Work Place Violence

Types of Workplace Violence: Type 2

(Client- on- worker) o Most common type of violence in health care settings. "Clients" includes patients, families, and visitors. *Research shows that this type of violence occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is by no means limited to these.*

Types of Workplace Violence: Type 1

(Criminal Intent) o The perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence. Example: home health nurse mugged on the way to a home visit. Type I is less common compared to the other types of violence in health care settings

Types of Workplace Violence: Type 4

(Personal Relationship) o Perpetrator has a personal relationship with the employee (domestic violence in the workplace).

Types of Workplace Violence: Type 3

(Worker-on-Worker) o Includes lateral/horizontal violence Type III - includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating though it can range all the way to homicide. Nursing has been considered the primary occupation at risk for lateral violence. Lateral violence - disruptive and inappropriate behavior demonstrated in the workplace by one employee to another who is in either an equal or lesser position.

Crisis continuum: Stage 4

Crisis o Acute crisis - characterized by unbearable anxiety and loss of cognitive, emotional, and behavioral control, with urgent need to end the emotional pain. A person is crisis is unable to solve problems or process information rationally without help. Behaviors of persons in crisis are erratic and unpredictable to point that they may pose a danger to themselves and others. Panic level anxiety, cannot problem solve or think logically, needs safety precautions.

Protect Yourself

Dress for safety by removing anything from your person that can be used as a weapon or grabbed by someone. o long hair should be tucked away so that it can't be grabbed; o jewelry - avoid earrings or necklaces which can be pulled; o overly tight clothing can restrict movement; o overly loose clothing, or scarves can be caught; o glasses, keys, or name tags dangling from cord or chains can be hazardous; make sure to use breakaway safety cords or lanyards.

Environmental Risk Factors for Violence

Environmental risks fall into four categories and include factors that: o Provide opportunity to gain access or avoid detection such as unmonitored entries or stairwells, insufficient lighting, blind corners, unsecured rooms or closets. o Increase stress such as signage that is confusing, long wait times, difficulty parking or accessing a building, insufficient heat or air conditioning, and disturbing noise levels. o Provide opportunities to be used as weapons such as unsecured furniture, fixtures, decorative items, office or medical supplies. o Limit staff's ability to appropriately respond to violent incidents such as the lack of security systems, alarms, or devices.

Clinical Risk Factors for Violence

Individuals who are at risk of perpetrating violence include those who: o *have a history of violence* o *are impulsive* o are under the influence of drugs or alcohol o are in pain o have cognitive impairment o are in the forensic (criminal justice) system o are angry about clinical relationships, e.g., in response to perceived authoritarian attitude or excessive force used by the health provider o have certain psychiatric diagnoses and/or medical diagnoses **The two most significant predictors of violence are a history of violence and impulsivity** **History of violence is a strong predictor. Clinical risk factors relate to the individual. Individuals includes patients, family members or other visitors** Substance abuse is a major contributor to violence for both people with and without mental health diagnosis. Although some psychiatric diagnosis are risk factors for violence most people with mental illness are not violent.

Organizational Risk Factors for Violence

Organizational risk factors are those that result from the policies, procedures, work practices and culture of the organization. Such risk factors include: o Careless management and staff attitudes toward workplace violence prevention; o Inadequate security procedures and protocols; o Lack of staff training and preparedness; o Cumbersome or nonexistent policies for reporting and managing crises; o Low staffing levels, extended shifts, overtime requirements. *Adequate staffing ratios are a large factor in reducing work place violence*

Crisis continuum: Stage 3

Severe stress and anxiety o Reasoning capacity is severely diminished, focus on here/now. Focuses on minute detail and does not grasp entire situation, responding to multiple stimuli - unable to focus on priority of events, agitation, pacing, decreased eye contact, increased tone, rate and pitch of speech, difficulty problem solving and following directions

Crisis continuum: Stage 1

normal stress and anxiety level o More aware of environmental stimuli, able to problem solve, rationale and in control of emotions and behavior.

Post-Incident Response for the Employer

o The employer should make counseling services available for all traumatized workers. Nurses should be free to decline such services and/or pursue their own counselors. o Support the injured nurse's right to file reports through the legal system, and name the perpetrator; o Provide guidance around initiating Workers' Compensation filings; o Initiate procedures to keep the injured nurse and the assailant separated. o Debrief o Employers are also responsible for reporting to OSHA if an injury involves lost time and/or more than first aid.

Under reporting

• A persistent perception within the health care industry that workplace violence is 'part of the job'; • Poor or non-existent institutional policies, procedures, staff training or supports; • Overly complex reporting procedures create a disincentive for reporting; • Concern that violence happens so frequently that it's time-consuming to report every event, in addition to a lack of response when time is taken to report; • Fear that reporting will reflect poorly on the nurse (victim blaming); • Belief that some patients cannot be held accountable for their violent actions.

Crisis Interventions

• A person in crisis is essentially out of control at cognitive, emotional, behavioral, levels of functioning. They are unresponsive to verbal intervention; cannot think clearly or appropriately or express needs and concerns; display great fear, anger, and/or threats; may cry uncontrollably; and/or experience symptoms such as hyperventilation or nausea. • Personal safety and the safety of others is paramount. • Observing an out-of-control person is frightening and may trigger your own "fight or flight" response. Emotional containment is important so that proper procedures and protocols are remembered and followed. • Response to an out-of-control person may require physical and/or chemical restraint, in which case you should follow your healthcare organization's policies and procedures for next steps. It is important that you continue to engage the patient, tell them what you are doing and why you are doing it.

Early and Middle Stages: Verbal Skills

• Allow the person to express concern: "Please tell me what's bothering you." • Use a shared problem solving approach: "How can we correct this problem?" • Be empathic: "I understand how frustrating this must be for you." • Avoid being defensive or contradictory. This only exacerbates a tense situation. • Apologize if appropriate: "I'm sorry this happened. Let's find a way to fix it." • Follow through with their problem: "I'm going to bring this to my supervisor immediately." • Avoid blaming others or "It's not my job." • "Let me get someone who can help you with this problem." • Be alert to early signs of a patient's rising anxiety. • If de-escalation is successful, thank individual for sharing their concerns. *Normal response is to fix the problem or become defensive. Need to allow patient to express their feelings and convey caring and empathy.*

Responses to Violence or Aggression

• Anger- Experience anger, rage, and/or resentment. May result in a subconscious, or even a conscious desire to punish the patient. • Desire to appease- Sometimes a way to avoid aggression. Try to "buy" peace at any price. • Avoidance- Fear of violence can cause nurse to avoid the patient. If situation is not addressed appropriately can lead to escalation. • Inconsistency of care- Can lead to conflicts between staff. Can escalate patient behavior.

Workplace Violence

• Any physical assault, threatening behavior, or verbal abuse occurring in the work setting (NIOSH, 1996). o Includes emotional and sexual abuse, and harassment o Includes lateral/horizontal violence • "incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health"

Power and Control Dynamics

• Be aware of power and control dynamics • Perpetrators of violence are often responding to a fear of losing control or the perception of loss of control • Loss of control is frightening - challenges are basic need for self-control • Violence is an abuse of power/act of controlling others, often to try and regain a sense of control • Our actions should try and help restore feelings of control rather than further threatening it o Never use verbal or physical control tactics yourself

Post-Incident Response

• Following an incident of violence, key actions on the part of the nurse include: o File an incident report and participate willingly in employer investigative actions. o Report any injuries (physical or emotional) through appropriate channels and get assessed through the Employee Health Office or Employee Assistance Program (EAP). o Seek counseling when appropriate. Everyone responds differently to trauma. Without psychological services and interventions, a nurse's post-traumatic stress may persist. o Learn about and utilize support resources offered by the employer and/or union. o Work with criminal justice authorities if legal action is called for. o The order in which a nurse initiates these actions may depend upon the extent of injury or trauma suffered and one's ability to recover.

Early and Middle stages: Non-verbal Skills

• It is important to be cognizant of and control your body position and posture so as not to inadvertently escalate an already tense situation. • Be calm, or at least act calm. Maintain non-threatening eye contact, smile, and keep hands open and visible. • Invite client to sit with you. • Listen. Nod your head to demonstrate that you are paying attention. • Respect personal space. Maintain arm/leg distance away from the individual. Avoid touching the upset individual as it may be misinterpreted. • Leave door open. • Approach the patient from an angle or from the side. • Demonstrating confidence in your ability to resolve the situation. • Demonstrate supportive body language. Avoid threatening gestures, such as finger pointing or crossed arms. • Avoid laughing or smiling inappropriately. Put self closest to door but do not block door. Don't stand in confronting manner -legs should be front/back

Late Stage: Limit setting

• Limit-setting techniques, properly applied, can help by placing some external control on the escalating situation, defusing it and facilitating decision-making. o Example: "Mr. Jones, please control yourself and sit down, otherwise I will have to call security." • The keys to effective limit setting are 1) using a command form to express the desired behavior and 2) providing a logical and enforceable consequence for non-compliance. Continue to acknowledge the agitated person's feelings and be empathic, reminding him or her that you're there to help (Lancee, Gallop, McCay & Toner, 1995). • Do not confuse setting limits with issuing threats which can signal to the patient that the situation is more hopeless than they had perceived, and may precipitate a violent response. Also, avoid arguing, as that may precipitate a violent resolution of crisis.

Self-assessment

• Pay attention to your instincts • Acknowledge personal history that may influence how you respond • Be aware of your own communication style • Assess your own socio-cultural biases • Fatigue can diminish alertness and ability to respond

Crisis

• Perpetrators of violence are often in crisis • Crisis is an acute emotional upset; it is manifested in an inability to cope emotionally, cognitively, or behaviorally and to solve problems as usual (Hoff, 2009) • Crisis is the final stage along a continuum of behavior and emotional responses • Challenge is to recognize when an individual is moving toward crisis, where they are along the continuum, and apply interventions that de-escalate their response to the stressful or traumatic events

Late Stage (3) Interventions

• Person may begin showing signs of loss of self-control and problem-solving ability. • Verbal and non-verbal interventions can still be effective but additional techniques and precautions should be taken. • Your focus now turns to protecting yourself and those around you. • Don't go it alone, enlist the help of security or colleagues. • Be prepared to use your panic device and to physically remove yourself if necessary. • Position yourself to exit easily. • Remove other patients or visitors from the room. • If the person continues to escalate, follow your organization's procedure for immediate response to violent behavior.

Crisis continuum: Stage 2

Rising anxiety level o Focus on immediate problem, voices concerns, able to follow directions, exhibits slight increase in physiological responses (trembling lip, facial twitches, foot or finger tapping). Voice may be higher pitched.

Consequences of Workplace Violence

• Physical • Emotional • Financial • Affects more than just the direct target **Acts of workplace violence against a nurse can exact a heavy physical and emotional toll. Consequences can be both acute (short-term) and chronic (long-term) and range in intensity from minor to serious physical injuries; from temporary to permanent disability; and from psychological trauma to death. **Beyond the immediate trauma, negative outcomes may also include low morale and productivity that result from lack of trust in management, loss of team cohesiveness, and a sense that the work environment is hostile and dangerous. Workplace violence may also result in increased job stress, absenteeism, family turmoil, and worker turnover. **In addition, there can be a financial impact on the individual due to lost time at work and other out-of-pocket costs of care, or legal expenses (Hoff & Slatin, 2006). Financial impact on healthcare organization with staff absenteeism and turnover. **All of this can impact patient safety. **Finally, it is important to realize that one does not need to be the direct target of a violent act to be affected by it. Witnesses, bystanders and coworkers often suffer emotional and psychological trauma no less significant than that of the victim.

Safety in Non-institutional Settings

• Review agency files to confirm that a background check was done on a patient regarding any history of violence or crime, drug and alcohol abuse, and mental health diagnoses. Also check to see if a patient's family member has a record of violence or arrest. • If entering a situation already assessed by telephone as potentially dangerous, you should be accompanied by a team member who has training in de-escalation and crisis intervention (Hoff & Hoff, 2012). • Travel with a cell phone. • Make sure someone knows where you are. Have a code: call your office and use the code word to let them know you're in trouble, assuming you can't call the police.

Limit Setting vs. Threats

• Threat: "If you don't stop I'm going to call security!" • Limit Setting: "Please sit down. I don't want to involve security but I may have to if you can't control yourself." • Threat: "If you keep pushing the call button like that I won't help you." • Limit Setting: "Ms. Ferris: I know you need help, but please don't ring your call like that, and give me a chance to get to your room." • Threat: "That type of behavior won't be tolerated!" • Limit Setting: "Mr. Barron: Would you please stop yelling and screaming at me... I'm trying to help you."

Workplace Violence Prevention

• Treat all people with dignity and respect • Listen to your patients; is there other meaning behind the words? • Address client and visitor concerns with a caring approach • Get workplace violence training • Report! • Grow your skills of communication and conflict management • Resolving conflict between coworkers early, before it can escalate to more serious forms, is an effective method for preventing violence and abuse between coworkers • Self-care

Cues for Violence

• Verbal Cues: Speaking loudly or yelling, Swearing, Threatening tone of voice • Non-verbal or Behavioral Cues: physical appearance (clothing and hygiene neglected), arms held tight across chest, clinched fists, heavy breathing, pacing or agitation, a terrified look signifying fear and high anxiety, a fixed stare, aggressive or threatening posture, thrown objects, sudden changes in behavior, indications of drunkenness or substance abuse