JKO Preventing Workplace Violence for Supervisors

September 4, 2022 Dwayne Morise

Workplace violence (WPV) refers only to incidents that involve physical violence. Is this statement true or false?

False

Consequences can be both acute (short-term) and chronic (long-term). Is this true or false?

True

Workplace violence in the healthcare setting may lead not only to nurses leaving the profession, but to negative side effects on recruitment into the nursing profession. Is this true or false?

True

Workplace violence is a recognized hazard within the healthcare industry. Is this true or false?

True

Studies have found higher patient satisfaction levels in hospitals where more nurses are dissatisfied or burned out. Is this true or false?

False; opposite of this

Type 1: Criminal Intent

the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence (robbery, shoplifting, trespassing).

For example:
- A hospital administrator assaulted in the hospital parking garage
- A home healthcare nurse is mugged while conducting a home visit

occurs less frequently

Type 2: Client-on-Worker

most common in healthcare settings accounting for almost 80% of incidents, according to the Bureau of Labor Statistics. This course considers the customer/client relationship to include patients, their family members, and visitors, and will be referred to as client-on-worker violence

Research shows that this type of violence occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is by no means limited to these.

Type 3: Worker-on-Worker

between coworkers is commonly referred to as lateral or horizontal violence. It includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating though it can range all the way to homicide

often directed at persons viewed as being "lower on the food chain" such as in a supervisor to employee or doctor to nurse though incidence of peer to peer violence is also common.

Type 4: Personal Relationship

the perpetrator has a relationship to the healthcare workers outside of work that spills over to the work environment

For example, the husband of a nurse follows her to work, orders her home and threatens her, with implications for not only this nurse but also for her coworkers and patients.

Work Behavior category

often sparked by unprofessional behavior, disagreement over responsibilities for work tasks or methods of patient care, and dissatisfaction with a co-worker's performance.

Work Organization category

involved conflicts or aggression arising from failure to follow protocol, patient assignments, limited resources and high workload. Incidents of worker-to-worker violence and incivility stemmed from dissatisfaction with employee behavior or from organizational practices or work constraints.

A patient strikes a nurse as he attempts to give the patient her medication. What type of violence does this scenario depict?

Client-on-Worker

Hailey has recently joined the hospital as a nurse in labor and delivery. Since she started, she has received verbal harassment from her colleagues. Often her possessions are moved and her paperwork goes missing. What type of violence does this scenario depict?

worker-on-worker

Nora was mugged by a stranger in the hospital parking garage as she arrived to start her shift. What type of violence does this scenario depict?

criminal intent

Margo, a newly-qualified physical therapist, has been working with her patient Simon for several weeks. He has made several comments on her appearance and clothing at previous appointments. At today's appointment he grabbed her breast and made some lewd comments. What type of violence does this scenario depict?

client-on-worker

Benjamin, a transport technician, was punched by a patient in the emergency room. He fell to the ground, hit his head on a table, he lost consciousness briefly, and required 8 stitches. Should this incident be reported to OSHA by Benjamin's employer?

Yes

During her shift Natasha, a nurse's aide, was walking one of her Alzheimer's patients to the dining hall. The patient was sundowning and acting very agitated. She pushed Natasha, knocking her off balance. Natasha hit her shoulder as she fell and irritated an old injury. As a result, she won't be able to work for 2 days. Should this incident be reported to OSHA by Natasha's employer?

Yes

Cameron is a nurse in a home health service for senior citizens and frequently visits two patients in their homes: Elise and Richard. Elise tends to forget that Cameron is her nurse, and can grow anxious and afraid due to her lapses in memory. She often points her fingers at Cameron, paces, breathes heavily, and clenches her fists. Richard, Cameron's other patient, is usually friendly, engages in conversation, and shakes Cameron's hand at the end of the visits. Which of Cameron's patients exhibits behaviors that could lead to violence?

Elise

Ava works the intake desk at an emergency room. One of the people in the waiting area comes up to her and asks how much longer the wait will be while looking at his watch. Is this person exhibiting behaviors that indicate the potential for violence?

Brenton is a therapist in a psychiatric ward. One day, while he's visiting with one of his patients, the patient suddenly stands up, looms over Brenton, and begins speaking loudly. Is this person exhibiting behaviors that indicate the potential for violence?

yes

Alice is getting close to the end of her shift at the ER. It's been a really hectic night and the waiting room has been full to capacity all night. She is approached by a patient who starts to complain about the wait in a loud voice. As she talks to Alice, she throws her keys on the counter. Alice notes that the patient's breathing is heavy. What would be an appropriate way for Alice to start to address the issue?

Apologize for wait time; (showing empathy is the 1st step)

Josh arrives to give Mr. Wilson his medication. As he enters the room, Josh notices that Mr. Wilson is staring fixedly at a painting on the wall. He then turns to Josh, starts cursing and accuses Josh of trying to poison him by giving him the wrong medication. He starts to flail his arms in an attempt to swat Josh. What should Josh do next?

- maintain no-threatening eye contact, smile, & keep his hands open & visible
- Ensure that he remains b/t the patient & the room exit
- Use limit setting language such as, "Mr. Wilson please control yourself or I will call security

What can you do to protect yourself from workplace violence?

- Participate in any training or violence prevention programs offered by your employer.
- Dress for safety.
- Be aware of your working environment

The consequences of acts of workplace violence against a healthcare worker can exact a heavy physical and emotional toll. Beyond the immediate trauma, negative outcomes may also include which of the following?

- Diminished productivity.
- Lack of trust in management.
- Loss of team cohesiveness.
- Increased job stress.
- Absenteeism.
- Worker turnover

A nurse manager is investigating a report made by a staff nurse. The nurse states that a visitor backed the nurse up against a wall and was verbally abusive but did not touch the nurse. How should the manager describe this incident to the human resources (HR) director?
1. Encounter with a disgruntled family member
2. Violence against the nurse
3. Incident with a family member
4. Physical attack against an employee

Answer: 2
Explanation: 1. Encounters with disgruntled family members can occur with no threat of violence.
2. This incident is an example of violence against the nurse.
3. Calling this an incident with a family member does not give it its full importance.
4. This is not an actual physical attack; the nurse was not touched.

A chief nurse officer (CNO) is contacted by the organization's supervisor on a Saturday night regarding a problem in the hospital's emergency department. The supervisor describes an incident in which an orderly was assaulted. Why is the CNO not surprised about this report?
1. This is a typical occurrence in the emergency department.
2. Healthcare violence is more likely to occur in emergency departments.
3. Healthcare violence generally occurs on the weekend.
4. Healthcare violence is likely to occur on the night shift.

Answer: 2
Explanation: 1. Violence should not be characterized as a typical or expected aspect of the workplace.
2. In healthcare, violence is more likely to occur in psychiatric settings, emergency departments, waiting rooms, and geriatric units.
3. Violence can occur on any day.
4. Violence can occur at any time of day.

The ICU staff has been dealing with several distractions over the last week. There was a scheduling error caused by a change in the staffing matrix and miscommunication between management and administration. The staff is also caring for a client whose family has been verbally abusive and threatening. The manager notes an increase in absenteeism with the staff during the past two days. To which of these distractions is the absenteeism most likely related?
1. The staffing dilemma caused by the scheduler
2. The change in the staffing matrix
3. The decline in staff morale due to a hostile environment
4. The miscommunication between management and nursing administration

Answer: 3
Explanation: 1. Staffing dilemmas are not uncommon occurrences in healthcare and would not result in an increase in absenteeism.
2. Changes in staffing matrix are not uncommon in healthcare and would not result in an increase in absenteeism.
3. The hostile work environment may cause a decline in morale or staff may be frightened to come to work.
4. Management miscommunication with administration is not uncommon in healthcare and would not result in an increase in absenteeism.

An ICU unit has experienced an influx of aggressive behaviors by visitors against nurses The ICU manager has instituted a policy to limit visiting hours. An employee asks the manager why the change in visiting hours has been implemented. Which response is likely the most accurate?
1. "The unit has been so busy, I must allow for the nurses to have time to provide client care."
2. "The visitor hours have not been adjusted in years. It was time to change them."
3. "The physicians have requested limited visiting hours."
4. "The visiting hours allowed for added stress and commotion to the nursing staff."

Answer: 4
Explanation: 1. It is true that nurses need time to care for clients, but this is probably not the real reason for the change.
2. Visiting hours are not changed simply because they have not been changed in years.
3. There is no indication that the physicians have anything to do with changing these hours.
4. Open visiting hours do allow for added stress and commotion. When visitors are aggressive toward nurses, restricting visiting hours may be essential.

An ICU nurse has just assisted the physician in placing a central line in a client. Over the past few days, the client's son has been increasingly verbally abusive to the nursing staff. The unit secretary tells the nurse that the son is at the nurse's station demanding to see the client. Which action by the nurse is most important?
1. Remove the central line tray from the room.
2. Inform the son regarding the client's condition.
3. Ignore the son as he enters the client's room.
4. Limit the son's visitation.

Answer: 1
Explanation: 1. Healthcare staff should be aware when and where to store medical instruments that may be used as weapons.
2. The son should be informed of the client's condition, but with the history and the escalation of his behavior, the nurse should take action to protect staff.
3. Ignoring the son may cause the violent behavior to escalate.
4. Limiting visitation may cause the violent behavior to escalate.

The hospital operator announced over the paging system, "Dr. Strong, fourth floor, A-wing, Dr. Strong, fourth floor, A-wing." A newly hired nurse asks another nurse, "Who is Dr. Strong?" The nurse replies, "This is the announcement that alerts security that there is violent behavior on that unit." Which statement would be an appropriate report to this unit's manager?
1. "Our new nurse does not know what 'Dr. Strong' means."
2. "There was an incident in which a staff person did not know what 'Dr. Strong' meant. Could we have an in-service on this policy?"
3. "The operator paged a 'Dr. Strong,' and we didn't know what to do."
4. "Why do they use 'Dr. Strong' when there is trouble? They should just call for help."

Answer: 2
Explanation: 1. This statement does not offer any plan for correction.
2. Because this is a newly hired nurse, one would expect that the 'Dr. Strong' page would have been covered in orientation. Because this nurse did not understand the meaning of the page, it is likely others will not. An in-service is needed.
3. The newly hired nurse did not know what to do, which indicates that others in the same orientation may also be uninformed. The more experienced nurse did know what the page meant.
4. The nurse needs to understand the policy, not make comments on its worth.

A hospital's safety committee has been asked to make recommendations to administration regarding methods to improve employee safety. Which suggestions should be made? Select all that apply.
1. Reserving parking spaces closest to the facility for staff
2. Security cameras throughout the facility
3. Curved mirrors in the corridors
4. Using restraints on all confused clients
5. Requiring all personnel to take physical self-defense training

Answer: 2, 3
Explanation: 1. Although isolated or unlit parking can be a safety concern, there is no reason that staff should have the parking next to the facility. There are also concerns for visitor and client safety to consider.
2. Instituting environmental controls such as security devices and curved mirrors are measures to ensure safety.
3. Instituting environmental controls such as security devices and curved mirrors are measures to ensure safety.
4. Just because a client is confused does not indicate a tendency toward violence or a need for restraints.
5. Although all staff should be trained regarding violence, physical self-defense training is not practical for every staff member.

A nurse manager has required that all nursing staff attend an in-service on dealing with verbal threats. A staff nurse wonders why this is necessary since, "Words don't hurt me. I just ignore them." What is the nurse manager's most appropriate response to this statement?
1. "Don't argue with me; I said everyone has to be in-serviced."
2. "Verbal threats often precede physical violence."
3. "I want my staff to be prepared to handle anything."
4. "This is a requirement from our accrediting agency."

Answer: 2
Explanation: 1. This response is aggressive and not appropriate.
2. Verbal aggression often precedes physical violence; if the situation can be defused at the verbal stage, physical violence may not occur.
3. Staff members cannot be expected to handle everything, but they should be prepared to handle common incidents.
4. The manager should have a more concrete and personally relevant rationale for this action.

An emergency department (ED) client is demanding pain medication and threatening to harm staff if they do not provide it. The ED physician calmly continues to ask the client about the level and location of pain as the nurse steps away and notifies security. What is the physician attempting to do by asking these questions?
1. Distract the client.
2. De-escalate the situation.
3. Determine the client's real reason for seeking treatment.
4. Assess the client's level of pain.

Answer: 2
Explanation: 1. The physician's tactics may distract the client, but this is not the reason for this action.
2. The physician's tactics is an attempt to de-escalate the situation until security arrives.
3. Determining the real reason the client is seeking treatment is not the current priority.
4. Assessing the level of pain is not the current priority.

The emergency department (ED) staff has been caring for a client who exhibited violent behavior when pain medication was denied. Once the situation was resolved, which action by the ED manager would be appropriate?
1. Arrange an agreement with law enforcement for rapid response on these incidents.
2. Post a sign stating that pain management medications are not given unless the client is admitted to the hospital.
3. Develop a team of staff who would be on call for these types of situations.
4. Organize a training program to educate staff on how to manage these types of situations.

Answer: 4
Explanation: 1. It is unlikely that the manager has the authority to institute such an arrangement. The staff also must know what to do until security or law enforcement arrives.
2. It is not possible to eliminate the use of pain medications in the ED.
3. Such a team might help in some situations, but the staff must still know what to do until they arrive.
4. The staff needs to be prepared in case of an emergency such as this one. This preparedness can occur through education.

A newly formed task force is addressing the prevention of violence in the healthcare organization. Which group of employees is most likely to experience violence? Select all that apply.
1. Private practice physicians
2. Nurses working in a geriatric unit
3. Nurses working in a pediatric clinic
4. Nurses whose work space includes large waiting rooms
5. Technicians working in the medical laboratory

Answer: 2, 4
Explanation: 1. Physicians in private practice can control their practice environment. Physicians are not in the group that experiences the most violence.
2. Geriatric units are among the sites in which violence is most likely to occur.
3. Clinics are among the sites in which violence is least likely to occur.
4. Waiting rooms are among the most common sites of healthcare violence.
5. Medical laboratories are isolated areas and are not among the places where healthcare violence commonly occurs.

A nursing supervisor is seeking staff input while developing policies regarding violence prevention. A staff nurse says, "We have lots of threatening behaviors on our unit." What is the most important question for the supervisor to ask?
1. "Why is so much threatening behavior happening on your unit?"
2. "Why haven't you reported that?"
3. "Where do you work?"
4. "When you report threats to your manager, is action taken quickly?"

Answer: 4
Explanation: 1. Although the reason for this behavior would be interesting to discuss, another question is more important.
2. This is the second best question to ask.
3. Where the nurse works is not as important as another factor.
4. This is the most important question. If the staff is reporting threats, yet nothing is done, it is very important for the supervisor to act.

A nurse is caring for a client who is aggressive, demanding, and verbally abusive toward staff and visitors. The client says, "I'm getting out of here. I'm going to end it all." What immediate action should the nurse take?
1. Attempt to block the exit door.
2. Call security.
3. Attempt to administer a sedative to the client.
4. Notify the client's family.

Answer: 2
Explanation: 1. The nurse should not get between the client and the exit door.
2. This client is a danger to self and perhaps to others. Security should be notified.
3. The nurse should not approach the client.
4. The family should be notified, but this is not the nurse's first action.

The nurse has just been notified that a client is to be admitted from the emergency department (ED) with a diagnosis of alcohol intoxication. The ED nurse says they have been unable to obtain much history because of the client's lethargic state. Which action is an appropriate intervention by the nurse?
1. Approach the client with caution when obtaining vital signs and shift assessments.
2. Place the client in a room farthest from the nurse's station so as not to disturb other clients.
3. Place the client in four-point restraints as a protective measure.
4. Post an armed security person at the client's door.

Answer: 1
Explanation: 1. Alcohol withdrawal clients may lash out in violence.
2. Placing the client farthest away from the nurse's station may cause added liability to the organization due to the client's lethargic state and potential for harm if not closely monitored.
3. There is no evidence that it is necessary to place this client is restraints.
4. There is no evidence that it is necessary to post an armed guard at the door.

The nurse is talking to a client who has a history of aggressive outbursts. What strategies should this nurse use? Select all that apply.
1. When addressing the client, use powerful body language.
2. Remain calm and speak in a moderate tone.
3. Approach the client with an aggressive "I'm in charge" attitude.
4. Speak in simple terms.
5. Allow the client to speak.

Answer: 2, 4, 5
Explanation: 1. Powerful body language may be interpreted as threatening.
2. A calm manner and moderate tone are calming to the client.
3. Aggression or aggressive attitudes can escalate this client's hostility.
4. The nurse should use simple terms when talking to this client.
5. The client should be allowed to speak, and the nurse should respectfully listen.

An OB nurse is caring for an unmarried woman who is in labor. The nurse learns the client is unwilling to name the baby's father. A male visitor who comes to visit the client raises the nurse's concern that he might be violent. Which behavior would raise this concern?
1. The visitor states, "I am the baby's father."
2. The client is very anxious with the visitor present.
3. The visitor moves into the nurse's personal space when asking about the client's status.
4. The visitor sits in a chair in the corner of the client's room, rocking and smiling constantly.

Answer: 3
Explanation: 1. Claiming paternity does not indicate potential for violence.
2. The client's anxiety may or may not be related to the visitor's potential for violence.
3. The most concerning behavior is the lack of respect for the nurse's personal space when asking questions. This behavior can indicate that the person can become threatening or violent.
4. Sitting in the corner, rocking, and smiling could be indicators of detachment from reality, but could also be benign behaviors.

When a nurse enters the room, the client states, "He has a gun," and points toward a male visitor. The nurse does not see a gun. What should the nurse do?
1. Question the visitor regarding the statement.
2. Contact security.
3. Call for another nurse to assist in confronting the visitor.
4. Notify the client's physician.

Answer: 2
Explanation: 1. The nurse should not make any attempt to question the visitor or to appear aggressive in any manner.
2. The nurse should contact security immediately and should implement any other strategies outlined in the security plan.
3. The nurse should not confront the visitor or allow any other nonsecurity employee to do so.
4. The client's physician will not be able to offer any assistance during the immediate incident.

A nurse hears screaming from a client's room. A male visitor leaves the client's room. Which is the nurse's priority action?
1. Call the police.
2. Notify the client's physician.
3. Follow the visitor.
4. Check on the client.

Answer: 4
Explanation: 1. Calling the police is not the priority action.
2. Notifying the client's physician is not the priority action.
3. The nurse should not follow the visitor but should make note of the direction the visitor took when leaving.
4. The priority action for the nurse is to ensure the safety of the client and the other staff.

Potential violence in healthcare organizations can include what risk factors?
1. Unlimited public access
2. Inadequate security
3. Locked down units
4. Long wait times
5. Over-crowded waiting rooms

Answer: 1, 2, 4, 5
Explanation: 1. Risk factors for potential violence in healthcare organizations include working understaffed especially at mealtimes and visiting hours, long wait times, overcrowded waiting rooms, working alone, inadequate security, unlimited public access, and poorly lit corridors, rooms, and parking lots.
2. Risk factors for potential violence in healthcare organizations include working understaffed especially at mealtimes and visiting hours, long wait times, overcrowded waiting rooms, working alone, inadequate security, unlimited public access, and poorly lit corridors, rooms, and parking lots.
3. Risk factors for potential violence in healthcare organizations include working understaffed especially at mealtimes and visiting hours, long wait times, overcrowded waiting rooms, working alone, inadequate security, unlimited public access, and poorly lit corridors, rooms, and parking lots.
4. Risk factors for potential violence in healthcare organizations include working understaffed especially at mealtimes, and visiting hours, long wait times, overcrowded waiting rooms, working alone, inadequate security, unlimited public access, and poorly lit corridors, rooms, and parking lots.
5. Risk factors for potential violence in healthcare organizations include working understaffed especially at mealtimes and visiting hours, long wait times, overcrowded waiting rooms, working alone, inadequate security, unlimited public access, and poorly lit corridors, rooms, and parking lots.

Incivility includes which of the following behaviors?
1. Laughing
2. Verbal abuse
3. Ignoring a person
4. Sexual harassment
5. Searching the room

Answer: 2, 3, 4
Explanation: 1. Incivility is aggressive behavior including ignoring a person, treating in a belittling manner, disparaging remarks purposely within hearing distance, ridiculing a person, speaking sarcastically about a person, direct verbal abuse, sexual harassment, and physical attack.
2. Incivility is aggressive behavior including ignoring a person, treating in a belittling manner, disparaging remarks purposely within hearing distance, ridiculing a person, speaking sarcastically about a person, direct verbal abuse, sexual harassment, and physical attack.
3. Incivility is aggressive behavior including ignoring a person, treating in a belittling manner, disparaging remarks purposely within hearing distance, ridiculing a person, speaking sarcastically about a person, direct verbal abuse, sexual harassment, and physical attack.
4. Incivility is aggressive behavior including ignoring a person, treating in a belittling manner, disparaging remarks purposely within hearing distance, ridiculing a person, speaking sarcastically about a person, direct verbal abuse, sexual harassment, and physical attack.
5. Incivility is aggressive behavior including ignoring a person, treating in a belittling manner, disparaging remarks purposely within hearing distance, ridiculing a person, speaking sarcastically about a person, direct verbal abuse, sexual harassment, and physical attack.

A staff nurse is known for having temper tantrums when the unit is stressful. The nurse slams doors, grumbles, and is demeaning to coworkers. The behavior has never been violent, but today it is becoming more threatening. The nurse just came into the station and said, "My nurse assistant is stupid. I'm not going to put up with that much longer. She needs to be put in her place." How should the manager respond to this situation? Select all that apply.
1. The nurse should be removed from the unit.
2. A critical incident report should be written about the behavior.
3. The manager should explain that this is a good nurse who has difficulty tolerating stress.
4. Security should be notified of the behaviors.
5. The manager should warn other staff to stay clear of this nurse for the rest of the shift.

Answer: 1, 2, 4
Explanation: 1. The nurse should be removed from the situation.
2. This behavior should be documented.
3. Making excuses for this nurse is not appropriate. The nurse's temper is escalating and may grow out of control. Excuses violate the zero-tolerance policy.
4. As the behaviors are escalating, security should be notified.
5. The nurse should not be allowed to remain on the unit for the rest of the shift.

As part of a presentation on healthcare workplace violence, the speaker says, "Injuries to nurses from violent acts in the workplace are probably underreported." What rationale should the speaker offer for this statement? Select all that apply.
1. Nurses may not clearly understand what constitutes workplace violence.
2. Nurses may be unaware of how to report violent actions.
3. Nurses may feel that dealing with violence is an expected part of the job.
4. Nurses may believe that reporting a violent act will mark them as a weak employee.
5. Most violence against nurses is initiated by physicians, and nurses are afraid to report them.

Answer: 1, 2, 3, 4
Explanation: 1. The definition of workplace violence may not be clear.
2. Reporting policies may not be in place.
3. For many years, violence was tolerated in healthcare.
4. Some believe that being the target of a violent act is the result of poor job performance.
5. Most violence against nurses is from clients.

A highly intoxicated client is brought to the emergency department. Paramedics report that the client was violent during transport and tried to kick the door out of the ambulance. How should the nurse prepare before seeing this client? Select all that apply.
1. Remove any hemostats from the pocket.
2. Take off the stethoscope and place it in the pocket.
3. Ask the paramedics to place the client in leather restraints.
4. Enter the room calmly, with a smile.
5. Give the client 20 minutes or so to calm down before the assessment begins.

Answer: 1, 2, 4
Explanation: 1. The nurse should remove any potential weapons.
2. A stethoscope hung around the neck is a convenient "handle" for anyone who would like to gain control of the nurse.
3. The nurse should not ask the paramedics to perform this intervention.
4. Being calm and pleasant can help defuse potentially violent situations.
5. The nurse should not wait 20 minutes to see a client who is highly intoxicated.

Two nurses are in the day room when a visitor approaches and starts yelling about the care his mother is receiving. One nurse says, "I'm sorry you are upset. What can I do for you?" The visitor continues to complain more loudly. What should the other nurse do? Select all that apply.
1. Quietly direct other people out of the room.
2. Leave the room and call security.
3. Say, "Who are you?"
4. Move toward the visitor and say, "Keep your voice down."
5. Stay next to the other nurse.

Answer: 1, 2
Explanation: 1. Isolating a person who is angry and aggressive is helped by taking away part of the audience. This is also a strategy to protect others.
2. It may be that the visitor is just upset and will calm down quickly with the other nurse's verbal intervention, but that is not assured.
3. This question may further infuriate the visitor because the nurses don't know him or his mother. Also, one nurse should carry the conversation.
4. The nurse should not make a move toward the visitor or demean him.
5. The nurse should move away and out of the room to call security.

A geriatric client in a long-term-care facility becomes increasingly confused and verbally aggressive as evening approaches. Which actions would the nurse interpret as potentially signaling a violent episode? Select all that apply.
1. The client is moving slowly toward the room door.
2. The client is staring blankly at the nurse.
3. The client suddenly becomes alert and oriented.
4. The client raises his fist.
5. The client says, "I know where there is a gun."

Answer: 1, 2, 4
Explanation: 1. The client may be about to flee the room or may be blocking the nurse's exit.
2. A blank stare could be related to pathology such as dementia or may signal a violent episode.
3. Alertness and orientation do not signal impending violence.
4. Preparing for battle signals impending violence.
5. It is fairly unlikely that a geriatric client in a long-term-care facility has access to a gun. The nurse must be aware of the statement but should consider the context.

An emergency department (ED) has doubled its client visits within the past year. This has led to increased wait times and overcrowding in the ED waiting room. Which recommendation by the ED nurse manager to the chief nurse officer (CNO) would be most effective?
1. Increase the size of the waiting room and add more beds to the ED unit.
2. Hire more ED nursing staff to manage the increased volume of clients.
3. Hire another ED physician.
4. Hire another registration employee to improve the intake process and reduce the volume in the waiting areas.

Answer: 2
Explanation: 1. Simply adding space and beds will not help with the rapidity in which clients are seen and discharged, if there are not enough nurses to staff the additional area.
2. The department has doubled in volume of clients, so it is necessary to increase staff to manage this volume. Increased wait times and overcrowding may lead to violent behavior.
3. Hiring an additional ED physician will not be helpful if there are not enough ED nurses to provide care.
4. Hiring another registration employee may speed up client registration, but it will not decrease wait times.

The emergency department (ED) has seen an increase in violent behavior over the past year. The manager has voiced concerns to the chief nurse officer (CNO) regarding the safety of the ED staff. What should be done as a first step in addressing this issue?
1. The manager should consult with local law enforcement.
2. The CNO should review the management of violent incidents procedure policy.
3. The CNO should discuss the matter with hospital security.
4. The CNO should have the manager discuss the matter with the ED staff.

Answer: 2
Explanation: 1. It might be beneficial to discuss the organization's policies and procedures with local law enforcement, but this is not the first step.
2. The first step should be to review and revise policies and procedures so that they are reflective of effectively managing the types of incidents seen in the department.
3. The CNO should certainly discuss the request with hospital security, but this is not the first step.
4. The CNO should not delegate this concern but should personally manage the issue.

A nurse enters a client's room and sees a visitor threatening the client. The nurse questions the visitor in a nonthreatening manner. The visitor begins to threaten the nurse. What should the nurse do in this situation?
1. Keep a safe distance from the visitor.
2. Yell for another nurse to assist with the visitor.
3. Leave the room.
4. Threaten the visitor with assault charges.

Answer: 1
Explanation: 1. The nurse should recognize threatening behavior and keep a safe distance from the visitor exhibiting the behavior.
2. The nurse should obtain assistance, but yelling may increase the visitor's aggression.
3. The nurse should not leave the client unless it is absolutely necessary to obtain assistance.
4. Threatening the visitor with assault charges may further escalate the situation.

A night shift supervisor has been called to the emergency department to assist in managing a violent situation with a visitor. Once the violent person has been contained and security and police have responded, what should be the supervisor's next action?
1. Notify staff on other nursing units.
2. Notify the violent person's physician.
3. Complete an incident report.
4. No action is necessary; the situation has been managed.

Answer: 3
Explanation: 1. The violent person is contained and security and police have arrived, so it is not necessary to alert other staff regarding the situation.
2. It is inappropriate to call the violent person's physician.
3. An incident report is a part of the reporting process for violent events.
4. The supervisor does have duties following a violent episode.

During orientation, a newly employed nurse asks about the process of reporting such things as bomb threats to the organization. The person conducting the orientation says, "Well, I guess you should call 911." What is incorrect about this statement? Select all that apply.
1. The person who is doing the orientation should be aware of the reporting policy.
2. The nurse should have been told to notify security.
3. The nurse should never call 911 from the hospital.
4. The nurse should have been told to follow the reporting policy.
5. The nurse should have been reported as suspicious for asking the question.

Answer: 1, 2, 4
Explanation: 1. The person conducting the orientation should be aware of the policy and relay the information accurately and with certainty.
2. Notification of security is essential.
3. There could be instances in which a nurse should call 911 from the hospital. In a small hospital with no full-time security, calling 911 may be the immediate response.
4. The hospital must have a bomb threat reporting policy. This would be a good time to introduce it to the orientation group.
5. There is no reason to report the nurse.

A manager is following up on an employee's injuries. The manager has contacted human resources to initiate the process of worker's compensation. Which action would be appropriate by the manager?
1. Contact the employee's physician and inform him or her of the injuries.
2. Follow up with human resources regarding scheduling staff to cover the employee's absences.
3. Follow up with the employee to express concern and answer any questions regarding the situation.
4. Follow up with the worker's compensation nurse.

Answer: 3
Explanation: 1. It is not appropriate for the manager to contact the employee's physician.
2. Human resources is not responsible for covering staff absences.
3. The manager should contact the injured employee to express concern for his or her well-being and follow up with any questions the manager may have.
4. The manager should not contact the worker's compensation nurse.

A nurse appears in the nursing station with multiple facial lacerations and says, "A visitor hit me." What is the manager's priority action?
1. Ask the nurse why the visitor became violent.
2. Ask a nurse to accompany the employee to the emergency department.
3. Call security to report the incident.
4. Call administration and inform them of the incident.

Answer: 2
Explanation: 1. Asking for information about the incident is not the manager's first priority.
2. The manager's first priority is to arrange treatment for the injured employee.
3. Reporting the incident is important, but it is not the first priority.
4. Administration should be informed of the incident, but this is not the manager's first priority.

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as any:

physical assault, threatening behavior or verbal abuse occurring in the workplace.

Workplace violence (WPV) refers only to incidents that involve physical violence. Is this statement true or false?

False.

Workers in healthcare and social assistance settings are ___ times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations.

Healthcare workers experience the most nonfatal workplace violence compared to other professions by a wide margin, with attacks on them accounting for almost ____% of all nonfatal workplace assaults causing days away from work in the U.S.

Consequences of acts of workplace violence against a healthcare worker

can exact a heavy physical and emotional toll. Consequences can be both acute (short-term) and chronic (long-term) and range in intensity from minor to serious physical injuries; from temporary to permanent disability; and from psychological trauma to death. Beyond the immediate trauma, negative outcomes may also include low morale and productivity that result from lack of trust in management, loss of team cohesiveness, and a sense that the work environment is hostile and dangerous. Workplace violence may also result in increased job stress, absenteeism, family turmoil, and worker turnover. In addition, there can be a financial impact on the individual due to lost time at work and other out-of-pocket costs of care, or legal expenses. Finally, it is important to realize that one does not need to be the direct target of a violent act to be affected by it. Witnesses, bystanders and coworkers often suffer emotional and psychological trauma no less significant than that of the victim.

Consequences for the Healthcare Profession

Results from a survey of registered nurses conducted by the American Nurses Association revealed that health and safety concerns played a major role in nurses' decisions about whether to remain in the profession. Internationally, an estimated 30% of nurses want to leave their positions because of worker-on-worker violence and abuse. Workplace violence in the healthcare setting may lead not only to nurses leaving the profession, but to negative effects on recruitment into the nursing profession.

Consequences for Healthcare Organizations:

Healthcare workplace violence leads to increased absenteeism by nurses, increased use of sick-leave, lower productivity, low morale and increased requests for transfers. Violence in the healthcare workplace is a major disruption to job satisfaction and has a negative impact on treatment plans, and the reputation of the healthcare facility within the community. It can result in added costs - from Workers' Compensation, to patient lawsuits, to costs associated with hiring and training replacement nurses due to staff turnover. When nurses leave the profession it makes an already critical nursing shortage and the cost of hiring nurses rises. Hospital and healthcare administrators should consider the role that prevention of work-related violence plays in improving the quality of working life for nurses with an eye on improving staff retention rates.

What OSHA Act all employers to provide a work environment "free from recognized hazards that are causing or are likely to cause death or serious physical harm?"

The General Duty Clause from the OSHA Act of 1970

Consequences for Patients:

a little harder to quantify but studies have found higher patient satisfaction levels in hospitals where fewer nurses are dissatisfied or burned out. Caregiver fatigue, injury, and stress are also tied to a higher risk of medication errors and patient infections.

Healthcare workers experience the most ____-_____ workplace violence compared to other professions by a wide margin, but this violence is under-reported and accepted due to cultural factors, cultural bias, reduced funding, and overly complex reporting procedures.

non-fatal

Consequences can be both acute (short-term) and chronic (long-term). Is this true or false?

true

Workplace violence in the healthcare setting may lead not only to nurses leaving the profession, but to negative side effects on recruitment into the nursing profession. Is this true or false?

true

Workplace violence is a recognized hazard within the healthcare industry. Is this true or false?

true

Studies have found higher patient satisfaction levels in hospitals where more nurses are dissatisfied or burned out. Is this true or false?

false

Type 1(violence): Criminal Intent

In type 1 violence, the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence (robbery, shoplifting, trespassing). For example:
- A hospital administrator assaulted in the hospital parking garage
- A home healthcare nurse is mugged while conducting a home visit
In healthcare settings, type 1 violence occurs less frequently compared to other types of violence.

Type 2(violence): Client-on-Worker

Type 2 violence is the most common in healthcare settings accounting for almost 80% of incidents, according to the Bureau of Labor Statistics. This course considers the customer/client relationship to include patients, their family members, and visitors, and will be referred to as client-on-worker violence. Research shows that this type of violence occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is by no means limited to these. This topic will be covered in more detail in this module.

Type 3(violence): Worker-on-Worker

Type 3 violence between coworkers is commonly referred to as lateral or horizontal violence. It includes bullying, and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating though it can range all the way to homicide. Worker-on-worker violence is often directed at persons viewed as being "lower on the food chain" such as in a supervisor to employee or doctor to nurse though incidence of peer to peer violence is also common.

Type 4(violence): Personal Relationship

In type 4 violence, the perpetrator has a relationship to the healthcare workers outside of work that spills over to the work environment. For example, the husband of a nurse follows her to work, orders her home and threatens her, with implications for not only this nurse but also for her coworkers and patients. Addressing this type of violence is outside the scope of this course, but NIOSH offers training on it.

What is type 1 violence?

criminal intent

What is type 2 violence?

client-on-worker

What is type 3 violence?

worker-on-worker

What is type 4 violence?

personal relationships

Type 2: Customer/Client workplace violence risk factors vary by healthcare setting, but common factors include the following:

Working with people who have a history of violence or who may be delirious or under the influence of drugs
Lifting, moving, and transporting patients
Working alone
Poor environmental design that may block vision or escape routes
Poor lighting in hallways or exterior areas
Lack of means of emergency communication
Presence of firearms
Working in neighborhoods with high crime rates
Lack of training and policies for staff
Understaffing in general, and especially during meal times and visiting hours
High worker turnover
Inadequate security staff
Long wait times and overcrowded waiting rooms
Unrestricted public access
Perception that violence is tolerated and reporting incidents will have no effect

There is a strong cultural component which has made the healthcare industry lag in its focus on occupational hazards for its workers in comparison with other industries with similar levels of risk. According to research conducted by Lipscomb & Borwegen, reasons for this include:

The focus on patient health and satisfaction over worker health
The false perception that the healthcare industry is self-regulated
The idea that an industry that employs mainly females is a safe industry
The focus in the hospital environment on curative rather than preventive medicine, which includes occupational health and safety
A low unionization rate within the healthcare sector
Traditionally occupations with a higher male workforce received more focus

WPV doesn't just consist of physical threats but also includes _______ outbursts as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.

verbal

Incidents in work behavior:

were often sparked by unprofessional behavior, disagreement over responsibilities for work tasks or methods of patient care, and dissatisfaction with a co-worker's performance.

Incidents in work organization:

So, what kind of impact can worker-on-worker violence have?

Violence and incivility between hospital employees can contribute to turnover of top performers, hinder effective teamwork, and jeopardize the quality of patient care.

Who is the most vulnerable to worker-on-worker violence?

newly hired or newly registered

What are the four types of worker violence?

criminal intent, client-on-worker, worker-on-worker, and personal relationship.

What are the most common types of worker violence?

client-on-worker and worker-on-worker.

Remember that workplace violence doesn't just consist of physical threats: it also includes

verbal outbursts and passive activities, such as refusing to perform certain tasks or quietly exhibiting uncooperative attitudes.

A patient strikes a nurse as he attempts to give the patient her medication. What type of violence does this scenario depict?

client-on-worker

worker-on-worker

Nora was mugged by a stranger in the hospital parking garage as she arrived to start her shift. What type of violence does this scenario depict?

criminal intent

client-on-worker

Absolutely. Accurate records of incidents, assaults, hazards, corrective actions, patient histories, and training can help employers to:

Determine the severity of their workplace violence problems
Identify any trends or patterns in particular locations, job categories, or departments
Evaluate methods of hazard control
Determine whether programs are working
Identify training needs

OSHA has a regulation (29 CFR 1904) that requires private sector employers and many public sector employers, including many healthcare establishments, to record and report all work-related fatalities to OSHA within ____ hours. Employers must report all work-related inpatient hospitalizations that require care or treatment, all amputations, and all losses of an eye to OSHA within ____ hours.

8, 24

What are the two exceptions to the OSHA regulation (29 CFR 1904)?

First, employers with 10 or fewer employees at all times during the calendar year are partially exempt from keeping records. Second, establishments in certain lower-hazard industries, including medical offices, are also partially exempt.

Employers covered by Part 1904 must record work-related injuries and illnesses that result in

Death
Days away from work
Restricted work
Transfer to another job
Medical treatment beyond first aid
Loss of consciousness
Significant injury or illness (e.g., cancer, chronic irreversible disease, fractured or broken bones, or a punctured eardrum) diagnosed by a physician or other licensed healthcare professional

Recording an injury or illness in accordance with OSHA regulations is _____ a violation of HIPAA.

not

OSHA's recordkeeping rule includes a provision that allows the employer to substitute "privacy case" for the employee's name in cases that involve:

An intimate body part or reproductive system
A sexual assault
A mental illness
A case of HIV, hepatitis, or tuberculosis
A needle stick injury or cut from an object contaminated with blood or potentially infectious material
An employee voluntarily requesting that his or her name not be entered

yes

While victims of WPV are not at fault nor should they be blamed, there are some things you can do to protect yourself and try to avoid becoming the victim of such an attack:

include actively participating in any training or violence prevention programs offered by your employer, dressing for safety, and being aware of your working environment. There are also some patient behaviors that can tip you off that an attack might be imminent. Think about this scenario: someone looks disheveled, smells of alcohol, is clenching their fists, and yelling.

Something that you may not consider as it relates to personal safety at the workplace is having items about your person that could be used as a weapon, used to grab you, or clothing that may restrict your movement making escape difficult.

if you have long hair, it should be pulled back so that it can't be grabbed. The same goes for jewelry such as necklaces or long earrings. Also, make sure to use breakaway safety cords or lanyards for items such as name badges, keys, or glasses.

You ________ take note of exits and emergency phone numbers if you change work areas. You also have to be active in following a safety checklist.

should

According to Hoff & Hoff, it is a best practice to....

review agency files to confirm that a background check was done on a patient regarding any history of violence or crime, drug and alcohol abuse, and mental health diagnoses. Also check to see if a patient's family member has a record of violence or arrest. If entering a situation already assessed by telephone by your employer as potentially dangerous, you should be accompanied by a team member who has training in de-escalation and crisis

You ________ have a mobile phone with you and ensure someone knows where you are. It is also recommended to have a code word so you can call your office and use the code word to let them know you're in trouble, assuming you can't call the police.

should

Verbal Tactics to help lessen the likelihood of a situation escalating into violence:

NIOSH recommends that you:
Allow the person to express concern.
Use a shared problem solving approach.
Be empathetic.
Avoid being defensive or contradictory.
Apologize if appropriate.
Follow through with their problem.
Avoid blaming others or "It's not my job".

Non-Verbal Tactics to help lessen the likelihood of a situation escalating into violence:

Be very aware of your body language and general demeanor:
Be calm, or at least act calm. Maintain non-threatening eye contact, smile, and keep hands open and visible.
Listen. Nod your head to demonstrate that you are paying attention.
Respect personal space. Maintain arm/leg distance away from the individual. Avoid touching the upset individual as it may be misinterpreted.
Approach the patient from an angle or from the side.
Convey that you are in control, by demonstrating confidence in your ability to resolve the situation.
Demonstrate supportive body language. Avoid threatening gestures, such as finger pointing or crossed arms.
Avoid laughing or smiling inappropriately.

Staying safe (to help lessen the likelihood of a situation escalating into violence):

Remember that situations can escalate rapidly. Always make sure that you position yourself so that you can exit the room quickly if the need arises. Call security or colleagues if you feel like the situation is beyond your ability.

You can protect yourself by actively by:

actively participating in any training or violence prevention programs offered by your employer, dressing for safety, and being aware of your working environment

Elise

yes

apologize for the wait time

Maintain non-threatening eye contact, smile, and keep his hands open and visible.
use limit setting language such as "Mr. Wilson, please control yourself or I will call security."
Ensure that he remains between the patient and room exit.
All of the answer options are correct.

Hospital workers may be especially sensitive to issues associated with the Health Insurance Portability and Accountability Act (HIPAA), which—among other things—guards the privacy of personal medical information. Is recording an injury or illness in accordance with OSHA regulations a violation of HIPAA?

Employer policies should include

security measures to prevent workplace violence:
-premises security
-data security

work place violence

any act of threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site

there should be policies on the following:

-workplace violence prevention
-weapons in the workplace
-non discrimination and harassment
-drug and alcohol use
-safety procedures

employers should have periodic review and update company policies to address issues related to:

-security
-safety
-anti harassment
-workplace violence prevention

employers should give employees a way to ________ violence. _______ and _________ need to know how to ________ potential act of violence

report
employees
supervisors
report

employers should identify

-potentially hazardous locations
-areas that are vulnerable because of ineffective lighting, storage, or use of harmful chemicals or equipment that could be used in violent act

employers should review security measures for

gaining entrance to the building as well as into work areas

homicide is currently the _________ leading cause of ______ __________ ___________ in the US

-4th
-fatal occupational injuries

employer should implement a _______ ________ ________

zero tolerance policy

Prevention Measures to take BEFORE workplace violence happens: (1-7)

1. adopt and promote prevention and reparation policy against harassment
2. establish clear codes of conduct
3. organize awareness and training sessions
4. don't allow conflicts to escalate into harassment or acts of violence
5. set up effective communication
6. pay special attention to quality of relationships among members
7. encourage acceptance of differences

employers should create a ______ ______ team with members from management, security, and other areas that will enhance effectiveness of team if violence erupts in workplace

crisis management team

employers should look for warning signs in employees such as:

-changes in behavior
-personal insults
-excessive complaining/whining
-unreasonable demands or threats