workplace violence, do you have a plan? I'd like to welcome Karen Doyle. She's the presenter today. She is currently in school for her Doctorate of Nursing Practice at the University of Maryland School of Nursing, while in the role of a Senior Vice President Nursing Operations at the Shock Trauma Center in Maryland Health Center. She is a key executive leader at the University of Maryland Medical Center, accountable for nursing operations, strategic planning, policy formation, program development, and regulatory compliance. Welcome, Karen. Thank you. I'm going to advance the slide and we'll go through a couple of the housekeeping. Be sure you enter in your audio pin after joining the webinar. This will allow you to ask questions at the very end. One registration per phone line per hospital, please. Go ahead, Karen. There's handouts available. You are muted by default. At the very end, we can use the question tab. Raise your hand, and I will ask you to go ahead and present your question to Karen. Afterwards, you will get an email with the evaluation through SurveyMonkey. If you could please fill out that, and then your CEs will come to you for the next two weeks. With the housekeeping part over, go ahead and start, Karen. Good afternoon, everyone. Thank you for joining. I look forward to hopefully imparting some knowledge here regarding workplace violence and hope to give you some material for which you can make a plan. Please know that there are no conflicts of interest in this presentation. The objectives really for me today is to define workplace violence and its characteristics and to give you some guidance on formulating an organizational plan for creating a safer environment for the healthcare workplace. Finally, I'd like to be able to synthesize advocacy strategies for influencing policy at the local, state, and national level. I do want to say that I don't consider myself an expert on this. I really do this presentation to share our experiences here in Baltimore and some of the things that we've accomplished. I really do like to gain knowledge from our colleagues across the country because I think we can only get better together. Our world is very dangerous right now. Any strategies that we can share with one another is really a goal of mine. Let me tell you about our environment a little bit. I am at the University of Maryland Medical Center. We are located in Baltimore, Maryland. We have over 800 licensed beds. As you can see, we have a lot of faculty. We are an academic quaternary care center. We have over 71,000 emergency visits. 25% of our business comes from our critical care transport process, which is our Maryland Express Care. Specifically about shock trauma, we are 104 licensed beds. The building that you see is our building. We are not freestanding, but we are closely freestanding trauma facility. Close to 800 employees. That does not include faculty. Those are staff. Close to 8,000 patient visits. 20% of our volume comes by air and 80% comes via EMS ambulance transport. Our patients in our trauma center do not walk in. Our patients can only get to us via the EMS system. One of the things, we are going to do some polling questions here. It will be very helpful if you could identify for me, have you or your facility, any of your faculty, staff experienced a workplace violence incident? It does not matter how you define that. I am interested in understanding whether you feel you have experienced a workplace violence incident. Deb, if you could coach me through the polling. We are at 86. We are almost done. Let us give a couple more seconds. We will go ahead and close that out and share. So, we have 101 attendees and 31 out of 101 have said yes, is that correct? We have 31 yes, so 88% of 32 people have said yes. That's significant. Yes, it is. Okay, but I'm not surprised at all. I've done part of this presentation at NTI and everybody that I spoke to, so all of us are experiencing this in the workplace and it's a real challenge for us. It has become more of a challenge for us in Baltimore because of our last year's event with Freddie Gray and I'm not sure how many, it's been national news for quite some time, but the environment before the Freddie Gray incident was volatile, but not nearly what it is today that we see here in Baltimore City. So, we really are in a much more different environment than we were prior to the event. We had civil unrest in our city and it really has changed the dynamics of the hospitals in the area and certainly our relationship with law enforcement in Baltimore. So, what about violence over the years, just to set the frame? I could update this. I submitted this a month ago and even in the last 30 days, we know of all of the most recent instances about violence over the years, but this specifically points out Columbine High School, the Virginia Tech shooting, and certainly we've had just the most recent in Dallas, Louisiana. It just goes on and on. And so, this points out the Colorado killings and then the new town, Connecticut, with all the elementary school children, pointing specifically to many of this regarding mental health issues. But closer to home for us, it's happening to nurses, it's happening to physicians. So, patients stabbed two nurses at Knoxville, Tennessee. This is in September 2015. Just this past weekend over the news, there were some healthcare workers, physicians, and nurses at Parrish Medical Center and they were harmed, injured, and killed by family members not happy with services. So, it is very much close to our hearts. For us, here in Baltimore in 2011, Suburban Hospital, which is in Bethesda, Maryland, there was a hospital employee that murdered their supervisor. They were not happy with the corrective action that was being issued and so that happened probably 40 miles from where I am. And then in September 2010, Hopkins, which is five miles from where we are, a patient and a family member shot a physician and murdered his mother himself. So, workplace violence includes the news-making, violent acts, as well as the low-level violence and verbal abuse. You know, it's interesting. The killings at Parrish Medical Center over the weekend was not big news for anybody. I have a wonderful chief nursing officer. None of us had heard about it and if I hadn't seen it across the ticker tape at the bottom of the TV, I'm not sure that it would have gone noticed at all. So, workplace violence is real. It's on the rise. More assaults occur in healthcare and social services industries than in any other industry. There are 1.7 million injuries each year due to workplace assaults. And between 2011 and 2013, there were 24,000 annual workplace assaults with 75% of them occurring in the healthcare setting. All of these, one of these things I hope to do is if you need to lay a framework for your senior administrators, all of this data you can get from the Department of Labor. You can get from OSHA, CDC, NIOSH, and the Bureau of Justice Statistics. So, it's out there, it's public, and just do a little digging and you can find this data. You can find it specific for your state as well. Workplace violence has remained among the top four causes of death at work for over 15 years and it is the number one cause of workplace death. It was the number one cause of workplace death for women in 2009. This presentation isn't going to speak much about domestic violence, but I don't want to. Domestic violence is a part of workplace violence and we have experienced some of that in my setting. Studies have shown that prevention programs can reduce incidents of workplace violence. So, much of what I'll talk about today is what can we do to mitigate episodes of workplace violence. So, what is the definition that I'll use today? The definition, as defined by the CDC, is violent acts, including physical assaults and threats of assaults, directed toward persons at work or on duty. What are the risk factors for violence in the hospital environment? You're going to know all of these, so I'll go quickly through them. Working directly with volatile people, especially if they are under the influence of drugs or alcohol and have a history of violence or certain psychotic diagnoses. I mean, you know, in trauma centers, emergency departments, this is what we routinely deal with. Working when understaffed, especially during mealtimes and visiting hours. Transporting patients is a big opportunity for workplace violence. As you know, long waits for service, people get irritated, they're unhappy, and they become irrational. Overcrowded, uncomfortable waiting rooms. All of us experience that. Working alone, when you're thinking about your environment and the CT scan or MRI, night travels to interventional radiology procedure areas, very tough. It's common for workplace violence to occur in places where people are working alone. Poor environmental design. I encourage you, if any of you are building new buildings, building new work areas, that you really bring in a security expert to lay out where panic buttons are, how your back is positioned to doors. You really need to have that level of expertise to help you design or redesign work areas that you consider unsafe. Inadequate security. I know that we have been dealing with that in my institution, and we certainly have stepped up the plate, I'll tell you about that, over the last couple of years. But I'm certain that all of you have issues with security. Lack of staff training and policies for preventing and managing crisis with potentially volatile patients. You know, while many of us got into healthcare, and we have some natural, compassionate abilities to negotiate with irrational patients or family members, many of our staff do not have the skill set that are required to de-escalate our patients and families. Investing in training for de-escalation is really critical. I will speak more about that. Certainly drug and alcohol abuse, access to firearms, unrestricted movement of the public when you get in very tight areas, poorly lit corridors, rooms, parking lots, and other areas are risk factors for violence in the hospital environment. I mentioned access to firearms. I'm not sure about you, but these are some things that we find on our patients and visitors that come into our building. So the potential is there. This is a firearm that fell out of somebody's pocket in our hallway. This is everything that our security team has collected, probably in a very short period of time. But patients come with scissors, knives, guns, to protect themselves in our city environment. So we can't forget that this is our population. I'm going to show you this picture here. This is a picture of a bite mark to one of my nurses on her stomach. She was taking care of a patient that was guarded by two policemen. They were done a lumbar puncture. She was positioning the patient. They hadn't even started the puncture, and he bit her. The police were awesome, and they, you know, took him down right away, but you know the emotion and the pain that goes along with being harmed in a workplace violence event. She did go to court. I'm going to talk a little bit about this, about our responsibility as leaders to support our staff when they experience a violent act against them. We encouraged our nurse to press charges, took a lot of courage to do that, and she did. We supported her with our hospital attorneys. She had to press the charges. She did do that, and we got a verdict just two weeks ago. And while the offender was already in prison, he did receive an additional nine months to his prison tour because of this event. So are you aware of a workplace violence assessment strategy or guideline in place at your facility? The polls are open. We'll leave it open for a few more seconds. All right. We're going to go ahead and close. And the results are, so are you aware of workplace violence assessment strategy or guideline in place at your facility? 59% said yes, 24% said no, and 18% are unsure. Okay. So that's a good starting point. I mean, it's really important for all of us to understand what our facilities have. And then I'm going to, the next probably 20 minutes are about policies, procedures, and strategies for creating guidelines in your workplace. So what types of assessment strategies exist and can you employ? First of all, there are ways that we can train our staff to recognize potentially violent persons and persons of concern. So potentially violent person is somebody who's made a threat of bodily harm and makes a reasonable person feel threatened. And then the person of concern are those individuals that are disruptive, are verbally abusive, and threaten litigation. Talk a little bit more in depth about this assessment strategy. We need to create consistent methods of reporting workplace violence. I don't know about you, but in my environment, we have several places, and I'm sure it's the same for you. We can report these things through our, we call it RL6, but that's our incident reporting mechanism. We can report it through employee health, where employees go when they're injured, or we can report it through our security team if they are called to a security event. So there's three places that our employees can report these workplace violence incidents. So we are working very hard to aggregate that data so that we can look at this on a monthly basis and understand where are our greatest risk areas and what type of mitigation strategies do we need to employ in those areas. So it is incumbent that we establish the online workplace violence reporting system, and we are doing that through our incident reporting system. The two other areas with security and employee health, we're trying to get that integrated with our risk management incident reporting system. We recommend that all incidents of workplace violence be reviewed by an interdisciplinary oversight committee. That is a best practice. I will tell you, in my world, we have begun doing this, over the last year, and it's incredibly insightful as to what does occur in our work environment. Talked about assessment strategies. This is a really great assessment strategy that you can teach your staff. It's really adopting methods of recognizing impending aggression and violence. And this is called the STAMPO method, as defined by Lutz, Jackson, and Usher. So the STAMPO method, it's very easy, and you can train people on this acronym, right? The S is staring and glaring eyes. You know, that's a method of intimidation. The tone, the tone of voice being raised, sarcastic, demeaning. You can see, you know when somebody's anxious, right? They're hyperventilating, they have the flush complexion, rapidity of speech, negativity, mumbling. Mumbling is a very, I don't know if you knew this, I was not aware, but mumbling is a very high indicator that somebody is about to really blow their top. It's an indication of increased frustration, which is a very strong sign of violent behavior. Pacing, pacing is a sign of increased agitation. And of course, there's this other physical attributes that you notice, you know, when something is about to happen. The clenched fist, the tense muscles, aggressive posturing. We've all had our patients that, you know, attack and throw objects. And certainly threatening action and body language, stepping into you and invading your personal space. So we highly recommend this assessment strategy, this STAMPO method, so people recognize the behaviors. We've, you know, I'm sure your team, like my team, we think that it is innate that people know how to deliver bad news and to provide bereavement notification. But, you know, that's just not the case. It's not taught in medical schools. It's not taught in residency programs. So the best people to teach it are those of us who do it every day. And so investing time and energy in teaching your faculty and your staff how to deliver bad news is incredibly important. Utilizing pastoral care and social work in the creation of the training program is immensely helpful. Having pastoral care and social work present when you deliver the bad news is really integral to mitigating these violent responses. Communication. The organization, we really need to be able to speak to workplace violence, focusing specifically on patient information, complaints of violence or civility issues, and flagging visitors and patients that have displayed acts of violence or incivility. So when I say that the organization can speak to these issues, what I mean is when we're doing handoffs from the ED to a medical unit to a surgical unit to a trauma unit, how do we convey from unit to unit, person to person, that this patient and or family member has conveyed behaviors of violence? Well, there are some things that we can do and that are legal. There are some organizations around the country that have computerized warning flagging systems. When we were implementing some strategies in my organization, we did a site visit at the University of Michigan, and they have a very well-defined computerized warning flagging system that all providers see that if this patient and or visitor displayed violent behaviors. The VA also has a very good system for that. I have this here in terms of aligning mission of all employees working at points of entry. In my institution, I don't know about yours, but we have many places for which visitors can enter the hospital. And we had one group of staff reported through guest services and the patient experience team. We had another group of individuals that reported to security. So therefore, the mission of those employees weren't aligned. Everybody was not looking at visitors that entered through our hospital through the same lens. We made a deliberate decision to align all of those employees under one leader so that everybody had the same mission and same goals and same tactics for screening visitors when they entered our hospital. We already talked about a consistent, uniform method of identifying and reporting violent incidents and injuries. I recognize that that can be difficult, but we need to work to do that. And I did not mention at the time, we are... I said we were in an academic environment. So on our campus, we have the School of Medicine, School of Nursing, School of Law, Dentistry, Pharmacy, a whole bunch of schools. And we are separate from the campus. So we have worked very hard to create campus-wide crime alerts so that we continue to inform our employees students and faculties about what is going on in the community. Panic buttons at all access points. You really need to evaluate this. And I really need to underline making sure that all of your staff have panic buttons. I was really shocked when I did the presentation at NTI. My colleague and I, Terry, did the presentation at NTI. We were in front of a group of about 150 people. And I asked everybody to raise their hand if they had panic buttons or knew where panic buttons were. About five people raised their hand. Panic buttons for your team is critical. It's the only way that they can get help from security when they are in a very, very bad position. So please evaluate that for your team. When I told you that we aligned the missionable employees at entrances, we are very clear that employees, visitors without badges, are held at the front desk until security is cleared and issued a badge. And I would love to create here in our facility, we have not done this yet, but some best practices around the country are to create an employee-only entrance so your employees are going through one door and then your visitors are coming through another. It really does help your security team out if you're able to do so. What types of administrative stuff can we do to create a more safe environment? Well, some of these things we have done in my institution and some I have garnered this information from around the country and some of our colleagues that have implemented these things. There are patient responsibility statements, family presence, visitation policies, visitor codes of conduct. We should review these things with our patients and our patient's designated support person at the time of admission. We're getting ready to implement a strategy where every visitor that enters the building gets a pamphlet on visitor expectations, posting the visitor code of conduct at every major entrance and public spaces and in all clinical and non-clinical waiting reception areas. You know, I don't know about your teams, but my team always wants to put up signage. A lot of people don't look at that signage. As you know, we have to. They ignore it. We overwhelm them with signage. So we're hoping that this active distribution of information to everybody who enters our hospital will be a little bit more effective than just posting signs everywhere. We have digital signs where we post the code of conduct, so it rotates on the TV monitors that go to patients and families. And we put it on our cable television system. We put it in inpatient rooms, and we certainly also put it in our outpatient ancillary service clinics. Some of our colleagues across the country have created administrative discharge policies for use in their medical centers. What do I mean by this? This means that if your patient cannot abide by a code of conduct, that we will administratively discharge them from the hospital. We do use this more frequently in our ambulatory setting than we do on inpatient, because as you know, in an inpatient setting, we are obligated to make sure they have a safe medical discharge. So it makes it a little bit more cumbersome, though we have discharged patients when we have felt that it's not emergent for them to be here, when they cannot abide by our code of conduct policies. Many of you probably have behavioral standards, guidelines, code of conduct guidelines for your own staff. We suggest, I suggest, that you build those visitor and patient behavioral standard guidelines into your consent for treatment, which is another way to have an active conversation with your patients and families. Many of you, 59% of you were aware that you had policies. Some of you weren't. This is an example of a policy on workplace violence prevention and response policy. All of our institutions should have those. If you don't, here's an example, and you can take this back to your leadership to say this really is best practice and let's make this happen. What other administrative controls and abatement strategies can you implement? Well, establish liaisons with local police and state prosecutors. For us in Baltimore in the trauma center, we have a very symbiotic relationship with our law enforcement, so it's very easy for us to have a nice relationship with our local police. If that's not the case for you, please make that happen. They're our friends. They're our colleagues, and together we can help mitigate these episodes. I've already spoken about the online reporting system. And then I'm going to highly recommend developing a behavioral response team, and I am going to talk a little bit more about that. So two more slides, and I'll tell you about our behavioral response team. Engineering controls. We've talked about panic alarms, alarm systems. There are handheld alarms or noise devices that go around people's necks or can be on their bodies. There's private channel radios, cellular phones. There's all kinds of engineering controls that we can employ to help our staff be more safe. Some organizations use metal detectors. We do not. We have closed-circuit recording on a 24-hour basis for high-risk areas. We have cameras everywhere. And our security is very good about monitoring that. Curved mirrors at hallway intersections or concealed areas. You know, for those areas at night when you have to travel and you're not sure who's lurking around the corner or in waiting rooms if you can't see people around the corner. We use curved mirrors so that our staff can see all angle of a room for which they're located by themselves. Conduct a workplace violence hazard analysis. I'm going to tell you how you can do that in a few seconds. I've already talked about the new construction or physical changes to the facility. And even though I say new construction here, go back and look at your current spot. Is there something that you can do to make that room, that area safer? And again, use your security colleagues to help you identify the safety of a room, where you deliver bad news, where you consult with families. And then provide employees with training on workplace violence. I mean, we really do owe it to our teams to provide them with the training that they need to deal with workplace violence. So what might that education look like? Well, determine the training and education modalities that are good for you. But just make sure that the training and education that you choose, it's uniform and that it's consistent. Establish minimal requirements for training and education. We have some mandatory training in certain high-risk areas, the ED, trauma. Labor and delivery, very high area for... very frequent area for violence. And so we've mandated some staff education and training in those areas, our psych areas. Significant opportunities there for workplace violence. The education that we have mandated in our organization, and this is based on what some of our colleagues have done across the country, is a mandatory education on managing volatile situations and how to recognize them. Mandatory education on delivering bad news and bereavement notification. And we, in certain areas, we have mandated critical conversations and conflict management education for our employees. So managing volatile situations, all employees receive that type of training. We orient them to de-escalation techniques, personal safety and awareness, and we provide them with the resources that are available to the staff. I told you that I would tell you about this BERT team. This is a behavioral emergency response team. This is a team that is designed to provide an immediate response to a patient or visitor displaying disruptive behaviors that are not life-threatening. There are many organizations now that have created these teams. It's just like a rapid response team. We developed ours based on the model at the University of Michigan. So the background, as all of you will have this background, is that we have challenging patient situations in clinical areas. These challenging patient situations really take up the resources of security, pastoral care, you name it, social work, psychiatry. All of us are spending an inordinate amount of time on these patients and families. And we didn't have an organized way or a coordinated way to manage these situations. Our data showed us that every month we were intervening on 50 to 60 patient interventions that were displaying some volatile behavior. And again, it lacked coordination. It might be the nurse at the bedside. It might be security. It might be pastoral care. But we did not organize our process around these events. So the literature suggested that these behavioral emergency response teams, their consultative resources, utilize when psychiatric behaviors are present in non-psychiatric settings. And all of you have that, right? So many of our patients have mental health issues that are in addition to their traumatic injuries. And so how do we manage that without having the psych resources right at our fingertips? We had no uniform standard of roles to approach these things. And we wanted to target behaviors that were generally disruptive or threatening. And these patients and families displayed actions that compromised safety to themselves, to other patients, or to other visitors and staff. In creating this behavioral emergency response team, we had strong administrative support. And what I mean by that, this is from the chief executive office. Our chief executive officer, CEO, was totally supportive of creating this behavioral emergency response team. The BERT team, we identified patients that would benefit from a specialized adjunctive support to maximize treatment outcomes and maintain safety. The BERT team provides a coordinated response for difficult and complex patients with disruptive behaviors, promotes workplace safety, and it enhances a plan of care for patients with disruptive or threatening behaviors. Many times you'll see in a minute that these patients that displayed these disruptive behaviors were because we did not communicate so well or coordinate their plan of care. So we, as healthcare providers, contributed to escalating their anger versus de-escalating their anger. The BERT team, also, our goal was to role-model communication strategies for de-escalation so we could teach our staff at the bedside how to de-escalate in a very therapeutic manner. So the best practices is that for this team to be comprised of three core members, security supervisor, pastoral care. And we are blessed to have a psychiatric emergency department, and so our psych emergency services, RNs, are part of this team. This team is available 24-7, and we have a licensed independent practitioner that will consult based on the recommendations of the BERT team. Ad hoc members of this team include our psych consultation liaison, social work, EAP, patient advocates, risk management, and legal. We rolled this out in July 1 of 2013 in a trauma acute care environment and a medical ICU. We piloted for 90 days, and we focused specifically on patient and visitor events. They would respond to a list of easily recognized behavioral triggers identified for staff initiation of the call, and then we created a mechanism for review and evaluation of effectiveness. So what were the behavioral triggers? I'm not going to go through all of these. You've experienced all of them. But one, if the staff perceived that they were in danger of safety, then it was okay for them to ask for assistance. We were not going to Monday morning quarterback that and say, why did you call me? You shouldn't have called me for that. All calls were considered real and necessary to the staff that requested the consult. This is the algorithm, all right? So in this algorithm, you can see the staff assessment and patient triggers, and if the patient is violent or a visitor threat and you're in immediate danger, then we were just to call security. We weren't to call the BERT team, right? So if you feel like you're in immediate danger, you call security. But if no, you don't feel like you're in immediate danger and that you just need additional help to deal with this complex patient, then you could call the BERT team. And we were expecting the BERT team to respond within 15 minutes, and they would debrief with the staff first, and then they would go in, make an assessment, and then implement a strategy for managing this patient. The BERT team goes in. They develop an immediate rapport with the patient to initiate de-escalation techniques. They communicate with all members of the healthcare team to discuss findings and recommendations. They recommend behavioral management plans, and then we do a post-event huddle to see what could we do as bedside providers to keep this patient de-escalated. We have a report, a BERT response report, and that becomes a permanent part of the medical record so that we understand that the BERT team was called and that these were their recommendations. So actions of the BERT team. This is a sample of 95 patients. Interventions utilized by the BERT team, the majority of their time were de-escalation techniques and identifying triggers for the staff. You can see a large part of the time the BERT team provided staff education, which was really great. We are in an academic environment, and we have a lot of new nurses under five years. So we did parallel education and training with them. And you can see how the list goes on there. What were the root causes of the BERT calls? This is the most stunning for me in that most patients were escalated because of their disease process, and we had not communicated with them properly about their plan. And that was a significant amount of the time. The other time of pain management, are we controlling their pain properly? Hunger and food choices. One quick story, one patient was really irritated because he was NPO, didn't want to be NPO. He did not want to have the procedure, and we were inflicting our desire for this patient to have the procedure on him. He just wanted to eat. He was not going to have the procedure. He had capacity. He was not incapacitated. He was not incompetent. So we had to do a lot of training with our staff, and what does capacity mean? And because a patient might make a bad decision for themselves that we would not make for ourselves, that doesn't mean it's wrong. So we spent a lot of time on that with our team. A lot of discharge concerns. I had one person call me. I was the administrator on call because a family member wouldn't leave, said that they were escalated. They were going to call security on them. Happens to be that the wife was admitted for seizures. She was a longstanding patient. Turns out the medication we put her on caused seizures, and we were discharging this patient with the same medication, and the husband was refusing to leave. Well, we understood that, right? If we just took care of the problem, then we wouldn't have had this escalated response. We've spent a lot of time with our staff helping them to understand the other side of the story. Average time spent. You can see the number of events, and the average time spent on these calls are really somewhere between 20 and 25 minutes. So what is important in this? The total number of calls to security for compatible patients. After the BERT team, we decreased significantly the number of security calls for de-escalation strategies after the implementation of the BERT team. We were really using our security team to manage de-escalation when we really needed therapeutic responses to de-escalation. I told you several emerging themes were identified. Refusal of care, leaving AMA, and what our perceptions are of that. Certainly patients' perceptions of not being listened to or not being respected. Really discussing the multidisciplinary team and how we coordinate care with our patients and families that are complex. And we really spent a lot of time on what causes our patients and families to become disruptive. So what we did was, after that pilot, we implemented it throughout the entire organization. We added some complementary medicine techniques for staff support and stress management, such as breathing exercises, aromatherapy. We have a very strong complementary medicine team here, and so that's available to our staff and faculty. We really look at rates of staff injury and lost days of work so that we can look at mitigation strategies there. We review our employee opinion survey results as it relates to workplace violence. And, honestly, we continue to address root causes. This is not a... You know, there is not one answer for addressing these issues. This is an evolution, and we continue to work on this every day. Okay, that's the BERT team. Other risk-assessment strategies that I recommend, and we are about to implement this in my institution, but there is a risk-assessment tool that's called the Brossett Violence Checklist. This is a reliable and valid tool in the literature, as defined by Clark, Brown, and Griffith, and it is a violence checklist that you can have your staff use to identify patients that may experience violent outbursts. This is the checklist, and you can see that it can be done every shift, and it takes you through the indicators. It takes you through the behaviors, and it's a scoring mechanism so that you understand where this patient is as it relates to potential for violent acts. Okay, so those are some assessment strategies. What can you do to assess your workplace environment? Well, do not reinvent the wheel. Go to OSHA. OSHA has this Workplace Violence Program Checklist. I just showed you one page here. It's about 50 pages long, but if you use your safety officer in your organization, they will be able to go through this with you so that you can identify where your risk factors are for workplace violence. On the OSHA website, it will also give you mitigating strategies. So what might be right for my environment in Baltimore City might not be right for your rural environment or suburban environment, so you need to pick strategies that are going to work in your environment, and this OSHA checklist will help you with that. Utilize your professional societies. The AONE and ENA have a wonderful toolkit for mitigating violence in the workplace. Society of Trauma Nurses has a position statement. If you need to use that with your administrators. I jumped ahead for a second, but the Joint Commission, right? The Joint Commission has standards about addressing disruptive, inappropriate behaviors and two elements of its performance. If you need to use these standards with your leadership to say, hey, it is incumbent upon us to address these, you have it right here in the Joint Commission standards. You have it through your professional societies. I mentioned position statements, so the American Nurses Association has a position statement on workplace violence. The Society of Trauma Nurses has a position statement on that. Use your societies to your advantage to make change in your organizations. The ENA has a wonderful position statement. Okay. Are you aware of any active legislation, regulation preventing workplace violence in your state? Thank you. We'll go ahead and close. 45% say yes, 29% say no, and 26% are unsure. Okay, that's not uncommon. I'm going to give you some information about workplace violence protection for nurses at the state level. Some states have sought legislative solutions, including mandatory establishment of a comprehensive prevention program for healthcare employers, as well as increased penalties for those convicted of an act of violence against a nurse, EMS provider, or healthcare provider. This is a map provided by the ANA of current states with an active legislation regulation preventing workplace violence. You can see that the green are states that have legislation regarding workplace violence, but you can see that it's only 21 states. Our state in Maryland has workplace violence against a healthcare provider as a misdemeanor. My colleague and I, Tara Carlson, were working on making it a felony because sometimes the juice just isn't worth the squeeze when you're looking at it being a misdemeanor. But your influence with your legislators, if you are a state that does not have regulation, I'm encouraging you to make sure that you use your policy advocates to make that happen. There is federal legislation that requires the Secretary of Labor to take necessary steps for OSHA to work with your states in creating these voluntary protection programs. So make sure you understand the federal legislation and our role as healthcare leaders in assuring a safe work environment for our healthcare providers. What have nurses done around the world? These are countries that have conducted studies on workplace violence, emphasizing the need for workplace violence management teams and enacting appropriate laws to improve workplace safety for nurses and patients' care quality. This just isn't the United States, as you can see what's happening in France just recently and then all across the globe. These are just a couple of a few of the countries that are working on either enacting legislation or emphasizing the need for workplace violence management teams. This is my team that went to Annapolis, Maryland to really push on the legislation regarding making it a felony and not a misdemeanor for workplace violence against healthcare providers. All right, I want to move quickly through these so I can get to questions. Barriers to implementation for workplace violence. First of all, as you know, we under-report the issue. It's part of the job. Lack of management accountability. So there are, I want you to pay attention to what the barriers are and we need to overcome those barriers because it is happening. Even though it's under-reported, it is happening in your environment. We need to make nurses comfortable, help them be comfortable with difficult conversations around workplace violence. We need to make sure that EAP is utilized. So what I want you to do as leaders is make sure you're familiar with these things in your hospital so that you can encourage and remove the barriers to creating a safer workplace. Most of us are desensitized, right? Has this just become a norm for us to accept this? Well, we can't accept it as the norm. We have to change this. There are de-escalation techniques. I'm not going to go through each of them, but these are three de-escalation techniques that you can use and I encourage you to investigate for your system. There's the MAN system, which is a very valid and reliable way to de-escalate. There's the Crisis Prevention Institute training that is a de-escalation method. And then I talked about the Behavioral Emergency Response Team. And these slides go through each of these just a little bit. So there's more information there for you. I have provided some resources. I mentioned, please do not reinvent the wheel. It is out there. You can adopt these without doing a whole lot of work on your own. It's just picking the right strategy for your own environment. And with that, I'm going to ask you for questions. I could talk another hour or two. Thank you, Karen. It's Jennifer. So if anyone has any questions, go ahead and either raise your arm if you put in your audio pin. Otherwise, you can type your question into the question tab. And until questions come in, Karen, I actually have one or two that I was going to ask about. So you mentioned that you don't have a metal detector. Do you have armed police officers in your facility? And is there any research or data out there showing about an armed officer, if it decreases the violence or increases the workplace violence? So we do not have metal detectors. We did have a security consultant in here a few years ago about metal detectors. And they weren't recommended for our environment at the time. And there are a number of issues with metal detectors. They don't find everything. And, yes, we do have an armed campus security police officer in our emergency department. And we have a Baltimore City police officer 16 hours a day. I'm not certain about the research on that. I will tell you, I mean, it is a little bit more comforting having them. But I don't know that it's reduced the number of instances. We have recently employed, it's called the Solutions Team. They are a martial arts team that walks the perimeter of our hospital. And they employ the use of a dog. It's a Mastiff. So this Mastiff is about an 80-pound dog. It only responds to Mandarin. And we use those in disruptive situations. And what the dog does is put the disruptor, the dog steps between the disruptor and the employee to really back the disruptor up against the wall. I will tell you, and this is anecdotal, this is in science, amazing what the dog does to de-escalate situations, immediate de-escalation. And my team loves it. Wow, very impressive. Very impressive. I'm going to ask one more question and then I'll let everyone else get their questions in. I'm sorry. I think you said you mentioned that you surveyed some of your employees. Have you noticed after implementing this that your employee happiness has went up or your patient dissatisfaction has went down? This is what I will say. Like you, we do many, many surveys. Our last employee opinion survey was in 2013 for a number of reasons. But we do the AHRQ Safety Culture Survey. And because of our increased focus and implementation of some of these strategies, one, those surveys help us decide what we're going to do with safety and security. But the staff definitely have shown that they feel that it's more secure based on the interventions we've employed. Outstanding. Okay, Phil, go ahead with your question, please. Hey, our team had a question about developing your BERT system. Did it start as a bedside project and then get pushed up through administration for implementation? Or did someone in administration champion it and then move it down to the bedside? It actually started at our senior executive level. So our CEO, this is about five years ago, deployed two teams. One team to look at patient public conflict, of which I was chair and my co-chair was our director of security. And then the other team was really lateral violence, co-worker civility. So my team actually had, he gave us three goals that he wanted us to achieve. And through that, we took a nine-month process. We researched it, did the literature review, did a site visit at University of Michigan, and we came up with this idea. I will tell you, we funded it. The psych emergency nurses were able to fund it without creating any new FTEs. We were in a fortunate position. So it was top-down driven. Okay, the next question is from Sandra. Who is on an interdisciplinary review team for the workplace violence event? A good question. So that, let me see if I can, it is me as the executive sponsor, some as senior executive for the entire organization. We have our director of safety, our director of employee health, a couple of nurse managers. I don't know if I missed anybody. So that's been the past year. We are going to add to that, and we're going to have some staff at the bedside. The first year, we really needed to organize. Remember I told you about the whole reporting mechanism and how convoluted that is? So the first year, we spent getting the reports aggregated in a way that are readable, legible, and meaningful to us, and we will be adding staff at the bedside to this meeting. Are there any other questions? I want to thank everybody. This is our first webinar, so I appreciate the opportunity, and I hope it was meaningful. It was, and I would like to thank you, Karen, for a great presentation. The wealth of information provided today as you digest information. If you have any other questions, please email or call the PCAA office, and we will forward this on to Karen. Please don't forget to complete the evaluation following the program so we can continue to improve our offerings. Once again, thank you again for participating in the webinar. Thanks, Karen.

workplace violence

plan

Karen Doyle

prevention program

risk factors

de-escalation techniques

security measures

behavioral response teams

legislative efforts