Post on 27-Oct-2020
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DEPARTMENT OF NURSING
Tarra Kerr, DNP, RN, NEA-BCJennifer Sanders, DNP, RN, NEA-BC
SAFER: IMPROVING WORKPLACE VIOLENCE COMPETENCE
WITHIN AN EMERGENCY DEPARTMENT
DEPARTMENT OF NURSING
TEXAS CHILDREN’S• Opened in 1954• World’s largest children’s hospital• Ranked third in the nation• 3 campuses with 971 licensed beds• 11 million square feet• 17,000 physicians, nurses, and staff• 150,000+ Emergency Center visits• 4.2 million+ patient encounters• 37,000+ surgeries• 6,000+ deliveries• 430,000+ Health Plan members
DEPARTMENT OF NURSING
• Dr. Beth Ulrich, DNP advisor
• Dr. Joseph Hagan, statistical consultant
• Site leadership• Michelle Riley-Brown, President of Texas Children’s West Campus• Mary Jo Andre, Chief Nursing Officer• Gail Parazynski, Vice President of Nursing• Paul Sirbaugh, former Chief of Pediatric Emergency Medicine• Dr. Kay Leaming, Medical Director of West Campus Emergency Center • Jacqueline Newton, former Assistant Director of West Campus Emergency Center
• Key Partners• Mike Hogan, former Director of Security• James Mitchell, Assistant Director of Emergency Management• Lauren Ivanhoe, Staff Development Specialist • Charlyn Davis, Pediatric Emergency Medicine Quality Specialist
ACKNOWLEDGEMENTS
DEPARTMENT OF NURSING
BACKGROUNDNational Institute of Occupational Safety and Health (NIOSH) Workplace Violence
(WPV) Definition: “physically and/or psychologically damaging actions that occur in the workplace or while on duty” (NIOSH, 2002, p. 1)
In one 7-day period 12% of Emergency Center (EC) RN’s experienced physical abuse, 59% verbal abuse (ANA, 2014)
Pediatric EC: 43% of staff concerned for personal safety & security; 30% report feeling fearful several times a month (Shaw, 2015)
People
$4.2 billion spent annually on WPV across all professions with nursing ranked second to law enforcement (Gallant-Roman, 2008)
Costs of medical treatment or loss of work for WPV for 1 hospital system over 1 year $94,156 (Speroni et al., 2014)
Finance
WPV tied to higher risk of medication errors & patient infection (Rogers et al., 2004)
ENA members: 37% reported negative productivity scores, including decreases in cognitive performance after a WPV event (Gates et al., 2011)
Quality
DEPARTMENT OF NURSING
• Vastly underreported (ASIS International, 2011; Gillespie et al., 2014)
• Increased turnover/attrition (Edwards et al., 2014; Schalk et al., 2010)• Psychological consequences (Fernandes et al., 1999; Gates et al., 2011)• Absenteeism (Speroni et al., 2014)• Decreased productivity (Gates et al., 2011)• Impaired job function (Fernandes et al., 1999; Kowalenko et al., 2013)
• Impact on quality of care (Gates et al., 2011; Gillespie et al., 2014)• Financial burden (Speroni et al., 2014)
SIGNIFICANCE
DEPARTMENT OF NURSING
SETTING AND CONTEXT
• Setting: pediatric, community based, acute-care hospital
• Context: 25 bed Pediatric Emergency Center as pilot unit
• 76 nursing team members: Registered Nurses, Patient Care Assistants, Unit Clerical Assistants, Patient Registration Staff
• Setting: pediatric, large urban quaternary facility
• Context: 42 bed Pediatric Emergency Center as pilot unit
• 128 nursing team members: Registered Nurses, Emergency Medical Technicians, Patient Care Assistants, Unit Clerical Assistants
Texas Children’s West Campus Texas Children’s Medical Center
DEPARTMENT OF NURSING
• Increase the EC nursing care team members competence and confidence when responding to workplace violence as indicated by a 5% increase in post-test scores.
• Improve the EC nursing care team members perception of environmental safety related to WPV as indicated by a 5% increase in post-test scores.
AIM STATEMENT
DEPARTMENT OF NURSING
METHODOLOGY
NIOSH computer based module
Didactic course
Simulation scenarios
Environmental assessment
Quality Improvement Model Utilized: IHI Model for Improvement• PDSA 1: pre-assessment survey pilot• PDSA 2: launch of final pre-assessment survey• PDSA 3: initial pilot of didactic course and simulation scenarios• PDSA 4: launch of final didactic course simulation scenarios
Comprehensive WPV Program
DEPARTMENT OF NURSING
OUTCOMES AND RESULTS Outcome Measurement Method Results – TCH West Results – TCH MC
Volume of Event Reports(Outcome Measure)
Organizational Event Reporting System
p-value 1.0 p-value 1.0
Staff Competence (Outcome Measure)
Pre/Post knowledge assessment toolbased on NIOSH content in modules
Validation of competence post simulation
p-value <0.05 in 9 of 20 questions p-value <0.05 in 12 of 20 questions
Staff Confidence(Outcome Measure)
Confidence assessment visual analog scale
p-value <0.05 for all 9 questions p-value <0.05 for all 9 questions
Staff Perception of physical safety(Outcome Measure)
Safety perceptions visual analog scale p-value <0.05 for 1 of 4 questions p-value <0.05 for 2 of 4 questions
Number of Employees Trained(Process Measure)
Educational database Program completion: 70 of 76 (91%) Program completion: 131 of 154 (85%)
Employee Evaluation of Training(Process Measure)
American Nurses Credentialing Center survey template
Online module 4.79/5.00 Didactic and simulation 4.71/5.00 Course instructor 4.81/5.00
Online module 4.80/5.00 Didactic and simulation 4.76/5.00 Course instructor 4.85/5.00
DEPARTMENT OF NURSING
OUTCOMES AND RESULTS Outcome Measurement Method Results – TCH West Results – TCH MC
Volume of Event Reports(Outcome Measure)
Organizational Event Reporting System
p-value 1.0 p-value 1.0
Staff Competence (Outcome Measure)
Pre/Post knowledge assessment toolbased on NIOSH content in modules
Validation of competence post simulation
p-value <0.05 in 9 of 20 questions p-value <0.05 in 12 of 20 questions
Staff Confidence(Outcome Measure)
Confidence assessment visual analog scale
p-value <0.05 for all 9 questions p-value <0.05 for all 9 questions
Staff Perception of physical safety(Outcome Measure)
Safety perceptions visual analog scale p-value <0.05 for 1 of 4 questions p-value <0.05 for 2 of 4 questions
Number of Employees Trained(Process Measure)
Educational database Program completion: 70 of 76 (91%) Program completion: 131 of 154 (85%)
Employee Evaluation of Training(Process Measure)
American Nurses Credentialing Center survey template
Online module 4.79/5.00 Didactic and simulation 4.71/5.00 Course instructor 4.81/5.00
Online module 4.80/5.00 Didactic and simulation 4.76/5.00 Course instructor 4.85/5.00
DEPARTMENT OF NURSING
OUTCOMES AND RESULTSQuestion
p-valueTCH-WC
p-valueTCH-MC
Workplace Violence (WPV) is defined as physically and/or psychologically damaging actions that occur in the workplace or while on duty. 0.033* 0.0050*Making others afraid or fearful through threatening behavior is intimidation. 0.082 0.0060*WPV includes many behaviors. Understaffing is not an example of WPV. 0.312 0.0647
According to the American Nurses Association, 59% of emergency department registered nurses experience verbal abuse in a 7-day period. 0.677 0.0010*
According to the National Institute for Occupational Safety and Health (NIOSH), 1.7 million people are victims of non-fatal workplace assaults each year. 0.000* 0.0000*
The main reason for WPV in the healthcare setting is stress. 0.004* 0.0030*
A nurse caring for an involuntarily admitted patient with a history of violent behavior is at highest risk for experiencing WPV in the healthcare setting. 0.059 0.0570
Enforcing limits on a patient eating or drinking is associated with higher risk for WPV. 0.000* 0.0000*Workplace violence can lead to low morale. 0.513 0.1140
One reason an employee is more likely to report WPV includes clear policies and procedures on WPV reporting. 0.016* 0.6490
True: Employees have the right to a safe working environment where WPV is not tolerated. 1.000 1.0000Patients often feel frustrated, vulnerable, and out-of-control. As feelings intensify, the patient’s hostile behavior is likely to intensify through 3 levels of tension, disruption, and violence. A patient yelling at the doctor is not an example of expressing tension. 0.000* 0.0000*
When a patient is tense, it is important to listen and ask questions to show you are interested and concerned. Then, ask follow-up questions and summarize what you have heard the patient say. 0.269 0.0760
When a patient is disruptive, it is important to explain that you will not be able to help until the patient stops the disruptive behaviors. Be polite, clear, and firm. 0.027* 0.1220
Your top priority when a patient is violent is to get yourself and others to safety 0.018* 0.0000*
True: According to hospital policy, Texas Children’s maintains a strict zero-tolerance policy prohibiting violence, harassment, and/or inappropriate and disrespectful conduct. 0.312 0.0220*The types of workplace violence outlined at Texas Children’s does not include violent acts in the community by a patients’ family members or any others from whom the organization provides services. 0.011* 0.0010*
True: Any Texas Children’s workforce member who believes he or she has been or is being subjected to, or has knowledge of workplace violence, harassment or prohibited conduct, is required to report the incident. 0.906 0.0370*
Texas Children’s has formed a multidisciplinary Workplace Violence Prevention and Response Team in order to effectively coordinate prevention and response activities. One of the primary members includes a representative from Risk Management. 0.516 0.2930
WPV awareness and training occur at Texas Children’s new employee orientation and annual required training. 0.272 0.0080*
DEPARTMENT OF NURSING
OUTCOMES AND RESULTSQuestion
p-valueTCH-WC
p-valueTCH-MC
Workplace Violence (WPV) is defined as physically and/or psychologically damaging actions that occur in the workplace or while on duty. 0.033* 0.0050*Making others afraid or fearful through threatening behavior is intimidation. 0.082 0.0060*WPV includes many behaviors. Understaffing is not an example of WPV. 0.312 0.0647
According to the American Nurses Association, 59% of emergency department registered nurses experience verbal abuse in a 7-day period. 0.677 0.0010*
According to the National Institute for Occupational Safety and Health (NIOSH), 1.7 million people are victims of non-fatal workplace assaults each year. 0.000* 0.0000*
The main reason for WPV in the healthcare setting is stress. 0.004* 0.0030*
A nurse caring for an involuntarily admitted patient with a history of violent behavior is at highest risk for experiencing WPV in the healthcare setting. 0.059 0.0570
Enforcing limits on a patient eating or drinking is associated with higher risk for WPV. 0.000* 0.0000*Workplace violence can lead to low morale. 0.513 0.1140
One reason an employee is more likely to report WPV includes clear policies and procedures on WPV reporting. 0.016* 0.6490
True: Employees have the right to a safe working environment where WPV is not tolerated. 1.000 1.0000Patients often feel frustrated, vulnerable, and out-of-control. As feelings intensify, the patient’s hostile behavior is likely to intensify through 3 levels of tension, disruption, and violence. A patient yelling at the doctor is not an example of expressing tension. 0.000* 0.0000*
When a patient is tense, it is important to listen and ask questions to show you are interested and concerned. Then, ask follow-up questions and summarize what you have heard the patient say. 0.269 0.0760
When a patient is disruptive, it is important to explain that you will not be able to help until the patient stops the disruptive behaviors. Be polite, clear, and firm. 0.027* 0.1220
Your top priority when a patient is violent is to get yourself and others to safety 0.018* 0.0000*
True: According to hospital policy, Texas Children’s maintains a strict zero-tolerance policy prohibiting violence, harassment, and/or inappropriate and disrespectful conduct. 0.312 0.0220*The types of workplace violence outlined at Texas Children’s does not include violent acts in the community by a patients’ family members or any others from whom the organization provides services. 0.011* 0.0010*
True: Any Texas Children’s workforce member who believes he or she has been or is being subjected to, or has knowledge of workplace violence, harassment or prohibited conduct, is required to report the incident. 0.906 0.0370*
Texas Children’s has formed a multidisciplinary Workplace Violence Prevention and Response Team in order to effectively coordinate prevention and response activities. One of the primary members includes a representative from Risk Management. 0.516 0.2930
WPV awareness and training occur at Texas Children’s new employee orientation and annual required training. 0.272 0.0080*
DEPARTMENT OF NURSING
OUTCOMES AND RESULTS – TCH WC Evaluation Metric Mean Median
Pre-Competence 66.6 77.0
Post-Competence 81.4 92.0
Competence Difference +14.8 +15.0
Competence % Change 22.4% 19.4%
Pre-Confidence 3.37 3.41
Post-Confidence 4.21 4.24
Confidence Difference +0.85 +0.83
Confidence % Change 25.1% 24.2%
Pre-Safety 2.99 3.00
Post-Safety 3.23 3.18
Safety Difference +0.24 +0.18
Safety % Change 8.1% 6.0%
12345
Q1. Q2. Q3. Q4. Q5. Q6. Q7. Q8. Q9.
VAS
CON
FIDE
NCE
SC
ORE
ASSESSMENT QUESTIONPRE POST
2.64 2.803.20 3.31
2.82 2.973.39
3.74
1
2
3
4
5
Waiting room Triage Exam room Majortreatment/trauma
room
VAS
SAFE
TY S
CORE
DEPARTMENT LOCATIONPRE POST
Goal = 5%
DEPARTMENT OF NURSING
OUTCOMES AND RESULTS – TCH MC Evaluation Metric Mean Median
Pre-Competence 68.4 75.0
Post-Competence 80.5 82.5
Competence Difference +12.1 +7.5
Competence % Change 17.7% 10.0%
Pre-Confidence 3.46 3.42
Post-Confidence 4.05 4.07
Confidence Difference +0.59 +0.65
Confidence % Change 17.1% 19.0%
Pre-Safety 2.86 2.84
Post-Safety 3.28 3.23
Safety Difference +0.43 +0.40
Safety % Change 14.7% 13.7%
2.58 2.66 3.01 3.183.00 3.00 3.46 3.67
1.02.03.04.05.0
Waiting room Triage Exam room Majortreatment/trauma
roomVAS
SAFE
TY S
CORE
DEPARTMENT LOCATIONPRE POST
12345
Q1. Q2. Q3. Q4. Q5. Q6. Q7. Q8. Q9.
VAS
CON
FIDE
NCE
SCO
RE
ASSESSMENT QUESTIONPRE POST
Goal = 5%
DEPARTMENT OF NURSING
LESSONS LEARNED
• Project implementation date
• Technology available
• Deployment of pre-test and post-test
• Key stakeholder partnerships
• Leveraging team member strengths
DEPARTMENT OF NURSING
• Texas Health & Human Services Grant• Innovative approaches for reducing
verbal and physical violence against nurses
• Partnership with UT Health Science Center Cizik School of Nursing
• Awarded $179,979.49
NEXT STEPS
DEPARTMENT OF NURSING
DEPARTMENT OF NURSING
REFERENCES
American Nurses Association (2014). American Nurses Association Health Risk Appraisal (HRA): Preliminary findings October 2013–October 2014. Retrieved from http://nursingworld.org/HRA-Executive-Summary
Einarsen, S., Hoel, H., & Notelaers, G. (2009). Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the Negative Acts Questionnaire-Revised. Work & Stress, 23 (1), 29-44.
Gallant-Roman, M. (2008). Strategies and tools to reduce workplace violence. AAOHN Journal, 56(11), 449-454.
Gates, D. M., Gillespie, G. L., & Succop, P. (2011). Violence against nurses and its impact on stress and productivity. Nursing Economic$, 29(2), 59-66.
Gerberich, S.G., Church, T.R., McGovern, P.M., Hansen, H.E., Nachreiner, N.M., Geisser, M.S.,… Ryan, A.D. (2004). An epidemiological study of the magnitude and consequence of work related violence: The Minnesota Nurses’ Study. Occupational and Environmental Medicine,61(6), 495–503.
DEPARTMENT OF NURSING
REFERENCES
Gillespie, G. L., Gates, D. M., Kowalenko, T., Bresler, S., & Succop, P. (2014). Implementation of a comprehensive intervention to reduce physical assaults and threats in the emergency department. Journal of Emergency Nursing, 40(6), 586-591.
Larrabee, J.H. (2009). Nurse to nurse: Evidence-based practice. New York: McGraw-Hill Publishers.
National Institute for Occupational Safety and Health. (2002). Violence occupational hazards in hospitals. Retrieved from http://www.cdc.gov/niosh/ docs/2002-101
Rogers, A.E., Hwang, W.T., & Scott, L.D. (2004). The effects of work breaks on staff nurse performance. Journal of Nursing Administration, 34 (11), 512–519.
Shaw, J. (2015). Staff perceptions of workplace violence in a pediatric emergency department. Work, 51 (1), 39-49.
Speroni, K.G., Fitch, T., Dawson, E., Dugan, L., & Atherton, M. (2014). Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing, 40(3), 218–228.
DEPARTMENT OF NURSING
APPENDIX
A. ENA Environmental Risk Assessment Tool SampleB. NIOSH Computer-based Training Course Map
DEPARTMENT OF NURSING
APPENDIX A: ENA ENVIRONMENTAL RISK ASSESSMENT
DEPARTMENT OF NURSING
APPENDIX B: NIOSH COMPUTER-BASED TRAINING MODULE
Workplace Violence Course Map
Introduction 1.1 Introduction 1.2 Course Rationale 1.3 Course Goals 1.4 Course Outline Violence in the Healthcare Setting 2.1 Introduction & Objectives 2.2 How High Is the Risk? 2.3 Why Are Healthcare Workers at Increased Risk? 2.4 Who Is at Greatest Risk? 2.5 When Is the Risk Greatest? 2.6 Where Is the Risk Greatest? 2.7 What Are the Risks? 2.8 Additional Risk Factors Workplace Violence Prevention Programs 3.1 Introduction & Objectives 3.2 OSHA Recommendations 3.3 Components of Violence Prevention Programs 3.4 Written Plan 3.5 Management Commitment 3.6 Employee Involvement 3.7 Worksite Analysis 3.8 Hazard Prevention & Control (1) 3.9 Hazard Prevention & Control (2) 3.10 Hazard Prevention & Control (3) 3.11 Health & Safety Training 3.12 Post-Incident Response 3.13 Evaluation & Recordkeeping Recognizing and Responding to Combative Behavior 4.1 Introduction & Objectives 4.8 Violence: Recognition 4.2 Safety Training 4.9 Violence: Response 4.3 Dynamics of Combative Behavior 4.10 Reporting 4.4 Tension: Recognition 4.5 Tension: Response 4.6 Disruptiveness: Recognition 4.7 Disruptiveness: Response