Workplace Violence Prevention Training Programs in Healthcare: An Analysis of Program Elements

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1 Workplace Violence Prevention Training Programs in Healthcare: An Analysis of Program Elements Sheila Arbury MPH RN Donna Zankowski MPH RN COHN

2 Disclaimer Views and opinions expressed in this presentation are those of the authors and do not necessarily reflect the policy of: The Department of Labor The Occupational Safety and Health Administration AOHP There are no financial or commercial conflicts of interests to disclose This research is pending publication in Workplace Health & Safety, the journal of AAOHN

3 Objectives Identify the essential elements of a comprehensive workplace violence (WPV) training program for Healthcare settings Evaluate the contents of available WPV training programs, and identify the essential elements that are lacking Identify the program elements and facility-specific content that is needed to supplement current WPV training programs

4 Outline Background on WPV in Healthcare Efforts to Reduce WPV This Research Methods Comparison of WPV programs to OSHA Guidelines Discussion of Findings Conclusions Recommendations to Healthcare Facilities Questions?

5 What is Workplace Violence? Workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers and visitors. (OSHA, Safety and Health Topics, Workplace Violence, 2014)

4 Types of WPV Type 1 Criminal Intent: the perpetrator has no legitimate relationship to the business or its employees, and

the most common type in healthcare settings.

settings, waiting rooms, and geriatric settings, but is not limited to these Type 3 Worker-on-Worker: violence between

It includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or

6 4 Types of WPV Type 1 Criminal Intent: the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence (robbery, shoplifting, trespassing) Type 2 Customer / Client: the most common type in healthcare settings. Includes patients, their family members, and visitors, and occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is not limited to these Type 3 Worker-on-Worker: violence between coworkers is commonly referred to as lateral or horizontal violence. It includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating and can range all the way to homicide Type 4 Personal Relationship: the perpetrator has a relationship to the nurse outside of work that spills over to the work environment. Photos and text courtesy of NIOSH Workplace Violence Prevention Training for Nurses (2013)

7 Background on WPV in Healthcare In 2014 rate of injury due to WPV in Healthcare and Social Service sector was 14.4 per 10,000 workers (BLS, 2014) By comparison, the rate in Private Industry is 4.0 per 10,000 There were 106 total fatalities in the Healthcare and Social Service sector, 28 of these fatalities were caused by WPV (BLS, Table A-1, 2014)

8 Why is there so much WPV in Healthcare? Photo courtesy of Microsoft Office Clipart

Factors R/T WPV in Healthcare Patient Related Factors: Patient in Pain Patient in Fear Working in Close Proximity Patient with Altered Mental Status Influence of Drugs/Alcohol

9 Factors R/T WPV in Healthcare Patient Related Factors: Patient in Pain Patient in Fear Working in Close Proximity Patient with Altered Mental Status Influence of Drugs/Alcohol Facility Related Factors: Understaffing Inadequate Security Physical Environment (NIOSH, Workplace Violence Prevention for Nurses (2013); Photo courtesy of Microsoft Office Clipart)

10 What has been done to reduce WPV in Healthcare? OSHA Guidelines (1996, 2004, 2015) Early WPV prevention training programs developed in Canada, and the VHA State Legislation NIOSH Training ANA and ENA advocacy and training Multiple private companies developed their own WPV training programs for commercial use

11 Prior Work in Evaluating WPV Training Morrison and Love (2003) did research on 4 WPV training programs used in Psychiatric settings. They evaluated: Content; Feasibility; Psychological comfort of staff; Effectiveness and Cost Farrell and Cubit (2005) looked at 28 programs sold internationally (6 from the USA). They evaluated 13 elements: Orientation; Cost; Cause; Type of violence; Risk; Communication; Pharmacology; Physical interventions; Restraints; Seclusion; Legal Issues; Leadership; and Debriefing

12 The Irish Health Service: Recommendations for Education and Training Education and training in the management of work-related aggression and violence be provided to all healthcare employees. The content and methodology of education and training to correspond to participants professional and organisational responsibilities. Education and training to include lone working, conflict resolution and the management of verbal aggression. The safety of physical intervention techniques be established as a priority. (Excerpts from Linking Service and Safety, pg. 13, McKenna, 2008)

13 This Research Project At the Request of OSHA OOMN, we looked at the question: What content is covered in workplace violence (WPV) prevention training programs used in healthcare settings in the United States today? Are there gaps in this training? How do these programs compare to specific criteria determined by a comprehensive literature review, and OSHA s WPV Guidelines training topics?

14 Methods Compile a comprehensive list of Program Elements Contact WPV prevention training companies, and ask permission to review their training materials (company will not be identified) Review all provided materials (12 companies responded) Code data and enter into database (excel and SPSS) Coding key for program elements: 1 = No no evidence of any kind 2 = Yes limited evidence 3 = Yes considerable evidence Analyze results

15 Program Elements to be Evaluated 1. Are there different levels of training available (specify) 2. Is it a Train-the-Trainer program 3. Is a training manual given to staff 4. Are on-line resources available to staff 5. Risk factors for workplace violence discussed 6. Orientation discussion of facility layout, policies and procedures, emergency planning, calling for help 7. Discussion of facility risk assessment 8. Situational threat assessment 9. Types of workplace violence discussed (NIOSH 4 types)

16 Program Elements (Cont.) 10. Recognition of planned vs. unplanned violence 11. Early recognition of escalating behavior taught 12. Are de-escalation techniques taught 13. Are de-escalation techniques practiced 14. Are extrication and evasion techniques taught 15. Are extrication and evasion techniques practiced 16. Is restraint training taught 17. Is restraint training practiced 18. Are risks associated with physical restraint discussed 19. Are certain types of restraint prohibited

17 20. Is a team approach taught Program Elements (Cont.) 21. Is there a discussion of pharmacology 22. Are safety techniques for working alone discussed 23. Is there a discussion of legal issues 24. Are reporting requirements discussed 25. Is info on multicultural diversity given 26. Is debriefing discussed Worker focused (injuries, need counseling/eap, resources given) 27. Is data supporting the effectiveness of the program given 28. Is data supporting the effectiveness of the program cited for further review are References given

Results Majority of reviewed training programs included: Train the trainer approach De-escalation of potentially violent situations Practice of de-escalation techniques Evasion/extrication with

18 Results Majority of reviewed training programs included: Train the trainer approach De-escalation of potentially violent situations Practice of de-escalation techniques Evasion/extrication with practice Restraints and holds Team approach Minority of reviewed training programs included: Facility-specific workplace violence risk assessment and policies Predatory violence Working alone Worker post-event follow-up Evaluation of program effectiveness

19 Graphic Comparison of 12 Reviewed Programs to Review Criteria Facility policies Facility-specific risk factors Early recognition Teach de-escalation Evasion/extrication Restraints and holds Predatory violence Team approach Yes - signficant evidence Yes - limited evidence No evidence Reporting violence Multicultural info Worker Follow-up Program evaluation 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

20 Discussion of Program Gaps Facility-specific assessment: Customization = facility can include/exclude topics Leads to overlooking facility s distinctive risks Ignores facility workplace violence policies and procedures Result: facility management must do their own training on facility-specific information Working alone: High risk not addressed; example: admitting patient on night shift w/o other staff near by One program has optional module added at client s request Information on Facility's Risk Assessment 75% 17% 8% Yes - Significant Content Yes - Limited Content No - No Content

21 Discussion of Program Gaps Post-event follow-up for workers Emphasis on therapeutic relationship with violent patients Possible worker needs: Medical treatment Psychological support Stress debriefing Counseling EAP Worker Post-Event Follow-Up 58% 17% 25% Yes - Significant Content Yes - Limited Content No - No Content Worker rights: complaints to state agencies or OSHA protected under whistleblower laws

Discussion of Program Gaps Restraints and Holds Teaching content dependent on: Training program s theoretical constructs Client facility s policies

22 Discussion of Program Gaps Restraints and Holds Teaching content dependent on: Training program s theoretical constructs Client facility s policies Risks of harm unless performed correctly Controversial in some settings Use not evidence-based Workers may not receive adequate preparation/understanding

Discussion of Program Gaps Legal issues: Legal definitions of types of assault State laws requiring workplace violence prevention programs OSHA

23 Discussion of Program Gaps Legal issues: Legal definitions of types of assault State laws requiring workplace violence prevention programs OSHA citations for inadequate worker protection Possible employer liability for negligence Multicultural content: increase staff sensitivity to cultural differences

24 Discussion of Program Gaps Predatory violence vs. spontaneous; planned vs. reactive Predatory: grudge vs. individual healthcare worker leads to planned attack Reactive: emotional response occurring in the moment Predatory violence less common and harder to prevent Training programs teach reactive violence prevention Workers should be aware of predatory violence

Discussion of Program Gaps Evaluation of program effectiveness in systematic data-based approach Evident in this training program review Lack of evaluation noted in workplace

25 Discussion of Program Gaps Evaluation of program effectiveness in systematic data-based approach Evident in this training program review Lack of evaluation noted in workplace violence literature Data collection Number/location of violent incidents Details of each event Tracking of events over time Research that supports program s theoretical basis

26 Small sample size: 12 programs Limitations Limited program information Programs controlled by client facilities restrictions Exclusion of content Less training for workers

Conclusions Need to integrate contracted workplace violence prevention program into facility s own program Incorporate 5 building blocks of OSHA Guidelines Base program on facility-specific

27 Conclusions Need to integrate contracted workplace violence prevention program into facility s own program Incorporate 5 building blocks of OSHA Guidelines Base program on facility-specific information Supplement contracted program with customized on-site training Facility risk assessment Organizational policies and procedures Emergency action plans Facility communication systems Post-incident debriefing and follow-up policies

Applying Research to Practice Occupational healthcare professionals should: Know the content of the workplace violence prevention training conducted at their facility.

28 Applying Research to Practice Occupational healthcare professionals should: Know the content of the workplace violence prevention training conducted at their facility. Notify management of training gaps; for example, the lack of facility-specific risk assessment. Understand the physical and psychological effects on workers who experience violent incidents and arrange for appropriate services and support.

29 References Bureau of Labor Statistics. (BLS). (2014). News Release Nonfatal occupational injuries and illnesses requiring days away from work. Retrieved from: Bureau of Labor Statistics. (BLS). (2014). Table A-1. Fatal occupational injuries by industry and event or exposure, all U.S Retrieved from: Farrell, G. Cubit, K. (2005). Nurses under threat: A comparison of content of 28 aggression management programs. International Journal of Mental Health Nursing, 14, Howard, J. (1996). State and local regulatory approaches to preventing workplace violence. Occupational Medicine, 11, Lehmann, L.,S., Padilla, M., Clark, S., Locks, S. (1983). Training personnel in the prevention and management of violent behavior. Hospital and Community Psychiatry, 34, Lipscomb, J. A., El Ghaziri, M. (2013). Workplace violence prevention: improving front-line healthcare worker and patient safety. New Solutions, 23, Lipscomb, J., McPhaul, K., Rosen, J., Brown, J.G., Choi, M., Soeken, K., Porter, P. (2006). Violence prevention in the mental health setting: the New York state experience. Canadian Journal of Nursing Research, 38,

30 References (cont.) Madden, D.J., Lion, J.R., Penna, M.W. (1976). Assaults on psychiatrists by patients. American Journal of Psychiatry, 133, McKenna, K. (2008). Linking Service and Safety: Together Creating Safer Places of Service. Health Service Executive Ireland. ISBN: McPhaul, K.M., London, M., Murrett, K., Flannery, K., Rosen, J., Lipscomb, J. (2008). Environmental evaluation for workplace violence in healthcare and social services. J Safety Res. 39, doi: /j.jsr Epub 2008 Mar 26. Morrison, E.F., Carney-Love, C. (2003). An evaluation of four programs for the management of aggression in psychiatric settings. Archives of Psychiatric Nursing, 17, National Institute for Occupational Safety and Health. NIOSH. (1996). Current Intelligence Bulletin 57: Violence in the Workplace. National Institute for Occupational Safety and Health. NIOSH. (2002). Violence: Occupational Hazard in Hospitals. Publication Number National Institute for Occupational Safety and Health. NIOSH. (2013). Workplace Violence Prevention for Nurses. CDC Course No. WB 1865 NIOSH, Pub. No Occupational Safety and Health Administration (OSHA). (2015). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. OSHA Publication R.

31 References (cont.) Peek-Asa, C., Casteel, C., Allareddy, V., Nocera, M.A., Goldmacher, S., O Hagan, E., Harrison, R. (2007). Workplace violence prevention programs in hospital emergency departments. Journal of Occupational and Environmental Medicine, 49, Peek-Asa, C., Howard, J., Vargas, L., Kraus, J.F. (1997) Incidence of non-fatal workplace assault injuries determined from employer s reports in California. Journal of Occupational and Environmental Medicine, 39, Rosen, J. (2001). A labor perspective of workplace violence prevention. Identifying research needs. American Journal of Preventive Medicine, 20, St. Thomas Psychiatric Hospital (1976). A program for the prevention and management of disturbed behavior. Hospital and Community Psychiatry, 27, The Joint Commission (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, Issue 40. Retrieved from The Joint Commission (2010). Preventing Violence in the Healthcare Setting. Sentinel Event Alert, Issue 45. Retrieved from Wassell, J.T. (2008). Workplace violence intervention effectiveness: A systemic literature review. Safety Science, 47,

32 Questions contact Sheila Arbury at: contact Donna Zankowski at:

Violence In The Workplace

Violence In The Workplace Preventing and Responding to Violence in The Medical Practice Workplace Presented by Tom Loughrey Economedix, LLC From The National Institute of Occupational Safety and Health