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Promoting a Nonviolent Health Care Culture

Promoting a Nonviolent Health Care Culture

Video illustrating disruptive behavior, verbal and physical violence Click on Video Link Above.

The Purpose of Promoting a Nonviolent Culture Training is…

To educate employees about creating a nonviolent health care culture by examining all forms of violence from disruptive behavior through extreme forms of verbal and physical violence

To support a safe environment for staff, patients and visitors.

Objectives

Define violence Recognize the different types of violence Understand the effects of violence, occurrence and

cost 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 and intervention techniques Explain debriefing of the person and the staff member Demonstrate basic and advanced intervention

techniques

Define Violence

What is your definition of violence?

Think about what your definition of violence is now….what impacts your definition (family, friends, ??)

Definitions/forms of violence

Bullying Creating a hostile or intimidating work

environment between employees; usually secret behavior

Nonverbal/gesture Violence Using violent and offensive gestures, postures,

facial expressionsVerbal Violence

Using violent and offensive words and/or threatening violence

Physical Violence The intentional use of physical force with the

potential for causing death, disability, injury, or harm.

Bullying

BULLYINGCreating a hostile or intimidating work environment

between employees; usually secret behavior

• May occur vertically from a supervisor of greater power towards an employee.

• May occur horizontally towards someone of equal power. Also known as lateral violence.

• May include written intimidation through letters, Facebook, notes.

• Examples include: eye rolling, changing assignments without informing the person, gossiping, isolating, withholding information, intimidation, excessive criticism, and denial of access to an opportunity

Bullying Behaviors

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

Click on Link Above

Bullying

Workplace Bullying is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators .

Bullying is not tolerated and must be reported.

Do not participate in bullying or stand by and watch other be bullied!

Bullying

almost always psychological frequently linked to a staged attack on competent and

popular individuals usually perpetrated behind closed doors and secret in 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.

Nonverbal/Gesture Violence

NONVERBAL/GESTURE VIOLENCE

Using violent and offensive gestures, postures, facial expressions

• Can often occur before verbal or physical violence

• Don’t ignore the gesture, discuss the frustration, anger, fear, etc.

• May be able to prevent the escalation of violence with intervention.

Verbal Violence

VERBAL VIOLENCEUsing violent and offensive words and/or threatening

violence by employees, visitors, patients or family members

• Often occurs before physical violence

• Is not tolerated and needs to be reported

• Can occur from other employees, patients, visitors and staff.

Physical Violence

PHYSICAL VIOLENCEThe intentional use of physical force with the potential

for causing death, disability, injury, or harm.

• Can occur due to a patients altered medical/mental status

• Often occurs due to one’s fear, anxiety, confusion and/or anger

• Can often be prevented with advanced and proper intervention

• Patient, visitors, family and staff all need to be protected from physical injury

• All physical violence needs to be reported

Effects of violence

Effects of Violence…

The damaging effects of workplace violence are far-reaching and may include:

1. Deterioration in the quality of care delivered

2. Deterioration in the quality of staff relations

3. Low staff morale 4. Increased stress levels and stress-related

illnesses 5. Feelings of shock, disbelief, shame, guilt,

anger, fear, and powerlessness 6. Depression and self-blame, loss of self-

confidence

Effects of Violence in the Workplace (cont.)

7. Sleeplessness and loss of appetite8. Lower levels of job satisfaction

9. Increased costs to employers and the health system10. Increased absenteeism and sick leave11. Poor performance and lost productivity12. Loss of creative problem-solving capacity13. Loss of staff

Occurrence /Cost

How often does workplace violence occur?

More assaults occur in healthcare and social services industries than any other

One million employees are assaulted per year

One thousand are murdered per year

Estimated that ½ of the cases go unreported

Cost

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

Intervene early and prevent violence!

Culture

Personal Culture

Discipline Culture

Culture of Organization

Culture

We all need to perform a self assessment of our personal attitude, values, culture and beliefs regarding violence What level of violence is acceptable in my home?

We need to examine discipline culture (nurse, technician, social work, MD) and how it contributes and interacts with other disciplines How do my peers interact in regards to violence?

Overarching culture of the organization is important in regards to what is acceptable and unacceptable…you are part of that culture!

Understand your personal culture, the culture of those you work close to and the organization…..

Everyone needs to assist the organization to have a ZERO TOLERANCE for violence….

NO BULLYING

BEING YELLED AT, SPIT ON, PHYSICALLY INJURED IS NOT OK

ALL VIOLENCE MUST BE REPORTED---Do not accept it as OK!

The employee’s role is…

• Adhere to your employer’s preventive policies and practices.

• Become aware of and report violent or threatening behavior or other warning signs. Anticipate and prevent an incident!

•Follow procedures established by the workplace violence prevention program, including those for reporting incidents.

Assessing Violence

Assessment of impending violence…

Assessment is the act of gathering data to be used in formulating a plan of intervention with the person in crisis to prevent a violent act!

Assessment is critical in de-escalating persons quickly.

Assess the following: the situation, the person, ourselves, co-workers, and the

environment.

What do we assess violence?

• What is happening in the situation

• How are you responding to the situation?

• What is our co-worker’s reaction and is it appropriate?

• What is the person or aggressor feeling?

• What is going on within the environment?

Assess the Situation…

Do I need help? If in doubt, get assistance!

Are communication devices in place?

Is there an aggressor?

What can I do to diffuse the situation?

Is the person in touch with reality or not?

Personal and co-worker assessment

Am I calm?

Is there some else that should handle this situation?

Can I de-escalate this situation?

Is my co-worker helpful or will they make this situation worse?

Is there another co-worker I should ask for?

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

Assessment of the Person…

What is person trying to say?

What is his/her purpose?

What is the tone?

Are they able to reason?

Any identifiable precipitating factors?

What is their diagnosis?

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?

Assessment of the Environment…

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?

Therapeutic Relationship, Communication and the

Environment

Therapeutic Relationship and Communication

How do you form a therapeutic relationship with a person if there is a potential for violence?

The following elements will support your relationship with the person: 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

Therapeutic Communication

Proper communication can be difficult to master. It involves verbal and non-verbal communication Try the following skills to listen actively….

S= sit facing the patientO= observe and exhibit an open postureL= lean forward toward the patientE= establish eye contactR= relax

Reflects that you care!

Therapeutic Environment

Violence prevention is assisted with the proper environment: You can try using…

Stress balls SnacksMusic GamesMassage Chair AromatherapyPrayer Books Warm BlanketWarm Colors Spacious Area

Chapel

Crisis Cycle

Crisis Development Cycle

Level 1Pre-

Crisis

Level 2Defensiv

e

Level 3Acting

Out

Level 4Tension Reductio

n

Understanding the cycle can help you intervene to prevent a violent act.

You can intervene at any stage of the crisis cycle to de-escalate violence!

Person Your Interaction

State of being uneasy and uses unproductive use of energy, non-directive behavior

A change in usual behavior

Be supportive, show concern, give eye contact

Offer alternatives Positive feedbackHelp person increase

insight/self-awarenessKeep it simple

Level 1- Pre-Crisis

Examples of early warning signs that violence might occur…

RestlessnessAgitationPacingShortness of breathSweatingRockingClenching Teeth

Bouncing LegsShakingCryingGigglingSingingSwearingWringing Hands

Person Your Interaction

The person becomes angry, anxious, more vocal.

Their movements are quicker.

Be aware of changes in behavior.

Staff may also become more anxious at this point.

Set behavioral limitsBe firm Not threateninggive limited choicesReduce environmental

stimuli

Level 2- Defensive

Person Your Intervention

Person is physically aggressive, combative

and will require direct physical intervention

Intervene using least restrictive means necessary

Team approachFollow policy and

procedure

Level 3- Acting Out

Person Your Intervention

Person is able to communicate with control

and 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

Level 4- Tension Reduction

Debriefing

Debrief with the aggressor…

It gives the person an opportunity to process what has happened.

Helps them with coping skills. You can assess for physical and emotional trauma. Provides an avenue for staff/person to further develop a

therapeutic relationship. Debriefing must be completed within 24 hours after person is

released from seclusion or restraint (Joint Commission standard)

Debriefing for employees…

Provides you with an opportunity to process what happened and what could be done differently.

All employees should seek debriefing for all forms of violence. Provides an opportunity to “vent.” Those directly involved should be the ones participating in

the debriefing. A manager or counselor can be very helpful with debriefing.

Check your Knowledge

1. Which of the following forms of violence are usually done in secret? physical, verbal, gestures or bullying

2. What is repeated, deliberate, disrespectful behavior with the intent of hurting someone else?___________

3. What violence often occurs before physical violence and often includes offensive words?_____________

4. T or F All forms of violence should be reported so organizations can prevent its occurrence in the future.

5. T or F The damaging effects of workplace violence are far-reaching and may include depression and feelings of powerlessness.

6. T or F It is important to listen carefully to our patients and visitors by establishing eye contact and sit facing the person.

7. T or F The basis of the therapeutic relationship is trust. 8. Tor F If a person becomes angry and anxious you should appear

nonthreatening but can set appropriate behavioral limits. 9. T or F If the person becomes physically violent intervene with the

least restrictive means necessary. 10. Tor F It is not necessary to debrief with those who were

physically violent.