176 Healthcare: Workplace Stress and Violence

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Violence in Healthcare

Healthcare and social service workers face a significant risk of job-related violence.
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Healthcare and social service workers face a significant risk of job-related violence. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as "violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty." According to the Bureau of Labor Statistics (BLS), In 2018, healthcare workers accounted for 73 percent of all nonfatal workplace injuries and illnesses due to violence. That same year, healthcare and social services workers suffered 20 out of the 453 workplace fatalities due to violence. The most common assailant in workplace homicides to healthcare workers was a relative or domestic partner of the injured worker.

Case Reports

  • An elderly patient verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night.
  • An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her.
  • A disturbed family member whose father had died in surgery at the community hospital walked into the emergency department and fired a small-caliber handgun, killing a nurse and an emergency medical technician and wounding the emergency physician.

These circumstances of hospital violence differ from the circumstances of workplace violence in general. In other workplaces such as convenience stores and taxicabs, violence most often relates to robbery. Violence in hospitals usually results from patients and occasionally from their family members who feel frustrated, vulnerable, and out of control.

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1. The most common assailant in workplace homicides to healthcare workers was a _____.

a. client or acquaintance of a patient
b. patient of the injured worker
c. relative or domestic partner of the injured worker
d. former work associate of the worker

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Risk Factors

Risk Factors
There are some common risk factors for violence in a hospital.

Although anyone working in a hospital may become a victim of violence, nurses and aides who have the most direct contact with patients are at higher risk. Other hospital personnel at increased risk of violence include emergency response personnel, hospital safety officers, and all health care providers.

The risk factors for violence vary from hospital to hospital, depending on location, size, and type of care. Common risk factors for hospital violence include the following:

  • working directly with volatile people, especially, if they are under the influence of drugs or alcohol or have a history of violence or specific psychotic diagnoses
  • working when understaffed-especially during mealtimes and visiting hours
  • transporting patients
  • long waits for service
  • overcrowded, uncomfortable waiting rooms
  • working alone
  • poor environmental design
  • inadequate security
  • lack of staff training and policies for preventing and managing crises with potentially volatile patients
  • drug and alcohol abuse
  • access to firearms
  • unrestricted movement of the public
  • poorly lit corridors, rooms, parking lots, and other areas

2. Which of the following is considered a risk factor for hospital violence?

a. Inadequate security
b. Lack of training
c. Restricted movement of the public
d. Working with other people

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Prevention Strategies for Employers

Violence Prevention Program
A violence prevention program needs to contain multiple components.

To prevent violence in hospitals, employers should develop a safety and health program. Employers should evaluate this program periodically. Although risk factors for violence are specific for each hospital and its work scenarios, employers can follow general prevention strategies.

Violence Prevention Program

The prevention program should:

  • Be made available to all employees, including managers and supervisors, and all employees should receive specific training concerning its content and implementation.
  • Track their progress in reducing work-related assaults.
  • Reduce the severity of injuries sustained by employees.
  • Decrease the threat to worker safety.
  • Reflect the level and nature of the threat faced by employees.

3. Who should have access to the violence prevention program?

a. Only management and supervisors
b. All employees
c. Patients
d. Visitors

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Violence Prevention Program Components

Violence Prevention Program Components
These main components need to be included in a facility's violence prevention program.

Include the following main components in a facility's violence prevention program:

  • Management Commitment and Employee Involvement
  • Worksite Analysis
  • Hazard Prevention and Control
  • Safety and Health Training
  • Recordkeeping and Evaluation of Program

Management Commitment and Employee Involvement

Management and employee commitment are complementary and essential elements of an effective violence prevention program. Incorporate concern for the employee's emotional and physical safety and health into a written program for safety and security.

Worksite Analysis

The program should include a step by step look at the workplace to find existing or potential hazards for workplace violence. An appointed Threat Assessment Team or similar task force, or coordinator should complete a worksite analysis. This "team" analyzes records, trends, workplace security, and gives screening surveys to staff to help identify hazards.

4. Who should analyze a hospital violence prevention program?

a. Supervisors
b. Employees
c. Patients
d. Threat assessment team

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Hazard Prevention and Control

Hazard Prevention and Control
Implement engineering and work practices to prevent and control identified hazards.

Implement engineering and work practices to prevent and control identified hazards. Here are some examples:

  • Provide better visibility and good lighting, especially in areas of high risk such as the pharmacy area, or in isolated treatment areas.
  • Implement safety measures to deter handguns inside the facility.
  • Use of security devices such as panic buttons, beepers, surveillance cameras, alarm systems, two-way mirrors, card-key access systems, and security guards.
  • Place curved mirrors at hallway intersections or concealed areas.
  • Provide training for staff in recognizing and managing hostile and assaultive behavior.
  • Provide adequate staffing even during night shifts. Increase staffing in areas where assaults by patients are likely (e.g., Emergency Department).
  • Ensure accurate reporting of all violent behavior.
  • Make patients aware of the zero-tolerance policy for violence.
  • Establish liaison with police authorities and contact them when indicated.
  • Obtain previous records of patients to learn of any past violent behaviors.
  • Establish a system to chart or track and evaluate possible assaultive behaviors, including a way to pass on information from one shift to another.

5. Placing curved mirrors at hallway intersections or concealed areas is an example of what?

a. Hazard Prevention and Control
b. Worksite Analysis
c. Safety and Health Training
d. Management Commitment and Employee Involvement

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Safety and Health Training

Training is vital to make all staff aware of security hazards and how to protect themselves.

You can't always prevent violence, because it can be unpredictable. Still, you can reduce the risk by planning and being prepared to act swiftly to deal with threats, intimidation, and other disruptive behavior at an early stage. Training is vital to make all staff aware of security hazards and how to protect themselves through established policies, procedures, and training. Training could include the following components:

  • an understanding of the facilities workplace violence policy and program
  • ways of preventing or diffusing volatile situations or aggressive behavior, conflict resolution
  • dynamics of violence
  • how to recognize and deal with hostile, aggressive persons, nonviolent responses
  • managing anger
  • techniques and skills to resolve conflicts
  • stress management and relaxation techniques
  • security procedures
  • personal security measures, such as self-defense
  • techniques for victim support

6. How can employers help reduce the risk of violence at healthcare facilities?

a. Release violent patients
b. Only allow one person to visit a patient at a time
c. Safety and health training
d. Easy access to patient records

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Recordkeeping and Evaluation of Program

It is crucial to evaluate the facility's violence prevention program to determine its effectiveness.

Recordkeeping is essential to the success of a workplace violence prevention program and can:

  • Help to identify the severity of the problem, evaluate methods of hazard control, and identify training needs.
  • Be useful for gathering or "pooling" data for other applications.

It is recommended that other records be considered such as:

  • medical reports of work injury
  • incidents of abuse (such as verbal abuse, or other acts of aggression, that do not result in injury)
  • record information on patients with a history of past violence on the patient's chart and staff made aware of the possible potential for aggression
  • training records

The overall effectiveness of the program is reduced because of the inability to identify and correct problems. It is crucial to evaluate the facility's violence prevention program to determine its effectiveness. The evaluation:

  • identifies any issues or deficiencies that can then be corrected
  • allows for management to review program effectiveness and re-evaluate policies and procedures regularly
  • helps management to analyze trends, measure improvements, and keep abreast of new trends to reduce workplace violence

7. Why is it important for employers to evaluate the violence prevention program?

a. It provides ways to manage anger
b. It is not necessary to evaluate the program after it has been implemented
c. To evaluate if employees are following procedures
d. It helps management measure improvements

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Environmental Designs

security camera
Install security devices such as cameras and good lighting in hallways.
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The following are environmental designs employers can use to help diffuse violence in the healthcare setting:

  • Develop emergency signaling, alarms, and monitoring systems.
  • Install security devices such as metal detectors to prevent armed persons from entering the hospital.
  • Install other security devices such as cameras and good lighting in hallways.
  • Provide security escorts to the parking lots at night.
  • Design waiting areas to accommodate and assist visitors and patients who may have a delay in service.
  • Design the triage area and other public areas to minimize the risk of assault.
  • Provide staff restrooms and emergency exits.
  • Install enclosed nurses' stations.
  • Install deep service counters or bullet-resistant and shatterproof glass enclosures in reception areas.
  • Arrange furniture and other objects to minimize their use as weapons.

8. Installing metal detectors is an example of _____.

a. Behavior Modifications
b. Environmental Design
c. Administrative Control
d. Workplace Idea

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Administrative Controls

security card
Restrict the movement of the public in hospitals by card-controlled access.
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  • Design staffing patterns that prevent personnel from working alone and minimizes patient waiting time.
  • Restrict the movement of the public in hospitals by card-controlled access.
  • Develop a system for alerting security personnel when violence is threatened.

Behavior Modifications

  • Provide all workers with training in recognizing and managing assaults, resolving conflicts, and maintaining hazard awareness.

Dealing with the Consequences of Violence

  • Violence may occur in the workplace despite preventive measures. Prepare employers to deal with the consequences of this violence by providing an environment that promotes open communication and by developing written procedures for reporting and responding to violence. Employers should offer and encourage counseling whenever a worker is threatened or assaulted.

9. Restricting movement of the public in hospitals by card-controlled access is an example of _____.

a. administrative control
b. training
c. environmental design
d. behavior modifications

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Safety Tips for Hospital Workers

safety tips
Watch for signals that may be associated with impending violence.

Watch for signals that may be associated with impending violence:

  • verbally expressed anger and frustration
  • body language such as threatening gestures
  • signs of drug or alcohol use
  • presence of a weapon

Maintain behavior that helps diffuse anger:

  • Present a calm, caring attitude.
  • Don't match the threats.
  • Don't give orders.
  • Acknowledge the person's feelings (for example, "I know you are frustrated").
  • Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly).

Be alert:

  • Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor.
  • Be vigilant throughout the encounter.
  • Don't isolate yourself with a potentially violent person.
  • Always keep an open path for exiting-don't let the potentially violent person stand between you and the door.

Take these steps if you can't defuse the situation quickly:

  • Remove yourself from the situation.
  • Call security for help.
  • Report any violent incidents to your management.

Case Reports: Prevention Strategies That Have Worked

  • A security screening system in a Detroit hospital included stationary metal detectors supplemented by hand-held units. The system prevented the entry of 33 handguns, 1,324 knives, and 97 mace-type sprays for six months.
  • A violence reporting program in the Portland, Oregon, VA Medical Center identified patients with a history of violence in a computerized database. The program helped reduce the number of all violent attacks by 91.6% by alerting staff to take additional safety measures when serving these patients.
  • A system restricting the movement of visitors in a New York City hospital used identification badges and color-coded passes to limit each visitor to a specific floor. The hospital also enforced the limit of two visitors at a time per patient. Over 18 months, these actions reduced the number of reported violent crimes by 65%.

10. A patient is in the exam room with her boyfriend, waiting for the doctor to return with some forms. The patient’s boyfriend then starts screaming and threatening the nurse on staff. If staff members cannot stop the violent behavior, the nurse should _____.

a. quit
b. walkout
c. call security
d. isolate with a violent person

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