Workplace Violence Prevention Training Programs in

Healthcare: An Analysis of Program Elements

Sheila Arbury MPH RN

Donna Zankowski MPH RN COHN

Disclaimer

• Views and opinions expressed in this presentation are those of the authors and do not necessarily reflect the policy of:

• The Department of Labor

• The Occupational Safety and Health Administration

• AOHP

• There are no financial or commercial conflicts of interests to disclose

• This research is pending publication in Workplace Health & Safety, the journal of AAOHN

Objectives

• Identify the essential elements of a comprehensive workplace violence (WPV) training program for Healthcare settings

• Evaluate the contents of available WPV training programs, and identify the essential elements that are lacking

• Identify the program elements and facility-specific content that is needed to supplement current WPV training programs

Outline• Background on WPV in Healthcare

• Efforts to Reduce WPV

• This Research

• Methods

• Comparison of WPV programs to OSHA Guidelines

• Discussion of Findings

• Conclusions

• Recommendations to Healthcare Facilities

• Questions?

What is Workplace Violence?

“Workplace violence is any act or threat of physical violence,

harassment, intimidation, or other threatening disruptive behavior

that occurs at the work site. It ranges from threats and verbal abuse

to physical assaults and even homicide. It can affect and involve

employees, clients, customers and visitors”.

(OSHA, Safety and Health Topics, Workplace Violence, 2014)

4 Types of WPV Type 1 – Criminal Intent:the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence (robbery, shoplifting, trespassing)

Type 2 – Customer / Client:the most common type in healthcare settings. Includes patients, their family members, and visitors, and occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is not limited to these

Type 3 – Worker-on-Worker: violence between coworkers is commonly referred to as lateral or horizontal violence. It includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating and can range all the way to homicide

Type 4 – Personal Relationship: the perpetrator has a relationship to the nurse outside of work that spills over to the work environment.

Photos and text courtesy of NIOSH Workplace Violence Prevention Training for Nurses (2013)

Background on WPV in Healthcare

• In 2014 – rate of injury due to WPV in Healthcare and Social Service sector was 14.4 per 10,000 workers (BLS, 2014)

• By comparison, the rate in Private Industry is 4.0 per 10,000

• There were 106 total fatalities in the Healthcare and Social Service sector, 28 of these fatalities were caused by WPV (BLS, Table A-1, 2014)

Why is there so much WPV in Healthcare?

Photo courtesy of Microsoft Office Clipart

Factors R/T WPV in HealthcarePatient Related Factors:Patient in PainPatient in FearWorking in Close ProximityPatient with Altered Mental StatusInfluence of Drugs/Alcohol

Facility Related Factors:UnderstaffingInadequate SecurityPhysical Environment(NIOSH, Workplace Violence Prevention for Nurses (2013); Photo courtesy of Microsoft Office Clipart)

What has been done to reduce WPV in Healthcare?

• OSHA Guidelines (1996, 2004, 2015)

• Early WPV prevention training programs developed in Canada,

and the VHA

• State Legislation

• NIOSH Training

• ANA and ENA advocacy and training

• Multiple private companies developed their

own WPV training programs for commercial use

Prior Work in Evaluating WPV Training

• Morrison and Love (2003) did research on 4 WPV training programs used in Psychiatric settings. They evaluated: Content; Feasibility; Psychological comfort of staff; Effectiveness and Cost

• Farrell and Cubit (2005) looked at 28 programs sold internationally (6 from the USA). They evaluated 13 elements: Orientation; Cost; Cause; Type of violence; Risk; Communication; Pharmacology; Physical interventions; Restraints; Seclusion; Legal Issues; Leadership; and Debriefing

The Irish Health Service: Recommendations for Education and Training

• Education and training in the management of work-related aggression and violence be provided to all healthcare employees.

• The content and methodology of education and training to correspond to participants professional and organisational responsibilities.

• Education and training to include lone working, conflict resolution and the management of verbal aggression.

• The safety of physical intervention techniques be established as a priority.(Excerpts from Linking Service and Safety, pg. 13, McKenna, 2008)

This Research Project

At the Request of OSHA OOMN, we looked at the question:

• What content is covered in workplace violence (WPV) prevention training programs used in healthcare settings in the United States today?

• Are there gaps in this training?

• How do these programs compare to specific criteria determined by a comprehensive literature review, and OSHA’s WPV “Guidelines” training topics?

Methods• Compile a comprehensive list of Program Elements

• Contact WPV prevention training companies, and ask permission to review their training materials (company will not be identified)

• Review all provided materials (12 companies responded)

• Code data and enter into database (excel and SPSS)

• Coding key for program elements:

1 = No – no evidence of any kind

2 = Yes – limited evidence

3 = Yes – considerable evidence

• Analyze results

Program Elements to be Evaluated

1. Are there different levels of training available (specify)

2. Is it a Train-the-Trainer program

3. Is a training manual given to staff

4. Are on-line resources available to staff

5. Risk factors for workplace violence discussed

6. Orientation – discussion of facility layout, policies and procedures,

emergency planning, calling for help

7. Discussion of facility risk assessment

8. Situational threat assessment

9. Types of workplace violence discussed (NIOSH – 4 types)

Program Elements (Cont.)

10. Recognition of planned vs. unplanned violence

11. Early recognition of escalating behavior taught

12. Are de-escalation techniques taught

13. Are de-escalation techniques practiced

14. Are extrication and evasion techniques taught

15. Are extrication and evasion techniques practiced

16. Is restraint training taught

17. Is restraint training practiced

18. Are risks associated with physical restraint discussed

19. Are certain types of restraint prohibited

Program Elements (Cont.)20. Is a team approach taught

21. Is there a discussion of pharmacology

22. Are safety techniques for working alone discussed

23. Is there a discussion of legal issues

24. Are reporting requirements discussed

25. Is info on multicultural diversity given

26. Is debriefing discussed – Worker focused (injuries, need counseling/EAP, resources given)

27. Is data supporting the effectiveness of the program given

28. Is data supporting the effectiveness of the program cited for further review –are References given

Results Majority of reviewed training programs included:

• Train the trainer approach

• De-escalation of potentially violent situations

• Practice of de-escalation techniques

• Evasion/extrication with practice

• Restraints and holds

• Team approach

Minority of reviewed training programs included:• Facility-specific workplace violence risk assessment and policies

• Predatory violence

• Working alone

• Worker post-event follow-up

• Evaluation of program effectiveness

Graphic Comparison of 12 Reviewed Programs to Review Criteria

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Program evaluation

Worker Follow-up

Multicultural info

Reporting violence

Team approach

Predatory violence

Restraints and holds

Evasion/extrication

Teach de-escalation

Early recognition

Facility-specific risk factors

Facility policies

Yes - signficant evidence

Yes - limited evidence

No evidence

Discussion of Program Gaps

Facility-specific assessment:• “Customization” = facility can include/exclude topics• Leads to overlooking facility’s distinctive risks• Ignores facility workplace violence policies and

procedures• Result: facility management must do their own training

on facility-specific information

Working alone:• High risk not addressed; example: admitting patient on

night shift w/o other staff near by• One program has optional module added at client’s

request

17%

8%

75%

Information on Facility's Risk Assessment

Yes - SignificantContentYes - LimitedContentNo - No Content

Discussion of Program GapsPost-event follow-up for workers

• Emphasis on therapeutic relationship with violent patients

• Possible worker needs:

• Medical treatment

• Psychological support

• Stress debriefing

• Counseling

• EAP

Worker rights: complaints to state agencies or OSHA protected under whistleblower laws

17%

25%58%

Worker Post-Event Follow-Up

Yes - SignificantContentYes - LimitedContentNo - No Content

Discussion of Program Gaps

Restraints and Holds• Teaching content dependent on:

• Training program’s theoretical constructs

• Client facility’s policies

• Risks of harm unless performed correctly

• Controversial in some settings

• Use not evidence-based

• Workers may not receive adequate preparation/understanding

Discussion of Program Gaps

Legal issues:• Legal definitions of types of assault

• State laws requiring workplace violence prevention programs

• OSHA citations for inadequate worker protection

• Possible employer liability for negligence

Multicultural content: increase staff sensitivity to cultural differences

Discussion of Program Gaps

Predatory violence vs. spontaneous; planned vs. reactive• Predatory: grudge vs. individual healthcare worker leads to planned attack

• Reactive: emotional response occurring in the moment

Predatory violence less common and harder to prevent

Training programs teach reactive violence prevention

Workers should be aware of predatory violence

Discussion of Program Gaps

Evaluation of program effectiveness in systematic data-based approach• Evident in this training program review• Lack of evaluation noted in workplace violence literature

Data collection• Number/location of violent incidents• Details of each event• Tracking of events over time

Research that supports program’s theoretical basis

Limitations

• Small sample size: 12 programs

• Limited program information

• Programs controlled by client facilities’ restrictions• Exclusion of content

• Less training for workers

Conclusions

Need to integrate contracted workplace violence prevention program into facility’s own program

• Incorporate 5 building blocks of OSHA Guidelines

• Base program on facility-specific information

• Supplement contracted program with customized on-site training• Facility risk assessment

• Organizational policies and procedures

• Emergency action plans

• Facility communication systems

• Post-incident debriefing and follow-up policies

Applying Research to Practice

Occupational healthcare professionals should:

• Know the content of the workplace violence prevention training conducted at their facility.

• Notify management of training gaps; for example, the lack of facility-specific risk assessment.

• Understand the physical and psychological effects on workers who experience violent incidents and arrange for appropriate services and support.

References

• Bureau of Labor Statistics. (BLS). (2014). News Release – Nonfatal occupational injuries and illnesses requiring days away from work. Retrieved from: http://www.bls.gov/news.release/pdf/osh2.pdf.

• Bureau of Labor Statistics. (BLS). (2014). Table A-1. Fatal occupational injuries by industry and event or exposure, all U.S. 2014. Retrieved from: http://www.bls.gov/iif/oshwc/cfoi/cftb0286.pdf.

• Farrell, G. Cubit, K. (2005). Nurses under threat: A comparison of content of 28 aggression management programs. International Journal of Mental Health Nursing, 14, 44-53.

• Howard, J. (1996). State and local regulatory approaches to preventing workplace violence.Occupational Medicine, 11, 293-301.

• Lehmann, L.,S., Padilla, M., Clark, S., Locks, S. (1983). Training personnel in the prevention and management of violent behavior. Hospital and Community Psychiatry, 34, 40-43.

• Lipscomb, J. A., El Ghaziri, M. (2013). Workplace violence prevention: improving front-line health-care worker and patient safety. New Solutions, 23, 297-313.

• Lipscomb, J., McPhaul, K., Rosen, J., Brown, J.G., Choi, M., Soeken, K., Porter, P. (2006). Violence prevention in the mental health setting: the New York state experience. Canadian Journal of Nursing Research, 38, 96-117.

References (cont.)• Madden, D.J., Lion, J.R., Penna, M.W. (1976). Assaults on psychiatrists by patients. American

Journal of Psychiatry, 133, 422-425.

• McKenna, K. (2008). Linking Service and Safety: Together Creating Safer Places of Service. Health Service Executive Ireland. ISBN: 978-1-906218-16-4.

• McPhaul, K.M., London, M., Murrett, K., Flannery, K., Rosen, J., Lipscomb, J. (2008). Environmental evaluation for workplace violence in healthcare and social services. J Safety Res. 39, 237-50. doi: 10.1016/j.jsr.2008.02.028. Epub 2008 Mar 26.

• Morrison, E.F., Carney-Love, C. (2003). An evaluation of four programs for the management of aggression in psychiatric settings. Archives of Psychiatric Nursing, 17, 146-155.

• National Institute for Occupational Safety and Health. NIOSH. (1996). Current Intelligence Bulletin 57: Violence in the Workplace.

• National Institute for Occupational Safety and Health. NIOSH. (2002). Violence: Occupational Hazard in Hospitals. Publication Number 2002-101.

• National Institute for Occupational Safety and Health. NIOSH. (2013). Workplace Violence Prevention for Nurses. CDC Course No. WB 1865 NIOSH, Pub. No. 2013-155.

• Occupational Safety and Health Administration (OSHA). (2015). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. OSHA Publication 3148-04R.

References (cont.)

• Peek-Asa, C., Casteel, C., Allareddy, V., Nocera, M.A., Goldmacher, S., O’Hagan, E., Harrison, R. (2007). Workplace violence prevention programs in hospital emergency departments. Journal of Occupational and Environmental Medicine, 49, 756-763.

• Peek-Asa, C., Howard, J., Vargas, L., Kraus, J.F. (1997) Incidence of non-fatal workplace assault injuries determined from employer’s reports in California. Journal of Occupational and Environmental Medicine, 39, 44-50.

• Rosen, J. (2001). A labor perspective of workplace violence prevention. Identifying research needs. American Journal of Preventive Medicine, 20,161-8.

• St. Thomas Psychiatric Hospital (1976). A program for the prevention and management of disturbed behavior. Hospital and Community Psychiatry, 27, 724-727.

• The Joint Commission (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, Issue 40. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.pdf.

• The Joint Commission (2010). Preventing Violence in the Healthcare Setting. Sentinel Event Alert, Issue 45. Retrieved from http://www.jointcommission.org/assets/1/18/sea_45.pdf.

• Wassell, J.T. (2008). Workplace violence intervention effectiveness: A systemic literature review. Safety Science, 47, 1049-1055.

Questions

contact Sheila Arbury at: Arbury.Sheila@dol.gov contact Donna Zankowski at: pdzank@Verizon.net