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Letter to the Editor

A Framework for Translating Workplace Violence Intervention Research into Evidence-Based Programs

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Kathleen M. McPhaul, PhD, MPH, RN
Matthew London, MS
Jane A. Lipscomb, PhD, RN, FAAN

Abstract

Workplace violence, a dangerous and complex occupational hazard in the modern health care work environment, presents challenges for nurses, other health care employees, management, labor unions, and regulators. Violence from patients, visitors, and coworkers is often tolerated and explained as part of the job in the fast-paced, stressful health care delivery workplace. Addressing violence in health care requires very purposeful organizational processes conducted by very specific organizational structures. The strength of the scientific evidence for workplace violence prevention strategies is well past the “emerging” evidence stage but has not achieved the “unequivocal” stage. It is unlikely that workplace violence interventions will be tested using randomized controlled experimental conditions. Consequently, educated and aware nurses often provide key leadership for organizations undertaking the development of workplace violence prevention programs, but must do so using local evidence generated at the facility level. In some cases, tools such as state regulations and federal workplace safety policies provide important impetus and support for nurses and hospitals undertaking these transformational programs. This article provides background information about workplace violence and offers a framework for developing comprehensive workplace violence prevention programs built on the existing scientific evidence, regulatory guidance, and locally generated practice evidence

Citation: McPhaul, K., London, M., Lipscomb, J., (January 31, 2013) "A Framework for Translating Workplace Violence Intervention Research into Evidence-Based Programs" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol18No01Man04

Key words: workplace violence, occupational hazards in health care, workplace violence prevention program, workplace violence prevention framework, evidence based programs

Violence from patients, visitors, and coworkers is often tolerated and explained as just part of the job in the fast-paced, stressful health care delivery workplace. Workplace violence, a dangerous and complex occupational hazard in the modern health care work environment, presents challenges for nurses, other health care employees, management, labor unions, and regulators. Violence from patients, visitors, and coworkers is often tolerated and explained as just part of the job in the fast-paced, stressful health care delivery workplace (Allen, 2011; CDC/NIOSH, 2002; McPhaul & Lipscomb, 2004; Trossman, 2010; University of Iowa, 2001). Addressing violence in health care requires purposeful organizational processes conducted within very specific organizational structures. The strength of the scientific evidence for workplace violence prevention strategies is well past the “emerging” evidence stage but has not achieved the “unequivocal” stage. It is unlikely that workplace violence interventions will be tested using randomized controlled experimental conditions. Consequently, educated and aware nurses often provide key leadership for organizations undertaking the development of workplace violence prevention programs, but must do so using local evidence generated at the facility level. In some cases, tools such as state regulations and federal workplace safety policies provide important impetus and support for nurses and hospitals undertaking these transformational programs. This article provides a framework for developing comprehensive workplace violence prevention programs built on solid scientific evidence; federal, state, and joint commission workplace safety policies; and locally generated practice evidence. “Comprehensive workplace violence prevention” is defined by the authors as programs that demonstrate evidence of management support and employee involvement; include a hazard assessment; utilize violence controls that are based on the hazard assessment (i.e. data driven); include employee training; and incorporate periodic evaluation.

Addressing violence in health care requires purposeful organizational processes conducted within very specific organizational structures.The framework presented is consistent with the Guidelines for Prevention of Workplace Violence in Health and Social Services, a United States (U.S.) Occupational Safety and Health Administration (OSHA) guidance document (OSHA, 2004). The framework is also consistent with several state laws requiring comprehensive workplace violence prevention programming in health care (California, Washington, New York, New Jersey, and Connecticut). Finally, this approach acknowledges the role of the Joint Commission Environment of Care and Leadership standards as additional tools to promote a culture of safety that is free from workplace violence. (CDC/NIOSH, 2006; Lipscomb, London, & McPhaul, 2007).

Background

Workplace violence program elements for health care and social services establishments as outlined by OSHA are considered comprehensive when each element is present and fully integrated into the program (OSHA, 2004). ...basic program elements for workplace violence prevention are derived from the standard occupational safety program paradigm... Much like the nursing process for planning nursing care, basic program elements for workplace violence prevention are derived from the standard occupational safety program paradigm and include: 1) management commitment and employee involvement; 2) hazard analysis or assessment; 3) hazard controls; 4) employee training; and 5) recordkeeping and evaluation (OSHA, 2004). Employers have had access to these voluntary guidelines since 1996 when they were first published, yet according to a nationally representative survey of U.S. employers, implementation appears to be limited (BLS, 2006).

Lipscomb (2006) evaluated a program based on federal OSHA guidelines and used both qualitative and quantitative measures to evaluate the program impact. A comparison of pre- and post-intervention survey data found an improvement in perceived violence climate factors, such as management commitment to violence prevention and employee engagement, but no overall change in assault rates (Lipscomb, 2006). [Studies] found that employees’ perception of management commitment to violence prevention was associated with less workplace violence.  This study, as well as later studies, found that employees’ perception of management commitment to violence prevention was associated with less workplace violence. Additional survey questions relating to violence prevention programming became known as safety culture and were also associated strongly associated with workplace violence prevention. (Lipscomb et al. 2006; Lipscomb, 2007; Lipscomb, 2012).

In 2005, the Bureau of Labor Statistics (BLS) conducted a national survey of a representative sample of all U.S. employers (including health care, but not exclusively health care) that assessed both workplace violence experiences and preventive strategies employed to prevent violence. Workplace violence prevention activities among firms surveyed included 1) presence of workplace violence policy; 2) presence and type of training; 3) cost tracking systems; 4) methods of assessing history of violence of employees and/or clients; 5) electronic surveillance; 6) security personnel; 7) access control; and 8) cash handling systems (Bureau of Labor Statistics, 2006). State government workplaces reported the highest levels of violence; were more likely to have workplace violence programs and policies; and were more likely to track the cost of workplace violence than the private sector, but the effectiveness of programs appears weak.

The Veterans Health Administration (VHA), a federal network of health facilities, outpatient clinics, long term care centers, domiciliaries, and community veteran service centers, has utilized its extensive computerized patient medical record system for flagging patients who display violent behavior. The VHA has created a national training curriculum to educate staff depending on their level of risk. The VHA has also designed facility-based structures, known as Disruptive Behavior Committees, which provide a specialized review of mental health care plans and make decisions about flagging patient records. Recently Mohr, Warren, Hodgson, and Drummond (2011) examined the extent of workplace violence program implementation on rates of workplace violence in 138 Veterans Administration (VA) facilities. Program implementation was scored on three dimensions: training, workplace practices, and environmental controls. A detailed list of items in each dimension is included in this article and represents a pragmatic list of strategies used by the VA.   Facilities with full program implementation noted a modest decline in assault rates (Hodgson et al. 2004; Hodgson et al. 2008; Mohr, Warren, Hodgson, Drummond, 2011).

Other reviews of interventions for violence prevention added incrementally to the intervention studies described above (Allen et al. 2011; Arnetz, 2000; Runyon et al., 2000; Wassell, 2009). Given the constraints of conducting organizational intervention research, it is not surprising that so few well-controlled intervention studies exist. Evidence from disciplines including criminology; occupational and public health; adult education; and mental health and psychology provide strategies that, when integrated, can be tested in evidence based practice environments. Evidence generated at the facility or organizational level can then guide program development and evaluation.

...several states have legislation requiring comprehensive workplace violence prevention programs in health care... These laws are worth noting for nurses and employers in states without similar laws because they represent a credible and feasible approach to workplace violence control. As indicated earlier, several states have legislation requiring comprehensive workplace violence prevention programs in health care. California, Washington, New York, New Jersey, and Connecticut require health care employers to provide comprehensive, workplace violence prevention programs. In New York, the law applies to all public sector workplaces, including health care and social services, but not to private sector health care employers (Workplace Violence Prevention Law, 2007). In the other states, laws are directed at health care settings. California’s law is the oldest, dating back to 1993, but currently legislative efforts are underway to strengthen the law in the wake of a tragic employee murder of a nurse in a correctional facility (California Hospital Safety and Security Act, 1993). Subsequent state laws incorporated elements of the initial California state law; federal OSHA Guidelines; and, in New York, Connecticut, and New Jersey, requirements that employees and/or their representatives have access to hazard analysis data and be equally represented on health and safety or violence prevention committees (Workplace Violence Prevention Law, 2007; Findings, Declarations Relative to Prevention of Violence Against Health Care Workers, 2007; State of Connecticut, 2011). These laws are worth noting for nurses and employers in states without similar laws because they represent a credible and feasible approach to workplace violence control (California Hospital Safety and Security Act, 1993; Health Care Workplace Violence Prevention Act, 2005; New Jersey, 2007; Workplace Violence Prevention Law, 2007; An Act Concerning Workplace Violence Prevention and Response in Health Care, 2011; Workplace Prevention Law, 1999.). Similar legislation has been proposed in several states. The American Nurses Association (ANA, 2012) web page for Workplace Violence provides a list of states with legislation related to workplace violence. The Emergency Nurses Association (ENA, 2009) also tracks state laws on their website.

There is some evidence for the effectiveness of the state laws. Research suggests that there is an association between enactment of regulation and the presence of stronger workplace violence program elements in workplaces (Casteel, Peek-Asa, & Nocera, 2009; Peek-Asa, Casteel, Allareddy, Nocera, Goldmacher, & O’Hagan, 2007; Peek-Asa et al. 2009). The specific workplace violence prevention elements that were examined included training, policies and procedures, environmental safeguards, and security. More research is needed as this study was limited by the inability to control for several threats to validity, including new training requirements for disruptive behavior which were instituted by the Joint Commission in 2009 during the study (Joint Commission, 2009)

A Workplace Violence Prevention Framework

Several models have been suggested to explain the mechanisms of workplace violence prevention, including the Haddon Matrix, the Job Demand Control model, other work stress models, the NIOSH Work Organization Framework, and Perceived Violence Climate (adapted from safety climate) (McPhaul, 2010; McPhaul, 2004Runyan, 2000; Spector, 2007). These models have important strengths and, together with the authors’ research, have contributed important dimensions to the development of the model depicted in Figure 1.

This framework delineates the dynamic interaction of factors that give rise to violence in health care and the equally dynamic interplay of deliberate strategies necessary to prevent workplace violence. The four inter-related levels depicted by the square boxes show that government policies and societal issues (e.g., access to mental health) impact agencies, health care systems, medical centers and hospitals, and ultimately the work unit where patient care is delivered.

Figure 1. Framework for Workplace Violence Prevention


[Access full size pdf of Figure 1 here.]

At the policy or “system” level, some states have workplace violence prevention laws which will compel hospitals to develop programs, There may also be regulations that impede some workplace violence prevention strategies. For example, some facilities may elect to terminate care or discharge unmanageable patients. In some state and federal systems, there may be no alternative to state care or, in the case of veterans, banning veterans from care is illegal (38 CFR, 2010).

Clearly, the care giving work environment is a complex and dynamic milieu, making it difficult to isolate a single risk factor or a single hazardous condition. Other strategies must be considered given the policy or “system” level factors. The care giving work environment itself includes many inter-related components such as: the experience and training of the staff in handling violent situations; the job demands and pace of work; staffing levels; levels of overtime (especially mandatory overtime); and the overall safety climate, including the perception that your supervisor cares about your safety and as well as about the patients/clients. Safety climate is conceptualized and measured by the staff perception of management commitment to workplace violence prevention; the extent to which employees are engaged in and consulted on violence prevention; the perception that management, supervisors and co-workers care about safety; and evidence that staff perception of the management commitment to workplace violence prevention (safety climate) is associated with violence outcomes (Lipscomb et al., 2006). Clearly, the care giving work environment is a complex and dynamic milieu, making it difficult to isolate a single risk factor or a single hazardous condition.

Preventing workplace violence involves dynamic processes that are based on elements of the OSHA Guidelines for Prevention of Workplace Violence in Healthcare and Social Services (2004) and the Joint Commission Environment of Care Standards (2009). For example, hazard analysis and assessment is a critical element of violence prevention. This process may involve analysis of a range of data, such as injury and incident data and workers compensation records; an environmental walk-through survey to assess the physical work environment; and the presence and absence of security features. Additional information, including an enhanced understanding of the workplace environment, can be obtained through tools such as staff surveys and focus groups. A thorough hazard analysis is essential to the overall program and drives the development of hazard controls (e.g., environmental and administrative controls, content and frequency of staff training, etc.).

Both a facility’s internal data about the patient population and evidence from the literature can be used to develop data collection systems for the purpose of characterizing the risk of a given health care unit or facility. Both a facility’s internal data about the patient population and evidence from the literature can be used to develop data collection systems for the purpose of characterizing the workplace violence risk and specific risk of a given health care unit or facility. Without such data a workplace violence prevention program cannot be customized and targeted to the high risk areas. In general, patients with a prior history of violence are at high risk for committing violence toward staff. But many other patient characteristics or treatment conditions such as transporting patients, waiting for medication, and cognitive or behavioral impairment from alcohol, drugs or disease processes are also associated with violence. (CDC/NIOSH, 2002). The literature can guide employers as they seek to target certain types of patients and units, but ultimately it is the facility’s own data that should determine specific hazard controls for their workplace violence prevention program.

The framework illustrates that the domains of violence, patients, caregiving work environment, and external health care policy must be thoroughly acknowledged and assessed for two important purposes. The first reason is so that appropriate hazard controls can be identified and matched to the risk factors, and the second is to benchmark, monitor, and evaluate program effectiveness. In summary, the hazard analysis drives the development of hazard control and the ongoing collection of data provides information on process and outcomes (CDC/NIOSH, 2002; University of Iowa, 2001; OSHA, 2004). The following section will describe concrete activities for employers to consider when developing programs.

Establishing Workplace Violence Prevention Programs

...an advisory group or task force consisting of a top management representative, a union or other legal employee representative, and several types of direct care workers... is recommended to steer workplace violence prevention efforts.The recommendations described here utilize the Workplace Violence Prevention Framework presented above and are based on a process compatible with the OSHA (2004) guidelines and used in ten years of intervention research and consultation by the authors. To start, an advisory group or task force consisting of a top management representative, a union or other legal employee representative, and several types of direct care workers (e.g., professional and allied health staff) is recommended to steer workplace violence prevention efforts. The advisory group can guide all aspects of program development and provide input and critical review. Ongoing  input from the group is also instrumental in ensuring the program's success, over time. If a facility is unionized, participation by the union shop steward or designee is also desirable. Finally, certain specialists such as mental and behavioral health, security, facilities management, and even dietary and/or admitting should be able to offer their expertise and describe their potential exposure to workplace aggression. The committee can be at the level of a health care system which expects to implement standardized workplace violence policies and procedures and/or at the level of the facility, depending on the size and complexity of the workplace.

Hazard Analysis

A thorough hazard analysis will uncover risk factors (predictors) of exposure to the hazard, as well as barriers to removing the risk factors. Analysis of hazards and evaluating program impact are inextricably linked in a comprehensive workplace violence program. Worksite analysis in the form of a hazard analysis to determine the potential and actual extent and severity of the violence is a necessary first step. A thorough hazard analysis will uncover risk factors (predictors) of exposure to the hazard, as well as barriers to removing the risk factors. As depicted in the Figure, the hazard analysis phase addresses the health care policy level; caregiving work environment; and patient and employee contributors to workplace violence. Methods for conducting a hazard analysis will vary depending on availability of data and resources. Note that the assessment methods provide both qualitative, or contextual data, as well quantitative survey data and injury rates. Examples of hazard analysis data sources are described here and are briefly summarized in Table 1.

Table 1. Hazard Assessment Methods

Method

Recommended Frequency

Data Features

Key Informant Interviews 

During program development andperiodic program reviews

  • Qualitative/contextual
  • Allows assessment of system level characteristics (e.g., competing priorities, barriers, safety climate)
  • Provides opportunity to develop key relationships between Workplace Violence Committee/Task Force and potential organizational allies

Staff Focus Groups

Baseline and after implementing major program or process changes

  • Qualitative data from direct care givers, maintenance, and administrative staff
  • Allows assessment of unit level work organization and safety climate characteristics such as
    • Overtime, supervisor support for safety, ease and attitudes toward reporting
    • Problems with team work
    • Usefulness of training
    • Descriptions of recent and on-going patterns of verbal and physical violence
    • Responsiveness of assault code team
  • Efforts must be made to include all shift workers, have credible, confidential, outside, moderators, and no supervisors in the focus groups

Environmental Assessment and Walk-Through

Annual

  • Assessment of design/layout of facility and units from standpoint of lighting, working in isolation, visibility, ability to communicate, placement of furniture, places to hide contraband
  • Includes assessment of technology such as hardware for locks, video surveillance, panic button systems
  • Direct care workers from all three shifts should provide input; the walkthrough assessment should be conducted on all three shifts

Staff Survey

As needed depending on quality of data systems

Seek information about:

  • Violence measures
  • Safety climate
  • Unit level work organization: job demands, overtime, staffing, supervisor support for safety, team work, training competence
  • Characteristics of high risk patients
  • Training outcomes knowledge, and practice patterns.

Facility Level Administrative/Injury/Cost Data

Annual

  • Facilities should make available any and all administrative data for purposes of assessing risk and evaluating program impact
  • May include workers compensation claims; patient on patient violence; incident reports; worker safety grievances; lost work time from injuries; staff turnover and exit interviews; security records; and patient characteristics such as those:
    • admitted directly from criminal justice system
    • with a prior history of violent behavior
    • with mental health diagnoses

Facility Program Audit

Annual with environmental walkthrough

  • Program data including changes/updates to policies; frequency of committee meetings; changes to training; training compliance; environmental changes and their impact and cost; security technology changes and effectiveness; and changes in work practices or procedures

 

These interviews allow the task force to learn about possible data collection structures already in place and the priorities and safety concerns of management. Key informant interview. Key informant interviews provide important contextual information about the facility; its management style; the relationship of management to union or employee leadership and direct care employees; and the functionality of the health and safety committee apparatus. These interviews can provide qualitative contextual information on health care policy influences, the care giving work environment, the clients and the amount and type of violence. Structured questions may include the history and capacity of the facility; the philosophy of care model; the management’s view of safety and violence prevention; the management’s approach to safety communication; and specifics about clinical care. In unionized facilities, union leaders should be asked complementary questions about the facility, such as queries about its systems for reporting violence, the safety climate of the facility, and the relationship with management (especially when discussing safety issues). When available, members of the health and safety committee should also be interviewed in terms of current and historical efforts to reduce or prevent workplace violence. These interviews allow the task force to learn about possible data collection structures already in place and the priorities and safety concerns of management. The interviews also serve to introduce the facility management and key safety individuals to the task force and their purpose.

Practically speaking, both the interviewers and the questions cannot be prescribed. Ideally, the coordinator or lead individuals for workplace violence will conduct the interviews. The list of interviewees can be compiled by consensus of the advisory committee members.  Those who are interviewed often become engaged in the issue and can be essential to the success of the process. The interviews provide an assessment of the resources that can be devoted to violence prevention. Developing relationships, while a secondary goal, is perhaps one of the more powerful byproducts of the key informant interview process. The interviews raise awareness of workplace violence with the interviewees and can begin a process of developing allies and breaking down organizational barriers. Peek-Asa et al.’s (2009) evaluation of the California Hospital Security Act included key informant interviews of each facility to best understand the extent of workplace violence programming in place in each facility.Table 2 outlines possible key informant interview elements to consider.

Table 2. Elements of Key Informant Interviews

  • Examples of violence or other safety issues in the facility and how they were addressed by management
  • Administrative structures for dealing with safety issues; i.e. safety professionals, security force, committees
  • Data sources such as security guard logs, incident reports, workers compensation reports, OSHA 300 logs, patient or staff surveys; OSHA or Joint Commission citations
  • Structures for reporting incidents of violence--Are these standardized? Well understood by staff?
  • Training programs for personal safety, violence prevention, seclusion and restraint reduction
  • Emergency code system/code team for violent incidents
  • Post incident procedures for documentation, counseling, referral to employee assistance programs (EAP) programs

An environmental audit is a “walk-around” that includes an assessment of the degree to which architectural design and facility layout, even furniture placement, may contribute to the risk of violence. Environmental audit. The environmental audit represents an invaluable and essential evaluation component of a workplace violence prevention program. While focused primarily on the caregiving work environment, an environmental auditor should be aware of patient characteristics and the nature and type of violence by history in the facility. An environmental audit is a “walk-around” that includes an assessment of the degree to which architectural design and facility layout, even furniture placement, may contribute to the risk of violence. It also includes an assessment of security hardware and technology and aspects of building materials or décor that can contribute to harm. A key recommendation for this activity is that the consultant (or in-house security or facilities person tasked with this assessment) have experience and be familiar with environmental audits for security purposes. Inviting direct care staff from all shifts to participate in the walk-around will ensure that staff concerns and perceptions about the environment are included in the report.

Audits can evaluate structural and security issues that, if addressed, increase safety but without compromising the caregiving environment (Lipscomb et al., 2006; McPhaul, 2008). For example, a well-designed unit can protect staff and provide reassuring surveillance of the clients by being designed to view all areas but allow staff protection behind elevated counters or Plexiglas® windows. The opposite is also true; poorly designed units and corridors can create very high risk spaces that are insufficiently lit and isolated.

Inviting direct care staff from all shifts to participate in the walk-around will ensure that staff concerns and perceptions about the environment are included in the report. Summaries of environmental and security findings have been published (McPhaul et al., 2008; Peek-Asa et al, 2009). Examples of specific recommendations from our studies include: increased use of mirrors at hallway intersections; installing view panels to improve surveillance of staff working in blind spots or hidden areas such as private staff offices; rearranging furniture to prevent entrapment; controlling access from outside the building; and reducing crowding in treatment and recreation areas (especially in older, retrofitted buildings).

The ENA has recently completed a web-based tool box with resources for organizations developing workplace violence programs. The ENA tool kit (2010) represents an excellent “translation” of research and policy adapted specifically for the emergency department. The OSHA Guidelines and OSHA E Tools also provide resources for conducting an environmental audit (see Table 3)

Table 3. Resources and Tool Kits

  1. Emergency Nurses Association (ENA) Tool Kit: www.ena.org/IENR/ViolenceToolkit/Documents/toolkitpg1.htm
  2. American Nurses Association Workplace Violence: www.nursingworld.org/MainMenuCategories/ WorkplaceSafety/bullyingworkplaceviolence
  3. Occupational Safety and Health Administration: www.osha.gov/SLTC/workplaceviolence/
  4. National Institutes for Occupational Safety and Health; Free On-line training with continuing education CE due for publication in 2013: www.cdc.gov/niosh/docs/2002-101/

Direct Care Staff Characteristics and Perceptions

Staff focus groups. Focus groups are a tool for assessing the perceptions of direct care staff in terms of the causes of violence, working conditions that may contribute to violence, and the understanding that staff have of safety policies. Staff can describe their perception of risk factors for violence. They will be able to provide information about staffing patterns; shift to shift differences in risk; issues with patient satisfaction or frustrations (e.g., food quality or delays in service); and the availability of patient information. Focus group participants can describe incidents which may not have been formally reported; this additional insight allows for further analysis of possible risk factors.

...these forums can be valuable to identify staff leaders to serve as champions for the violence prevention efforts. As with the key informant interview process, the focus groups provide a forum for direct care staff to identify risk factors and talk amongst themselves about safety and violence. In addition to providing contextualized data for the violence prevention program, these forums can be valuable to identify staff leaders to serve as champions for the violence prevention efforts. Staff may become energized and more aware that violence is preventable. In our experience, hazard identification and hazard analysis activities are meaningless to direct care staff unless concrete hazard controls are developed in the context of a dynamic workplace violence prevention program.

Features of successful and credible focus groups include conducting the groups on all shifts in order to make them available to all staff; providing relief time so that direct care staff can attend the focus groups; not allowing any participants’ direct supervisor to be in the group; and creating a transparent process where the aggregated focus group findings without identifiers are communicated to participants as well as management. Finally, it is important that the focus group moderators be trustworthy and credible to staff, which in some cases may involve contracting the activity to a professional and neutral outside organization.

Typical focus group probes may include the following open ended questions to generate descriptive data:

  • Describe your work and stressors.
  • To what extent is the fear or threat of violence a stressor for you?
  • What activities, in your view, lead to violence on the unit?
  • What tells you that top management is or is not committed to your safety?
  • If you were running this facility, what would you do to make it safer?

Groups usually consist of eight to twelve direct care staff and sometimes non-supervisory administrative personnel.

Transparency of the process and the aggregate findings should be balanced with the need for confidentiality. For example, the report of focus group findings must be carefully worded to avoid any possibility of identification of any one participant or any specific staff person’s views. Themes that are repeated across groups and issues that appeared to unique to one facility can be described in the report to provide valuable information.

Surveys can assess the level of verbal and physical violence that is not reported through the formal mechanisms... Staff survey. Workplace violence prevention programs can also benefit from carefully constructed staff surveys. Surveys can assess the level of verbal and physical violence that is not reported through the formal mechanisms (e.g. incident reports). Surveys can also quantify facility-level risk factors for violence and staff perceptions of the quality of existing OSHA program elements within the facility (e.g., knowledge, attitudes, and perceptions regarding facility level policies and training). A transparent process of reporting survey findings to each facility’s managers and direct care staff will assure that the findings are fully examined. It is recommended that each facility or unit receive both an in person review and a written summary of the findings. One successful communication method used by our research team was to summarize the entire hazard analysis (focus groups, survey, and environmental audit) on a colorful wall poster with clear, simple, bar graphs and text and then display it in the halls and staff areas.

Patient Perceptions and Characteristics

Patients, their families, and/or interviews with their representatives or ombudsmen provide insights on sources of frustration and triggers for violence. Patient focus groups. Interviews with patients, their families, and/or their representatives or ombudsmen can provide insights on sources of frustration and triggers for violence. Focus groups can be conducted using in-house staff and resources, but the likelihood of obtaining deep insight into staff perceptions is increased when confidentiality of discussants is assured. In the focus groups we conducted in an addictions treatment facility, clients were very positive about the staff and they reported generally feeling safe. When asked about ways to make the community safer they suggested: improving the food; more structured activities such as learning life skills; better discharge planning; more access to psychiatrists; and increasing the evening and weekend staff. It is essential to understand the client and family population of the facility or health care system and develop an appreciation of the client and family perspectives. In our project, there was very close congruence of the staff and client views. Both staff and clients concurred that there was insufficient staffing. Both identified food as a source of unhappiness and conflict. Most importantly, staff and clients identified the need for more specialized mental health services for the clients (Lipscomb, 2012).

In other settings and institutions, there may be patient satisfaction surveys or formal organizations that represent patients and families. Including and appreciating the perspective of these stakeholders is an integral part of the violence prevention process.

data sets often include workers compensation claims, patient incidents reports, security response logs, the OSHA 300 logs, and occasionally other data sources. Facility administrative data. Each facility must assess its own sources of data to assist in characterizing the patient population(s); the level of violence experienced at the facility; and the cost in terms of lost work time, turnover, and medical care costs. These data sets often include workers compensation claims, patient incidents reports, security response logs, the OSHA 300 logs, and occasionally other data sources. It is recommended that these data sources be carefully reviewed in the context of the workplace violence prevention model to assess the level of violence and any data that describe the patient population (e.g., age, gender, diagnosis, involvement with the criminal justice system, prior history of violence).

The Veterans Affairs system has an electronic mechanism for flagging a file of a patient who has committed violence against a staff person within the past two years. These patients are required to have a security escort with them whenever they are in a facility for treatment (Hodgson, 2004). Such a system is an example of a hazard control matched to a hazard identified during the hazard analysis.

Organizations will vary in their collection of administrative data, but available data can provide clues to the population being served by the institution. In one of our projects (Lipscomb, 2012), administrative data from each facility provided valuable organizational and patient level data that we could not get from staff surveys. For example, 33% of residents had a criminal justice history; 40% were homeless upon admissions, 34% had a history of mental health problems, and 79% abused more than one substance. Organizations will vary in their collection of administrative data, but available data (e.g., proportion of patients with mental health, criminal justice, and substance abuse involvement) can provide clues to the population being served by the institution. Furthermore, age, gender, insurance coverage, average length of stay, and income status may be useful for purpose of obtaining a representative viewpoint from the client population(s).

In summary, each of these workplace violence hazard analysis and program impact measures, derived from the literature and our own practice and research, include features which are adaptable for workplace violence prevention programs in health care and social services facilities.   These methods have been discussed in terms of the literature, current findings and future feasibility, and translation for use by employers. Table 1 lists the hazard analysis methods, a recommended frequency for their use, and the types of data that a facility can expect to collect relative to the model portrayed in Figure 1.

Discussion

Evaluation research designs such as randomized experimental designs are typically not feasible in workplace violence research and none have been conducted to date. Consequently, standard methods for rating evidence leave employers without a key to translate the available research into tangible programs. Regulatory agencies, employers, and nurses require evidence in order to commit resources to workplace violence prevention programs. A framework based on national guidelines (CDC/NIOSH, 2006; OSHA, 2004; The Joint Commission, 2009) allows health systems and individual facilities to address workplace violence by customizing their own strategies for on-going hazard analysis; hazard control; employee training and recordkeeping; and evaluation.

Employers must acknowledge that workplace violence exists and seek system-wide solutions. Workplace violence, like societal violence, injures communities such as workplaces and takes a demonstrable toll on patients, visitors, and staff. Employers must acknowledge that workplace violence exists and seek system-wide solutions. The framework described here will hopefully be useful to discover potential and actual risks and issues unique to a given facility. These facilities will then have to develop customized strategies based upon individual hazard analyses. We present this framework to provide a process which, when implemented, will help to satisfy regulators and demonstrate a reduction in risk and injury.

Author

Kathleen M. McPhaul, PhD, MPH, RN
E-mail: kate.mcphaul@va.gov

Kate McPhaul is a senior administrator with the Office of Occupational Health and Public Health, Veterans Health Administration, a system of 153 hospitals and over 300, 000 employees. She oversees occupational health policy, training, and programs on workplace violence, safe patient handling and other employee health services. She also continues an affiliation with the University of Maryland School of nursing where she continues to conduct research about occupational hazards in the healthcare work environment, particularly workplace violence.

Matthew London, MS
E-mail: MLondon@pef.org

Matt London has worked in occupational health and safety for 30 years, first at the National Institute for Occupational Safety and Health (NIOSH) conducting Health Hazard Evaluations.  Beginning in 1987, Matt worked at the New York State (NYS) Department of Health (DOH), helping to develop New York’s statewide Occupational Health Clinic Network and overseeing the DOH’s industrial hygiene activities. Since May 2004, Matt has worked for the New York State Public Employees Federation in the Health and Safety Department.  Under the direction of the University of Maryland-Baltimore School of Nursing (UMB), he has been project coordinator for two NIOSH-funded workplace violence prevention projects conducted within NYS government.

Jane A. Lipscomb, PhD, RN, FAAN
E-mail: Lipscomb@son.umaryland.edu

Dr. Jane Lipscomb is a Professor, University of Maryland Schools of Nursing and Medicine in Baltimore, MD. She has conducted research into the prevention of occupational injuries and illness in the health care and social service workplace for over twenty years, with a focus on workplace violence prevention. Prior to joining the faculty, Dr. Lipscomb spent three years as a senior scientist in the Office of the Director of the National Institute for Occupational Safety and Health (NIOSH) and five years at the University of California, at San Francisco (UCSF) School of Nursing, as Assistant Professor and Director of the graduate program in Occupational Health Nursing. Dr. Lipscomb received her BSN from Boston College, her MS in occupational health from Boston University/Harvard School of Public Health and PhD in Epidemiology from the University of California, Berkeley Dr. Lipscomb is the recipient of the University Of Maryland’s 2008 Founders Day Research Lecturer Award

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© 2013 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2013


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