By
Michele M. Valentino, MSN,CNS, BC, NP

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Identify scope of WPV in the health care settings
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Identify the role of professional nursing organizations
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Describe violence in psychiatric, ED &
Homecare settings
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Interventions for reducing WPV
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Recommendations for reducing WPV

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Violence is pervasive in our world!!!!!
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Smoyak & Blair wrote in 1992 that violence was epidemic with US Dept. of Justice statistics on violence increasing each year.
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2002 US Dept. of Labor reported nearly 2 million acts of nonfatal work-related violent acts annually.
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2006 ICN reported that occupational violence is a major worldwide public health problem

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Work-related violence is the 3 rd leading cause of occupational injury fatality in the
US
2 nd leading cause of death for women at work
10 yr study of rape in the workplace in
Washington State found 11% of victims were health care workers in hospitals or other care facilities.
2007 Hatch-Maillette found 63% of sample reported sexual threat & 84% reported a past incident of physical or sexual assault

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According to the Department of Justice (Myers,
1996), nurses are identified as the occupation experiencing the greatest number of assaults by a client, patient, or student served by the facility.
These results were further validated by the
Occupational Safety and Health Administration
(Trape, 1998) stating “more assaults occur to health care and social services industries than any other,” with nurses experiencing the most assaults.

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In addition, mental health professionals experience assault & robbery at the alarming rate of 79.5% (Lanza & Campbell, 1991).
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Workplace violence has been linked to decreased job performance and job satisfaction, as well as increased absenteeism and mental health issues among doctors, nurses, and other health care professionals (Bartholomew, 2006).

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Nurses are exposed to, or are victims of, various types of abuse from sources that include patients, visitors, other nurses, physicians, or others in the work environments.
As the incidence and severity of workplace violence rises in all areas, the issue becomes of significant concern in healthcare settings
(Jackson, Clare, & Mannix, 2000).
Over 2 million workers are victims of harassment, threats, or assault each year

 the actual scope of workplace violence is difficult to capture since more than 50-80% of acts may go unreported (Gates, 2004,
Lanza & Campbell, 1991, Gates, Ross &
McQueen, 2006).

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Violence in the workplace is one of the most dangerous hazards facing nurses (McPhaul and
Lipscomb, 2004).
Violence against all health care workers presents a special challenge. Nurses experience the most assaults.
(U.S. Department of Justice Federal Bureau of
Investigation 2004, 54) of health care workers.
In 1999, 2,637 nonfatal assaults on hospital workers occurred in the following settings:
Hospitals: rate of 8.3 assaults/10,000 workers
Private sector industries: 2 assaults/10,000 workers (Centers for Disease Control and
Prevention/NIOSH, 2002, 1)

Canadian Study (Hesketh et al., 2003)
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Emergency Nurses
39.9 percent were threatened with assault
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21.9 percent were physically assaulted
Medical Surgical Nurses
22.6 percent were threatened with assault
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24.2 percent were physically assaulted
Psychiatry Nurses
20.3 percent were threatened with assault
43.3 percent were physically assaulted

Florida Study (May and Grubbs, 2002)
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Emergency Nurses
100 percent were verbally assaulted
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82 percent were physically assaulted
ICU Nurses
85.2 percent were verbally assaulted
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77.8 percent were physically assaulted
Floor Nurses
80.6 percent were verbally assaulted
63.3 percent were physically assaulted

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Centers for Disease Control and Prevention/NIOSH. 2002. Violence:
Occupational Hazards in Hospitals. CDC: National Institute for
Occupational Safety and Health, No. 2002-101. Retrieved February 16,
2006, from www.cdc.gov/niosh/2002-101.html.
Hesketh, K., S. M. Duncan, C. A. Estabroks, et al. 2003. Workplace violence in Alberta and British Columbia hospitals. Health Policy 63:
311.321.
May, D., and L. Grubbs. 2002. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. Journal of Emergency Nursing 28(1): 11.17.
McPhaul, K., J. Lipscomb. 2004. Workplace Violence in Health Care:
Recognized but Not Regulated. Online
Journal of Issues in Nursing 9 (3) Manuscript 6. Retrieved February 16,
2006, from www.nursingworld.org/ ojin/topic25/tpc25_6.htm.
U.S. Department of Justice Federal Bureau of Investigation. 2004.
Workplace Violence: Issues in
Response. Retrieved February 16, 2006, from www.fbi.gov/page2/march04/violence030104.htm.

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Bureau of Justice workplace assaults injure
1.7 million workers (2001)
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Health care & social service industries are 2 nd only to law enforcement for WPV (2003)
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Nearly 500,000 nurses become victims of violence in workplace annually.
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Nurses are 3 X more likely to be victims of violence than any other professional group

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Nursing Management 2008 1400 respondents
74% experienced some form of violence in the workplace (Hader, 2008). Included US &
17 other countries.
51-75% were bullying, intimidation & harassment.
26% = physical violence
Weapons = 5.6 to 7.5 %
Perpetrators = 53/2% patients, 52% colleagues, 49% physicians, visitors 47%, other health care workers (37.7%)

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Joint Commission found that more than 50% of nurses reported verbal abuse ( AACCN,
2005)
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Survey of 303 nurses, 53% reported being bullied at work(Vessey, Demarco, Gaffney &
Budin, in press)

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ICN, AAN, ANA have advocated for increased protective regulations & research to study effective risk management programs.

The Center for American Nurses has issued a statement on WPV & a position statement on
Bullying & Horizontal Violence.

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AORN 2003 & 2007
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Am. Assoc. of Critical-Care Nurses (2004)
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National Student Nurses Assoc 2006
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Code of Ethics for nurses ( ANA 2001)
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Joint Commission 2007
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APNA Position Statement (Oct. 2008)

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SCDONA (Stark-Carroll District of ONA) wrote a reference item for convention in 2007 concerning WPV
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ONA requested that SCDONA write & submit a position statement on WPV
 adopted by ONA in 2008

Developed: 2007 Revised:
The American Nurses Association’s Code of Ethics for Nurses states, in part:
The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
The nurse owes the same duties to self as to other, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of of the profession and its practice, and for shaping social policy.

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Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care.
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Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
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Nurses have the right to a work environment that is safe for themselves and their patients

One of ONA's goals is to prevent violence in the workplace, and ONA supports the following objectives:
Pursuit and support of legislation making the assault of any nurse a felony offence, punishable as determined by law;
Development of programs to support nurses who report assaults and assistance with the process;
Development of workplace standards through
OSHA, OHA, and the Ohio Department of Health, and;
Development of materials to educate nurses to their rights and legal remedies.

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ONA's Nursing Practice Statement on Workplace
Violence (Members Only)
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Behaviors that Undermine a Culture of Safety (Joint Commission
Sentinel Event)
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The Center for American Nurses Position Statement on Lateral
Violence and Bullying in Nursing Work Environments
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Guidelines for Preventing Workplace violence for Health Care &
Social Services Workers
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Violence Against Nurses: The Silent Epidemic (Independent
Study)
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NIOSH Occupational Hazards in Hospitals: Exposure to Stress

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OSHA (2002) has information on preventing and controlling workplace violence in a fact sheet on workplace violence, available at http://www.osha.gov/OshDoc/data_General
_Facts/factsheetworkplace-violence.pdf.
OSHA guarantees all workers a “safe & healthful workplace”.
Employers must provide a safe workplace using written policies, employee training, proper staffing, and follow-up of any incidents.

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The Center for American Nurses (Carroll, 2003) has a two page print-out on their website http://www.centerforamericannurses.org entitled “Guidelines for Preventing Workplace
Violence for Health Care and Social Service
Workers”. The four main components are:
1. Management commitment and employee involvement
2. Workplace analysis
3. Hazard prevention and control
4. Safety and health training

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The American Nurses Association’s has a bulleted brochure that they allow the
Constituent Member Associations to print with their logo. It is titled “Workplace
Violence, Can You Close the Door on It?”
(ONA, 1996). It includes information on
“Know your Patients,” “Steps to a Safer Work
Place,” and “Addressing Workplace
Violence.”


Workplace Violence Data Collection Form (Adobe
PDF File)
Preventing Workplace Violence Brochure (Adobe
PDF File)
Workplace Violence in the Health Care Setting
(Adobe PDF File)
Occupational Hazards in Hospitals (Adobe PDF
File)
Nurses and Workplace Violence Fact Sheet
(Adobe PDF File)
NIOSH Occupational Hazards in Hospitals:
Exposure to Stress (Adobe PDF File)
The Center's Position Statement on Lateral
Violence and Bullying (Adobe PDF File)

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2007 survey by APNA, Safety was one of the top issues for front line providers
I was honored to chair this task force May 2007
Call to members Response of 150 persons
25 members selected for steering committee
Expert Consultant Panel
3 areas = Psychiatric (inpatient, outpatient, forensic, state-funded), other health care settings (ED’s and homecare), & schools and universities.

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ROL from 1970 to 1990 –most articles described characteristics of units where violence occurred & described staff response to assault.
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Pressing need for research describing successful violence prevention interventions

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ROL using key words of “psychiatric, nursing,
& violence” in the data bases in CINAHL,
PsycINFO, and Academic Search Premier.

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Bullying is repetitive horizontal or lateral violence and it can be detrimental to a person’s physical or mental wellbeing
( Center for Am. Nurses)
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DISRUPTIVE BEHAVIOR = behavior that interferes with effective communication among healthcare providers and negatively impacts performance & outcomes. Bullying is repetitive horizontal or lateral violence and it can be detrimental to a person’s physical or mental well-being
( Center for Am. Nurses)

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Now receiving more attention
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JAHCO addresses “disruptive behavior”
(July 9, 2008)
JAHCO uses the term “zero tolerance”

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Horizontal Violence, a term used to identify violence that occurs between peers, is seen when nurses “bully” their coworkers.
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Behaviors exhibited with horizontal violence may include criticizing, sabotaging, undermining, infighting, blaming, scapegoating, intimidation and bickering.

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The 10 most frequent forms of horizontal violence are nonverbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting scapegoating, backbiting,failure to respect privacy, and broken confidences (Griffin,
2004).

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Being accused of errors made by someone else
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Nonverbal intimidation, included being stared at or glared at
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Being belittled
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Having thoughts or feelings ignored
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Being excluded from activities or conversations

Colleague? Supervisor? Physician?

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Use of cue cards & scripting for responses
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Educate nurses & students about it
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Create an infrastructure to support managers and staff
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Assertiveness training
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Appraisal of risky situations
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Communication skills Training

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Nsg Curriculum to include: awareness-raising & empowering strategies
Educate Nurses emphasizing non-hierarchical leadership & supportive relationships.

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Each of us tolerates the behaviors of others a bit differently. However, if the behavior is offensive to you, or undermines you and your job in any way, it needs to be reported to your manager.
Speaking up is difficult, especially if one has to face the bully everyday in the work environment. Fear of retaliation from the perpetrator.

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To gain self-confidence, nurses need to articulate clearly & confidently their common vision of nursing and its future
(Buresh & Gordon 2000)
Nurses must “PAY IT FORWARD” – praise each other for jobs well done
VALUE each other & the work of others
New staff need mentored in a kind, nurturing manner

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Mentor new hires and new grads
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Appreciate diverse points of views
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Value the differences in colleagues from various generations. It is not a burden it is an advantage.

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Express pride in being a nurse
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Accept and celebrate compliments about good patient care
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Actively compliment others for work well done
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Look for and acknowledge improvements to the system
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Be an ambassador to those outside the profession about the true contribution nurses make to quality patient care.

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Gain control
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Get help from your employer
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Make a plan for action
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Take action
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Confront the aggressor
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Make a formal written complaint
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Take legal action

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Solicit support from family & friends
Consult an outside physician or therapist
Solicit witness statements
Confront the bully
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File the internal complaint
Preparing of the case against the bully
“Rule of 2”meeting presenting your case
Taking your case public

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Replace your own internalized misperception with a belief that we are gifted, dedicated and highly skilled professionals who have struggled against great odds
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Resist messages from coworkers or superiors that denigrate your professionalism or that of the nursing profession
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Be a supportive colleague

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Direct concerns about workplace negativity clearly and concisely to appropriate individuals.
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Develop an understanding that “rocking the boat” can be the first step in the service of positive change.
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Start confronting problems, not people

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Support, insight, and connection can help nurses change the cycle that impinges their own empowerment .
Develop a positive personal and professional identity
Develop Assertive Behaviors

 and help regain control of the situation, i.e. ensuring facial expressions correspond with message learn to ignore distractions listen effectively to the other understanding the other person’s message before responding stand straight use good eye contact use relaxed natural gestures
Use level, well-modulated voice
Speak clearly

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Assertiveness is not about throwing your weight around. Its about articulating your thoughts, feelings, and opinions in a clear, honest, and straightforward manner.
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Defuse intense anger
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Resolve to release anger
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Consult an expert if conflict is festering in the workplace
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Exhibit care and compassion for your colleagues
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Compliment rather than complain
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Cultivate team spirit

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Inurnment due to chronic & protected exposure to violent individuals
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Underreporting
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Few effective regulations
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Attitude & perception that Violence is “just part of the job”
32% of assaulted employees and 8% who experienced nonphysical violence reported that violence was part of the job.

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Peer pressure not to report ( lANZA, 1988)
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Ambiguity in defining violence ( Lanza, 1988)
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Excusing the behavior of “ill” patients
(Mayhew, 2000)
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Organizational culture, including onus on the victim to be proactive & make the complaint
& the employer’s belief that it would be too costly to institute protective measures for the staff

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Stigma of victimization, including embarrassment, shame, isolation, & fear of judgment
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Fear of job loss
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Fear of blame of provoking the assault or being negligent
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Victim’s self-blame
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Time-consuming, ineffective, or genderbiased reporting mechanisms

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No benefit, either personal or organizational, of reporting
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Unhelpful experience with prior reporting

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Typically, acts of physical violence that do not result in injury or are nonphysical are not reported (Findorff, McGovern & Sinclair,
2005)
43% of physical violence & 61% of nonphysical violence was unreported.
Estimated that 1 in 5 violent events in psychiatric settings are reported (Mayhew,
2000)

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Physical
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Sexual
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Verbal
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Horizontal violence
 stalking

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Inconsistent definitions
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Suggest use of Typology of WPV by NIOSH
2006)

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I: Criminal intent The perpetrator has no legitimate relationship to the business or its employee, and is usually committing a crime in conjunction with the violence. These crimes can include robbery, shoplifting, trespassing, and terrorism. The vast majority of workplace homicides (85%) fall into this category.
II: Customer/client The perpetrator has a legitimate relationship with the business and becomes violent while being served by the business. This category includes customers, clients, patients, students, inmates, and any other group for which the business provides services. It is believed that a large portion of customer/client incidents occur in the health care industry, in settings such as nursing homes or psychiatric facilities; the victims are often patient caregivers. Police officers, prison staff, flight attendants, and teachers are some other examples of workers who may be exposed to this kind of workplace violence, which accounts for approximately 3% of all workplace homicides.
III: Worker-on-worker The perpetrator is an employee or past employee of the business who attacks or threatens another employee(s) or past employee(s) in the workplace. Worker-on-worker fatalities account for approximately 7% of all workplace homicides.
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IV: Personal relationship The perpetrator usually does not have a relationship with the business but has a personal relationship with the intended victim. This category includes victims of domestic violence assaulted or threatened while at work, and accounts for about 5% of all workplace homicides.
Note: From NIOSH, 2006.

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About ½ of assaulted staff have minor injuries ( Hunter & Carmel, 1992.
Emotional consequences (anxiety, depression, insomnia, burnout & exhaustion, etc.)
Bullying is associated with fear, demoralization, HTN, panic attacks, low morale, negative relationships at work.
PTSD, depression
Can lead to suicide
Burn-out & leaving the nursing profession

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NIOSH reported employees lost 160 days due to patient violence (2002)
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Pres. Of the Federal Nurses Assoc. estimates cost of violence at $4.3 million annually or
$250,000 per incident, excluding emotional $
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Costs include increased staff turnover, recruitment, & retention costs
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Increased staff absence from work

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Reduced efficiency & performance at work
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Reduced staff morale
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Higher incidence of pt. complaints
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Falling reputation for the organization.

 mental health professionals experience assault & robbery at the alarming rate of
79.5% (Lanza & Campbell, 1991).
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Workplace violence has been linked to decreased job performance and job satisfaction, as well as increased absenteeism and mental health issuesamong doctors, nurses, and other health care professionals (Bartholomew, 2006).

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Nurses working in emergency rooms
(Lyneham, 2000) and in services for the elderly (Gates,Fitzwater & Meyers 1999) are at high risk for interacting with violent patients.
The potential for violence may stem from frustration of waiting time for appointments and patient clinical characteristics, such as intoxication and dementia (McKenna, 2003).
Length of wait time in Emergency
Departments should be kept to a minimum.

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Position Paper to be on APNA website soon www.apna.org

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To be released soon on APNA website www. Apna.org

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Position Paper will be on www.apna.org
website soon

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Every health care organization should have a comprehensive plan for WPV including horizontal violence.
Survey staff attitudes about intimidation & lateral violence.
Create a code of conduct & have staff sign the code at hire & annually
Hold frank discussions about WPV
Establish a standard, assertive communication process

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Create a conflict resolution process stated in a professionalism policy & include a chain of command for resolution
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Encourage 1-on-1 conflict resolution & provide a mechanism for confidential reporting
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Enforce a zero tolerance policy (full punishment for an infraction) (Hader, 2008;
Joint Commission, 2008).

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Provide ongoing education to reinforce the organization’s commitment to ensuring a caring & respectful environment
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Lead by example & reward outstanding role models(Schaffner, Stanley, & Hough, 2006).
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Utilize a screening & risk assessment tool in combination with traditional clinical assessment techniques for violence risk.
(Otto,2008).

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Develop healthy nurse-client relationships
Use structured assessment tools with traditional assessment techniques to identify risks.
Recognize factors that may predispose patients to becoming violent including:
-history of violence, especially recent
-head injuries, CVA, organic or clinical brain injury
-hypoxia

-endocrine disorders: hypoglycemia or hyper
-seizures
-psychotic disorders
-hs of PTSD
-S.E. of prescribed medication
-intoxication or drug OD, or drug or ETOH withdrawal
- dementia or senility
- disorders of childhood & adolescence

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Implement preventive measures based on training & educational programs
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Examine incidents of violence in the workplace to Identify underlying causes & impact on individuals
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Establish protocols to assist staff victims & administrators in navigating complex issues occurring after a violent event

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Encourage group discussions for victims of violence
Design intervention strategies to address specific types of violence ( physical & nonphysical)
Stress the importance of reporting physical & nonphysical incidents of violence
Develop policies & procedures for safety in the event of a weapon threat, i.e. lockdown procedures & practice them

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Be informed & aware of one’s legal rights
Take all threats seriously, even verbal threats & follow up on them
Check patients for contraband
Familiarize staff with takedown procedures
& practice them regularly (even though rarely used)
Have a system in place for reporting all threats by phone & take immediate measures involving local police

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There should be a post-incident evaluation and counseling plan for any violent incident.

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Define workplace violence , types, causes & consequences
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Discuss work-related violence prevention & management policies & procedures
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Recognize early signs of escalation, identify patient & staff factors that increase risk
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Conduct personal safety training
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Explain legal & unethical concepts related to
WPV

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Develop consensus-based definitions
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Study effet of relationships on reducing incidence of violence
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Evaluate outcomes related to staff training
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Assess outcomes of use of structured assessment tools in combination eith traditional assessment techniques to identify risk

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Identify which techniques help contain violent individuals with the greatest degree of safety
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Examine staff characteristics & environmental factors that increase the risk of aggression & violence
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Explore effect of nurse-patient relationships
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Develop a uniform standard instrument for measuring aggression & violence that will identify type & mode of aggression & severity

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Test effectiveness of proactive strategies such as establishment of work environments that are not conducive to violent behavior
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Include longer follow-up periods in studies

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Create a work environment that facilities & supports colleagiality & effective communication & IPR
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Develop clear organizational guidelines for leaders & employees to be accountable for workplace behaviorIntervene when witnessing victimization & bullying of colleagues
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Discuss concerns of horizontal violence at staff meetings

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Educate new nurses on horizontal violence & provide cognitive rehearsal techniques
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Coach nurses to develop their conflict management & conflict resolution skills
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Provide ongoing education to reinforce organization’s commitment to ensuring a caring & respectful environment

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Teach students that horizontal violence is not acceptable
Educate about horizontal violence, how to
Identify it & confront it
Mentor students, building self-esteem & self worth
Equip students with assertiveness tools & with conflict resolution & healthy communication techniques.

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Continue to advocate for a safe work environment for all nurses
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Continue to recommend research & ed
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Acknowledge horizontal violence, including bullying
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Increase awareness of this issue
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Use the standard definition for workplace aggression & violence

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Lobby for legislation that would increase assault of a health care worker to felony status
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Request that OSHA guidelines become mandatory for health care workplaces

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Establish & Maintain a comprehensive program for Prevention & management of all types of workplace violence
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Analyze workplace security & perform risk assessments
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Improve screening of potential employees
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Select staff preceptors
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Make ongoing formal ed. @wpv compulsory

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Reward outstanding role models
Track all assaults
Ensure anonymity in reporting
Ensure time-out areas & quiet places adequate staffing specialist security staff covert distress messages & coded responses

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Personal alarms & panic buttons
Bulletproof glass
Adequate lighting
Metal detectors
Two-way communication systems
Closed-circuit TV’s
Controlled access to & security monitoring of entrances, exists & high risk areas

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Employees working with high-risk patients should not do rounds alone; it is recommended staff be in pairs, especially on psychiatric inpatient units and in Emergency
Rooms.

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Educate staff @ warning signs
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Educate methods of coping with violence
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Report protocol
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Instruct @ counseling
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Provide legal information
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Provide risk assessment
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Develop a risk management plan

 www.bullyinginstitute.org
 www.osha.gov
 www.cdc.gov/niosh
 www.nursingworld.org/can

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Questions???
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Any sharing of personal experiences??

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You are a Great Audience!!!
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LET’s END VIOLENCE in the WP
And Everywhere!!!