Background: Violence & Aggression. ED Violence Survey Study Mental Health Hospitals NCHA/NCNA Survey NCQC PSO SubmiDed Events

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Rebecca Harmon
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1 NCQC PSO Safe Tables Patient Violence & Aggression July 2015 Background: Violence & Aggression ED Violence Survey Study Mental Health Hospitals NCHA/NCNA Survey NCQC PSO SubmiDed Events 2 1

org/ienr/documents/enaedvsreportnovember2011.pdf 3 ED Violence Study: Reporting What contributes to underreporkng of violence among ED nurses? 1.

2 ED: Reporting Workplace Violence Physical Violence Verbal Abuse Did NOT report 65.6% 86.1% Did nokfy: Security 65.7% 44.9% Immediate Supervisor 64.2% 45.4% Other ED Nurses 63.2% 58.1% ED Physician 54.6% 37.9% Emergency Department Violence Surveillance Study, (November 2011)available at: hdp:// 3 ED Violence Study: Reporting What contributes to underreporkng of violence among ED nurses? 1. A percepkon that assaults are part of the job 2. An employee belief that reporkng will not benefit them 3. Assaults may be viewed as evidence of poor performance 4. Lack of insktukonal policies 4 2

Workplace Violence Experienced by ED Nurses Physical Violence % of ED Nurses Grabbed/Pulled 48% Hit/slapped/ punched 41% Spit on 36% Pushed/shoved/ thrown 28% Kicked 26% Verbal Abuse % of ED Nurses

3 Workplace Violence Experienced by ED Nurses Physical Violence % of ED Nurses Grabbed/Pulled 48% Hit/slapped/ punched 41% Spit on 36% Pushed/shoved/ thrown 28% Kicked 26% Verbal Abuse % of ED Nurses Sworn/cursed at 89% Yelled/shouted at 89% Called names 68% Threatened with legal ackon 52% Emergency Department Violence Surveillance Study, (November 2011)available at: hdp:// 5 ED Patient Characteristics & Activities Pa7ent Characteris7cs % of ED Nurses Under the influence of alcohol 56% Under the influence of drugs (illicit/ prescripkon) 47% Psychiatric pakent 45% Ac7vi7es Where Violence Occurs % of ED Nurses Triaging pakent 40% Restraining/subduing 35% Performing a procedure 29% 6 3

Psychiatric Hospitals CA DMH State Forensic PaKent PopulaKon: 1997 62% 2010 90% Staff assaults (2007-2010) increased 18% Psychiatric Technicians 30% RN s 52% 58% of

The employer did not conduct effeckve inspeckons and evaluakons of physical assault hazards 3.

4 Psychiatric Hospitals CA DMH State Forensic PaKent PopulaKon: % % Staff assaults ( ) increased 18% Psychiatric Technicians 30% RN s 52% 58% of staff report being adacked 7 CA DMH Citations $110 K in fines 1. Employees were not provided with effeckve training and instruckon 2. The employer did not conduct effeckve inspeckons and evaluakons of physical assault hazards 3. Facility did not maintain effeckve Injury and Illness PrevenKon Program (Program) procedures did not provide for communicakon to the employees the history and behavioral triggers of the hundreds of unsupervised individuals that they were expected to confront. 8 4

Clinical Decision Making: Effective Risk Assessment 18% of civilly commided pakents assault others 30-35% engage in fear- inducing behavior 66% of pakents who are a danger to others are likely to

5 Clinical Decision Making: Effective Risk Assessment 18% of civilly commided pakents assault others 30-35% engage in fear- inducing behavior 66% of pakents who are a danger to others are likely to engage in some type of violence within 72 hours of admission Small clusters of pakents are typically involved in a large number of violent incidents Newton VM, Elbogen EB, Brown Cl, Synder J, Barrick Al. Clincial decision- making about inpakent violence risk at admission to a public- sector acute psychiatric hospital. J AM Acad Psychiatry Law 2012; 40(2): VA- Behavioral Threat Management Program Program Goals 1. Facility preparedness 2. Successful interackon during first few minutes 3. Improved control of pakent s behavior 4. Delivery of beder & more complete medical care DisrupKve Behavior CommiDee PrevenKon & Management of DisrupKve Behavior Curriculum Incident Surveillance System Preven7on & Management of Disrup7ve Behavior Curriculum 1. General knowledge 2. Personal safety skills ( break away skills) 3. De- escalakon skills 4. TherapeuKc containment for out of control pakents PaKent Record Flags Behavioral Threat Management Program 10 5

6 VA- Behavioral Threat Management Program 11 NC Nursing Survey on Workplace Violence: Respondents 426 NCNA nurses Direct Care (62%) Nurse Supervisor/management (27%) Other (11%) Represented InpaKent unit (incl. Behavioral Hlth) (51%) ED or Primary Care/OutpaKent (35%) 27% 11% 62% 12 6

7 Assault in the ED Respondents reported witnessing assaults and adempts during the past month (29%) ED respondents witnessed a higher percentage of assaults and adempts during the past month (58%) ED nurses also reported greater likelihood of receiving training, needed medical treatment, counseling and Kme off 13 What Would Reduce Violence? 1. Provide more training (de- escalakon, situakonal awareness) 2. Greater security guard presence ( but number 1 response among direct care RN) 3. Technology: panic budons, metal detectors 4. Hold visitors & pakents accountable, laws enabling prosecukon 5. Increase staffing & improve planning (direct care RN) 14 7

8 Assault Support Direct Care RN responses: How many agreed or strongly agreed that they Were prepared to mikgate assault 51% Received strong support from employer ater the assault 40% Felt protected from further assault 26% Received needed medical care 53% Received follow- up and/or counseling 25% 15 NCNA Survey: Policies Ater an assault did you or someone on your behalf nokfy supervisor? Ater an assault did the affected employee nokfy their supervisor? Does your employer/facility have a policy for treatment post assault? Training is not offered on idenkficakon, prevenkon and management of violence or is offered no more frequently than every 5-10 years. Direct Care Nurse: 67% Yes Nurse supervisor: 96% Yes 67% Yes 22% Yes 16 8

9 NCQC PSO Database 17 Type of Violence/Aggression & Harm 50.0% Type of Violence/Aggression Event Reported to NCQC PSO January June 2015 AHRQ Harm Scale All Violence/Aggression Events Reported to NCQC PSO January June % 30.0% 20.0% 10.0% 0.0% No harm 16% Moderate harm 32% Mild harm 52% 18 9

Potential Causes of Violence & Aggression Internal factors Previous aggressive/violent behaviors Mental or physical condikons External factors Environmental

and ackons Care team characteriskcs SituaKonal/ InteracKonal Factors 19 Potential Causes of Violence & Aggression 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.

10 Potential Causes of Violence & Aggression Internal factors Previous aggressive/violent behaviors Mental or physical condikons External factors Environmental factors MedicaKon side effects SituaKonal/interacKonal factors Internal Factors External Factors Violence or Aggressive Behavior Incongruent organizakonal systems and ackons Care team characteriskcs SituaKonal/ InteracKonal Factors 19 Potential Causes of Violence & Aggression 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Poten7al Causes of Violence/Aggression Events Reported to NCQC PSO January June 2015 External Factors Internal Factors SituaKonal/InteracKonal Factors Unknown 20 10

Contribu7ng Factors Culture of safety, management Staff training Presence of policies PaKent- to- PaKent PaKent- to- Staff Self- Inflicted Clarity of policies CommunicaKon among team

11 Contributing Factors to Violence & Aggression 80.0% 60.0% 40.0% 20.0% 0.0% Poten7al Contribu7ng Factors to Violence/Aggression Events Reported to NCQC PSO January June 2015 Environmental Factors PaKent Factors Process Factors Staff Factors Reported Contribu7ng Factors Culture of safety, management Staff training Presence of policies PaKent- to- PaKent PaKent- to- Staff Self- Inflicted Clarity of policies CommunicaKon among team Human Factors: Stress 21 History of Violence/Aggression 100.0% Reported History of Violence/Aggression for All Violence/Aggression Events Reported to NCQC PSO January June % 60.0% 40.0% 20.0% 0.0% 1 prior episode MulKple prior episodes No prior episodes Subsequent episodes Not Reported 22 11

It is difficult to prevent patients from becoming aggressive Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2,3 2005 2013 34% Agree/Totally Agree

2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), 469-478. 3 Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20, 296-304.

12 It is difficult to prevent patients from becoming aggressive Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2, % Agree/Totally Agree Disagree/Totally Disagree Psychiatric Facility Staff 66% No Response Disagree Disagree Behavioral Health PaKents Agree Disagree 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20, Patients are aggressive because they are ill Psychiatric Nurse Response 1 15% 1% Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2, % Agree/Totally Agree Disagree/Totally Disagree No Response Psychiatric Facility Staff Agree Agree Behavioral Health PaKents Disagree Unsure 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20,

Patients are aggressive because of the environment they are in Psychiatric Nurse Response 1 1% Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2,3 2005 2013 49% 50%

University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), 469-478. 3 Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20, 296-304.

2,3 2005 2013 57% 43% Agree/Totally Agree Disagree/Totally Disagree No Response Psychiatric Facility Staff Disagree Disagree Behavioral Health PaKents Agree Disagree 1 Bock TM (2011) Masters

13 Patients are aggressive because of the environment they are in Psychiatric Nurse Response 1 1% Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2, % 50% Agree/Totally Agree Disagree/Totally Disagree No Response Psychiatric Facility Staff Agree Disagree Behavioral Health PaKents Agree Unsure 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20, Patients commonly become aggressive because [of perception that] staff do not listen to them Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2, % 43% Agree/Totally Agree Disagree/Totally Disagree No Response Psychiatric Facility Staff Disagree Disagree Behavioral Health PaKents Agree Disagree 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20,

Poor communication between staff and patients leads to patient aggression Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2 2005 2013 43% 57%

14 Poor communication between staff and patients leads to patient aggression Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response % 57% Agree/Totally Agree Disagree/Totally Disagree No Response Psychiatric Facility Staff Disagree Agree Behavioral Health PaKents Agree Agree 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20, The use of de-escalation is successful in preventing violence Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2,3 9% % Agree/Totally Agree Disagree/Totally Disagree Psychiatric Facility Staff 70% No Response Agree Agree Behavioral Health PaKents Disagree Agree 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20,

Physical restraint is sometimes used more than necessary Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2,3 30% Agree/Totally Agree

15 Physical restraint is sometimes used more than necessary Psychiatric Nurse Response 1 Psychiatric Facility Staff vs Behavioral Health Pa7ents Response 2,3 30% Agree/Totally Agree Disagree/Totally Disagree Psychiatric Facility Staff 70% No Response Disagree Disagree Behavioral Health PaKents Disagree Disagree 1 Bock TM (2011) Masters Thesis, Stellenbosch University, South Africa 2 Duxbury J, Whivngton R (2005) Journal of Advanced Nursing, 50(5), Pulsford D et al (2013) Journal of Psychiatric and Mental Health Nursing, 20, Management of Violence & Aggressive Behavior: The Process Help clinicians detect pakents at high risk Assist in idenkfying appropriate steps to manage risk Reduce number of injuries to staff & pakents 30 15

Recognition Understand PotenKal Causes of Violence & Aggression Conduct Individual Risk Assessment Communicate Risk 31 Conduct Individual Risk Assessment Do you use any risk assessment

16 Recognition Understand PotenKal Causes of Violence & Aggression Conduct Individual Risk Assessment Communicate Risk 31 Conduct Individual Risk Assessment Do you use any risk assessment tools in your organizakon to idenkfy pakents with potenkally violent or aggressive behaviors? PaKent Risk Factors Individualized Behavioral Care Plans Violence & Aggression Assessment Scale 32 16

17 Psychiatric Settings Variety of risk assessment tools available Brøset Violence Checklist (BVC) Violence Risk Screening- 10 (V- RISK- 10) Violence Screening Checklist (VSC) Brief RaKng of Aggression by Children and Adolescents Dynamic Appraisal of SituaKonal Aggression 33 Emergency and Acute Care Settings Emergency Department STAMP based on 5 behaviors Behavioral Cue Checklist (BCC) 17 queskons In- PaKent Units Aggressive Behavior Risk Assessment Tool (ABRAT) 34 17

STAMP Framework Staring Prolonged glaring at nurse while engaged in nursing prackce Absence of eye

Demeaning infleckon Increase in volume Anxiety Flushed appearance HypervenKlaKon Rapid speech Dilated

Expressed lack of understanding about ED processes Mumbling Talking under their breath CriKcizing

Slurring or incoherent speech Pacing Walking around confined areas such as waikng room or bed space

Checklist (BCC) More PredicKve Less PredicKve Only Violent Pa7ents More OVen in Pa7ents that Exhibited

back/forth to RN stakon Name calling Demanding adenkon InKmidaKon Sharp retorts Increased volume of

18 STAMP Framework Staring Prolonged glaring at nurse while engaged in nursing prackce Absence of eye contact (culture is a variable here) Tone and volume of voice Sharp or causkc retorts Sarcasm Demeaning infleckon Increase in volume Anxiety Flushed appearance HypervenKlaKon Rapid speech Dilated pupils Physical indicators of pain, grimacing, writhing, clutching body Confusion & disorientakon Expressed lack of understanding about ED processes Mumbling Talking under their breath CriKcizing staff or the insktukon just loudly enough to be heard RepeKKon of same/ similar queskons or requests Slurring or incoherent speech Pacing Walking around confined areas such as waikng room or bed space Walking back and forth to nurses area Flailing around in bed ResisKng health care 35 Behavioral Cue Checklist (BCC) More PredicKve Less PredicKve Only Violent Pa7ents More OVen in Pa7ents that Exhibited Violence Both Violent & Non- Violent Pa7ents Threat of Harm Clenched fists Irritability Walking back/forth to RN stakon Name calling Demanding adenkon InKmidaKon Sharp retorts Increased volume of speech Aggressive statements ResisKng healthcare Swearing Demeaning infleckon HumiliaKng remarks Prolonged staring Belligerence Pacing room 36 18

Aggressive Behavior Risk Assessment Tool (ABRAT) ABRAT Items Confusion/cogniKve impairment Anxiety AgitaKon ShouKng/demanding History of physical aggression Threatening to leave Physically

19 Aggressive Behavior Risk Assessment Tool (ABRAT) ABRAT Items Confusion/cogniKve impairment Anxiety AgitaKon ShouKng/demanding History of physical aggression Threatening to leave Physically aggressive/threatening History, signs/symptoms of mania Staring Mumbling Categories of Violence Risk Low Risk (0) Medium Risk (1) High Risk ( 2) Violent Pa7ents by ABRAT Score 1 1 Kim SC, et al (2012) Usefulness of Aggressive Behavior Risk Assessment Tool for prospeckvely idenkfying violent pakents in medical and surgical units. Journal of Advanced Nursing 68(2), Implementing Risk Assessment Consider what factors to assess QuanKtaKve risk assessment Clinical observakon Determine when to perform the assessment IdenKfy which assessment scale to use Do not label the pakent! 38 19

20 Communicate Risk Document risk assessment process Communicate with care team Translate potenkal risk into care plan (prevenkon phase) 39 Prevention PrevenKon Strategies Key PrevenKon ConsideraKons 40 20

21 Prevention Strategies What prevenkon strategies do you use to adempt to prevent violent or aggressive behaviors? 41 Prevention Strategies Implement prevenkon strategies appropriate for care sevng Environmental Assessments Security Rounding Limit Sevng Behavioral Contracts Time Out Token Economy 42 21

Key Prevention Considerations PaKent Incorporate structured risk assessment in care planning Include the pakent in the process (transparency) Staff Establish posikve pakent- staff alliance Ensure

22 Key Prevention Considerations PaKent Incorporate structured risk assessment in care planning Include the pakent in the process (transparency) Staff Establish posikve pakent- staff alliance Ensure staff is harmonious and ackng off same care plan Maintain self awareness Environment Minimize environmental factors that may impact behavior 43 De-escalation Immediate PrecauKons IntervenKons to De- escalate 44 22

Immediate Precautions Ensure Safety Move pakent to quieter room or open space (if possible) ADempt to de- escalate 45 Interventions to De-escalate If

23 Immediate Precautions Ensure Safety Move pakent to quieter room or open space (if possible) ADempt to de- escalate 45 Interventions to De-escalate If someone escalates up to the top of the safety ladder what do you get? What types of de- escalakon techniques are you using at your organizakon? 46 23

24 Interventions to De-escalate IdenKfy lead to adempt to de- escalate Do not leave the area ADempt de- escalakon techniques Ascertain what pakent actually wants & urgency Use empathekc non- confrontakonal approach Avoid excessive skmulakon, aggressive postures and prolonged eye contact Recruit family, friends, care managers to help 47 Response & Action IntervenKons to Halt AcKons Incident Management Ongoing Quality Improvement 48 24

incident 49 Where are violent/aggressive behavior events reported in your organiza7on?

25 Interventions to Halt Actions AcKvate behavior response team IdenKfy leader of responding team Develop and execute plan Close the loop - document and report the incident 49 Where are violent/aggressive behavior events reported in your organiza7on? A. Security B. Case Management C. Risk Management D. Safety/Quality E. Unit Manager/ Director 50 25

26 Incident Management Individual Case Conduct review within 72 hours of incident Talk to pakent, vickm of harm and witnesses Determine if behavior was related to symptoms of mental or physical illness Review behavior response process Provide staff support 51 Incident Management In the Aggregate Are staff adequately trained in recognikon & early intervenkon to de- escalate potenkal violence? Does the analysis reveal other info useful for clinical treatment of pakents? Are lessons learned from reviews incorporated into treatment plans to improve outcomes & safety for those conknuing to treat? 52 26

27 Ongoing Quality Improvement Examine how policies address: risk assessment for violence or aggressive behavior care for persons at risk, procedures for management of violence or Evaluate policy vs. prackce Develop measurement strategies 53 A Success Story in Our Own Backyard* IntervenKons Staff educakon on de- escalakon techniques Implement Response Team for crisis situakons Outcome: ReducKon in mechanical restraint use Conclusion ReducKon in mechanical restraint use is possible Strong leadership, staff buy- in, provision of feedback, and quality monitoring are key * Godfrey et al. (2014) Anatomy of a TransformaKon: A SystemaKc Effort to Reduce Mechanical Restraints at a State Psychiatric Hospital. Psychiatric Services, 65(1):

28 Is There a Better Way? PaKent refused all medicakon and became increasingly agitated. Immediately ater administering a psychotropic medicakon to pt against his will, Behavioral Health Hospital staff held pt in a physical hold. Pt struggled against the restraint then appeared to relax. Behavioral Health Hospital staff discovered that pt had shallow respirakons and a low pulse. Despite efforts to revive him, pt died... approximately one hour ater he was restrained. The medical examiner determined pt's exerkon against the restraint was a contribukng factor in his death. 55 Violence Prevention Programs Management commitment and employee involvement Worksite & event analysis Hazard reduckon and response Safety and health training Record keeping and program evaluakon The Joint Commission s 45th sen8nel event alert recommends that all healthcare facili8es iden8fy high risk areas and perpetrators of violence to pa8ents, and then ins8tute preven8on strategies to reduce the level of violence. Guidelines for PrevenKng Workplace Violence for Healthcare and Social Service Workers. OSHA R

29 Penalties for Violence Against Hospital Workers 57 Thank You for Sharing! Contact informakon: Nancy Schanz, Kara Lyven, 29

PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015

PATIENT AGGRESSION & VIOLENCE BEST PRACTICES NCQC PSO Safe Table July 2015 Minimize the impact of patient aggression and violence by focusing on various phases of the care process. RECOGNITION Understand