Critical Incident Pre-Briefing: How a Student can Prepare for the Complexity of Practice

Protecting Yourself from Workplace Violence in Healthcare

Academia prepares practicing clinicians for many things, but many lessons do not sink in until we experience them firsthand. You may have sat through workplace violence training during your time in school, but do you feel prepared to act should such an event arise during your time in practice? Maybe you’ve experienced workplace violence in healthcare first hand already, either as a student or practicing as a clinician, and you are searching for meaning and empowerment. I hope this article can aid in your journey, and provide you with insights on how to prepare and protect yourself, your peers and your patients.

What is considered a Workplace Violence Incident?

Familiarity with workplace violence is important to fully understand and prepare to address this problem. The World Health Organization provides a general definition of workplace violence, acknowledging variance in terminology from country to country and situation to situation:

“Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health” (p.3).1

Physical violence in the workplace has long been the focus of many prevention programs, but verbal violence in the form of threats, verbal abuse, hostility, and harassment is the “silent killer” causing much psychological trauma and stress.2 It is important to note verbal violence can increase the likelihood of physical violence.2

Among medical and nursing students:

1. Workplace violence in nursing. Twenty-one percent of RNs and nursing students report a history of physical assault in the workplace, and over 50% reported verbal abuse in a 12-month period (according to a 2014 American Nurses Association Health Risk Appraisal)2

2. Workplace violence in medicine. Among medical students, reported incidence of workplace violence can range from 21.5% to 72.5%, and verbal violence is found as most prevalent.3 Further, in a cross-sectional survey by Sahraian, Hemyari, Ayatollahi & Zomorodian: 26.1% of the 193 medical students participating reported a history of sexual harassment. Many of the same challenges in reporting workplace violence in healthcare are the same when identifying and reporting sexual harassment and assault.

“That could have been me.”

“Standing in the ambulance bay, my former non-commissioned officer in charge told me over the phone,’ I don’t know if you knew, but Katie was attacked last night by Cliff.”

It was over a year since I’d left employment at Munson Army Health Center in Fort Leavenworth, KS to work in the emergency department at Joint-Base Lewis McChord, Washington. My first thought upon hearing the news was selfish: “That could have been me.” First Lieutenant Katie Blanchard was my replacement as the Pediatric Clinic and Exceptional Family Member Program Clinical Nurse Officer in Charge. She took over the clinic and personnel, including her eventual perpetrator. A little over a year since this transition, the warm and competent nurse I had only known for a few weeks was now fighting for her life.

Katie is strong, and her road to recovery was plagued with unnecessary suffering. She unjustly suffered a predictable and preventable event. She currently works hard addressing the workplace culture and modifiable risks which breed workplace violence (among other advocacy efforts). As the former direct supervisor to Katie’s perpetrator, any action or inaction I took ultimately resulted in her attack. Retrospectively, I see the warning signs during my time, and understand the direction they took. I can blame inexperience, lack of training, a toxic work environment and a myriad of excuses. However, there is nothing I can do to change the past, and I feel as much guilt now as I did the day I received the phone call. This does not mean I am powerless now, and I hope I can help others feel less powerless as well.

Hope Head On

It’s important to note the scariness of this topic, but to say we live in a frightening world is an understatement. My intention is to prepare you, Dear Reader, with the knowledge necessary to navigate the dangerous seas of ambiguity and misunderstanding and be(come) the health-care professional your family and friends see. It’s obvious you have the courage to be this person (you’ve made significant steps into the unknown), and your current or future roles will require this same courage.

You can do things now to prepare for the possible and unwelcomed challenge of workplace violence. First, start by finishing this article to find great advice and resources to improve your understanding and develop a personal strategy for workplace violence prevention.. Second, speak with your co-workers, instructors, family and friends about it. Discussions such as these can help to create zero-tolerance organizations and groups not afraid of the problem, but ready to address it in meaningful ways.

How to Identify Potentially Risky Situations Before They Become a Problem

WHO highlights possible background findings and warning signs for understanding how individuals can become potential perpetrators of workplace violence. Thinking of these characteristics and behavior as akin to a medical history and lifestyle choices, they contribute to a disease process but require careful assessment for comprehensive understanding of future risk.

WHO’s Considerations of Potential Perpetrators1

Background

  • History of violent behavior
  • Difficulty in childhood
  • Substance abuse, especially alcohol abuse
  • Severe mental illness not thoroughly understood or controlled through therapy
  • Access to firearms or other weapons

Warning Signals

  • Aggressive or hostile postures and attitudes
  • Repeated manifestations of discontent, irritability or frustration
  • Alterations in tone of voice, size of pupils (dilation during periods of aggression or stress), muscular tension, sweating
  • Escalation of signals and building up of tense situations

Workplace Violence Policy in Healthcare

Sadly, there is no federally-mandated standardized process or regulatory requirement for health care workers to report workplace violence in the U.S.7. Workplace violence reporting policies and procedures are the responsibility of local healthcare facilities, and as you can imagine, this leads to a fragmented system7. Further, there is no centralized database or external support network to these facilities where incidents can be accessed by administrators, researchers or policy-makers for further understanding7. Currently, nine U.S. states (Washington, Oregon, California, Illinois, New York, Maine, Connecticut, New Jersey and Maryland) offer some form of State-directed workplace violence prevention program with possible standardized reporting procedures8.

The bottom line is: assess your local health care facility (or University) for their current policies and procedures on how to report workplace violence. Speaking with administrators, like instructors, preceptors, supervisors or HR personnel, about how to report may provide good insight into how incidents are handled. Starting with those (unless the person is your perpetrator) familiar with the workplace environment and standards can provide you with valuable allies and resources. Addressing this issue needs not just one, but many, in a cohesive effort to address and prevent workplace violence. Also, many of these administrators may represent greater agencies (like those listed below) at the facility. It is important to know there are individuals readily available to help you when you need assistance.

If you have further concerns above what your local facility can address, or if you’ve personally experienced a workplace violence incident that was not managed adequately, there are other supporting agencies where you can seek assistance:

  1. The Occupational Safety and Health Administration (OSHA). Federal law ensures you are entitled to a safe workplace. OSHA has regional and area offices throughout the country, as well as a toll-free number at 1-800-321-6742 (OSHA)9.
  2. The U.S. Equal Employment Opportunity Commission (EEOC).

Unsurprisingly, many instances of workplace violence are vastly underreported, especially bullying or verbal abuse.2,6 Among emergency nurses, reasons contributing to not and underreporting workplace violence includes not sustaining an injury as a result of the event, bureaucracy and perceived futility in reporting, workplace violence seen as “normal” for the profession, and not holding patients accountable due to their age/condition/illness.6 OSHA cites risk for underreporting due to absence of formal reporting policies, a lack of trust in the reporting system and fear of retaliation.

Documenting Incidents

Workplace violence policies vary by organization. Documenting incidents requires a dedicated organized effort by a team of professionals in addition to the person affected by workplace violence. These professionals can be supervisors, department heads, security personnel, patient/employee safety offices, and others. Though there is not a centralized reporting database, ensuring incidents of workplace violence are adequately documented and catalogued is integral to any functioning health care organization. Failure to do so by said organizations can lead to litigation or penalty. There are some important points to note, and a model reporting checklist comes from Oregon’s Health Safety Initiative and OSHA10. Some recommended documents include10:

  • OSHA Log of Work-Related Injuries and Illnesses (OSHA Forms 300 and 301) – Federally mandated reporting forms
  • Medical report of work injury, workers’ compensation reports or supervisor reports for each recorded assault
  • If available, a Health Care Assault Log (currently mandatory for hospitals and ambulatory surgical centers in Oregon)
  • Security personnel and threat response team reports
  • Local facility emergency response reports for Codes related to workplace violence or combative patients

Is the patient’s electronic medical record (EMR) a suitable place to document these incidents? The EMR and other clinical documents are only used to document relevant medical information pertaining to the patient’s condition. For example, a patient under the influence of drugs who physically assaults a nurse may exemplify specific and objective information pertaining to the incident. Some details such as specific behavior before, during and after the assault, clinical assessment by health care professionals involved in patient care during the incident, evaluation of injuries sustained by the patient after the assault, and other details affecting the patient should be inputted into the clinical record. Any details not pertaining to the patient’s health status should be placed into facility approved documentation or recommended documentation (in the absence of facility approved policies, documents and procedures to handle workplace violence), as listed above.

Training and Educational Programs for Students

In addition to the resources provided by your school, here are a few resources that can help you better prepare for your future as a practicing clinician.

  1. Workplace Violence Prevention for Nurses4 – Presented by the National Institute for Occupational Safety and Health (NIOSH), this free and interactive course can help not just nurses, but other healthcare workers, to further understand workplace violence in healthcare4. Not only is an overview provided in the course, specific strategies for nurses and organizations are outlined. It may increase confidence in communication and working with teams to prevent and mitigate risks of violence, and identify specific resources for those who’ve been harmed4.
  2. Aspire…to Lead: Worker-on-Worker Workplace Violence 20205 – Sponsored by the Association for Nursing Professional Development (NPD), CPT (Retired, US Army) Katie Ann Blanchard, BSN, RN discusses the prevalence of workplace violence in healthcare5. This continuing education (1 contact hour) seminar can increase knowledge and awareness of the problem, and present mitigation techniques for attendees. Registration with the NPD and a $15.00 member charge ($30.00 non-member) is required for online attendance.
  3. #EndNurseAbuse6 – The American Nurses Association’s (ANA) empowering initiative to address workplace violence in the health care setting, they advocate for individual and collective prevention of this critical issue. An issue brief, online webinar, resource guide, and advocacy tools (collective pledge and link to contact legislation) are offered through this link6.

As always, I wish you luck on all your endeavors. Whether you are a doctor, nurse, therapist or physician assistant, or a student in any of these graduate healthcare training programs, being informed and trained to protect yourself from workplace violence is an important step in your healthcare career training. The team at Picmonic not only hopes to support your academic endeavors through innovative products, but is ready to support students in meaningful ways during these trying times. I, as a representative of this open-minded organization, serves as an ambassador of this caring mission to you, Dear Reader. I hope to see you soon on the front lines, advocating not only for our patients, but for all our current and future healthcare professionals. -Josh

References

  1. WHO. (2002). Framework guidelines for addressing workplace violence in the health sector [Collaborated Framework]. Retrieved from https://www.who.int/violence_injury_prevention/violence/interpersonal/en/WVguidelinesEN.pdf?ua=1
  2. National Institute for Occupational Safety and Health. (n.d.). Workplace violence in healthcare [Issue Brief]. Retrieved from https://www.osha.gov/Publications/OSHA3826.pdf
  3. Sahraian, A., Hemyari, C., Ayatollahi, M., & Zomorodian, K. (2016). Workplace violence against medical students in Shiraz, Iran. Shiraz E-Med, 17(4-5), 1-7. https://doi.org/10.17795/semj35754
  4. CDC. (n.d.). Workplace violence for nurses. Retrieved from https://www.cdc.gov/niosh/topics/violence/training_nurses.html
  5. NPD. (2020). Professional development center: Aspire…to lead: worker-on-worker violence. Retrieved from anpd.mycrowdwisdom.com/diweb/catalog/item/id/3387976/q/q=workplace*20violence&c=164
  6. Emergency Nurses Association. (2019). Violence and its impact on the emergency nurse [Position statement]. Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/violenceintheemergencycaresetting.pdf?sfvrsn=49343551_10
  7. American Nurses Association. (2019). Reporting incidents of workplace violence [Issue Brief]. Retrieved from https://www.nursingworld.org/globalassets/practiceandpolicy/work-environment/endnurseabuse/endabuse-issue-brief-final.pdf
  8. Occupational Safety and Health Administration. (n.d.). Workplace violence prevention and related goals [White paper]. Retrieved from https://www.osha.gov/Publications/OSHA3828.pdf
  9. OSHA. (n.d.). Concerned about health and safety on the job? Retrieved from https://www.osha.gov/workers/index.html
  10. Oregon Association of Hospitals Research and Education Foundation. (2017). Stop violence in health care [Prevention Toolkit]. Retrieved from https://osha.oregon.gov/edu/grants/train/Documents/oahhs-workplace-safety-violence-prevention-toolkit.pdf
I began my 14-year medical/ “Mursing” career as a Combat Medic for the Army Reserve. Shortly after completion of my BSN, I commissioned into the U.S. Army as an Army Nurse and began my tour of duty at Brooke Army Medical Center in San Antonio, TX. My adventures have brought forth a beautiful wife, three red-headed children, and two dogs (Whisky and Pancakes). We’ve lived in Arkansas, Texas, Kansas, Texas (yes, twice), Washington and Missouri. As of this captain’s log, I’m working on completion of my BSN-DNP program at Missouri State University to become a family nurse practitioner. My prior experience and friends in medical-surgical, outpatient primary/specialized care, nursing administration, and emergency/trauma nursing (MY FAVES) motivate me to guide, mentor, teach, learn from, share bread with, play dodgeball against, and be inspired by the next generation of not only nurses and APRNs, but the entire medical and allied health community.
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