professional Assault Response Training; police assault avoidance programs, or personal safety training such as awareness, avoidance and how to prevent assaults. The emphasis should be on basic intervention skills. Remain calm, keep conversation going, set the expectation that the other person (whether it is a patient, family member, coworker etc.) will do the right thing, and allow enough space to provide alternatives or quickly exit the area.

Post Incident Response and Follow Up

When nurses encounter workplace violence, these violent events are to be reported as soon as possible and victims must receive appropriate medical care and crisis counseling. If the violent event is not followed up, the victims may be left feeling angry or abandoned. Such an experience can be avoided.

• Involve police and security immediately.
• Obtain emergency medical treatment.
• Notify management.
• Request trauma counseling or debriefing.

Debriefing should be a confidential process between the clinician and the victim and is usually accomplished in one or two sessions. If additional treatment is needed, referrals can be made by the trauma counseling staff to the Employee Assistance Program, or CARE program as it is known at UHS. (see phone contact list at end of this section)

Points to remember when seeking medical intervention:

1. Always report workplace incidences as soon as possible.
2. Fill out injury reports in detail. Be sure that you give enough information (such as home phone, work phone) so that you can be contacted later if necessary.
3. Report any problems to your supervisor and get assistance in filling out the report. You should always get the supervisor’s signature on the report.
4. Your supervisor may be able to make assignment changes that can lessen the impact of the situation.
5. If you are in a domestic violence situation outside of work, report the problem to Protective Services as well as your supervisor to protect yourself and others from potential workplace violence incidents.
6. The Employee Health and Wellness Clinic will take you as a walk-in if you experience bodily injury while on the job. For follow-up care, appointments should be made.
7. Your medical records are confidential and any information released requires an employee’s signature. Other employees are not privy to your information, with the only exception being Protective Services on a need to know basis for the protection of your fellow employees.

What do I do when an employee is a victim of family violence?²

All employers should have a policy in place that helps to support employees who are victims of violence. In addition to the obligation of the employer to ensure a safe working environment, it is also in the best legal and financial interests of employers to put such policies into place. It is estimated that anywhere from $3 to $5 billion dollars is lost every year from lost wages and productivity due to domestic violence (National Institute for Justice, 1995). There may be exceptional times when an employee finds it necessary to take time off for reasons related to domestic abuse. These may include time to go to court, finding babysitting, meeting with lawyers, attending counseling, etc. It is important that survivors of domestic abuse be afforded a leave of absence to attend to these personal needs, family duties and other special reasons.

Recommended Procedures for Safety and Protection in Family Violence Situations²

Staff Member

1. Notify your supervisor/manager of the situation and the possible need to be absent. Supervisors/managers cannot assist until an employee self discloses.
2. Discuss options available to you with your supervisor and Human Resources Administrator. (see contacts at end of this section)
3. Be clear about your plans for returning to work, taking time off.
4. Make arrangements for receiving your paycheck while you are absent.
5. Submit a recent photo to security personnel so that identification can be made if the abuser appears at your worksite.
6. Maintain communications with your Human Resources Administrator throughout your absence.

Supervisor/Manager

1. Be aware of unusual absences and/or behavior of employees as job performance concerns.
2. Be aware of signs of bruises to face, arms, etc. Remember, the employee must self disclose.
3. Consult with your local EAP counselor and/or Human Resources officer to discuss your concerns and how to approach the employee.
4. Maintain confidentiality at all times.
5. Contact the security office and make sure that the employee has provided a photo of the abuser and other pertinent information, such as the existence of a court protective order.
6. Be sensitive to the seriousness of the situation.

The goal of work place involvement in domestic violence cases is to protect the individual who is a victim of violence at work, while still maintaining normal activity at the work site. Once an employer becomes aware of the fact that an employee has a restraining order some of the following steps may help:

• Involve the survivor in the decisions to be made. Ascertain how public she/he wants to be. Be non-judgmental and sensitive, always letting her/him know how genuinely concerned you are for her/his safety.
• Make sure all employees know how to get help in case of an emergency. (e.g., overhead page code, or panic buttons) and assure that the employee has a way to summon help and that other employees are aware of it.
• Offer close on-site parking with a police/security escort.
• When possible, offer to change the hours of the employee to assure safety.
• Encourage the survivor to develop a safety plan with the assistance of their EAP counselor and/or their UHS protective services officer.

1 Reprinted from, "Violence in Health Care: What Nurse Managers Need to Know", Elliott, Pamela P., MSN, RN. Nursing Management. CE offering 11/30/99 at www. springnet.com/.

2 Reprinted with permission from: Polaroid Corporation Family Violence Resource Manual. November 1997.

REMEMBER - Prevention is KEY!

What can I do to reduce the potential for workplace violence in my area?

All Employees Should…

• Come to work with a positive attitude, heavy on compassion, understanding and customer service approach. Many violent situations between care givers and patients escalate when the patient is reacting in an impaired manner resulting in rude behavior, which the caregiver reacts to in an emotional rather than a professional manner.
• Dealing with a patient in understanding manner, rather than debating the appropriateness of the patient’s actions may reduce the level of hostility in the patient’s reactions to the caregiver.
• Do what you can to address patient issues as they occur. If the issue cannot be addressed by the employee, refer the patient to someone who may be able to help. This customer service oriented approach can many times help to diffuse potentially violent situations. When you show compassion, empathy and understanding, it allows the patient and their family to better understand their options and what you are able to do for them.
• Be vigilant of your surroundings and maintain awareness of what is going on around you at all times. Be alert to any situations or potential issues that may escalate into a violent situation.
• Everyone should be familiar with their own workspace and the people that belong there so that any strangers or suspicious people can be identified, their motives examined and any potentially violent situations resolved quickly.

In the case of a work place violence situation needing immediate assistance-contact your UHS Protective Services Dispatcher at 358-2465.

If an employee hears of a coworker with a problem potentially affecting the workplace, encourage the coworker to utilize the UHS system’s resources for intervention.

Human Resources -Employee Assistance Theresa Scepanski

358-2275 Helen Young, R.N.

The University Hospital’s Employee Assistance Program (EAP) is known as C.A.R.E. This program is a benefit provided to all UHS employees that provides counseling, information, and assistance in finding the right help to solve personal problems of any type. Services are contracted through a private counseling firm, and are free and confidential.

CARE
614-CARE or
1-800-657-4EAP

Deer Oaks Office Park, Bldg. 5, Suite 501
7272 Wurzbach, San Antonio, TX 78240