The Hospital Violence Surveillance Study

Lisa Pompeii, PhD, Principal Investigator Ashley Schoenfisch, PhD John Dement, PhD Hester Lipscomb, PhD Claudia Smith, PhD, RN, NE-BC Mudita Upadhyaya, PhD Candidate Type II Violence in Six U.S. Hospital Emergency Departments

Ashley Schoenfisch, PhD Assistant Professor Duke University Medical Center

Recommended Elements of a Hospital-Based Violence Surveillance System

Lisa Pompeii, PhD Associate Professor The University of Texas Health Science Center Houston Committee on Nonfatal Workplace Violence

• In 2001, published recommendations regarding next steps in non-fatal workplace violence research – Coordinated surveillance – Data are needed to create evidence -based prevention policies and programs

References: Peek-Asa, 2001; Merchant et al., 2001 Workplace Violence Types

I: Criminal intent (e.g., robbery)

II. Perpetrator is a customer receiving services from the company (titiit(e.g., patient, visitor)

III: Perpetrator is employed by the establishment (e. g., worker assaults co-worker)

IV: Perpetrator has a personal relationship with an employee (e.g., domestic violence spills into the workplace) Study Definition of Type II Violence

 Physi cal A ssault : AihiltthAggressive physical contact such as hitting, biting, scratching, pushing, shoving and/or sexual assault. A physical injury may or may not occur.

 Physical Threat: Threatening or aggressive physical behavior or phy sical force that makes y ou feel that y ou may be harmed.

 Verbal : Aggressive or inappropriate language that makes you feel threatened, scared and/or uncomfortable. Study Settings

1 Texas Hospital System 1 North Carolina Hospital System 1 Tertiary Care Medical Center 1 Tertiary Care Medical Center 2 Community Hospitals 2 Community Hospitals Study Population

• 6 study hospitals: vary by size, location, and types of communities they serve – Level 3 Medical Center (n = 2) – Community Hospital (n = 4)

• Eligible study participants – 12,000 workers – 3,000 Registered Nurses – 500 PCAs/Nurses’ Aides – 800 Emergency Room Workers Inclusion/Recruitment

• All workers were eligible to participate • This a llowe d us to examithikfkline the risk of workplace violence within and across hospitals, occupational ggproups and work units. Hospital Violence Surveillance Study

Phase I: Phase II: Phase III: Needs Design, Implementation of Assessment of Enhanced Surveillance Surveillance System System

Data Collection & Analysis - Administrative Data - Cross-sectional Surveys - Phone Interviews - Focus G&KGroups & Key Informant Interviews - Walk-Throughs Purpose

• To describe patient and visitor perpetrated violence against health care workers (Type II) in hospital emergency departments. The Blitz Survey

Phase I: Phase II: Phase III: Needs Design, Implementation Evaluation of Assessment of Enhanced Surveillance Surveillance System System

Data Collection & Analysis - Administrative Data “Blitz” Survey sent to ~12,000 staff (9/2011) - Cross-sectional Surveys • Brief (5 minutes), Voluntary, Anonymous - Phone Interviews • Subset of participants interviewed (phone) - Focus G&KGroups & Key Informant Interviews Purpose: Learn more about type II violence - Walk-Throughs experienced by health care workers including physical assault, threat of physical assault and verbal abuse Cross-sectional surveys and telephone interviews, Emerggypency Department workers (n=282 )

• Three-quarters (74.8%; n=211) of hospital ED workers experidienced atlt least one t ype II vi ol ent event ti in th e previous 12 months:

– Physical assault 26.2% – Physical threat 47.2% – Verbal abuse 73.8% Cross-sectional surveys and telephone interviews, Emerggypency Department workers (n=211 )

Among events that participants deemed the most serious: • Perpetrator more often a patient (80 .6%) than visitor • Common perceived contributing factors: Focus Groups and Key Informant Interviews

Phase I: Phase II: Phase III: Needs Design, Implementation Evaluation of Assessment of Enhanced Surveillance Surveillance System System

Data Collection & Analysis - Administrative Data - Cross-sectional Surveys Focus groups, interviews - Phone Interviews • 55 Emergency Department workers - Focus G&KGroups & Key • SiSemi-sttdidtructured guide Informant Interviews - Walk-Throughs Focus Groups and Key Informant Interviews

Violence in the Emergency Department as “part of the ” “It’s kind of drilled into you – ‘Your patient is under stress…It’s behavior that’s not unexpected’ – Blow it off”

“You just get kind of used to it. ”

“If somebody just came into triage and called me a bit** or something, I don’t know if I would necessarily report that, because that happens a lot.” Focus Groups and Key Informant Interviews

A focus on customer satisfaction, even at the expense ofkf worker we ll-bibeing

“I feel like customer service comes first , above all else. ”

“[[]Administration] cares more about p pppatients’ perception of our hospital than they do about the staff…”

“[Disruptive behavior gets rewarded] all the time.” Focus Groups and Key Informant Interviews

• There is a need for policies and training on: – how to handle these situations

• “What are we allowed to do?” • “What type of response from a nurse is acceptable by the hospital? hospital?” Focus Groups and Key Informant Interviews

– Define the role of security personnel in managing and preventing type II violence – differences between hospital employed versus contract security

“So you can call security all day long, and they can watch you get beat up”up Focus Groups and Key Informant Interviews

– Need for policy of where and when to report an event

“Being about customer service and patient satisfaction ….., that makes us report it less, because we’re supposed to just take it.”

“When [a patient or visitor] crosses that threshold for me personally , that’ s when I feel it ’s time to escalate things and report things that are going on” Lessons Learned So Far….

• Efforts to address type II violence should: – be supported by management – be made available to all staff – address perceptions that type II violence is “part of the job” – address expectations to maintain customer satisfaction, even at the cost of workers’ well-being Purpose

• To describe the development of a workplace vio lence surve illance sys tem a ime d a t cap tur ing incident cases of violence perpetrated by patients or visitors towards hospital workers (type II). Administrative Data

Phase I: Phase II: Phase III: Needs Design, Implementation Evaluation of Assessment of Enhanced Surveillance Surveillance System System

Data Collection & Analysis - Administrative Data Purpose: Examine the frequency and types - Cross-sectional Surveys of violent events are being reported in existing - Phone Interviews electronic reporting systems. - Focus G&KGroups & Key Informant Interviews - Walk-Throughs Typical Occupational Injury Surveillance

First Report Safety Reporting OSHA Log Workers’ Comp of Injury System Review of Existing Surveillance Methods NC Hosppyital System

• 484 worker injuries due to workplace violence were captured from 2004-2009 – 82% captured through workers’ comp – All were patient-perpetrated events – All were physical injuries The Blitz Survey

Phase I: Phase II: Phase III: Needs Design, Implementation Evaluation of Assessment of Enhanced Surveillance Surveillance System System

Data Collection & Analysis - Administrative Data “Blitz” Survey sent to ~20,000 staff (9/2011) - Cross-sectional Surveys • Brief (5 minutes), Voluntary, Anonymous - Phone Interviews • Subset of participants interviewed (phone) - Focus G&KGroups & Key Informant Interviews - Walk-Throughs Response Rate

(n=5,385 / 10,485)

No, Yes 46% 54% Number of violent events in the Previous 12 Months n=9,062

Physical Assault 1180

Physical Threat 2206

VblVerbal Abuse 5676

0 1000 2000 3000 4000 5000 6000 Number Funny Math

Physical Assaults 6 Years 3 Hospitals (1 Hospital System)

484 vs. 3,540 Reppported vs. Not Reported Most Serious Violent Event in Previous 12 Months ((,)n=2,098)

Physical Assault 19%

Physical Threat 19%

Verbal Abuse 62%

0% 20% 40% 60% 80%

Mutually Exclusive Violent Events Reported

No 25% n=524 Yes 75% N=1,574 Method of Reporting

Medical Record/Chart 16%

Verbal Report to 58% Coworker/Manager Formal Report/FRI/Patient 26% Safety

0 010.1 020.2 030.3 040.4 050.5 060.6 N=1,574 Reason For Not Reporting (n=524)

Event was not serious Person did not intend harm me I was not physically harmed This is part of my job It happens so often I'm desensitized It is too time consuming to report Management would not do anything I was concerned I would be blamed Manager knew the person was … Concerned the person would hurt … Other

0% 10% 20% 30% 40% 50%

*Categories not mutually exclusive Hospital Violence Surveillance Study

Phase I: Phase II: Phase III: Needs Design, Implementation Evaluation of Assessment of Enhanced Surveillance Surveillance System System

Design & Implement StSystem

Accompanying Workplace Violence Reporting Policies Central Workplace Violence Reporting System

First Report Safety Reporting Workers’ Comp of Injury OSHA Log System

Violence Reporting System Recommendations

•Quick • Online • Part of the patient record • Anonymous • Report should be made available to other staff taking care of the patient/family member • Threshold for reporting Elements of Online Reporting

• Type of Violence – Phys ica l Assau lt, Phys ica l Threa t, Ver ba l Abuse • Perpetrator Characteristics – Demographic, Health Factors • Contributing Issues – Emerggyency event , Patient in p ain • Environmental Factors – Location, Isolated/Alone, • Weapon Used – Body fluids, furniture, gun/knife • Brief Description of Event and How it Was Handled Next Steps

• Pilot test online system among groups of workers • Examine utility of data received • Roll out workplace violence reporting policy Thank You