1. Silent No More - Dealing with Challenging Patients and Families TMMC’s “Watcher Program”
Julie Che, MSN, RN NEA-BC; Sean Yokoe BSN, RN CNML, Bethany Mota BSN, RN PCCN Torrance Memorial Medical Center, Torrance, CA
Background
Implementation
Discussion and Conclusion
Workplace violence is a serious occupational risk for the healthcare workforce. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “an act of aggression directed toward persons at work or on duty, ranging from offensive or threatening language to homicide” (CDC, 2016).This may include physical assault, emotional or verbal abuse, or threatening, harassing, or coercive behavior that causes physical or emotional harm (McPhaul 2004). The Joint Commission encourages organizations to develop policies and procedures to promote a safe work environment (TJC, 2018).
Staggering facts about workplace violence…
Occurs most frequently in the ED, waiting rooms, ICU, and Geriatric units
Diminishing number of psychiatric beds and resources are a contributing factor
Up to 50% of nurses surveyed in EDs, Med/Surg units, & ICUs have experienced verbal and physical assaults by patients or family members but fail to report such events
Some nurses feel that this is part of the job
An ANA survey In 2002 reported only 20% of nurses felt safe in their work environment
The Watcher Program has fulfilled a need voiced by staff to better manage challenging patient and family situations in the workplace.
The program had been successful in part due to the multidisciplinary involvement of many services including Nursing Administration, Nursing Staffing Office, Security, PBX Department, Medical Staff, Legal Department, Case Management, and frontline Nursing Staff
Staff have reported that they appreciate the additional assistance and support as well as having a defined process and procedure to assist them in these difficult situations.
Components of Effective Violence Prevention Program
A violence prevention program focused on developing processes and procedures should:
Have clear goals and objectives for preventing workplace violence,
Be suitable for the size and complexity of operations and adaptable to specific situations/facilities/units
Be incorporated into an organization’s overall safety and health program,
Offer an effective approach to reduce or eliminate the risk of violence in the workplace.
Include the following building blocks in program development:
1) Management commitment and employee participation
2) Interdisciplinary Team
3) Worksite analysis,
4) Hazard prevention and control,
5) Safety and health training, and
6) Recordkeeping and program evaluation.
Development
The “Watcher Program” was developed in collaboration with several disciplines ( Hospital & Nursing Administration, Legal Affairs, Case Management, Physicians – Psychiatry & Hospitalists, Social Work, and Security) working together to identify criteria to assist staff in early recognition and mobilization of resources and implementation of appropriate procedures promote a safe environment. The new program provides an objective way for staff to identify and categorize disruptive behavior . Levels of violent behavior are described and algorithms identify interdisciplinary resources, as well as guide the steps in the process and procedure and delineate responsibilities:
Implementation
Patients or visitors who exhibit disruptive behavior are identified and level of threat is assessed at the unit level. If unable to deescalate at the unit level, staff may call a “Code Gray” to launch security (Level Three Threat) or report to house supervisor
Behavioral contracts are incorporated to explicitly identify the applicable behavior, address triggers, and set expectations for consequences
The Nursing Office maintains records of all situations and the location on a daily shift by shift basis
The Watcher Program Threat Assessment Team will mobilize in the event that there is an incident involving violent behavior or non-violent behavior which is out of compliance despite all efforts
Evaluation
The Watcher Program was pilot tested in Fall 2017, with full launch in December Since initiation, there has been significant use validating the need for the program. The utilization across shifts is similar. Med-Surg, PCU, and Critical Care Units tend to have higher usage.
Future Directions
Purpose
The Nursing Office will continue to monitor the number of “Watchers” per shift. Specific information such as whether the situation involves the patient or family or both, type of situation, and level of threat will be monitored in order to identify possible early interventions that can be implemented and evaluated to minimize escalation.
Feedback from staff in all disciplines is welcomed in order to improve the program and better meet the needs of our staff and promote a safe environment for staff, patients and families.
As of 2017, TMMC did not have a formalized mechanism to address this problem. Maintaining a safe work environment for staff is a high priority for the organization.
The purpose of this project was to develop a program , “The Watcher Program”, that included a process and structure aimed at promoting safety and lessening compassion fatigue for health care workers that could be used by any staff, in any department, at any time.
Methods
The Watcher program was developed based on evidence identifying effective strategies for deescalating situations that could lead to violent outcomes.
Strategies recommended to reduce the threat of workplace violence include: (NIOSH,2016)
Development of comprehensive prevention programs (involve employer & employees, include risk assessment, safety training, reporting systems and intervention/support for at-risk employees)
Establish policies regarding threatening, harassing and violent behavior and procedures for appropriate response and reporting
Provide employee education and training to promote early recognition of warning signs and increase ability of employees to appropriately respond
Encourage prompt reporting of threat and violence
Enhance security and provide needed resource support to address the immediate situation
Acknowledgements
Special thanks to the Dr. Moe Gelbart for the unending support with the Watcher Program development and education of the frontline staff, the Torrance Memorial legal department for continued guidance and to the security department for their partnership and efforts to keep the staff safe.
References
McPhaul, KM (2004). Workplace Violence in Heath care: recognized but not regulated, Online J Issues Nurs.. Available at
The Joint Commission, Work Place Violence (2018)
The National Institute for Occupational Safety and Health (NIOSH). (2016). Workplace Violence Prevention for Nurses. CDC Course No. WB1865 – NIOSH Pub. No CDC website