1.1 Workplace Violence Prevention: Know Your Way Out
Notes:
Welcome to the Emergency Nurses Association's course: “Workplace Violence
Prevention: Know Your Way Out.”
This interactive, self-learning course focuses on risk factors that contribute to workplace
violence and strategies to prevent and reduce the occurrence of violent incidents in
emergency departments.
This course was created in collaboration with emergency nurses and is intended for
nurses, managers and other staff who work in emergency care settings.
1
1.2 Program Instructions
Notes:
(No narration on slide)
2
1.3 Susan Harwood Training Grant
Notes:
Financial support for this program was made possible through a grant from the
Occupational Safety and Health Administration. The Emergency Nurses Association is
solely responsible for the content.
3
1.4 Learning Objectives
Notes:
At the end of this course, you should be able to summarize the incidence and
prevalence of workplace violence in the U.S., and describe the individual and
environmental factors that contribute to a low, moderate or high level of risk for
violence in emergency departments.
4
1.5 Learning Objectives
Notes:
This course is designed to assist you in assessing and responding to the risk for violence
in your emergency department, including the application of federal and state laws that
apply to occupational safety and health.
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1.6 Occupational Safety and Health Act of 1970
Notes:
The Occupational Safety and Health Act became federal law in 1970.
The purpose of the legislation is to assure safe and healthy working conditions through
research, information, education and training.
6
1.7 1970 Occupational Safety and Health (OSHA) Act:
Notes:
The OSHA Act defines the rights of workers in the U.S., including
access to information about workplace hazards,
training in prevention and protection methods, and
filing of complaints without fear of retaliation or discrimination.
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1.8 1970 OSHA Act: Employer Responsibilities
Notes:
The Act also requires employers to
maintain safe working conditions,
provide safety training and information about workplace hazards for employees,
and
keep records of work-related injuries and illnesses.
8
1.9 State and Federal OSHA Coverage
Notes:
Most private sector and federal employees in the U.S. come under OSHA's jurisdiction
either directly through the Federal OSHA system or through an OSHA-approved state
program.
Employees who work for state and local governments are not covered by Federal OSHA,
but have OSHA Act protections if they work in a state that has an OSHA-approved state
program. You can find the contact information for the OSHA office nearest you using the
Regional and Area Offices map on OSHA's Web site.
Self-employed individuals or immediate family members of farm employers that do not
employ outside employees are not covered under the OSHA Act.
9
1.10 Background and Significance
Notes:
(No narration on slide)
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1.11 Defining Workplace Violence
Notes:
Workplace violence has gained recognition as a violent crime that requires targeted
responses from employers, law enforcement, and the community.
Yet, all too frequently, the resulting physical and emotional harm are still considered to
be “part of the job”.
A successful workplace violence prevention program will require a paradigm shift not
only among hospital administrators, managers and the general public, but also among
emergency care providers.
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1.12 U.S. Occupational Injuries: Private Industry Sector, 2011
Notes:
The U.S. Bureau of Labor Statistics collects data on non-fatal and fatal occupational
injuries reported by employers.
12
1.13 ENA ED Violence Surveillance Study
Notes:
The ENA Emergency Department Violence Surveillance Study collected data
approximately every three months from May 2009 to January 2011, utilizing a sample of
emergency nurses who were randomly selected from the ENA membership database.
One third of the emergency nurses who responded to the survey reported that they had
considered leaving their job or profession because of workplace violence.
This suggests that workplace violence in emergency departments is an overarching
problem, not an unusual event.
This course will discuss ways to potentially improve this statistic through recognition
and mitigation of violence against emergency health care providers.
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1.14 ENA ED Violence ENA Violence Surveillance Study Results
Notes:
Results from the ENA study indicate that the incidence and prevalence of workplace
violence has stayed fairly constant for this group of nurses who worked in U.S.
emergency departments during the study period.
Over half of all nurses who participated, indicated that they had experienced either
physical violence or verbal abuse while at work during the preceding week.
These incidents have a huge impact on the ability of emergency nurses and other health
care workers to provide high quality patient care in a safe work environment.
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1.15 ENA Violence Surveillance Study
Notes:
(No narration on slide)
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1.16 ENA Violence Surveillance Study
Notes:
ENA study results showed a statistically significant lower risk of nurses experiencing
violence in the ED if they worked in facilities in which hospital and ED administrators
were committed to controlling workplace violence.
Likewise, in facilities that had policies for reporting workplace violent incidents, nurses
were less likely to have experienced physical and verbal abuse.
Despite this, a majority of those who were victims of workplace violence did not file a
formal event report-something we'll discuss more in a few minutes.
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1.17 Organizations’ Policies and Statements About Workplace Violence
Toward Nurses
Notes:
OSHA recommends that employer policies include a ‘zero tolerance' statement for
workplace violence.
This requires that organizations have a coordinated institutional and departmental
approach to recognizing and mitigating violence.
AND, that policies and procedures are disseminated to all employees, patients and
visitors.
Information on the ENA and OSHA websites can help emergency departments develop
appropriate policies to help reduce the incidence of workplace violence.
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1.18 Why Are Nurses Not Reporting?
Notes:
There are numerous reasons that nurses may decide not to file an official incident
report.
Among the most common are the challenges with the reporting process, a lack of belief
that reporting will have any benefits, fear of negative impacts, or a lack or institutional
response.
Perhaps the most disconcerting reason that nurses choose not to report a violent event,
is the perception that violence is part of the job.
This perception can be perpetuated by individuals, by management and even by officials
in the legal and judicial system whose job it is to protect citizens from harm.
Therefore, changing these perceptions will require a broad-based effort from nurses,
hospital administrators and the community at large.
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1.19 Why Are EDs Especially Prone
Notes:
The environment in which you practice is critical to the safety of the health care team
and the patients you serve.
Some environmental features of the ED workplace are difficult to change such as 24hour accessibility by the public, or crowding.
Other aspects - such as staff preparedness and an organization's commitment to the
safety of its workforce - can be more readily improved to reduce the occurrence of
workplace violence.
A first step toward early recognition and mitigation of violence is the awareness of highrisk elements, how they contribute to violent incidents, and what factors can be
modified to reduce the risk of an event.
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1.20 Why Are EDs Especially Prone
Notes:
Both environmental and personal factors are important to consider as part of your
efforts to reduce the occurrence of violence in your facility.
In the next section, we will look at risk factors that contribute to the occurrence of
workplace violence as well as some techniques for recognizing and avoiding those risks.
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1.21 Recognition and Avoidance
Notes:
There are many factors that contribute to occupational risks in emergency care settings,
but a fundamental challenge is a healthcare culture that focuses more on patient safety
than on worker safety.
To create a greater focus on worker safety, both employers and employees must be
accountable for implementing violence control measures.
By learning to recognize warning signs or “cues” for violence, you can protect yourself
and assist your colleagues in avoiding and preventing workplace violence.
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1.22 Recognizing Cues for Violence:
Notes:
With over 38,000 members, the American Society for Industrial Security is the largest
organization for security professionals.
They produce training materials, guidelines and standards for mitigating workplace
violence.
This list, developed by their organization, shows some of the most common warning
signs that can indicate a potential risk for violence from an individual patient or visitor in
your emergency department.
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1.23 Recognizing Cues for Violence:
Notes:
Early recognition of behaviors such as verbal harassment, threatening language or
gestures, and lack of cooperation can alert you and your team to the potential for
violence.
These cues are a first step to taking appropriate actions that not only help to protect
staff, but also patients and visitors.
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1.24 STAMP Acronym
STAMP Acronym
Staring
No eye contact; prolonged glaring
Tone
Increased volume; demeaning inflection; sarcasm; sharp or caustic
retorts
Anxiety
Dilated pupils; hyperventilation; rapid speech; confusion and
disorientation; expressed lack of understanding; physical indicators
of pain; grimacing, writhing, clutching body; flushed appearance
Mumbling Slurred or incoherent speech; talking “under their breath”; criticizing
staff or the institution; repetitive requests or questions
Pacing
“Resisting” healthcare; flailing around in bed; walking around
confined areas or back and forth to the nurses area
Source: Luck, L., Jackson, D., & Usher, K. (2007). STAMP: Components of observable behavior that indicate potential for patient violence
in emergency departments. Journal of Advanced Nursing, 59(1), 11–19.
Recognizing Cues for Violence
Notes:
Dr. Luck is an Australian researcher who has studied observable behaviors that indicate
potential for patient violence in emergency departments. She and her team developed
the STAMP acronym as a method for cue recognition.
STAMP stands for:
Staring
Tone of voice
Anxiety
Mumbling and
Pacing
Each category is defined by a set of behaviors that were associated with patient violence
toward ED staff. For example, mumbling includes criticism and repetitive questioning
from patients. Pacing includes patient restlessness and resistance to health care
procedures.
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1.25 Assessing Zones of Risk for Violence
Notes:
(No narration on slide)
25
1.26 The Zones of Risk
Notes:
The next series of slides will discuss a risk assessment tool for identifying levels or
‘zones' of risk for violence. There are three ‘zones of risk' depicted here: low, moderate
and high. You should think of the categories as interdependent rather than mutually
exclusive.
The advantage of learning to use a clinical violence risk assessment is its flexibility and
the recognition of individual and environmental conditions in which the assessment is
made. A useful risk assessment takes into consideration the patient's interview data,
history of violence and observable behavior, as well as the surrounding context.
In everyday practice, lines are often blurred and situations can shift rapidly from one
zone of risk to another. What's important is to develop an awareness and ability to
determine whether a given situation requires watchful waiting or taking further action.
Taking prompt and appropriate action can actually lower the level of risk and potentially
prevent a violent incident from occurring.
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1.27 LOW RISK → Watchful Waiting → Violence Is Potential
Notes:
A low risk patient is one that requires ‘watchful waiting' - meaning that, a state of
heightened awareness should be maintained so that you can recognize any warning
signs or cues that may indicate an increased risk for violence.
An example of a low risk patient might be the worried parent who's been waiting for
hours with their sick child who has not yet been evaluated. Mild displays of frustration
and anxiety are understandable within this context, but only as long as there is ongoing
cooperation with limit setting requests.
Watchful waiting requires an awareness of the potential for the current situation to
escalate.
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1.28 LOW RISK → Watchful Waiting → Violence Is Potential
Notes:
Environmental circumstances also contribute to the potential for violence. This includes
not only the physical environment, but also the workplace culture, safety controls and
policies.
Watchful waiting may be all that is required when conditions are at the most optimal meaning that, waiting rooms and hallways are not crowded and safety and security
measures are in place. But, because these conditions can change quickly, the ED
environment demands attention to safety concerns at all times.
With practiced attention, we can learn to recognize cues and warning signs as they
occur.
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1.29 Recognizing Cues for Violence
Notes:
(No narration on slide)
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1.30 MODERATE RISK → Active Planning Required → Violence Is Possible
Notes:
An escalating warning sign can be any observable behavior that the patient exhibits
during the visit, including verbal abuse, threatening body language, or resistance to
health care procedures and limit setting requests.
Other individual risk factors include a history of violent or criminal behavior, substance
use, and certain psychiatric diagnoses.
When a cluster of these elements are present, we should consider the risk level to be
moderate with active planning being required because violence is possible-although still
not predictable.
It's important to remember, however, that most patients do not become violent. By
anticipating what could happen and taking preventive action, we can reduce the
likelihood that a violent incident will happen.
30
1.31 MODERATE RISK → Active Planning Required → Violence Is Possible
Notes:
Risky environments also contribute to an increasing possibility of violence.
Inadequate safety controls or a lack of preparedness and staff training make it more
difficult to recognize and respond appropriately to an escalating crisis.
Crowded conditions or the burden of too many patients waiting in hallways can further
contribute to a heightened risk for violence.
When too many risk factors are present, the environment becomes more volatile and
your level of alertness must be adjusted accordingly.
31
1.32 Recognizing Cues for Violence
Notes:
(No narration on slide)
32
1.33 HIGH RISK → Action Required →
Notes:
Despite our best efforts to mitigate violence, there will be times when the situation
escalates to a high risk event.
Under these circumstances, a patient's assaultive or aggressive behavior requires
immediate action in order to prevent harm to both patients and staff.
33
1.34 HIGH RISK → Action Required →
Notes:
Recognizing that certain conditions can contribute to a heightened risk for violence
creates an opportunity to control and calm the environment.
There may be specific, somewhat predictable times in your facility when the
environment is particularly chaotic.
Emergency preparedness plans for mass casualty events include an accelerated infusion
of resources to handle the patient volume and high acuity level.
Similarly, anticipating and preparing for such contingencies when there is a heightened
risk for violence can be an integral part of your emergency department's violence
prevention strategy.
34
1.35 Other High-risk Environmental Factors
Notes:
For example, if your hospital is near a college campus, are there rave parties, concerts or
other large events at certain times of the year that may precipitate an increase in the
number of intoxicated or drug-impaired youth who end up in your ED?
If so, is it possible to secure extra staff and security personnel to provide sufficient
coverage at these critical times? Thinking and preparing in advance allows your facility
and staff to respond more effectively.
35
1.36 Recognizing Cues for Violence
Notes:
(No narration on slide)
36
1.37 In the last Case Study #3, indicate which of the following
environmental risk factors were present:
Notes:
(No narration on slide)
37
1.38 Workplace Violence Interventions
Notes:
So now that we've described elements of low, moderate and high risk for violence, in
the next section we'll focus on workplace safety control measures.
Violence prevention strategies often emphasize patient-focused interventions such as
de-escalation techniques, use of restraints, and isolation.
In this training, we will introduce you to the idea of personal safety controls that
emergency care providers can use to keep themselves safe. We will discuss 3 broad
categories of safety controls: personal, environmental, and administrative.
These strategies take into account that an effective violence prevention strategy needs
to incorporate control measures that protect both patients and staff.
38
1.39 LOW-RISK Interventions
Notes:
As we've been discussing, the best way to prevent violence is early recognition of the
warning signs, including both personal and environmental risk factors.
In low risk situations, use of personal safety controls such as the buddy system,
personal stress management, and appropriate body language can help to reduce the
likelihood of violence.
Similarly, environmental and administrative controls include measures that may help to
ease patient anxieties and concerns, such as providing clear instructions about hospital
policies, or creating a calmer environment whenever possible.
Finally, at every state, it's important to continue monitoring and adjusting your plan
accordingly, as the situation can change at any time.
39
1.40 Cues for Case Study 1
Notes:
Remember, in our low risk case scenario, the parents of a sick child have been waiting a
long time and are becoming increasingly impatient. The father is verbally aggressive
with the triage nurse, using inappropriate language to demand the child be seen
immediately.
40
1.41 LOW-RISK Interventions Case Study 1 Exercise
Notes:
(No narration on slide)
41
1.42 LOW-RISK Interventions
Notes:
In a workplace culture that includes a zero tolerance policy for violence, the parents can
be openly informed that verbally abusive behavior is not tolerated and will have
consequences. Taking this preventive action could keep this low risk situation from
escalating.
At the same time, it's important to acknowledge the parents' concerns and reassure
them that everything is being done to provide appropriate care for their child.
42
1.43 MODERATE-RISK Interventions
Notes:
There are some additional personal safety controls that should be considered in a
moderate risk situation. These include:
alerting other staff to the possible need for intervention,
maintaining a visual sight line to the patient at all times, and
having an exit plan.
43
1.44 MODERATE-RISK Interventions
Notes:
As a best practice, nurses can develop the habit of scanning the environment for objects
that could be used as weapons. It may not be feasible to remove all dangerous items
from the patient's reach, but by monitoring the situation regularly, you can heighten
your awareness and be more prepared.
Other environmental best practices include controlling room access by unauthorized
personnel and following procedures for safe transport of patients.
Administrative controls include following your hospital's safe practices for conducting
timely patient assessments and preparing contingency plans to meet the patient's
treatment needs.
44
1.45 Cues for Case Study 2
Notes:
Remember, in our moderate risk case scenario, the male patient was physically
intimidating and his irrational behavior made the nurse nervous.
She was acting as a preceptor for a student nurse at the time. However, she did not feel
prepared to advise the student nurse on how to handle this difficult patient and his
verbally aggressive aunt.
Consider the moderate risk scenario and think about appropriate interventions that
could have helped the nurse manage this situation more effectively.
45
1.46 MODERATE-RISK Interventions Case Study 2 Exercise
Drag Item
Drop Target
Alert security, ED managers and other staff as necessary
YES
Remove visitors from the treatment area
YES
Prepare contingency plans for patient treatment
YES
Follow lock-down procedures
NO
Have an exit plan
YES
Use chemical and/or physical restraints to calm patient
NO
Notes:
(No narration on slide)
46
1.47 MODERATE-RISK Interventions Case Study 2 Exercise
Notes:
(No narration on slide)
47
1.48 MODERATE-RISK Interventions
Notes:
This scenario demonstrates that communication with other staff is critical early on in
the patient visit. This is even more important because the nurse manager did not feel
confident directing the student nurse on how to handle the situation. The inability to
take appropriate action at this stage could cause the situation to escalate.
Additionally, asking the aunt to leave the treatment area, at least temporarily, could
help calm the patient and prevent further violence. Preparing contingency plans - such
as moving the patient to a secured area - may also help calm the patient, prevent
elopement, and keep staff and other patients safe.
48
1.49 HIGH-RISK Interventions
Notes:
The intention of any violence prevention training is to learn to recognize early warning
signs and respond appropriately, so that the potential for workplace violence is reduced.
But, when a high risk situation arises, the focus must quickly shift to immediate
protection for you, other staff and visitors in the surrounding area.
49
1.50 HIGH-RISK Interventions
Notes:
Immediate action in a high risk situation includes activation of all communication
channels necessary to alert managers, staff and security personnel. Hospital lock-down
procedures should be activated to secure the area and isolate the individual.
A patient who is in restraints or who needs constant observation can potentially drain
the resources of a department, thereby affecting the delivery of care to other patients.
This situation may require extra alertness and actions to maintain safety throughout the
department until the situation is under control.
50
1.51 Cues for Case Study 3
Notes:
(No narration on slide)
51
1.52 HIGH-risk Interventions
Notes:
The recommended interventions in a high risk situation are dependent on the presence
of environmental control measures. For example, if there is an alarm system in place but
it is not regularly maintained, it may not be reliable when it's needed.
Similarly, the violent incident described in this case scenario could have been prevented
had procedures been followed to transfer this patient to a safe area and alert staff of his
combative behavior. Despite the fact that it may not always be possible to avoid
working alone, the nurse could have escaped injury if other staff had responded
appropriately and not left this patient in an isolated hallway.
This example underscores the importance of repetitive and ongoing staff training - not
only for new employees, but for all staff.
52
1.53 Mitigating Risks for Violence:
Notes:
This next video demonstrates an encounter between a psychologist and a patient after
he was admitted to the emergency department following an incident in which he
physically attacked his father. Aaron has a history of mental illness, including periodic
violent episodes.
As you watch the video, think about the interventions being demonstrated by the
psychologist and security guard.
53
1.54 Think about personal safety controls. Which of the following personal
safety controls was NOT demonstrated by staff in Aaron's Video Scenario?
Notes:
(No narration on slide)
54
1.55 Think about environmental/administrative controls.
Notes:
(No narration on slide)
55
1.56 Mitigating Risks for Violence:
Notes:
Watch the video scenario a second time and note the best practice interventions that
the psychologist and security guard use during their interactions with this patient.
Although the emergency department may be a more challenging setting, in almost every
case, at least some of these same interventions could be utilized to prevent violence.
56
1.57 Pick Many
(Answer key follows on next page)
Notes:
Think about Aaron's behavior demonstrated in the previous video scenario. His behavior
did not lead to a violent incident in this case, because the health care team took
appropriate action.
It's important to remember that any risk assessment has a degree of subjectivity, since it
is based on decisions made by an observer within a particular setting and context. The
STAMP acronym can help you learn to recognize observable cues that may increase the
risk for violence.
What cues were present in this video scenario?
57
1.58 Answer Key
Notes:
(No narration on slide)
58
1.59 Communication
Notes:
In thinking about the culture of your emergency department, it's important to know
how to help facilitate better communication about workplace violence. This includes
communications between nurse colleagues and staff, as well as with patients and
hospital managers and administrators.
Communication does not only involve the exchange of information in the midst of an
event. It must be something that is established in advance, so that problem situations
are consistently monitored, people are alerted to potential risks, and plans are shared
about the appropriate procedures that should be followed.
59
1.60 History Does Not Condemn You
Notes:
We each have past experiences that we bring into the workplace. Personal history and
assumptions about the world can affect our ability to assess patients.
Being aware of factors such as work stress, burnout, and personal attitudes or beliefs,
can provide insights into how we react and respond to the potential risk for violence in
the workplace. A lack of awareness about our personal history in managing conflict and
aggressive behavior, can affect our ability to manage potentially violent patients.
60
1.61 Think About Your Own History
Notes:
If you've been assaulted at work or have experienced other forms of personal violence,
those life events could affect how you approach patients in your daily practice. After
experiencing a violent incident, some nurses become more confrontational in an
attempt to establish control over the situation. Others become very timid or lose
confidence in their ability to manage conflict.
Learning to manage our own internal reactions is important to managing conflict in the
workplace. Additionally, we can learn from colleagues who are wrestling with the
aftermath of an assault by openly addressing safety concerns and providing a supportive
environment. A workplace culture that perpetuates the idea that violence is “part of the
job” is detrimental to the health and safety of individuals, patients and staff.
61
1.62 Essential Components of a Workplace
Notes:
(No narration on slide)
62
1.63 Leaving Behind a Workplace “Culture of Acceptance”
Notes:
Both hospital management and employees contribute to a culture of acceptance
through administrative and personal actions that tolerate abuse by co-workers, patients
or visitors. Changing that paradigm requires effort from staff, managers and the nursing
profession at large.
It also requires broad-based change regarding society's views and reactions toward
violence. A complacent culture in the community contributes to the incidence and
consequences of violent events both inside and outside the walls of our emergency
departments.
ENA's violence surveillance study, as well as other ongoing efforts, help to draw national
attention to the issue of violence toward emergency nurses.
63
1.64 Management Commitment
Notes:
To demonstrate an organizational commitment to the health and safety of employees,
managers and supervisors must take active roles in monitoring and informing staff
about issues of workplace violence. This includes an equal commitment to the safety of
both workers and patients.
One way to accomplish this is to develop a workplace violence prevention plan that
assigns specific roles and responsibilities to various staff members. This ensures that
managers, supervisors and employees all understand their obligations.
64
1.65 Management Commitment
Notes:
(No narration on slide)
65
1.66 Employee Commitment
Notes:
Employees also have a commitment to carrying out and complying with workplace
safety and security measures. This includes participating in program planning and
recommendations for corrective actions, as well as taking part in workplace violence
prevention efforts and reporting violent incidents when they do occur.
66
1.67 Mitigation of Workplace Violence:
Notes:
In this next section, we'll discuss organizational policies and federal guidelines that
provide recommendations for preventing and mitigating workplace violence.
67
1.68 Institutional Policies and Procedures
Notes:
Institutional policies and procedures are an essential part of any workplace violence
prevention program. The basic components should include:
A standard action plan for responding to violent situations
Availability, operation and maintenance of safety devices
Mandatory staff training
Simplified reporting and timely response to incidents
Documentation and recordkeeping
Employee instructions for obtaining medical care and other services after a
violent incident
68
1.69 Institutional Policies and Procedures
Notes:
Institutional policies and procedures must also clearly define the safety controls and
interventions that are recommended for managing zones of risk.
Policies and procedures should be established for transporting patients, managing
visitors, and handling patients who are brought in by police, as well as using a buddy
system, documenting patients with a known history of violence, and appropriate use of
restraints.
69
1.70 Of the following recommended policies for workplace violence
prevention, which one was MOST obviously lacking in the incident
description for Case Study 2? (Select only one answer)
Notes:
(No narration on slide)
70
1.71 Worksite Assessment and Analysis
Notes:
Worksite assessment and analysis is another important aspect of an effective workplace
violence prevention initiative. This includes two important components: data analysis
and hazard assessment.
Information obtained through worksite assessment and analysis is critical to
identification of hazards that contribute to workplace violence, examination of trends
over time, and ongoing progress toward mitigation of workplace violence.
71
1.72 Which component of worksite assessment and analysis would have
been MOST helpful in preventing the incident described in Case Study 3?
(Select only one answer)
Notes:
(No narration on slide)
72
1.73 OSHA Guidelines State That, at a Minimum,
Notes:
According to OSHA's guidelines for workplace violence prevention, organizations should
ensure that
adequate resources are available;
responsible individuals have expertise on workplace violence prevention;
management demonstrates a commitment to employee safety; and
affected employees are supported through their recovery.
73
1.74 OSHA Guidelines State That, at a Minimum,
Notes:
OSHA guidelines state that organizations should have a clear policy of zero tolerance for
violence and that everyone is informed about those policies.
The importance of this federal guideline is underscored by ENA's study which found that
nurses were less likely to experience workplace violence when their hospital
administration and ED management were committed to workplace violence control.
74
1.75 OSHA Guidelines State That, at a Minimum,
Notes:
Prompt reporting of violence-related incidents is another critical component of efforts
to reduce workplace violence.
Again, in ENA's study, nurses who worked in facilities that had reporting policies especially zero-tolerance policies - were less likely to experience physical violence and
verbal abuse.
One way to help improve the reporting process is to assign responsibility and authority
to individuals or teams with appropriate training and skills, so they can help facilitate
and simplify the process.
75
1.76 OSHA Guidelines for Employee Education and Training
Notes:
Employees who may face safety and security hazards should receive formal instruction
on the specific hazards associated with the unit or job and facility. This includes
providing information on the types of injuries or problems identified in the facility and
the methods to control the specific hazards.
Employee instructions should set limitations for physical interventions in workplace
altercations, according to the availability of staff or emergency response teams and
security personnel. In addition, all employees should be compassionate toward
coworkers when an incident occurs.
The training program should involve all employees, including supervisors and managers,
with consideration to cultural diversity and differences.
76
1.77 OSHA Guidelines for Recordkeeping and Reporting
Notes:
OSHA establishes specific guidelines for reporting by employers. You can refer to their
Web site for more details.
At the beginning of this course, we explored some of the reasons that nurses fail to
report. However, without incident reports we lack the data to track, monitor and
respond to workplace violence in emergency departments.
You can use this information to set a baseline, goals, and benchmarking objectives to
measure improvement in mitigating workplace violence.
77
1.78 OSHA Guidelines for Recordkeeping and Reporting
Notes:
Reports should be made of all incidents involving physical or verbal abuse, threatening
or aggressive behavior, or any act of aggression toward other patients or employees.
Medical reports should include a description of the type of assault, the nature of injuries,
who was involved, the location and the costs that resulted from the incident.
The confidentiality and protection of paper and electronic medical records should be
managed under the direct responsibility of a health care professional. It's important to
include as much information as possible to describe the assault, where it occurred, and all
associated costs.
78
1.79 OSHA Guidelines for Recordkeeping and Reporting
Notes:
Documentation is an important preventive measure because staff who care for a
potentially aggressive, abusive or violent patient should be aware of the person's
background and history.
Similarly, staff should be made aware of the results of hazard assessments and
corrective actions that have been taken. This feedback is important, because employees
may be more likely to report incidents when they experience the benefits.
79
1.80 The Haddon Matrix:
Notes:
In 1970, Dr. William Haddon developed a framework for organizing and understanding
precipitating factors that contribute to motor vehicle crashes.
Known as the Haddon Matrix, this framework is most widely used in the field of injury
prevention, but other disciplines have also adopted it. The matrix provides a tool to
systematically evaluate risk factors and design interventions that decrease the likelihood
of an injury event, the severity of an injury, and its long-term consequences.
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1.81 Haddon Matrix Description
Notes:
The Haddon Matrix functions by breaking down an injury or workplace violence event
into three phases: Pre-event, Event. Post-event.
It then arranges the precipitating factors into four categories: Host, Agent, Physical
environment, and Social environment; thereby allowing for a systematic evaluation of
the incident.
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1.82 Using Haddon's Matrix as a Debriefing Tool
Notes:
The Haddon Matrix can be used as a debriefing tool after an incident of workplace
violence.
Start by compiling a description of the incident with as much detail as possible. Then,
plug the precipitating factors that are identified at each phase into the proper cell in the
matrix.
This allows you to identify the common host, agent and environmental factors that lead
to high risk situations for workplace violence in your emergency department.
You can use this information to help plan and carry out appropriate interventions.
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1.83 Pre-event Description
Notes:
Let's look at an example of how this is done. Take a moment to read the pre-event
description.
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1.84 Pre-event Description
Notes:
Let's summarize the pre-event conditions for this case study.
The nurse is caring for a half dozen patients on night shift. Paramedics and police arrive
with a clearly intoxicated male patient who is yelling and doesn't want to be in the ED.
The police transfer the patient to an available bed in an isolated hallway and then leave.
The paramedics give their report, which includes the fact that the man took a swing at
them on board the ambulance.
When the nurse assesses the patient, he seems relatively calm and cooperative. But, he
keeps stating that he wants to leave. The nurse expresses frustration with his behavior.
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1.85 Pre-event Precipitating Factors
Notes:
You can see here how the precipitating factors during the pre-event phase are entered
into the matrix for the host, the agent and the environment.
For example, the nurse is busy and distracted by other patients, and is therefore not
paying attention to cues from the patient which include his intoxicated status and
history of violence.
On the next few slides, continue to read the description of what happened during the
violent incident that resulted from these precipitating factors.
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1.86 Event Description
Notes:
(No narration on slide)
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1.87 Event Description
Notes:
(No narration on slide)
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1.88 Precipitating Factors During Event
Notes:
Again, by entering information into the event phase, we can see the precipitating
factors that contributed to this violent incident, despite the fact that the nurse did not
recognize the risks.
From the completed matrix, it becomes apparent that there were “red flags” or cues
that made this patient high risk, such as
Intoxication
Prior violent action
Belligerent and verbally abusive behavior; and
Resistance to being in the ED
Likewise, the environment is considered high risk because the nurse is
Working alone in an
Isolated and dark hallway with
No security or safety device
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1.89 Post-event Description
Notes:
(No narration on slide)
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1.90 Post-event Precipitating Factors
Notes:
At the post-event phase, it becomes apparent that the necessary intervention strategies
were not in place that could have prevented this violent incident.
The consequences are considerable and include possible liability issues for the hospital,
lost work productivity, financial costs, and other personal costs for the employee.
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1.91 Post-event Debriefing
Notes:
The last step is to use the Haddon Matrix for a post-event debriefing.
By analyzing this event, it's possible to identify appropriate intervention strategies that
could be implemented to reduce the likelihood of other workplace violence incidents
similar to the one described in this case study.
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1.92 Change Is Possible
Notes:
Change is possible…and sometimes it can be achieved by knowing the right questions to
ask and then using the answers to innovate positive solutions.
The Haddon Matrix is one tool that can be used to provide systematic analysis for
identifying and addressing the precipitating factors that contribute to workplace
violence.
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1.93 Using The Haddon Matrix
(Answer key follows on next page)
Notes:
Let's go back to Case Study 1, and use it to apply the principles of the Haddon Matrix.
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1.94 The Haddon Matrix Exercise: Answer Key
Notes:
(No narration on slide)
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1.95 Implications for Emergency Nursing:
Notes:
Use of the Haddon Matrix can identify precipitating factors that center around particular
staff, patients, and physical or social environments.
By recognizing the patterns of violent events in your emergency department, you can
uncover opportunities for early recognition and implementation of best practices to
mitigate workplace violence.
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1.96 The Take Home Lesson
Notes:
(No narration on slide)
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1.97 Remember: Low-risk interventions
Notes:
(No narration on slide)
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1.98 Remember: Moderate-risk interventions
Notes:
(No narration on slide)
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1.99 Remember: High-risk interventions
Notes:
(No narration on slide)
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1.100 Contact Information
Notes:
Thank you for participating in this interactive course on recognition and prevention of
workplace violence. We hope you find it to be beneficial to your nursing practice and
your efforts to mitigate violence in emergency departments.
Please note that the intention of this one-hour module is not to present a
comprehensive course. We encourage you to continue to pursue further knowledge and
education as you work to integrate workplace violence prevention strategies into your
emergency department daily practice. There are numerous resources available from
ENA, OSHA, the CDC and other organizations to help reduce workplace violence in
emergency departments and other health care settings.
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