RECORD or PRINT THE CONFIRMATION ID This unique ID is displayed upon successful submittal of your answer form.

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1 2013 course one self-study course The Ohio State University College of Dentistry is a recognized provider for ADA, CERP, and AGD Fellowship, Mastership and Maintenance credit. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit house by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at The Ohio State University College of Dentistry is approved by the Ohio State Dental Board as a permanent sponsor of continuing dental education contact us p h o n e t o l l f r e e f a x e - m a i l smsosu@osu.edu w e b sterilization ABOUT this COURSE READ the MATERIALS. Read and review the course materials. COMPLETE the TEST. Answer the eight question test. A total of 6/8 questions must be answered correctly for credit. SUBMIT the ANSWER FORM ONLINE. You must submit your answers ONLINE --- from a link on this web page RECORD or PRINT THE CONFIRMATION ID This unique ID is displayed upon successful submittal of your answer form. ABOUT your FREE CE TWO CREDIT HOURS are issued for successful completion of this self-study course for the OSDB biennium totals. CERITIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. ALLOW 2 WEEKS for processing and mailing of your certificate. ABOUT your QUESTIONS Q: Who can earn FREE CE credits? A: EVERYONE - All dental professionals in your office may earn free CE credits. Each person must read the course materials and submit an online answer form independently. Q: What if I did not receive a confirmation ID? A: Once you have fully completed your answer form and click submit you will be directed to a page with a unique confirmation ID. Q: Where can I find my SMS number? A: Your SMS number can be found in the upper right hand corner of your monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for your office only, and, is the same for everyone in the office. Q: How often are these courses available? A: FOUR TIMES PER YEAR You will receive 4 per year (8 CE credits).

2 2013 course one WORKPLACE VIOLENCE: plans for prevention and tips for protection against incidents in the dental practice With incidents of workplace violence on the rise in the United States, it is imperative that all workplaces be well educated and fully informed as they deal with this daunting topic. This continuing education course will review the topic of violence in the workplace, discuss steps that can be taken to prevent or diffuse its effects and most importantly, explain how to create and implement an effective workplace violence prevention plan. INTRODUCTION While quality written by jessie f. e. tudortangeman ms, mba, msph, PhD edited by laura m cotton, ba carl m. allen, dds, msd karen k. daw, mba, cecm Here in the United States, we live in a nation of great diversity. While these differences add to the rich melting pot that is the American experience, they also help to create a complex society. It is this very complexity that can foster the disharmony that sometimes results in conflict and even violence. It is an unfortunate reality that we live in a world where violence can happen at any time and in any place. As we know too well, violence does not discriminate and can occur in schools, shopping malls, healthcare facilities, places of worship and any work environment. Workplace violence is considered by OSHA to be an occupational health and safety hazard and is defined as any violent act directed towards an individual at work. When viewing national statistics as a whole, the risk that an individual will become the victim of workplace violence appears to be low, but recent tragic events serve to highlight the fact that incidents of workplace violence appear to be on the rise. Even more alarmingly, when the incidences do occur, they are increasingly lethal in nature. Employees in the workplace can be subject to a variety of inappropriate behaviors that can easily escalate into threats, intimidation or violence and dental practices are no exception. The key to addressing the issue of workplace violence is prevention and intervention based policies implemented by the employer. In this CE, we will discuss: The prevalence of violence in the workplace Risk factors associated with workplace violence The perpetrators of violence in the workplace The warning signs that violence may be imminent Various types of behavior that can lead to violence Ways to minimize the risk of violence occurring in the workplace. Suggestions and guidelines for creation of a prevention plan Training techniques for staff members to help increase workplace safety

3 page 2 PREVELANCE Each year, approximately 2 million American workers report being a victim of some form of workplace violence; this number becomes even more striking when we realize that it includes only reported cases and in reality, the actual number of incidents is likely much higher. In addition to these 2 million individuals there are also 6.3 million workers threatened by violence each year and 16.1 million that are harassed in the workplace. More disturbing still is the fact that on average, 565 workrelated homicides occur each year and these murders comprise 10 percent of all fatal workplace injuries. In 2008, there were 30 incidents of workplace violence in which there were multiple fatalities. Recent statistics indicate a trend that suggests that lethal workplace incidents will continue to rise. RISK FACTORS INDIVIDUALS WORKING IN DENTAL PRACTICES OR ANY OTHER TYPE OF HEALTH CARE FACILITY SHOULD BE AWARE OF THE RISK FACTORS ASSOCIATED WITH THESE UNIQUE ENVIRONMENTS. Working directly with people who have the potential to become volatile (i.e. those in pain or under the influence of medication) A perception by patients that they are waiting too long to receive treatment Physically isolated work settings Buildings with inadequate security and that are often accessible to armed individuals Workplaces that are directly accessible to the public Locations with poor lighting inside and deficient lighting in the parking areas Insufficient staff training regarding workplace violence prevention Unsatisfactory workplace violence prevention plans in place PERPETRATOR PROFILES Healthcare facilities are unique in several respects: there is public access to the work site, staff members have close contact with the public on a regular basis, patients visit the practice in various states of physical and/or mental health, and staff can frequently be exposed to individuals seeking drugs and access to cash. These conditions provide a setting where there is ample opportunity for violence to occur. A review of available data indicates that healthcare workers are at a high risk for experiencing workplace violence. The Bureau of Labor statistics noted that there were 2,637 incidents of violent assault on hospital workers in 1999, which translates to a rate of 8.3 assaults per 10,000 workers. When compared to the rate of 2 per 10,000 workers in all private-sector industries combined, one can certainly acknowledge the significant risk posed to health care workers. While it is crucial that all threats be taken seriously and that the proper authorities be contacted immediately when they occur, it is difficult to predict in advance who may become the perpetrator of workplace violence. Patterns have emerged, however, that may point to individuals who are more likely to act out violently in the work environment. It is especially advisable to be on the lookout for the following: THE STRANGER: Possibly the most elusive perpetrator, the stranger has no link to the dental practice but gains entry to either commit robbery, physical or sexual assault, or various other crimes without warning. It is imperative that employees are vigilant and always aware of their surroundings and that they report, immediately, any individuals seen in workplace areas where they do not belong.

4 page 3 THE DISGRUNTLED EMPLOYEE: Always unpredictable and with a tendency to feel wronged by their employers for various reasons including reprimands, being placed on probation, accused of wrong doing, or terminated. These disgruntled employees and former employees can decide to act out via threats, harassment and even violence. THE TROUBLED EMPLOYEE: The troubled or stressed employee can reveal their distress in many ways. The once sociable assistant who begins to withdraw, the punctual hygienist who suddenly begins arriving late, and the conscientious front desk person who starts missing deadlines or whose general work performance begins to decline may all be exhibiting signs of a potential problem. These employees should be sought out and if necessary referred to some type of mental health service. It is crucial to pay attention to these behavioral changes in order to prevent the potential for the issues to escalate and possibly manifest themselves in violence, either self-inflicted or toward others. Managers should show empathy towards the victim while also stressing the obligation of the practice to ensure workplace safety for all who enter. They should request that the victim alert them if their safety in the workplace becomes a concern due to threats made by the perpetrator. Furthermore, the victim must be informed that should threats of, or actual, violence occur in the workplace, local law enforcement will be notified. THE DISTRESSED PATIENT: The patient or family member of a patient who has become frustrated by their perceptions of the quality of their care may resort to acting out violently as well. Healthcare providers should be alert for indicators that their patients emotional state may be deteriorating. Should a patient become quiet when normally talkative, appear more tense than normal, or begin using demeaning or derogatory language, it is important to remain calm and respectful and to present a caring and soothing attitude. Make every attempt to engage the patient in a productive dialogue that allows them to vent their concerns or frustrations. Review their treatment plan with them if this is creating the distress and explain thoroughly the rationale behind the treatment. Discuss the care the patient has received thus far, the progress that has been made and a projection of how long treatment will take. As long as the patient seems receptive, spending time to address their concerns can go a long way toward mitigating their distress and calming their attitude. A WORD OF WARNING WHEN ALL EFFORTS TO DIFFUSE A POTENTIALLY VOLATILE SITUATION WITH A PATIENT HAVE BEEN UNSUCCESSFUL AND THE DECISION IS THE ABUSIVE INDIVIDUAL: Abusive individuals with personal links to an employee including family members, a spouse, domestic partner, and boy or girlfriend can pose a significant threat to workplace safety. The physical violence, sexual, emotional and psychological abuse perpetrated by this individual can find its way from the employee s personal life into their professional one as the perpetrator begins to exhibit such behavior at the worksite. Such occurrences create danger not only for the intended victim but to bystanders as well. It is critical for managers to reach out to employees in a confidential manner should they suspect that they are experiencing abuse in their personal lives. MADE TO TERMINATE THE PATIENT RELATIONSHIP, DENTAL PRACTICES MUST ADHERE TO THE LAWS WITHIN THEIR STATE AS THEY PERTAIN TO THIS PROCESS. STEPS IN THE TERMINATION PROCESS, ESPECIALLY IN CASES WHERE THE PATIENT HAS NOT COMPLETED THEIR TREATMENT, MAY INCLUDE BUT ARE NOT NECESSARILY LIMITED TO: A THOROUGH DISCUSSION OF THE SITUATION WITH THE PATIENT, OFFERS OF ASSISTANCE AND REFERRAL TO A NEW DENTAL PROFESSIONAL FOR THE COMPLETION OF THEIR TREATMENT, AND A REQUEST FOR THE PATIENT S CONSENT TO TERMINATE THEIR RELATIONSHIP WITH THE PRACTICE. PRACTITIONERS SHOULD ALWAYS BE SURE TO REVIEW THE LAWS APPLICABLE TO THEIR HOME STATE TO INSURE THIS PROCESS IS HANDLED LEGALLY.

5 page 4 WARNING SIGNS TO WATCH FOR Aggressive behavior A pattern of conflicts with customers, vendors, patients, co-workers and/or supervisors Bringing a weapon to the workplace Inappropriate references about weapons and/or making threats about using weapons to harm or retaliate against someone Exhibiting a fascination with or approval of using violence as a means to solve a problem Making statements that indicate desperation in one s personal or professional life Threatening harm, either directly or in a veiled manner, to individuals Substance abuse Extreme fluctuations in moods or behaviors TYPES OF VIOLENCE Workplace violence can include any attempt, actual physical act, and/or statement or behavior that can result in intimidation, bullying, harassment or physical harm brought upon a worker in their work environment. Examples of workplace violence include: Destruction of property Indicating a desire to inflict harm Harassing individuals via demeaning, humiliating, or threatening comments or gestures Verbally attacking by the use of inappropriate language or insults Physical attacks of any nature It is vitally important that any acts of this nature be taken seriously and that any criminal acts are reported immediately to the proper authorities. REDUCING RISK The first step in reducing risk for the dental practice is to design and implement a workplace violence prevention plan. Such a plan can be integral in the prevention of injury and mortality amongst workers, patients and the community at large. These measures can eliminate the need for costly medical and mental health related services required for potential victims, and by providing a perception of concern and safety in the practice, improved morale can lead to greater productivity. Finally, by taking steps to prevent or mitigate violence in the workplace practice management can greatly reduce vulnerability to negligence lawsuits. THE WORKPLACE VIOLENCE PROTECTION PLAN The first and most logical step in the creation of a workplace violence prevention plan is to gather all pertinent information. It is helpful to begin by ascertaining the threat level at the particular facility including an examination of the crime statistics in the community that can be provided by local law enforcement authorities and can often be found through a quick internet search. In the initial stages of plan development, management should speak to staff members to gain insight into their perceptions of personal safety and to solicit suggestions on steps to improve workplace safety. Ideally, staff members should be surveyed annually with regard to their safety perceptions to provide a baseline and to allow for a comparison of perceptions from year to year. An annual review of survey results should reveal best practices and will also shine a light on areas that need improvement. During the information-gathering stage of plan development, management may wish to talk to confer with other dental practices in their area. By sharing this information, managers can help each other develop the most effective plans that are applicable to the situation in their area. Throughout the planning process, it is also extremely advisable for the practice manager to seek out and gain a thorough understanding of the legal obligation of the practice to provide a safe environment for both staff and anyone who visits the practice.

6 Page 5 PLEASE NOTE THAT ENFORCEMENT IS EVERY BIT AS IMPORTANT AS PLANNING OF YOUR WORKPLACE VIOLENCE PREVENTION PLAN. LANGUAGE THAT INDICATES A ZERO TOLERANCE POLICY REGARDING VIOLENT ACTIVITIES IN THE WORKPLACE MUST BE INCLUDED IN THE WRITTEN PLAN. ONCE THE PLAN IS COMPLETED IT MUST BE MADE CLEAR TO STAFF MEMBERS THAT MANAGEMENT WILL ENSURE THE PLAN WILL BE FOLLOWED AND THAT ZERO TOLERANCE WILL BE ENFORCED. KEY AREAS OF FOCUS Key areas of focus that should be addressed when developing a workplace violence prevention plan include the environmental design of the physical space, the administrative controls that can be put in place to ensure workplace safety and behavioral modification efforts necessary to control the risks associated with workplace violence. It is of note that legal counsel, human resource professionals, practice management professionals, local law enforcement and/or other applicable qualified professionals should be utilized during all phases of the in the writing and implementation of the workplace violence prevention plan. If possible, establish a safe room within the practice where staff members and patients may safely secure themselves should they be unable to evacuate safely during a violent incident. Access to the various physical spaces within the practice should be controlled as warranted. Dental practices must also ensure that proper interior and exterior lighting is available in all areas. Installing curved mirrors in hallways and other concealed areas will allow staff and visitors a better vantage point of their surroundings. Waiting areas should be comfortably arranged, but should not include furnishings that might be used as weapons. A peaceful and calming waiting environment can help to eliminate stress and might diffuse or deescalate anger or violence among patients. Use of deep service counters at the billing/reception areas and bullet resistant and shatterproof glass enclosures provide additional protection for staff. Practice exits should be well marked and placed in multiple locations and should be accessible to all members of your staff. Establish a safe meeting place outside of the building to ensure employees and patients are out of harm s way should a violent incident take place. Once gathered at the safe meeting place, designate an individual to make sure all personnel and patients are accounted for. ADMINISTRATIVE CONTROLS On the administrative level, there are important steps that management should take to put safety measures in place quickly at the policy level. ENVIRONMENTAL CONTROLS When reviewing environmental controls for workplace safety, the first area to focus on is communication. Can staff communicate with each other from all areas of the practice in the event of an emergency? It is a good idea to install emergency signaling devices, alarms and monitoring systems when and wherever possible. Such devices must be accessible to all personnel and training, including guidelines for when they should be used must be provided for everyone who works in the practice. Institute a sign-in procedure for all visitors so practice staff knows who is on the premises at all times. Develop, with input from all stakeholders, a proactive conflict resolution policy for internal and external grievances. Designate a liaison who will notify security personnel/police should threats of violence occur and be sure all employees are aware of this policy. Conduct regular staff meetings to address any current threats to the safety of the practice. Institute contingency plans for treating patients who may unexpectedly act out in an inappropriate manner. Make available the appropriate medical and/or mental health services needed should employees become the victim of a violent attack.

7 page 6 BEHAVIORAL MODIFICATION When creating a workplace safety plan, it is important to review staffing patterns and current behaviors and to modify any established routines that might be unsafe or unwise. Try to avoid having any staff scheduled to work alone, and if it is deemed necessary, encourage employees to leave in pairs or with on-site security personnel, particularly after dark Incidents of menacing or violent behavior should be documented as thoroughly as possible. Upon review at a later time, such documentation can indicate patterns and/or areas in which improvement is needed. Training created specifically for managers and supervisors is also beneficial and should also be conducted annually. Included should be methods for identifying high-risk situations and techniques for deescalating these situations. Managers should be given tips for recognizing and addressing employees who are potential targets for violence and how to communicate with them in a supportive and non-threatening manner. Managers should also be aware of resources that are available to refer troubled employees for assistance when necessary. Qualified trainers should instruct managers on how to evaluate current workplace violence prevention plans while stressing the importance for modification when warranted. STAFF TRAINING It is strongly recommended that staff safety training be conducted at every practice on an annual basis. Qualified, professional trainers should review a number of elements that include: A presentation of the written workplace violence plan that emphasizes that its purpose is to avoid or mitigate incidents of violence through preparation and vigilance. While it is painful to consider, violent episodes continue to occur in our society with troubling frequency. Health care practitioners provide essential services to their patients and their community in an open setting where stress and tension are frequently present. It is crucial then, that practices provide a safe environment for staff and patients alike. By creating a workplace violence prevention plan, reviewing it regularly and enforcing it with a zero tolerance policy, the practice can feel confident that they have taken every precaution possible in the fight against this insidious threat. A briefing on hazards specific to their workplace in particular. A review of the risk factors associated with violent incidents. An overview of methods that may be used to diffuse volatile situations and tips for dealing with hostile individuals. Exercises, possibly including role playing that highlight cultural sensitivity and other interpersonal skills. During the annual training session, as well as periodically throughout the year, safety drills should be conducted to review proper procedures in the event of an actual incident. Items reviewed should include the use of any communication systems, emergency signaling devices, alarms or monitoring systems. Staff members should be made aware of the current crime statistics within the local community as well as possible trends within the industry. JESSIE F.E. TUDOR-TANGEMAN MS, MBA, MSPH, PHD, HAS A LONG BACKGROUND IN THE FIELDS OF COUNSELING AND HUMAN SERVICES. SHE MOST RECENTLY RECEIVED HER PHD IN PUBLIC HEALTH WITH A FOCUS ON COMMUNITY HEALTH EDUCATION FROM WALDEN UNIVERSITY. SHE IS CERTIFIED IN SUICIDE PREVENTION AND CRISIS INTERVENTION AND HAS VOLUNTEERED IN THE MENTAL HEALTH FIELD AS BOTH A COUNSELOR AND TRAINER. TOPICS OF PRIOR CE COURSES AUTHORED BY DR. TUDOR-TANGEMAN INCLUDE MANDATORY REPORTING AND TREATMENT OF PATIENTS WITH A HISTORY OF SUBSTANCE ABUSE. SHE HAS ALSO CO-AUTHORED SEVERAL JOURNAL ARTICLES ON THE INTEGRATION OF DOMESTIC VIOLENCE EDUCATION IN THE DENTAL CURRICULUM AND HAS BEEN THE GUEST LECTURER FOR DENTAL AND DENTAL HYGIENE CLASSES. DR. TUDOR-TANGEMAN IS CURRENTLY EMPLOYED BY THE OHIO STATE UNIVERSITY COLLEGE OF DENTISTRY. REFERENCES ARE AVAILABLE UPON REQUEST DR. TUDOR-TANGEMAN CAN BE CONTACTED AT: TUDOR.9@OSU.EDU

8 instructions - answer each question online - press submit - record your confirmation id - deadline is March 1, test 1 T F Staff members should be surveyed annually regarding their perceptions of workplace safety. 2 T F Dental practices can refuse treatment to disruptive patients at their own discretion and without cause. 3 T F Managers should avoid seeking out or initiating conversations with troubled employees. 4 T F 5 T F 6 T F 7 T F Workplace violence is considered an occupational health and safety hazard by OSHA. Bullying, intimidation and harassment are all forms of workplace violence. Language that emphasizes a three strikes policy should be written into the Workplace Violence Prevention Plan. All threats of violence should be taken seriously and reported to authorities immediately. d i r e c t o r carl m. allen, dds, msd allen.12@osu.edu a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm daw.37@osu.edu p r o g r a m a s s i s t a n t laura m. cotton, ba cotton.1072@osu.edu l a b t e c h n i c i a n mei-ling shotts, bs shotts.5@osu.edu 8 T F Overall, health care workers are at a fairly low risk for incidents of workplace violence.