Solutions to Violence Against Health Care Workers

Proposed solutions

Over the past few years, violence against health care workers has gained attention. Every day health care workers are faced with the possibility of both physical and verbal abuse from patients and family member, coworkers.

Organizations must find a balance between creating a safe work environment and offering care that is accessible for the patients they serve. Prevention is unquestionably the best solution to combat workplace violence that not only impacts employees but the quality of care that a health care organization offers. A common reason that patients may have violent outburst is due to the setting that healthcare creates. A patient may have extreme stress, fear, physical and mental state may contribute to agitation and aggression (Stephens, 2019). Ultimately organizations need to recognize the issue and develop solutions to create a safe work environment for employees. After a review of the literature, a few solutions were created.

• Establish a comprehensive workplace violence prevention program. Employees will revive proper training and education on recognition of violent behavior, communication skills to assist in de-escalation and step to take if a situation cannot be diffused.
• Identification of workplace hazards or potential risk for workplace violence.
• Create an environment that is secure and includes multiple resources such as panic buttons, security cameras, hourly walkarounds by a security officer.
• Provide resources and education on the need to report incidents of violent behavior or perceived threats of violent behavior. A post-event review should take place in which the organization can identify trends and changes that should take place.
• Ensure appropriate follow-up to violent events, including communication, post-incident support, and investigation.
• Creation of additional resources for employees after violent events such as counseling and debriefing.
• Collaboration agreement between security and law enforcement to responded when altered about a potential or actual violent patient.
• Creation of an event response team with advance education in diffusion and de-escalation.

Proposed Solutions / Project Approach

After reviewing the topic of workplace violence, it was evident that it is a multifactorial issue. It was felt that one solution is not enough to ensure success. The first solution is the identification of workplace hazards or potential risk for workplace violence to occur. According to OSHA (2016), evaluation of the workplace can help to identify and reduce the probability of a violent events occurring. A second solution that will be implemented is establishing a comprehensive workplace violence prevention program. OSHA suggest the implementation of well-designed workplace violence prevention program with changes made to the physical environment, training, and tracking of the violent incident can help to reduce violent events in the workplace. Employees will receive proper training and education on recognition of violent behavior, communication skills to assist in de-escalation and steps to take if a situation cannot be diffused. The organization will also provide resources and education on the need to report incidents of violent behavior or perceived threats of violent behavior. A post-event review should take place in which the organization can identify trends and changes that should take place. And will also ensure appropriate follow-up to violent events, including communication, post-incident support, and investigation. Implementing a reporting system along with education on the need to report prevented or actual violent events is crucial to the success of reducing workplace violence.

Resources utilized for the quality project include the ability of nurse’s educators to teach the course and availability of staff to attend the course and perform online training. Estimated cost for annual ongoing workplace violence prevention program is estimated to be $144,000.00.  Assuming the hourly rate per hour for physicians is $133 per hour, nursing staff $35, leadership staff $62 per hour and other staff such as housekeeping, techs and kitchen staff at $18. A small price considering that failure to prevent workplace violence can result in overtime, training of a replacement, decreased productivity, and even lawsuits. Three point one million was the average award from a jury for workplace violence cases in which the employer did not take the initiative to prevent workplace violence (ECRI Institute, 2017).

To determine the success of the proposed solutions, numerous research articles, and data was reviewed. Research has shown that workplace violence prevention programs should focus on the needs of the organization are more successful. Proper training of staff, sufficient resources and the use of evidence-based tools can help reduce the risk of violence occurring. OSHA (2016) identified five building blocks for an effective workplace violence program called the “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers,” however, it is just guidelines and is not enforceable. Other resources considered were the availability of security and local law enforcement to responded to violent events. Support from administration, managers, supervisors, and employees must be active participants to ensure success.

Implementation plan

Introduction to problem

Healthcare workers only account for 13% of the US workforce, yet they experience 60% of all reported workplace assaults (Wax, Pinette, & Cartin, 2016). The culture of accepting workplace violence is a contributing factor because healthcare works have accepted that violence if part of the job (Wax, Pinette, & Cartin, 2016). Providers may feel that patients actions are due to health or mental conditions. Most violent events that occur are non-fatal but still may result in both physical and mental trauma for the victim and the healthcare organization. Health care workers may lack education of the signs of aggression and ways to help de-escalate patients. Identification of risk factors and solutions may help to break down the barriers of workplace violence.

Goal/ objective

Zero events of workplace violence is the best indicator of success. However, this may not be a realistic goal due to the unpredictable environment of health care.

The goal will be to reduce workplace violence by 40% over two years. All solutions implemented will result in the formation of a culture of patient and staff safety.

Performance measures

At three months 70% of employees will have completed education requirements and 100% by nine months after implementation. Three months a reduction of violent events by 10 % and 15% increase of reporting actual or potentially violent events. Twenty-four months after implementation. A 20% reduction in violent events and 30% increase in reporting of potential violent events.  Three years a 40% decrease in violent events and 60% increase in reporting of potential violent events.

Major task

The primary task is the creation of an environment that is safe for both the public and health care providers. The Occupational Health and Safety Act, 1990 requires that employers assess for risk of workplace violence and put into action a plan and controls that decrease or eliminate identified hazards (OSHA, 2016).

The worksite analysis will be used to identify existing and potential hazards that may lead to workplace violence. The assessment will be used to reduce or eliminate potential hazards and can assist in the development of training for staff. Simple changes to the environment can be inexpensive solutions. Such as ensuring patients rooms are well lit, furniture is placed in a way that does not affect employee’s ability to exit rooms quickly.

 

One significant task will be the development of a comprehensive and practical education program for all employees. Employees will be educated on the definition of violence and assault. Employees will be trained on warning signs of aggression, situational awareness, and how to track patients with a history of violence (OSHA, 2016).  Educational resources that will be the used are power-point with lecture, hands-on training on holds and proper use of restraints. Education on the behaviors and physical signs of aggression can assist staff in acting before a violent event occurs. Teaching employees to pay attention to surroundings and contemplate exit strategies, recognizing when a co-worker may be in a violent situation are crucial for prevention. Managers and supervisors will attend the same training as employees plus a two-hour additional training. The additional training will teach leadership to recognize a high-risk situation and how to encourage employees to report incidents and receive care after experiencing a violent event.

 

Research shows that up to 70% of violent events are underreported and may be part of the reason for the inadequate response to workplace violence (Strickler, 2018). Studies show that organization without a policy to report workplace violence have an incident rate of 18% compared to 8% with an organization who has a zero-tolerance policy (Strickler, 2018).  Education and supporting staff to report violent incidence is key to understating the full scope of the problem along with performing in-depth root cause analysis to make necessary changes. Reporting events, both internally and to law enforcement, are part of the process to obtain accuracy in documentation and events that occur. It also allows the organization to have a history of violent patients and can be analyzed to prevent future events. Also reporting to law enforcement can be vital when legal action must be taken. Collaboration with security and local law enforcement to determine the activation system and proper way report violent incidents when needed.

 

After a violent event takes place, established protocols will be in a place that ensures adequate support given to any employee who experiences a violent event. Employees should receive medical care and be released from all work-related duties until cleared medically. Experiencing workplace violence may cause PTSD, fear, shame, guilt, and even self-blame (Ahmed Higazee & Rayan, 2017). If employees feel they need time off due to emotional or physical trauma, time off will be granted up to one week and then reevaluated. Employees will be offered free counseling services through the employee assistance program. When health care organization devote time and effort into employee’s wellbeing in shows employees that management cares and wants to help protect them and created a culture of safety.

Barriers for successful implementation

Multiple potential barriers are present for implementing the proposed solutions.

One barrier in the initial cost of training and possibly the expense of new equipment. From a financial perspective staff turnover due to violent events can cost the health care organization between $60,000 and $100,000 for RN replacement (Strickler, 2018). The inability of staff to attend required education course. The culture in which workers have accepted workplace violence. Health care workers believe that their attackers are not accountable for their actions due to physical or mental state (OSHA, 2016).  Another barrier is that employees may be uncertain of the definition of workplace violence. The perception of administration lack of concern about workplace violence and can be a significant barrier to implementing the solutions.

Implementation schedule

The timeline for the completion and development of the quality project is approximately six months.

Activity	Who is responsible	Due	Goal
Creation of a project team	Project leader		The team will also reviewing violent events after they occur during the post-implementation phase.
Obtain a commitment from management and administration to support the program.	Project leader	Day 1	The success of the project is based on the support and collaboration of management, administration and employees.
Obtain approval from administration.	Project team/leader	Week 1	Educate on the need for change. Satsticats on workplace violence events within the organization, review of organization policy on violence and explain why the policy needs to change.
Meeting with managers, administration, security, senior employees, legal team, human resources, quality nurses, leadership team members.	Project leader	Week 2	Discuss strategies will be used to address the issue and what their roles will be in the program.
The cost and implication of incidents should be reviewed with managers, human resource, and the finance department to determine the finical impact the project will have on the organization.	Project leader	Week 2	Workplace violence results in a cost to the organization such as turnover, time off work, and decreases productivity. The ANA reported that in one hospital with 5,000 nurses that the treatment-related to workplace violence cost $94,156 annually (Potera, 2016).
Worksite analysis to identify potential hazards.	Nurse managers, senior employees, security, quality nurses, engineering, chief security officer and administration,	Week 4	Allows for everyone to gain perspective of what needs to take place to produce an effective program. Senior employees are crucial to the worksite assessment to identify potential hazards and equipment needed.Chief security officer will need to determine location of cameras and panic buttons.
Meet with security to identify the best way to alert them of violent behavior. Decided when outside resources should be called/used.	Nurse manager, supervisor, chief security, quality nurses, project leader.	Week4	Project leader will responsible to contact local law enforcement to collaborate.
The development of the education program	Project leader with the assistance of managers, senior employees, and nurse educators.	Week 6	Involved parties will use resources such as OSHA, CDC and JTC. Guidelines obtained from resources will be used to create education program. Input from senior employees. Psychtraitc and ER charge nurses will be asked to help educate on signs of escalation and proper use of restraints and holds.
Overhauling of the online reporting system.	Project leader, managers and senior employees. Review by administration.	Week 8	The creation of a form that takes less than five minutes to complete. Review of form will be sent to administration for review and approval.After implementation managers, chief security officer, and senior employees will review all violent events that are reported and identify changes and gaps in policy
Changes identified by the worksite assessment will be completed.	Managers and engineering.	Week 12	The identified changes made to units will be carried out by engineering and equipment will be set up as needed.
Identification of resources for employees of violent events.	Human resources and project leader.	Week 14	Human resources will provide managers and leadership team members with a list of employee resources.
Completion of educational program	Nurses educators, managers and project leader.	Week20	Manager will attend training at this time. Which will allow for feedback on changes that should occur before employees attend.
Creation of protocols after violent events occur.	Managers, senior employees and leadership.	Week 22	What steps will be taken when a violent event occurs. Such as helping victim obtain medical care. Repotting events to law enforcement. Ensuring that all information is collected and passed on to project team. Project team will review events and identify changes that need to be made.
Coordinate training of employees	Nurse educators	Week 23	Will send out email that provides class dates and times. Email will also contain general information on policy change and why its occurring.
Initiation of training program	Project leader and nurse educators	Week 26	All staff will be required to attend an annual education session for 2-hours. This year the classes will offered Monday, Tuesday, and Friday. Classes will be offered both during the morning and multiple evening courses. Nurses educators from both the emergency room and psychiatry units along with security will demonstration standard escape techniques. Nurse educators for each unit will provide education on how the policy for reporting a violent event. Time and attendance reports will be provided to managers after each training session, along with reports on complementation on online learning modules.

The program will be monitored and reviewed annually by the managers and quality nurses to evaluated for effectiveness and identify any needs for adjustment. Continuous collaboration is required by employees to share strategies, barrier encountered, and new ideas. Training and education material will be updated accordingly and distributed or demonstrated. Review of violent events will be discussed weekly in administrative meetings and huddle meetings for staff. Unit managers will meet every three months to review violent events and suggestion to strength program. Project team will meet every three months to preform review of events and evaluate performance indicators.

Communication Plan

Communication is a crucial point for the implementation and success of the quality project. Communication will be used to educate employees, manager, supervisor, and administration on the need for change. Communication will occur use multiple mediums such as e-mails, phones call, hand-outs, and in-person communication. Below is a chart of the communication plan that will be used.

Who?	What information do they need?	When do they need the info?	Who will provide the information?	Medium used
Administration	Implementation plan, policies, education on the need for change procedures, timelines, expectations. Cost of project. Reports on violent events that occur. Changes to policy.	Will be approached during the first week to obtain approval for project. Updates will continue as need throughout the project. Will receive a copy of the online reports when violent events occur.	Project leaders and managers.	Personal communication, meeting, reports, emails.
Managers	Implementation plan, Worksite analysis procedures, education timelines, expectations. Involved in the creation process. Made aware of violent events that occurred on the unit and evolved in the debriefing of employees and root analysis that occur. Reports on employees who complete training.	Updated weekly	Quality nurse, Nurses educators and employees.	Personal communication, email, reports.
Educators	Copy of the implementation plan, new policies, and procedures, expectations of the educational program.	Weekly	Manager	Personal communication and email.
Security	Implementation plan, policies, timeline for implementation, copy of worksite analysis. Activation plan.	Week 4Week 26 Any time an event occurs post-project.	Manager, Employees, and Administration.	Personal communicationReports and emails.
Local law enforcement	Activation plan. Reports when violent events occur.	Week 4Week 26 Any time an event occurs post-project.	Chief security officer.	Phone calls, email meetings, personal communication.
Human recourses	Implementation plan, policies, education on the need for change procedures, timelines, expectations, educational requirements activation system, cost analysis, worksite analysis.	Week 1Week 14 Week 26	Manager, Quality nurse/staff, Administration	E-mailMeeting and personal communication
Employees	Education requirements, creation of new online reporting system, changes made to environment.	Week 1Week 12 Week 23 Week 26	Manager and EducatorsVarious educational programs	Personal communicationEmails, meetings, and handouts
Engineering	Worksite analysis and when changes can be implemented into the environment.	Week 4Week 12	Project leader and managers.	Personal communication and e-mail.
Senior employees on project team.	Implementation plan, policies, education on the need for change procedures, timelines, expectations, worksite analysis, educational requirements, online reporting tool.	Week 1Week 2 Week 4 Week 6 Week 8	Project leader and unit manager.	Personal communication and e-mail.
Nurse managers	Outcomes analysis	Will obtain views and input from staff on changes they would like to see occur. yearly survey.	Employees	Personal communication and survey.

References

• Ahmed Higazee, M. Z., & Rayan, A. (2017). Consequences and Control Measures of Workplace Violence among Nurses. Journal of Nursing and Health Studies, 02(03). doi:10.21767/2574-2825.100028
• Occupational Safety and Health Administration. (2016). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Retrieved from https://www.osha.gov/Publications/osha3148.pdf
• Potera, C. (2016). Violence Against Nurses in the Workplace. AJN, American Journal of Nursing, 116(6), 20. doi:10.1097/01.naj.0000484226.30177.ab
• Stephens, W. (2019, May 12). Violence Against Healthcare Workers: A Rising Epidemic. Retrieved from https://www.ajmc.com/focus-of-the-week/violence-against-healthcare-workers-a-rising-epidemic///?p=2
• Strickler, J. (2018). Staying safe. Nursing, 48(11), 58-62. doi:10.1097/01.nurse.0000545021.36908.28
• Wax, J. R., Pinette, M. G., & Cartin, A. (2016). Workplace Violence in Health Care—It’s Not “Part of the Job”. Obstetrical & Gynecological Survey, 71(7), 427-434. doi:10.1097/ogx.0000000000000334