Evidence Based Practice: For nurses, will the use of de-escalation techniques as compared to no use of de-escalation techniques reduce workplace violence?
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C361Nonresearcharticle.pdf
Author Affiliations: Clinical Nurse Educator (Dr Bromley), University Hospitals Cleveland Medical Center; and Lead Faculty (Dr Painter), Family Systems Psychiatric Mental Health Program, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
The authors declare no conflicts of interest. Correspondence: Dr Bromley, University Hospitals Cleveland
Medical Center, 11000 Euclid Ave, Cleveland, OH 44106 ([email protected]).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com).
DOI: 10.1097/NNA.0000000000000807
JONA � Vol. 49, No. 11 � November 2019
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JONA Volume 49, Number 11, pp 525-530 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N
Ensuring Workplace Safety
Evidence Supporting Interventions for Nurse AdministratorsGail Bromley, PhD, RN Susan Painter, DNP, PMHNP-BC
Healthcare workplace violence is a growing concern among nurses; however, nurse administrators and man- agers may not be fully aware of the level, frequency, or extent of the trauma that staff nurses experience. This information gap is influenced by nurses' failure to report violent incidents, their belief that they are expected to care for violent/assaultive patients, time required for extensive documentation about these incidents, and perceptions that minimal follow-up to mitigate future episodes will occur. This article describes the evidence- based structures, processes, and practices supported to minimize organizational risk and protect nurses and other staff from being physically or emotionally injured and/or traumatized in the workplace.
Prevalence of violence and acts of aggression in health- care are increasing, with 80% of nurses reporting that they have been victims of verbal or physical assaults.1
Because of assaults, nurses become distracted and stressed and are more likely to make errors. Workplace violence prevention strategies based on empirical evi- dence and tailored to the hospital's needs can effec- tively minimize assaults. These strategies along with productive open communication, reinforcement of attitudes about the importance of a safe environment, an infrastructure that decreases work stress, and
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vigilance to sustain a respectful work culture contrib- ute to the success of interventions.2 The purpose of this article is to describe the evidence-based struc- tures, processes, and practices supported to mitigate or- ganizational risk and protect nurses and other staff members from being physically or emotionally in- jured and/or traumatized in the workplace.
Healthcare workplace violence, primarily perpe- trated by patients, is substantial with 7.8 cases of serious workplace violence per 10 000 full-time employees.3
Currently, data about workplace violence in healthcare do not provide a complete picture of the problem. Na- tional employer data are currently based on reported employee injuries where a minimum of a 1-day absence occurred.4 These data provide inadequate details for employers to benchmark the nature and types of vio- lence, threatening behaviors, and trauma that nurses experience because of exposure to workplace violence.5
Challenges persist in accessing meaningful data, and a negligible number of rigorous studies report effective interventions that minimize assaults and promote a safe healthcare environment.6 Victims of workplace injuries7 understand the urgency and necessity to imple- ment violence prevention strategies for the workplace. In- cidents of nurses being assaulted by patients and visitors report injuries so extreme that careers have ended whereas othershavelosttheirlives.8 Theimplicationsareextraordi- nary given the demanding healthcare environment and a future projected 1.1 million nurse shortage.9
The paucity of empirical evidence about effective measures to reduce the incidence of workplace violence poses an organizational dilemma. Violence prevention training and physical plant safety improvements are costly. Compelling rationale is essential when proposing capital and operational dollars to address workplace violence.
Few published studies consider the multidimen- sional factors that impact workplace safety. A review of the literature reported an organizational study
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conducted in a large midwestern hospital that exam- ined variables correlated to violence reduction. Arnetz and colleagues10 studied organizational determinants of workplace violence including healthcare climate, nurse competencies in handling challenging interactions, types of workplace violence prevention interventions, and tracking of severity, frequency, and types of violence. These structural, organizational, and educational inter- ventions were identified as enhancing coworker rela- tionships, promoting work efficiency, and emphasizing administrative promotion of the institution's violence prevention climate. Findings reported interpersonal con- flict asarisk factorforverbal violence, low work efficiency is a risk factor for physical violence, and poor violence prevention climate is a risk factor for verbal and physi- cal violence. Such findings lend credibility to implemen- tation of ongoing staff education to preempt violence.
Lending further support for violence-free health- care environments are national professional and health- care organizations that strongly advocate for safer organizations. The 2015 American Nurses Association position paper on workplace violence11 underscores the importance of a safe environment for staff and patients. A zero harm climate is reflected in standards of both Magnet® certification12 and The Joint Commission.13
Serious healthcare assaults have come to the attention of politicians as well. Representative Joe Courtney (D-CT) introduced the Workplace Violence Prevention for Health Care and Social Service Workers Act, H.R. 7141.14 The act specifies a standard for the Occupational Safety and Health Administration and requires healthcare and social service employers to have workplace violence prevention plans that ensure employee protection from violent incidents; address the need to implement standards in all healthcare set- tings with protective service staff, as well as workplace violence education and training; provide improve- ments in the physical environment; ensure detailed re- cord keeping of violent incidents and protection for staff reporting to organization and law enforcement; and establish minimum requirements for workplace violence prevention plans based on employee input, specific to the unit with prevention components.15
Assessing the Prevalence and Exposure of Workplace Violence Conducting a gap analysis of incidents and risk of workplace violence is an initial step in assessing work- place violence. Areas of focus include: 1) inadequately or nonmonitored entrances and exits; (2) hallways and rooms with unattended facility, dietary, or housekeep- ing carts with sharp and heavy objects; and 3) depart- ments with high levels of stress and volume such as emergency departments (EDs) and labor and delivery
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units.16 These baseline measures provide data to use for comparison following recommended safety interventions.
A thorough internal assessment of the organi- zation based on current practices entails a broad organizational commitment with multidisciplinary participation. The review should include clinical and administrative policies, procedures, communication processes, data analysis of violent incidents, detailed staff injury reports, lost work days, analysis of debriefings, and staff safety recommendations, among other ele- ments (Figure 1).17
Best Practices to Ensure a Safe Workplace Best practices for a safe workplace encompass clinical competencies, a culture committed to critical examina- tion, open communication, professional development, and benchmarking to ensure continuous improvement.18
Patients with a history of violence, substance abuse, a trauma history, and known perpetrators should be flagged in the electronic medical record to alert staff to a possible risk situation to preempt incidents. These alerts should include clinical interventions that trig- gered or mitigated violence.
Open dialogue promoted through shared gover- nance structures may be an avenue for staff to discuss violent episodes and generate recommendations to minimize future episodes. Self-care among nurses is a best practice that promotes resilience, reduces stress, and is a critical component to ensure a safe workplace.19
Specialty Units Safety, particularly in EDs as well as geriatric and psychi- atric units, is challenging given the risk and prevalence of patients with a history of violence or assault.20 Staff in these patient care areas identify the need to develop and refine assessment skills and de-escalation techniques to preempt violent episodes specific to their exposure.21
SAFER Strategies Safe patient-staff culture is inherently a continuous commitment that involves critical examination and evaluation of violent incidents. Staff and leaders gain meaningful insights into the care environment when they become active, with 5 evidence-based priorities incorporated into ongoing SAFER strategies.20 SAFER strategies are based on an ongoing review conducted by administrators to evaluate the institutional workplace violence prevention safety scorecard to monitor suc- cessful interventions and identify opportunities to improve the culture (Figure 2).22
Reporting Misperceptions and assumptions by nurses about pa- tient violence impede the achievement of best practices. Nurses identify violent episodes in various reporting
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Figure 1. Aspects of an organizational safety assessment.
forms. These include institutional incident reports and employee injury reports in addition to communiqués and reports to supervisors and concerns about patients shared during daily/shift safety huddles. Cumbersome incident reports and employee injury reports are onerous and time consuming. Other factors interfere with documenting violent incidents. Staff perceive violence related to a patient's illness as “part of their job.”23
Underreporting of incidents or not reporting inci- dents can be attributed to a perception that “nothing will be done anyway.”24
Recommendations For staff nurses, administrators, and nurse managers to have a shared understanding of the healthcare
Figure 2. SAFER strategies.
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environment, transparency regarding the definition and expectations associated with a safe workplace is essential. Leadership presence on the units as vio- lent episodes occur, or after incidents, provides con- text and shared observations. Nurses perceive a level of support when their peers, nurse managers, and administrators facilitate a debriefing, review inci- dent reports with feedback, offer verbal support and validation for effective crisis interventions, and see the implementation of organizational initia- tives to prevent future high-risk incidents (Supple- mental Digital Content 1, available at http://links. lww.com/JONA/A720). This level of commitment on the part of nursing leaders is identified by staff nurses as important and reinforces best practices.25
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Didactic and experiential sessions that demon- strate verbal and physical interventions to preempt assaults and enhance clinical competencies for the as- sessment of early signs of escalating behaviors require practicing team skills. These team skills, analogous to best practices of rapid response teams and emergency codes when applied to violent episodes, have been shown to minimize risks.26
Self-care Measures for Nurses Self-care practiced by nurses and selected based on individual preference has been shown to improve well-being.27 Nursing leaders should review mea- sures including staff morale, job satisfaction, and turnover rates as important metrics in monitoring staff retention. Self-care literature about nurses sup- ports monitoring of nurse attitudes, behaviors, and resilience as mindfulness and meditation techniques that promote focus, improve staff satisfaction, improve retention, and prevent/minimize workplace violence.28
Electroniccopingtoolssupport mindfulnesspractices.29-31
As an example, Mindfulness-Based Stress Reduction is an evidence-based self-care program with techniques to enhance coping skills in stressful environments.32
This intensive program offers effective self-care tech- niques and practices for coping with stress to enhance functioning and ensure a clear focus.
Employee assistance programs within healthcare organizations refer staff to or offer self-care techniques and encourage supportive services for nurses to cope with the trauma of violent episodes.33 Employee assis- tance program counseling services and nurse peer group support influence staff coping particularly related to violence and stressful interactions. The cycle of vio- lence will continue unless organization leaders invest the time commitment and improves communication with staff.
Workplace Violence Prevention Programming Optimal staff education focused on workplace violence prevention delivered with a combination of didactic and interactive sessions can assist nurses to refine skills.34
Workplace violence prevention education should be ini- tiated in orientation. Nurses must develop or enhance skills and competencies regarding escalating patient be- haviors including confusion, suspicions, and verbal and physical threats, which when assessed early on, preempt patient violence.35 Proficiency in recognizing these be- haviors allows nurses to assess patients and share this critical information during handoff to promote continu- ity of care about high-risk patients.
Code violet/rapid response teams for behavioral episodes serve to augment staff de-escalation with pa- tients. These teams of clinical experts trained in crisis intervention, de-escalation, and effective teamwork
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are summoned to units to respond to the continuum of violent patient episodes, provide nursing staff the support during an incident, and facilitate the debriefing with staff and patients. Trained teams are composed of clinicians and protective service staff who implement communication and intervention techniques based on the philosophy of the education program selected by the healthcare organization and policies. These patient-centered, clinically focused programs embrace a philosophy that emphasizes least restrictive interven- tions and approaches. During preemptive education, nurses practice verbal and paraverbal/nonverbal ap- proaches that do not retraumatize patients and encour- age patients to gain control and/or take medications to treat their symptoms of agitation. Administrators and nurse managers who have attended these sessions are better able to reinforce violence prevention techniques and support effective debrief sessions.
Critical Issues When violent occurrences are unaddressed by leaders, staff nurses believe their professional work is devalued and they are demoralized. Nurse retention and team performance are negatively impacted if leaders are perceived as unsupportive, unconcerned, unaware of safety concerns, and not openly discussing violent ep- isodes and assaults with staff.36 Staff concerns about violent episodes have led healthcare organizations to institute remedial actions, improved entrance and egress safety mechanisms, random visible presence of police/ protective service officers on patient care units, weapons checks, support for nurses traumatized by violent incidents, and policies enforced when staff are injured.37,38
Healthcareorganizationswhoadvocateonbehalfofnurse victims ensure ongoing dialogue about violent incidents, monitor these incidents, and implement strategies that minimize violent incidents.
Organizational Infrastructure to Promote Workplace Safety Healthcare institutions' interprofessional committees should meet regularly to monitor and recommend systematic approaches to reduce the incidence of workplace violence.39 Committee membership requires inclusivity with active participation by decision-makers, support personnel, and direct caregivers. Key commit- tee members selected to drive the workplace violence agenda include senior level managers, risk managers, human resources directors, protective service managers, accreditation directors, frontline managers, psychiatric staff, quality team managers, and educators. The pur- pose and function of such an interprofessional com- mittee is to provide oversight, and collect and review data to promote safety and alignment with regulatory
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Figure 3. Workplace violence prevention committee priority agenda items.
safety standards (Figure 3). Workplace violence pre- vention committee members assume significant re- sponsibility in the formulation and implementation of measurable initiatives. On an annual basis, members should review and evaluate the institution's policies and procedures, ensure the delivery of evidence-based workplace violence prevention education, review ag- gregate data of incident reports including workers' compensation reports, and continually benchmark and identify best practices.
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Conclusion
Florence Nightingale in Notes on Hospitals remarks: “It may seem a strange principle to enunciate as the very 1st requirement in a Hospital that it should do the sick no harm.”40 So too, hospitals cannot tolerate an environment that harms nurses. Organizational commitment to ensure zero tolerance of workplace violence is critical as it directly impacts patient experi- ence, patient care quality, and nurse safety.
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