Be a Nurse, Not a Victim: Implementation of a Violence Prevention and Mitigation Program Tonya Barlow, RN, MSN, CNS-BC, CEN, CPEN Belinda Shaw, RN, MS, CEN, NE-BC Porter Adventist Hospital Denver, Colorado Concurrent Session February 24, 2012 10:30 AM – 11:45 AM Emergency Nurses Association ® Leadership Conference 2012
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Be a Nurse, Not a Victim: Implementation of a Violence
Prevention and Mitigation Program
Tonya Barlow, RN, MSN, CNS-BC, CEN, CPEN Belinda Shaw, RN, MS, CEN, NE-BC
Porter Adventist Hospital
Denver, Colorado
Concurrent Session February 24, 2012
10:30 AM – 11:45 AM Emergency Nurses Association® Leadership Conference 2012
Centura Health
• A faith-based, nonprofit health care organization formed in 1996 by Catholic Health Initiatives and Adventist Health System
• Colorado’s fourth largest private employer with nearly 13,000 associates
• The Centura system encompasses 13 hospitals, seven senior living communities, and Centura Health at Home – home care, hospice, infusion, home medical equipment and oxygen services
2
Centura Health Parker
Avista
Littleton
St. Thomas More
St. Anthony North St. Mary Corwin
Penrose/St. Francis
Porter
St. Anthony Summit
Ortho Colorado
St. Anthony
Mercy
Porter Adventist Hospital
• Acute Care Hospital - Cancer Care Center
- Center for Joint Replacement
- Craniofacial & Skull Base Disorders
- Complex Medicine
- Heart Institute
- Centura Health Transplant Program
- Robotics Institute
- Spine Institute
• 368 licensed beds with 1450 associates
• Founded in 1930
• Magnet designation – January 12, 2009
4
Sharon Pappas, RN, PhD, NEA-BC
Chief Nursing Officer - Porter Adventist
Chief Nursing Executive - Centura
Objectives
• Identify characteristics of an environment with potential for violence.
• Assess the emergency department environment
for potential threats. • Appreciate the importance of violence
prevention and mitigation. • Integrate knowledge, resources and tools to
move towards an environmental culture of violence prevention and mitigation.
5
Outline of Presentation
• Characteristics of a Potentially Dangerous Environment
• What to Expect When We Are Not Prepared for Violence
• Community Assessment
• Environment Assessment
• Violence Prevention Implementation
6
My Evolution as an ER Nurse
7
New Graduate Nurse! Crusty/Jaded Nurse
My Evolution as an ER Nurse
• Teamwork Among Staff, Security & Law Enforcement
• Violence Prevention and Mitigation • Healthy Respect for My Patients While Still
Retaining Control of the Situation
• Dorothy still enters the subway without fear but she has her cash securely stashed and carries travelers checks.
8
Literature Review
• Identify the Problem
• Change of Culture for Emergency Nurses
• Environment of Safety
• No Tolerance for Violence Policy
9
Definitions
What is Workplace Violence????
‚Workplace Violence is generally defined as any physical assault, emotional or verbal abuse, or
threatening, harassing, or coercive behavior in the work setting that causes physical or emotional harm.‛
The National Institute for Occupational Safety and Health (NIOSH)
10
Workplace Violence
• 8 Registered Nurses were FATALLY Injured at Work Between 2003-2009 - 4 RNs received Gunshot Wounds - 4 RNs received other Fatal Injuries - 8 of 8 RNs were Working in Private Healthcare Facilities - 8 of 8 RNs were 35-54 years of age
• 45% of All Nonfatal Assaults against Healthcare Workers Result in Lost Work Days in the U.S.
U.S. Bureau of Labor Statistics, (2011)
11
Characteristics of a Potentially
Dangerous Environment • Environmental Design
• Round the Clock Access
• Long Waits
• Fast Paced Environment
• Patient and Family State of Crisis
• Areas of High Crime
• Perception of Easily Attained Prescription Meds Emergency Nurses Association (2011)
12
National Overview
• Emergency Department Violence Surveillance Study
- Cross-Sectional Online Survey - May 2009 – January 2011 Findings - N= 7169 Emergency Room Nurses Surveyed
Quarterly Emergency Nurses Association (2011)
13
National Overview
14
Emergency Nurses Association (2011)
No Abuse 45%
Verbal Abuse 43%
Physical Abuse 12%
Emergency Department Violence Surveillance Study
May 2009-January 2011 n=7169 RNs Surveyed About
Events in Their Past 7 Days!
National Overview
15
Emergency Nurses Association (2011)
Verbal Abuse 43% of Survey Nurses = 3083 in 7 days!
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Cursed at
Yelled at Called names
Threat Legal Action
Sexual Harassment
Threat Physical Assault
Series1 89% 89% 68% 52% 23% 20%
National Overview
16
Emergency Nurses Association (2011)
Physical Abuse 12% of Surveyed Nurses = 860 in 7 days!
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patient Room Lucid
Series1 98% 82% 73%
National Overview
17
Emergency Nurses Association (2011)
Physical Abuse 12% of Surveyed Nurses = 860 in 7 days!
0%
10%
20%
30%
40%
50%
60%
ETOH Drugs Psych
Series1 56% 47% 45%
National Overview
18
Emergency Nurses Association (2011)
Physical Abuse 12% of Surveyed Nurses = 860 in 7 days!
0%
5%
10%
15%
20%
25%
30%
35%
40%
Triage Restraint Procedure
Series1 40% 35% 29%
National Overview
• Formal Reporting of Perpetrators – 66% of nurses physically assaulted did not
file a formal report
– 86% of nurses verbally assaulted did not file a formal report
• Interestingly most of them did tell someone and still they did not report!
19
Emergency Nurses Association (2011)
National Overview
20
Emergency Nurses Association (2011)
0% 5% 10% 15% 20% 25% 30%
Warning Issued
Transfer to Psych Facility
Asked to Leave ED
Arrested
Left Before Action Taken
Treated Sooner/Faster
Actions Taken Against Perpetrators of Violence
Verbal Abuse n=3217 Physical Abuse n=784
National Overview
21
Emergency Nurses Association (2011)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Increased or remained the same
over past yr.
Not considered leaving ED
Considered leaving
current ED
Considered leaving nursing
profession
Series1 96% 73% 27% 10%
Impact of Workplace Violence
National Overview
• Zero Tolerance Policy
– Hospitals must adopt a Zero Tolerance Policy in order to support Nursing to move towards a culture where violence is not a part of our daily work.
Emergency Nurses Association (2011)
• We must come together as a culture where this action is not tolerated or
expected as “part of the job.”
22
National Overview
• Workplace Violence Toolkit
www.ena.org/IENR/ViolenceToolKit/Documents/toolkitpg1.htm
• Emergency Department Violence Surveillance (EDVS) Study
www.ena.org/IENR/Pages/WorkplaceViolence.aspx • Emergency Nurses Association Position Statement
www.ena.org/about/position/position/
23
National Overview
24
•9 States have Legislation Mandating Employer Run Workplace Violence Programs •17 States have Laws That Strengthen Penalties for Acts of Workplace Violence Affecting Nurses American Nurses Association, (2012)
SC
VA
NM
CO
TX
OK
WA
OR
CA
ID
NV UT
MT
WY
ND MN
KS
NE
MO
IA
AR
MS
IL IN OH
KY
TN
wv
WI MI
PA NJ
NY
HI
MD DE
MA
NH VT
RI
NC
GA AL
FL
LA
(18 states) Enacted/ adopted: AL, AZ, CA , CO, CT, IL, ME, NC, NJ, NM, NY, NV, OK, OR, VT, VA, WA and WV; plus HI (resolution)
*refer to report for distinctions; laws vary – either reflect required programs or establish penalties for assaults on nurses/healthcare personnel .
ME
JANUARY 2012
The American Nurses Association’s Nationwide State Legislative Agenda
WORKPLACE VIOLENCE
SD
AZ
CT
National Overview
• What can happen when we are not ready for violence?
– Environmental Instability – Stress: Acute or Chronic – Injury – Disability – Death
26
Emergency Nurses Association (2011)
National Overview
• The Joint Commission (TJC)
– The Joint Commission’s Environment of Care standard require a written plan of how an organization will protect patients, staff and visitors.
The Joint Commission, Sentinel Event Alert, 45, June 3, 2010
27
National Overview
• TJC Suggested Actions
– Audit the facilities risk of violence
– Identify strengths and weaknesses
– Extra security precautions in the Emergency Department
– HR to conduct thorough background checks and pre-employment screenings
– Violence prevention and mitigation training for all staff
– Procedures for responding to and reporting violence
– Counseling programs for victims of violence The Joint Commission, Sentinel Event Alert, 45, June 3,
2010
28
Denver Metro Data
29
Denver Metro Data
30
Colorado Department of Human Services, (2009)
0
100
200
300
400
500
600
700
Denver 1990
Denver 2009
Colorado 1990
Colorado 2009
Series1 700 230 541 273
Reduction of Psychiatric Beds
Denver Metro Data
31
• Population Growth in Colorado
– 1990: ~3.5 Million
– 2009: ~5 Million Colorado Department of Human Services, (2009)
Community Assessment
32
Inner Circle = 1 mile radius or 25,000 people Outer Circle = 3 mile radius or 100,000 people
CrimeCast (2010)
Facility Overview
• 368 Licensed Beds
• 1450 Associates
• Founded in 1930
• Inpatient Psychiatric Services: 35 Beds (1936)
• Psychiatric Emergency Dept: 5 Beds (2004)
• Geriatric Inpatient Psychiatry: 14 Beds(2010)
33
Emergency Department Overview
• ~60 Staff Members
• ~24,000 Visits Annually
• 23 Bed Emergency Department
• 5 Bed Psychiatric Emergency Department
• 5 Bed Cardiac Short Stay
• Emergency Department Treatment Protocol .EDTP Program
• “30 Minute Service Promise”
• Sexual Assault Nurse Examiner Program
34
Emergency Department Overview
• Areas of the hospital that are most prone to violence
- Psychiatric Units - Emergency Departments
- Waiting Rooms
- Geriatric Units or Nursing Homes
Emergency Nurses Association (2011)
35
Emergency Department Overview
• Number of Psychiatric Evaluations
36
This translates into roughly one in every twelve patients we see at Porter!
0
500
1000
1500
2000
2500
1 2 3 4
Series1 2184 1802 1801 2096
2008 2009 2010 2011
Emergency Department Overview
37
Hospital Shared Services (2009)
Factors Influencing Violence in the Past 6 Months by Patients
Never Rarely Sometimes Mostly Always
Alcohol Use 1 1 11 41 9
Drug Use 1 3 17 37 5
Psychiatric 2 0 20 32 9
Advanced
Age
6 8 35 11 3
Emergency Department Overview
38
Hospital Shared Services (2009)
Factors Influencing Violence in the Past 6 Months by Visitors
Never Rarely Sometimes Mostly Always
Alcohol Use 6 10 27 16 4
Drug Use 9 13 26 12 2
Psychiatric 9 12 24 15 2
Advanced
Age
22 18 19 1 2
Meet Our Stretcher Side Staff
39
Proposal
• Approached by Security Provider to Serve as a Beta Site for Violence Prevention and Mitigation Program
• Assessed Need Within the Unit
• Stakeholder Approval
– Unit Based Practice Council
– Physicians
– Security
– Administration
40
Proposal
• Financial Implications • Program Costs
• Training Costs
– $6,000
• Installation of Light/Alert System
• Physical Plant Improvements
41
Implementation
• How to Measure Success
• Unit Risk Assessment
• Policies and Procedures
• Training
• Ongoing Training and Program Maintenance
42
Measurement Tools
• Pre and Post Surveys
• Patient Satisfaction – Overall, How Quickly Evaluated, Door to Room (Minutes)
• Associate Satisfaction (PES)
• Turnover
• Lost Time Injuries
• Code Green Data
• Metal Detector
• Light system changes
43
Unit Risk Assessment
• Physical Assessment of the Environment
• Interviews with Key Personnel
• Presentation of Findings
44
Risk Assessment: Environment
• Front Entrance: Proposed Improvements
- Consider Solid Physical Barriers
- Electronic Locks on Main Entrance Door
- “No Weapons” Signs to Include Visual Warning
45
Risk Assessment: Environment
46
Risk Assessment: Environment
• Ambulance Entrance: Proposed Improvements
- Consider Hand-Held Metal Detector
- Guidelines for At-Risk Admissions
47
Risk Assessment: Environment
48
Risk Assessment: Environment
• Patient Care Perimeter Doors: Proposed Improvements
- Education and Accountability for Securing Access
- Signage
- Bold
- Consistent
- Visible
49
Risk Assessment: Environment
50
Risk Assessment: Environment
51
Risk Assessment: Environment
52
Risk Assessment: Environment
• Waiting Area: Proposed Improvements
- 24 X 7 Security Presence
- Metal Detector
- Hand-held Metal Detector Option
- Storage for Confiscated Property
- Secure Access to Waiting Area
- Consider Affixed Seating
53
Risk Assessment: Environment
54
Risk Assessment: Environment
55
Risk Assessment: Environment
56
Risk Assessment: Environment
• Admissions and Triage: Proposed Improvements
- Raise Height of Counter
- Install Physical Barrier from Ceiling to Counter
57
Risk Assessment: Environment
58
Risk Assessment: Environment
• Main Patient Care Area: Proposed Improvements
- Evaluate TV Mounts
- Move Framed Photos from Patient Care Areas
- Glove Holders
- Coat Hooks
- Equipment and Clutter
59
Risk Assessment: Environment
60
Risk Assessment: Environment
61
Risk Assessment: Environment
62
Risk Assessment: Environment
63
Risk Assessment: Environment
64
Risk Assessment: Environment
• Psychiatric Treatment Area: Proposed Improvements
- Affix Bed and Table
- Remove Un-affixed Items When Not in Use
- Remove or Lock Fire Extinguisher
- Remove or Affix Code Blue Alarms
- Change Window from Glass to Plexiglas
- Create Escape Exit
- Review Security Staffing Model
65
Risk Assessment: Environment
66
Risk Assessment: Environment
67
Risk Assessment: Environment
68
Risk Assessment: Environment
69
Risk Assessment: Environment
70
Risk Assessment: Environment
71
Risk Assessment: Environment
72
Risk Assessment: Environment
73
Policies and Procedures
• Violence Prevention and Mitigation Plan
• Care of the Psychiatric Patient in the ED
• Visitor Policy
• “Code Green” – Out of Control Patient
• TASER Policy
• Metal Detection and Screening
• Elopement and Escape Precautions and Response
• At Risk Patient Admission
• Pre-Divert, Advisory and Divert Policies
74
Policies and Procedures Violence and Mitigation Plan
• Recognition and Response Framework
• Communication – Red
– Yellow
– Green
• Decision – Security
– Charge RN
– Physician
– House Supervisor
75
Policies and Procedures Violence and Mitigation Plan
• Business as Usual
– One Security Officer at Metal Detector at Minimum
– Access to Department May be Granted Remotely
76
Policies and Procedures Violence and Mitigation Plan
• Environment with Potential for Escalation
– Second Officer in ED
– Consider Visitor Restriction
– All Doors Secured
– Focused De-escalation and Separation
77
Policies and Procedures Violence and Mitigation Plan
• Potential or Loss of Control of the Environment
– Two Additional Officers
– No Remote Release of Access for Doors
– Consider Lock Down of Exterior ED Doors
– Restricted Visitor Access
– Focused De-escalation and Separation
78
Policies and Procedures TASER Policy
• Supervisor Training • Drills with Staff • Protocols • Reporting • Removal of Probes • Physician Exam
Following Deployment
79
Staff Training
• Security • All ED Staff
Members • House
Supervisors • Psychiatric
Evaluators • Chaplains
80
Training: Secure the Space and Train to the Environment
81
• Policies and Practices
• Training
• Response
• Environmental Controls
Access
Environment
Security Presence
Local Police Participation
Stages of Escalation
At Risk Patients
Effective Throughput
Engaged and
Educated Staff
Concept Used with Permission by Hospital Shared Services; ED Safe (2009)
Staff Training
82
Prepare for Your Patient
Own Your Work Environment
Work Within Your Training
Expect the Unexpected
Remember Your Resources
Acronym Used with Permission by Hospital Shared Services; ED Safe (2009)
Measurement Lack of Security/Police Presence
83
0
5
10
15
20
25
30
35
40
45
Pre-training
1 yr Post- Training
Measurement Lack of P & P’s Regarding Violence
84
0
5
10
15
20
25
30
35
40
45
Pre-Training
1 yr Post-Training
Measurement Patient Satisfaction
0
10
20
30
40
50
60
70
80
90
100
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
85
Healthstream Percentile Ranking 2011
Measurement Patient Satisfaction
0
10
20
30
40
50
60
70
80
90
100
How Quickly Evaluated % Ranking
Door to Room (Mins)
86
Measurement Associate Satisfaction
Practice Environment Survey
2.85
2.9
2.95
3
3.05
3.1
3.15
3.2
3.25
2009 2010 2011
87
Measurement Nursing Turnover Rate
0
2
4
6
8
10
12
2008 2009 2010 2011
88
RN Turnover Percentage (Voluntary and Involuntary)
Measurement Associate Injuries
• Employee Injuries Due to “Patient Altercations” 2008-2011
– No Lost Time Injuries
– July 2011: Wrist Strain During Restraint Episode
• Limitation: Does Not Include Verbal and Threatening Behavior
89
Measurement “Code Green” Episodes
90
0
5
10
15
20
25
30
35
40
45
2008 2009 2010 2011
Facility
ED
Measurement Metal Detector
0
100
200
300
400
500
600
700
800
900
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Items Confiscated Total for 2011 = 6831
91
Measurement Light Color Changes
92
• 3 hrs
15 min Red
• 225 hrs 41 min
Yellow
2011
Conclusion
93
• Implications for Practice • Outcomes • Limitations
Testimonials
94
‚Implementation of this program gave us the feeling of control and safety. ED Safe as a concept allows the emergency department staff and security to work as a team where each players opinion is valuable. I am supported in my
‚The graphs and data that our Director and CNS have presented are great and they show you that the program works; but hearing the opinion of Brooke and other ED associates ‘Tells’ me that it works.‛ – Tom McDermott RN: ED Clinical Nurse Manager
decision to change the lights to yellow even if based solely on my gut feeling a patient might be a problem. The implementation and continued dedication to ED Safe gives me permission to expect nothing short of a safe work environment. – Brooke RN: Charge Nurse
Next Steps
95
• Continue Current ED Safe Program and Ongoing Training • “OXY Free ED” (Cherry Hill ED, Seattle) • SBIRT • Non Violent Crisis Intervention Training • Team STEPPS
Questions?
96
‚Change is not an invitation, it is an obligation and expectation.‛
-Tim Porter-O’Grady, 2008
Contact Information
Tonya Barlow, RN, MSN, CNS-BC, CEN, CPEN
Porter Adventist Hospital
Emergency Department Clinical Nurse Specialist
Belinda Shaw, RN, MSN, CEN, NE-BC
Porter Adventist Hospital
Associate Chief Nursing Officer
Director Emergency Department & Critical Care
97
Porter Adventist Hospital Denver, Colorado
References • American College of Emergency Physicians (December 9, 2008). Emergency Medicine Report Card. Retrieved from
http://www.emreportcard.org. Accessed on January 8, 2012.
• Auge, K. (2009). Psych Units Shutting Doors. Denver Post, January 25, 2009. Retrieved from
http://www.denverpost.com. Accessed on January 8, 2012.
• Bureau of Labor Statistics. (2010). Case and demographic characteristics for work-related injuries and illnesses
involving days away from work. Retrieved from http://www.bls.gov/iif/oshcdnew.htm. Accessed on August 19, 2011.
• Colorado Department of Human Services: Metro Crisis Triage Program (January 2009). Psychiatric Resources in
Colorado. Retrieved from http://www.colorado.gov/cs/Satellite/CDHS-Main/CBON/1251575083520. Accessed on
August 19, 2011.
• Denver Post (April 11, 2005). Man commits suicide after walking into hospital emergency room. Denver Post
(4/11/05), 2B.
• Emergency Nurses Association. ENA Workplace Violence Toolkit. 2011. Available at
www.ena.org/IENR/pages/WorkplaceViolence.aspx. Accessed June 12, 2011.
• Gacki-Smith J, Juarez AM, Boyett L, Homeyer, C, Robinson, L, MacLean SL. Violence against nurses working in US
emergency departments. JONA: Journal of Nursing Administration. 2009; 39(7/8): 340-349.
• Hospital Shared Services. ED-SAFE: Workplace Violence Prevention and Mitigation Program. 2009. Available at
www.hss-us.com/healthcare-security/violence-prevention/. Accessed June 12, 2011.
• Joint Commission on the Accreditation of Healthcare Organizations (2010). Sentinel Event Newsletter: Preventing
Violence in the Healthcare Setting. Issue 45 (June 3, 2010). Retrieved from
http://www.jointcommission.org/assets/1/18/SEA_45.PDF. Accessed July 23, 2011
• May, D. D., & Grubbs, L. M. (2002). The extent, nature, and precipitating factors of nurse assault among three groups
of registered nurses in a regional medical center. Journal of Emergency Nursing, 28, 11-17.
• National Institute for Occupational Safety and Health. (2002). Violence: Occupational hazards in hospitals. Retrieved
from http://www.cdc.gov/niosh/2002-101.html
• US Census Bureau (2010) Census 2010. Retrieved from http://www.census.gov Accessed February 8, 2012.
• Whelan, T. (2008) The escalating trend of violence towards nurses. Journal of Emergency Nursing, 34, 130-133.
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