1. THE BIG PICTURE OF HEALTHCARE VIOLENCE 1

2. Objectives  Describe the current trends and statistics for violence in the healthcare environment.  Recognize potential threats and triggers for healthcare workplace violence (specific examples of verbal and non- verbal)  Explain the lessons learned and recommended methods for responding active shooter situations.  Understand the importance of conducting risk assessments and drills to ensure a safer response to violence in the emergency department.  Identify key elements for response to potentially violent behavioral health and prisoner (forensic) patients.  Recognize future security threats in healthcare and the importance of developing strategies in collaboration with the local community. 2

3. It’s Not Just a Full Moon on a Friday Night  For years, many people believed there was a correlation between full moons and critical events.  The frenzied pace for healthcare professionals does not simply escalate based on the lunar effect.  Although there are many difficult, stressful, and even violent events in the ED on nights with a full moon, these same types of incidents occur any night of the week and regardless of the phase of the moon. 3

4. 4

5. A Culture of Tolerance  According to the Online Journal of Issues in Nursing, “Workplace violence is one of the most complex and dangerous occupational hazards facing nurses working in today’s healthcare environment.”  More than 53% of nurses reported experiencing verbal abuse at work. Thirteen percent reported experiencing physical violence in the past seven days. The study results come from the Emergency Nurses’ Association (ENA), which surveyed more than 7,000 emergency room nurses nationwide regarding their experiences from 2010 to 2011. 5

6. Clinical References 1. Based on February 10, 2014, presentation at MidMichigan Health by J. Bryan Sexton, Ph.D., Director of Patient Safety Center, Duke University Health System. Research data based on clinical trials conducted at Duke University with three cohorts: neonatal ICU, internal medicine residents and patient safety leadership. 2. Seligman, Steen, Park & Petersen (July-August 2005). Positive Psychology Progress; Empirical Validation of Intervention. American Psychologist. 3. Martin E.P. Seligman (2011). Flourish: A Visionary New Understanding of Happiness and Well-being. New York, NY: Free Press. 4. “Three Good Things” is also referred to as “The Three Blessings” in some literature. www.midmichigan.org/3goodthings 6

7. A Culture of Tolerance  Unfortunately, many doctors and nurses see violence in the workplace as an accepted hazard of the occupation. They perceive a “culture of tolerance” relative to violent individuals. According to the 2010–11 ENA survey results, 66% of nurses who were physically assaulted never formally filed a report.  Violent crimes in hospitals continue to create serious concern. According to Campus Safety magazine, “The rate of violent crime, assaults, and disorderly conduct incidents at U.S. hospitals in 2013 was significantly higher compared to the previous year, according to research released by the IHSS Foundation (International Association for Healthcare Security and Safety). 7

8. A Culture of Tolerance  According to the 2014 IHSSF Crime Survey relative to hospital violence:  Assault cases rose from 10.7 to 11.1 per 100 beds from 2012 to 2013.  Disorderly conduct rates per 100 beds rose from 28.0 in 2012 to 39.2 in 2013.  The number of violent incidents involving hospital workers jumped 37% in the past three years.  A 2013 study by the International Journal of Nursing Studies found that:  33% of nurses worldwide had been exposed to physical violence and bullying in the workplace  66% reported nonphysical violence (verbal, nonverbal, intimidation, other)  Physical violence was most prevalent in emergency departments and psychiatric facilities. 8

9. 9

10. Four Categories of Workplace Violence  According to the FBI’s National Center for the Analysis of Violent Crime, there are four broad categories of workplace violence:  Type 1 – Violent acts by criminals who have no other connection with the workplace, but enter to commit a robbery or other crime.  Type 2 – Violence directed at employees by customers, clients, patients, students, inmates or any others for whom an organization provides service.  Type 3 – Violence against co-workers, supervisors or managers by a present or former employees.  Type 4 – Violence committed in the workplace by someone who does not work there, but has a personal relationship with an employee (domestic violence). 10

11. Unique Environmental Considerations for Healthcare  Diverse Population Can’t turn anyone away Ambulatory & non-Ambulatory Patients, Family, Friends, Vendors, Staff Microcosm of a City  Open Access to Public 24/7 Multiple Access Points  Duty to Provide Care & Protect the Vulnerable  Prescriptive Culture  Heightened Anxiety and Frustration Levels Crisis Mentality Staffing Shortages Unpredictable  Last Place People Want to Be… 11

12. Violence Spectrum 12

13. Interim Summary  Awareness Mindset Critical CANNOT Ignore Behaviors of Concern Do NOT Go Away Escalation Likely  Recognition Intervene Early and Appropriately  Alert supervisors to concerns  Report ALL incidents Nothing is insignificant 13

14. OSHA Considerations OSHA DIRECTIVE NUMBER: CPL 02-01- 052 EFFECTIVE DATE: September 8, 2011 SUBJECT: Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents  This instruction establishes general policy guidance and procedures for field offices to apply when conducting inspections in response to incidents of workplace violence  Significant amount of information applies specifically to healthcare organizations. 14

15. “Flashpoint” For Healthcare Recognizing and Preventing Violence in the Healthcare Community 15

16. Who is the Active Shooter? 16

17. Active Shooter Definition  An armed person who has used deadly force on other persons and continues to do so while having unrestricted access to additional victims, different from hostage situations. Sheriff’s Office Policy and Procedure Manual. Colorado Springs, Colorado, USA: El Paso County Sheriff's Office. 2004-01-01. http://shr2.elpasoco.com/PDF/policy/chapter_07/731_policy.pdf.Colorado SpringsColoradoUSA http://shr2.elpasoco.com/PDF/policy/chapter_07/731_policy.pdf 17