A CURE for VIOLENT TENDENCIES.
A SECURITY GUARD at an urban medical facility confides to his supervisor that he has flashbacks from Vietnam and often gets so nervous that he fears he will lose control. The supervisor talks to the officer and calms him down. The supervisor tells no one and decides to take care of the officer's problem himself. A month later, the security officer takes a psychiatrist hostage in the emergency room. * In another acute care facility, staff frequently treat patients suffering from painful diseases such as sickle cell anemia and certain types of cancer. The pain from these diseases often causes sufferers to be short-tempered and tense. One such patient, angry that the telephone wasn't working properly, assaulted a nurse with the telephone, causing head injury. And in another incident, a patient hit a dietary worker repeatedly with a tray. * These incidents are but a sampling of the types that occur daily in otherwise secure healthcare environments. All of them could have been avoided.
HEALTHCARE SETTINGS are unique in many ways that create greater risk of workplace violence. For example, when emergency rooms take in victims of gang violence from outside the hospital's walls, they may become the site of violence within as gangs carry their feuds onto the premises. Hospitals are also associated with stressful situations for both patients and visitors. This tension may lead to violent or abnormal behavior. Employees working in a hospital, who themselves will be subject to internal and external stress, must be educated about these many sources of violence through a comprehensive workplace violence program. The program should include a clear policy, supplemented by risk assessments, hazard prevention, training, reporting, and incident response.
POLICY. In developing a program, the hospital must first decide where to draw the line. At St. Catherine's of Siena in Smithtown, New York (the author's facility), zero tolerance is the rule. The policy statement disseminated to employees is stern but positive, emphasizing that the wellbeing of employees is the main priority. It states that the hospital "believes that all employees are entitled to a nonthreatening workplace where the basic safety of each staff member is promoted. Based on these beliefs, any form of violence, whether actual or perceived, will not be tolerated."
The policy should then define what the hospital will consider workplace violence. At St. Catherine's, workplace violence is described as disruptive behavior, threats, possession of a weapon, sabotage, fighting, stalking, or any behavior that is perceived as threatening by the recipient.
Punishment. How incidents will be dealt with should also be clearly defined. St. Catherine's policy, for example, states that offenders will be consistently punished with penalties up to and including termination. The hospital also makes it clear that no reprisals are to be taken against any employee who reports workplace violence.
RISK ASSESSMENT. A security evaluation is a critical first step in developing any workplace violence prevention program. The security team should look for exposures regarding, for example, valuable assets (drugs or cash) that might attract criminal activity and result in violence against employees. The existence of a cashier's office warrants special attention, particularly if it is not enclosed. Other considerations are whether there is a history of robberies and whether employees are adequately protected by such measures as bullet-resistant barriers or panic buttons. Similarly, the risk assessment team would look for vulnerabilities that might expose staff to aberrant patient or visitor behavior.
Security directors can use several methods to conduct such an evaluation. At St. Catherine's, the security director uses a risk assessment grid. The grid, which is broken into four columns, lists the department concerned, the issues raised, the short- or long-term effects, and the action needed. Security interviews directors and supervisors in each department. Each concern raised by the department is placed on the grid. Security then lists the possible effects of each point raised.
After the analysis is completed, a course of action is determined. The hospital may find that a modest change in design can eliminate some exposures. For example, in one inner-city hospital emergency room, there was no door between the waiting room and the treatment room. The guard was the only barrier between hysterical relatives and those in the treatment room.
Initially, the administration was reluctant to put up a door because they did not want to shut out the public. One afternoon, a young man burst into the emergency room demanding to see his mother, who had been in a car accident. Staff tried to talk to the man but he forced his way into the treatment area, injuring several hospital employees in the process. After this altercation, security was allowed to put up a door with a buzzer. No incidents have occurred since the door was installed.
In other cases, the risk analysis may reveal a need for a change in hospital policy. At one medical center, for example, the emergency department was concerned about excessive waiting times in the ER. Employees noted that, when faced with a long wait, patients and their loved ones often became angry, frustrated, or hostile.
Security proposed three solutions: assigning more nurses to make the wait shorter, offering patients periodic updates, and offering liberal visitation to persons accompanying patients who were being treated. The last two suggestions were combined to provide the solution because they were the least expensive and easiest to implement.
Under the new policy, a staff member explains to waiting patients that certain patients will be given priority because of the severity of their injuries. Waiting patients are then given an update every thirty minutes and told the approximate wait time remaining. In addition, visitors waiting for those being treated are allowed a ten-minute visit every hour. The new policy has eliminated stress among patients and gives visitors a greater sense of control.
Follow-up. After St. Catherine's security personnel have itemized each problem through the risk assessment process, issues are prioritized. Security then follows up on each item in order of urgency to ensure that the appropriate action is taken.
During these follow-up sessions, security determines how well the solution is working. If the original problem still exists, additional solutions are sought, and the item is marked for later assessment. When the problem has been resolved, security has all department employees fill out a questionnaire to determine whether they agree that security has adequately addressed their concerns.
PREVENTION. After addressing existing workplace violence concerns, security should mitigate potential hazards. This is different from the security evaluation because security is looking to prevent future problems rather than address existing ones. At St. Catherine's this task is accomplished by creating a hazard surveillance team. (In the case of smaller facilities, security can assign a hazard surveillance coordinator.) The team conducts annual security evaluations to determine how employee tasks, work conditions, and situations could lead to violence, Other variables, such as ineffective security equipment, isolated work areas, lighting problems, lack of telephones, or other communication problems, should then be explored as contributing factors to violence.
Survey. To gather data for the hazard prevention team, security asks all employees to fill out a written survey. The survey evaluates each employee's tasks to identify hazards, conditions, operations, or situations that could lead to violence. High risk factors, such as a patient population disoriented by drugs or alcohol, are analyzed for violence potential.
As part of the survey, which is conducted at least annually or whenever operations change, all employees are asked to submit ideas for improving workplace safety. They are asked to rate the potential for violent incidents in their work area and to identify or confirm the need for improved security measures. Employees are assured that all information given will be kept confidential.
In addition to standard information such as name, sex, work site, and shift, the survey determines whether the employee works alone and whether anyone is notified when the employee leaves work. Security also asks where in the facility a workplace violence incident is most likely to occur and whether the employee has ever been a victim of a violent incident in the workplace.
Such questions can be illuminating for security. For example, one hospital's surveys routinely indicated that a workplace violence incident was most likely to break out in the kitchen area. After analyzing the circumstances, security learned that the temperature in the kitchen often rose to 100 degrees in the summer. The installation of proper ventilation and air conditioning tamed both the heat and raging tempers, reducing the possibility of workplace violence.
The survey can also serve as an evaluation of security's educational efforts. By asking whether the employee has received workplace violence-related training or assistance, security can tell whether any employees have been overlooked in training. Similarly, security uses the survey to test its own systems by asking whether the employee has obtained a copy of the written workplace violence policy or knows what to do in case of a verbal or physical threat.
As part of the process, all workers' compensation claims and security reports are reviewed by the team to identify trends that may indicate a problem that could be prevented by modifications to the workplace, procedural changes, or employee training.
Reviewing existing measures. The team should next evaluate existing security measures specifically to predict and prevent future incidents of workplace violence. These are policies, procedures, and equipment that seem effective and have received no complaints but could cause problems in the future. This can be done by conducting a work-site analysis. Some examples of physical hazards evaluated by St. Catherine's security personnel include poorly lit areas such as corridors, stairwells, and parking lots; unmonitored entrances; and remote areas that are not monitored via CCTV. The team took an especially close look at high-risk areas, such as the psychiatric care unit and the emergency department.
If for some reason the hazard cannot be removed or avoided, then barriers between the worker and the hazard must be created. For example, at hospitals where gang members are often treated in the ER, security must ensure that doors and other barriers are present to protect staff from angry visitors.
Anticipating difficult situations. St. Catherine's security also attempts to mitigate workplace violence by anticipating difficult situations. Security has a trained team to respond to outbursts of violence in the psychiatric and detoxification units, for example. Similarly, admissions flags patients with a history of violent behavior and reports them to security.
When security personnel receive a notification that a patient has a history of past problems, they should talk with the patient's caregivers--social workers, patient advocates, or physicians--to get more specific information on how to avoid problems and to make it clear that violent behavior from the patient will not be tolerated. This procedure was tested and proven effective in the case of a man who was visiting his wife, a patient at an acute care facility. One day, when his wife was out of the room being tested, the man grabbed one of the nurses. While the nurse went to report the incident to her supervisor, the man exposed himself to a nurse's aide. Security escorted the man from the hospital, but security managers knew that this was a temporary solution. The man's wife was truly ill and frequently stayed in the hospital. The hospital could not, in good conscience, ban her husband from the facility. So, security contacted a social worker to provide more help for the patient. Security limited the hours when the man could come to the hospital and it made a note in the patient's record. Now, each time the wife is readmitted, the report of her husband's behavior comes up on the computer. The admissions attendant notifies the nur ses on call and contacts security. An officer then conducts frequent patrols of the floor.
TRAINING. At St. Catherine's, workplace violence prevention training is given to all new hires. Refresher training is then conducted annually at the departmental level. The training process encompasses every level of the organization. Senior management, middle management, supervisors, and staff are all taught to understand workplace violence. (The workplace violence prevention policy is also included in patient admissions packets and posted in hallways for the benefit of visitors.)
Employee training includes an overview of the workplace violence prevention policy, risk factors that could contribute to assaults, early intervention training, and anger management. It is stressed that, while workplace violence is usually predictable, it can be spontaneous and can erupt anywhere in the facility. Thus, all hospital staff are trained to anticipate violence. Staff is also instructed to limit physical interventions in workplace altercations whenever possible and to call security instead.
Staff who work in high-risk areas receive special training on the specific security issues associated with their department. For example, violent incidents in the psychiatric unit led to a special program on defusing patient hostility.
REPORTING. Critical to any workplace violence program is a strict reporting policy. At St. Catherine's all workplace violence incidents, no matter how small, must be reported to security. Staff are aware of the policy, and security attempts to make employees feel comfortable giving such information.
To do this, the hospital developed a uniform complaint procedure. Staff are told to report all incidents to their supervisor. In the supervisor's absence, or if the supervisor is the offending party, the policy provides another contact, such as a department head.
Complaints against a patient or other outside party are processed by security and, depending on whether the victim wishes to press criminal charges, the police are involved, All complaints against fellow employees are thoroughly investigated by security, Security is trained to conduct these investigations with the highest level of professionalism and with regard to the target employee's privacy. (A potentially violent situation may be closely watched, but an employee should not be singled out before an incident takes place.)
As part of an internal investigation, security profiles the history of the employee, canvasses staff for additional information, instructs the supervisor to closely monitor the target of the investigation, and confers with human resources for possible referral to an employee assistance program.
The results of the investigation are shared with the department head. A course of action is then determined and shared with those who must implement the solution.
Security has a follow-up procedure to ensure that any actions that were required were taken and have worked as intended. Security personnel also keep records of incidents to track trends and assess the overall program.
INCIDENT RESPONSE. St. Catherine's has plans in place to deal with incidents that occur despite the training and prevention program. After every incident, security conducts a comprehensive evaluation to see whether any prevention or response lessons can be learned. Staff is also evaluated both medically and psychologically to address any aftereffects of an incident.
Even seemingly minor incidents must be followed up. For example, while walking to her car one night, a nurse working the late shift at a hospital was startled by a man wearing a long raincoat. He exposed himself to her and ran away. Rattled by the incident, the nurse reported it to security. The security team investigated but could not identify the attacker. Several days later, the nurse was transferred to the psychiatric ward. Making rounds on her first shift in the ward, the nurse walked into a room and saw the man. He was one of her new patients. She was traumatized and requested an immediate transfer. Had security investigated more thoroughly or offered the nurse counseling to help her deal with the initial attack, the situation might have ended differently.
Workplace violence is an ever present concern for healthcare environments. While hospitals cannot fulfill their missions without accepting some risk, security can help make the workplace safer for employees and patients alike by diagnosing potential problems and administering a healthy dose of preventive medicine.
James Johnson, Jr., is director of environmental safety and security for St Catherine's of Siena in Smithtown, New York. He is a member of ASIS.
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|Author:||JOHNSON, JR., JAMES|
|Date:||Mar 1, 2000|
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