will_a_violence_plan_reduce_the_negative_effects_of_workplace_violence

Running head: WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE Will a Violence Prevention Plan Reduce the Negative Effects of Workplace Violence? Joan Herr Grand Canyon University Professional Capstone Project NRSV 441 Dr Joyce Morrison March 08, 2011 WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF Abstract Workplace Violence (WV) is increasing at an alarming rate especially in the hospital setting (Dickinson, 2009, p 34) Nurses have the second most dangerous profession (GallantRoman, 2008, p 450) The definition of and effects of WV will be identified in this capstone project Most facilities not have strategies in place to deal with WV (AbuAIRub, Khalia, & Habbib, 2007, p 281) Suggested solutions to minimize the effects of WV will be presented in order to minimize the dangers to the employee, reduce costly expenses of WV, and to improve the quality of care and patient satisfaction that are negatively affected by WV An extensive review of the literature will be provided to support all aspects of capstone project A theory to reduce the negative effects of WV will be discussed Methods to educate, implement, evaluate, and disseminate results of the WV plan will be presented WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF Will a Violence Prevention Plan Reduce the Negative Effects of Workplace Violence? Introduction On January 8th, 2011, Americans were shocked upon hearing the morning news The news reported that an Arizona congresswoman, Gabriel Giffords along with at least 17 others were shot outside a neighborhood Safeway grocery store by a suspect who had previously displayed increasingly strange behavior (Lacey & Herszenhorn, 2011, p 1-2) Violence in our world is a common occurrence Workplace Violence, (WV) is a situation that occurs on a daily basis for many employees WV can be bullying, verbal abuse, harassment, inappropriate sexual comments or actions, and can also be violent threats or actions (VenturaMadangeng & Wilson, 2009, p 37) WV can be from fellow employees, patients, or visitors The true incidence of WV is undetermined and considered under-reported due to many factors (Ventura-Madangeng & Wilson, 2009, p 37) This underreporting can occur due to nurses feeling it is just part of the job, concern over repercussions or simply because the definition of WV has never been standardized (Ventura-Madangeng & Wilson, 2009, p 38) Many facilities not have WV preventions plans in place Violence in the workplace is anticipated to rise in the future due to the strained economic conditions that exist (Hoobler, 2006, p 229) WV has many physical, psychological and financial effects that are costly to the employee, the patient and the institution Facilities that recognize WV as a problem and have instituted WV prevention plans note a drastic decrease in its incidence Keefe, 2011, p 10) It is time for organizations to begin to identify WV as a huge problem before the effects of its lack of recognition as a problem and lack of planning to prevent it are beyond solutions and the end result is disasters such as occurred on March 8, 2011 to Congresswoman Giffords WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF Problem Definition Problem Identification: According to the American Nurses Association (as cited by Gallant, 2008, p1.), “Nurses have the right to a safe and secure workplace in which to provide quality patient care.” Due to the presence of WV, a safe place to practice nursing is not the reality that most nurses practice in Problem Description Verbal abuse, harassment, bullying, sexual abuse, and physical violence are all part of what many nurses consider to be “part of the job”(Keefe, 2011, p 10), and are all terms associated with WV (Ventura-Madangeng & Wilson, 2009, p 37) WV may come from patients, visitors, or coworkers Wherever people are under considerable conflict or stress, this increases the chances of WV occurrence (Holmes, 2006, p 222) In the hospital setting, Emergency Departments (ED) and Mental Health Units appear to experience the highest number of violent incidents (Chapman, Sytles, Perry, & Combs, 2010, p 479) According to the Emergency Nurses Association, (ENA), (Keefe, 2011, p 10), 8-13% of ED nurses are victims of physical violence at work every week Most occurrences of WV occur in a hospital room Police officers have the first highest incidence of violence; nurses are second (Spector, Coulter, Stockwell, & Matz, 2007, p 119) Impact of Problem Workplace violence can have physical, financial, emotional and organizational effects (Ventura-Madangeng & Wilson, 2009, p 39) Despite Zero Tolerance and efforts to manage this problem, the problem of violence is escalating at an alarming rate (Ople et al., 2010, p 21) Many nurses report being involved in or witnessing WV frequently Up to 63% of WV incidents WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF go unreported for reasons including not feeling that management will respond, worrying about punitive responses, or just feeling it is a normal part of the day (Ventura-Madangeng & Wilson, 2009, p 38) Even the fact that there is not one accepted definition of WV may contribute to underreporting, and because of underreporting the true extent of the magnitude of the problem of WV exists (Ventura-Madangeng & Wilson, 2009, pp 37-38) Seventy Five percent of ED nurses received no response to reports of violence according to Keefe (Keefe, 2011, p10) Work place violence can contribute to decreased productivity, absenteeism, high turnover rate, and many costs related to litigation and rehabilitation fees (Speedy, 2006, p 243) Many nurses feel their workplace is not safe and work in an atmosphere of fear (Ople et al., 2010, p 18) The more civil your workplace, the lower the rates of sick leave, fewer complaints to Equal Employment Opportunity commission, higher patient and employee satisfaction rates, standards will be met and patient care safer ("Bullying takes toll", 2010, p 30) Workplace injuries from on the job violence cost organizations $202 billion dollars annually (Hoobler, 2006, p 230) Significance to Nursing In one study an alarmingly 93% of the nurses felt that the hospital did not have policies to protect them (AbuAIRub, Khalia, & Habbib, 2007, p 283) Physical layouts of many hospitals not promote safety with visitors coming and going freely Many times security is not a visible deterrent Many employees are not trained in identifying or dealing with those who may become violent, nor are they trained in de-escalation The nursing profession has long endured the effects of WV Although Joint Commission mandates “Zero Tolerance” and requires hospitals to have codes of conduct ("Bullying takes toll", 2010, p 28), the problem continues Nursing operates under conditions of great stress Lateral violence and bullying are a daily occurrence for many Nursing should take an active role WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF in their hospitals, and also in the legislature to bring to the attention of those in higher authority the extent of the problem Nurses need to recognize that violence is not an acceptable part of their job Reports should be filed whenever violence occurs and nurses need to demand a consequence for this behavior Nurses need to educate themselves on workplace violence, its causes, effects, and solutions Hospitals with no policy to address WV had 18.1% rate of violence, those with an effective zero-tolerance policy had a rate of 8.4 % (Keefe, 2011, p 10) Solutions A multi-faceted approach to develop an effective WV prevention plan is suggested by the following authors who are recognized, referenced and cited in this paper and credit will be given to each in the following solutions that are listed Definition of the term WV in order to better research the problem Recognition of the problem, causes, effects, and the most effective strategies to prevent WV.(VenturaMadangeng & Wilson, 2009, p 38) Zero tolerance for any WV from bullying to verbal aggression to physical violence (Keefe, 2011, p 10) Do not allow or ignore bullying or other abusive actions WV cannot be tolerated: if organizations ignore and deny its presence; with the help of nurses, educators, the community and at the legislative level strategies must be develop and enforced to address this problem Have a threat assessment completed to identify areas of improvement (Lewis & Contino, 2010, p 1) Educate all staff on the recognition of potentially violent behavior, de-escalation techniques, and how to physically restrain patients (Keefe, 2011, p 11) Reassess and monitor the responses to the strategy WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF Involve community and legislative personnel in the process Federal mandates for violence prevention, safety assessment, regular training, and prevention programs (Dickinson, 2009, p 34-36) Institute measures to improve your physical layout of facility (keypads, panic alarms, lighting) (Lewis, 2010, p 1) Investigate underlying causal factors such as poor staffing, customer service skills, overcrowding, and inadequate staff training in dealing with violence (Holmes, 2006) Develop a “code of conduct” which promotes civility respect, cooperation, conflict resolution, and antidiscrimination ("Bullying takes toll", 2010, p 30) WV cannot be tolerated Organizations cannot continue to ignore and deny the presence of WV With the help of nurses, educators, community involvement and legislative action, strategies can be developed and enforced to address the problem of WV PICOT Format Population of Focus: Abusive, Aggressive, or violent patients, family or coworkers in the hospital setting Intervention: Workplace Violence prevention strategies Comparison: None Outcome: Reduction in physical injuries, psychological effects, costs, improved climate which promotes quality patient care PICOT Question In the hospital setting of abusive aggressive or violent family, patients or coworkers, will a WV prevention plan reduce the number of physical injuries, adverse psychological effects, reduce costs and improve the climate to improve quality patient care? WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF Rapid Appraisal of Evidence Based Research Articles Utilizing NRS441V Sample Format for Review of Literature (see Appendix A for continued resource appraisal) AbuAIRub, R F., Khalia, M F., & Habbib, M B (2007) Workplace violence among Iraqi hospital nurses Journal of Nursing Scholarship, 39(3), 281-288 Summary of Article: This article investigated the occurrence and frequency of workplace violence (WV) among Iraqi nurses, the nurses’ responses to both the violence itself and the policies dealing with the violence and the violence prevention strategies (AbuAIRub, Khalia, & Habbib, 2007, p 281) Research Elements: Design, Methods, Population, Strength, Limitation: A descriptive exploratory survey was utilized interviewing 116 Iraqi nurses in a hospital setting in Bagdad City (AbuAIRub, Khalia, & Habbib, 2007, p 283) A pilot study of 20 nurses was utilized who were then excluded from the study (AbuAIRub et al., 2007, p 283) Modifications were done due to culturally sensitive topics in Iraq (AbuAIRub et al., 2007, p 283) The questionnaire was taken from several sources including the World Health Organization (AbuAIRub et al., 2007, p 283) There were sections to the questionnaire, 71 items were assessed with open ended questions(AbuAIRub et al., 2007, p 283) Consent, anonymity, and confidentiality were protected A statistical package of social sciences (SPSS) version 14 was utilized to analyze the data The sample size was small with over half being male participants This was a unique study as violence in the hospital setting has not been explored previously WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF The data was collected over a short two month period of time in a war torn area of the world The participants were chosen which could create a bias of the examiner potentially The results are believable This was definitely a necessary study Not all areas of the study were presented Further data to be discussed in future manuscripts This study was subject to the recall of the individual which may be skewed This is also a war torn country where violence is seen to be an everyday occurrence so may be underreported Outcome(s): Research Results The majority of participants reported that there were no procedures for reporting violent incidents in the workplace; 30.2% were worried about workplace violence; 91% had been exposed to workplace violence in the past year, 41% attacked physically, 14.3% with lethal weapons (AbuAIRub et al., 2007, p 284) The effects on the nurse were described in a table Most participants reported that no policies against workplace violence existed in their facility (AbuAIRub et al., 2007, p 283) Significance to Nursing and Patient Care: This study presented the psychological effects of violence to the nurses, along with the injuries and stressors a nurse must work under It defined a clear need for federal legislation and hospital support to protect healthcare workers, prevention strategies such as limiting access to hospital, security, and education programs, War conditions and major stressors contribute to violence and other countries can take precautions to recognize and plan for violence prevention Violence in a hospital setting does not contribute to quality of care and can result in injuries, and job dissatisfaction, which all will eventually affect patient care (AbuAIRub et al., 2007, p 287) Bullying takes toll on HCWs and patients: Joint Commission: Zero Tolerance for intimidation (2010, March) Hospital Employee Health, (March), 28-30 WILL A VIOLENCE PREVENTION PLAN REDUCE THE NEGATIVE EFFECTS OF 10 Summary of Article: The more that workplace bullying is allowed, the worse the condition is and this affects staff and patients alike ("Bullying takes toll", 2010, p 28) Research Elements: Design, Methods, Population, Strength, Limitation: Article noted effects of bullying on patients and staff A pilot study to institute CREW (Civility, Respect and Engagement in the Workplace) a program to promote civility in the workplace noted Lower Equal Employment Opportunity Commission complaints, higher employee and patient satisfaction noted with high levels of civility ("Bullying takes toll", 2010, p 30) Outcome(s): Research Results Workplaces that permit intimidation and bullying have lower satisfaction ratings, poorer patient care, and injuries ("Bullying takes toll", 2010, p 28) Injury, illness and assault are higher in workplaces that allow workplace harassment ("Bullying takes toll", 2010, p 28) Ten to fourteen percent of workers noted bullying ("Bullying takes toll", 2010, p 29) Significance to Nursing and Patient Care: Joint Commission requires a zero tolerance for bullying, and nurses and other coworkers must ensure that this is upheld ("Bullying takes toll", 2010, p 29) Assisting in your own practice to improve the civility in your culture is important ("Bullying takes toll", 2010, p 30) Chapman, R., Styles, I., Perry, L., & Combs, S (2010) Examining the characteristics of workplace violence in one non-tertiary hospital Journal of Clinical Nursing, 19, 479488 Summary of Article: To examine the prevalence and characteristics of WV and investigate reasons for not reporting incidents Research Elements: Design, Methods, Population, Strengths, Limitations: This quantitative, qualitative survey was distributed to 332 nurses in a Western Australia non-tertiary ED Medical Director Security Director ED staff (2) minimum Clinical coordinators, one representative each from days and nights Member of registration staff Representative from Human Resources department Social Worker II Description of current problem, deficit: A Organization has no current WV prevention plan B Zero tolerance is not a champion cause C No current reporting system for episodes of WV D No educational programs related to WV E ED is not a secure area F Employees consider WV to be part of the job and not report, an accepting climate of bullying, verbal abuse and violence prevail G Employee and patient safety and satisfaction are at risk due to WV III Proposed Solution A Threat Assessment of facility Prepare to install keypads, glass barrier, improve lighting B Define the term WV, Written plan for zero tolerance, WV prevention plan Education of WV (Initial and yearly training) a How to identify potentially violent persons, b De-escalation measures c How to manage a physically violent patient d How and when to report WV e Investigate underlying causal factors to WV i Customer service skills ii Over-crowding iii Conflict resolution iv Noise and comfort in Ed v Degree of civility in Ed vi Throughput issues vii Potential involvement in community and legislative mandates IV Rationale for proposed solutions: A Various negative psychological, physical, financial effects cited B.WV prevention plan will improve patient care, reduce injuries, create civil climate with improved patient and employee satisfaction, retention, V Evidence from literature to support proposal (Provide complete Literature Review) A Supports federal mandates and zero tolerance policies B Reduction in injuries cited in literature, V Logistics A When: September, 2011 B Where: Pilot in ED C Who will initiate, educate, and oversee change: Leadership and Multidisciplinary team This combined team will be called the WV Committee V Resources: A Staff Security to give hands on training on restraining violent patients, restraint application Social Worker to present lectures on de-escalation techniques, recognition of potentially violent persons B Educational tools Bundled educational packets of WV prevention plan Bundles of reporting device, de-escalation techniques, identifying potentially violent patients C Assessment tools Pre and Post test knowledge of WV (Appendix C.) D Technology Video equipment utilized in education department for PPP, Panic alarms, key pads installed, glass barriers, improved lighting Current computers for research, printers, and fax machines are available E Funds Threat assessment Cost of completion of suggested physical changes after threat assessment Cost of printing supplies Paper supplies Cost of compiling data, implementing process, Cost of evaluating effectiveness of Plan Cost to oversee, evaluate change, WV Committee evaluating WV reports As much work will be completed during normal work day as is possible to limit costs Appendix C WORK PLACE VIOLENCE QUESTIONNAIRE Hospital X is gathering information on the topic of Workplace Violence (WV) This is a serious issue that requires an organized plan This committee is gathering data which will direct future responses to this topic All responses will be analyzed anonymously and a report will follow for your perusal Thank you for your time and attention In your own words define workplace violence . _ _ With what frequency you personally experience WV? Please circle response: Employee to employee: Never Daily Weekly Monthly Yearly Visitor to employee: Never Daily Weekly Monthly Yearly Patient to employee: Never Daily Weekly Monthly Yearly Supervisor to employee: Never Daily Weekly Monthly Yearly Have you ever reported incidences of WV? YES What method did you use to report incident? Phone call Report Alert-Line NO Email Occurrence To your knowledge was any action taken after reporting incident? YES Do you feel safe at work? YES NO NO Describe what ways you not feel safe at work if any? Are you aware of a hospital WV prevention plan? YES NO Appendix C: Workplace Violence Questionnaire What education have you received while employed at Hospital X regarding dealing with WV? _ _ _ _ 10 Do you believe WV is a problem at Hospital X? YES NO _ _ _ _ 11 Have you ever experienced any negative effects from WV? _ 11 Do you believe that Hospital X takes WV seriously as evidenced by its actions policies or physical layout? YES NO _ _ 12 What barriers exist that keep Hospital X from creating and implementing a WV prevention plan? _ _ _ 13 Would you be in support of a WV prevention plan at Hospital X? YES NO 14 Any additional comments are welcomed _ _ _ _ Appendix D: Stop WV poster WATCH FOR UPCOMING ANNOUNCEMENTS REGARDING IMPLEMENTATION OF WV PREVENTION PLANS! Appendix E: Risk Assessment tool to identify potentially violent patients Risk Assessment Tool to Identify Potentially Violent Patients An assessment is to be completed on each patient presenting to the hospital to effectively identify patients who may become violent If a patient is identified as potentially violent, the patients chart will be placed on an orange chart, and patient will be placed in an orange gown This will be termed a CODE ORANGE response Circle indicators that are present on admit: + Any of the following indicators will initiate a CODE ORANGE response: ~ Expresses verbally hostile or threatening comments ~ History of violence or aggressive actions ~ Threatening or appearing physically aggressive ( getting in your personal space, aggressive gesturing) + Any three or more indicators will initiate a CODE ORANGE response: ~ Threatening to leave ~ Altered level of consciousness related to hypoxia, metabolic causes, drug intoxication, alcohol intoxication , withdrawal from drugs or alcohol, organic causes ~ Hallucinations ~ Confusion or cognitive impairment ~ Agitation of unknown causes( pacing, tachycardia, sweating, red face, mumbling, chanting, swearing, negative remarks, crying, inappropriate behavior for situation ~ Withdrawn (poor eye contact, defiant ) ~ Loud, demanding, shouting ,slamming doors, kicking furniture, ~ Paranoid behavior, suspicious actions or comments Above data taken in part from a risk assessment tool by (Kling et al., 2006) Appendix F: De-escalation Techniques and Rapid Response DE-ESCALATION TECHNIQUES and Rapid Response Early recognition of patient who displays mounting tension is necessary Inform security or others of any concerns you may have of potentially violent patient in the event that a CODE ORANGE RESPONSE is needed Quick risk assessment utilizing CODE ORANGE tool to identify potentially violent persons Approach person in a calm, unhurried, and non-confrontational manner that lets the patient know you are concerned and in control but in a non threatening manner Do not place yourself or others in an unsafe compromised position Identify yourself by name and identify person Call them by name in a pleasant manner Show Respect Listen; help person express their concerns, use reality orientation If necessary, attempt to isolate patient from others, but not place yourself in a potentially unprotected position Attempt to ascertain if patient may have weapons or devices which may harm them or others and obtain if able Attempt to communicate to patient that you are concerned for them and would like to know how to help Attempt to meet persons’ reasonable requests that may defuse situation which may prevent escalation of situation Attempt to orient person to reality if appears delusional Do not attempt to reason with out of control person Keep hands visible Maintain readiness stance Quick assessment to determine reality, evidence of injury, hypoglycemic event, withdrawal from or presence of altering substance Anticipate and be prepared for sudden violence Keep yourself closest to EXIT Attempt to utilize verbal means, possibly chemical means before physical restraints to ensure safety Appendix F: De-escalation techniques and rapid response Give directions to patient and expectations of person Explain yourself, and offer alternatives 10 If patient not able to exhibit control or take direction from staff, instruct person of consequences which will be taken if person unable to maintain control Don’t crowd person 11 Be prepared for restraints if needed rapidly and decisively 12 If other staff must become involved in restraint of patient, have one person who has best rapport with person, to be in charge of direction Don’t yell or become aggressive Don’t criticize or argue with person 12 If necessary minimum of persons to physically restrain patient in a methodical manner utilizing skill, speed and surprise Carry person if necessary to secluded room 13 Remind patient that they are not being punished, and of the conditions that must exist before restraints can be removed 14 Involve physician as soon as possible for assessment and or chemical intervention 15 Initiate appropriate restraint/ seclusion documentation Person is to be under constant supervision 16 Always anticipate violence in any situation but especially if any indicators of risk assessment of potentially violent person exist 17 Complete WV reporting form and restraint log De-escalation tool formulated by author of capstone after review of article by (Barash, 2011) Appendix G: Evaluation Tool to Assess Nurses Response to WV Education and Implementation Do you consider WV to “just be part of my job?” Has the WV plan changed your idea regarding this concept? Have your skills, beliefs, practice, or knowledge changed about WV since the initiation of the WV plan at this facility? Has the education for WV benefitted your practice? In what way could the education regarding WV be improved to assist your care or understanding of WV? _ Please comment on whether you feel the WV plan has had any impact on burnout, job dissatisfaction, stress, patient satisfaction, or quality of care at this facility? _6 Have you routinely utilized the following forms? De-escalation techniques Yes No Identification of potentially violent patients Yes No Reporting form for WV Yes No Appendix G: Evaluation Tool to assess nurse’s response to WV education and implementation Have you utilized Code Orange Responses? Orange clip boards Yes No Orange gowns Yes No Do you feel the WV plan has raised awareness of the presence of WV? Yes No 10 Do you see an improvement in the safety climate at this facility? Yes No 10 Do you feel WV plan has been effective in identifying and attempting to prevent WV? Yes No 11 Please make any suggestions for improving the WV plan, and or any additional comments from above questions. _ Appendix H: WV Reporting Form (Please complete this form anytime you are a victim of WV This form may be completed anonymously or you may add your name on form You will receive a response to all incidences in as timely a manner as is possible Place completed forms in locked box in the break room labeled WV All forms will be evaluated by the WV committee and a response to your concern will be forthcoming.) Date Time Place WV occurred _ _ What persons were involved in incident? Employee to Employee Supervisor to employee Patient to employee Patient to other person than employee Visitor to employee Type of WV bullying harassment verbal abuse physical assault verbal assault/ threat intimidation sexual comments sexual abuse Describe incident _ _ _ _ _ _ _ What action did you take after incident? _ _ _ _ _ _ _ _ Appendix H: WV Reporting Form Did you, or you plan to have any treatment after this incident? (Counseling, time-off or medical treatment?) _ _ _ _ How has this incident made you feel about the person, about work? _ _ _ 10 Additional comments _ _ _ _ Account # if patient involved Your name _ Anonymous if desired