Preventing Violence in the Healthcare Workplace
Violence. When it erupts in the healthcare setting, we are surprised. As nurses, we see ourselves as good and reasonably cautious people providing services to the sick and injured. This shouldn’t happen to us. However, when the Colorado Nurses Association Task Force on Workplace Violence surveyed nurses in seven states in 1997, one-third of the 586 respondents stated that they had been a victim of workplace violence in the last year. According to the Department of Labor statistics released in 1999, Health care services led all service industries in non-fatal assaults and violent acts resulting in lost workdays, with 43 percent of the incidents, followed by social services with 17 percent of the assaults.
That Healthcare workers suffer a high number of non-fatal assaults should not be a surprise. Many clients treated in hospitals, long-term care facilities, and in-home health situations have a high risk for violence. Problems associated with violence include hypoglycemia, electrolyte imbalances, anemia, hypoxia, alcohol intoxication, pain, the use of cocaine, PCP, LSD, and other drugs, and dementia. The wave of de-institutionalized mental health patients has increased the number of disturbed and potentially dangerous patients appearing in community emergency departments. Both the victims and perpetrators of gang violence are treated in hospitals and long term care facilities. And healthcare workplaces are not immune to the effects of poor management practices and the actions of disgruntled employees. The frustration levels of patients and families seem to increase as nursing staffing levels decline. Security departments, too, are often understaffed and lack adequate training and resources.
The U.S. Occupational Safety and Health Administration (OSHA) has published “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers,” which lists four main components to any effective safety and health program, as well as preventing workplace violence: 1) management commitment and employee involvement, 2) worksite analysis, 3) hazard prevention and control, and 4) safety and health training.
Training for employees in recognizing potential violence, and dealing with the aftermath of violence is needed in many healthcare workplaces. Training in the recognition and management of aggressive and assaultive behavior may be lifesaving for healthcare workers. In a comprehensive workplace violence survey initiated by the Hawaii Nurses Association and returned by 509 nurses, 89 percent of those who had received training in the handling of violent situations stated it has helped them in their work. The Crisis Prevention Institute (CPI) offers a training program entitled, “Nonviolent Crisis Intervention.” A pilot study published in 1996 evaluated staff use of the CPI techniques in averting crisis episodes. One hundred and forty six observations of patient incidents were completed, indicating that staff use of CPI training was effective in resolving more than 84 percent of the episodes observed. For an example of the CPI approach, see the sidebar, “Seven Principles for Effective Verbal Intervention.”
Trish Falcon, a nurse and clinical psychologist, tells this story:
“I was asked to come to the ER to evaluate an intoxicated, middle-aged man for suiciality. This man had not made a statement indicating a desire to kill himself, but had been drinking and smoking marijuana mixed with cocaine (commonly called “coco puffs”). He had been brought to the ER by a friend who was concerned about the hallucinations he was exhibiting.
“The ER doctor called me because of the combination of drugs and alcohol, and the man’s refusal to communicate with any of the staff except for statements of “I don’t care anymore.” The ER staff had restrained him because he was not cooperative with the exam. He readily spoke to me, and indeed he had both suicidal and homicidal ideation. The ideation was associated with some paranoid delusions about his boss, and he intended to kill his boss. I decided to ask security to stand by and have another person accompany me to deliver the news that he would be hospitalized to detox and be evaluated against his wishes. Using all the psych skills I have, I was able to deliver the news without a problem initially. A guard was posted near his room. Later a nurse entered his room to give him some Ativan, and she loosened his restraints when he promised to behave. He then pulled out a gun and started yelling that he was going to shoot the nurse unless he was allowed to leave the ER. I was able to effectively negotiate with this man and he let the nurse go. He also slid the gun out the door and gave himself up. I could not have been able to do the above if I had not been properly trained in negotiation techniques, and how to deliver bad news to aggressive and violent patients.”
According to Mike Napier, a retked FBI hostage negotiator, the most dangerous person is the one who does not speak. If they are talking – even threatening – options are available. The response to a violent person’s statements will likely set the course of what follows. The most dangerous threats or statements are those that are unequivocal, contain no room for negotiation, or are not conditional, according to Napier. “I will get you before the week is over,” is different from, “One of these days, you will get yours.”
Mike Napier is one of the experts at the Academy Group (listed in the Resource section) who can deliver listening and calming training, which includes the following: “I” messages are useful in calming techniques, often helping to relieve tension and calm things down. They illustrate how you feel, and how the other person’s actions impact you: “I became concerned when you say…” “I can hear the distress in your voice.” “I can see that you are angry.”
Paraphrasing is a calming technique wherein you state, in your own words, what the other person has stated. It demonstrates that you are listening, that you care. Paraphrasing can clear up misunderstandings. It is difficult to reason with someone who is under the influence of emotions. You must address the emotions before you can address the problem.
In their article, “Managing the Violent Patient,” Doctors Rice and Moore offer several suggestions that can be applied to visitors, patients, and co-workers as well. They suggest the best approach is honest, straightforward, and frank. Eye contact and close positioning should be avoided as they can provoke stress and anxiety. The healthcare provider should act as an advocate, not an adversary. Never lie, as they may take out their anger on you and others when they find out they have been deceived. Arguing and machismo are improper responses to a potentially violent person according to Rice and Moore. Commanding someone to calm down invites escalation as the person must protect his ego. Ignoring the patient can also lead to escalation. These psychiatrists suggest that the most dangerous reactions are denial and absence of concern.
Over and over again, experts tell us to take threats seriously. Threats must be taken seriously, and communicated to security and other staff members. When a patient declared he was going to kill the next person who tried to get him out of bed, that information was not passed on to the next shift. A healthcare worker was stabbed in the abdomen the next day while trying to coax the patient into a chair.
OSHA guidelines suggest that violence prevention training should involve all employees at facilities and cover topics such as:
* The workplace violence prevention policy.
* Early recognition of escalating behavior.
* Ways of diffusing volatile situations, managing anger, and appropriately using medications.
* The location and operation of safety devises such as alarms.
* Policies and procedures for obtaining medical care, counseling, workers’ compensation, or legal assistance after a violent episode.
Training in the management of aggressive behavior is a necessary tool for today’s healthcare worker. Utilizing the training will promote your safety and that of your clients and co-workers.
Crisis Prevention Institute
3315-K North 124th Street
Brookfield, WI 53005 USA
The Academy Group
7542 Diplmat Drive
*Occupational Safety and Health Administration (OSHA)
“Guidelines for Preventing Workplace Violence for Healthcare & Social Service Workers”
* In 2003, the U.S. Occupational Safety and Health Administration (OSHA) published “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers,” which lists four main components to any effective safety and health program, as well as preventing workplace violence: 1) management commitment and employee involvement, 2) worksite analysis, 3) hazard prevention and control, and 4) safety and health training.
The Center for American Nurses is a professional association whose mission is to create a community of nursing organizations that supports individual nurses by providing programs, services, and policies that address the concerns of nurses and promote their personal and professional growth.
Carroll V., & Morin, K.H., (1998, Sept./Oct).
Workplace violence affects one-third of nurses. The American Nurse. 15.
Rice, M.M., & Moore, G.P. (1991, February). Management of the violent patient. Emergency Medicine Clinics of North America. Vol. 9, No. 1, 13-30.
by Vicki Carroll, MSN, RN
Reprinted by permission of the Crisis Prevention Institute
Copyright Alabama State Nurses’ Association Mar-May 2004
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