SAFER IMPROVING WORKPLACE VIOLENCE COMPETENCE … · SAFER: IMPROVING WORKPLACE VIOLENCE COMPETENCE WITHIN AN EMERGENCY DEPARTMENT. DEPARTMENT OF NURSING TEXAS CHILDREN’S • Opened

DEPARTMENT OF NURSING

Tarra Kerr, DNP, RN, NEA-BCJennifer Sanders, DNP, RN, NEA-BC

SAFER: IMPROVING WORKPLACE VIOLENCE COMPETENCE

WITHIN AN EMERGENCY DEPARTMENT


TEXAS CHILDREN’S• Opened in 1954• World’s largest children’s hospital• Ranked third in the nation• 3 campuses with 971 licensed beds• 11 million square feet• 17,000 physicians, nurses, and staff• 150,000+ Emergency Center visits• 4.2 million+ patient encounters• 37,000+ surgeries• 6,000+ deliveries• 430,000+ Health Plan members


• Dr. Beth Ulrich, DNP advisor

• Dr. Joseph Hagan, statistical consultant

• Site leadership• Michelle Riley-Brown, President of Texas Children’s West Campus• Mary Jo Andre, Chief Nursing Officer• Gail Parazynski, Vice President of Nursing• Paul Sirbaugh, former Chief of Pediatric Emergency Medicine• Dr. Kay Leaming, Medical Director of West Campus Emergency Center • Jacqueline Newton, former Assistant Director of West Campus Emergency Center

• Key Partners• Mike Hogan, former Director of Security• James Mitchell, Assistant Director of Emergency Management• Lauren Ivanhoe, Staff Development Specialist • Charlyn Davis, Pediatric Emergency Medicine Quality Specialist

ACKNOWLEDGEMENTS


BACKGROUNDNational Institute of Occupational Safety and Health (NIOSH) Workplace Violence

(WPV) Definition: “physically and/or psychologically damaging actions that occur in the workplace or while on duty” (NIOSH, 2002, p. 1)

In one 7-day period 12% of Emergency Center (EC) RN’s experienced physical abuse, 59% verbal abuse (ANA, 2014)

Pediatric EC: 43% of staff concerned for personal safety & security; 30% report feeling fearful several times a month (Shaw, 2015)

People

$4.2 billion spent annually on WPV across all professions with nursing ranked second to law enforcement (Gallant-Roman, 2008)

Costs of medical treatment or loss of work for WPV for 1 hospital system over 1 year $94,156 (Speroni et al., 2014)

Finance

WPV tied to higher risk of medication errors & patient infection (Rogers et al., 2004)

ENA members: 37% reported negative productivity scores, including decreases in cognitive performance after a WPV event (Gates et al., 2011)

Quality


• Vastly underreported (ASIS International, 2011; Gillespie et al., 2014)

• Increased turnover/attrition (Edwards et al., 2014; Schalk et al., 2010)• Psychological consequences (Fernandes et al., 1999; Gates et al., 2011)• Absenteeism (Speroni et al., 2014)• Decreased productivity (Gates et al., 2011)• Impaired job function (Fernandes et al., 1999; Kowalenko et al., 2013)

• Impact on quality of care (Gates et al., 2011; Gillespie et al., 2014)• Financial burden (Speroni et al., 2014)

SIGNIFICANCE


SETTING AND CONTEXT

• Setting: pediatric, community based, acute-care hospital

• Context: 25 bed Pediatric Emergency Center as pilot unit

• 76 nursing team members: Registered Nurses, Patient Care Assistants, Unit Clerical Assistants, Patient Registration Staff

• Setting: pediatric, large urban quaternary facility

• Context: 42 bed Pediatric Emergency Center as pilot unit

• 128 nursing team members: Registered Nurses, Emergency Medical Technicians, Patient Care Assistants, Unit Clerical Assistants

Texas Children’s West Campus Texas Children’s Medical Center


• Increase the EC nursing care team members competence and confidence when responding to workplace violence as indicated by a 5% increase in post-test scores.

• Improve the EC nursing care team members perception of environmental safety related to WPV as indicated by a 5% increase in post-test scores.

AIM STATEMENT


METHODOLOGY

NIOSH computer based module

Didactic course

Simulation scenarios

Environmental assessment

Quality Improvement Model Utilized: IHI Model for Improvement• PDSA 1: pre-assessment survey pilot• PDSA 2: launch of final pre-assessment survey• PDSA 3: initial pilot of didactic course and simulation scenarios• PDSA 4: launch of final didactic course simulation scenarios

Comprehensive WPV Program


OUTCOMES AND RESULTS Outcome Measurement Method Results – TCH West Results – TCH MC

Volume of Event Reports(Outcome Measure)

Organizational Event Reporting System

p-value 1.0 p-value 1.0

Staff Competence (Outcome Measure)

Pre/Post knowledge assessment toolbased on NIOSH content in modules

Validation of competence post simulation

p-value <0.05 in 9 of 20 questions p-value <0.05 in 12 of 20 questions

Staff Confidence(Outcome Measure)

Confidence assessment visual analog scale

p-value <0.05 for all 9 questions p-value <0.05 for all 9 questions

Staff Perception of physical safety(Outcome Measure)

Safety perceptions visual analog scale p-value <0.05 for 1 of 4 questions p-value <0.05 for 2 of 4 questions

Number of Employees Trained(Process Measure)

Educational database Program completion: 70 of 76 (91%) Program completion: 131 of 154 (85%)

Employee Evaluation of Training(Process Measure)

American Nurses Credentialing Center survey template

Online module 4.79/5.00 Didactic and simulation 4.71/5.00 Course instructor 4.81/5.00



OUTCOMES AND RESULTS Outcome Measurement Method Results – TCH West Results – TCH MC

Volume of Event Reports(Outcome Measure)

Organizational Event Reporting System

p-value 1.0 p-value 1.0

Staff Competence (Outcome Measure)

Pre/Post knowledge assessment toolbased on NIOSH content in modules

Validation of competence post simulation

p-value <0.05 in 9 of 20 questions p-value <0.05 in 12 of 20 questions

Staff Confidence(Outcome Measure)

Confidence assessment visual analog scale

p-value <0.05 for all 9 questions p-value <0.05 for all 9 questions

Staff Perception of physical safety(Outcome Measure)

Safety perceptions visual analog scale p-value <0.05 for 1 of 4 questions p-value <0.05 for 2 of 4 questions

Number of Employees Trained(Process Measure)

Educational database Program completion: 70 of 76 (91%) Program completion: 131 of 154 (85%)

Employee Evaluation of Training(Process Measure)

American Nurses Credentialing Center survey template




OUTCOMES AND RESULTSQuestion

p-valueTCH-WC

p-valueTCH-MC

Workplace Violence (WPV) is defined as physically and/or psychologically damaging actions that occur in the workplace or while on duty. 0.033* 0.0050*Making others afraid or fearful through threatening behavior is intimidation. 0.082 0.0060*WPV includes many behaviors. Understaffing is not an example of WPV. 0.312 0.0647

According to the American Nurses Association, 59% of emergency department registered nurses experience verbal abuse in a 7-day period. 0.677 0.0010*

According to the National Institute for Occupational Safety and Health (NIOSH), 1.7 million people are victims of non-fatal workplace assaults each year. 0.000* 0.0000*

The main reason for WPV in the healthcare setting is stress. 0.004* 0.0030*

A nurse caring for an involuntarily admitted patient with a history of violent behavior is at highest risk for experiencing WPV in the healthcare setting. 0.059 0.0570

Enforcing limits on a patient eating or drinking is associated with higher risk for WPV. 0.000* 0.0000*Workplace violence can lead to low morale. 0.513 0.1140

One reason an employee is more likely to report WPV includes clear policies and procedures on WPV reporting. 0.016* 0.6490

True: Employees have the right to a safe working environment where WPV is not tolerated. 1.000 1.0000Patients often feel frustrated, vulnerable, and out-of-control. As feelings intensify, the patient’s hostile behavior is likely to intensify through 3 levels of tension, disruption, and violence. A patient yelling at the doctor is not an example of expressing tension. 0.000* 0.0000*

When a patient is tense, it is important to listen and ask questions to show you are interested and concerned. Then, ask follow-up questions and summarize what you have heard the patient say. 0.269 0.0760

When a patient is disruptive, it is important to explain that you will not be able to help until the patient stops the disruptive behaviors. Be polite, clear, and firm. 0.027* 0.1220

Your top priority when a patient is violent is to get yourself and others to safety 0.018* 0.0000*

True: According to hospital policy, Texas Children’s maintains a strict zero-tolerance policy prohibiting violence, harassment, and/or inappropriate and disrespectful conduct. 0.312 0.0220*The types of workplace violence outlined at Texas Children’s does not include violent acts in the community by a patients’ family members or any others from whom the organization provides services. 0.011* 0.0010*

True: Any Texas Children’s workforce member who believes he or she has been or is being subjected to, or has knowledge of workplace violence, harassment or prohibited conduct, is required to report the incident. 0.906 0.0370*

Texas Children’s has formed a multidisciplinary Workplace Violence Prevention and Response Team in order to effectively coordinate prevention and response activities. One of the primary members includes a representative from Risk Management. 0.516 0.2930

WPV awareness and training occur at Texas Children’s new employee orientation and annual required training. 0.272 0.0080*


OUTCOMES AND RESULTSQuestion

p-valueTCH-WC

p-valueTCH-MC

Workplace Violence (WPV) is defined as physically and/or psychologically damaging actions that occur in the workplace or while on duty. 0.033* 0.0050*Making others afraid or fearful through threatening behavior is intimidation. 0.082 0.0060*WPV includes many behaviors. Understaffing is not an example of WPV. 0.312 0.0647

According to the American Nurses Association, 59% of emergency department registered nurses experience verbal abuse in a 7-day period. 0.677 0.0010*

According to the National Institute for Occupational Safety and Health (NIOSH), 1.7 million people are victims of non-fatal workplace assaults each year. 0.000* 0.0000*

The main reason for WPV in the healthcare setting is stress. 0.004* 0.0030*

A nurse caring for an involuntarily admitted patient with a history of violent behavior is at highest risk for experiencing WPV in the healthcare setting. 0.059 0.0570

Enforcing limits on a patient eating or drinking is associated with higher risk for WPV. 0.000* 0.0000*Workplace violence can lead to low morale. 0.513 0.1140

One reason an employee is more likely to report WPV includes clear policies and procedures on WPV reporting. 0.016* 0.6490

True: Employees have the right to a safe working environment where WPV is not tolerated. 1.000 1.0000Patients often feel frustrated, vulnerable, and out-of-control. As feelings intensify, the patient’s hostile behavior is likely to intensify through 3 levels of tension, disruption, and violence. A patient yelling at the doctor is not an example of expressing tension. 0.000* 0.0000*

When a patient is tense, it is important to listen and ask questions to show you are interested and concerned. Then, ask follow-up questions and summarize what you have heard the patient say. 0.269 0.0760

When a patient is disruptive, it is important to explain that you will not be able to help until the patient stops the disruptive behaviors. Be polite, clear, and firm. 0.027* 0.1220

Your top priority when a patient is violent is to get yourself and others to safety 0.018* 0.0000*

True: According to hospital policy, Texas Children’s maintains a strict zero-tolerance policy prohibiting violence, harassment, and/or inappropriate and disrespectful conduct. 0.312 0.0220*The types of workplace violence outlined at Texas Children’s does not include violent acts in the community by a patients’ family members or any others from whom the organization provides services. 0.011* 0.0010*

True: Any Texas Children’s workforce member who believes he or she has been or is being subjected to, or has knowledge of workplace violence, harassment or prohibited conduct, is required to report the incident. 0.906 0.0370*

Texas Children’s has formed a multidisciplinary Workplace Violence Prevention and Response Team in order to effectively coordinate prevention and response activities. One of the primary members includes a representative from Risk Management. 0.516 0.2930

WPV awareness and training occur at Texas Children’s new employee orientation and annual required training. 0.272 0.0080*


OUTCOMES AND RESULTS – TCH WC Evaluation Metric Mean Median

Pre-Competence 66.6 77.0

Post-Competence 81.4 92.0

Competence Difference +14.8 +15.0

Competence % Change 22.4% 19.4%

Pre-Confidence 3.37 3.41

Post-Confidence 4.21 4.24

Confidence Difference +0.85 +0.83

Confidence % Change 25.1% 24.2%

Pre-Safety 2.99 3.00

Post-Safety 3.23 3.18

Safety Difference +0.24 +0.18

Safety % Change 8.1% 6.0%

12345

Q1. Q2. Q3. Q4. Q5. Q6. Q7. Q8. Q9.

VAS

CON

FIDE

NCE

SC

ORE

ASSESSMENT QUESTIONPRE POST

2.64 2.803.20 3.31

2.82 2.973.39

3.74

1

2

3

4

5

Waiting room Triage Exam room Majortreatment/trauma

room

VAS

SAFE

TY S

CORE

DEPARTMENT LOCATIONPRE POST

Goal = 5%


OUTCOMES AND RESULTS – TCH MC Evaluation Metric Mean Median

Pre-Competence 68.4 75.0

Post-Competence 80.5 82.5

Competence Difference +12.1 +7.5

Competence % Change 17.7% 10.0%

Pre-Confidence 3.46 3.42

Post-Confidence 4.05 4.07

Confidence Difference +0.59 +0.65

Confidence % Change 17.1% 19.0%

Pre-Safety 2.86 2.84

Post-Safety 3.28 3.23

Safety Difference +0.43 +0.40

Safety % Change 14.7% 13.7%

2.58 2.66 3.01 3.183.00 3.00 3.46 3.67

1.02.03.04.05.0

Waiting room Triage Exam room Majortreatment/trauma

roomVAS

SAFE

TY S

CORE

DEPARTMENT LOCATIONPRE POST

12345

Q1. Q2. Q3. Q4. Q5. Q6. Q7. Q8. Q9.

VAS

CON

FIDE

NCE

SCO

RE

ASSESSMENT QUESTIONPRE POST

Goal = 5%


LESSONS LEARNED

• Project implementation date

• Technology available

• Deployment of pre-test and post-test

• Key stakeholder partnerships

• Leveraging team member strengths


• Texas Health & Human Services Grant• Innovative approaches for reducing

verbal and physical violence against nurses

• Partnership with UT Health Science Center Cizik School of Nursing

• Awarded $179,979.49

NEXT STEPS



REFERENCES

American Nurses Association (2014). American Nurses Association Health Risk Appraisal (HRA): Preliminary findings October 2013–October 2014. Retrieved from http://nursingworld.org/HRA-Executive-Summary

Einarsen, S., Hoel, H., & Notelaers, G. (2009). Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the Negative Acts Questionnaire-Revised. Work & Stress, 23 (1), 29-44.

Gallant-Roman, M. (2008). Strategies and tools to reduce workplace violence. AAOHN Journal, 56(11), 449-454.

Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and its impact on stress and productivity. Nursing Economic$, 29(2), 59-66.

Gerberich, S.G., Church, T.R., McGovern, P.M., Hansen, H.E., Nachreiner, N.M., Geisser, M.S.,… Ryan, A.D. (2004). An epidemiological study of the magnitude and consequence of work related violence: The Minnesota Nurses’ Study. Occupational and Environmental Medicine,61(6), 495–503.


REFERENCES

Gillespie, G. L., Gates, D. M., Kowalenko, T., Bresler, S., & Succop, P. (2014). Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department. Journal of Emergency Nursing, 40(6), 586-591.

Larrabee, J.H. (2009). Nurse to nurse: Evidence-based practice. New York: McGraw-Hill Publishers.

National Institute for Occupational Safety and Health. (2002). Violence occupational hazards in hospitals. Retrieved from http://www.cdc.gov/niosh/ docs/2002-101

Rogers, A.E., Hwang, W.T., & Scott, L.D. (2004). The effects of work breaks on staff nurse performance. Journal of Nursing Administration, 34 (11), 512–519.

Shaw, J. (2015). Staff perceptions of workplace violence in a pediatric emergency department. Work, 51 (1), 39-49.

Speroni, K.G., Fitch, T., Dawson, E., Dugan, L., & Atherton, M. (2014). Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing, 40(3), 218–228.


APPENDIX

A. ENA Environmental Risk Assessment Tool SampleB. NIOSH Computer-based Training Course Map


APPENDIX A: ENA ENVIRONMENTAL RISK ASSESSMENT


APPENDIX B: NIOSH COMPUTER-BASED TRAINING MODULE

Workplace Violence Course Map

Introduction 1.1 Introduction 1.2 Course Rationale 1.3 Course Goals 1.4 Course Outline Violence in the Healthcare Setting 2.1 Introduction & Objectives 2.2 How High Is the Risk? 2.3 Why Are Healthcare Workers at Increased Risk? 2.4 Who Is at Greatest Risk? 2.5 When Is the Risk Greatest? 2.6 Where Is the Risk Greatest? 2.7 What Are the Risks? 2.8 Additional Risk Factors Workplace Violence Prevention Programs 3.1 Introduction & Objectives 3.2 OSHA Recommendations 3.3 Components of Violence Prevention Programs 3.4 Written Plan 3.5 Management Commitment 3.6 Employee Involvement 3.7 Worksite Analysis 3.8 Hazard Prevention & Control (1) 3.9 Hazard Prevention & Control (2) 3.10 Hazard Prevention & Control (3) 3.11 Health & Safety Training 3.12 Post-Incident Response 3.13 Evaluation & Recordkeeping Recognizing and Responding to Combative Behavior 4.1 Introduction & Objectives 4.8 Violence: Recognition 4.2 Safety Training 4.9 Violence: Response 4.3 Dynamics of Combative Behavior 4.10 Reporting 4.4 Tension: Recognition 4.5 Tension: Response 4.6 Disruptiveness: Recognition 4.7 Disruptiveness: Response

Documents

SAFER IMPROVING WORKPLACE VIOLENCE COMPETENCE … · SAFER: IMPROVING WORKPLACE VIOLENCE COMPETENCE WITHIN AN EMERGENCY DEPARTMENT. DEPARTMENT OF NURSING TEXAS CHILDREN’S • Opened