Reducing Workplace Violence

Reduce Workplace Violence

with These Three T's

By Brian Uridge

Here’s an eye-popping factoid: According to the Bureau of Labor Statistics, health care workers are five times more likely to suffer an intentionally inflicted injury at work than are workers in any other field. Pre-pandemic statistics, shown for 2011-2018 in Chart 1, below, indicate that workplace violence is growing at an alarming rate. But over the past two years we know that intentionally inflicted injuries – many delivered by those infected with the COVID virus or their family members – are on an even steeper rise.

WHAT IS WORKPLACE VIOLENCE?

Health care professionals, particularly nurses and nurse aides, report an increase in cases of being pushed, punched, spat upon, yelled at, threatened with bodily harm (including shooting), and being stalked (when leaving the hospital) since the pandemic began.

Some COVID-related incidents occur because, in the quest to keep case transmissions down, family members not allowed to accompany loved ones into the hospital become angry and abusive. Some occur because patients refuse to believe they have a diagnosis of COVID. And some occur when a patient’s “preferred” treatment – hydrochloroquine, ivermectin, herbal concoctions, and other non-authorized treatments touted on the internet – are not acknowledged and administered.

In Missouri, nurses and other staff at Cox Medical Center in Branson are experiencing such a surge in assaults from patients that they now have panic buttons installed on their badges. If a staff member is in danger and the panic button is pushed, security is alerted, and a tracking system pinpoints the staff member’s location. Help is immediately sent.

Between 2019 and 2020, assaults by patients tripled at the Branson hospital. In 2020, 123 attacks against hospital staff were reported – up from 40 in 2019. Injuries related to the assaults jumped from 17 to 78 during the same period.

Similar reports of rising assaults are reported from many regions of the country. Actual data, however, are difficult to discern as studies show that only 30% of nurses and 26% of physicians who are assaulted will officially report the assault. This underreporting indicates that violence in the health care field is even more prevalent than statistics show.

To effectively address workplace violence and foster a culture of security in health care, we need to change existing culture and our understanding of what it means to keep an organization “safe.”

Outside our hospital walls, commun- ities rely upon relationships of trust to build effective cultures of security. Neighborhood leaders, families, police officers, and firefighters, all work together and build trust as security for the community – and each neighborhood – is defined.

As we consider the culture of security in the health care setting, it’s helpful to look at each health care organization as a community, with each floor, department, or clinic within a health care organization as a neighborhood. As in our outside communities, effective security in our hospital workplaces depends on relationships built between members of each “neighborhood.” Nurses, aides, physicians, therapists, environmental care staff, patients, families … each are members of the neighborhood and every person wants to feel safe.

Using non-traditional measures focused on reducing risk and anxiety will help our hospitals in their quest to ramp up their security cultures while ramping down incidents of workplace violence.

The increase in workplace violence incidents affecting health care workers was already on the rise 2011-2018. Incidents attributed to patients with COVID or their family members increased even more 2020-2021.

THE THREE T's

Actively building and improving your hospital’s security culture involves addressing the three T's of security: trust, training, and technology.

TRUST

Building trust in your health care security teams means focusing first on relationships.

I work as Director of Michigan Medicine Security at the University of Michigan, where we ask our security officers to do two unusual things every day: Make a non-traditional contact with both 1) a patient and 2) an employee they have never met, and engage each of these people in a three-minute conversation. There is no assigned topic of conversation; these conversations can be about anything. The goal is to reduce people’s anxiety around security staff, to build trust, and to help create a feeling of assurance. Studies tell us that “assurance” is our patients’ number one need; we know that feeling safe and assured around hospital security staff is also important for every hospital worker.

We also ask that each week our officers create an unexpected, exceptional experience for a patient or staff member. For example, instead of simply offering verbal directions, an officer may walk the person to their destination and engage them in conversation along the way. It’s amazing how meaningful and reassuring these small gestures can be. Below, I share a letter from a patient who was deeply grateful that an officer walked them to their destination and spoke with them the entire time. These interactions make a marked difference in levels of trust. Remember, 75% of all patients make their health care decisions based on a recommendation from a friend or family member. While improving your security culture, you might also be improving future HCAHP scores.

When security officers go out of their way to help patients, families, and hospital workers, their kindness begets goodwill and raises the trust level for everyone.

People training for the REACT program, designed to help health care workers who see and care for patients in their homes, receive both classroom training and on-location training.

TRAINING

When assessing how best to prevent workplace violence, the word “de-escalation” is always a top consideration. De-escalation is one of your most important security tools. Training your staff – at all levels – by creating scenario-based training programs for high-risk areas is critical. At Michigan Medicine, we use a variety of training programs to help us reduce workplace violence. Each of these programs is based upon open-source training modules that combine tactics used in health care, law enforcement, and the military. Each of our programs (outlined below) has been developed, designed, and delivered by clinical nurse educators, security staff, and law enforcement professionals. Each augments traditional security training and supports de-escalation. You can research similar programs and choose those that seem most appropriate for your staff culture and desired outcomes. I’m sharing some of our most useful programs here, for your consideration.

REACT

Rapid Environmental Assessment Control Training (REACT) is a first-of-its-kind, in-home health care situational awareness training for professionals delivering care in people’s homes. It’s a four-hour training that combines classroom learning with virtual and real-life, scenario-based training that includes role-playing in actual home environments.

During the classroom portion of the training, participants learn about different safety mindsets, scanning the environment for potential threats, and the importance of things like eye contact and body language. Employees learn to assess their surroundings and identify immediate and potential concerns.

When designing this program, each of our Michigan Medicine security officers was required to do a ride-along with a home health care worker to understand what they face every day. After this step was completed, nurse educators and security officers developed scenario-based training that includes situations an in-home caregiver might face, such as incidents of domestic violence, the threatening use of weapons in homes, and how to respond to critical incidents like encountering illegal drugs lying out in the open. We teach what to look for when exiting a car or entering a room – how to scan your environment and look for anomalies. In addition, a separate module focuses on vehicle awareness and preparedness. We want to be sure all employees, especially those who are going into unfamiliar environments, are armed with knowledge and experience that will help them stay safe.

We are glad to share the REACT program with other hospitals at no charge.

An email from one of the nurses who attended the REACT training says: “OMG, this will help me so much. This was

priceless … I am so grateful!"

MILO

Multiple Interactive Learning Objectives (MILO) was originally developed for training military and law enforcement personnel. MILO creates a feeling of reality by surrounding the learner with 300 degrees of multimedia screens, essentially mimicking a real-life situation where the learner is at the center of the action. Skills taught through reallife scenarios include verbal de-escalation, good judgment, recognizing implicit bias, dealing with an active shooter, and other skills. Through established partnerships with local law enforcement agencies, this training tool is free and has now become standard training for ED nurses, security officers, and guest services staff at Michigan Medicine. When you present this training at your hospital, your MILO training coordinator can change the intensity and outcome of each scenario based on the learner’s response and verbal skills.

One of our security staff had just gone through the MILO training for the first time, and within two days she was faced with a person screaming at her in the ED. When our security video of the incident was reviewed, we saw that the officer had done an exceptional job in maintaining a reactionary gap and de-escalating the situation.

SAPS

Situational Awareness and Personal Safety (SAPS) is a program that teaches staff how to stay safe before, during, and after work. Using methods derived from law enforcement programs and the military’s Combat Hunters Course, staff members are taught to remain aware of their surroundings at all times. They learn to identify a baseline, look for anomalies, detect potential threats, and avoid any threats that present themselves. These training materials are available in a wide variety of scenarios and can be found free-of-charge from open-source materials. You can find training videos that teach how to react when a patient becomes agitated, how to de-escalate a potentially violent encounter, and how to stay safe when entering or exiting the hospital and moving through the parking lot. For example, if you do a YouTube search using the full title of the program – Situational Awareness and Personal Safety – you will find multiple training tools to review and utilize. Remember, an engaged workforce that is trained to spot and react to threatening behavior provides the best defense while preventing incidents and minimizing risk.

We want to be sure all employees ... are armed with knowledge and experience that will help them stay safe.

Curb Workplace Violence in Your Facility

The TEAM® program offered by HSS is designed for health care workers who may encounter angry, disruptive, or potentially dangerous individuals. Unlike generic programs, TEAM® is focused exclusively on situations health care workers, including medical, clinical, and professional support staff, are likely to encounter. TEAM® is fully compliant with The Joint Commission, CMS, OSHA, DNV (NIAHO), and NIOSH guidelines.

HSS can train staff to recognize the signs of potential violence. Properly training your staff to recognize, understand, react to, and manage aggressive behavior provides a safer, more productive environment for both health care staff and patients.

Hospital employees are routinely exposed to volatile patients and visitors. This dynamic environment and its potential for violent disruptions have health care leaders searching for answers.

AHA’s endorsed vendor, HSS, can help with its TEAM® program. As an AHA member hospital, you will receive preferred rates and exceptional customer service.

SAVE

Situational Awareness for Violent Events is an active shooter program that focuses on pre-incident indicators and behaviors that most often precede an active shooter incident. SAVE also provides training on what actions to take during these traumatic, though rare, events. Statistically, active shooters account for less than 1% of all homicides in the United States, however this is one of the most sought-after trainings requested in the health care field. Active shooter incidents anywhere cause anxiety among citizens and workers everywhere. In a study of active shooters in school-related settings, the FBI completed a 20year study finding that in every case, the attackers exhibited concerning behaviors prior to the incident itself. In fact, they showed an average of three planning behaviors, preincident. Learning to identify these behaviors before an incident occurs can save lives. When looking for SAVE programs, you might also consider searching for TED talks devoted to surviving active shooter incidents.

TECHNOLOGY

Successful security planning can focus on those technologies that reduce risk and anxiety. Security cameras and closedcircuit video monitoring are popular forms of technology employed in the safety field. Necessary to their successful use is the concurrent employment of trained staff who monitor them, people taught to recognize, identify, and alert security officers when someone exhibits rapid changes in behavior and/ or movements which are above the baseline for that area.

Magnetometers, although only used by 12% of hospitals, are an oftenrequested technological addition. Overall patient experience, security staffing requirements, and the possible need for an armed officer at the checkpoint are all areas that need to be evaluated prior to implementation of this equipment.

Increased lighting, self-locking doors, and panic buttons like those used by our friends in Missouri are additional forms of technology employed by many hospitals today.

In any health system small changes, like ensuring lines of sight, creating safer reception desks (those with a 30-degree slope toward the public side, fabricated from a slick material like stainless steel that make it difficult to climb over), and the use of nonbreakable glass, can enhance safety. Most importantly, creating lockdown capabilities in our EDs, where 41% of all health care violence occurs, must be a priority. Controls need to be installed in both clinical stations and security stations so that multiple people, upon seeing a problem outside, can immediately lock the perimeter. STOP WORKPLACE VIOLENCE

AHA Collaborative Invites Participation

Eliminating or reducing workplace violence in the health care setting is the mission of a new collaborative being formed by the Arkansas Hospital Association. You’re invited to join us as we learn from one another in our quest to stop workplace violence in our hospitals.

The collaborative meetings are free and open to all employees of AHA member hospitals. More information will soon be available at the AHA website, www.arkhospitals.org, and employees of member hospitals may register through the AHA website calendar (https://bit.ly/35pQFwF).

Future dates of the collaborative:

• March 24 • April 28 • May 26 • June 23 • July 28 • August 25 • September 29 • October 27 • December 8

For questions regarding the collaborative, please contact Tina Creel, AHA’s Vice President of Member Services, by email (tcreel@arkhospitals.org) or phone (501) 224-7878 x131.

Scan QR code for AHA website calendar

ENVIRONMENTAL DESIGN AND K-9 CREWS

Crime Prevention through Environmental Design (CPTED) is a timetested method to reduce both risk and anxiety. Used by law enforcement for years, the process focuses on physical improvements that change an environment and are proven to reduce violent incidents. For example, in parking garages, better lighting and bright paint colors on walls will deter perpetrators.

Ensuring that landscaping doesn't hinder safety is an element of CPTED as well. Trees with branches hanging below six feet and bushes growing higher than two feet are examples of landscaping that detract from safety. Low-hanging

branches and tall bushes provide possible concealment and cover for would-be attackers. Keeping vegetation trimmed is an important safety tactic. Several studies show the benefit of using Security K-9s in the health care setting. At Michigan Medicine, our K-9s are trained in both explosives detection and pet therapy. They do not respond to situations where patient, staff, or visitor behaviors are escalating. Instead they make rounds on units proactively engaging patients, staff, and visitors, allowing them to pet the K-9 and interact with the handler. K-9s are one of the best examples of non-traditional technologies that reduce both risk and anxiety.

An email from a patient who interacted with one of our K-9s tells the whole story: "I seriously can’t thank you

enough for bringing Leo to see me. It totally made my entire year. Thank you both for keeping us all safe."

Michigan Medicine seeks to reduce workplace violence and uses these programs to increase security. We encourage their use for teams on your hospital campus as well. Now more than ever, we need to engage our security staff members in non-traditional outreach. The focus must be on building trust, creating scenario-based training for clinical staff, and implementing technologies that proactively keep people safe. Excellent security measures reduce risk and anxiety while ensuring people both feel safe and experience a reduction in workplace violence.

Now more than ever, we need to engage our security staff members in non-traditional outreach.

Brian Uridge, MPA, CPP, CHPA, CTM, is the Deputy Director of the University of Michigan Division of Public Safety and Security and Director of Michigan Medicine Security. You may reach him at buridge@med.umich.edu.

Consider training your K-9 force as both pet therapy ambassadors and explosives detection experts.