Nurses can sometimes find themselves in tricky situations that may even turn violent, whether it be violence from a patient, patient's family member, or even a co-worker.
To address these concerns, the American Organization of Nurse Executives (AONE) and the Emergency Nurses Association (ENA) in 2015 jointly released Guiding Principles on Mitigating Violence in the Workplace. These principles provide a framework to systematically reduce lateral, patient, and family violence in hospital settings.
Their research found that there are clear predictors and antecedents to violence, both personal and environmental. The costs to nursing in terms of physical injury and financial loss are significant. The culture of acceptance may contribute to the difficulty in enacting and enforcing felony laws related to the assault of health care workers.
1. Necessary foundational behaviors. What is the social environment of the institution or unit? How do nurses relate to each other? What is the hierarchical structure of a given unit? The entire institution? Is there a sense of collaboration, or are disciplines working in silos?
2. Elements of a zero-tolerance policy. Environmental hazards must be addressed. Establish a code of conduct that defines and manages disruptive or inappropriate behavior by all staff, health care providers, and administrators. Develop an identification system for potential violence, response to threats or violent events, and constructive support procedures after the event. Threats of violence must be acknowledged by hospital administration.
3. Ownership and accountability. Develop institutional and individual response protocols. All staff must understand the overall culture around violence in the workplace and the specific behaviors that comprise violence in its myriad forms.
4. Training and education. Conduct evidence-based training in violence recognition and mitigation, de-escalation techniques, communication strategies, and security measures.
5. Outcome metrics. To measure success, the facility must report all violent incidents and track the nature and number of incidents institution-wide. Put interventions in place to reduce escalation and assault.
There are six steps in the Guiding Principles on Mitigating Violence in the Workplace.
Step 1. Understand workplace violence. The Occupational Health and Safety Administration (OSHA) defines workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults, and even homicide. It can be any action, incident, or behavior that departs from reasonable conduct in which a person is assaulted, threatened, harmed, injured in the course of, or as a direct result of, his or her work.
Workplace violence exists in three forms: lateral (staff – staff), organizational (administration – staff), and external (patients/visitors – staff).
Step 2. Develop a zero-tolerance policy. Instituting a zero-tolerance workplace violence policy sends a clear message to everyone working in the hospital that all threats or incidents of violence will be taken seriously. The policy should clearly define what acts the organization considers to be violent behavior and what consequences will ensue if the policy is broken.
Step 3. Assess the risk factors in your facility. Potential risk factors are high stress in the workplace, lack of appropriate training for supervisors, and lack of appropriate management protocols for disciplinary actions. Workplace violence hazards can be reduced by assessing your facility’s vulnerability to incidents of violence, tracking records of violence at work, examining specific violence incidents carefully and noting the location of the incident. Minimize access by outsiders through identification badges, electronic keys, and security guards. Periodically inspect the worksite to identify risk factors that could contribute to violent incidents.
Step 4. Develop a workplace violence prevention plan. The OSHA Workplace Violence Prevention Plan says, “A comprehensive organizational violence prevention program should include a reporting and documentation system for acts of violence and a workplace violence prevention policy that includes specific strategies that can be instituted system-wide in the event of a violent incident, as well as post-event support and adequate training of personnel for pre and post-event incident management”.
Examine your stated outcomes and define what would need to be done within your department to move towards accomplishing these goals. Be cognizant of budget constraints and have a plan to work around these limitations. Create a response team comprised of members of the multi-disciplinary team. Prioritize your outcomes and designing action items for a few initiatives to start; choose a few action items that meet a stated outcome quickly with visible improvement that will help build cooperation and collaboration among team members and staff.
In addition to a zero-tolerance policy, the hospital can create procedures to tell employees and volunteers how they are expected to handle specific threats. All hospital employees should notify management of any threats that they've witnessed or were told about. Employees should always report the presence of a weapon immediately to a manager, a supervisor, or if appropriate, to law enforcement.
Step 5. Train and deploy staff. Provide safety education for employees so they know what conduct is not acceptable, what to do if they witness or are subjected to workplace violence, as well as how to protect themselves. Some training materials include: ENA’s Violence Prevention Tools, OSHA’s Workplace Violence Prevention for Nurses, ENA’s “ Know Your Way Out” training module, and OSHA’s Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers.
Step 6. Evaluate the changes and identify next steps. Recordkeeping and evaluation of the violence prevention program are necessary to determine its overall effectiveness and identify any deficiencies or changes that should be made. Timing is key to the re-evaluation of your facility/department. At the beginning of the project plan, determine a reasonable time frame for re-evaluation with the assessment tools used in Step 3.
Post-intervention re-evaluation should be done using the same tools used to establish the scope of the problem. If you introduce new assessment tools, use the first data collection as a baseline in which to compare other data collected during re-evaluation. Get feedback from your workplace violence team to contribute to the success of your workplace violence initiative.
Have you encountered violence in the workplace, and if so - how did your team handle the situation?