Nurses and Workplace Violence

1
Nurses andWorkplace Violence

• By
• Michele M. Valentino, MSN,CNS, BC, NP

2
Objectives

• Identify scope of WPV in the health care settings
  
• Identify the role of professional nursing
  organizations
• Describe violence in psychiatric, ED Homecare
  settings
• Interventions for reducing WPV
• Recommendations for reducing WPV

3
SCOPE of the Problem

• Violence is pervasive in our world!!!!!
• Smoyak Blair wrote in 1992 that violence was
  epidemic with US Dept. of Justice statistics on
  violence increasing each year.
• 2002 US Dept. of Labor reported nearly 2 million
  acts of nonfatal work-related violent acts
  annually.
• 2006 ICN reported that occupational violence is a
  major worldwide public health problem

4
Scope

• Work-related violence is the 3rd leading cause of
  occupational injury fatality in the US
• 2nd leading cause of death for women at work
• 10 yr study of rape in the workplace in
  Washington State found 11 of victims were health
  care workers in hospitals or other care
  facilities.
• 2007 Hatch-Maillette found 63 of sample reported
  sexual threat 84 reported a past incident of
  physical or sexual assault

5
Scope

• According to the Department of Justice (Myers,
  1996), nurses are identified as the occupation
• experiencing the greatest number of assaults
  by a client, patient, or student served by the
  facility.
• These results were further validated by the
  Occupational Safety and Health Administration
• (Trape, 1998) stating more assaults occur to
  health care and social services industries than
  any other, with nurses experiencing the most
  assaults.

6
Scope

• In addition, mental health professionals
  experience assault robbery at the alarming rate
  of 79.5 (Lanza Campbell, 1991).
• Workplace violence has been linked to decreased
  job performance and job satisfaction, as well as
  increased absenteeism and mental health issues
• among doctors, nurses, and other health care
  professionals (Bartholomew, 2006).

7
Scope

• Nurses are exposed to, or are victims of, various
  types of abuse from sources that include
  patients, visitors, other nurses, physicians, or
  others in the work environments.
• As the incidence and severity of workplace
  violence rises in all areas, the issue becomes of
  significant concern in healthcare settings
  (Jackson, Clare, Mannix, 2000).
• Over 2 million workers are victims of harassment,
  threats, or assault each year

8
Scope

• the actual scope of workplace violence is
  difficult to capture since more than 50-80 of
  acts may go unreported (Gates, 2004, Lanza
  Campbell, 1991, Gates, Ross McQueen, 2006).

9
Background

• Violence in the workplace is one of the most
  dangerous hazards facing nurses (McPhaul and
  Lipscomb, 2004).
• Violence against all health care workers presents
  a special challenge. Nurses experience the most
  assaults.
• (U.S. Department of Justice Federal Bureau of
  Investigation 2004, 54) of health care workers.
• In 1999, 2,637 nonfatal assaults on hospital
  workers occurred in the following settings
• Hospitals rate of 8.3 assaults/10,000
  workers
• Private sector industries 2
  assaults/10,000
• workers (Centers for Disease Control
  and
• Prevention/NIOSH, 2002, 1)

10
Hospitals

• Canadian Study (Hesketh et al., 2003)
• Emergency Nurses
• 39.9 percent were threatened with assault
• 21.9 percent were physically assaulted
• Medical Surgical Nurses
• 22.6 percent were threatened with assault
• 24.2 percent were physically assaulted
• Psychiatry Nurses
• 20.3 percent were threatened with assault
• 43.3 percent were physically assaulted

11
Hospitals

• Florida Study (May and Grubbs, 2002)
• Emergency Nurses
• 100 percent were verbally assaulted
• 82 percent were physically assaulted
• ICU Nurses
• 85.2 percent were verbally assaulted
• 77.8 percent were physically assaulted
• Floor Nurses
• 80.6 percent were verbally assaulted
• 63.3 percent were physically assaulted

12
References

• Centers for Disease Control and Prevention/NIOSH.
  2002. Violence Occupational Hazards in
  Hospitals. CDC National Institute for
  Occupational Safety and Health, No. 2002-101.
  Retrieved February 16, 2006, from
  www.cdc.gov/niosh/2002-101.html.
• Hesketh, K., S. M. Duncan, C. A. Estabroks, et
  al. 2003. Workplace violence in Alberta and
  British Columbia hospitals. Health Policy 63
  311.321.
• May, D., and L. Grubbs. 2002. The extent, nature,
  and precipitating factors of nurse assault among
  three groups of registered nurses in a regional
  medical center. Journal of Emergency Nursing
  28(1) 11.17.
• McPhaul, K., J. Lipscomb. 2004. Workplace
  Violence in Health Care Recognized but Not
  Regulated. Online
• Journal of Issues in Nursing 9 (3) Manuscript 6.
  Retrieved February 16, 2006, from
  www.nursingworld.org/
• ojin/topic25/tpc25_6.htm.
• U.S. Department of Justice Federal Bureau of
  Investigation. 2004. Workplace Violence Issues
  in
• Response. Retrieved February 16, 2006, from
  www.fbi.gov/page2/march04/violence030104.htm.

13
Incidence

• Bureau of Justice workplace assaults injure 1.7
  million workers (2001)
• Health care social service industries are 2nd
  only to law enforcement for WPV (2003)
• Nearly 500,000 nurses become victims of violence
  in workplace annually.
• Nurses are 3 X more likely to be victims of
  violence than any other professional group

14
Incidence

• Nursing Management 2008 1400 respondents 74
  experienced some form of violence in the
  workplace (Hader, 2008). Included US 17 other
  countries.
• 51-75 were bullying, intimidation harassment.
  
• 26 physical violence
• Weapons 5.6 to 7.5
• Perpetrators 53/2 patients, 52 colleagues,
  49 physicians, visitors 47, other health care
  workers (37.7)

15
Incidence

• Joint Commission found that more than 50 of
  nurses reported verbal abuse ( AACCN, 2005)
• Survey of 303 nurses, 53 reported being bullied
  at work(Vessey, Demarco, Gaffney Budin, in
  press)

16
Attention to WPV

• ICN, AAN, ANA have advocated for increased
  protective regulations research to study
  effective risk management programs.
• The Center for American Nurses has issued a
  statement on WPV a position statement on
  Bullying Horizontal Violence.

17
Attention to WPV

• AORN 2003 2007
• Am. Assoc. of Critical-Care Nurses (2004)
• National Student Nurses Assoc 2006
• Code of Ethics for nurses ( ANA 2001)
• Joint Commission 2007
• APNA Position Statement (Oct. 2008)

18
OHIO NURSES ASSOCIATION (ONA)

• SCDONA (Stark-Carroll District of ONA) wrote a
  reference item for convention in 2007 concerning
  WPV
• ONA requested that SCDONA write submit a
  position statement on WPV
• adopted by ONA in 2008

19
Position Statement on WPVNursing Practice
Statement NP 83

• Developed 2007 Revised
• The American Nurses Associations Code of Ethics
  for Nurses states, in part
• The nurse, in all professional relationships,
  practices with compassion
• and respect for the inherent dignity, worth, and
  uniqueness of every
• individual, unrestricted by considerations of
  social or economic status,
• personal attributes, or the nature of health
  problems.
• The nurses primary commitment is to the patient,
  whether an individual,
• family, group, or community.
• The nurse promotes, advocates for, and strives to
  protect the health,
• safety, and rights of the patient.
• The nurse owes the same duties to self as to
  other, including the responsibility
• to preserve integrity and safety, to maintain
  competence, and to continue
• personal and professional growth.
• The nurse participates in establishing,
  maintaining, and improving health
• care environments and conditions of employment
  conducive to the
• provision of quality health care and consistent
  with the values of the
• profession through individual and collective
  action.
• The profession of nursing, as represented by
  associations and their members,
• is responsible for articulating nursing values,
  for maintaining the integrity of

20
American Nurses Associations Bill of Rights for
Registered Nurses

• Nurses have the right to practice in a manner
  that fulfills their obligations to society and to
  those who receive nursing care.
• Nurses have the right to freely and openly
  advocate for themselves and their patients,
  without fear of retribution.
• Nurses have the right to a work environment that
  is safe for themselves and their patients

21
Workplace Violence

• One of ONA's goals is to prevent violence in the
  workplace, and ONA supports the following
  objectives
• Pursuit and support of legislation making
  the assault of any nurse a felony offence,
  punishable as determined by law
• Development of programs to support nurses
  who report assaults and assistance with the
  process
• Development of workplace standards through
  OSHA, OHA, and the Ohio Department of Health,
  and
• Development of materials to educate nurses
  to their rights and legal remedies.

22
Workplace Violence Information Resources

• ONA's Nursing Practice Statement on Workplace
  Violence (Members Only)
•  
• Behaviors that Undermine a Culture of
  Safety (Joint Commission Sentinel Event)
•  
• The Center for American Nurses Position Statement
  on Lateral Violence and Bullying in Nursing Work
  Environments
•  
• Guidelines for Preventing Workplace violence for
  Health Care Social Services Workers
•  
• Violence Against Nurses The Silent
  Epidemic (Independent Study)
•  
• NIOSH Occupational Hazards in Hospitals Exposure
  to Stress

23
Resources

• OSHA (2002) has information on preventing and
  controlling workplace violence in a fact sheet on
  workplace violence, available at
  http//www.osha.gov/OshDoc/data_General_Facts/fact
  sheetworkplace-violence.pdf. OSHA guarantees all
  workers a safe healthful workplace.
• Employers must provide a safe workplace using
  written policies, employee training, proper
  staffing, and follow-up of any incidents.

24
Resources

• The Center for American Nurses (Carroll, 2003)
  has a two page print-out on their website
  http//www.centerforamericannurses.org entitled
  Guidelines for Preventing Workplace Violence for
  Health Care and Social Service Workers. The four
  main components are
• 1. Management commitment and employee
  
• involvement
• 2. Workplace analysis
• 3. Hazard prevention and control
• 4. Safety and health training

25
Resources

• The American Nurses Associations has a bulleted
  brochure that they allow the Constituent Member
  Associations to print with their logo. It is
  titled Workplace Violence, Can You Close the
  Door on It? (ONA, 1996). It includes information
  on Know your Patients, Steps to a Safer Work
  Place, and Addressing Workplace Violence.

26
Related Files

• Workplace Violence Data Collection Form (Adobe
  PDF File)Preventing Workplace Violence Brochure
  (Adobe PDF File)Workplace Violence in the Health
  Care Setting (Adobe PDF File)Occupational
  Hazards in Hospitals (Adobe PDF File)Nurses and
  Workplace Violence Fact Sheet (Adobe PDF
  File)NIOSH Occupational Hazards in Hospitals
  Exposure to Stress (Adobe PDF File)The Center's
  Position Statement on Lateral Violence and
  Bullying (Adobe PDF File)

27
APNA Task Force on WPV

• 2007 survey by APNA, Safety was one of the top
  issues for front line providers
• I was honored to chair this task force May 2007
• Call to members Response of 150 persons
• 25 members selected for steering committee
• Expert Consultant Panel
• 3 areas Psychiatric (inpatient, outpatient,
• forensic, state-funded), other health
  care
• settings (EDs and homecare), schools
  and
• universities.

28
APNA Task Force on WPV

• ROL from 1970 to 1990 most articles described
  characteristics of units where violence occurred
  described staff response to assault.
• Pressing need for research describing successful
  violence prevention interventions

29
APNA Task Force on WPV

• ROL using key words of psychiatric, nursing,
  violence in the data bases in CINAHL, PsycINFO,
  and Academic Search Premier.

30
What is Horizontal Violence (HV)?

• Bullying is repetitive horizontal or lateral
  violence and it can be detrimental to a persons
  physical or mental well-being
• 
  ( Center for Am. Nurses)
• DISRUPTIVE BEHAVIOR behavior that interferes
  with effective communication among healthcare
  providers and negatively impacts performance
  outcomes. Bullying is repetitive horizontal or
  lateral violence and it can be detrimental to a
  persons physical or mental well-being
• 
  ( Center for Am. Nurses)

31
Bullying
32
Horizontal Violence

• Now receiving more attention
• JAHCO addresses disruptive behavior
• (July 9, 2008)
• JAHCO uses the term zero tolerance

33
Horizontal Violence

• Horizontal Violence, a term used to identify
  violence that occurs between peers, is seen when
  nurses bully their coworkers.
• Behaviors exhibited with horizontal violence may
  include criticizing, sabotaging, undermining,
  infighting, blaming, scapegoating, intimidation
  and bickering.

34
Horizontal Violence

• The 10 most frequent forms of horizontal violence
  are nonverbal innuendo, verbal affront,
  undermining activities, withholding information,
  sabotage, infighting scapegoating,
  backbiting,failure to respect privacy, and broken
  confidences (Griffin, 2004).

35
Examples of bullying behaviors(Hastie,
2002Workplace Bullying Institute, 2003)

• Being accused of errors made by someone else
• Nonverbal intimidation, included being stared at
  or glared at
• Being belittled
• Having thoughts or feelings ignored
• Being excluded from activities
• or conversations

36
Who is the Bully?
Colleague? Supervisor?
Physician?
37
Horizontal Violence

• Use of cue cards scripting for responses
• Educate nurses students about it
• Create an infrastructure to support managers and
  staff
• Assertiveness training
• Appraisal of risky situations
• Communication skills Training

38
Interventions

• Nsg Curriculum to include
• awareness-raising empowering strategies
• Educate Nurses emphasizing non-hierarchical
  leadership supportive relationships.

39
The cycle of Violence

• Each of us tolerates the behaviors of others a
  bit differently. However, if the behavior is
  offensive to you, or undermines you and your job
  in any way, it needs to be reported to your
  manager.
• Speaking up is difficult, especially if one has
  to face the bully everyday in the work
  environment. Fear of retaliation from the
  perpetrator.

40
Intimidation
41
Remember the Bully
42
Complications of WPV
43
Develop a New Culture in Nursing

• To gain self-confidence, nurses need to
  articulate clearly confidently their common
  vision of nursing and its future
• (Buresh Gordon
  2000)
• Nurses must PAY IT FORWARD praise each
  other for jobs well done
• VALUE each other the work of others
• New staff need mentored in a kind, nurturing
  manner

44
Create A New Culture in Nursing

• Mentor new hires and new grads
• Appreciate diverse points of views
• Value the differences in colleagues from various
  generations. It is not a burden it is an
  advantage.

45
Creating a New Culture in Nursing

• Express pride in being a nurse
• Accept and celebrate compliments about good
  patient care
• Actively compliment others for work well done
• Look for and acknowledge improvements to the
  system
• Be an ambassador to those outside the profession
  about the true contribution nurses make to
  quality patient care.

46
Interventions for Horizontal Violence

• Gain control
• Get help from your employer
• Make a plan for action
• Take action
• Confront the aggressor
• Make a formal written complaint
• Take legal action

47
Be Savvy if necessary

• Solicit support from family friends
• Consult an outside physician or therapist
• Solicit witness statements
• Confront the bully
• File the internal complaint
• Preparing of the case against the bully
• Rule of 2meeting presenting your case
• Taking your case public

48
Interventions for Horizontal Violence

• Replace your own internalized misperception with
  a belief that we are gifted, dedicated and highly
  skilled professionals who have struggled against
  great odds
• Resist messages from coworkers or superiors that
  denigrate your professionalism or that of the
  nursing profession
• Be a supportive colleague

49
Interventions with Horizontal Violence

• Direct concerns about workplace negativity
  clearly and concisely to appropriate individuals.
  
• Develop an understanding that rocking the boat
  can be the first step in the service of positive
  change.
• Start confronting problems, not people

50
Interventions for Horizontal Violence

• Support, insight, and connection can help nurses
  change the cycle that impinges their own
  empowerment .
• Develop a positive personal and professional
  identity
• Develop Assertive Behaviors

51
Develop self-Assertive Behaviors

• Practice physical cues that confirm confidence
  and help regain control of the situation, i.e.
• ensuring facial expressions correspond with
  
• message
• learn to ignore distractions
• listen effectively to the other
• understanding the other persons message
• before responding
• stand straight
• use good eye contact
• use relaxed natural gestures
• Use level, well-modulated voice
• Speak clearly

52
Self-Assertive Behaviors

• Avoid reciprocating with aggressive behavior
• Handle situations diplomatically using active
  listening skills.
• Inform the abuser of his/her feelings
• Let the abuser know that the abuse will not be
  tolerated
• Say NO and use I statements.

53
Self-Assertive Behaviors

• I did not appreciate the language you used
  today, Please do not use it again.
• State what behavior is unacceptable

54

• Assertiveness is not about throwing your weight
  around. Its about articulating your thoughts,
  feelings, and opinions in a clear, honest, and
  straightforward manner.

55
Create a New Culture in Nursing

• Defuse intense anger
• Resolve to release anger
• Consult an expert if conflict is festering in the
  workplace
• Exhibit care and compassion for your colleagues
• Compliment rather than complain
• Cultivate team spirit

56
Obstacles to Reporting

• Inurnment due to chronic protected exposure to
  violent individuals
• Underreporting
• Few effective regulations
• Attitude perception that Violence is just part
  of the job
• 32 of assaulted employees and 8 who
  experienced nonphysical violence reported that
  violence was part of the job.

57
Obstacles to reporting

• Peer pressure not to report ( lANZA, 1988)
• Ambiguity in defining violence ( Lanza, 1988)
• Excusing the behavior of ill patients (Mayhew,
  2000)
• Organizational culture, including onus on the
  victim to be proactive make the complaint the
  employers belief that it would be too costly to
  institute protective measures for the staff

58
Obstacles

• Stigma of victimization, including embarrassment,
  shame, isolation, fear of judgment
• Fear of job loss
• Fear of blame of provoking the assault or being
  negligent
• Victims self-blame
• Time-consuming, ineffective, or gender-biased
  reporting mechanisms

59
Obstacles

• No benefit, either personal or organizational, of
  reporting
• Unhelpful experience with prior reporting

60
Obstacles to reporting

• Typically, acts of physical violence that do not
  result in injury or are nonphysical are not
  reported (Findorff, McGovern Sinclair, 2005)
• 43 of physical violence 61 of nonphysical
  violence was unreported.
• Estimated that 1 in 5 violent events in
  psychiatric settings are reported (Mayhew, 2000)

61
Types of WPV

• Physical
• Sexual
• Verbal
• Horizontal violence
• stalking

62
Difficulty with Definitions

• Inconsistent definitions
• Suggest use of Typology of WPV by NIOSH
• 2006)

63
Table 1. Typology of workplace violence Type
Description

• I Criminal intent The perpetrator has no
  legitimate relationship to the business or its
  employee, and is usually committing a crime in
  conjunction with the violence. These crimes can
  include robbery, shoplifting, trespassing, and
  terrorism. The vast majority of workplace
  homicides (85) fall into this category.
• II Customer/client The perpetrator has a
  legitimate relationship with the business and
  becomes violent while being served by the
  business. This category includes customers,
  clients, patients, students, inmates, and any
  other group for which the business provides
  services. It is believed that a large portion of
  customer/client incidents occur in the health
  care industry, in settings such as nursing homes
  or psychiatric facilities the victims are often
  patient caregivers. Police officers, prison
  staff, flight attendants, and teachers are some
  other examples of workers who may be exposed to
  this kind of workplace violence, which accounts
  for approximately 3 of all workplace homicides.
  
• III Worker-on-worker The perpetrator is an
  employee or past employee of the business who
  attacks or threatens another employee(s) or past
  employee(s) in the workplace. Worker-on-worker
  fatalities account for approximately 7 of all
  workplace homicides.
• IV Personal relationship The perpetrator
  usually does not have a relationship with the
  business but has a personal relationship with the
  intended victim. This category includes victims
  of domestic violence assaulted or threatened
  while at work, and accounts for about 5 of all
  workplace homicides.
• Note From NIOSH, 2006.

64
Consequences of Violence

• About ½ of assaulted staff have minor injuries (
  Hunter Carmel, 1992.
• Emotional consequences (anxiety, depression,
  insomnia, burnout exhaustion, etc.)
• Bullying is associated with fear, demoralization,
  HTN, panic attacks, low morale, negative
  relationships at work.
• PTSD, depression
• Can lead to suicide
• Burn-out leaving the nursing profession

65
Financial Costs

• NIOSH reported employees lost 160 days due to
  patient violence (2002)
• Pres. Of the Federal Nurses Assoc. estimates cost
  of violence at 4.3 million annually or 250,000
  per incident, excluding emotional
• Costs include increased staff turnover,
  recruitment, retention costs
• Increased staff absence from work

66
Financial Costs

• Reduced efficiency performance at work
• Reduced staff morale
• Higher incidence of pt. complaints
• Falling reputation for the organization.

67
Overview of Psychiatric Settings

• mental health professionals experience assault
  robbery at the alarming rate of 79.5 (Lanza
  Campbell, 1991).
• Workplace violence has been linked to decreased
  job performance and job satisfaction, as well as
  increased absenteeism and mental health
  issuesamong doctors, nurses, and other health
  care professionals (Bartholomew, 2006).

68
Overview of ED

• Nurses working in emergency rooms (Lyneham, 2000)
  and in services for the elderly (Gates,Fitzwater
  Meyers 1999) are at high risk for interacting
  with violent patients.
• The potential for violence may stem from
  frustration of waiting time for appointments and
  patient clinical characteristics, such as
  intoxication and dementia (McKenna, 2003).
• Length of wait time in Emergency Departments
  should be kept to a minimum.

69
WPV in ED

• Position Paper to be on APNA website soon
• www.apna.org

70
Overview of Homecare

• To be released soon on APNA website
• www. Apna.org

71
Colleges Universities

• Position Paper will be on www.apna.org website
  soon

72
Interventions to decrease WPV

• Every health care organization should have a
  comprehensive plan for WPV including horizontal
  violence.
• Survey staff attitudes about intimidation
  lateral violence.
• Create a code of conduct have staff sign the
  code at hire annually
• Hold frank discussions about WPV
• Establish a standard, assertive communication
  process

73
Interventions

• Create a conflict resolution process stated in a
  professionalism policy include a chain of
  command for resolution
• Encourage 1-on-1 conflict resolution provide a
  mechanism for confidential reporting
• Enforce a zero tolerance policy (full punishment
  for an infraction) (Hader, 2008 Joint
  Commission, 2008).

74
Interventions

• Provide ongoing education to reinforce the
  organizations commitment to ensuring a caring
  respectful environment
• Lead by example reward outstanding role
  models(Schaffner, Stanley, Hough, 2006).
• Utilize a screening risk assessment tool in
  combination with traditional clinical assessment
  techniques for violence risk. (Otto,2008).

75
Recommendations for Nurses
76
Recommendations for Nurses

• Develop healthy nurse-client relationships
• Use structured assessment tools with traditional
  assessment techniques to identify risks.
• Recognize factors that may predispose patients to
  becoming violent including
• -history of violence, especially recent
• -head injuries, CVA, organic or clinical
  
• brain
  injury
• -hypoxia

77
Recommendations for Nurses

• -endocrine disorders hypoglycemia or
• 
  hyper
• -seizures
• -psychotic disorders
• -hs of PTSD
• -S.E. of prescribed medication
• -intoxication or drug OD, or drug or ETOH
  
• withdrawal
• - dementia or senility
• - disorders of childhood adolescence

78
Recommendations for Organizations

• Implement preventive measures based on training
  educational programs
• Examine incidents of violence in the workplace to
  Identify underlying causes impact on
  individuals
• Establish protocols to assist staff victims
  administrators in navigating complex issues
  occurring after a violent event

79
Recommendations

• Encourage group discussions for victims of
  violence
• Design intervention strategies to address
  specific types of violence ( physical
  nonphysical)
• Stress the importance of reporting physical
  nonphysical incidents of violence
• Develop policies procedures for safety in the
  event of a weapon threat, i.e. lockdown
  procedures practice them

80
Recommendations

• Be informed aware of ones legal rights
• Take all threats seriously, even verbal threats
  follow up on them
• Check patients for contraband
• Familiarize staff with takedown procedures
  practice them regularly (even though rarely used)
• Have a system in place for reporting all threats
  by phone take immediate measures involving
  local police

81
Recommendations

• There should be a post-incident evaluation and
  counseling plan for any violent incident.

82
Recommendations for staff education

• Define workplace violence , types, causes
  consequences
• Discuss work-related violence prevention
  management policies procedures
• Recognize early signs of escalation, identify
  patient staff factors that increase risk
• Conduct personal safety training
• Explain legal unethical concepts related to WPV

83
Recommendations for research

• Develop consensus-based definitions
• Study effet of relationships on reducing
  incidence of violence
• Evaluate outcomes related to staff training
• Assess outcomes of use of structured assessment
  tools in combination eith traditional assessment
  techniques to identify risk

84
Recommendations for Research

• Identify which techniques help contain violent
  individuals with the greatest degree of safety
• Examine staff characteristics environmental
  factors that increase the risk of aggression
  violence
• Explore effect of nurse-patient relationships
• Develop a uniform standard instrument for
  measuring aggression violence that will
  identify type mode of aggression severity

85
Recommendations for Research

• Test effectiveness of proactive strategies such
  as establishment of work environments that are
  not conducive to violent behavior
• Include longer follow-up periods in studies

86
Recommendations for Horizontal Violence

• Create a work environment that facilities
  supports colleagiality effective communication
  IPR
• Develop clear organizational guidelines for
  leaders employees to be accountable for
  workplace behaviorIntervene when witnessing
  victimization bullying of colleagues
• Discuss concerns of horizontal violence at staff
  meetings

87
Recommendations for Horizontal Violence

• Educate new nurses on horizontal violence
  provide cognitive rehearsal techniques
• Coach nurses to develop their conflict management
  conflict resolution skills
• Provide ongoing education to reinforce
  organizations commitment to ensuring a caring
  respectful environment

88
Recommendations for Horizontal Violence

• Teach students that horizontal violence is not
  acceptable
• Educate about horizontal violence, how to
  Identify it confront it
• Mentor students, building self-esteem self
  worth
• Equip students with assertiveness tools with
  conflict resolution healthy communication
  techniques.

89
Recommendations for Professional Nursing
organizations

• Continue to advocate for a safe work environment
  for all nurses
• Continue to recommend research ed
• Acknowledge horizontal violence, including
  bullying
• Increase awareness of this issue
• Use the standard definition for workplace
  aggression violence

90

• Lobby for legislation that would increase assault
  of a health care worker to felony status
• Request that OSHA guidelines become mandatory for
  health care workplaces

91
Recommendations to employers of Nurses

• Establish Maintain a comprehensive program for
  Prevention management of all types of workplace
  violence
• Analyze workplace security perform risk
  assessments
• Improve screening of potential employees
• Select staff preceptors
• Make ongoing formal ed. _at_wpv compulsory

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Employers

• Reward outstanding role models
• Track all assaults
• Ensure anonymity in reporting
• Ensure time-out areas quiet places
• adequate staffing
• specialist security staff
• covert distress messages coded
  
  
• 
  responses

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Utilize security feature

• Personal alarms panic buttons
• Bulletproof glass
• Adequate lighting
• Metal detectors
• Two-way communication systems
• Closed-circuit TVs
• Controlled access to security monitoring of
  entrances, exists high risk areas

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Recommendations

• Create a culture of a Just Culture with regard
  to unacceptable behavior
• Employees working with high-risk patients should
  not do rounds alone it is recommended staff be
  in pairs, especially on psychiatric inpatient
  units and in Emergency Rooms.

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Recommendations

• Educate staff _at_ warning signs
• Educate methods of coping with violence
• Report protocol
• Instruct _at_ counseling
• Provide legal information
• Provide risk assessment
• Develop a risk management plan

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More Resources

• www.bullyinginstitute.org
• www.osha.gov
• www.cdc.gov/niosh
• www.nursingworld.org/can

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THANKS!!!!!

• Questions???
• Any sharing of personal experiences??

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Thanks!!!

• You are a Great Audience!!!
• LETs END VIOLENCE in the WP
• And Everywhere!!!