Disrupting Disruptive Behavior:

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Disrupting Disruptive Behavior

• Dealing With Jousting Violence in Healthcare

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What Is The Problem?

• Glenna A. Schindler, MPH, RN, CPHQ, CHES
• Senior Risk Management Consultant

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Defining Violence

• World Health Organization (WHO)
• The intentional use of physical force or power,
  threatened or actual, against oneself, another
  person, or against a group or community, that
  either results in or has a high likelihood of
  resulting in injury, death, psychological harm,
  maldevelopment, or deprivation.

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Definition (Contd)

• Workplace violence includes instances of
• Threatened or actual physical abuse
• Verbal abuse
• Threats
• Obscene gestures
• Sexual harassment
• DelBel, JC.

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Growing Problem

• 69 homicides from 1996 2000
• In 2000 48 of all non-fatal injuries from
  occupational assaults violent acts occurred in
  healthcare social services
• Most assaults occurred in hospitals, skilled
  residential care settings
• Nurses, aides,orderlies, attendants suffered
  the most non-fatal assaults resulting in injury

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Statistics

• In 2000 assaults resulting in injury per 10,000
  full-time workers
• 2 Overall private sector rate
• 9.3 Health service workers
• 25 Nursing personal care facility workers
• 15 Social workers
• Bureau of Labor Statistics

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Statistics (Contd)

• 1993 1999 non-fatal violent crime per 1,000
  workers
• 12.6 All workers
• 16.2 Physicians
• 21.9 Nurses
• 68.2 Mental health professionals
• 69 Mental health custodial workers
• Department of Justice

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Settings Most Associated With Violence

• Behavioral health
• units
• Home health setting
• Physician office

• Emergency departments
• Clinics
• Inpatient units

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Who is Involved

• Employees
• Physicians
• Patients/Families/Intruders
• Domestic Partners

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Types of Violence

• Verbal
• Non-verbal
• Physical

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Verbal Violence

• Verbal threats
• Offensive jokes
• Public humiliation
• Use of sarcasm
• Ridicule

• Stalking
• Sexual innuendos
• Offender may say its just a joke
• May blame the victim as having no sense of
  humor

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Non-verbal

• Stalking offender may not directly say anything
  to the victim
• Shaking the head, rolling the eyes when victim
  speaks/acts
• Obscene gestures
• Intimidation

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Physical

• Simple assault
• Battery
• Aggravated assault
• Using a weapon
• Rape
• Murder

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Six-Steps of Escalating Aggression

• Step I Calm nonthreatening
• Step 2 Verbally agitated but anger is not
  directed to specific persons
• Step 3 Verbally hostile agitated oblivious of
  efforts to calm him
• Step 4 Verbally threatening, focused on specific
  people making demands
• Step 5 Physically threatening
• Step 6 Physical violence
• Steve Wilder, Security Consultant with Sorenson,
  Wilder Associates

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Risk Factors for Violence

• ? Handguns other weapons among Pts, visitors
• Use of hospitals by criminal justice system for
  criminal holds, care of acutely violent
  individuals
• ? acute chronic mentally ill Pts released
  without follow-up care
• Availability of drugs money within the facility
• Unrestricted movement of the public within
  facility long waits in ED or clinics

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Risk Factors for Violence (Contd)

• ? gang members, substance abusers, trauma Pts
  distraught family members
• ? staffing levels during times of increased
  activity (mealtime, visiting hours, when staff
  are transporting Pts, etc.)
• Isolated work with patients during exams tx
• Solo work in remote locations without a way to
  communicate (alarm systems, communication
  devices)
• Lack of staff training in recognizing managing
  escalating behavior
• Poorly lit parking areas

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Impact of Violence

• Minor physical injuries
• Serious physical injuries/death
• Temporary or permanent physical disability
• Can decrease productivity sense of well-being
• Emotional distress anxiety, increased stress

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Impact of Violence (Contd)

• Low worker morale
• Increased worker turnover (increased costs to
  replace)
• Reduced trust in management co-workers
• Hostile working environment
• Community mistrust

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Perpetrator Characteristics

• Violent behavior Hx (Biggest predictor of
  violence)
• Psychosis Dx
• Substance abuse disorders (Alcohol, illegal
  drugs)
• Dementia
• Involved in highly emotional situations (trauma
  victims, sudden death, long waits)
• Anger management issues
• Appears tense angry
• Challenges authority
• Talks complains loudly, uses profanity, or
  makes sexual comments

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Victim Characteristics

• Untrained in de-escalation techniques
• Inexperienced staff
• Belief that violence/assaults are part of the job
• Ignore behavioral cues/signs
• Show indifference or hostility to
  patients/visitors, colleagues
• Domestic abuse victims (patients employees)
• Victims of stalking (patients employees)

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Prevention is Required/Encouraged

• Centers for Medicare and Medicaid (CMS)
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)
• Occupational Safety and Health Administration
  (OSHA)
• Centers for Disease Prevention and Promotion
  (CDC)
• National Institute for Occupational Safety and
  Health (NIOSH)

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CMS

• Facilities must comply with the CoP
• Hospitals long-term care facilities must
  provide a safe environment
• CoP interpreted by CMS to include the prevention
  of patients from harming themselves or others
• CMS has imposed civil monetary penalties (CMP) on
  long-term care facilities for failing to prevent
  patients with known violent tendencies from
  harming other residents healthcare workers

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JCAHO

• No standards explicitly pertain to patient
  violence
• Many standards require actions or plans that will
  result in violence reduction
• Environment of Care
• Intent of this section clearly supports violence
  prevention
• Requires written security management plan
  (addressing all forms of workplace violence
  prevention)
• Facility must identify steps needed to identify
  respond to potentially violent patients
  situations

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OSHA

• No federal regulations pertaining to any form of
  workplace violence
• 1998 issued voluntary program for healthcare
  facilities (revised 2004)
• Since 2003 OSHA has cited facilities under its
  general duty clause for failure to prevent
  patient violence against healthcare workers
• Emphasized management commitment employee
  involvement in developing enforcing a violence
  prevention program

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CDC/NIOSH

• Conduct research re violence in the workplace
• Healthcare settings ARE different from other
  workplaces
• Make recommendations as a result of research
• Encourage
• Hazard identification by hospitals
• Hazard prevention
• Safety health training
• Controlling hazards
• Reporting

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Court Cases

• As a general rule for facility liability is the
  foreseeability of the attack the reasonableness
  of the facilitys attempts to prevent it.
• Univ of Kentucky v. Hammock (Kentucky 1907)
• First case of hosp liability for pt-on-pt assault

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Court Cases (Contd)

• Delk v. Columbia/HCA Healthcare Corp (Virginia
  2000)
• Generally there is no duty to protect someone
  from a third party. However
• Special relationship of Pt with healthcare
  providers does impose a duty to protect the Pt
  from harm

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Court Cases (Contd)

• Young v. Huntsville Hospital (Alabama 1992)
• Trespasser assaulted a Pt
• Hosp did not enforce posted visiting hours
• Individuals roaming the hosp at odd hours were
  not recognized as potential threats to Pt safety
• Sumblin v. Craven County Hosp Corp (South
  Carolina 1987)
• Appeals court found no special skill was required
  to protect a Pt the nurses failed to act as a
  reasonably prudent person would

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Questions?Discussion?
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Management Employee Solutions

• Mary Sue Hamilton RN, MSN, ARM, CPHRM
• Senior Risk Management Consultant

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Why Do People Become Violent?
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Why do People Become Violent (Cont)

• They want something!
• Negotiation, give options, viable alternatives
• Communication
• De-escalation is convincing the person that he
  cannot get what he wants through violence.

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Employee Personal Prevention of Violence

• Attitude Friendly, listening
• Respond promptly
• Help persons feel as comfortable as possible
• Clothing Accessories
• Dont wear restrictive clothing
• Earrings, necklaces, stethoscopes, watches,
  neckties can become weapons
• Be physically fit
• Need to be able to react quickly with strength
  stamina

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Administrative Controls

• Commitment from administration, resources
• Zero tolerance policy statement
• Violence of any type, which can range from
  intimidation, threats, harassment to assault,
  rape and even homicide, will not be tolerated.
  Any and all violators of this policy, no matter
  what position they occupy on the organizational
  chart or within the community, will be dealt with
  in a swift, judicious and definitive manner
• Workplace violence damages trust, community, and
  sense of security every employee has a right to
  feel while on the job

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Administrative Controls (Cont)

• System for employees to report assaults and
  threats
• Establish trained response teams
• Identify those patients/families with a history
  of violence
• Put flag in your computer system

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Multidisciplinary Safety Committee/Team

• Develop a work place violence program
• Focus on identification of risks and problem
  solving
• Address patient, visitor, employee issues
• Information must be shared
• Tightening of security, a heightened awareness
  may create uneasiness within the organization.
  People may feel more vulnerable. Never talked
  about before.

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Worksite Analysis

• Analyze community violence trends
• Local law enforcement communication
• Examine Workers Comp and event reports
• Ask questions
• Periodic surveys of employees
• Analysis of staff perceptions

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Facility Assessment

• Unobserved doors, hallways
• Isolated work areas
• Adequate lighting
• Inside outside
• Unrestricted areas where unauthorized persons may
  gain access
• Ambulance entrances

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Facility Assessment (Cont)

• Appropriate locks on doors windows
• Adequate, clearly identified escape routes
• Waiting areas
• Restrooms, vending machines, phones, comfort,
  distractions
• ED waiting area consideration for bored children
  anxious parents

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Engineering Controls

• Access control
• Outside entrances
• Entrances into inside areas of hospital
• Pharmacy
• Alarms, panic buttons
• Convenient, easy to reach
• Unobtrusive
• Can be activated without notice by aggressor
• Where do they alarm? Staffed unit, police
  station?
• Closed circuit surveillance
• Most effective in infrequently traveled areas

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Engineering Controls (Cont)

• Communication Devices
• Walkie talkies for security
• Cell phones
• Locator devices with emergency call feature
• Barriers
• Unbreakable safety glass or acrylic
• Deep counters
• Mounted mirrors
• Blind corners
• Arrangement of furniture so exit accessible

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Reporting of Violence, Threats

• A system for employees to inform management about
  security hazards or threats of violence. For all
  types of violent incidents, whether or not
  physical injury occurred
• Consider confidentiality
• Employees should not fear retaliation
• Employees being stalked, threatened
• Sexual harassment
• We will not discriminate against victims of
  workplace violence
• Violence log
• Record all threats incidents, alert local law
  enforcement

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Training Education

• Standard response action plan
• Drills
• Recognition of escalating behavior
• Confusion
• Frustration
• Blame
• Anger
• Hostility
• Ways to defuse hostile or threatening situations

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Training Education (Cont)

• Ways to summon assistance
• Sensitivity to racial ethnic issues
• Personal protection
• Routes of escape
• Notification of law enforcement when a criminal
  act may have occurred
• Post event trauma counseling

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Crisis Intervention Training

• One study concluded that serious assault is
  negatively related to amount of training received
  by staff (Rosenthal TL, 1992)
• Nurses with no training were three times more
  likely to face events of deadly violence
• When dealing with agitated patients, poorly
  trained staff may add fuel to the fire
• May try to control the situation using harsh or
  rigid means
• People may respond with counter aggression

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Verbal De-escalation

• Soften your tone
• Take a time out
• Acknowledge the other persons point of view
• Agreement is not necessary
• Avoid defensive or hostile body language
• Rolling eyes, crossing arms, tapping foot
• Focus on how you can get what the aggressor wants
• Reduce stimulation in the environment
• NOTE Verbally you cannot reach some pts with
  dementia psychosis

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What NOT to Say

• 1. Do NOT challenge person
• 2. Do NOT insult person
• 3. Do NOT deny what is happening
• These three actions will provoke attacks

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The DO List

• Demonstrate self confidence
• 2. Stay calm relaxed
• 3. Keep voice pitch/volume down
• 4. Listen
• 5. Offer honest options

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The DO List (Cont)

• 6. Maintain safe personal distance
• Dont invade personal space
• Stay on weak side of person (93 are right
  handed)
• Stand with one foot in front of other
• 7. Keep open access to a door
• 8. Keep eye contact, but dont stare down
• 9. Monitor the environment
• 10. Address the aggressor by name

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Violent Employees

• Front end precautions
• Reference checks (frequent job changes)
• Criminal background checks
• Pre-employment interview
• Defensive, blaming others
• Educate employees to be alert to signs of
  potential violence in their co-workers
• Overreactions
• Threats
• Excessive absenteeism
• Paranoia

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Violent Employee (Cont)

• Management techniques
• Often because of actual or perceived unfairness
  by management
• Follow policies work rules consistently
  fairly
• Review work performance objectively
• Address issues with sensitivity but make sure
  employees know threats or violence will not be
  tolerated
• Reassignment, discipline
• Have a plan when termination of problem
  employee occurs or mass layoffs are announced

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Domestic Violence Stalking in the Workplace

• If comes through the workplace door, becomes
  employers concern
• Frightening disruptive for victim co-workers
• What is an employer to do?
• Terminate Easiest but brings up ethical legal
  questions
• Assist support victim
• Environment of trust respect
• Training awareness programs
• Employee Assistance Program
• Change hours or place of work, buddy system
• Take steps to keep the abuser out of the
  workplace

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Potentially Violent Patients

• Instability
• Excessive restlessness agitation
• Tension anger
• Loud profane speech
• Argumentative, defiant, threatening
• Diagnostic cues
• Intoxication
• Drug seeking behavior
• Central nervous system disorders
• Anoxia (COPD, emphysema)
• Large of visitors
• Grieving (In some cultures, initial reaction is
  extreme anger)

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Home Health Security for Employees

• Confirm by phone before you visit
• Make sure you have detailed directions to a new
  clients home
• Keep your car in good working order gas tank
  full
• Keep car windows closed car doors locked
• Lock bag other valuables in the trunk
• Have an extra set of keys in case you lock yours
  in the car
• Make sure someone knows where you are at all
  times
• Have a method to check in between visits
• Dont touch the animalsrequest they be removed
  before you come
• Trust your instinctsdont put yourself at risk
• Do not enter a location where you feel unsafe or
  threatened

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Emergency Department

• Risk Issues
• Persons under stress, anxiety
• May come into ED with weapons
• Long waits, impatience can turn into hostility
• Easy access
• Decreased staffing during night time hours
• Patients leaving under the influence
• Hostage situations

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Questions?Discussion
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Jousting In The Medical Workplace

• Robert S. Thompson RT, JD, CPHRM
• Senior Vice President-Risk Management
• Associate In-House Counsel

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Jousting-What Is It?

• Criticizing the care of other providers
• Finger-pointing
• Ego-Building
• Revenge taking
• Outright deceit

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Malpractice Crisis Environment

• Increased media coverage
• Increased public awareness
• Healthcare in national spotlight
• Concern about litigation sharply increased
• Response to try to shift blame

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Current Issues Related to Jousting

• Lack of cooperation among providers
• Active encouragement of potential claims
• Quick to criticize others
• Willingness to testify against colleagues
• Diminishing cohesion in medical community

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Jousting A Malpractice Trigger

• Implies you disapprove of care
• Patient concerns validated/heightened
• Plants a seed that negligence occurred
• Patient may not relay all the facts, so the joust
  is often built on faulty grounds

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Significant Factors Causing Claims

• Malpractice
• Physician-Patient Communication
• Communication among healthcare team
• System Failures
• Documentation
• Informed Consent

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Why Patients Sue Physicians
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Communication Among Healthcare Team - Jousting

• Intentional
• Unintentional
• Nonverbal
• Verbal
• Written

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Intentional Jousting

• Most destructive form
• Ego or spite based
• Easiest to avoid
• Biggest malpractice liability
• Absolutely inexcusable

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Intentional Jousting

• Dr. Jones was called repeatedly and, as usual,
  he ignored every page.
• Despite the best efforts of nursing staff, the
  patient survived. Barely.

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Unintentional Jousting

• Most common form of jousting
• May be difficult to avoid
• Provider must be cognizant of comments
• Creates patient doubt
• Interferes with the trust relationship

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Unintentional Jousting

• Why did he take you off your Coumadin?
• Who did this to you?
• She couldnt have prescribed that for you if
  taken with your heart medication, it could kill
  you!

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Jousting Nonverbal

• Raising eyebrows
• Shaking head
• Acting surprised

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Verbal Jousting

• Do you think for once you could get a dressing
  on straight?
• Have you ever actually worked on a human
  before? (RN to Resident)
• I asked for pain medicine hours ago! Nurse
  Smith isnt finished with her game of solitaire
  yet.

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Written Jousting

• Difficult to deny
• Easy to blow up on a big screen at trial

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Written Jousting

• I never felt this patient was stable enough to
  transfer, and his arrest and subsequent death in
  the ambulance proves me right!
• Nurse reprimanded for error.

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Jousting is Contagious

• Newer physicians hear it--believe it to be
  acceptable behavior
• Physicians begin to retaliate against criticizers
• Charting entries escalate into angry retorts

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Jousting is Abusive

• Jousting is a common form of medical workplace
  abuse
• Medical workplace abuse is tolerated from high
  producers
• Abuse has been accepted as normal over time
• Physicians to nurses
• Attending physicians to residents
• Staff to patients

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Jousting and Malpractice

• Increases medical malpractice risk exposure
• Claims more likely for abusive physicians
• Abused staff may give harsh testimony
• Jousters may end up on the other side

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What to do about Jousting

• DONT DO IT!

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Ending the Jousting Cycle

• Recognize jousting does occur in your facility
• Identify and hold staff and physicians
  accountable for jousting activity
• Ensure reporting of all jousting activity to risk
  management

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Ending the Jousting Cycle

• Institute clear policies of zero-tolerance for
  abusive behavior
• Involve hospital and physician leadership
• Initiate cooperation and cohesiveness within the
  medical community as a whole

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Ending the Jousting Cycle

• Ignoring the problem will not make it stop
• Identify any issues among providers yours and
  others
• Develop policies against jousting
• Audit charts notes and monitor for inappropriate
  entries

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Appropriate Jousting

• Above all be OBJECTIVE
• Patients are known to have selective recollection
  
• Dont be afraid to contact other providers or
  facilities
• Honesty is the best policy
• Avoid CYA and finger-pointing

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Jousting in The Medical Workplace

• Questions???