Will a Violence Plan Reduce the Negative Effects of ...
Will a Violence Prevention Plan Reduce the Negative Effects of Workplace Violence?
Joan Herr
Grand Canyon University
Professional Capstone Project
NRSV 441
Dr. Joyce Morrison
March 08, 2011
Abstract
Workplace Violence (WV) is increasing at an alarming rate especially in the hospital setting (Dickinson, 2009, p. 34). Nurses have the second most dangerous profession (Gallant-Roman, 2008, p. 450). The definition of and effects of WV will be identified in this capstone project. Most facilities do not have strategies in place to deal with WV (AbuAIRub, Khalia, & Habbib, 2007, p. 281). Suggested solutions to minimize the effects of WV will be presented in order to minimize the dangers to the employee, reduce costly expenses of WV, and to improve the quality of care and patient satisfaction that are negatively affected by WV. An extensive review of the literature will be provided to support all aspects of capstone project. A theory to reduce the negative effects of WV will be discussed. Methods to educate, implement, evaluate, and disseminate results of the WV plan will be presented.
Will a Violence Prevention Plan Reduce the Negative Effects of Workplace Violence?
Introduction
On January 8th, 2011, Americans were shocked upon hearing the morning news. The news reported that an Arizona congresswoman, Gabriel Giffords along with at least 17 others were shot outside a neighborhood Safeway grocery store by a suspect who had previously displayed increasingly strange behavior (Lacey & Herszenhorn, 2011, p. 1-2).
Violence in our world is a common occurrence. Workplace Violence, (WV) is a situation that occurs on a daily basis for many employees. WV can be bullying, verbal abuse, harassment, inappropriate sexual comments or actions, and can also be violent threats or actions (Ventura-Madangeng & Wilson, 2009, p. 37). WV can be from fellow employees, patients, or visitors. The true incidence of WV is undetermined and considered under-reported due to many factors (Ventura-Madangeng & Wilson, 2009, p. 37). This underreporting can occur due to nurses feeling it is just part of the job, concern over repercussions or simply because the definition of WV has never been standardized (Ventura-Madangeng & Wilson, 2009, p. 38). Many facilities do not have WV preventions plans in place. Violence in the workplace is anticipated to rise in the future due to the strained economic conditions that exist (Hoobler, 2006, p. 229). WV has many physical, psychological and financial effects that are costly to the employee, the patient and the institution. Facilities that recognize WV as a problem and have instituted WV prevention plans note a drastic decrease in its incidence Keefe, 2011, p. 10). It is time for organizations to begin to identify WV as a huge problem before the effects of its lack of recognition as a problem and lack of planning to prevent it are beyond solutions and the end result is disasters such as occurred on March 8, 2011 to Congresswoman Giffords.
Problem Definition
Problem Identification:
According to the American Nurses Association (as cited by Gallant, 2008, p1.),
“Nurses have the right to a safe and secure workplace in which to provide quality patient care.” Due to the presence of WV, a safe place to practice nursing is not the reality that most nurses practice in.
Problem Description
Verbal abuse, harassment, bullying, sexual abuse, and physical violence are all part of what many nurses consider to be “part of the job”(Keefe, 2011, p. 10), and are all terms associated with WV (Ventura-Madangeng & Wilson, 2009, p. 37). WV may come from patients, visitors, or coworkers. Wherever people are under considerable conflict or stress, this increases the chances of WV occurrence (Holmes, 2006, p. 222). In the hospital setting, Emergency Departments (ED) and Mental Health Units appear to experience the highest number of violent incidents (Chapman, Sytles, Perry, & Combs, 2010, p. 479). According to the Emergency Nurses Association, (ENA), (Keefe, 2011, p. 10), 8-13% of ED nurses are victims of physical violence at work every week. Most occurrences of WV occur in a hospital room. Police officers have the first highest incidence of violence; nurses are second (Spector, Coulter, Stockwell, & Matz, 2007, p. 119).
Impact of Problem
Workplace violence can have physical, financial, emotional and organizational effects (Ventura-Madangeng & Wilson, 2009, p. 39). Despite Zero Tolerance and efforts to manage this problem, the problem of violence is escalating at an alarming rate (Ople et al., 2010, p. 21). Many nurses report being involved in or witnessing WV frequently. Up to 63% of WV incidents go unreported for reasons including not feeling that management will respond, worrying about punitive responses, or just feeling it is a normal part of the day (Ventura-Madangeng & Wilson, 2009, p. 38). Even the fact that there is not one accepted definition of WV may contribute to underreporting, and because of underreporting the true extent of the magnitude of the problem of WV exists (Ventura-Madangeng & Wilson, 2009, pp. 37-38). Seventy Five percent of ED nurses received no response to reports of violence according to Keefe (Keefe, 2011, p10). Work place violence can contribute to decreased productivity, absenteeism, high turnover rate, and many costs related to litigation and rehabilitation fees (Speedy, 2006, p. 243). Many nurses feel their workplace is not safe and work in an atmosphere of fear (Ople et al., 2010, p. 18). The more civil your workplace, the lower the rates of sick leave, fewer complaints to Equal Employment Opportunity commission, higher patient and employee satisfaction rates, standards will be met and patient care safer ("Bullying takes toll", 2010, p. 30). Workplace injuries from on the job violence cost organizations $202 billion dollars annually (Hoobler, 2006, p. 230).
Significance to Nursing
In one study an alarmingly 93% of the nurses felt that the hospital did not have policies to protect them (AbuAIRub, Khalia, & Habbib, 2007, p. 283). Physical layouts of many hospitals do not promote safety with visitors coming and going freely. Many times security is not a visible deterrent. Many employees are not trained in identifying or dealing with those who may become violent, nor are they trained in de-escalation.
The nursing profession has long endured the effects of WV. Although Joint Commission mandates “Zero Tolerance” and requires hospitals to have codes of conduct ("Bullying takes toll", 2010, p. 28), the problem continues. Nursing operates under conditions of great stress. Lateral violence and bullying are a daily occurrence for many. Nursing should take an active role in their hospitals, and also in the legislature to bring to the attention of those in higher authority the extent of the problem Nurses need to recognize that violence is not an acceptable part of their job. Reports should be filed whenever violence occurs and nurses need to demand a consequence for this behavior. Nurses need to educate themselves on workplace violence, its causes, effects, and solutions. Hospitals with no policy to address WV had 18.1% rate of violence, those with an effective zero-tolerance policy had a rate of 8.4 % (Keefe, 2011, p. 10).
Solutions
A multi-faceted approach to develop an effective WV prevention plan is suggested by the following authors who are recognized, referenced and cited in this paper and credit will be given to each in the following solutions that are listed.
1. Definition of the term WV in order to better research the problem. Recognition of the problem, causes, effects, and the most effective strategies to prevent WV.(Ventura-Madangeng & Wilson, 2009, p. 38)
2. Zero tolerance for any WV from bullying to verbal aggression to physical violence. (Keefe, 2011, p. 10). Do not allow or ignore bullying or other abusive actions. WV cannot be tolerated: if organizations ignore and deny its presence; with the help of nurses, educators, the community and at the legislative level strategies must be develop and enforced to address this problem.
3. Have a threat assessment completed to identify areas of improvement (Lewis & Contino, 2010, p. 1)
4. Educate all staff on the recognition of potentially violent behavior, de-escalation techniques, and how to physically restrain patients (Keefe, 2011, p. 11).
5. Reassess and monitor the responses to the strategy
6. Involve community and legislative personnel in the process. Federal mandates for violence prevention, safety assessment, regular training, and prevention programs (Dickinson, 2009, p. 34-36).
7. Institute measures to improve your physical layout of facility. (keypads, panic alarms, lighting) (Lewis, 2010, p. 1).
8. Investigate underlying causal factors such as poor staffing, customer service skills, overcrowding, and inadequate staff training in dealing with violence. (Holmes, 2006)
9. Develop a “code of conduct” which promotes civility respect, cooperation, conflict resolution, and antidiscrimination ("Bullying takes toll", 2010, p. 30). WV cannot be tolerated. Organizations cannot continue to ignore and deny the presence of WV. With the help of nurses, educators, community involvement and legislative action, strategies can be developed and enforced to address the problem of WV.
PICOT Format
Population of Focus: Abusive, Aggressive, or violent patients, family or coworkers in the hospital setting.
Intervention: Workplace Violence prevention strategies
Comparison: None
Outcome: Reduction in physical injuries, psychological effects, costs, improved climate which promotes quality patient care.
PICOT Question
In the hospital setting of abusive aggressive or violent family, patients or coworkers, will a WV prevention plan reduce the number of physical injuries, adverse psychological effects, reduce costs and improve the climate to improve quality patient care?
Rapid Appraisal of Evidence Based Research Articles Utilizing NRS441V Sample Format for Review of Literature (see Appendix A for continued resource appraisal).
AbuAIRub, R. F., Khalia, M. F., & Habbib, M. B. (2007). Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship, 39(3), 281-288.
1. Summary of Article: This article investigated the occurrence and frequency of workplace violence (WV) among Iraqi nurses, the nurses’ responses to both the violence itself and the policies dealing with the violence and the violence prevention strategies (AbuAIRub, Khalia, & Habbib, 2007, p. 281).
2. Research Elements: Design, Methods, Population, Strength, Limitation: A descriptive exploratory survey was utilized interviewing 116 Iraqi nurses in a hospital setting in Bagdad City (AbuAIRub, Khalia, & Habbib, 2007, p. 283). A pilot study of 20 nurses was utilized who were then excluded from the study (AbuAIRub et al., 2007, p. 283). Modifications were done due to culturally sensitive topics in Iraq. (AbuAIRub et al., 2007, p. 283) The questionnaire was taken from several sources including the World Health Organization (AbuAIRub et al., 2007, p. 283) There were 5 sections to the questionnaire, 71 items were assessed with 3 open ended questions(AbuAIRub et al., 2007, p. 283). Consent, anonymity, and confidentiality were protected. A statistical package of social sciences (SPSS) version 14 was utilized to analyze the data. The sample size was small with over half being male participants. This was a unique study as violence in the hospital setting has not been explored previously. The data was collected over a short two month period of time in a war torn area of the world. The participants were chosen which could create a bias of the examiner potentially. The results are believable. This was definitely a necessary study. Not all 5 areas of the study were presented. Further data to be discussed in future manuscripts. This study was subject to the recall of the individual which may be skewed. This is also a war torn country where violence is seen to be an everyday occurrence so may be underreported.
3. Outcome(s): Research Results. The majority of participants reported that there were no procedures for reporting violent incidents in the workplace; 30.2% were worried about workplace violence; 91% had been exposed to workplace violence in the past year, 41% attacked physically, 14.3% with lethal weapons (AbuAIRub et al., 2007, p. 284). The effects on the nurse were described in a table. Most participants reported that no policies against workplace violence existed in their facility (AbuAIRub et al., 2007, p. 283).
4. Significance to Nursing and Patient Care: This study presented the psychological effects of violence to the nurses, along with the injuries and stressors a nurse must work under. It defined a clear need for federal legislation and hospital support to protect healthcare workers, prevention strategies such as limiting access to hospital, security, and education programs, War conditions and major stressors contribute to violence and other countries can take precautions to recognize and plan for violence prevention. Violence in a hospital setting does not contribute to quality of care and can result in injuries, and job dissatisfaction, which all will eventually affect patient care (AbuAIRub et al., 2007, p. 287).
Bullying takes toll on HCWs and patients: Joint Commission: Zero Tolerance for intimidation. (2010, March). Hospital Employee Health, (March), 28-30.
1. Summary of Article: The more that workplace bullying is allowed, the worse the condition is and this affects staff and patients alike ("Bullying takes toll", 2010, p. 28).
2. Research Elements: Design, Methods, Population, Strength, Limitation: Article noted effects of bullying on patients and staff. A pilot study to institute CREW (Civility, Respect and Engagement in the Workplace) a program to promote civility in the workplace noted. Lower Equal Employment Opportunity Commission complaints, higher employee and patient satisfaction noted with high levels of civility ("Bullying takes toll", 2010, p. 30).
3. Outcome(s): Research Results Workplaces that permit intimidation and bullying have lower satisfaction ratings, poorer patient care, and injuries ("Bullying takes toll", 2010, p. 28). Injury, illness and assault are higher in workplaces that allow workplace harassment ("Bullying takes toll", 2010, p. 28). Ten to fourteen percent of workers noted bullying ("Bullying takes toll", 2010, p. 29).
4. Significance to Nursing and Patient Care: Joint Commission requires a zero tolerance for bullying, and nurses and other coworkers must ensure that this is upheld ("Bullying takes toll", 2010, p. 29). Assisting in your own practice to improve the civility in your culture is important ("Bullying takes toll", 2010, p. 30).
Chapman, R., Styles, I., Perry, L., & Combs, S. (2010). Examining the characteristics of workplace violence in one non-tertiary hospital. Journal of Clinical Nursing, 19, 479- 488.
1. Summary of Article: To examine the prevalence and characteristics of WV and investigate reasons for not reporting incidents.
2. Research Elements: Design, Methods, Population, Strengths, Limitations: This quantitative, qualitative survey was distributed to 332 nurses in a Western Australia non-tertiary hospital (Chapman, Styles, Perry, & Combs, 2010, p. 479). Only 113 nurses participated in the study over a 12 month period (Chapman et al., 2010, p. 479). This type of study has not been done previously in Australia and so there is no data to compare findings to see if reflective of other studies (Chapman et al., 2010, p. 479). The nurses that did respond may have been biased in their views of violence as they did volunteer for study. The study of a non tertiary hospital in the private sector generally has less incidence of violence than a public hospital (Chapman, Styles, Perry, & Combs, 2010, p. 480). Consent for study obtained, an initial testing of instrument done by 12 nurses was completed. Fifty nine questions were asked with 18 being open ended so a great deal of data was obtained. SSPS version 15 utilized to analyze data. Organizations are obligated to provide a safe environment, and this article points to the need for education and changes in policy. Quantitative portion was not random, so bias could occur. This was retrospective so participants recall could be inaccurate. Study seems reliable and necessary. Tables were utilized to show data results.
3. Outcome(s): Research Results: Of the 113 participants, 75 % reported workplace violence in the past year of study (Chapman et al., 2010, p. 482). Violence defined as verbal abuse threats and assault (Chapman et al., 2010, p. 482). Weapons such as knives guns and hospital equipment were utilized as often as noted 3% weekly of respondents (Chapman et al., 2010, p. 484). Only 16 % filled out an occurrence report; 50% reported this to a supervisor (Chapman et al., 2010, p. 484). Reasons not to report were that the nurses considered violence to be a part of the job and they perceived management would not be responsive to the report, and the nurse might be punished (Chapman et al., 2010, p. 484). Only 16% of WV incidents had been reported (Chapman et al., 2010, p. 485)
4. Significance to Nursing and Patient Care: It is significant that nurses consider workplace violence to be a part of the job. The occurrence of WV is probably greater than what any statistics can reveal due factors which keep nurse from reporting WV incidents (Chapman et al., 2010, p. 481). If nurses do not bring WV’s occurrence to the attention of the legislature or to their superiors, the problem will continue to escalate and nurses will continue to experience WV. This will ultimately affect patient care critically causing nurses to leave the profession and worsen the nursing shortage (Chapman et al., 2010, p. 481). Nurses must not allow themselves to become victims but push for prevention strategies to reduce this serious trend. Organizations are obligated to provide a safe environment, and this article points to the need for education and changes in policy.
Cleary, M., Hunt, G., Walter, G., & Robertson, M. (2009). Dealing with bullying in the workplace: Toward zero tolerance. Journal of Psychological Nursing, 47(12) , 34-:41.
1. Summary of Article: This article focused on the effects of a form of WV called bullying. The effects of bullying can cause disruptions in the harmonious working of a unit and compromise the care and safety of patients (Cleary, Hunt, Walter, & Robertson, 2009, p. 35). Zero tolerance for bullying and harassment of nurses by patients or other staff must be adopted.
2. Research Elements: Design, Methods, Population, Strengths, Limitations: This article provided statistics that were cited and referenced regarding the occurrence and effects of bullying. There was variance in the percentage of bullying reported in three studies which varied from 27% to 46% of reports of recent bullying. Bullying may result in psychological or physical harm. Bullying according to the article was “widespread “despite zero tolerance (Cleary et al., 2009, p. 35).
3. Outcome(s): Research Results: Bullying is widespread and can result in poorer outcomes for patient care (Cleary et al., 2009, p. 35). Bullying should not be tolerated and several suggestions for treatment of bullies included keeping documentation of events, not allowing victimhood to occur, organizations creating an environment of caring and creating polices supportive of this goal (Cleary et al., 2009, p. 40). Failure of organizations to champion this goal by policies, dealing with bullies through counseling or termination, will ultimately affect the consumer, the organization and the profession (Cleary et al., 2009, p. 40). Article results were valid and consistent with other literature sources that were read.
4. Significance to Nursing and Patient Care: Nurses and organizations must recognize that bullying can affect patient satisfaction, productivity, absenteeism, and attrition (Cleary et al., 2009, p. 35). Nurses need to be aware that bullying is not an acceptable manner of communication or standard of conduct. It is time for nurses to take charge of their work environment and improve the climate through reporting of incidents and making sure that action is taken in regards to their reports.
Dalton, R., Eracleous, H. (2005). Threats against health care workers, part 1: a review; classification, prevalence and management. Review, 20-24.
1. Summary of Article: Workplace threats are noted to be having a direct negative effect on the patient/staff relationship, safety and security and lowering standard of care (Dalton & Eracleous, 2005, p. 20).
2. Research Elements: Design, Methods, Population, Strengths, Limitations: A review of eleven previous studies regarding WV was done (Dalton & Eracleous, 2005, p. 20).
3. Outcomes: Research Results: Results seem valid and trustworthy. Results of this study should be helpful to those who wish to implement WV prevention strategies. Verbal abuse and threats are to taken seriously as they may lead to further aggression and violence (Dalton & Eracleous, 2005, p. 23)
4. Significance to Nursing and Patient Care: Of particular interest is the listing of the stages of an aggressive episode which would be helpful to teach to staff to recognize at an early stage a potentially violent person’s intent (Dalton & Eracleous, 2005, p. 23). De-escalation is a valuable tool to help a potentially aggressive patient to regain control and was described in this article (Dalton & Eracleous, 2005, p. 23).
Dickinson, J., (2009).”What will your staff members do when violence erupts in your workplace?” Same Day Surgery, 33(4), 33-40
1. Summary of Article: WV is inevitable in this economy and organizations should expect it but have policies in place to manage the problem (Dickinson, 2009, p. 33). This article had specific checklists, policies and advice on how to handle layoffs, which could result in violent behavior of an employee (Dickinson, 2009, p. 33). Training is essential for the employee to learn warning signs of impending violence and measures to respond appropriately to situations that arise (Dickinson, 2009, p. 33).
2. Research Elements: Design, Methods, Population, Strength, Limitation: Article lists the incidence of WV homicides increased 13% in 2007 (Dickinson, 2009, p. 34). Often WV goes unreported but several states are requiring violence tracking programs requiring security and safety assessment, training and assault prevention programs (Dickinson, 2009, p. 34). Information seemed valid, reliable and necessary.
3. Outcome(s): Research Results: Managing WV requires the support of administrative policies stating what good behavior is; what consequences for violent behavior is; training of employees to recognizing potentially violent behavior; training in de-escalation, and how to manage a violent patient (Dickinson, 2009, p. 34). Having a zero tolerance for violence is essential (Dickinson, 2009, p. 36). Risk of violence assessment is needed (Dickinson, 2009, p. 34). Security guards, protecting access points banning weapons, and improving building surveillance is needed to reduce violence (Dickinson, 2009, p. 36). All threats of violence, abuse, or assault are to be reported and appropriate actions taken.
4. Significance to Nursing and Patient Care: Very detailed checklist of steps to take to manage violence. The article summed up by saying that “we have to expect violence and prepare for it (Dickinson, 2009, p. 33).” Their zero tolerance policy defined acts or threats of physical violence, intimidation, harassment, or coercion will not be tolerated. A strong statement such as the above would require administration to back up any reports and for employees to report such incidents and not tolerate violence of any sort. The increasing stressors of our world condition will ultimately increase acts of violence and we must be ready. Protecting our employees protects our patient’s interests.
Gallant-Roman, M. (2008). Strategies and tools to reduce Workplace Violence. AAOHN, 56(11), 449-454.
1. Summary of Article: WV was defined and further categorized by 4 different types depending on who commits acts of WV and on whom (Gallant-Roman, 2008, p. 450). Described the expected shortage of nurses by 2020. The literature has shown that nursing is a dangerous profession. Providing a safe work environment is guaranteed by the Occupational Safety and Health Administration.
2. Research Elements: Design, Methods, Population, Strengths, Limitations: Study seemed necessary, reliable and valid. Data presented complimented itself and other articles on the topic of WV.
3. Outcomes: Research Results: Nurses are victims of WV four times higher than the average employee (Gallant-Roman, 2008, p. 453). Cost of WV is $4.2 billion dollars annually (Gallant-Roman, 2008, p. 451). Guidelines on how to create a program to prevent WV listed (Gallant-Roman, 2008, p. 452)
4. Significance to Nursing and Patient Care: The American Nurses Association says nurses have a right to a safe workplace, and that this is key to solving the growing nursing shortage (Gallant-Roman, 2008, p. 451) Zero tolerance and policies to improve the safety of the workplace are necessary. Facilities must evaluate the workplace to find areas that may make them vulnerable to violence Nurses must be educated to identify potentially violent patients (Gallant-Roman, 2008, p. 452).Nurses must not accept WV as just a part of the job (Gallant-Roman, 2008, p. 453).
Hegney, D., Plank, A., Parker, V., (2003) “Workplace violence in nursing in Queensland, Australia: A self reported study.” International Journal of Nursing Practice, (9), 261-268 1. Summary of Article: To ascertain the nurses’ perception of violence and to use the results to plan strategically.
2 .Research Elements: Design, Methods, Population, Strengths, Limitations: Quantitative study with random collection of 1436 unionized nurses in the public and private sector (Hegney, Plank, & Parker, 2003, p. 261). There was a response rate of 53% with a total of 1477 persons were analyzed (Hegney et al., 2003, p. 262). Fifteen nurses were pre tested to test the accuracy and validity, accuracy and appropriateness. Likert scale was utilized to answer questions regarding violence and the existence of policies to deal with violence. In the aged care section it was noted that nurse assistants were not represented so results could have been biased. Study seemed valuable and reliable compared to similar studies of WV. Narratives and graphs were utilized to display study.
3. Outcome(s): Research Results: Violence was more prevalent in the care of aging sector@ 50% experiencing violence in the past 3 months, 47 % in the public sector, and only 27 % in the private sector (Hegney et al., 2003, p. 261). Patients were the top violators of violence, and nurse against nurse was the prevalent offender in the private and aged care sectors (Hegney et al., 2003, p. 264). Less experienced nurses had an increased reported incidence while experienced nurses were more apt to find that workplace policies were ineffective to manage violence (Hegney et al., 2003, p. 264). Lack of polices to manage violence were less in practice in remote locations. Nurses were asked to rate if the policies were effective to manage violence and results varied from 48% to 60% noted adequate (Hegney et al., 2003, p. 265). Rural facilities were less likely to be aware of policies to deal with aggressive patients with a result of 57% and public sectors 74-78% (Hegney et al., 2003, p. 265).Thirty per-cent of the respondents experience daily aggression/ violence.
4. Significance to Nursing and Patient Care: This study predominantly described the incidence of violence, and how it varied from different settings. This would translate into various strategies for what area the nurse worked in. The effects on WV contribute to poor retention of nurses which indicates the need for WV to be addressed (Hegney et al., 2003, p. 267).
Holmes, C., (2006).“Violence zero tolerance and the subversion of professional practice.” Content Management, 21(2), 212-227.
1. Summary of Article: WV has occurred for many years and the government has begun to acknowledge this problem. Assaults on HCW can create fear, decrease morale, cause serious psychological and physical trauma, and decrease the care quality (Holmes, 2006, p. 212). This can increase costs due to lost labor costs and legal and work-mans’ compensation costs (Holmes, 2006, p. 212). Author of this article felt that zero tolerance was an ineffective response to violence (Holmes, 2006, p. 212).
2. Research Elements: Design, Methods, Population, Strengths, Limitations: Author reviewed how zero tolerance had not decreased violence and that despite laws and policies to manage violence the trend continues for violence (Holmes, 2006, p. 213). This author felt that base line studies had not been done to compare the effect of zero tolerance (Holmes, 2006, p. 220).
3. Outcome(s): Research Results: Author notes that many cases of WV go unreported for a variety of reasons including not aware that they can and should, fear of victimization, and feeling that reporting was pointless as nothing would be done (Holmes, 2006, p. 215) Studies had shown that even if incidences of violence were reported that the offenders went un-prosecuted and this was especially apparent if the victim was a nurse or doctor (Holmes, 2006, p. 215). Efforts to “blacklist” a violent patient resulted in the facility not enforcing the policy (Holmes, 2006, p. 215). The author cited articles of “zero tolerance” ineffectiveness in preventing drug use and violence in the school system (Holmes, 2006, p. 213-214). This author comprehensively described the beginnings of zero tolerance, its effect and spoke of many factors that could potentiate violence that hospitals should address which would decrease violence more effectively. Examples of crowding, noise, long waits, staff with poor people skills and training in dealing with potentially violent patients, inadequate staffing, and many other points that could be addressed to manage the problem of violence (Holmes, 2006, p. 222).
4. Significance to Nursing and Patient Care: The author made good points in that the above stressors that contribute to workplace violence need to be addressed, and that the term “zero tolerance” may be just a band-aid or smoke screen to a much larger problem that needs to be addressed (Hegney et al., 2003, p. 219).He says that in the 8 years a zero-tolerance policy has been in effect the rate of violence to nurses has increased indicated that a more comprehensive action plan is needed (Holmes, 2006, p. 219). It is necessary to train staff to deal with WV and have effective strategies in place to deal this the issue of WV (Holmes, 2006, p. 222).
Hoobler, J., Swanberg, J., (200).”The enemy is not us: Unexpected workplace violence trends.” Public Personnel Management, 35(3), 229-245.
1. Summary of Article: Organizational acceptance of workplace violence and aggression may play a large role in its occurrence and customers are more often the perpetrators of violence and aggression. Murder, mayhem anger hostility are everyday occurrences in the businesses in this country. The stresses of the country including downsizing, retaliation on the job, personal conflict and distress and budgetary shortfalls are all contributors to violence. 2. Research Elements: Design, Methods, Population, Strengths, Limitations: Pie charts, graphs and tables utilized to present data. Eight hundred sixty eight employees from police officers to social workers were surveyed by mail in a Midwest municipal government (Hoobler, 2006, p. 234). This is a 35 % response rate. SPSS software was utilized to analyze results. Of the respondents, 81 % were Caucasian, 65% male. Half reported verbal abuse or harassment in the past year; 15 % were physically abused or assaulted; 49% had witness abuse of others (Hoobler, 2006, p. 234-235). While customers were the largest offenders of threatening behavior, supervisors were guilty of verbally threatening behavior 11% of the time, and physically intimidating behavior 1% of the time (Hoobler, 2006, p. 235) Of 44 sexual assaults, superiors were guilty 62% of the time. Data revealed in article noted 20 workers killed each week, and 18000 assaulted in the US workplace. Data seems valid, necessary and reliable. This was a study aimed at the Midwest not a cross-section of the US, so unsure of how this reflects in the entire country. Bias is always a possibility due to inaccurate recall of incidents. Bias possible as why did the 35% that respond, respond?
3. Outcome(s): Research Results: Government employees were victims of 37 % of the violent crimes in the study (Hoobler, 2006, p. 231). Social norms in the workplace allow and precipitate rude comments which can easily turn into physical confrontations left unchecked (Hoobler, 2006, p. 231). Persons who work in healthcare and jails noted violence as an everyday part of the job (Hoobler, 2006, p. 232). Noted in the study that in one organization a supervisor’s behavior might provoke an emotional abuse charge while in another company taught in a training class (Hoobler, 2006, p. 232). On the job violence costs organization $202 billion annually plus lost days, damage to public image, stress and strain to employee, high turnover, and lower employee commitment (Hoobler, 2006, p. 230).
4. Significance to Nursing and Patient Care: Attention must be made in our workplace to not accept workplace violence as just part of the job (Hoobler, 2006, p. 232). More attention needed to identify those who may potentially become violent and teach nurses how to de-escalate and deal with these circumstances (Hoobler, 2006, p. 243). Efforts to improve the physical environment such as increased lighting, locked access, keypads, and monitoring security systems needed (Hoobler, 2006, p. 243). Data revealed that 40% or organizations do not have policies to deal with WV (Hoobler, 2006, p. 244)
Keefe, S., (2011). Zero tolerance. Advance for Nurses. 8(1), 10-11.
1. Summary of Article: Nurses are physically and verbally assaulted often especially in the Emergency Room environment (Keefe, 2011, p. 10). Little response from reports to managers results in any action to reduce violence (Keefe, 2011, p. 10). Zero tolerance policy was instigated which resulted in a reduction in the number of incidents (Keefe, 2011, p. 10). Having a well developed plan to handle violence is needed.
2. Research Elements: Design, Methods, Population, Strength, Limitation: This facility instigated violence prevention strategies and noted a decrease in its violent incidence and injuries (Keefe, 2011, p. 10)
3. Outcome(s): Research Results Rates of violence can be reduced by 50 % with a violence reduction policy (Keefe, 2011, p. 10). Hospitals with no policy had an 18.1% rise in violence (Keefe, 2011, p. 10) Hospitals with policies decreased the incidence rate to 8.4% (Keefe, 2011, p. 10).
4. Significance to Nursing and Patient Care: Providing a safer environment with environmental factors such as lighting, panic alarms, adequate visible security, training employees in recognizing, de-escalation skills, and dealing with violence is necessary (Keefe, 2011, p. 10-11)
Lewis, S., Continuo, D., (2010) “Sentinel Event Alert says access control holds the key to reducing ED violence”. ED Management, August, 1-2
1. Summary of Article: In attempting to be compliant to Joint Commission Guidelines, this article reviews reasons the ED is vulnerable to episodes of violence, discusses causes, and gives guidance for violence prevention (Lewis & Contino, 2010, p. 1).
2. Research Elements: Design, Methods, Population, Strengths, Limitations: Offered views of ways to improve security in the ED. Basic primer complemented by other articles that stress physical changes in the ED such as keypads and security (Lewis & Contino, 2010, p. 1). No data on effect of these changes. Reasonable suggestions were given.
3. Outcome(s): Research Results. Advised to have a threat assessment of your facility to see where changes need to be made to the physical layout of your ED (Lewis & Contino, 2010, p. 1). Training and support for staff in dealing with recognizing violent patients needed (Lewis & Contino, 2010, p. 2). Ed and community advocates worked to develop strategy to deal with gang violence that occurred in the ED, stressing the need to have community involvement (Lewis & Contino, 2010, p.2). The ED is high risk for violence since the majority of traffic enters through the ED; many are impaired from stress, grief, drugs or alcohol or have mental health issues (Lewis & Contino, 2010, p. 1).
4. Significance to Nursing and Patient Care: Nurses can be instrumental in bringing to the attention of manager threats to the security of their workplace. Policies and education are instrumental to improve the safety of the employee and patient.
Ople, T., Lenthall, S., Dollard, M., Wakerman, J., MacLeod, M., Knight, S., Dunn, S., Rickard, G., (2010), “Trends in workplace violence in the remote area nursing workforce.” Australian Journal of Advanced Nursing, 27(4). 18-23.
1. Summary of Article: WV reviewed and compared to data collected 13 years previous to study. Study desired to ascertain the correlation of WV and post-traumatic stress disorder signs and symptoms.
2. Research Elements: Design, Methods, Population, Strength, Limitation: Questionnaire utilized from a cross sectional design in a remote area of Australia. Working nurses (349) One thousand and seven nurses were contacted and 34.6% responded ((349) (Ople et al., 2010, p. 18). A 5 point scale was used to determine responses. Study was small and not random; recall method used which could result in bias, and error.
3. Outcome(s): Research Results: As was noted in other studies dealing with the issue of WV, underreporting of WV is noted as the nurse wished to avoid unwelcome media attention (Ople et al., 2010, p. 22) Findings indicated an increase in WV between 1995-2008 (Ople et al., 2010, p. 18). Verbal Aggression, damage to property and physical violence were the most frequent types of violence (Ople et al., 2010, p. 18). Nurses in this remote area of Australia indeed do fear for their safety and this affects the nursing care provided (Ople et al., 2010, p. 18). Results verified 79.5% of nurses experienced verbal aggression, 31.6% experienced property damage, and 28.6% experienced physical violence, sexual harassment (22.5%) and stalking (22.5%) and sexual abuse/ assault (2.6%) (Ople et al., 2010, p. 20). This data revealed an increase from 13 years previous and also correlated with evidence of PTSD symptoms (Ople et al., 2010, pp. 20-21).
4. Significance to Nursing and Patient Care: Points out a need for identification, management and prevention strategies to protect nurses. Nurses are not currently being protected. Burnout and job dissatisfaction are on the rise due to lack of protection and nurses are resigning from their profession and not entering the field of nursing (Ople et al., 2010, p. 22). WV continues despite legislation which demands zero tolerance with littler repercussion to offender nor improved safety to the nurses (Ople et al., 2010, p. 22).
Spector, P, Coutler, M., Stockwell, H., Matz, M., (2007). “Perceived violence climate: A new construct and its relationship to workplace physical violence and verbal aggression, and their potential consequences” Work and Stress, 21(2), 117-130.
1. Summary of Article: The perceived workplace climate was found to correlate to physical violence, injury and verbal aggression toward nurses, pointing to a need for employers to create a safe working climate (Spector, Coulter, Stockwell, & Matz, 2007, p. 117). When a safety climate is encouraged, nurses feel the safety as evidenced by policies and education directed at the safety of the institution (Spector et al., 2007, p. 117).
2. Research Elements: Design, Methods, Population, Strengths, Limitations: One hundred ninety eight (198) female nurses were surveyed, being a 29% return from 690 nurses given questionnaires. This was voluntary and anonymous, and completed by mail. A 7 point scale was used. This was a small study with volunteers. Recall method used which can be inaccurate.
3. Outcome(s): Research Results: Results showed that 28% of nurses experience violence in the previous year, 39% of those experienced injury from this, and 58% experienced verbal aggression (Spector et al., 2007, p. 123). Further study needed to determine causal factors contributing to the violence. The author of study noted limitation of study related to being the first time this was studied and it could be imprecise, and secondly that it was cross-sectional and utilized a single source and bias could occur (Speedy, 2006, p. 127).
4. Significance to Nursing and Patient Care: Violence is a common occurrence in nursing practice, demanding both further study and measures to improve the safety environment related to this danger.
Speedy, S., (2006). “Workplace violence: The dark side of organizational life.” Content Management. 21(2), 239-250.
1. Summary of Article: Addresses workplace violence through a review of literature from disciplines including nursing, management, psychology and organizational culture (Speedy, 2006, p. 239). Bullying and mobbing types, causes, targets and impact are discussed (Speedy, 2006, p. 239). Examines issues related to gender as nurses are primarily female (Speedy, 2006, p. 239).
2. Research Elements: Design, Methods, Population, Strengths, Limitations: Many other research articles were quoted and date back to the 1990’s. This data however seems pertinent to today’s workplace climate as evidenced by more current research. Study seems reliable, meaningful and valid
3. Outcome(s): Research Results: Men tend to bully more than women and can be dishonest and passive-aggressive (Speedy, 2006, p. 240). Teasing, joking, insults, theft and vandalism characterize these persons. Bullying was seen to be common to managers, who will then deny or ignore bullying behavior in their subordinates (Speedy, 2006, p. 240) Among the noted effects of bullying behavior include counter aggression toward others, lack of productivity, absenteeism, turnover, and a range of stress reactions (Speedy, 2006, p. 242). Cost of workplace bullying estimated at $13 billion dollars per year due to absenteeism, loss of productivity, legal fees, payouts, additional rehiring costs (Speedy, 2006, p. 243). In the US, it is estimated that each case that progresses to litigation may cost from $30,000 to $100000 (Speedy, 2006, p. 243).Bullied workers leave their jobs at a rate of 25% (Speedy, 2006, p. 243). Psychological effects are massive including loss of self esteem, lack of belief in competency, PTSD , suicide, homicide, increased destructive behavior with drug abuse, alcohol abuse excess smoking may result related to WV (Speedy, 2006, p. 243).
4. Significance to Nursing and Patient Care: Efforts for persons to improve work relationships must be fostered in order to build a solid team that is able to collaborate, trust, and be honest (Speedy, 2006, p. 247). The tendency of workers and management to ignore and deny workplace bullying and violence must end, and nurse need to take active roles to move this forward (Speedy, 2006, pp. 247-248).
Tuckey, M. R., Dollard, M. F., Hosking, P. J., & Winefield, A. H. (2009). Workplace Bullying: the Role of Psychosocial Work Environment Factors. American Psychological Association, 16(3), 215-232
1. Summary of article: Review of data to determine the effects of Job Demand-Control-Support theory (Tuckey, Dollard, Hosking, & Winefield, 2009, p. 215).
2. Research Elements: Design, Methods, Population, Strength, Limitation: Utilized reports from observers and targets of bullying of a sample 716 worker (Tuckey, Dollard, Hosking, & Winefield, 2009, p. 215)
3. Outcome: Research Results: Bullying linked to increased psychological effects, poorer health, less job satisfaction, absenteeism, and decrease in organizational commitment (Tuckey et al., 2009, p. 216). The less control of the worker who has demands with little support for the worker, resulted in increased negative effects of bullying (Tuckey et al., 2009, p. 216).
4. Significance to Nursing and Patient Care: The effects of WV can be moderated by decreasing the demands placed on the worker (nurses), improving support (policies and education to protect the nurse, and giving nurses more control ( a voice in establishing measures to prevent WV(Tuckey et al., 2009, p. 217).
Ventura-Madangeng, J., & Wilson, D. (2009). Workplace Violence experienced by Registered Nurses: A concept analysis. Nursing Praxis in New Zealand, 35(3), 37-50.
1. Summary of Article: Workplace violence has escalated in the past decade with serious effects which extend beyond nurses to the entire facility (Ventura-Madangeng & Wilson, 2009, p. 37). The lack of a clear cut definition of WV contributes to the lack of reporting of incidences by nurses which masks the true extent of the problem of WV (Ventura-Madangeng & Wilson, 2009, p. 37). Universal definition of WV is not evident and this article attempted to define WV (Ventura-Madangeng & Wilson, 2009, p. 37).
2. Research Elements: Design, Methods, Population, Strengths, Limitations: Extensive literature search done using common data bases such as EBSCO, CINAHL, and OVID (Ventura-Madangeng & Wilson, 2009, p. 39)
3. Outcome(s): Research Results: WV definition is extensive and involves verbal and physical abuse, harassment, bullying and its effects are numerous and causes of WV are multi-causal (Ventura-Madangeng & Wilson, 2009, p. 39).A clear definition of WV, causes and the effects is paramount to fully identifying the issues related to WV (Ventura-Madangeng & Wilson, 2009, p. 39).
4. Significance to Nursing and Patient Care: WV is a serious issue which has not adequately been addressed despite the attention given it for many years. Quality care will be impacted if organizations do not recognize its presence and with the help of nurses, educators, the community and at the legislative level and develop strategies to address this problem (Ventura-Madangeng & Wilson, 2009, p. 47)
Incorporating Theory
Introduction
The Demand-Support-Control Work Stress Theory is a theory that suggests that in situations where there is little control, where stresses are great and support limited, the negative effects of a work situation will be worsened. WV continues without sufficient intervention to limit its existence and the negative effects on the employee and patient. According to this theory unless the employee is given control over the situation and support from employer, the stress of the situation will continue and the physical, psychological and financial effects to employee, patient and organization will continue. Demand-Support-Control Work Stress Theory
Identify a theory that can be used to support proposed solution
Five work stress theories have been described in the research. The work stress theory that supports the solution to WV is the theory of Demand-Support-Control (Devereux, Hastings, & Noone, 2009, p. 562). This theory was published in 1990 by Karasek and Theorell (Devereux et al., 2009, p. 563).
Main components of theory are described
This is a simple model which could be utilized in discussion for policy change for the safety and well being of employees ("Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior development.” p. 1). The author of this theory Robert Karasak notes several key aspects of theory:
a. Social organizational characteristics not just physical hazards can lead to injury and illness. ("Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior
development", p. 1).
b. Stress related consequences are related to the organization of work not just the demands of the job ("Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior development.” p. 1).
c. Positive and Negative stress can be explained in terms of the combined demands and the amount of control the employee has over the job. Social and organizational support can minimize effects of stress ("Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior development”, p. 1). ("Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior development", p. 1).
d. This simple theory can be utilized to begin discussion for the stress response that workers experience. ("Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior development", p. 1).
Rationale for Theory is listed
The theory enforces that when the job demands are high as in the case of WV, and the control of the job is low, stress and adverse reactions are higher than if employee demands were low and the employee had a large amount of control in his job role. Demands are listed as activities that require action and effort and control is the decision latitude; the freedom to make decisions and control when and how activities are performed (Tuckey, Dollard, Hosking, & Winefield, 2009, p. 216).
Discussion of how theory works to support solution to WV
A multi-faceted approach to the solution of WV violence is needed. If the demands of the job are enormous as is seen in the hospital atmosphere, but the employee has not the control as evidenced by lack of support of management to recognize the problem or want to assist in the solutions, the employee who already has stress related to the problem of violence, will feel more powerless and experience further stress due to lack of control and support (Tuckey et al., 2009, p. 217).
How theory will be incorporated into project?
This theory will assist the author in further pointing out the need for the employee to be more empowered through control so they are able to bring about desired solutions to the problem of WV. Ultimately this will lessen the psychological and physical effects to the employee. The job characteristics of capacity for control over their assignment can ease the burden of high job demands and organizational and social support can buffer the negative health concerns of WV (Tuckey et al., 2009, p. 217).If these job characteristics are improved health of employee will be improved and patient satisfaction and quality of care will also be enhanced. Development of Implementation Plan
Introduction
The issue of WV has long been tolerated in the healthcare setting despite efforts by Joint Commission and governmental legislation to prevent its occurrence. WV is a complex multi-causal problem that has not a simple answer. Even the definition of WV is complex. WV has been defined as bullying, verbal abuse, inappropriate sexual comments or actions, or physical violence (Ventura-Madangeng & Wilson, 2009, p. 39). This can be directed employee to employee or patient and or visitor to employee. Despite its complexity to treat, WV must be recognized and not ignored for the protection and safety of our employees and patients. WV has many short and long term effects on the psychological, physical, and the financial condition of the facility (Speedy, 2006, p. 243).WV results in worker dissatisfaction, injuries, lack productivity, burnout, fear, stress, safety issues, quality of care issues, patient dissatisfaction and increased staff turnover (Ventura-Madangeng & Wilson, 2009, p. 43). WV can result in physical injury, with resultant costs related to rehabilitation care and legal fees (Speedy, 2006, p. 243). WV not only affects the worker, but it ultimately is passed on to our precious customer who ultimately will receive less quality care and have poorer satisfaction outcomes (AbuAIRub, Khalia, & Habbib, 2007, p. 287).The current stresses of our country will only escalate with rising costs, layoffs, and governmental deficits (Hoobler, 2006, p. 229). The problem of WV is anticipated to rise significantly in the coming years. The forthcoming proposal suggests that it is time for organizations to recognize WV and promote Zero tolerance through adoption of a Zero tolerance Workplace Violence Prevention Plan to prepare for this crisis of increased WV. Outline
The following implementation Plan will be followed to introduce and implement an effective WV plan ( see Appendix B for Workplace Prevention Plan implementation outline).
limit costs.
Method to Obtain Approval for Proposal
Developing a Workplace Violence Prevention Plan is a new endeavor to this hospital. There is a safety policy but it relates to safe use of equipment, keeping the grounds safe, but does not address safety for employees or patients. It does not address Workplace Violence. Even recognizing its existence will be a first major step for this hospital. The hospital does not embrace Evidence Based Practice.
Initial contact will be to schedule an appointment with Emergency Room director. In this meeting, plans for the proposal and the implementation process will be discussed. The plan will first be trial based in the Emergency Department and then hospital wide. After gaining approval and feedback from ED director, an appointment with our Chief Operating Officer who is next in command at this facility. The proposal will be discussed and permission to begin process obtained.
Description of current problem
Current existence of WV is not well documented at this hospital. Organization has no current WV prevention plan. Zero-tolerance and code of conduct are Joint Commission Mandates (Lewis & Contino, 2010, p. 1), and this facility needs to champion these causes. World -wide WV exists in such forms as bullying, verbal abuse, inappropriate sexual contact, and or physical violence(Ventura-Madangeng & Wilson, 2009, p. 39). WV has been shown to cause multiple negative effects on the employee and quality patient care and satisfaction (Ventura-Madangeng & Wilson, 2009, p. 47). Psychological and physical effects result. Increased turnover, absenteeism, poor job productivity, and difficulty recruiting and retaining nurses in an already nursing shortage occur with WV (Holmes, 2006, p. 212). Financial costs soar with payment of workplace injuries, rehabilitation and or legal fees (Speedy, 2006, p. 243). The true extent of WV is unknown as WV is underreported for a number of reasons such as being considered part of the job, worry for retribution, and concern that no one will take action. Since the hospital has no WV prevention plan, nor a current tool or method to report WV. There are no current educational programs to teach employees to deal with WV. A climate of bullying, verbal abuse and violence prevail in the ED. The ED is high risk of violence due to the majority of traffic enters through the Ed and many are impaired from stress, grief, drugs, alcohol or have mental health issues (Lewis & Contino, 2010, p. 1). Employee and patient safety and satisfaction are at risk due to WV. WV is expected to escalate due to worsening world conditions such as job retaliation, budget cuts, downsizing, persnla conflict (Hoobler, 2006, p. 232). It is time to address this problem. Data to support that WV affects employee retention, satisfaction, and customer satisfaction and quality of care will be presented as noted in Literature Review. Results of Questionnaire regarding Workplace Violence Knowledge will be presented (See Appendix A).
Proposed Solution: An initial threat assessment is to be conducted to identify physical access threats to security. This threat assessment is to be conducted by a local security agency specializing in WV. Any deficiencies such as improper lighting, need for controlling access to departments must be addressed.
The term WV requires a definition and a policy to prevent it. A climate for Zero-tolerance for WV must develop. Education initially and yearly is necessary. Education to include topics such as identifying potentially violent patients and learning de-escalation techniques, methods to control a violent patient are also needed. A form to report WV must be developed. Underlying causal factors contributing to WV must be investigated such as long wait times in Ed, overcrowding, noise and comfort issues, and customer service skills. Basic issues such as learning respect and promoting civil climate in ED is needed.
Rationale for Proposed Solutions
As noted various psychological, physical and financial effects of WV have been well documented. Bullying alone has been linked to increased psychological effects, poor health, less job satisfaction, absenteeism and a decreased commitment to the organization (Tuckey, Dollard, Hosking, & Winefield, 2009, p. 216). The literature shows that hospitals that address WV with a WV prevention plan, improve patient and employee satisfaction, reduce costs, and improve quality of care. The evidence in the literature supports recognizing the problem no longer ignoring the evidence of WV and creating an effective plan to combat WV. Hospital must be in compliance to federal mandates regarding WV. Evidence to support development of a WV prevention plan
1. Fewer Equal Employment Opportunity Commission complaints, higher employee satisfaction, higher patient satisfaction with less WV ("Bullying takes toll", 2010, p. 30).
2. In a quantitative-qualitative study by Chapman, 75% of those surveyed reported WV, including verbal threats and assault; 3% reported weapons used, only 16% of those reporting violence in the study completed an occurrence report. Reasons that the participants did not fill out incident report included fearing punishment, they considered it part of the job, and they perceived management would not be responsive to the report (Chapman, Sytles, Perry, & Combs, 2010, p. 484-485).
3. Results of a study which evaluated the effects of bullying showed incidences of psychological or physical harm; 27-46% of participants noted being bullied (Cleary, Hunt, Walter, & Robertson, 2009, p. 35). Bullying can cause decreased patient satisfaction, decreased productivity, absenteeism and result in attrition (Cleary et al., 2009, p. 35).
4. WV has a direct negative effect on patient/staff relationship, safety and security and lowers standard of care (Dalton & Eracleous, 2005, p. 20). Identification of a potentially violent patient and learning de-escalation techniques is essential to dealing with violence (Dalton & Eracleous, 2005, p. 23).
5. WV homicides increased 13% in 2007(Dickinson, 2009, p. 34). Violence is to be expected and organizations should have plans in place to deal with this issue. Training of employees imperative to identify those who may become potentially violent, and learning de-escalation techniques is important (Dickinson, 2009, p. 23). Study stresses importance of planning, reporting and taking action for all reports of WV.
6. Nursing is a dangerous occupation and nurses are victims of WV 4 times higher than average employee. Cost of WV annually is 4.2 Billion dollars (Gallant-Roman, 2008, p. 451).
7. Noted numerous effects of WV such as fear, decreased morale, serious psychological and physical trauma, decrease in quality of care, increased labor cost and legal and work –man’s compensation costs (Holmes, 2006, p. 212). Suggest that it is important to consider other causal factors to WV such as overcrowding, noise, poor customer service skills, long waits, poor staffing (Holmes, 2006, p. 222).
8. Another author said costs related to WV cost $202 billion annually due to lost days, damage to public image, stress and strain to employee, high turnover, lower employee commitment (Hoobler, 2006, p. 230). Hoobler notes that WV should not be considered just part of the job (Hoobler, 2006, p. 232).
9. This study showed that of nurses studied, 28% experienced WV. 58% experienced verbal aggression (Spector, Coulter, Stockwell, & Matz, 2007, p. 123).
10 This study showed 79% of nurses studied experienced verbal aggression, 28.6% experienced physical violence.(Ople et al., 2010, p. 20). Nurses reported PTSD symptoms related to WV (Ople et al., 2010, p. 20).
11. Keefe reports a 50% reduction in WV with a violence prevention plan. Improving physical access, education, zero-tolerance policy caused decrease (Keefe, 2011, p. 1-2).
12. Lewis notes that Emergency Departments need to have access control with keypads, visible security, threat assessment done, proper lighting can improve safety and reduce violence (Lewis & Contino, 2010, p. 1). Training of staff to deal with WV is essential (Lewis & Contino, 2010, p. 2).
13. Poor retention of nurses related to WV (Hegney, Plank, & Parker, 2003, p. 267). Implementation Logistics:
A core group of interested leadership stakeholders will be created and the topic discussed and a formal plan made to implement. A multidisciplinary team of ED Director, Medical Director, 2 staff nurses, two clinical coordinators, a supervisor, security director, and one member from Human Resources and a representative from Registration will be invited to meet to discuss proposal. The Social Worker will also be invited to attend. Evidence based research will be presented and discussion regarding development and implementation of a WV prevention plan will be the main focus of this group. The above groups will meet routinely weekly to identify strategy. Meeting will begin in June after leadership group has first had a chance to meet and Employee WV Questionnaire distributed and results analyzed to share with the second group. The above group will be responsible to encourage the vision of zero tolerance, educate staff on WV plan, and evaluate effectiveness of plan on an ongoing basis.
Resources
Staff resources include the above leadership and multidisciplinary groups who will educate the staff. This combined group will be termed the WV committee. A poster will be displayed on the education board to announce events related to WV (see Appendix D).Initial education given in a 4 hour block provided by security personell. Efforts to avoid overtime will be made. Educational tools will include bundled packets of information regarding the WV prevention plan, Employee questionnaire, de-escalation techniques, reporting device and pamphlet to identify potentially violent patients. Funds:
The cost of threat assessment will be approximately $500-$1000.
The cost of printing supplies for 30 employees will be $500.
The cost of additional paper supplies, and to have professional poster made, will be $300.
Cost of compiling data, implementing process, and training to be done during normal working hours.
The cost of education effectiveness of plan by reviewing injury reports and reviewing reporting device and post employee knowledge questionnaire will be adsorbed and performed by day charge nurse on regular duty time. Conclusion
The costs of WV are not easily determined due to the underreporting that occurs with this topic. Many people consider WV to be a part of the job and work in a climate of violence without ever realizing the full negative effect. It is the desire of this author to raise the standard at our facility: to improve the climate at our facility; reduce the injuries and many other negative effects and improve the quality and care of our facility. Initiating a WV prevention plan and creating an atmosphere of Zero Tolerance will have many positive effects as seen in the literature.
Development of an Evaluation Plan for WV Plan
Introduction
Florence Nightingale once said “For us who nurse, our nursing is a thing, which, unless in it we are making progress every year, every month, every week, take my word for it, we are going back”(Melnyk & Fineout-Overholt, 2011, p. 322). Making progress through use of Evidence based research is as applicable today as it was 140 years ago, and Ms. Nightingale’s words of wisdom are as true now as then. Evidence-based research was utilized to formulate this plan for WV improvement. The plans overall effectiveness will be evaluated in this section. Methods to evaluate
Various methods will be utilized to evaluate the effectiveness of the WV plan 6 months after implementation. The WV Questionnaire (see Appendix C) will be redistributed and results compared to assess the nurses’ knowledge prior to plans’ initiation to determine if knowledge was increased. Patient Satisfaction scores will be evaluated pre and post WV implementation to determine if plan improved these scores. Incident reports pre and post will be evaluated to determine if fewer employees were injured post implementation. The WV Committee (Leadership group and multidisciplinary group) will be gathered together and the program’s effectiveness will be evaluated by review of above methods plus review of use of assessment tools and education tools (see Appendix C, E, F,G, and H). Suggestions for improvement will be obtained and implemented. Results of the WV Reporting form (see Appendix H) will be reviewed to determine if nurses are beginning to identify WV as not just part of the job and an issue that requires a solution through identification and a WV plan.
Variables
Numerous variable exist that may not be measurable. Some data may not be obtained depending on use of forms related to WV. Some variables that may exist but not limited to include:
1. Did the organization champion this issue? Did they spend the necessary money to have threat assessment completed, and if so did they initiate all suggested measures from that assessment to improve safety? Was cost a barrier to full implementation of WV plan?
2. Was education adequate?
3. Were there adequate mentors for the success of the WV plan?
4. Did incidence of WV get reported utilizing the form in Appendix F?
5. Were suggested responses to potentially violent persons initiated as educated to do utilizing Appendix C?
6. Were de-escalation techniques utilized as suggested in Appendix D?
7. What un- anticipated cost barriers existed?
8. Did all staff member embrace WV as an important issue and support the WV plan?
9. It is difficult to determine the physical, psychological and cost effects of WV plans effectiveness if it has never been studied prior to the WV implementation plan and identified as a true cause of absenteeism, fear, stress, turnover and many other negative effects as listed in the literature review.
Education Tools
1. See Appendix E (Risk Assessment tool to identify potentially violent patients)
This educational tool is to be used to train nurses to identify the behaviors of a potentially violent patient and guide the nurse in the care of this type of patient to increase the safety of a potentially violent patient.
2. See Appendix F (De-escalation techniques)
This form will be utilized to supplement education regarding de-escalation of patients who potentially could become violent and what to do when the patient becomes violent. This tool will not only serve as a constant educational tool but can be used to guide the practice on a day to day basis when evaluating and caring for the potentially violent patient.
Assessment Tools
1. See Appendix C (WV Questionnaire)
The WV knowledge tool will be utilized to assess the nurse’s knowledge after implementation of the WV plan to determine increased knowledge and success of education.
2. See Appendix G (Evaluation tool to assess nurse’s response to WV education and implementation)
An assessment tool to evaluate nurse’s evaluation of the WV plan will be formulated and circulated. Results will be compiled and analyzed to determine any changes that would improve the WV plan.
3. See Appendix H (WV Reporting form)
An Assessment tool to report episodes of WV will be formulated for use to report any type of violence in the workplace including bullying verbal abuse harassment, physical and verbal assault that may occur employee to employee or patient to employee.
Conclusion
The WV plan will be evaluated utilizing various methods. Variables will be analyzed to determine whether the WV plan has been a success. Assessment and educational tools will be developed to both educate and assess the success of the WV plan. It is desired to see a vast improvement in the awareness, identification and knowledge of WV, and due to this heightened knowledge and awareness begin to enlist staff and organization in championing the full implementation of a successful WV plan. It is also desirable that the anticipated positive results of the evaluation will prove effective in reducing the negative effects of WV and provide a safer workplace environment.
Dissemination of Evidence of WV Plan
Introduction
After a 6 month pilot in the ED, the WV plan will be evaluated and the results disseminated to stakeholders, the hospital, corporate and to local ENA and Trauma Symposium. Sharing the outcome of this WV plan will assist others in development of a successful WV plan and improve safety of the workplace for employees and patients.
Strategy for dissemination of results to key stakeholders
At the end of 6 months all data will be analyzed and shared with key stakeholders. A bundle of data of knowledge questionnaire, WV reports, patient satisfaction, costs, and staff reports will be compiled and distributed at a meeting. The group will be asked to review and share any feedback in order to determine their analysis of the effectiveness of this program. If the WV plan appears to have met outcomes, any changes that are suggested will be made, and the plan will go hospital wide.
Strategy for dissemination of project outcomes to greater nursing community
When the WV plan has been shared with the stakeholders and it is deemed a success, Corporate will be contacted by phone and then with a follow up letter to determine interest in the WV plan to be implemented corporation wide. The corporation has two other hospitals in this city. If Corporate is interested in the WV plan, all data will be compiled and mailed to them for their evaluation. Plans to implement city wide and potentially country wide will be initiated. If corporate would allow, results of WV plans effectiveness could be shared at local ENA meetings and also at yearly Trauma Symposium at Southeast Arizona Trauma Network (SAT Net).
Conclusion
After implementation of WV plan in the ED, the program will be evaluated from a physical basis. Did the plan reduce injuries? Is the ED a safer more secure place to work? Are plans being implemented as directed? Has patient care and satisfaction been positively affected? It will also be evaluated from a psychological basis. Does staff have less fear? Do they embrace Zero-Tolerance for WV? Is the staff experiencing less stress, burnout or dissatisfaction? Have we impacted retention, absenteeism? It will also be evaluated from a cost basis. Was the cost of the program less than what the cost of workplace, injuries, hiring of new staff, legal fees related to WV? Have costs been reduced by WV plan? Once the program has been evaluated and variables considered, the results will be shared with stakeholders to determine the likelihood of implementing hospital wide, city wide and potentially corporate wide. Efforts to reduce WV through use of this Evidence-Based Research plan will make progress in the promotion of safety and a decrease in WV for the benefit of all patients’ and staff. Creating a policy to prevent WV will not alone decrease WV Other factors such as employees with poor customer service skills overcrowding, long wait times in ED, inadequate staffing can also contribute to WV and these factors should be investigated when creating a WV plan. Other things to consider include that violence that is ignored and allowed will spread. Our society has violent uncivil tendencies so it is not always appreciated to treat others with dignity and respect. Creating a civil atmosphere would be difficult when this value is not embraced by society in general. So in answering the PICOT question “In the hospital setting of abusive, aggressive or violent family, patients or coworkers, will a prevention plan reduce the number of physical injuries, adverse psychological effect, reduce costs and improve the climate to improve quality patient care?” The answer lies in the organizations commitment to recognizing workplace violence as a problem that requires a plan and solution, maintaining a Zero-tolerance for any form of WV, the workers commitment to the WV plan, and the underlying foundation of the commitment of both the organization and the employee to creating and maintaining a civil safe atmosphere in which to provide quality care. Stopping WV with a violence prevention plan, before it escalates may prevent disasters as in the example of the violent attack on Congresswoman Gifford’s, and is necessary now.
References
AbuAIRub, R. F., Khalia, M. F., & Habbib, M. B. (2007). Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship, 39(3), 281-288. Retrieved from
American Nurses Association (2001). Code of Ethics for Nurses. Retrieved January 6, 2011, from
Barash, D. A. (2011). Defusing the violent patient before he explodes. RN, 47, 1-6. Retrieved from http:web..library.gcu.edu
Bullying takes toll (2010, March). Hospital Employee Health, 28-30. Retrieved from
Chapman, R., Styles, I., Perry, L., & Combs, S. (2010). Examining the characteristics of workplace violence in one non-tertiary hospital. Journal of Clinical Nursing, 19, 479-488. Retrieved from
Cleary, M., Hunt, G., Walter, G., & Robertson, M. (2009). Dealing with bullying in the workplace: Toward zero tolerance. Journal of Psychological Nursing, 47(12), 34-:41. Retrieved from
Dalton, R., & Eracleous, H. (2005). Threats against health care workers, part 1: a review; classification, prevalence and management. Review, 20-24. Retrieved from
Demand/Control Model: A social, emotional, and psychological approach to stress risk and active behavior development (n.d.). Retrieved February 12, 2011 from
Devereux, J., Hastings, R., & Noone, S. (2009, February 17). Staff Stress and Burnout in Intellectual Disability Services: Work Stress Theory and its Application. Journal of Applied Research in Intellectual Disabilities, 22, pp.561-573. Retrieved from
Dickinson, J. (2009). What will your staff members do when violence erupts in your workplace? Same Day Surgery, 33(4), 33-40. Retrieved from
Gallant-Roman, M. (2008). Strategies and tools to reduce workplace violence. AAOHN, 56(11), 449-454. Retrieved from http:web..librarygcu.edu
Hegney, D., Plank, A., & Parker, V. (2003, March). Workplace violence in nursing in Queensland, Australia: A self -reported study. International Journal of Nursing Practice, 9, 261-268. Retrieved from
Holmes, C. A. (2006, May). Violence, zero tolerance and the subversion of professional practice. Content Management, 21(2). , 212-227. Retrieved from
Hoobler, J. M., Swanberg, J., (2006, Fall). The Enemy is not us: Unexpected Workplace Violence trends. Public Personnel Management, 35(3)229-245. Retrieved from
Keefe, S. (2011, January 17). Zero Tolerance. Advance for Nurses, 8(1), 10-11
Kling, R., Corbie’re, M., Milford, R., Morrison, J., Craib, K., Yassi, A., Saunders, S. (2006, November). Use of a violence assessment tool in an acute care hospital. AAOHN Journal, 54, 481-487. Retrieved from
Lacey, M., & Herszenhorn, D. M. (2011, January 8). In attack’s wake, political repercussions. The New York Times, 1-4. Retrieved from
Lewis, S., & Contino, D. S. (2010, August). Sentinel Event Alert says access control holds the key to reducing ED violence. ED Management, 1-2. Retrieved from
Melnyk, B. M., & Fineout-Overholt, E. (2011). Teaching Evidence-Based Practice in Academic Settings. In H. Surrena (Ed.), Evidence-Based Practice in Nursing and Healthcare (pp. 291-329). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
Ople, T., Lenthall, S., Dollard, M., Wakerman, J., MacLeod, M., Knight, S., Dunn, S., Rickard, G. (2010, June-August). Trends in workplace violence in the remote area nursing workforce. Australian Journal of Advanced Nursing, 27(4), 18-23. Retrieved from
Spector, P. E., Coulter, M. L., Stockwell, H. G., & Matz, M. W. (2007). Perceived violence climate: A new construct and its relationship to workplace physical violence and verbal aggression, and their potential consequences. Work and Stress, 21(2), 117-130. doi: 10.1080/02678370701410007
Speedy, S. (2006, May). Workplace Violence: The dark side of organizational life. Content Management, 21, 239-250. Retrieved from
Tuckey, M. R., Dollard, M. F., Hosking, P. J., & Winefield, A. H. (2009). Workplace Bullying: the Role of Psychosocial Work Environment Factors. American Psychological Association, 16(3), 215-232. doi: 10.137/a0016841
Ventura-Madangeng, J., & Wilson, D. (2009). Workplace Violence experienced by Registered Nurses: A concept analysis. Nursing Praxis in New Zealand, 35(3), 37-50. Retrieved from
Appendix A: Resource Appraisal
AbuAIRub, R. F., Khalia, M. F., & Habbib, M. B. (2007). Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship, 39(3), 281-288.
1. How does article describe the nature of the problem, issue, or deficit?
Demonstrated the occurrence and frequency of workplace violence (WV)
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Statistical information regarding the gravity of the issue of WV was provided.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Numerous examples of occurrence of violence against nurses in Iraqi hospitals were provided. WV with physical attacks including lethal weapons was documented. Policies to report incidents were not apparent to nurses. Nurses’ fear for their safety was identified.
4. Does article support proposed change?
Article supports nurse’s view that workplace policies to protect nurses are necessary; that violence is underreported for many reasons; and that violence takes many forms with many physical and psychological effects.
Bullying takes toll on HCWs and patients. (2010, March). Hospital Employee Health, 28-30.
1. How does article describe the nature of the problem issue or deficit?
Stresses that workplace bullying is allowed despite the mandates Joint Commission has for hospitals to have a code of conduct and process for dealing with offenders of the mandates. Hospitals must not tolerate any intimidating behavior.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Data revealed that bullying and intimidation are widespread and experienced by a large percentage of our workers in this country.
2. Provide examples of morbidity mortality or rate of occurrence in the population.
WV and bullying are widespread and some reports note a high incidence of superiors being guilty of this practice. Joint Commission receives complaints related to intimidating conduct.
1. Does article support proposed change?
Article supports the proposal for Zero-tolerance. Hospital workers must be held to this proposal to not tolerate bullying or other unacceptable behaviors. WV potentiates itself and the more workplaces ignore this problem, the larger it will become. Article advised numerous steps in changing the climate in the organization.
Chapman, R., Sytles, I., Perry, L., & Combs, S. (2010). Examining the characteristics of workplace violence in one non-tertiary hospital. Journal of Clinical Nursing, 19, 479-488.
1. How does article describe the nature of the problem, issue, or deficit?
Examines the prevalence and characteristics of workplace violence and reasons for not reporting incidents.
2. Does article provide statistical information to demonstrate the gravity of the issue, problem or deficit?
The incidence of WV was well documented .WV definition from verbal abuse to physical assault with weapons was documented. A low incidence of reporting was noted for several reasons.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Rate of occurrence was documented as well as types of violence as well as the effects on the nurses. Nurses reported WV as a normal part of the job which contributed to the underreporting.
4. Does article support proposed change?
Supports need for policies to protect the safety of the nurses, need for education, and need for zero-tolerance for WV.
Cleary, M., Hunt, G., Walter, G., & Robertson, M. (2009). Dealing with bullying in the workplace: Toward zero tolerance. Journal of Psychological Nursing, 47(12), 34-:41.
1. How does article describe the nature of the problem issue or deficit?
Focused on an area of WV called bullying which can cause disruption in the harmony of the working of the unit and compromise the safety and care of the patients.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
The reported incidence of bullying was documented and widespread despite zero-tolerance.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
The effects of WV in the form of bullying were documented. WV causes psychological and physical harm and is common to the workplace. Organizations tolerating WV will ultimately see its negative effect on the consumer, organization and the nursing profession
4. Does article support proposed change?
Supports the proposal for change; Bullying should not be tolerated by organizations. Policies are needed and have policies to prevent this form of WV. Supports view that nurses should not tolerate WV as a standard of conduct. Incidents should be reported. Nurses must work toward improving the environment in which they work.
Dalton, R., & Eracleous, H. (2005). Threats against health care workers, part 1: a review; classification, prevalence and management. Review, 20-24.
1. How does article describe the nature of the problem issue or deficit?
Literature recognizes the importance of the effect of threats on healthcare workers (HCW). Threats are recognized to undermine the patient/ staff relationship and lower the standard of care. Article recognized the risk to safety and security in hospitals.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Studies were reviewed regarding the incidence of threats and assaults on healthcare workers.
3. Provide examples of morbidity, mortality or rate of occurrence in the population. Results reveal threats and assaults were particularly high and the response to these
incidents’ were not always proactive or immediate.
4. Does article support proposed change?
Article enforces the need for actions to be taken against the threats and assaults including police notification. Educational efforts to learn to identify and manage patients who are becoming agitated are necessary Protection of the nurse is needed.
Dickinson, J. (2009). What will your staff members do when violence erupts in your workplace? Same Day Surgery, 33(4), 33-40.
1. How does article describe the nature of the problem issue or deficit?
This article describes that violence is expected in this economy and circumstances and stresses the need for workplaces to have policies to deal with WV.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Several statistics provided incidence of homicide in the literature.
3. Provide examples of morbidity, mortality or rate of occurrence in the population.
Notes effect of WV with layoffs, budget cuts, and other conditions which increase peoples’ often violent reaction to the stressors in their lives.
4. Does article support proposed change?
Supports aspects of change that would require organizations to define violence, maintain zero tolerance for WV in all forms, and provide for the safety of employees and patients.
Gallant-Roman, M. (2008). Strategies and Tools to Reduce Workplace Violence. AAOHN, 56(11), 449-454
1. How does article describe the nature of the problem issue or deficit?
Research notes that nursing is a dangerous occupation and this may further contribute to the current nursing shortage which will impact the quality of care to our patients. Providing a safe working environment is a guaranteed Occupational Safety and Health Administration (OSHA) regulation. Further research is necessary to determine which plans are effective to provide a safe working environment.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Statistics provided on the actual and predicted shortage of nursing. A definition of the 4 levels of violence is listed. Statistics regarding the actual incidence of violence in the workplace are listed.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Workplace Violence is well documented in this article reminding the country that nursing is four times more dangerous than other occupations.
4. Does article support proposed change?
Specific work plans to reduce WV are listed and based on research in this area. Instituting zero-tolerance for WV recommended as well as other key points that support this author’s proposed change including empowering nurses and education to predict violence and to deal with WV.
Hegney, D., Plank, A., & Parker, V. (2003, March). Workplace violence in nursing in Queensland, Australia: A self -reported study. International Journal of Nursing Practice, 9, 261-268.
1. How does article describe the nature of the problem issue or deficit?
The nurses’ perception of violence is important to plan to reduce WV strategically. This study reviewed three different settings in the workplace and identified that varying strategies are necessary for each situation.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Violence was experienced frequently in all 3 study areas, with care of the aging having the highest incidence of WV.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Poor retention of nurses found to be related to WV. Lack of policies to deal with WV was apparent as well as knowledge of staff on how to deal with these events effectively. Less experienced nurses had an increased prevalence of WV.
4. Does article support proposed change?
Article demonstrates the need for a varied approach to WV based on the situation. The need for WV stresses the need for a plan to deal with this enormous problem.
Holmes, C. A. (2006, May). Violence, zero tolerance and the subversion of professional practice. Content Management, 21(2). , 212-227
1. How does article describe the nature of the problem issue or deficit?
WV is a huge problem that the government has begun to acknowledge. WV has a number of poor outcomes for both employee and patient. The effects include fear, decrease in morale, serious physical and psychological harm; increased costs to organizations related to legal, labor and workman’s compensation.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
The articles author felt that zero tolerance studies to determine its effectiveness had not been done and necessary to determine its effectiveness. The author felt zero tolerance had not been effective and that efforts to treat the causes of WV such as poor staffing, overcrowding, noise and other factors contribute to the issue of WV.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Noted that zero tolerance in the school system were not effective. Efforts to prohibit a patient from returning to the facility if they had demonstrated violence toward staff had not prevented the patient from returning.
4. Does article support proposed change?
Author of article made strong points that zero tolerance is simply not enough of an action to help reduce WV. Address issues that contribute to WV are needed.
Hoobler, J. M. (2006, Fall). The Enemy is not us: Unexpected Workplace Violence Trends. Public Personnel Management, 35(3), 229-245.
1. How does article describe the nature of the problem issue or deficit?
Organizational acceptance of the occurrence of WV plays a role in the occurrence of WV. The country’s economic problems contribute to the WV.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
A large study pointed to the frequent degree of violence in the workplace. Various
types of violence were evaluated and the violence included everything from verbal abuse,
threatening behavior, sexual assault, and murder.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
The country’s difficulties with downsizing, economic woes, budgetary cuts, personal conflict, and job layoffs create the perfect atmosphere for WV.
4. Does article support proposed change?
Proposed changes were supported in this research article in several ways including not accepting violence in the workplace, identifying those who may become violent and teaching nurses to learn to deal with de-escalation of violence and how to manage the violent patient.
Keefe, S. (2011, January 17). Zero Tolerance. Advance for Nurses, 8(1), 10-11.
1. How does article describe the nature of the problem, issue, or deficit?
Nurses are physically and verbally assaulted most often in the Emergency room setting. Little action is taken when these events are reported to managers.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
The percent-age of ED nurses that are victims of WV is noted.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Types of WV including assaults were noted. Violence was reduced by 50% after WV program was initiated.
4. Does article support proposed change?
This article recommended numerous strategies to reduce violence in the workplace. A well evaluated plan to deal with WV including education, improving physical layout, a strong security system, and securing the environment was recommended
Lewis, S., & Contino, D. S. (2010, August). Sentinel Event Alert says access control holds the key to reducing ED violence. ED Management, 1-2
1. How does article describe the nature of the problem issue or deficit?
Article discusses the likelihood of WV in the ED setting due to the easy access to the department. Guidance for prevention of WV listed.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Limited general information regarding violence in ED was discussed. Discussion of why WV occurs was seen in article.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
WV occurs in the ED setting due to the fact that a large number of visitors, employees, and patients can enter through this area with little to prevent them from doing so.
4. Does article support proposed change?
Article supports the need to secure the hospital environment to promote the safety of the workers and patients. An initial first step is to have a threat assessment done in the facility. In this article the community was involved in the discussion of violence after a threat assessment was done and problems identified. Training for employees is necessary.
Ople, T., Lenthall, S., Dollard, M., Wakerman, J., MacLeod, M., Knight, S., Rickard, G. (2010, June-August). Trends in workplace violence in the remote area nursing workforce. Australian Journal of Advanced Nursing, 27(4), 18-23.
1. How does article describe the nature of the problem issue or deficit?
This was an excellent study of the effect of WV and its impact on causing post-traumatic stress disorder (PTSD) symptoms. The WV was compiled and compared to results of a study done 13 years previously.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
WV included verbal aggression, property damage, physical violence sexual harassment and stalking. An increase in the violence had occurred in the 13 year period.
3. Provide examples of morbidity mortality or rate of occurrence in the population. An increase in WV was noted which correlated with PTSD symptoms.
4. Does article support proposed change?
The data supported changes to better identify, manage, and protect nurses through effective policies. Nurses are not being protected which leads to burnout and job dissatisfaction. Despite zero-tolerance, legislation, offenders often suffer no repercussion for their acts of violence.
Spector, P. E., Coulter, M. L., Stockwell, H. G., & Matz, M. W. (2007). Perceived violence climate: A new construct and its relationship to workplace physical violence and verbal aggression, and their potential consequences. Work and Stress, 21(2), 117-130.
1. How does article describe the nature of the problem issue or deficit?
Physical violence verbal aggression and other WV occurrences were studied to determine if it directly correlated to the perceived climate of the workplace. The effect of providing education and policies to manage WV were compared to results of the perceived safety climate.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Statistical evidence pointed to the evidence of WV, injuries and verbal aggression.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
The actual magnitude of the problem and the perceived safety climate were correlated
4. Does article support proposed change?
Violence is common; further study is recommended to determine the factors which are contributing to it. The safety of nurses must be provided.
Speedy, S. (2006, May). Workplace Violence: The dark side of organizational life. Content Management, 21, 239-250
1. How does article describe the nature of the problem issue or deficit identified?
Gender issues were reviewed from nursing, management, psychology, and organizational cultures Bullying, mobbing types, targets, causes and impact were discussed.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Comprehensive data dating back to the 1990’s is reviewed.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Many types of WV were reviewed including bullying. Effects of WV were listed in a monetary and per-cent age basis. Many effects from WV were listed including absenteeism, turnover, stress reactions, lack of productivity, PTSD, suicide and counter- aggression.
4. Does article support proposed change?
Article supports the need for WV to be recognized and an effective plan to reduce it. The need for nurse to take an active role in this process was promoted.
Tuckey, M. R., Dollard, M. F., Hosking, P. J., & Winefield, A. H. (2009). Workplace Bullying: the Role of Psychosocial Work Environment Factors. American Psychological Association, 16(3), 215-232.
1. How does article describe the nature of the problem issue or deficit?
WV and bullying were defined and the effect of the demands placed on the worker, the lack of the workers control of how they perform their work, and lack of support from coworker and management all showed numerous negative effects on the workers.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
The prevalence, demands, control and support of elements of bullying were well documented.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Examples of WV were presented. The effect on the worker was demonstrated.
4. Does article support proposed change?
Supports the interventions to identify WV; provide changes to reduce the demands improve support and give control to the worker to reduce the negative effects of WV particularly bullying in this article. Article supports theoretical data for change.
Ventura-Madangeng, J., & Wilson, D. (2009). Workplace Violence experienced by Registered Nurses: A concept analysis. Nursing Praxis in New Zealand, 35(3), 37-50.
1. How does article describe the nature of the problem issue or deficit?
The problems related to reporting of WV identified due to lack of a standard recognized definition of WV. Violence is actually considered under-reported. Underreporting is considered to be due to lack of a definition, nurses not reporting the incidences for fear of reprisal or blame, and or considering WV to be part of the job.
2. Does article provide statistical information to demonstrate the gravity of the issue problem or deficit?
Statistical data was documented and the methods were listed.
3. Provide examples of morbidity mortality or rate of occurrence in the population.
Increasing WV is evidenced by the literature, despite data which indicates that WV is underreported. Serious effects were noted including job dissatisfaction, and numerous psychological and physical effects.
4. Does article support proposed change?
Definitely supports that a need for the definition of WV so reporting may become more accurate. WV is viewed as a serious moral, ethical, legal and financial problem requiring an immediate workable solution for the safety and well-being of workers.
Appendix B: WV Prevention Plan Implementation Outline
I. Identify Objectives, Strategy, and Outcomes:
A. Identify fellow colleagues who could be considered stakeholders in the development of proposal
1. Study evidence based materials
2. Share goals of plan and implementation
B. Gain administrative approval and support beginning at Director level and follow chain of command for process to proceed
1. Review of adverse effects of WV, benefits of WV prevention plan
2. Review of Joint Commission Code of conduct and Zero tolerance
3. Review of incidence of documented work injuries and occurrence reports related to WV
4. Review patient satisfaction scores
5. Present WV quality improvement initiative to administration
C. Assess staff understanding and interest in topic, identify barriers to plan
1. Pre test of knowledge and occurrence of WV (see Appendix A)
2. Poster to inform staff of upcoming WV events (see Appendix B)
D. Create multidisciplinary team for implementation of all phases of plan
1. Emergency Department (ED) Director
2. ED Medical Director
3. Security Director
4. ED staff (2) minimum
5. Clinical coordinators, one representative each from days and nights.
6. Member of registration staff
7. Representative from Human Resources department
8. Social Worker
II. Description of current problem, deficit:
A. Organization has no current WV prevention plan
B. Zero tolerance is not a champion cause
C. No current reporting system for episodes of WV
D. No educational programs related to WV
E. ED is not a secure area
F. Employees consider WV to be part of the job and do not report, an accepting climate of bullying, verbal abuse and violence prevail
G. Employee and patient safety and satisfaction are at risk due to WV
III. Proposed Solution
A. Threat Assessment of facility
1. Prepare to install keypads, glass barrier, improve lighting
B. Define the term WV,
1. Written plan for zero tolerance,
2. WV prevention plan
3. Education of WV (Initial and yearly training)
a. How to identify potentially violent persons,
b. De-escalation measures
c. How to manage a physically violent patient
d. How and when to report WV.
e. Investigate underlying causal factors to WV
i. Customer service skills
ii. Over-crowding
iii. Conflict resolution.
iv. Noise and comfort in Ed.
v. Degree of civility in Ed
vi. Throughput issues
vii. Potential involvement in community and legislative mandates
IV. Rationale for proposed solutions:
A. Various negative psychological, physical, financial effects cited
B.WV prevention plan will improve patient care, reduce injuries, create civil climate with improved patient and employee satisfaction, retention,
V. Evidence from literature to support proposal (Provide complete Literature Review)
A. Supports federal mandates and zero tolerance policies
B. Reduction in injuries cited in literature,
V. Logistics
A. When: September, 2011
B. Where: Pilot in ED
C. Who will initiate, educate, and oversee change: Leadership and Multidisciplinary team. This combined team will be called the WV Committee.
V. Resources:
A. Staff
1. Security to give hands on training on restraining violent patients, restraint application
2. Social Worker to present lectures on de-escalation techniques, recognition of potentially violent persons
B. Educational tools
1. Bundled educational packets of WV prevention plan
2. Bundles of reporting device, de-escalation techniques, identifying potentially violent patients.
C. Assessment tools
1. Pre and Post test knowledge of WV (Appendix C.)
D. Technology
1. Video equipment utilized in education department for PPP,
2. Panic alarms, key pads installed, glass barriers, improved lighting
3. Current computers for research, printers, and fax machines are available E. Funds
1. Threat assessment
2. Cost of completion of suggested physical changes after threat assessment
3. Cost of printing supplies
4. Paper supplies
6. Cost of compiling data, implementing process,
7. Cost of evaluating effectiveness of Plan
8. Cost to oversee, evaluate change, WV Committee evaluating WV reports
9. As much work will be completed during normal work day as is possible to limit costs.
Appendix C WORK PLACE VIOLENCE QUESTIONNAIRE
Hospital X is gathering information on the topic of Workplace Violence (WV). This is a serious issue that requires an organized plan. This committee is gathering data which will direct future responses to this topic. All responses will be analyzed anonymously and a report will follow for your perusal. Thank you for your time and attention.
1. In your own words define workplace violence. .______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. With what frequency do you personally experience WV? Please circle response:
Employee to employee : Never Daily Weekly Monthly Yearly
Visitor to employee: Never Daily Weekly Monthly Yearly
Patient to employee: Never Daily Weekly Monthly Yearly
Supervisor to employee: Never Daily Weekly Monthly Yearly
3. Have you ever reported incidences of WV? YES NO
4. What method did you use to report incident? Phone call Email Occurrence Report Alert-Line
5. To your knowledge was any action taken after reporting incident? YES NO
6. Do you feel safe at work? YES NO
7. Describe what ways you do not feel safe at work if any? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
8. Are you aware of a hospital WV prevention plan? YES NO
Appendix C: Workplace Violence Questionnaire
9. What education have you received while employed at Hospital X regarding dealing with WV?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10. Do you believe WV is a problem at Hospital X? YES NO
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11. Have you ever experienced any negative effects from WV? _____________________________________________________________________________
11. Do you believe that Hospital X takes WV seriously as evidenced by its actions policies or physical layout? YES NO
____________________________________________________________________________________________________________________________________________________________
12. What barriers exist that keep Hospital X from creating and implementing a WV prevention plan?
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
13. Would you be in support of a WV prevention plan at Hospital X? YES NO
14. Any additional comments are welcomed. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix D: Stop WV poster
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WATCH FOR UPCOMING ANNOUNCEMENTS REGARDING IMPLEMENTATION OF WV PREVENTION PLANS!
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Appendix E: Risk Assessment tool to identify potentially violent patients
Risk Assessment Tool to Identify Potentially Violent Patients
An assessment is to be completed on each patient presenting to the hospital to effectively identify patients who may become violent. If a patient is identified as potentially violent, the patients chart will be placed on an orange chart, and patient will be placed in an orange gown. This will be termed a CODE ORANGE response. Circle indicators that are present on admit:
|+ Any of the following indicators will initiate a CODE ORANGE response: |
| |
|~ Expresses verbally hostile or threatening comments |
|~ History of violence or aggressive actions |
|~ Threatening or appearing physically aggressive ( getting in your personal space, aggressive gesturing) |
|+ Any three or more indicators will initiate a CODE ORANGE response: |
| ~ Threatening to leave |
|~ Altered level of consciousness related to hypoxia, metabolic causes, drug intoxication, alcohol intoxication , withdrawal from drugs or |
|alcohol, organic causes |
|~ Hallucinations |
|~ Confusion or cognitive impairment |
|~ Agitation of unknown causes( pacing, tachycardia, sweating, red face, mumbling, chanting, swearing, negative remarks, crying, |
|inappropriate behavior for situation |
|~ Withdrawn (poor eye contact, defiant ) |
|~ Loud, demanding, shouting ,slamming doors, kicking furniture, |
|~ Paranoid behavior, suspicious actions or comments |
Above data taken in part from a risk assessment tool by (Kling et al., 2006).
Appendix F: De-escalation Techniques and Rapid Response
DE-ESCALATION TECHNIQUES and Rapid Response
1. Early recognition of patient who displays mounting tension is necessary. Inform security or others of any concerns you may have of potentially violent patient in the event that a CODE ORANGE RESPONSE is needed. Quick risk assessment utilizing CODE ORANGE tool to identify potentially violent persons.
2. Approach person in a calm, unhurried, and non-confrontational manner that lets the patient know you are concerned and in control but in a non threatening manner. Do not place yourself or others in an unsafe compromised position. Identify yourself by name and identify person. Call them by name in a pleasant manner. Show Respect. Listen; help person express their concerns, use reality orientation.
3. If necessary, attempt to isolate patient from others, but do not place yourself in a potentially unprotected position. Attempt to ascertain if patient may have weapons or devices which may harm them or others and obtain if able.
4. Attempt to communicate to patient that you are concerned for them and would like to know how to help. Attempt to meet persons’ reasonable requests that may defuse situation which may prevent escalation of situation.
5. Attempt to orient person to reality if appears delusional. Do not attempt to reason with out of control person.
6. Keep hands visible. Maintain readiness stance.
7. Quick assessment to determine reality, evidence of injury, hypoglycemic event, withdrawal from or presence of altering substance.
8. Anticipate and be prepared for sudden violence. Keep yourself closest to EXIT. Attempt to utilize verbal means, possibly chemical means before physical restraints to ensure safety.
Appendix F: De-escalation techniques and rapid response
9. Give directions to patient and expectations of person. Explain yourself, and offer alternatives.
10. If patient not able to exhibit control or take direction from staff, instruct person of consequences which will be taken if person unable to maintain control. Don’t crowd person.
11. Be prepared for restraints if needed rapidly and decisively.
12. If other staff must become involved in restraint of patient, have one person who has best rapport with person, to be in charge of direction. Don’t yell or become aggressive. Don’t criticize or argue with person
12. If necessary minimum of 4 persons to physically restrain patient in a methodical manner utilizing skill, speed and surprise. Carry person if necessary to secluded room.
13. Remind patient that they are not being punished, and of the conditions that must exist before restraints can be removed.
14. Involve physician as soon as possible for assessment and or chemical intervention.
15. Initiate appropriate restraint/ seclusion documentation. Person is to be under constant supervision.
16. Always anticipate violence in any situation but especially if any indicators of risk assessment of potentially violent person exist.
17. Complete WV reporting form and restraint log.
De-escalation tool formulated by author of capstone after review of article by (Barash, 2011)
Appendix G: Evaluation Tool to Assess Nurses Response to WV Education and Implementation
1. Do you consider WV to “just be part of my job?” Has the WV plan changed your idea regarding this concept? __________________________________________________________________________________________________________________________________________________________________________
2. Have your skills, beliefs, practice, or knowledge changed about WV since the initiation of the WV plan at this facility?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Has the education for WV benefitted your practice? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. In what way could the education regarding WV be improved to assist your care or understanding of WV? _____________________________________________________________________________________________________________________________________________________________________
5. Please comment on whether you feel the WV plan has had any impact on burnout, job dissatisfaction, stress, patient satisfaction, or quality of care at this facility?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. Have you routinely utilized the following forms?
De-escalation techniques Yes No
Identification of potentially violent patients Yes No
Reporting form for WV Yes No
Appendix G: Evaluation Tool to assess nurse’s response to WV education and implementation
8. Have you utilized Code Orange Responses?
Orange clip boards Yes No
Orange gowns Yes No
9. Do you feel the WV plan has raised awareness of the presence of WV? Yes No
10. Do you see an improvement in the safety climate at this facility? Yes No
10. Do you feel WV plan has been effective in identifying and attempting to prevent WV? Yes No
11. Please make any suggestions for improving the WV plan, and or any additional comments from above questions.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix H: WV Reporting Form
(Please complete this form anytime you are a victim of WV. This form may be completed anonymously or you may add your name on form. You will receive a response to all incidences in as timely a manner as is possible. Place completed forms in locked box in the break room labeled WV. All forms will be evaluated by the WV committee and a response to your concern will be forthcoming.)
1. Date______________________________
2. Time______________________________
3. Place WV occurred
______________________________________________________________________________
4. What persons were involved in incident? Employee to Employee Supervisor to employee
Patient to employee Patient to other person than employee Visitor to employee
5. Type of WV bullying verbal abuse physical assault verbal assault/ threat harassment intimidation sexual comments sexual abuse
6. Describe incident _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7. What action did you take after incident?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix H: WV Reporting Form
8. Did you, or do you plan to have any treatment after this incident? (Counseling, time-off or medical treatment?)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. How has this incident made you feel about the person, about work?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
10. Additional comments.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Account # if patient involved
________________________________________________________
Your name_______________________________________________
Anonymous if desired
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