1. A Train the Trainer Program Module 1

2. Promoting a Nonviolent Health Care Culture VIDEO--Violence from disruptive behavior through homicide. VIDEO

3. Purpose of Training Educate attendees about disruptive behavior through extreme forms of violence JC sentinel events #40 and #45 OSHA standards Increased employee satisfaction and person/family satisfaction Safer working environment Best practice

4. Objectives Define violence Recognize the different types of violence Discuss local and national statistics related to workplace violence Explain current research and trends in evidence based practice to promote a non-violent workplace Define culture and identify a need to shift paradigms Define assessment of person, situation, environment, self, and co- workers Discuss the assessment of person, situation, environment, self, and co-workers Define and discuss therapeutic communication and therapeutic relationship Explain the crisis cycle Demonstrate protective stance, blocks and releases

6. Joint Commission Sentinel event #40- Behaviors that undermine a culture of safety- addresses disruptive behavior amongst staff. Reveals that this behavior fosters medical errors, poor patient satisfaction, increase in cost of care, adverse outcomes, and attrition of professional staff. These behaviors are not rare and occur across all disciplines.

7. JC Sentinel Event #40 LD 03.01.01 EP 4- Code of conduct in place that defines acceptable and disruptive and inappropriate behaviors. EP 5- Process for managing disruptive and inappropriate behaviors. Other suggestions- reporting process, surveillance system, skills-based training for leaders.

8. JC Sentinel Event #45 Preventing violence in the healthcare setting- addresses assault, rape and homicide to patients and visitors by staff, visitors, other patients and intruders. Significant increase in reports since 2004 62% problems with policy and procedures 60% HR related factors 58% Flawed assessments 53% Communication failures 36% Physical Environment RI 01.06.03- patient’s right to be free from neglect, exploitation, verbal, mental, physical and sexual abuse.

9. OSHA Section 5 (a)(1) Each employer -- (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.

11. Exercise What is your definition of violence? _______________________________________________ _______________________________________________ _______________________________________________

12. What exactly is violence? Webster’s dictionary violence 1.a :exertion of physical force so as to injure or abuse b : an instance of violent treatment or procedure 2: injury by or as if by distortion, infringement, or profanation: outrage 3 a : intense, turbulent, or furious and often destructive action or force Does this belong in the workplace? No standardized definition for workplace violence. This leads to confusion, many sub-categories, and underreporting of events.

13. Other Definitions/forms of violence Verbal violence-Using violent and offensive words and/or threatening violence Nonverbal violence-Using violent and offensive gestures, postures, facial expressions Disruptive Conduct- Creating a hostile or intimidating work environment. This conduct includes, but is not limited to 1. Intimidation 2. Bullying 3. Physically touching someone 4. Throwing objects 5. Writing threatening notes 6. Non-constructive criticism 7. Use of inappropriate language, gestures

14. Definitions Intimidation- behaviors or threats that imply loss of future opportunity, worsening abuse, or compromise of education, abuse of power through threats or coercion. Stalking-repeated persistent following with no legitimate reason and with the intention of harming, or to arouse anxiety or fear of harm in the person being followed. May also take the form of harassing telephone calls, computer communications, letter-writing, and texting. Assault- Intentionally, knowingly, or recklessly causing physical harm. Mobbing-A number of workers who unfairly gang up on a manager, peer, or subordinate, tormenting the person in usually non-violent ways.

15. Definitions Involuntary Manslaughter-occurs where there is no intention to kill or cause serious injury but death is due to recklessness or criminal negligence. Voluntary Manslaughter-is the killing of a human being in which the offender had no prior intent to kill and acted during "the heat of passion", under circumstances that would cause a reasonable person to become emotionally or mentally disturbed. Homicide-the killing of a human being by another human being.

17. 4 types of workplace violence Criminal- the person committing act of violence has no relationship with employer or the workplace. Most common is robbery- 85% Customer/Client- the person committing act of violence is a client and is dissatisfied with a product/service-3% Employee on employee- one employee is being violent towards another-7% Domestic violence- home violence spills over into the workplace-5%

18. Employee on Employee Violence Vertical violence- Supervisor is using covert or overt violence towards employee Horizontal violence- Also known as lateral violence, peer(s) is using covert or overt violence towards employee Covert forms of violence-psychological harassment. Ex. eye rolling, changing assignments without informing the person, gossiping, isolating, withholding information, intimidation, excessive criticism, and denial of access to opportunity Overt forms of violence-verbal abuse, shoving, hitting, slapping, kicking and throwing objects

19. Bullying Behaviors http://www.bing.com/videos/watch/video/bullying- at- work/263dd594ad8a5207568d263dd594ad8a5207568d - 306029265671?q=bullying%20videos%20at%20work&F ORM=VIRE5 http://www.bing.com/videos/watch/video/bullying- at- work/263dd594ad8a5207568d263dd594ad8a5207568d - 306029265671?q=bullying%20videos%20at%20work&F ORM=VIRE5

20. Bullying in the workplace Bullying-Workplace Bullying is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms: Verbal abuse Offensive conduct/behaviors (including nonverbal) which are threatening, humiliating, or intimidating Work interference — sabotage — which prevents work from getting done

21. Bullying VS. Harassment BullyingHarassment almost always psychological frequently linked to a staged attack on competent and popular individuals usually perpetrated behind closed doors Covert nature A target of this type of abuse may not realize it for weeks or months, until great damage is done. shows its face through trivial untrue criticisms of under-performance repeated, deliberate, disrespectful behavior with the intent of hurting someone else. strong intrusive component including physical contact such as invading physical space, including personal possessions and damage to possessions. overt nature A target of workplace harassment knows he or she is being harassed immediately. unwanted conduct that violates people's dignity or creates an intimidating, hostile, degrading, humiliating or offensive environment

22. Case Example Discuss examples of violence in the workplace.

23. Effects of Violence in the Workplace The damaging effects of workplace violence are far-reaching and may include: Deterioration in the quality of care delivered- as many as 70% of preventable errors result from poor communication Deterioration in the quality of staff relations- oppression theory Low staff morale Increased stress levels and stress-related illnesses Feelings of shock, disbelief, shame, guilt, anger, fear, and powerlessness Depression and self-blame, loss of self-confidence Sleeplessness and loss of appetite Lower levels of job satisfaction Increased costs to employers and the health system Increased absenteeism and sick leave Poor performance and lost productivity Loss of creative problem-solving capacity Attrition of staff

24. Risk Factors Staffing patterns Stress, tension, and frustrations Lack of training to recognize or cope with bullying Shift work and demanding workloads Lack of reporting system or punishment against perpetrators Working alone Poor management skills and policies

25. Attributes Clash of personalities between perpetrator and victim Workplace relationships Appearance or disability Success or achievement / jealously Culture of tolerance or acceptance of violence Race, gender, religion, and sexual orientation

27. How often does workplace violence occur? More assaults occur in healthcare and social services industries than any other National Institute Occupational safety and health (NIOSH) reports that 3 people are murdered per day on the job One million employees are assaulted per year One thousand are murdered per year 111,000 incidents costs 6.3million dollars Estimated that ½ of the cases go unreported

28. ISMP Survey during the past year, 88% of respondents encountered condescending language or voice intonation (21% often); 87% encountered impatience with questions (19% often); and 79% encountered a reluctance or refusal to answer questions or phone calls (14% often). Almost half of the respondents reported more explicit forms of intimidation during the past year, such as being subjected to strong verbal abuse (48%) or threatening body language (43%). Incredibly, 4% of respondents even reported physical abuse.

29. Cost Difficult to determine but has been estimated to cost hospital organizations up to $4 billion/year

30. Awareness- Why Now? Raised to public awareness in 1986 after a series of postal shootings #1 myth and why remains a problem is that most people feel “That could never happen to me” Workplace interaction last piece to the puzzle in errors on the job Shift in healthcare culture from a patriarch approach to a team approach

32. What does the Research Tell Us? No standardized definitions makes benchmarking and comparative research difficult Inconsistent legal and protective measures Belief that violence is “part of the work” Not including all acts of violence as acts of violence No standardized way of reporting the incidents Little research related to intervention evaluation

33. Barriers Denial- doesn’t happen at “my” hospital Employers don’t see the connection of work place violence and turnover No laws or regulations that address all types of violence No set policy or procedure Lack of reporting and follow up Lack of awareness Lack of communication/training Lack of resources Inadequate data

34. Key players in Workplace Prevention Management is the first key player to workplace violence prevention. Management must be committed to the Violence Prevention Program, or the program will fail. Management needs to have a commitment or statement letter indicating that violence of any form will not be tolerated. Management should also support: -medical and psychological follow-up for employees that are victims of violence -ensure safety of employees and persons -provide security officers with authority and adequate resources to keep facility safe -encourage all employees to report violent incidents -inform employees there will be no retaliation for reporting violence

35. Employee Involvement Employees must be included in the planning or the program will not succeed Employees should be encouraged to report all incidents of violence and lack of reporting needs to be addressed Employees need to understand importance of report is to identify, address, and correct security problems.

36. Evidence Based Research- Employer’s role Adopting a workplace violence policy and prevention program and communicating the policy and program to employees. Providing regular training in preventive measures for all new/current employees, supervisors, and managers. Supporting, not punishing, victims of workplace or domestic violence. Adopting and practicing fair and consistent disciplinary procedures. Fostering a climate of trust and respect among workers and between employees and management. When necessary, seeking advice and assistance from outside resources, including threat-assessment psychologists, psychiatrists and other professionals, social service agencies, and law enforcement.

37. Evidenced Based Research- Employee’s role Accept and adhere to an employer’s preventive policies and practices. Become aware of and report violent or threatening behavior by coworkers or other warning signs. Follow procedures established by the workplace violence prevention program, including those for reporting incidents.

38. Break Out Session Create an outline for your ideal Workplace Violence Plan

39. What should be included in Workplace Violence Plan? The plan should describe all part of the violence prevention program. The plan should include: 1. State clear goals for preventing violence 2. Adapt and state a zero tolerance for violence with consequences 3. Identify an employee reporting protocol 4. Encourage employees to keep records of violence and emphasize no retaliation against employee making report 5. Identify role of security and/or police

40. Laws in Existence or Being Requested States that have requested violence prevention programs, better reporting system or increase research: California, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Washington, West Virginia States with laws that increase or strengthen penalties for offenders: Alabama, Arizona, Colorado, Hawaii, Illinois, Massachusetts, Nevada, New York, North Carolina, New Mexico

41. Laws Pertinent to Tristate Area HB 154 reintroduced as it never made it to a vote. Rep. Denise Driehaus and Rep. Stephen Slesnick are seeking increased penalty for those assaulting healthcare workers. Requesting that offenders be charged with a fourth degree felony, 6-18 months in jail, $5,000 fine. Currently charged as assault with up to 6 months in jail and fine up to $1,000.

42. Sample Cases Raess v. Doescher, Indiana Supreme Court (2008) $325,000 award for assault to a perfusionist related to workplace violence Physician stormed at perfusionist with “clenched fists, piercing eyes, beet-red face, popping veins, and screaming and swearing at him” Physician did not hit the perfusionist but did state “you’re finished, you’re history”

43. Raess v. Doescher Court rejected a challenge to expert testimony about workplace bullying Decision of the case received national attention because media characterized it as a successful workplace bullying claim No new tort laws or creation of new legal claims as result of case to help pave the way for future plaintiffs.

44. Hollomon v. Keadle, Arkansas Supreme Court (1996) Hollomon was a female employee of Dr. Keadle Dr. Keadle would frequently degrade Hollomon with obscene language and comments such as “women who work outside of the home are whores and prostitutes.” Hollomon also reported that Dr. Keadle informed her that he was “connected with the mob and carried a gun.”

45. Hollomon v. Keadle Hollomon left on her own free will and filed an intentional infliction of emotional distress case against Keadle citing that working for him caused her to suffer from “stomach problems, loss of sleep, loss of self-esteem, anxiety attacks and embarrassment.” Court ruled for Keadle citing Hollomon for not making Keadle aware of her peculiar vulnerability to emotional distress.

46. Snyder v. Truck, Ohio Court of Appeals (1993) Dr. Turk was performing a gall-bladder operation and became upset when a nurse, Snyder, was making mistakes and complicating a difficult procedure. Turk became increasingly frustrated when Snyder handed him the wrong instrument. He then grabbed Snyder by the shoulder and pulled her face down toward the surgical opening and stated “Can’t you see where I’m working? I’m working in a hole. I need long instruments.”

47. Snyder v. Turk Judge ruled at trial that Turk had not established the elements of intentional infliction of emotional distress and had not established the elements of battery The appeals court agreed that there was no emotional distress but did support the battery claims

48. Role of Worker’s Compensation Workers’ compensation prevents workers from bringing individual lawsuits against their employers for intentional harm at work. WC is designed to replace personal injury lawsuits as a means of compensating employees for injuries suffered on the job.

50. Culture Personal Culture Discipline Culture Culture of Organization

51. Culture Need to perform a self assessment of personal attitude, values, culture and beliefs Need to examine discipline culture and how it contributes and interacts with other disciplines Overarching culture of the organization is the employers desire and the combination of personal and discipline culture

52. Paradigm Shift What is the current culture of violence in the workplace? No current laws preventing bullying in the workplace If any form of lesser violence is accepted it will lead to more serious forms of violence being tolerated In order for there to be a lasting paradigm shift a ZERO TOLERANCE has to be adapted and followed

54. Assessment Assessment is the act of gathering data to be used in formulating a plan of intervention with the person in crisis. Assessment is critical in de-escalating persons quickly. We assess: the situation, the person, ourselves, co- workers, and the environment.

55. The Situation Situation- The combination of circumstances at a given time Need to examine and define the situation at present time Situations are dynamic and can change at any given time depending on the circumstances

56. Assessment of Situation Do I need help? Communication device Ask for help beforehand What must be done? Is there an aggressor? What can I do to diffuse the situation? Is the person in touch with reality?

57. Assessment of self and co-workers Self assessment- Self-assessment is the process of doing a systematic review of one's own performance -How do I handle stressful situations? Co-workers- systematic review of others using subjective and objective data -Is my co-worker able to help me? -How does my co-worker handle stressful situations?

58. Assessment of Self and Co-Workers Fear- may cause you to freeze Anger- you may feel violated, angry you are being a target and personalize the aggression Anxiety- panic is often the end result of fear or anger that is out of control Frustration- “here we go again.” Inadequacy- feeling you are being judged

59. Assessment of the Person  Assessment of the person is an ongoing process and not just related to crisis. Mental status Emotional status Influence of drugs or alcohol Precipitating factors Culture Support systems- family assessment Non-verbal communication Posture Speech Motor activity Perceived level of crisis

60. Assessment of the Person What is person trying to say? What is his/her purpose? What is the tone? Ability to reason? Any identifiable precipitating factors? Diagnosis

61. Assessment of the Overall Environment What is the design of the building? How much access does a visitor have? Is security present and visible? Does the agency check or ask if visitors are carrying weapons? Is the reception area visible and easily identified by visitors/staff? What is the distance between waiting room chairs? Are activities available to prevent boredom?

62. Assessment of the Unit/Area of Work Environment Environmental rounds Possible weapons Position of furniture in room Lighting Noise Temperature Doors- open/closed, entry and exit doors Obstacles Where is staff? Where are the other persons and visitors?

63. Therapeutic Relationship and Communication How do you form a therapeutic relationship with a person if there is a potential for violence? Elements of a therapeutic relationship include: Rapport~ relationship that is based on acceptance, warmth, friendliness, and non-judgmental attitude Trust~ Basis of a therapeutic relationship Respect~ Implies the dignity and worth of an individual regardless of his/her unacceptable behavior Genuineness~ Being open, honest, and real Empathy~ Acknowledging how the person feels

64. Therapeutic Communication Difficult skill to master Involves an interaction where the sender and receiver are participating Involves verbal and non-verbal communication Active listening S= sit facing the patient O= observe and open posture L= lean forward toward the patient E= establish eye contact R= relax

66. Crisis Development Cycle Level 1 Pre-Crisis Level 2 Defensive Level 3 Acting Out Level 4 Tension Reduction

67. Level 1- Pre-Crisis Person Interaction State of being uneasy. person exhibits unproductive use of energy, non-directive behavior A change in usual behavior Be supportive, show concern, give eye contact Offer alternatives Positive feedback Help person increase insight/self-awareness Keep it simple

68. Level 2- Defensive Person Interaction The person becomes angry, anxious, more vocal. person may be responding to a trigger. Movements are quicker. Be aware of changes in behavior. Staff may become more anxious at this point. Set behavioral limits Be firm Not threatening give limited choices Reduce environmental stimuli

69. Level 3- Acting Out Person Intervention person is physically aggressive, combative. The person will require direct physical intervention Intervene using least restrictive means necessary Team approach Follow policy and procedure

70. Level 4- Tension Reduction Person Intervention person is able to communicate with control Person returns to a state of calm and pre-crisis behavior Appropriate verbal intervention Debriefing Allow the person dignity with goal to regain composure Calm environment

71. Debriefing with Person Gives the person an opportunity to process what has happened. Help with coping skills. Assess for physical and emotional trauma. Provides an avenue for staff/person to further develop therapeutic relationship. Debriefing must be completed within 24 hours after release from seclusion or restraint.

72. Debriefing with Staff Provides the staff an opportunity to process what happened and what could be done differently. Provides the staff an opportunity to “vent.” Those directly involved should be the ones participating in the debriefing.

74. Protective stance… Wide stance at legs (feet apart) and open arms/palms.

75. Blocking an over-head strike… Cross hands over head to block blow to head and deflect down.

76. Blocking a Kick… Rotate body so kick strikes lateral side of leg. video

77. Blocking a Punch Block punch between shoulder and elbow and between elbow and wrist; keep moving in downward direction of fist. video

78. Biting… Push and hold head into bite.

79. Ponytail hair pull… Grab arm and stabilize hands to head, then bend forward to throw them off balance. video

80. Hair Pull… Stabilize hair pull and bend forward to promote release. video

81. Choking or strangle… Lift arms, shrug shoulders and twist out for release. video

82. Choke from behind… Lean forward as you bump with your hip and back out of hold. video

84. Restrain and Walk… Hold under arms and hold at wrist, push hip into person and walk forward keeping hip pressure. video 1video 1, video 2, video 3video 2video 3

85. Take Down… Hold under arms and at wrist; place inside leg behind calf; rotate backwards and take down to the floor; third staff member protects head. video

86. Roll over onto abdomen… Roll in the direction of crossed leg. Person at the head checks airway. *see next slide for complete video

87. Lift… Support under arms, link with staff at the head, 2 staff members support and lift legs (knees and ankles). video

88. Re-Play the Video VIDEO-what could have been done to stop the cycle of violence? VIDEO

89. References http://www.fbi.gov/publications/violence.pdf http://www.HHS.gov http://www.osha.gov/workplace_violence/wrkplaceViolence.Table.html International Council of Nurses (2001). Nurses, Always there for You: United Against Violence. Available: http://www.icn.ch/indkit2001_01.pdf Royal College of Nursing (2005). International Council of Nurses (2006). ICN Position Statement: Abuse and Violence Against Nursing Personnel. Available: http://www.icn.ch/psviolence00.htm

90. References International Council of Nurses (2006). ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector (2003) Lebanon Country Case Study. Available: http://www.icn.ch/WPV_HS_Lebanon.pdf Royal College of Nursing (2002). Rosenstein, AH and O’Daniel, M: Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing, 2005, 105,1,54-64 Institute for Safe Medication Practices: Survey on workplace intimidation. 2003. Available online: https://ismp.org/Survey/surveyresults/Survey0311.asp (accessed April 14, 2008)https://ismp.org/Survey/surveyresults/Survey0311.asp Morrissey J: Encyclopedia of errors; Growing database of medication errors allows hospitals to compare their track records with facilities nationwide in a non punitive setting. Modern Healthcare, March 24, 2003, 33(12):40,42

91. References Gerardi, D: Effective strategies for addressing “disruptive” behavior: Moving from avoidance to engagement. Medical Group Management Association Webcast, 2007; and, Gerardi, D: Creating Cultures of Engagement: Effective Strategies for Addressing Conflict and “Disruptive” Behavior. Arizona Hospital Association Annual Patient Safety Forum, 2008 Ransom, SB and Neff, KE, et al: Enhancing physician performance. American College of Physician Executives, Tampa, Fla., 2000, chapter 4, p.45-72 Rosenstein, A, et al: Disruptive physician behavior contributes to nursing shortage: Study links bad behavior by doctors to nurses leaving the profession. Physician Executive, November/December 2002, 28(6):8-11. Available online: http://findarticles.com/p/articles/mi_m0843/is_6_28/ai_94590407 (accessed April 14, 2008)http://findarticles.com/p/articles/mi_m0843/is_6_28/ai_94590407 Gerardi, D: The Emerging Culture of Health Care: Improving End-of-Life Care through Collaboration and Conflict Engagement Among Health Care Professionals. Ohio State Journal on Dispute Resolution, 2007, 23(1):105-142 Weber, DO: Poll results: Doctors’ disruptive behavior disturbs physician leaders. Physician Executive, September/October 2004, 30(5):6-14

92. References Leape, LL and Fromson, JA: Problem doctors: Is there a system-level solution? Annals of Internal Medicine, 2006, 144:107-155 Porto, G and Lauve, R: Disruptive clinical behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare, July/August 2006. Available online: http://www.psqh.com/julaug06/disruptive.html (accessed April 14, 2008)http://www.psqh.com/julaug06/disruptive.html Hickson, GB: A complementary approach to promoting professionalism: Identifying, measuring, and addressing unprofessional behaviors. Academic Medicine, November 2007, 82(11):1040-1048 Rosenstein, AH: Nurse-physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 2002, 102(6):26-34 Hickson GB, et al: Patient complaints and malpractice risk. Journal of the American Medical Association, 2002, 287:2951-7 Hickson GB, et al; Patient complaints and malpractice risk in a regional healthcare center. Southern Medical Journal, August 2007, 100(8):791-6 https://ismp.org/Survey/surveyresults/Survey0311.asp Stelfox HT, Ghandi TK, Orav J, Gustafson ML: The relation of patient satisfaction with complaints against physicians, risk management episodes, and malpractice lawsuits. American Journal of Medicine, 2005, 118(10):1126-33 Gerardi, D: The culture of health care: How professional and organizational cultures impact conflict management. Georgia Law Review, 2005, 21(4):857-890

93. References Keogh, T and Martin, W: Managing unmanageable physicians. Physician Executive, September/October 2004, 18-22 ECRI Institute: Disruptive practitioner behavior report, June 2006. Available for purchase online: http://www.ecri.org/Press/Pages/Free_Report_Behavior.aspx (accessed April 14, 2008)http://www.ecri.org/Press/Pages/Free_Report_Behavior.aspx Kahn, MW: Etiquette-based medicine. New England Journal of Medicine, May 8, 2008, 358; 19:1988-1989 Kuhn, Thomas, S., "The Structure of Scientific Revolutions", Second Edition, Enlarged, The University of Chicago Press, Chicago, 1970(1962) Lamontagne, C: Intimidation: A concept analysis. Nursing Forum, January- March 2010, 45(1). Marshall, P and Robson, R: Preventing and managing conflict: Vital pieces in the patient safety puzzle. Healthcare Quarterly, October 2005, 8:39-44 MEDSURG Nursing—September/October 2009—Vol. 18/No. 5