NUR 7020 Module 5 Health Care Environment Paper: Workplace Violence and an Emergency Department Prevention Program Example

Not Part of the Job: Building a Violence Prevention Program in a Jersey City Emergency Department

Student Name

M.S. in Nursing, Nursing Administration, Thomas Edison State University

NUR-7020: Nursing Administration: Executive Managerial Process

Mentor Name

Month Day, Year

Not Part of the Job: Building a Violence Prevention Program in a Jersey City Emergency Department

The Event and the Pattern

Everything about this Jersey City department, its staff and its patients is invented. The emergency department at a hospital in Jersey City sees about 85,000 visits a year and cares for many patients in behavioral crisis or intoxicated. One night in March, a man brought in by police after a fight struck a nurse who was taking his blood pressure. She fell, hit her head and missed six weeks of work with a concussion. The department's staff were shaken but not surprised. In a quick survey after the event, 71 percent of emergency nurses said they had been physically threatened in the past year and 38 percent said they had been hit, kicked, scratched or spat on, yet the hospital's reporting system held only nine reports of violence from the department for the whole year.

The manager, completing her MSN in nursing administration, was asked to lead the response with the hospital's security director and the employee health office.

What the Evidence Shows

Phillips (2016) gathered what is known about assaults and threats against American health care staff. Health care workers face nonfatal violence at work at rates well above those of most other occupations, and most of it comes from patients and their visitors rather than from coworkers or strangers. Emergency departments and psychiatric settings carry the highest risk. Much violence goes unreported, because staff see it as part of the job, believe that reporting will change nothing or worry about being blamed. The review described consequences for workers, including injury, fear, burnout and leaving the profession, and noted that the evidence on what prevents violence was still limited but that comprehensive programs showed promise.

The department's survey and its nine reports fit that picture exactly.

Regulatory Expectations

Federal guidelines (Occupational Safety and Health Administration, 2016) set out how hospitals and social service agencies should prevent violence against their staff. They build a program from five parts: leaders committed and workers involved, an analysis of the worksite, controls on the hazards found, training in safety, and records kept and used to evaluate the program. The guidelines give examples for each, such as alarm systems, furniture arranged so staff are not trapped, limits on access to treatment areas, training in recognizing escalation and procedures for reporting and responding.

In 2018, the Joint Commission (2018) warned accredited organizations, in a sentinel event alert, about staff being hit, threatened and verbally abused. It asked organizations to define workplace violence clearly, make it easy to report, capture and analyze all incidents, train staff in de-escalation and response, support staff after an event and review the program regularly. New Jersey's own law on violence prevention in health care facilities also requires hospitals to maintain a violence prevention program with a committee that includes direct care staff, assess risks and train employees.

The Program

The program follows OSHA's five elements, adapted to the department.

Management commitment and worker participation. The hospital president issued a statement that violence against staff is not part of the job, and the violence prevention committee added four emergency nurses, a technician and a security officer, who meet monthly.

Worksite analysis. The committee walked the department at different hours with security and found treatment rooms where the door was behind the patient's bed, blind spots in the waiting room and no quick way to call for help from the triage desk.

Hazard prevention and control. Rooms used for behavioral crises were rearranged so staff have a clear exit, wearable alarms were issued to every staff member, a security officer was stationed at triage from 1800 to 0600 and the electronic record now flags patients with a history of violence so that staff can plan an approach, without denying care.

Training. All staff complete four hours of de-escalation training with role play, and staff in high-risk areas complete an additional session on safe physical response. The training includes recognizing early signs of agitation and using a team approach.

Reporting and evaluation. A two-minute electronic report replaced the paper form, and the manager announced that reporting will never count against a nurse's performance review. Every report receives a response within 72 hours. The committee reviews all events monthly.

Working With Security and Behavioral Health

The program depends on partners the manager does not supervise. Security officers had been trained to respond to threats but not to help de-escalate, and some staff felt that officers arrived too late or too forcefully. The manager and the security director arranged joint de-escalation training so that nurses and officers practice together and agree on who leads. The hospital's behavioral health team agreed to respond within thirty minutes to emergency department calls for patients in crisis, reducing the hours such patients wait in a busy, noisy space that can make agitation worse. These agreements address the conditions that lead to violence, not only the response once it starts.

Support After an Event

After any assault, the charge nurse arranges immediate relief for the staff member, employee health follows up within 24 hours and peer supporters trained by the hospital offer a conversation within a week. The manager meets with the injured nurse before her return to discuss what she needs, such as a different assignment for her first shifts.

Measures

The department will track reports of violence by type and severity, injuries requiring treatment, lost workdays, completion of training and staff perceptions of safety on an annual survey. Reports are expected to rise at first, because better reporting is a goal of the program.

Limits

The evidence that specific interventions prevent violence is still limited. A security presence may make some patients feel unwelcome, and flags in the record can lead to stigma if used carelessly. Training does not change the behavior of patients in crisis, only staff responses to it.

Conclusion

A serious injury exposed a pattern of violence that the department had accepted and rarely reported. Evidence, federal guidelines, the Joint Commission's expectations and state law all point toward a comprehensive program. The department's program commits leaders, analyzes the worksite, changes the environment, trains staff, simplifies reporting and supports staff after an event.

References

Joint Commission. (2018). Physical and verbal violence against health care workers. Sentinel Event Alert, (59). https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/

Occupational Safety and Health Administration. (2016). Guidelines for preventing workplace violence for healthcare and social service workers (OSHA 3148-06R). U.S. Department of Labor.

Phillips, J. P. (2016). Workplace violence against health care workers in the United States. New England Journal of Medicine, 374(17), 1661-1669. https://doi.org/10.1056/NEJMra1501998