Workplace Violence

Dana Bartlett, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Rocky Mountain Poison Control Center.

ABSTRACT Workplace violence is a complex and widespread issue that has received increased attention from the public, mental health experts, law enforcement, and healthcare professionals. Workplace violence in healthcare can include violence from the patient, relatives and friends of patients, and it also includes workplace bullying. Pain, anxiety, loss of control, powerlessness, and disorientation may result in aggressive incidents against healthcare workers. Violence in emergency departments may result due to varied reasons, including access to weapons and crowded and emotional situations occurring in emergency settings. Some healthcare organizations have implemented a code for violence that evokes a rapid response. The incidence of occurrences, type of violent incidents and prevention of violence are discussed.

1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Workplace violence in healthcare can take many forms. It is a widespread and complex issue. Healthcare workers need to be informed and appropriately trained to recognize warning signs and to act to prevent harm to self, co-workers and others, including harm to patients during the delivery of healthcare.

Course Purpose

To provide health clinicians with knowledge on how to recognize and understand the implications of workplace violence upon clinicians and the health environment, and of available resources to report violence and to seek help.

2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. ______percent of all nonfatal injuries from occupational assaults and violent acts occur in healthcare and social service settings.

a. Twenty-five b. Sixty-nine c. Fifteen d. Thirty-three

2. True or False: Workplace Type I incidents involve offenders in a relationship with either the victim or the establishments.

a. True b. False

3. Healthcare workers are at increased risk for workplace violence from a patient’s relatives or friends because

a. prevalence of firearms among the public. b. hospitals do not discharge patients timely. c. availability of drugs or money at pharmacies. d. of frustration with a perceived lack of care or communication.

4. True or False: A manager issuing a threat to report an employee or making threats about the employee’s performance evaluation is not considered workplace violence because these threats are part of a manager’s legitimate role.

a. True b. False

5. If a violent situation seems imminent or is occurring in the workplace, de-escalation techniques are used to

a. physically restrain the violent person. b. control the situation using chemical restraints. c. calm a violent person by talking to the person. d. All of the above

4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction

Violent occurrences in healthcare settings have pushed the issue of workplace violence to the forefront of the health community and other agencies taxed with ensuring staff and patient safety.1-3 Health clinicians care for their patients and envision making a difference in their patient’s health status, decision-making abilities, and health outcomes. Workplace violence also includes workplace bullying; this may not be as dramatic as violent incidents, but it is pervasive and has a very harmful effect on employees and organizations. Violence is a serious and unanticipated risk for health clinicians, and the incidence of workplace violence, the causes and consequences, and strategies that can prevent and deal with occurrences of workplace violence are highlighted in the following sections.

What Is Workplace Violence?

In September 2010, the Baltimore city police and tactical team rushed to Johns Hopkins Medical Center to subdue a gunman on the eighth floor of the hospital. Patients and healthcare workers in the hospital and vicinity were immediately evacuated when the alert was sounded. The suspect became emotionally distraught after a surgeon updated him on the status of his mother’s grave condition. After hearing the news, the gunman allegedly fired a semiautomatic handgun and shot the physician in the abdomen, seriously wounding him.

Workplace violence in healthcare can take many forms. Violence from relatives and friends of patients may occur because of frustration with a perceived lack of care or communication. Pain, anxiety, loss of control, powerlessness, and disorientation may result in aggressive incidents from patients to health clinicians. Violence in Emergency Departments (EDs) may

5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com result from the crowded and emotional situations that can occur in EDs when people are ill or in pain. In addition, ED patients could be involved with crimes, weapons and violent behaviors that could put the ED employee at an increased risk of workplace violence.

There is a wide range of acts that fall under the rubric of workplace violence, including violent behavior and threats of violence, as well as any conduct that can result in injury, damaged property, induce a sense of fear, and otherwise interfere with the normal course of work. Threats, harassment, intimidation, bullying, stalking, intimate partner violence, physical or sexual assaults, and homicides can also be considered workplace violence. Workplace violence can also occur between employees in the form of bullying and incivility. The World Health Organization (WHO) defines workplace violence as “Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, wellbeing or health.”4 Also, the National Institute of Occupational Safety and Health (NIOSH) defines workplace violence in the following way. “Workplace violence is the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.”5

The National Institute of Occupational Safety and Health classifies workplace violence into four categories, Types I-IV.6 Types II and III are the most common in healthcare settings: 1) Type I involves criminal intent, and the perpetrators of Type I workplace violence do not have a relationship to the business or its employees, 2) Type II involves a customer, client, or patient, the individual has a relationship with the business and the employees, and he/she becomes violent while receiving services, 3) Type III violence is worker-on-worker violence, i.e., an employee who attacks or threatens another employee, and 4) Type IV violence occurs when the perpetrator and

6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com the victim have a personal relationship, the violence happens in the workplace, but the attacker has no formal relationship to the business. Table 1 provides explanations and examples of violence that can occur at work.

Table 1 – Types of Violence

Type of Violence Description Verbal Outbursts of yelling and screaming; use of exaggerated or angry tone of voice, cursing, derogatory, foul, condescending, or inappropriate language, or use of racial/ethnic slurs. It is not always what but how it is said, and when and where a comment is made. Nonverbal Includes eye rolling, raising eyebrows, making a face, turning away from a person, or physically excluding someone. Although these nonverbal behaviors are not spoken, they are seen and felt as abusive. Passive behaviors The absence of an action rather than an overtly identifiable action that directly affects communication between caregivers and can include not answering pages or returning phone calls, not responding to or being impatient with questions, deliberately communicating incomplete information, and silence. Passive- Behavior such as complaining about an individual to others; Aggressive gossiping; badmouthing the organization, colleagues, or Behaviors physicians to patients or others; discrediting leaders; fostering disregard of policies and procedures; and being unnecessarily sarcastic or negative. This type of behavior negatively affects the patient care culture by demoralizing staff and destroying team support. Physical Abuse Behavior such as fighting, hitting, spitting, pushing, shoving, pinching, kicking, and throwing objects is easy to identify and must be off-limits to everyone. This includes any unwanted or hostile physical contact, threatening body language or aggressive movements or gestures. Sexual Demonstrates a lack of respect for an individual through the use Harassment of overtly friendly or sexual behavior, inappropriate touching, unwelcome advances or invasion of personal space with intent to intimidate, or verbal conduct of a sexual nature (i.e., using vulgar or sexual language; telling off-color “dirty” jokes or stories; referring to an individual’s body; describing instruments or equipment in a sexual manner). Employer/Manager Issuing threats to report a person, making threats about the Abuse employee’s performance evaluation, berating staff members in public or private, or denying an employee’s physical or emotional response to an on the job injury. Employers and managers have a responsibility to provide a safe workplace. This involves being aware of and addressing the physical and emotional safety of employees.

7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

How Common Is Workplace Violence?

Workplace violence in healthcare and violence at work places in general are not new phenomena1 and there is evidence that in recent years, the incidence of both has been increasing. But how common is workplace violence, especially in healthcare settings, and are they increasing in frequency?

In 2014, the American Nurses Association (ANA) published the results of a survey of 3,765 registered nurses and nursing students. Forty-three percent of the respondents reported that they had been verbally and/or physically threatened by a patient or family member of a patient and 24% of respondents had been physically assaulted by a patient or family member of a patient.1 Also, in 2014 the Bureau of Labor Statistics noted that 15,980 workers in the private industry had suffered nonfatal injuries from workplace violence and 69% of these incidents occurred in healthcare and social assistance settings.3

According to the United Department of Labor and the Occupational Safety and Health Administration (OSHA), almost 2 million American workers report having been victims of workplace violence each year.7 From 2012 to 2014, injuries caused by patients nearly doubled among nurses and nurse assistants.8 Between 2011 and 2013, 70%-74% of the reported workplace assaults happened in the healthcare and social service settings, and these injuries result in a disproportionately high number of missed days of work.9

From 2002-2013, incidents of serious violence that required time off from work for recovery were four times as likely to happen to healthcare workers

8 nursece4less.com nursece4less.com nursece4less.com nursece4less.com than to workers in private industries.10 A survey of 762 registered nurses found that 76% had experienced physical and/or verbal violence from a patient or a patient’s family member.11

These statistics seem to confirm the perception that workplace violence in healthcare settings is common and it is increasing. However, the true extent of workplace violence, notably violence that occurs in healthcare settings, is not known. Gomaa, et al., (2015) reported that from 2012-2014 injuries to nurses and nursing assistants caused by patients doubled, but the statistics were derived from data gathered from 19 states and only 112 U.S., healthcare facilities.8 The OSHA publication, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, noted that 70%-74% of the reported workplace assaults happened in the healthcare and social service settings but also pointed out that research indicates that workplace violence is underreported;9 and, the NIOSH publication, Workplace Violence for Nurses, stated that “most incidents of violence go unreported for one or more of the following reasons:”6

• Healthcare workers and the health care industry have a perception that workplace violence is an inevitable risk associated with the job. • Institutions do not plan or prepare for workplace violence and the staff is not educated on the topic. • Complicated reporting procedures discourage reporting workplace violence. • There is a perception that workplace violence happens so often that there is no time to report every incident. In addition, healthcare workers may feel that reporting will be of little use, i.e., no action will be taken. • Fear that reporting will reflect poorly on the nurse (victim blaming). • Believing that reporting violence is blaming a patient, and in many situations patients are not accountable for their violent actions.

9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

Another factor that may contribute to the underreporting is a lack of a clear and consistent definition of workplace violence; a situation in which a confused patient attacks and injures a health clinician may be interpreted as a regrettable consequence of the patient’s mental status and not as a violent incident.

Regardless of the extent of workplace violence in healthcare and whether or not it is becoming more common, it is a serious problem and many of the major health professional organizations, such as the American Nurses Association (ANA) and American Medical Association (AMA), have issued position statements and recommendations about it.12-15 It happens in urban settings and in communities with high crime rates, in community hospitals, and in rural and suburban areas; and, workplace violence is also a significant problem in nursing homes and long-term care facilities and for community health professionals.16-18

Causes Of Workplace Violence

The occurrence of workplace violence cannot be reliably predicted, but there are environmental, organizational, and patient factors that have consistently been shown to be risk factors for workplace violence in healthcare settings.6,9,19-21 The risk factors have been divided into three categories, but there is overlap between them and there are certainly more than what are listed here.

Environmental Risk Factors

Poor lighting, patient care areas that are isolated, have poor sight lines, or offer no avenue for escape, working in a high-crime area, unrestricted movement in and out of the healthcare setting and/or patient care areas,

10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com patient care areas that do not have a means of emergency communication or security alarms, working alone with patients, i.e., community healthcare, inadequate security personnel, and inadequate mental health care facilities on premises comprise some of the environmental risk factors. When patient care is delivered in emergency rooms (particularly urban emergency rooms that have a high patient volume), in-patient and acute psychiatric facilities, geriatric long-term care facilities, and residential and social service settings, the risk for violence is increased.

Organizational Fisk Factors

Organizational risk factors include inadequate or no training of staff on workplace violence, inadequate or no policies on how to respond to or report a violent incident, inadequate staffing, workplace conflicts that prevent staff cohesion, new and/or inexperienced staff, the perception that patient violence is unavoidable, and the perception that patients should not be accountable for violent acts.

Patient Risk Factors

Alcohol and substance use and intoxication with alcohol and/or drugs are perhaps the most significant and consistent risk factors for patient violence.21 Certain psychiatric disorders, for example, psychosis, being held involuntarily for psychiatric treatment, or a history of violence are strong predictors for patient violence,21 as are cultural norms that make violence, if not acceptable, considered less socially aberrant. Additionally, pain, repeat visits to an ER for pain medication, serious injuries, unfamiliar surroundings, emotional stress, dissatisfaction with the care that is delivered, and a perception that healthcare staff is indifferent or uncaring can also cause a patient to become violent.6,21 Men are more likely than women to be physically violent,22,23 and physical violence is more likely to occur than

11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com verbal violence when a patient is intoxicated or under the influence of drugs.22

Workplace violence, of course, is not limited to healthcare facilities. Anyone who works with volatile, unstable people is at risk. A job that requires exchanging money with the public or serving alcohol increases the risk, as does working alone or in an isolated area, working at night, or working in a high-crime area.3

Bullying and Incivility

Workplace violence also includes bullying and incivility between health workers, which is called horizontal and lateral violence. The ANA describes incivility as rude and discourteous actions, gossiping, spreading rumors, and refusing to help a co-worker.1 Bullying is described as “... repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient.”1 The AMA released a policy in 2016 that stated "As violent incidents continue to plague hospitals, emergency departments, residential care settings and treatment centers, we must do everything we can to protect the health and wellbeing of our healthcare workers." The AMA's new policy indicated that physicians were encouraged to train and to proactively prevent and report threats and incidents of workplace violence, and to become part of the solution to promote a workplace culture of safety.40

Health clinicians experience bullying and incivility in many ways such as acts of unkindness, discourtesy, divisiveness, and lack of cohesiveness. Belittling gestures, verbal abuse, infighting, scapegoating, gossiping, sarcastic comments, faultfinding, devaluing comments, disinterest and discouragement, and controlling behaviors can undermine health team morale. Workplace bullying is characterized by many incidents of

12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com unjustifiable actions of an individual or group toward a person or group over an extended period.

Bullying behaviors are persistent, offensive, abusive, threatening, and malicious in nature with the intent to do harm. The person who bullies may be in a position of power (actual or perceived). Bullying involves intentionally targeting a colleague or employee and systematically creating a negative work environment for them through degradation, social exclusion and other negative acts aimed at tormenting or frustrating the victim.

Workplace violence also includes bullying and Bullying and incivility are long-standing incivility between nurses, which is called horizontal and very common problems that and lateral violence. This is long-standing and very specifically affect health clinicians, notably common problem affecting the nursing profession,24-26 and they have the nursing profession, and it has many consequences, many adverse consequences, such as job including (but limited to) burn-out, job dissatisfaction and burn-out, poor patient dissatisfaction, poor patient care, and a wide range of care, and a wide range of psychological psychological issues.24-26 issues.24-26

Consequences Of Workplace Violence For Health Professionals

Workplace violence in healthcare has emotional and psychological, financial, physical, professional and organizational consequences.

Emotional and Psychological Consequences

Acute and chronic emotional and psychological consequences of workplace violence include (but are not limited to) anxiety, decreased self-esteem, depression, irritability, post-traumatic stress disorder (PTSD), substance

13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com use, and suicide.1,6,22,27-31 It is important to note that witnesses to workplace violence can suffer emotional and psychological harm, as well.

Financial Consequences

The financial consequences of workplace violence accrue from missed days at work, staff turnover, and the costs of treating the injured employee/employees,1,6 and these affect the organization and individuals.

Physical Consequences

A significant number of violent workplace incidents result in injuries that are serious enough to require time off for recovery.10 Physical injuries may be minor or quite serious and result in acute and chronic problems.6

Professional and Organizational Consequences

Workplace violence can cause absenteeism, burnout, career dissatisfaction, inadequate staffing, medication errors, poor patient care, staff turn-over, and health professionals leaving the workforce.1,6 Poor performance, lost productivity, loss of self-confidence, concentration, and creative problem- solving capacity could put the health professional and patient in danger.

Abusive work situations can lead health clinicians to make mistakes, the consequences of which patients may suffer. Patient safety is further compromised when communication flow is interrupted, collegial relationships are weakened, and team collaboration is disrupted.

Workplace violence and patient aggression can cause clinicians to adopt non- productive strategies for coping with anxiety that are consequentially detrimental to the quality of care. One good example of this is health

14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com clinicians working in an inpatient setting employing “patient-avoiding behaviors” or “social distancing” (i.e., avoiding verbal interaction or talking and listening to patients less than other colleagues on non-violent units).

Prevention Of Workplace Violence

Violence should never be accepted and tolerated as part of the job. In addition, workplace policies and procedures are needed that focus on the security of the environment, reporting and surveillance, and education for all employees and managers on how to prevent and manage violence. When violence does occur, it is critical that formal or informal debriefing be offered to all health staff members experiencing violence. Unfortunately, this level of support is not found in all organizations. Many clinicians report that unless they are physically injured, they are often expected to return immediately to their work after being physically assaulted by a patient or visitor.

Prevention is the key concept in dealing with workplace violence, and OSHA recommends a structured program for violence prevention that has the five elements discussed below.32 The ANA and NIOSH have similar recommendations.1,6

Management Commitment and Employee Participation

Management commitment requires administrative and organizational staff to recognize the problem of workplace violence, and to take the lead in establishing a program that educates the staff in how to prevent workplace violence and how to deal with it when it happens. Additionally, management is expected to allocate resources and time for education and preparation, to establish goals and objectives for the prevention of workplace violence, and to evaluate, as needed, the effectiveness of the program.

15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Employee commitment requires that the staff learn and apply the principles and techniques of preventing workplace violence, to learn and apply the principles and techniques of dealing with, and reporting workplace violence, and, to conduct themselves in a way that avoids promulgating workplace violence by treating others “... with respect, dignity, collegiality, and kindness; avoid gossip and spreading rumors, and recognize that abuse of power or authority is never acceptable.”1

Worksite Analysis and Hazard Identification

Worksite analysis and hazard identification is primarily an administrative or organizational responsibility but conditions can change and workplace violence is always a risk in healthcare settings. This means that employees must recognize and report conditions or situations that may increase the possibility of workplace violence.

Hazard Prevention and Control

Hazard prevention and control refers to the specific measures that should be put in place for preventing workplace violence, such as, educational programs, follow-up and reporting procedures, environmental changes that increase staff safety and reduce risk (i.e., lighting, avoiding isolated patient care areas, emergency communication equipment), and a well-practiced, unambiguous plan for handling violent situations. In high-risk areas like EDs, restricted access, metal detectors, dedicated security personnel, safe areas for shelter if a violent event happens, and close control over patient and visitor movements should be in place.33

16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Safety and Health Training

OSHA recommends that “... employees have education or training on hazard recognition and control, and on their responsibilities under the program, including what to do in an emergency.”32

Recordkeeping and Program Evaluation

Accurate recordkeeping and program evaluation involves reporting and trending outcomes related to employee injuries, illnesses, incidents, assaults, hazards, corrective actions, patient histories. Training employers on the importance of record keeping and evaluation of program efficacy can help employers to 1) determine the severity of the problem, 2) identify trends or patterns, 3) evaluate methods of hazard control, 4) identify training needs, and 5) develop solutions for an effective program.32

If the above five steps are followed they will help to prevent workplace violence, Applying recommended principles that are integral to but they are very basic and somewhat a workplace violence prevention program would broad. Healthcare workers, however, seem to be a straightforward need guidance; they need to know what and common-sense approach. Yet, lack of management to do to prevent workplace violence and commitment, lack of agreement on the definition of how to deal with violent situations. It is workplace violence, and barriers to reporting have not enough, for example, to know that been identified as persistent limitations in effective handwashing prevents the spread of implementation of workplace pathogens; employees need to know violence prevention programs.34 when and how to wash their hands. The next several sections outline specific actions health workers can take to prevent workplace violence and to de- escalate and effectively handle a violent or potentially violent situation.

17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Workplace Violence Education Program

Preventing workplace violence begins with education. Education programs can help health clinicians attain confidence, knowledge, and skills, and more effectively manage violent and potentially violent situations.35 Key components of a workplace violence prevention education program would include:35

• Understanding aggression and violence. • Knowing and recognizing risk factors for workplace violence. • Protecting oneself from workplace violence. • Specific techniques for de-escalating violent and potentially violent situations (discussed in a later section).

Understanding Aggression and Violence

There is no single factor that can explain aggression and violence and why it happens in the workplace. A patient may become aggressive and violent because of a specific medical and psychological history; he/she may have a history of violence, intoxication with alcohol and/or drugs can lower inhibitions, there may be an acute state of confusion and/or delirium, and pain. Moreover, recent stressful events, an insensitive and/or unprofessional attitude from the staff may precipitate aggression and violence, and, not infrequently, there is a combination of these factors present.

Regardless of why a patient becomes aggressive or violent in those time he/she is “... is essentially out of control at cognitive, emotional, and behavioral, levels of functioning. They are unresponsive to verbal intervention; and, cannot think clearly or appropriately or express needs and concerns.”6

18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Recognizing Risk Factors

There are environmental, organizational, and patient factors that increase the risk of workplace violence, and healthcare workers should certainly be aware of them. Healthcare workers should also be aware of and observe for immediate aggressive and violent speech and behaviors that indicate the potential for violence, including (but not limited to) agitation, aggressive acts, i.e., breaking or throwing things or pounding walls, angry demeanor, clenched fists, confusion, intoxication, pacing, previous violent behavior, provocative behavior, provocative language, swearing, tense body positions, threats, direct or implied, tone of voice, i.e., monotone, mumbling, loud and strident, and yelling.6,33,36,37

Health clinicians who work in clinical areas in which violence may occur or who care for patients likely to become violent should always make an initial assessment of the situation and the patient. The behavioral and verbal cues that signal the potential for violence can be obvious or quite subtle and in the latter case, detection requires an active and attentive mindset.

Protection

Understanding aggression and violence Aggression and violence occur and knowing and recognizing risk factors along a continuum and there is often a progression from for workplace violence are part of self- anxiety and distress to actual violence.6 This is mentioned protection against workplace violence. because nurses and other Healthcare workers should also know healthcare workers may, through recognition of workplace violence prevention protocols potentially violent situations and skillful interventions, of their facility; they should know who is interrupt this progression, keeping themselves and the responsible (i.e., security personnel, patient safe. police) for assisting if violence occurs, be aware of the surroundings (i.e., an isolated patient care location, the

19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com presence of disruptive visitors, objects that could be used as weapons), and dress safely. The last recommendation includes tucking long hair in a position so that it cannot be grabbed, not wearing anything around the neck that could be used to choke, and avoiding carrying objects that can be used as a weapon.

De-escalation Techniques

If a violent situation seems imminent or is occurring, chemical restraints, physical restraints, or verbal restraints (or a combination of three) can be used.33 It is preferable to use less invasive and intrusive measures first,33 and the verbal techniques used for this clinical situation are called de- escalation.

De-escalation techniques are designed to prevent a violent situation from getting worse or to reduce the intensity of a violent occurrence. In simpler terms, the clinician is trying to defuse the situation and calm the patient down, and this can be very challenging. As was stated previously, regardless of why a patient becomes aggressive or violent, in those times when he or

20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com she is in a crisis, the patient “... is essentially out of control at cognitive, emotional, and behavioral, levels of functioning. They are unresponsive to verbal intervention; cannot think clearly or appropriately or express needs and concerns.”6 De-escalation techniques have two basic components: 1) the attitudes and basic behaviors of the person who is trying to de-escalate and 2) specific things that can be said and done.

Attitudes and Behaviors

Attitudes and behaviors (i.e., body language, tom of voice) that should be used for de-escalation are listed in Table 2 below.6,35,38

Table 2: De-Escalation Attitudes and Behaviors

Be aware of posture and gestures; ensure they are not provocative or threatening Be calm, or maintain an attitude of calmness Don’t be judgmental Do not touch someone who is agitated or violent Don’t stare If possible, do not approach the patient directly from the front Listen Maintain a safe distance Respect personal space Speak clearly, concisely, and simply Try and convey an attitude of confidence

Specific de-escalation Techniques

Several examples of de-escalation are outlined below in Table 3.

21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Table 3: De-Escalation Techniques Allow and encourage the patient to express herself/himself. Example: “Tell me what is upsetting you.”

Include the patient in the plans, use a collaborative approach. Example: “How can we work to solve this issue?”

Listen closely to what the patient is saying and confirm with him/her that you have understood. Example: “You said that you are angry about being in the ER and the long wait. Am I right about that?”

Provide validation. This may be difficult if you do not immediately understand why the patient is upset, or his/her reasoning is illogical. However, the patient’s emotions feelings are important, not how you feel or think about them. Example: “I understand. What you are feelings is reasonable, given the situation, and I can see why it’s upsetting.”

Ask the patient what can be helpful. Example: “What would be the best thing we can do to make you feel less anxious? What has worked before?”

Offer alternatives. Choices allow the patient to feel in control of the situation. Example: “There are several ways we can work on this, and I’m sure we can find a solution.”

Apologize if necessary. Example: “I’m sorry if I didn’t understand what you were feeling.”

Set clear limits, but don’t make threat. Example of limit-setting: “Please stop waving your fist at me. It’s frightening and if it continues the security personnel will have to become involve.” Example of a threat: “Stop waving your fist at me or you’ll be sedated.”

There are also ways to behave and speak that should be avoided when trying to de-escalate a situation.

22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

Do not be argumentative Don’t criticize or scold Don’t interrupt Do not deny the patient’s feelings, even if they seem inappropriate, odd, or irrational. Do not use threats Don’t take the patient’s behavior or content of speech Personally Do not be defensive

Chemical Sedation and Physical Restraints

Chemical sedation is the next step in controlling aggressive and/or violent behavior if verbal de-escalation is ineffective. The primary choices for chemical sedation are the benzodiazepines, atypical antipsychotics, and typical anti-psychotics.33 Each class has benefits and risks, they can be used in combination, and the correct medication to use will depend on the situation.33 For example, the benzodiazepines have a rapid onset of effect, but they can cause respiratory depression; the typical antipsychotics (often called first-generation anti-psychotics) can be very effective, but they can cause hypotension, QT prolongation, and arrhythmias.

Physical restraints may be necessary, but the must be used correctly and cautiously. There are many well-documented cases in the medical literature of serious injuries and death caused by psychical restraints, and they should only be used if other methods have been tried but have not been successful and there is a risk of serious harm to the patient, the staff, or others.33 The use of physical restraints will not be covered in detail.

A healthcare facility should have a protocol for when and how to use physical restraints; this should include:

23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Indications for use. • Indications for discontinuing physical restraints. • How to apply them. • Patient monitoring, i.e., how often, specific neurological and vascular parameters to monitor.

Strategies to Combat Horizontal Violence

In some workplaces, an interdisciplinary team consisting of leadership from management, administration, as well as the occupational and safety officer and other experts initiate the process of creating a culture of civil behavior. The aim is to rebuild social relationships, focus on prevention, and repair the harm from horizontal violence. This process is also sensitive to acknowledging that changing culture takes time, requiring wisdom, compassion, diligence and patience. Naming the actions and behaviors that are unacceptable is a step toward controlling inappropriate behavior and moving toward a culture of patient safety.

Employees can work to prevent workplace bullying by reporting incidents, behaving professionally, promoting a culture of respect in the workplace, and “both individually and through their professional associations ... to advocate for incivility and bullying identification and prevention education...”1

Summary

Workplace violence is a significant issue that crosses all health worker environments and has far reaching consequences. Patient, family and visitor aggression and violence towards health workers is a common phenomenon seen for clinicians working in a variety of care environments. The aftermath

24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com effects are found to be associated with negative psychological and emotional responses and job dissatisfaction that can reciprocally lead to inadequate quality of care and a vicious cycle of patients’ aggression and violence towards health workers. This is a significant issue as the Bureau of Labor Statistics found that nurses, specifically, were victims of nonfatal assaults more than twice as often as any other medical field workers.

Workplace violence can take many forms and be either overt and obvious, or covert and hidden. Any type of workplace violence can have serious consequences for all involved and should not be tolerated by the staff or management or administration of the organization. This course has described the different types of workplace violence, discussed the incidence of workplace violence, its consequences, and some strategies to prevent and deal with occurrences of workplace violence as well as some online resources that may be helpful to further study.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. ______percent of all nonfatal injuries from occupational assaults and violent acts occur in healthcare and social service settings.

a. Twenty-five b. Sixty-nine c. Fifteen d. Thirty-three

2. True or False: Workplace Type I incidents involve offenders in a relationship with either the victim or the establishments.

a. True b. False

3. Healthcare workers are at increased risk for workplace violence from a patient’s relatives or friends because

a. True b. False

5. If a violent situation seems imminent or is occurring in the workplace, de-escalation techniques are used to

a. physically restrain the violent person. b. control the situation using chemical restraints. c. calm a violent person by talking to the person. d. All of the above

26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. The following can contribute to the potential for violence in the workplace:

a. Working alone or in isolated areas. b. Time of day. c. Location of work. d. All of the above

7. True or False: The AMA's new policy encourages physicians to train, prevent and report threats and incidents of workplace violence, and to become part of the solution to promote a workplace culture of safety.

a. True b. False

8. Organizational risk factors leading to workplace violence include all of the following EXCEPT

a. new and/or inexperienced staff. b. workplace conflicts that prevent staff cohesion. c. the perception that patients are accountable for their violent acts. d. the perception that patient violence is unavoidable.

9. When a patient becomes violent, or when violence is imminent, specific de-escalation techniques may be used, such as

a. do not apologize to the patient- this is a sign of weakness. b. providing validation to the patient. c. be defensive so you can get the patient’s attention. d. interrupt the patient when he or she is irrational.

10. Bullying behaviors do not include behaviors that are

a. unintentionally harmful. b. persistent. c. offensive. d. threatening.

27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11. At the heart of OSHA’s guidelines for preventing workplace violence in healthcare is

a. tolerance. b. horizontal violence. c. prevention. d. lateral violence.

12. True or False: Passive-Aggressive behavior includes eye rolling, raising eyebrows, making a face, turning away from a person, or physically excluding someone.

a. True b. False

13. Common risk factors for aggression and violent behavior include a patient’s

a. recent stressful events. b. confusion or delirium. c. alcohol or drug use. d. All of the above

14. Workplace violence has been divided into four categories. Type IV incidents involve

a. offenders who have no relationship with the victim. b. offenders currently receiving services from the facilities when they commit an act of violence. c. when the perpetrator and the victim have a personal relationship. d. current or former employees acting out toward their present or former places of employment.

15. Most incidents of violence in the healthcare industry go unreported because

a. they are unpredictable. b. of the perception that workplace violence is an inevitable risk associated with the job. c. violence is perpetrated by an unknown person. d. the perpetrator does not have a business relationship with the facility.

28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16. The most significant and consistent risk factor for patient violence is

a. an inexperienced staff member. b. a recent stressful event in a patient’s life. c. the lack of security. d. alcohol and substance use.

17. ______are useful as a chemical restraint because they have a rapid onset of effect.

a. Typical anti-psychotics b. Antidepressants c. Benzodiazepines d. Atypical anti-psychotics

18. The ANA includes ______within the definition of incivility.

a. gossiping b. repeated harmful actions c. intimidation d. physical assaults

19. True or False: A person who bullies must be in a position of actual power.

a. True b. False

20. An example of a clinician adopting a “non-productive strategy” as a response to workplace violence is

a. increased security. b. spending more time talking to patients. c. “patient-avoiding behaviors.” d. “patient-verbal interaction.”

21. Preventing workplace violence begins with

a. education. b. increased security. c. patient-avoiding behaviors. d. hiring more staff.

29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22. Healthcare workers should take actions that protect them from workplace violence such as

a. not wearing anything around the neck that could be used to choke. b. avoiding carrying objects that can be used as a weapon. c. tucking long hair in a position so that it cannot be grabbed. d. All of the above

23. Which of the following is NOT an indicator of a potential for violence?

a. Confusion b. Previous violent behavior c. Pacing d. None of the above

24. True or False: Aggression and violence occur along a continuum and there is often a progression from anxiety and distress to actual violence.

a. True b. False

25. If a violent situation seems imminent, which of the following responses should preferably be used first?

a. Chemical restraints b. Physical restraints c. Verbal restraints d. Call security and let security handle it

26. Which of the following is a component of the de-escalating technique?

a. The attitude of the clinician b. Using physical restraints c. Waiting to see what happens d. Calling security

27. True or False: Just because a patient exhibited previous, violent behavior should not be an indicator of future violence.

a. True b. False

30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28. De-escalating attitudes and behaviors include

a. restraining someone who is agitated. b. staring at a potentially violent person so they know you are watching them. c. maintaining a safe distance from the potentially violent person. d. approaching the potentially violent person from the front.

29. A clinician may de-escalate a confrontation by setting clear limits with a potentially violent patient by

a. immediately calling security. b. telling the patient if he or she continues you will call security. c. approaching the potentially violent person from the front. d. telling the patient to “stop or you’ll be sedated.”

30. ______(often called first-generation anti- psychotics) can be very effective in chemically restraining a violent patient under appropriate circumstances.

a. Typical anti-psychotics b. Atypical anti-psychotics c. Benzodiazepines d. Antidepressants

31. True or False: Any incident of workplace violence should be reported and never ignored- it is not part of the job.

a. True b. False

32. Physical restraints should be used

a. as a primary response. b. only if other methods have been tried and failed. c. if de-escalation techniques fail. d. as soon as a patient appears to be violent.

31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33. A healthcare facility should have a protocol for when and how to use physical restraints, which include

a. restraints as a primary response. b. use of restraints as soon as a patient appears violent. c. monitoring of patients who have been restrained. d. All of the above

34. The process of creating a culture of civil behavior aims to

a. repair the harm from horizontal violence. b. focus on the individuals who are uncivil. c. hold individuals responsible for their actions. d. forcing change from the administration level down to staff.

35. True or False: The process of creating a culture of civil behavior will only succeed if change in culture is immediate.

a. True b. False

32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS:

1. ______percent of all nonfatal injuries from occupational assaults and violent acts occur in healthcare and social service settings.

b. Sixty-nine

“Also, in 2014 the Bureau of Labor Statistics noted that 15,980 workers in the private industry had suffered nonfatal injuries from workplace violence and 69% of these incidents occurred in healthcare and social assistance settings.”

2. True or False: Workplace Type I incidents involve offenders in a relationship with either the victim or the establishments.

b. False

“Type I involves criminal intent, and the perpetrators of Type I workplace violence do not have a relationship to the business or its employees,....”

3. Healthcare workers are at increased risk for workplace violence from a patient’s relatives or friends because

d. of frustration with a perceived lack of care or communication.

“Workplace violence in healthcare can take many forms. Violence from relatives and friends of patients may occur because of frustration with a perceived lack of care or communication.”

b. False

“Table 1 – Types of Violence ... Employer/Manager Abuse: Issuing threats to report a person, making threats about the employee’s performance evaluation, berating staff members in public or private, or denying an employee’s physical or emotional response to an on the job injury. Employers and managers have a responsibility

33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com to provide a safe workplace. This involves being aware of and addressing the physical and emotional safety of employees.”

5. If a violent situation seems imminent or is occurring in the workplace, de-escalation techniques are used to

c. calm a violent person by talking to the person.

“If a violent situation seems imminent or is occurring, chemical restraints, physical restraints, or verbal restraints (or a combination of three) can be used. It is preferable to use less invasive and intrusive measures first, and the verbal techniques used for this clinical situation are called de-escalation.”

6. The following can contribute to the potential for violence in the workplace:

a. Working alone or in isolated areas. b. Time of day. c. Location of work. d. All of the above [correct answer]

“Workplace violence, of course, is not limited to healthcare facilities. Anyone who works with volatile, unstable people is at risk. A job that requires exchanging money with the public or serving alcohol increases the risk, as does working alone or in an isolated area, working at night, or working in a high-crime area.”

a. True

“The AMA's new policy indicated that physicians were encouraged to train and to proactively prevent and report threats and incidents of workplace violence, and to become part of the solution to promote a workplace culture of safety.”

34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8. Organizational risk factors leading to workplace violence include all of the following EXCEPT

c. the perception that patients are accountable for their violent acts.

“Organizational risk factors include inadequate or no training of staff on workplace violence, inadequate or no policies on how to respond to or report a violent incident, inadequate staffing, workplace conflicts that prevent staff cohesion, new and/or inexperienced staff, the perception that patient violence is unavoidable, and the perception that patients should not be accountable for violent acts.”

9. When a patient becomes violent, or when violence is imminent, specific de-escalation techniques may be used, such as

b. providing validation to the patient.

“Specific de-escalation Techniques - Several examples of de- escalation are outlined below in Table 3: Apologize if necessary. Example: ‘I’m sorry if I didn’t understand what you were feeling.’ ... Provide validation.... There are also ways to behave and speak that should be avoided when trying to de-escalate a situation.... Don’t interrupt ... Do not be defensive.”

10. Bullying behaviors do not include behaviors that are

a. unintentionally harmful.

“Bullying involves intentionally targeting a colleague or employee and systematically creating a negative work environment for them through degradation, social exclusion and other negative acts aimed at tormenting or frustrating the victim.”

11. At the heart of OSHA’s guidelines for preventing workplace violence in healthcare is

c. prevention.

“Prevention is the key concept in dealing with workplace violence, and OSHA recommends a structured program for violence prevention that has the five elements discussed below.”

35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12. True or False: Passive-Aggressive behavior includes eye rolling, raising eyebrows, making a face, turning away from a person, or physically excluding someone.

b. False

“Passive: Includes eye rolling, raising eyebrows, making a face, turning away from a person, or physically excluding someone. Although these nonverbal behaviors are not spoken, they are seen and felt as abusive. Passive-Aggressive: Behavior such as complaining about an individual to others; gossiping; badmouthing the organization, colleagues, or physicians to patients or others; discrediting leaders; fostering disregard of policies and procedures; and being unnecessarily sarcastic or negative. This type of behavior negatively affects the patient care culture by demoralizing staff and destroying team support.”

13. Common risk factors for aggression and violent behavior include a patient’s

a. recent stressful events. b. confusion or delirium. c. alcohol or drug use. d. All of the above [correct answer]

“There is no single factor that can explain aggression and violence and why it happens in the workplace. A patient may become aggressive and violent because of a specific medical and psychological history; he/she may have a history of violence, intoxication with alcohol and/or drugs can lower inhibitions, there may be an acute state of confusion and/or delirium, and pain. Moreover, recent stressful events, an insensitive and/or unprofessional attitude from the staff may precipitate aggression and violence, and, not infrequently, there is a combination of these factors present.”

14. Workplace violence has been divided into four categories. Type IV incidents involve

c. when the perpetrator and the victim have a personal relationship.

“Type IV violence occurs when the perpetrator and the victim have a personal relationship, the violence happens in the workplace, but the attacker has no formal relationship to the business.”

36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15. Most incidents of violence in the healthcare industry go unreported because

b. of the perception that workplace violence is an inevitable risk associated with the job.

“‘... most incidents of violence go unreported for one or more of the following reasons:’ Healthcare workers and the health care industry have a perception that workplace violence is an inevitable risk associated with the job. Institutions do not plan or prepare for workplace violence and the staff is not educated on the topic. Complicated reporting procedures discourage reporting workplace violence. There is a perception that workplace violence happens so often that there is no time to report every incident. In addition, healthcare workers may feel that reporting will be of little use, i.e., no action will be taken. Fear that reporting will reflect poorly on the nurse (victim blaming).”

16. The most significant and consistent risk factor for patient violence is

d. alcohol and substance use.

“Alcohol and substance use and intoxication with alcohol and/or drugs are perhaps the most significant and consistent risk factors for patient violence.”

17. ______are useful as a chemical restraint because they have a rapid onset of effect.

c. Benzodiazepines

“... the benzodiazepines have a rapid onset of effect, but they can cause respiratory depression; the typical anti-psychotics (often called first-generation anti-psychotics) can be very effective, but they can cause hypotension, QT prolongation, and arrhythmias.”

18. The ANA includes ______within the definition of incivility.

a. gossiping

“The ANA describes incivility as rude and discourteous actions, gossiping, spreading rumors, and refusing to help a co-worker.”

37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19. True or False: A person who bullies must be in a position of actual power.

b. False

“The person who bullies may be in a position of power (actual or perceived).”

20. An example of a clinician adopting a “non-productive strategy” as a response to workplace violence is

c. “patient-avoiding behaviors.”

“Workplace violence and patient aggression can cause clinicians to adopt non-productive strategies for coping with anxiety that are consequentially detrimental to the quality of care. One good example of this is health clinicians working in an inpatient setting employing “patient-avoiding behaviors” or “social distancing” (i.e., avoiding verbal interaction or talking and listening to patients less than other colleagues on non-violent units).”

21. Preventing workplace violence begins with

a. education.

“Preventing workplace violence begins with education. Education programs can help health clinicians attain confidence, knowledge, and skills, and more effectively manage violent and potentially violent situations.”

22. Healthcare workers should take actions that protect them from workplace violence such as

“Healthcare workers should ... dress safely. The last recommendation includes tucking long hair in a position so that it cannot be grabbed, not wearing anything around the neck that could be used to choke, and avoiding carrying objects that can be used as a weapon.”

38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23. Which of the following is NOT an indicator of a potential for violence?

a. Confusion b. Previous violent behavior c. Pacing d. None of the above [correct answer]

“Healthcare workers should also be aware of and observe for immediate aggressive and violent speech and behaviors that indicate the potential for violence, including (but not limited to): ... Confusion ... Pacing ... Previous violent behavior.”

24. True or False: Aggression and violence occur along a continuum and there is often a progression from anxiety and distress to actual violence.

a. True

“Aggression and violence occur along a continuum and there is often a progression from anxiety and distress to actual violence.”

25. If a violent situation seems imminent, which of the following responses should preferably be used first?

c. Verbal restraints

26. Which of the following is a component of the de-escalating technique?

a. The attitude of the clinician

“De-escalation techniques have two basic components: 1) the attitudes and basic behaviors of the person who is trying to de- escalate and 2) specific things that can be said and done.”

39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27. True or False: Just because a patient exhibited previous, violent behavior should not be an indicator of future violence.

b. False

28. De-escalating attitudes and behaviors include

c. maintaining a safe distance from the potentially violent person.

“Table 2: De-Escalation Attitudes and Behaviors: ... Do not touch someone who is agitated or violent; Don’t stare; If possible, do not approach the patient directly from the front; Maintain a safe distance.”

29. A clinician may de-escalate a confrontation by setting clear limits with a potentially violent patient by

b. telling the patient if he or she continues you will call security.

“Table 3: De-Escalation Techniques: Set clear limits, but don’t make threat. Example of limit-setting: ‘Please stop waving your fist at me. It’s frightening and if it continues the security personnel will have to become involve.’ Example of a threat: “‘Stop waving your fist at me or you’ll be sedated.’”

30. ______(often called first-generation anti- psychotics) can be very effective in chemically restraining a violent patient under appropriate circumstances.

a. Typical anti-psychotics

“Each class has benefits and risks, they can be used in combination, and the correct medication to use will depend on the situation. For example, the benzodiazepines have a rapid onset of effect, but they can cause respiratory depression; the typical anti-psychotics (often called first-generation anti-psychotics) can be very effective, but they can cause hypotension, QT prolongation, and arrhythmias.”

40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31. True or False: Any incident of workplace violence should be reported and never ignored- it is not part of the job.

a. True

“... any incident of workplace violence should be reported and never ignored; it is not part of the job.”

32. Physical restraints should be used

b. only if other methods have been tried and failed.

“Physical restraints may be necessary, but the must be used correctly and cautiously. There are many well-documented cases in the medical literature of serious injuries and death caused by psychical restraints, and they should only be used if other methods have been tried but have not been successful and there is a risk of serious harm to the patient, the staff, or others.”

33. A healthcare facility should have a protocol for when and how to use physical restraints, which include

c. monitoring of patients who have been restrained.

“A healthcare facility should have a protocol for when and how to use physical restraints; this should include: Indications for use. Indications for discontinuing physical restraints. How to apply them. Patient monitoring, i.e., how often, specific neurological and vascular parameters to monitor.”

34. The process of creating a culture of civil behavior aims to

a. repair the harm from horizontal violence.

“In some workplaces, an interdisciplinary team consisting of leadership from management, administration, as well as the occupational and safety nurse and other experts initiate the process of creating a culture of civil behavior. The aim is to rebuild social relationships, focus on prevention and repair the harm from horizontal violence.”

41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35. True or False: The process of creating a culture of civil behavior will only succeed if change in culture is immediate.

b. False

“In some workplaces, an interdisciplinary team consisting of leadership from management, administration, as well as the occupational and safety nurse and other experts initiate the process of creating a culture of civil behavior. This process is also sensitive to acknowledging that changing culture takes time, requiring wisdom, compassion, diligence and patience.”

Reference Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. American Nurses Association. (2015). Position Statement on Incivility, Bullying, and Workplace Violence. July 22, 2015. http://www.nursingworld.org/MainMenuCategories/Policy- Advocacy/State/Legislative-Agenda-Reports/State- WorkplaceViolence/Incivility-Bullying-and-Workplace-Violence.html. Accessed November 11, 2017. 2. American Nurses Association. Workplace Violence. http://www.nursingworld.org/workplaceviolence. Accessed November 11, 2017. 3. Centers for Disease Control and Prevention. (2017). The National Institute for Occupational Safety and Health (NIOSH). Occupational Violence. Fast Facts. December 13, 2016. https://www.cdc.gov/niosh/topics/violence/fastfacts.html. Accessed November 11, 2017. 4. World Health Organization. (2002). Framework Guidelines for Addressing Workplace Violence in the Workplace Sector. http://www.who.int/violence_injury_prevention/violence/interpersonal/e n/WVguidelinesEN.pdf. Accessed November 11, 2017. 5. Centers for Disease Control and Prevention. (2017). The National Institute for Occupational Safety and Health (NIOSH). Occupational Violence. August 17, 2017. https://www.cdc.gov/niosh/topics/violence/default.html. Accessed November 10, 2017.

42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. Centers for Disease Control and Prevention. (2017). The National Institute for Occupational Safety and Health (NIOSH). Occupational Violence. Workplace Violence for Nurses. CDC Course No. WB2908 – NIOSH Pub. No. 2013-155. August 12, 2013. https://www.cdc.gov/niosh/topics/violence/training_nurses.html. Accessed November 11, 2017. 7. United States Department of Labor. Occupational Safety and Health Administration. Workplace Violence. https://www.osha.gov/SLTC/workplaceviolence/. Accessed November 11, 2017. 8. Gomaa, A.E., et al. (2015) Occupational traumatic injuries among workers in health care facilities - United States, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015;64(15):405-410. 9. U.S. Department of Labor: Occupational Safety and Health Administration. (2016). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. OSHA 3148-06R 2. 2016. https://www.osha.gov/Publications/osha3148.pdf. Accessed November 11, 2017. 10. Occupational Safety and Health Administration. (2015). Workplace Violence in Healthcare: Understanding the Challenge. https://www.osha.gov/Publications/OSHA3826.pdf. Accessed November 14, 2017. 11. Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. (2014). J Emerg Nurs. 2014;40(3):218-228; quiz 295. doi: 10.1016/j.jen.2013.05.014. Epub 2013 Sep 17. 12. Emergency Nurses Association. Position Statement: Violence in the Emergency Care Setting. (2014). http://members.ena.org/docs/default- source/resource-library/practice-resources/position- statements/violenceintheemergencycaresetting.pdf?sfvrsn=49343551_2. Accessed November 14, 2017. 13. Canadian Nurses Association, Canadian Federation of Nurses Unions. Position Statement: Workplace Violence and Bullying. http://cna- aiic.ca/~/media/cna/page-content/pdf-en/Workplace-Violence-and- Bullying_joint-position-statement.pdf. Accessed November 14, 2017. 14. American Psychiatric Nurses Association. (2008). Workplace Violence. APNA 2008 Position Statement. https://www.apna.org/files/public/APNA_Workplace_Violence_Position_P aper.pdf. Accessed November 14, 2017. 15. Framework Guidelines for Addressing Workplace Violence in the Health Sector. (2002) International Labour Office, ILO International Council of Nurses, ICN World Health Organization WHO Public Services International PSI. Joint Programme on Workplace Violence in the Health

43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Sector.http://www.who.int/violence_injury_prevention/violence/interpers onal/en/WVguidelinesEN.pdf. Accessed November 15, 2017. 16. Miranda, H., et al. (2014). Musculoskeletal pain and reported workplace assault: a prospective study of clinical staff in nursing homes. ProCare Research Team; Hum Factors. 2014;56(1):215-227. 17. Gabrovec, B. and Eržen I. (2016). Prevalence of violence towards nursing staff in Slovenian nursing homes. Zdr Varst. 2016;55(3):212-217. eCollection 2016 Sep 1. 18. Terry, D., et al (2015). Workplace health and safety issues among community nurses: a study regarding the impact on providing care to rural consumers. BMJ Open. 2015 Aug 12;5(8):e008306. doi: 10.1136/bmjopen-2015-008306. 19. Pich, J.V., et al (2017). Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J. 2017;20(3):107-113. 20. Schnapp, B.H., et al. (2016). Workplace violence and harassment against emergency medicine residents. West J Emerg Med. 2016;17(5):567-573. 21. Claudius, IA., et al. (2017). Case-controlled analysis of patient-based risk factors for assault in the healthcare workplace. West J Emerg Med. 2017;18(6):1153-1158. 22. Ferri, P., et al. (2016). Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study. Psychol Res Behav Manag. 2016;9:263-275. eCollection 2016. 23. Al-Turki, N., et al (2016). Violence against health workers in family medicine centers. J Multidiscip Healthc. 2016;9:257-266. 24. Ebrahimi, H., et al. (2017). Violence against new graduated nurses in clinical settings: A qualitative study. Nurs Ethics. 2017;24(6):704-715. 25. Sanner-Stiehr E, Ward-Smith, P. (2017). Lateral violence in nursing: Implications and strategies for nurse educators. J Prof Nurs. 2017;33(2):113-118. 26. Gillespie, G.L., et al. (2017). "Nurses eat their young": A novel bullying educational program for student nurses. J Nurs Educ Pract. 2017;7(7):11-21. 27. Berry PA, et al. (2016). Psychological distress and workplace bullying among registered nurses. Online J Issues Nurs. 2016 Aug 10;21(3):8. doi: 10.3912/OJIN.Vol21No03PPT41. 28. Nemeth LS, Stanley KM, Martin MM, Mueller M, Layne D, Wallston KA. (2017). Lateral violence in nursing survey: Instrument development and validation. Healthcare (Basel). 2017 Jul 19;5(3). pii: E33. doi: 10.3390/healthcare5030033. 29. Gates DM, Gillespie GL, Succop P. (2011). Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011; 29(2):59-66.

44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30. Shi L, Wang L, Jia X, et al (2017). Prevalence and correlates of symptoms of post-traumatic stress disorder among Chinese healthcare workers exposed to physical violence: a cross-sectional study. BMJ Open. 2017 Aug 1;7(7):e016810. doi: 10.1136/bmjopen-2017-016810. 31. Gillespie GL, Bresler S, Gates DM, Succop P. (2013). Posttraumatic stress symptomatology among emergency department workers following workplace aggression. Workplace Health Safe. 2013; 61(6), 247-254. 32. Occupational Safety and Health Administration. (2015). Preventing Workplace Violence: A Road Map for Healthcare Facilities. https://www.osha.gov/Publications/OSHA3827.pdf. Accessed November 18, 2017. 33. Moore G, Pfaff JA. (2017). Assessment and management of the acutely agitated or violent adult. UpToDate. October 2, 2017. https://www.uptodate.com/contents/assessment-and-emergency- management-of-the-acutely-agitated-or-violent-adult. Accessed November 18, 2017. 34. Blando J. Ridenour M, Hartley D, Casteel C.(2015). Barriers to effective implementation of programs for the prevention of workplace violence in hospitals. Online J Issues Nurs. 2015 Jan;20(1). pii: 5. Epub 2014 Dec 4. 35. Halm, M. (2017). Aggression management education for acute care nurses: What's the evidence? Am J Crit Care. 2017;26(6):504-508. 36. Luck L, Jackson D, Usher K. (2007). STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. J Adv Nurs. 2007;59(1):11-19. 37. Kaunomäki J, Jokela M, Kontio R, Laiho T, Sailas E, Lindberg N. (2017). Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward. BMC Health Serv Res. 2017 Jan 11;17(1):26. doi: 10.1186/s12913-016-1942-0. 38. Richmond JS, Berlin JS, Fishkind AB, et al. (2012). Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. 39. United States Department of Labor. Occupational Safety and Health Administration. Workplace Violence. Enforcement. https://www.osha.gov/SLTC/workplaceviolence/standards.html. Accessed November 11, 2017. 40. American Medical Association (2016). Protecting Health Care Workers from Violence. AMA Adopts New Public Health Policies to Improve Health of Nation. AMA; 2017. Retrieved online at https://www.ama- assn.org/ama-adopts-new-public-health-policies-improve-health-nation.

45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.

46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com