VIOLENCE PREVENTION PLANNING Participant s Guide

Transcription

1 VIOLENCE PREVENTION PLANNING Participant s Guide The

2

3 September 2008, Occupational Health and Safety Agency for Healthcare (OHSAH) in British Columbia. All rights reserved. Although OHSAH encourages the copying, reproduction and distribution of sections of this guide to promote effective Joint Health and Safety activities in the Healthcare Industry; OHSAH, or the organization OHSAH has noted as owner of certain excerpts, should be acknowledged. Written permission must be received from OHSAH if any part of this publication is used for any other publication or other activities for profit. Special thanks to: Worksafe BC for allowing reprint of OSH Regulations, OHS Act, and other materials, and, the HELP Advisory Group: Alison Hutchison, FHA Allen Peters, OHSAH Ana Rahmat, HEU Andrew Whyte, NHA Anita Chau, OHSAH Anita Jezowski, VIHA Dave Keen, FHA David Bell, OHSAH Della McGaw, HEU Frances Kerstiens, HEABC Gurjit Loodu, PHSA Jackie Spain, OHSAH Jacqueline Per, VCH Jaime Guzman, OHSAH Also thanks to our partners: BC Government & Service Employees Union British Columbia Nurses Union Health Employers Association of BC Provincial Health Services Authority Vancouver Island Health Authority British Columbia Institute of Technology University of Northern British Columbia BC Public Service Agency Healthcare Benefit Trust Jeanette Pedersen, OHSAH Joe Divitt, OHSAH Jolene Simpson, OHSAH Karen LaCombe, HEABC Kathryn Wellington, OHSAH Lara Acheson, BCNU Lynn MacDonald, NHA Marjorie Brims, IHA Michael Sagar, WorkSafeBC Mona Sykes, BCGEU Natasha Sharwood, OHSAH Paul Elsoff, VCH Stacey Grant, IHA Tracy Larsen, VIHA Hospital Employees Union Health Sciences Association of BC Fraser Health Authority Interior Health Authority Vancouver Coastal Health Authority Simon Fraser University University of British Columbia BC Ministry of Health Services Northern Health Authority Questions? Contact OHSAH s Healthcare, Education & Learning Program: Mail: Suite West Broadway, Vancouver, BC V6H 3X5 Phone: Toll free: Fax: E: train@ohsah.bc.ca

4

5

6

7 Provincial Violence Committee Contacts Affiliate PHSA Kathleen Strath Kathryn Wellington FHA Alison Jones Alison Hutchison David Keen IHA VCH Carole Taylor Rob Senghera Leslie Gamble Jacqueline Per NHA VIHA Lynn MacDonald Tracy Larsen Frank Talarico Ministry of Health Helen Coleman Judy Thompson Janet Nobert Donna Langford BCGEU HSABC Darryl Walker Marty Lovick Mona Sykes Carol Riviere BCNU HEABC Marg Dhillon Frances Kerstiens Lara Acheson Karen LaCombe Sherry Parkin Deb Niemi HEU WorkSafeBC Jennifer Whiteside Michael Sagar Joyce Winter Della McGaw UPN OHSAH Sherry Moller Andrea Lam Charles Ballantyne Catherine Trask Chris Back Joe Divitt

8 Resource Contacts OHSAH West Broadway Vancouver, BC V6H 3X5 Bus: BC Nurses Union 4060 Regent Street Burnaby, BC V5C 6P5 Bus: Workers Compensation Board of BC 6951 Westminster Highway Richmond, BC V6B 5L5 Bus: BC Ministry of Health In Vancouver call: In Victoria call: Elsewhere in BC call: Canadian Centre for Occupational Health & Safety 135 Hunter Street East Hamilton, Ontario Canada L8N-1M5 Bus: Hospital Employees Union 5000 North Fraser Way Burnaby, BC V5J 5M3 Bus: National Institute for Occupational Health & Safety Robert A. Taft Laboratories 4676 Columbia Parkway Cincinnati, OH USA Bus: Canadian Labour Congress 2841 Riverside Drive Ottawa, Ontario K1V 8X7 Bus: Human Resources and Social Development Canada Regional Office and the Vancouver District Office Harry Stevens Building th Avenue East Vancouver, British Columbia V5T 1Z3 Telephone: , local Toll free: (B.C. only) Canadian Public Health Association (CPHA) Carling Ave Ottawa, Ontario K1Z 8N8 Bus: Health Employers Association of BC West Broadway Vancouver, BC Bus: Ontario Safety Association for Community & Healthcare (OSACH) Yonge Street Toronto, Ontario M2N 6K1 Bus: Health Sciences Association Joyce Street Vancouver, BC V5R 4H1 Bus: Healthcare Benefit Trust West Broadway Vancouver, BC V6H 4C1 Bus: International Agency for Research on Cancer 150 Cours Albert Thomas F Lyon, Cedex 03 France United Food and Commercial Workers Union 4021 Kingsway Burnaby, BC V5H 1Y9 Bus: Health Canada Bus: BC Government & Services Employees Union 4911 Canada Way Burnaby, BC V5G 3W3 Bus: Douglas Street Victoria, BC V8T 4N4 Bus: Bus:

9 Helpful Websites US Occupational Health & Safety Administration American Industrial Hygiene Association Canadian Centre for Disease Control Human Resources Development Canada National Institute for Disability Management and Research American Conference of Governmental Industrial Hygienists Environmental Protection Agency World Health Organization MSDS Search Medical Research Council of Canada

10

11 Healthcare Education & Learning Program Violence Prevention Planning Action Plan Use this worksheet to keep track of actions you would like to take when you return to the workplace, and/or your committee activities Action Items Target Date Completed? 1

12 Violence Prevention Planning Healthcare Education & Learning Program 2

13 Healthcare Education & Learning Program Violence Prevention Planning 3

14 Violence Prevention Planning Healthcare Education & Learning Program 4

15 Healthcare Education & Learning Program Violence Prevention Planning 5

16 Violence Prevention Planning Healthcare Education & Learning Program 6

17 Healthcare Education & Learning Program Violence Prevention Planning H&S Roles and Responsibilities Program Elements Safety Program Documents: Management Supervisors Joint Health & Safety Committee Ensure Safety Program roles and responsibilities are documented Assist in manual preparation and procedure development Review manuals and comment for improvement Safe Work Procedures: Ensure procedures are developed and enforced Train staff in procedures and enforce compliance Review procedures and recommend improvement Documented Inspection Procedures: Designate supervisors who will conduct inspections Conduct supervisory inspections, correct unsafe conditions Conduct inspections, recommend corrective actions Accident Investigations and Reports: Review all investigations, prevent recurrence. Participate in investigations, prevent recurrence Participate in investigations; Make recommendations Joint Health & Safety Committees: Assign appropriate management staff to committee Serve if appointed, facilitate activities of committee Meet, promote, recommend and keep minutes Management System: Set policy, review performance, set goals, recognize achievements Report activities, suggest improvements, enforce safety rules Review department activities, training needs, accident trends Workers Be aware of program, JOHSC membership, cooperate with JOHSC Follow safe work procedures, report problems, accidents Assist inspectors, cooperate with inspection teams Cooperate with investigation teams Support committee activities, report safety concerns to immediate supervisor & JOHSC Mentor safe work practices, report safety training needs 7

18 Violence Prevention Planning Healthcare Education & Learning Program 8

19 Healthcare Education & Learning Program Violence Prevention Planning 9

20 Violence Prevention Planning Healthcare Education & Learning Program 10

21 Healthcare Education & Learning Program Violence Prevention Planning Sample Worksheet - Information Summary Date/Time Data Source Incident Description Occupation Involved 11/17/05 7:30 am Incident Report Grabbed Arm Lab Tech 12/15/05 1:15 pm Incident Report Client spit at care aid during bathing Care aid 12/22/05 Incident Report/Police Report Patient grabbed and choked nurse Nurse 1/6/05 Police reports Neighbourhood crime profile thefts from cars All Incident Locations Patient Room Bathroom/ bath Secured ward Neighbourhood Contributing Factors Working alone Patient upset due to unusual routine Client agitated due to noise and lack of privacy Late medication Patient hidden in alcove Dark parking lots Gang activity Corrective Actions Reassess Work in pairs Assess client bath time Assess alcove block it off Communicate risk to workers Action Following Incident First aid Report only Time loss 11

22 Violence Prevention Planning Healthcare Education & Learning Program Risk Factors (Hazards) for Violence Environmental - Physical and Social Physical Noise levels Workplace design Clutter Home like environment Lighting Air quality/temperature Isolated area Equipment/tools that could be used as weapons Secure worksite Social Safety culture Team work Co-worker support Interpersonal relationships Communication styles Communication tools(book; shift change) Individual /Client and worker Client physical and mental health Medications Drug dependence Family support Early morning routines Waiting for meals Rule enforcement Worker knowledge Worker skills Worker abilities Worker experience Worker demographics - age, gender, ethnicity Workload effects Working alone Organizational - Policies, procedures, work process, training Communication processes Policies, standards and procedures (e.g., scheduling, staff development and training, working alone procedures) Budget considerations 12

23 Healthcare Education & Learning Program Violence Prevention Planning Hazard Evaluation and Control Case Studies Hazard Program Area - Violence Prevention Community Care Helen, a community health worker, has several clients assigned who live in rural areas north east of Castlegar. The only access to their homes is via a gravel road in the mountainous area. On a number of visits she has been worried about working alone, and wished that she had some way of communicating with the office or emergency personnel in case of an emergency. She also worries what she might do if her car broke down. It is almost an hour drive to the client s residence. She has asked for a cell phone, but her agency did not supply them, and there were dead zones along the route anyway. In February, on her last visit to one of the client s homes, she became very frightened over an incident with a shotgun. The client is an elderly, slightly senile man. He is becoming increasingly moody and is sometimes unpredictable. On this visit he has a loaded shotgun standing in the hallway. Helen looked at it when she arrived and asked what it was for. To protect myself what do you think?! said the client. It was clear he was in one of his moods, so Helen dropped the matter. While she was working in the kitchen, she heard shots in the front room. She ran to see what happened, and there was her client, shooting out the window. Get out of here! he shouted, they are out there again! Helen looked and saw that there was nothing there. He had imagined someone standing out there in the snow. She managed to convince him that all was okay, and to put the gun away. While driving home at dusk, Helen worried about her next visit. She asked you to address her concerns. Use the Risk Factors (Hazards) for Violence Worksheet and complete as much of it as you can, using the information above. Identify all of the potential hazards. Determine what other information you would like to have and where you need to go to obtain it. (If time permits, develop your recommendations. Determine what obstacles you may encounter in having them implemented.) Community Care Dialysis Unit Two healthcare workers and a unit clerk staff a community dialysis unit on Vancouver Island. Community outpatients are scheduled for dialysis through the day, and the clinic is open from 7am to 7pm. It has been busier lately and staff has been working a lot of overtime to cover the 12-hour operation. To complicate matters, one of the nurses has been ill and has not been replaced because of nursing shortages. Sometimes patients are late for appointments and often a client will have to wait their turn. One of the clients has become very upset because of this, and has been verbally abusive to staff. Complete the Risk Factors (hazards) for Violence Worksheet as much as possible, using the information above. After discussing possible solutions, suggest what elements of a violence prevention program may be needed in the community unit. 13

24 Violence Prevention Planning Healthcare Education & Learning Program Worksheet 1 - Risk Factors (Hazards) for Violence Environmental Physical and Social Individual /Client and worker Organizational - Policies, procedures, work process, training 14

25 Healthcare Education & Learning Program Violence Prevention Planning 15

26 Violence Prevention Planning Healthcare Education & Learning Program 16

27 Healthcare Education & Learning Program Violence Prevention Planning Worksheet 2 - Risk Reduction Planning Worksheet Job or Job Task: Hazards: 1) 2) Level of Risk List recommended control measures using the table and hierarchy below. If a control is not possible, move to the next category. Category Hazard Control Measure Practicable? Elimination Substitution Engineering Control Administrative Control PPE

28 Violence Prevention Planning Healthcare Education & Learning Program 18

29 Healthcare Education & Learning Program Violence Prevention Planning Worksheet 3 - Intervention Action Plan Risk Factor(Hazard): Level of Risk High Medium Low Current Policies and Procedures Possible Interventions/ Controls Chosen Control & Objective Activity Timeline Person Responsible Resources Required Status Monitoring and Evaluation Activities Certified Complete: Certified Complete: (Employer Representative) Date (Worker Representative) Date 19

30 Violence Prevention Planning Healthcare Education & Learning Program 20

31 Healthcare Education & Learning Program Violence Prevention Planning Community Clinic Scenario Narrative Community Clinic is in a typical West Coast BC small city (e.g. Nanaimo, Victoria, Campbell River, Prince George, Powell River, Courtenay). The clinic is funded directly by the Health Authority and it is within a few minutes walk of the downtown core. The clinic serves the primary health needs of various at risk portions of the public. The clinic is also responsible for the region s harm reduction strategy. The clinic is open six days a week Monday to Saturday 9am to 12 midnight. Specifically, the clinic provides the following services: A well-baby clinic aimed at single moms Low income seniors clinics STDs/HIV/AIDS clinic Hep/IV drug harm reduction (including methadone treatment) Needle Exchange Youth@risk counseling GP services for the above patients The staff mix in the day shift is: Two GPs Two clinical nurse practitioners One specialist or one counselor (depending on the day of the week) A dispensary/meds RN Two unit clerks During the evening (5-12am) staffing consists of a GP, a CNP, a counselor or other specialist and one unit clerk. The harm reduction clinics are held in the evenings and serve a young population. Often seniors and young moms with their babies have appointments in the late afternoon or in the evening as well. Several incidents have recently occurred resulting in this risk assessment. On three occasions when the unit clerk has been away in the back, fights have broken out in the waiting room. In another room, a patient threatened a doctor while they were alone in Exam Room 1. And, finally, an unruly patient reached over the counter and grabbed a unit clerk. 21

32 Violence Prevention Planning Healthcare Education & Learning Program Community Clinic 22

33 Healthcare Education & Learning Program Violence Prevention Planning Worksheet 1 - Risk Factors (Hazards) for Violence Environmental Physical and Social Individual /Client and worker Organizational - Policies, procedures, work process, training 23

34 Violence Prevention Planning Healthcare Education & Learning Program Worksheet 2 - Risk Reduction Planning Worksheet Job or Job Task: Hazards: 1) 2) Level of Risk List recommended control measures using the table and hierarchy below. If a control is not possible, move to the next category. Category Hazard Control Measure Practicable? Elimination Substitution Engineering Control Administrative Control PPE

35 Healthcare Education & Learning Program Violence Prevention Planning Worksheet 3 - Intervention Action Plan Risk Factor(Hazard): Level of Risk High Medium Low Current Policies and Procedures Possible Interventions/ Controls Chosen Control & Objective Activity Timeline Person Responsible Resources Required Status Monitoring and Evaluation Activities Certified Complete: Certified Complete: (Employer Representative) Date (Worker Representative) Date 25

36 Violence Prevention Planning Healthcare Education & Learning Program 26

37 Healthcare Education & Learning Program Violence Prevention Planning 27

38 Violence Prevention Planning Healthcare Education & Learning Program Six Step Problem-solving Process Continuous Improvement: Review, Update and Inform OHS Issue Identification: Communication and Support Hazard Identification and Risk Assessment Evaluation: Follow-up and Monitor Planning Intervention/ Risk controls Implementation of Controls Healthcare Education & Learning Program 19 28

39 Healthcare Education & Learning Program Violence Prevention Planning Workshop Evaluation Help us improve the quality of our sessions. Please complete all items and return this form to your facilitator. Thank you! Which workshop did you complete? Intro/Joint Committee Bootcamp Hazards, Risks & Inspections Incident Investigations Violence Prevention Planning Preventing & Managing Aggressive Behaviour I am from: Fraser Health Interior Health Northern Health Other Vancouver Coastal Health Provincial Health Services Vancouver Island Health On the JOHSC I represent: Workers Employers Don t know Not a member I have taken an OHSAH workshop previously: Yes No If yes, which one? OVERALL Poor Fair Good Great No opinion 1. Rate the general class room environment noise, light, heat, set up. 2. Overall quality of the power point, manual, and handouts. 3. Comments or concerns regarding class room environment: 4. Comments or concerns regarding quality of materials: PRESENTATION Poor Fair Good Great No opinion 1. The course content was explained using real world examples. 2. The course goals and learning objectives were clearly outlined. 3. The course was presented in a logical and well organized manner. 4. There was a good balance between presentation and group involvement. 5. The presentation kept my interest and attention. 6. The audio-visual aids (flip charts, slides, video, etc.) were effective. 7. The course was: too short too long adequate 8. The amount of information presented during the course was: too short too long adequate 29

40 Violence Prevention Planning Healthcare Education & Learning Program APPLICATION 1. The activities and course materials helped me understand and learn the concepts presented. 2. I will be able to apply much of the material to my safety work. 3. The handouts and examples presented today will be helpful to my safety work. 4. The examples and activities were relevant in my safety work. 5. Can you suggest an example or activity we can use in future workshops? 6. What was the most useful thing you learned in this workshop? THE FACILITATOR 1. The facilitator encouraged questions and discussion. 2. The facilitator answered my questions effectively. 3. The facilitator was knowledgeable. 4. The facilitator was well prepared. 5. The facilitator was enthusiastic. COMMENTS Thank You! 30

41 RESOURCES

42

43 Healthcare Education & Learning Program Violence Prevention Planning Establishing a Violence Prevention Working Group Forming an Effective Working Group A violence prevention program is part of an organization s overall OHS program. The working group can be composed of the joint worker/employer health and safety committee or sub committee of the joint committee. Workplaces with 10 to 19 regularly employed workers, which are required to have a worker health and safety representative instead of a joint committee, may decide to involve individuals with expertise in specialized areas. Any such person must be jointly agreed to by the JOHS committee. Consider who should be invited to participate in the working group based on the nature and complexity of the organization and the expertise needed for specific tasks: A broad representation from each site, department, and shift Safety personnel, employee assistance representatives, and security who are responsible for the overall safety performance of the organization Individuals with expertise in specialized areas, for example, psychiatry, dementia, head injury, or substance abuse. (If sufficient expertise is not available within the organization consider consulting outside experts.) The structure and commitment of the working group will play a key role in determining the quality of the violence prevention program. Input from all levels of the organization will ensure that policies and procedures are relevant to the unique nature of the workplace, work environment, type of patient/client population, and risk/hazards workers may encounter. 31

44 Violence Prevention Planning Healthcare Education & Learning Program Overall Violence Prevention Program Planning Guide Activities Establish steering committee (joint reps from workers/union and employers) Timelines(6-12 Months) Person(s) Responsible Resource Requirements Status Develop steering committee terms of reference Ensure violence prevention policy in place Develop communication plan for informing staff/workers/families Create risk assessment work plan which includes risk identification / assessment & the prioritizing of risks Meet with steering committee to plan interventions/risk controls Implement interventions/risk controls \Monitor interventions/risk controls Evaluate interventions/risk controls Document and report results to senior management Formal review of VP program 32

45 Healthcare Education & Learning Program Violence Prevention Planning Sample Worksheet - Information Summary Date/Time Data Source Incident Description Occupation Involved Incident Locations Contributing Factors Corrective Actions Action Following Incident 33

46 Violence Prevention Planning Healthcare Education & Learning Program Risk Factors (Hazards) for Violence Environmental Physical and Social Individual /Client and worker Organizational - Policies, procedures, work process, training 34

47 Healthcare Education & Learning Program Violence Prevention Planning Worksheet 2 - Risk Reduction Planning Worksheet Job or Job Task: Hazards: 1) 2) Level of Risk List recommended control measures using the table and hierarchy below. If a control is not possible, move to the next category. Category Hazard Control Measure Practicable? Elimination Substitution Engineering Control Administrative Control PPE

48 Violence Prevention Planning Healthcare Education & Learning Program Worksheet 3 - Intervention Action Plan Risk Factor(Hazard): Level of Risk High Medium Low Current Policies and Procedures Possible Interventions/ Controls Chosen Control & Objective Activity Timeline Person Responsible Resources Required Status Monitoring and Evaluation Activities Certified Complete: Certified Complete: (Employer Representative) Date (Worker Representative) Date 36

49 Healthcare Education & Learning Program Violence Prevention Planning BCGEU Sample Risk Factors Checklist Use this checklist to assist in identifying risk factors that affect the workplace. This process takes into consideration job characteristics, environmental conditions, client characteristics and situational risk elements. Characteristics of a workers occupation that might increase risk: The risk of violence is generally higher when the occupation involves physical contact with clients, particularly if the contact is one where the job involves regulation enforcement. List any job characteristic that can potentially place a worker at an increased risk of violence such as: Dealing with the public Child apprehension Delivering social services Working alone Working at night Performing security functions Changing nature of level of services Organization of work Violence considered part of the job Public perception that organization does not do enough to protect workers Denial of service Client characteristics that might be risk factors: What are the risk factors related to the client that may create risk of violence? The idea is to list any characteristics that could have caused the incident to occur. Examples could include the following: Chronically disgruntled History of violence Pushes limit of normal conduct Unresolved psychological problems Domestic abuser Financial distress Verbal abuse or threats Abuse of alcohol or drugs/medication Destroys property Mental or physical injury or illness Gang activity Client access to weapons Environmental conditions that might increase the risk of violence: Consider the time of day, location of worksite, time of year and any other contributing environmental factors such as the following: Workers working alone or who work in high crime neighbourhoods Workers who work in remote or isolated areas Workers who travel by car Nightshift Correctional settings with increased inmate population Clients who can touch employees Poor lighting Physical design and worksite layout Low service counters Obscured windows Public accessibility Reception areas Interview rooms Parking lot 37

50 Violence Prevention Planning Healthcare Education & Learning Program BCGEU Sample Risk Factors Checklist, continued Situational risk: What is the nature of the interaction; whether from a client or family member? Some of the items to consider would be the prior history of the client and violence prevention initiatives that are in place. What are the policies and procedures that might increase the risk to the worker assigned, including the location where the work is being performed? Community profile Working at night Working late or early No check in or out procedure High crime areas No method of communications Arriving and leaving court proceedings Wearing a uniform when leaving work Unwanted public having access to building No evacuation plan Having to wait for appointments Investigation taking place 38

51 Healthcare Education & Learning Program Violence Prevention Planning Health & Safety Services: Violence Prevention Employee Risk Assessment Survey In the development/revision of Violence Prevention materials, and in accordance with the Workers Compensation Board of BC (WCB), a comprehensive risk assessment must be performed in any place of employment in which a risk of injury to workers arising out of their employment may be present. The WCB regulation defines violence as the attempt or actual exercise by a person, other that a worker, of any physical so as to cause injury to a worker, and includes any threatening statement or behaviour which gives a worker reasonable cause to believe that he or she is at risk of injury. The staff survey will be of great assistance in the completion of the risk assessment for your workplace and facility. Your responses are anonymous and the results will be shared with the Occupational Health and Safety Committee. General Employee Information Facility or Location of Work Job Title Department Date (dd/mm/yy) Number of Years in Current Work Area Number of Years in Current Job/Position Working Alone 1. In the past 12 months, have you been required to work alone (i.e. no other staff member, security or RCMP present in the area)? Every day 3 or more times per week 5 or more times per month 1 time per month Less than 5 occasions Never 2. Did you (or would you if you have never worked alone) feel at an increased risk of violence because you work alone? Yes No Don t know Experiences Within Past 12 Months 3. In the past 12 months, have you witnessed an aggressive act by someone other than a coworker? Yes No If Yes, was this act reported? Yes No Don t know 4. In the past 12 months, have you been subject to an incident of violence (verbal or physical)? Yes No If Yes, please indicate number of incidents: If No, please move to question #25 5. Where did the incident take place? At bedside or in patients/residents/clients bedroom Other area within the facility Parking area Within immediate work area (i.e. nursing station, corridor, conference room, bathroom, staff room, office, etc.) Vehicle Resident s house Other (please specify): 39

52 Violence Prevention Planning Healthcare Education & Learning Program 6. Did you seek medical aid as a result of the incident(s)? 7. Did you have time off from work as a result of the incident(s)? 8. If injured as a result of the violence act, the injury resulted in: Minor laceration Major laceration Minor bruising Major bruising Fracture Sprain or strain Internal injuries Head injury Stress Other (please specify): 9. Who was the aggressor (i.e. the person who precipitated the violent act)? Patient Resident Family member of patient/resident/client Client Visitor of patient/resident Neighbour/visitor of client Public Physician Unknown Other (please specify): 10. Was the aggressor: Male Female Unknown 11. What was the nature of the incident? (Please check all that apply). You were: Struck by an object Grabbed/held by aggressor Kicked/punched/slapped by the aggressor Pushed by the aggressor Spit on Verbally threatened Other (please specify): 12. If verbally threatened, were the threats to: Injure you Sexually assault you Kill you Injure members of your family Damage or destroy your property Other (please specify): 13. Under what circumstances did the act of violence occur; that is, what events preceded the act or what do you believe precipitated the violent act? Interaction with patient/resident/client/public under Providing care to patients/residents/clients who are the effects of alcohol or drugs known to be violent Interaction with known violent person Handling or delivery of drugs Stressful situation resulting from bad news or negative information Enforcing rules of conduct, e.g. noise level, visiting hours, smoking policy, etc. Handling cash or other items that may precipitate violent acts Other (please specify): 14. Prior to the incident, did you suspect that a violent incident might arise? Yes, documented on care plan No Yes, warned by other professional or staff in the area Yes, identified on alert/risk identification system Yes, warned by co-worker Yes, warned by supervisor or manager Other (please specify): Yes, personal previous knowledge of behaviour 15: At what time did the incident(s) happen? 0800 to to to Were other people, other than the aggressor, close enough to provide assistance at the time the incident(s) occurred? No Yes, other employees Yes, security or the RCMP Yes, other (please specify): 40

53 Healthcare Education & Learning Program Violence Prevention Planning 17. Were the incident(s) reported? No Yes, verbally to manager or supervisor Yes, using Unusual Occurrence Report Yes, using Accident and Injury Report Yes, verbally to union representative Yes, other (please specify): 18. What was done as a result of the violent incident? Don t know Nothing to my knowledge Modification of work area or work procedures Adjustment to care plan More training Additional security or RCMP presence Other (please specify): 19. Do you think the corrective action was adequate? Yes No Don t know 20. Were you offered Critical Stress defusing or debriefing as a result of the incident(s)? Yes No 21. Were you offered counselling through an Employee and Family Assistance Program (EFAP)? Yes No 22. If you received Critical Incident Stress defusing or debriefing, or accessed through an EFAP, did youfind it useful? Yes No 23. Was the Occupational Health and Safety Committee involved in the investigation of the violent incident? Yes No Don t know 24. Was the WCB involved in the investigation of the violent incident(s)? Yes No Don t know Knowledge Level 25. Do you know the current policy(s) and procedure(s) for identification of aggressive patients/residents/clients/public? Yes No Don t know 26. Do you know the current policy(s) and procedure(s) for reporting incidents of violence? Yes No Don t know 27. Have you ever received specific training on Violence Prevention in the workplace? No Yes, at new hire orientation Yes, in the last 2 years at current workplace Yes, through organization/institution Yes, other (please specify): 28. If Yes, do you feel the training was adequate to enable you to: (check those that apply) Recognise the potential for violence in your workplace Respond to violence or threats of violence Obtain assistance Report and document incidents of violence 41

54 Violence Prevention Planning Healthcare Education & Learning Program Beliefs About Your Job Regardless of whether you have experienced an incident of either actual or threatened violence, please answer the following questions. 29. Is the risk of violence in your workplace a serious concern for you? Yes No Don t know 30. If yes, how often would you say this concern impacts you? Daily Weekly Monthly Occasionally Infrequently Other (please specify): 31. Do you feel you would be supported by your manager or supervisor in reporting incidents of violence? Yes No Don t know 32. If you believe you are at risk, is it as an individual or as a consequence of the nature of your occupation? Individual Occupation Both Don t know 33. Do you believe your occupational risk is related to the nature of your work environment? Yes No Don t know 34. If Yes, could that be related to: (check all those applicable) The city or geographical area of service The facility location or layout The number of entrances in your work area Signage i.e. lack or characteristics of Noise and lighting Visibility of your work area Other (please specify): 35. Do you believe your occupational risk is related to the nature of your interactions with patients/residents/clients/public? Yes No Don t know 36. If Yes, could that be related to: (check all those applicable) Delivery of hands-on patient care Giving and receiving of information Delivery of medications Explaining of policies/procedures Enforcing of policies/procedures Entry into private homes and residences Other (please specify): 37. Do you believe risk to aggression is related to personal attributes? Yes No Don t know 38. If Yes, could that be related to: (check all those applicable) Gender Experience Confidence in communication skills Training relating to personal safety Other (please specify): 39. Do you believe incidences of violence may go unreported? Yes No Don t know 42

55 Healthcare Education & Learning Program Violence Prevention Planning Comments and Recommendations Additional comments and recommendations on anything about violence in your workplace, the causes and how to reduce the risks and number of incidents Survey content from Employee Risk Assessment Survey, Health & Safety Services, Violence Prevention, Vancouver Island Health Authority 43

56 Violence Prevention Planning Healthcare Education & Learning Program Key Elements of a Workplace Violence and Aggressive Behaviour Prevention Program (Wvabpp): Suggested Guidelines I. Organizational Commitment and Support Commitment Allocation of resources and appropriate authority to responsible parties Clear lines of authority and accountability what happens to a report, who follows up, outcomes Communications Provide staff with regular updates Build links with community resources Work together with community to promote a safe, nonviolent culture Employer s Workplace Violence Policy Statement of Belief - employer commitment to a violence-free workplace - safety priority: staff, patient/client/visitor, environment - zero tolerance for violence expectations of clients/community - balance of good patient care (clinical practice) with workplace safety (OH&S) - create an organizational safety culture - Definitions of violence (WCB SECTION 4.27) - Regulatory requirements WCB, part 3 (regulations 3.5, 3.6, 3.9, 3.12, 3.18) and part 4 (regulations ) - Goals of WVABPP Responsibilities: - Board of Directors - Senior Executive Team - Directors/Medical Directors - Managers and Supervisors - Employees and Medical Staff - Corporate Employee and Workplace Health and Safety (EWHS) - Joint Health and Safety Committees - Contractors II. Risk Assessment Site/sector-specific acute care complex/long term care community/home care mental health and social services/addictions services other risks may pertain to location, geography, size of institution, demography 44

57 Healthcare Education & Learning Program Violence Prevention Planning Identify the hazards: (incident reports, investigations, OHS program evaluations, records of training, policies and procedures in place, WHITE database, employee questionnaires, focus groups) gives baseline data to be able to evaluate pre and post intervention; review hazards re: worker, clients, environmental (physical, social) and organizational (employer) Evaluate existing precautions, policies and procedures Assess the risk and set priorities for action III. Interventions Before Incident (General and Site-Specific) Prevention of Violence Engineering controls layout alarms locks signage security cell phones staffing levels Administrative controls Policies and procedures (corporate and site-specifi c): Employee identification Violence alert identification Visiting guidelines/rules Application of restraints Patients who are victims of criminal acts Patients under custody Search of a patient s belongings for weapons Patient consumption of intoxicating/illegal substance Alcohol and drug withdrawal management Working alone Control of crime scene/incident scene/patient/visitor Guidelines for safe work practice in various healthcare settings Patients with history of violence Requesting assistance process Right of refusal Clinical practice guidelines IV. Education/Training Needs Assessment What types based on evaluation of previous training and follow-up (re: did people actually use the training?) Information about use of current and new engineering and administrative controls Skills training re: prevention and management of aggressive behaviour (PMAB) - General guidelines for managing aggressive behaviour (also develop site-specific guidelines) - Causes of aggression and violence - triggers - Prevention - assessing stages of aggressive behaviour/de-escalation techniques - Interaction with aggressive people breakaway training, restraint techniques 45

58 Violence Prevention Planning Healthcare Education & Learning Program V. Interventions After Incident Response to Violence Development of policies and procedures as well as education and training in implementation of controls Emergency Response Mechanisms - Code white - Security, police, etc. Incident Protocols Investigation/Follow-up - - Incident reporting, documentation, investigation Follow-up for client/staff counseling and support Incident debriefing; staff support (EFAP, CISM) Documentation Legal action criminal charges VI. WVABPP Audit/Evaluation Annually at least with follow-up after introducing certain interventions Determine what is to be measured, e.g., knowledge/awareness level, change in worker injury, violent incidents, perceptions of workers safety, knowing how to respond post training, etc. Must be assessed before interventions are introduced. Criteria for success: Information reported on incident reports - documentation Time frame risk assessments must be done regularly and incident reports analyzed monthly Response to assessments - Who does them?; What happens to the assessments? How quickly are they responded to? Guidelines need to be site specific for different work settings Credibility adequately funded and fully implemented Sustainability incorporated into all aspects of daily schedule, actions documented, pro grams reviewed regularly Management commitment managers must ensure development and endorsement of a written violence prevention policy Employee involvement in risk assessment and determining interventions; regular consultation re: how it is working? Dissemination of policy to all employees in an accessible format 46

59 Healthcare Education & Learning Program Violence Prevention Planning Preventing Violent and Aggressive Behaviour in Healthcare Excerpts from a Literature Review (OHSAH, Y. Cvitkovich June 2005) Background Four World Health Organization (WHO) reports provide a background of violence prevention programs and what are consensus interventions: Di Martino (2003), Wiskow (2003), Richards (2003), and Sethi et al (2003). Di Martino (2003) reports that violence in the health sector constitutes 25% of all workplace violence. He discusses the risk factors for violence in the workplace and describes the relationship between work stress and workplace violence. Wiskow (2003) compared 12 violence prevention guidelines across four countries: Sweden (1), the United Kingdom (4), The USA (2), Australia (5) and reports that the National Health Service (NHS) Zero Tolerance commitment to reducing risk of violence for the health workforce is the most comprehensive of all the violence prevention programs. Examples of the UK guidelines are presented in Appendix 1). Richards (2003) summarizes the different types of interventions based on the practice in the United Kingdom. Sethi et al (2003) provides a handbook for the documentation of violence prevention programs. Criteria for Evaluating Violence Prevention Programs Wiskow (2003) in a WHO review of international programs reports the following criteria for evaluating violence prevention programs: Information reported Time frame Relevance (setting-specific) Credibility Sustainability Management commitment Employee involvement Dissemination An effective program is setting-specific with measurable, achievable objectives within realistic timeframes. Information Reported The minimum information required in reporting a violent incident in the workplace: Details of victim and perpetrator Location, date, time of incident Circumstances of incident - actions taken prior (risk assessment, training) and during incident (e.g., conflict resolution method attempted, etc. [de-escalation, breakaway techniques, restraint techniques]) Details of outcome (injuries, time off, etc.) Action taken post-incident (medical aid, psychological aid, legal action/ consequences regarding perpetrators, follow-up on victim, reporting, tracking & analysis of incidents, review of risk assessment & training) The following series of questions are recommended as a guide for auditing (evaluating) a violence prevention program. 47

60 Violence Prevention Planning Healthcare Education & Learning Program Series Q1 Do the incident reports provide at least the minimum information required above? Time Frame Risk assessments must be done regularly or when there is a change in setting, work procedures or client disposition. Record analysis must be conducted at a minimum on a monthly basis. Series Q2 Who does the assessment? What is done with the assessment? (Filed, Posted, Distributed, Reviewed). How regularly are assessments reviewed? What action was taken? (e.g., prior to next home visit, the worker calls client to ensure that the dog is tied up or confirms that the aggressive relative is not going to be present). Is there any documentation of warnings concerning the withholding treatment if the client refuses to act on requests to decrease risk factors? Is there any documentation regarding complaints by client concerning the threat of withholding services and whether the supervisor supported the worker s situation? Series Q3 Is there some evidence of documentation concerning analysis of records ( i.e., minutes of JOHS discussion, action taken, etc )? Is there documentation of post-incident responses: 1) within 1 hour of incident, 2) 24-hour follow-up; and 36-hour follow-up. Is there documentation regarding the analysis of the post-incident response? Is there evidence of prepost measures to evaluate the effect of the trauma and the intervention? Relevance The guidelines may cover a variety of work settings. Series Q4 Do the guidelines differentiate between settings? Do the guidelines explicitly provide case studies relevant to the work setting? Environmental change is more relevant to stationary institutions but less relevant to outreach workers. Societal background may influence content of guidelines. Wiskow (2003) provides the following examples: 1) The USA guidelines are more relevant to violence related to guns whereas in other countries this issue is less relevant. 2) Developing countries have a greater weakness in overall infrastructure of their health system and do not have many options for post-incident response. 3) Panic buttons and mobile phones may be less realistic for rural clinics and remote areas (due to lack of available service). 48

61 Healthcare Education & Learning Program Violence Prevention Planning Credibility: To be effective, a violence prevention program must be adequately funded and fully implemented. Series Q5 Is implementation of violence prevention programs enforced? Are there significant examples of citations for non-compliance? Is there documentation showing that action was taken following non-compliance? Does zero tolerance receive buy-in from all sectors? What process do they have to measure this? Is the measurement process effective? What resources are made available to enable implementation of violence prevention programs? Is there a budget? How often is the budget reviewed? Are resources made available for control measures? How much is provided? Is there allowance for increase or re-distribution of budget according to changing risks? Sustainability To be effective, a violence prevention program must be incorporated into all aspects of the daily schedule, systems maintained, actions documented and programs reviewed on a regular basis. Series Q6 How well are strategies integrated into daily work on a regular basis? Is there documentation of violence prevention drills and objective assessments by police/health authorities? Is there documentation of refresher training for each worker? Is there an assessment of the worker s knowledge and skill at managing violence and aggression (de-escalation, breakaway techniques, restraint techniques)? Is there documentation showing the tracking and analysis of the frequency and type of aggression incidents? Is there documentation showing action taken to rectify the factors that caused the aggression incident? Management Commitment To be effective, a violence prevention program must have tangible commitment from management. Managers must ensure the development and endorsement of a written violence prevention policy including the following: Recognition of workplace violence risk and pledge to protect staff at work Employer s legal obligations Employer s goals and objectives with the program Details of managers and employees responsibilities Details of the local prevention and reduction plan. Provide staff with regular updates and progress reports (in-house newsletter, annual reports on action taken and improvement measures introduced).allocation of resources and appropriate authority to responsible parties. 49

62 Violence Prevention Planning Healthcare Education & Learning Program Series Q7 Is there documentation illustrating that the policy is implemented as a living actionable program and not just a paper copy? Employee Involvement Successful programs profit substantially with the experience and feedback from staff. Series Q8 Are workers involved in the process of risk assessments and determining the best ways of using prevention measures? Is there documentation showing that staff are consulted on a regular basis through the joint OH&S committee and through surveys? (Minutes of JOHS meetings, reports of incidents and action taking) Dissemination To be effective the written program must be communicated and be accessible to all employees. Series Q9 Are relevant sections of policy provided in a readily accessible format (card, booklet, posters)? Is the policy published on internet? Is time made available for group discussions regarding: incidents, what could be done differently, what triggers were missed, was post-incident action effective? Guidelines Thirty-five current violence prevention guidelines were reviewed as current practice (see Appendix 1). All the government and union guidelines agree that a risk assessment is the key to prevention of violence in the workplace. There is consensus that a risk assessment must lead to violence prevention programs tailored to the particular needs of each specific healthcare setting. There is general consensus declaring that violence prevention must be based on effective implementation of three main steps: 1) 2) 3) Identification of the problem(s) or hazard(s) Evaluation of existing precautions Assessment of the risk A violence prevention program should have the following components: 1) A risk assessment evaluating the risks arising from administrative/work procedures and environmental factors 2) Education and training of personnel to help them identify potential risks and to manage aggression 3) Incident reporting and investigations 4) Post-incident responses and follow-up to moderate the effect of the trauma 5) Program reviews to determine what changes are required to make the program more effective. 50