Preventing Workplace Violence Nurses Voices Being Heard

Preventing Workplace Violence Nurses Voices Being Heard Gail Bromley, PhD, RN Rose Anne Berila, MSN, RN October 21, 2016 Workplace Violence in Healthcare: Is it a Problem? A nurse asks the question, Who is the wolf at the door? Is it: Menacing behavior? An active shooter? Incivility from a supervisor or colleague? A violent patient? Statistics 80% of nurses report having experienced some form of attack by a patient/family member. Annually, 9,200 of healthcare workers report workplace violence incidents perpetrated by patients/family members which require time away from work to recover. 67% of all nonfatal violence-related injuries are in healthcare settings that are represented by 11.5% of all workers. (NIOSH-National Institute for Occupational Safety and Health, 2013) 1 4 Effects of Workplace Violence on Nurses The speaker has no conflicts of interest to disclose. Significant impact Serious physical injuries Temporary and permanent physical disability Psychological trauma and PTSD Death Negative individual and organizational outcomes Low morale Increased job stress Increased turnover Reduced trust of management, colleagues Hostile healthcare environment 2 5 Objectives 1. Utilize assessment and individualized clinical interventions to pre-empt violence. 2. Determine effective strategies to implement a QI study that decreases violence on a medical surgical unit. Nurses Voice Safety Concerns Be assessed and access resources related to assault. Report assault to the police. Copy photographs of injuries, reports and chronological account of incident. Investigate legal rights to prosecute perpetrators. Debrief/Counsel with professional. Advocate for safety. 3 6 Bromley 1

Massachusetts Nursing Association Mandate to Improve Nurse Safety/Security Improved access control to buildings. Signs at all hospital entrances notify entrants that weapons are prohibited and video surveillance is in effect. Additional panic alarms installed, with training for staff and regular testing. Staff training to include online, live discussion and/or mock drills regarding personal safety, self-defense, security awareness, active shooter, threat assessment, de-escalation, SAFE response, codes, crisis protocols. Supervisors will contact nurses affected by workplace violence and ensure that nurses receive medical/psychological care. Code Violet Team Members Nurse caring for patient Emergency Psychiatric Access Team (EPAT) UH Police Code White (rapid response) Nurse Nursing Supervisor Clinical Interventions Minimize the stress/distress caused by a violent patient to maintain safety and security of all patients, visitors, and staff. De-escalate a combative, abusive and/or potentially dangerous situation; assist the patient to regain self-control. Intervene when staff, at any time, feels their safety is or may be threatened. Intervene when initial measures to distract/de-escalate a situation have failed and there is risk of harm to self/others. 7 10 Nurses Develop Competencies through Education Code Violet Five Year Trends Language to de escalate patient In person training-crisis Prevention Institute (CPI) Online training-niosh-cdc website Activate Code Violets, clinical interventions to manage violence Utilize state law to report workplace assaults 8 11 A Steering Committee is Born The Tide is Rising: Impact on the Healthcare Environment University Hospitals Cleveland Medical Center signage We will not tolerate any form of threatening or aggressive behavior toward our staff. Assaults against our staff might result in a felony conviction. All staff have the right to carry out their work without fear of their safety. Workplace Violence Steering Committee Purpose: Representative group of various roles and work locations charged with guiding continuous enhancement of safety through a focus on specific areas: policies, employee education and culture change. Members: Director UH Psychiatry Service Line and Nursing Practice, UH Police Director, QI Director, Risk Manager, Human Resources staff, Nurse Managers, Occupational Safety staff, EPAT Manager (Code Violet Team), Educators, Psychiatric Mental Health CNS, Legal Counsel Northeast Ohio has an inadequate number of psychiatric inpatient beds, requiring boarding of patients with psychiatric diagnoses/comorbidities on medical-surgical units. In 2015, 579 patients with psychiatric diagnoses were boarded on medical-surgical units. From 10/2014 to 10/2015, 100 Code Violets were called on medical-surgical units, with 61% of the patients requiring two or more Code Violets. 49%-patients with psychiatric diagnoses 57%- patients with history of substance abuse 51% patients with medical diagnoses only 9 12 Bromley 2

Organizational Readiness Assessment Broset Violence Checklist Decision Tree Environment and Culture Units experiencing higher rates of patient violence Emergency Department Medical Surgical Units Cancer Center Zero Tolerance of Workplace Violence Nurses and staff members safety concerns Code Violet Team responds to violent incidents 13 16 Why Implement a QI focused on Violence? Stakeholders Experiences Patients- Expect zero violence in a healing environment. Nurses- Perceive culture as unsupportive. Physicians- Perceive to be at risk when incidents of violence occur. Security- Aware of responsibility to ensure safety for all. Administrators- Concern about violence within the hospital. 14 Broset Violence Checklist QI Pilot Project Background Violent behavior on psychiatric units is managed on contained units. Predictive assessment tools such as the Broset Violence Checklist (BVC) provide data for individualized therapeutic clinical interventions. Throughout the United States, delivery of care challenges are associated with psychiatric bed shortages necessitating that patients with psychiatric diagnoses are boarded on medical surgical units. As a result, medical surgical nurses identify the need to increase their knowledge, skills and competencies to care for this patient population. This Broset QI pilot project is the first implementation of the BVC with patients cared for on medical surgical units. In addition to developing skills in the use of the BVC, medical surgical nurses completed Crisis Prevention Institute (CPI) training and Trauma Informed Care education. 17 Broset Tool (EMR) Broset Violence Checklist Date Instructions: Place a 1 in the Day or Evening or Night column, indicating the shift when the patient s Behaviors were observed. If the Sum of the scores is 2 or more, a pre emptive clinical intervention is indicated. Behaviors Day Evening Night Confused Appears obviously confused and disoriented. May be unaware of person, place, or time. Irritable Easily annoyed or angered. Unable to tolerate presence of others. Boisterous Behavior is overly loud or noisy slams doors, shouts when talking. Verbal Threats A verbal outburst which is more than just a raised voice: where there is a definite intent to intimidate or threaten another person verbal attacks, abuse, name calling, verbally neutral, comments uttered in a snarling aggressive manner. Physical Threats Where there is a definite intent to physically threaten another person taking an aggressive stance; grabbing another person s clothing; raising of an arm, leg, or making a fist directed toward another person. Attacking Objects An attack directed at an object, not an individual the indiscriminate throwing of an object; banging or smashing windows; kicking, banging or hitting head into objects; or the destruction of furniture. SUM Total number of 1s per shift. 15 BVC QI Pilot Project Management Tool Broset Pilot Project Can nurses predict violent behavior on a medical surgical unit using the Broset Violence Checklist? Initiative Action Broset Pilot Project Education and Implementation Plan Educational sessions will be provided to nurses and unlicensed Clinical Nurse Specialists and graduate students from the QI course personnel using a standardized education session (Seidman 4, presented Broset Violence Checklist use Education sessions to staff nurses. Lakeside 20, Emergency Department) Emergency Department will implement education, surveys and use tool to ensure a smooth transition with Trauma level I. Timeline and education implementation PowerPoint of Broset Violence Checklist (BVC) Education Nurses received copies of the Broset Violence Checklist during the focus presentation to nursing staff, copies of the Broset Violence group discussions regarding workplace safety as well as during the Checklist given to nurses, clinical assessment competencies to educational sessions and discussed use of BVC and strategies for score the scenario during the video and discussion of intervention, if the score was 2 or greater. interventions. Behavioral Health Competency Checklist Survey Monkey Nurse Managers from Lakeside 20 and Seidman 4 will send the Nurses on Lakeside 20 completed the Behavioral Health Competency Survey Monkey link of the Behavioral Health Competency Checklist using Survey Monkey. Data will be analyzed for review when all of Checklist designed to assess medical surgical nurses the nurses have completed this survey. knowledge and comfort with the care of patients with aggressive, assaultive behaviors. Printed paper surveys of the Behavioral Health Competency The educator will keep completed surveys in an envelope and add to the Checklist Survey Monkey will also be available for nurses to database to include in the data analysis. complete to capture as many responses as possible for this Quality Improvement project. 18 I iti l f RN Bromley 3

BVC QI Pilot Project Management Tool (cont.) BVC QI Pilot Project Findings Initiative Action Nurse implementation Nurses will complete the Broset Violence Checklist for each of Lakeside 20 completed the Boset pilot with data analyzed by the graduate the assigned patients between 8:30 9:30 am and between 8:30 students from the QI course, who then presented their findings to Karen Boyd, 9:30 pm. The clinical assessment about the patent should be Director Quality Institute for Healthcare Quality & Innovation and to nurse shared during the patient bedside handoff so nurses plan and managers and educators involved in this initiative. discuss strategies for interventions. When Code Violets are called for a patient, a nurse educator will Audits are being completed and submitted to Lisa Courtot, Manager of EPAT, perform a quality improvement assessment that includes the for Code Violet Quality reviews. Broset Violence Checklist score, clinical interventions, the patient care plan and patient outcomes. Data Collection Data collection regarding the Lakeside 20 nurses use of the Data collected on Lakeside 20, 96% of the nurses completed and utilized the Broset Violence Checklist on November 15, 2015. Data Broset findings to plan care as analyzed by graduate students from the QI collection for the Broset Pilot Project ended on December 5, course. 2015. Data collection from Seidman 4 and the Emergency Department to be completed. Indicators for QI initiative Focus group themes QI survey information Range of Broset Violence Checklist scores Behavioral Health Competency Checklist Code Violet data for patients Documented clinical interventions in coping section of A&I. Evidence of Nurse Engagement Broset Violence Checklist was utilized by nursing staff 96% of the time;target of 80%). No staff assaults occurred. 2 Code Violets in October 2 Code Violets in November 19 22 BVC Pilot Project QI Assessment Critical Points At Risk Patients Quality Improvement Assessment ED hand off Risk Indicator and coordinated care plan [Need to ensure that staff are educated and are signed off on the use of this information for safe care.] Broset Violence Checklist Score of 2 or greater requires notification of receiving inpatient unit that a safe room is needed Medication Reconciliation Patient Safety Checklist Inventory of belongings include location of locked belongings Protective Services Escort to unit Nurses need additional information and Broset Violence Checklist assessment from ED prior to patient arriving on unit. Patient medication reconciliation, safety checklist, and belongings inventory are needed from ED prior to patient arriving on unit. Barriers to Implementation Time Limitations Data Validity Staff Perceptions about patient behaviors Patient admission to unit Risk Indicator and coordinated care plan [Need to ensure that Nurses need to utilize patient information from staff are educated and are signed off on the use of this ED and assess patient on the unit. Nurses need information for safe care.] to establish expectations with patient to Medication Reconciliation ensure a safe, quality environment. Patient Safety Checklist Cultural Buy-in Inventory of belongings include location of locked belongings Hospitalist nurse handoff, review of medications Room safety assessment Confusion regarding tool usage Broset Screening Tool Ongoing QI review Broset Violence Checklist review Risk indicator and coordinated care plan QI data to be collected on Lakeside 20 and Seidman 4, with feedback provided to staff and Lack of resources Monitor room safety Broset Pilot Project team. Ensure sitter skills checklist to ensure therapeutic, vigilant interaction with patients Mandatory training Ensure safe rooms available on units 20 23 De-identified Staff Survey for QI How often do you encounter workplace violence (times/week)? less than once a week (4) once a week (8) twice a week (2) three or more times a week (4) How frequently are you able to de-escalate the situation? less than 25% (7) 26-50% (7) 51-75% (3) more than 75% (0) Time from last CPI training (months)? less than one month (2) 2-3 months (5) 4-6 months (8) more than 6 months (4) Was their debriefing after your training? Yes (12)- No (7) Themes from responses: Would like a psych floor/limit number of psych patients on floor?; Education (sitters, security, MDs, nursing staff); standing orders/policy changes; modes of transportation; room safety Environmental Designs to Enhance Patient Experience and Reduce Workplace Violence Develop emergency signaling, alarms and monitoring systems. Police/security walk through of the clinical units and public areas. Install security devices/metal detectors, cameras and good lighting. Provide police/security escorts to the parking lots at night. Design waiting areas to accommodate individuals who experience a long wait time. Design the triage area and other public areas to minimize the risk of assault. Provide staff restrooms and emergency exits. Install bullet-resistant/shatterproof glass enclosures in reception areas. Arrange furniture and other objects to minimize their use as weapons. (NIOSH-National Institute for Occupational Safety and Health, 2013) 21 24 Bromley 4

Workplace Violence Prevention Safety Toolbox UH Intranet Categories Hospital Policies Resource Tools Education-CPI s Nonviolent Crisis Intervention Training Program Objectives: Identify behaviors that could lead to a crisis. Respond to each type of behavior to prevent escalation. Demonstrate verbal and nonverbal techniques to defuse hostile behavior. Identify own personal fears and anxiety. Utilize CPI s Principles of Personal Safety to avoid injury. Know when physical intervention is required to minimize a crisis. Develop team intervention strategies and techniques. Demonstrate safe/effective control/transport techniques for an acting-out person. Code Violet Debriefing Tool ENVIRONMENTAL DETAILS: Day: S M T W TH F S Date: Time: a.m. / p.m. Patient Diagnosis: EXACT LOCATION OF INCIDENT: DESCRIPTION OF INCIDENT: Yes No Was there a leader identified? Name Yes No Were staff members present with patients prior to incident? Yes No Was escalating behavior identified prior to incident (physical or verbal)? Yes No Was a trigger identified relative to the acting-out-behavior and added to the care plan? Yes No Did staff attempt to set limits or enforce consequences prior to incident? Yes No Was a de-escalation technique used to prevent an angry outburst? Yes No Was medication offered or given prior to acting-out-behavior? Yes No Did the Physician/LIP order medications? Yes No Was there effective communication and teamwork among staff during the code? Yes No Was an advocate/objective observer identified? Yes No Was the UH Police or additional staff assistance needed? Yes No Were there injuries sustained to either staff or patient? Describe Yes No If there was an injury did a Violence Risk Indicator get added to the EMR? Yes No Was there a need to contact the Nurse Manager, Assistant Manager, or Supervisor? Yes No Was patient restrained? What went well in this code? How can we improve future safety or communication issues? 25 28 Violence Risk Indicator Criteria Assaultive within the healthcare setting Destructive in the healthcare setting Verbal/physical threatening behavior Significant disruptive visitor interactions Resources Crisis Prevention Institute http://www.crisisprevention.com/ CDC/NIOSH http://www.cdc.gov/niosh/topics/violence/training_nurses.html Significant forensic history 26 29 Psychiatric Patient Hand off Patient Name Age Gender Room Patient s reason for admission Currently restrained Y N Previously restrained Y N Risk indicator Y N Brought in by UH police escorting Y N Precautions Suicide Risk Y N Homicide Risk Y N Elopement Risk Y N Falls Risk Y N Patient needs 1:1 observer Y N Patient is weight bearing Y N Safe Room Y N Safe dietary tray Y N Admission Status Voluntary Medical Certificate Broset score Patient in gown Y N IV removed Y N Belongings inventoried Y N Weapons, illegal drugs Y N Location of belongings Safety checklist completed Triggers that upset patient Interventions that calm patient SBAR Situation Background Assessment Psychiatric History Medications currently taking Medications Administered/times given Psychiatric Medication orders/times given Medical history Guardian name and contact Outpatient provider-name and contact Living situation Report given by Hospital Contact number APNA 2007 Recommendations Professional nursing organizations-advocate for workplace safety, laws, regulations, education Health organizations-establish and maintain a comprehensive program for the prevention, reporting, and management of workplace violence. Nurse managers-create and maintain supportive work environments where respectful communication is the norm; policies followed, incident reports blame-free. Nurses-clinically intervene to pre-empt violence; report incidents of violence. Nursing educators-provide professional development regarding prevention, assessment, and management of violent incidents. Investigators-study proactive prevention/intervention strategies, efficacy of training modalities/policies/leadership styles to prevent workplace violence. Researchers-develop consistent and operationally defined definitions of violence. 27 30 Bromley 5

Safety is Everyone s Responsibility Nurses Voices Must be Heard to Avoid Catastrophes 31 Bromley 6