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Protecting our Caregivers and Patients from Workplace Violence

Patti Boucher RN, MHSM, BHSC(N), COHN(C), CRSP, CDMP

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Who we are …

• We serve Ontario’s public service sector

• We assist over 9,000 organizations to achieve

safer and healthier work environments for

their one million workers

• Our highly skilled staff are located across the

province, providing ready access and timely

response to all our clients

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Types of Violence in the Workplace

• Type I External

• Type II Client/customer

• Type III Employee related

• Type IV Personal relationship

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Types of Violence in the Workplace

Type II: Client/customerViolence versus Aggression

Violence (Predatory)

• ‘Willful intent’ to cause harm

• No contributing physiological or psychological conditions rendering person incompetent

Aggression/Responsive Behaviours (Affective)

• No intent to cause harm

• Underlying physiological/psychological condition

• Often results form inability to communicate a need –response to stimulus

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Prevalence In Mental Health

• Rates of violence in mental health facilities increasing (Decaire et al., 2006; Almvik, Woods & Rasmussen, 2000 ).

• > 90% of physicians and nurses working in mental health have been subjected to violence

• Highest risk during initial days of hospitalization

• Assaults on health care staff by psychiatric patients constitute a sizeable proportion of violence

– good body of evidence internationally over a 30-year period has documented prevalence

• An investigation of 1,144 incidents within a secure mental health facility revealed that 61% of

violent events were categorized as serious and 31% as life-threatening to either staff and other

clients (Decaire et al., 2006)

• Incidence of violence in a locked inpatient psychiatric unit was higher during the daytime

within 1st week of admission and when unit exceeded its max. capacity

• Violence directed at staff members and other clients as opposed to visitors (Brasic & Ainsworth, 2007).

• Study in UK reported that most violent episodes occurred in lounges and corridors at night and

on weekends – where staffing numbers were lower (Brasic & Ainsworth, 2007)

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Lost Time Injuries due to Workplace Violence or Client Aggression

Date Source: PDM Injury Analysis by SWA cube Data Source: Injury Analysis Snapshot

Jun 2009 Snap Shot Date: Aug 2009 Jun 2009 Snap Shot Date: Aug 2009

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Lost Time Injuries due to Workplace Violence or Client Aggression

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Mental Health – Triggers of Violence

• Disrespect (real or perceived)

• Rude and/or condescending

staff

• Police presence

• Long waits

• Lack of privacy

• Fear

• Frustration

• Excessive noise

• Crowded environment – lack of

personal space

• Unmet needs – hunger, pain,

inability to communicate

• Sedative drugs in high doses

• Poor surveillance

• Frequent medication changes

• Long hospitalization

• Anxiety

• Loss

• Restraint use

• Approach to Care Giving

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Workplace Violence Prevention

• To-date, focus of research on prevention in healthcare has remained outside clinical practice.

• Much of existing literature has examined internal factors (i.e.type of mental illness; age;

gender) and external factors (i.e. environmental conditions; staff behaviours)

• One recent study examined societal factors and safety climate in addition to internal and

external factors (Sheilds & Wilkins, 2009)

• Traditional approaches to managing violence focus on methods to contain or reduce impact

(de-escalation, medication, seclusion and restraint)

• No studies have looked at clinical practice as a determinant of violence prevention.

• Adoption of evidence-based interventions to avert aggression/violence – safety must be

considered a priority; integrated into client care

• Research has shown quality client care is dependent on the health and safety of the

caregiver and an organizational culture where safety is a priority (Boucher, Sikorski, & Nichol,

2009).

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Clinical Practice Assessment Tool

• Employee safety

considerations

• Patient safety considerations

• Two Tools – management

and front-line staff

• Incorporates safety

strategies and infrastructure

for:

– Collaborative Recovery

Model

– Therapeutic Alliance

– Reduction of Seclusion

and Restraints

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Clinical Practice Assessment Tool

Caregiver Tool

• Leadership Commitment

• Supporting Program Infrastructure

• Environmental Considerations

• Client Admission and Assessment

• Client Engagement

• Client Care & Communication

• Staff Development

Management Tool

• Leadership Commitment

• Program Infrastructure

• Client Admission and Assessment

• Staff Development

• Security & Emergency Response

• Environmental Considerations

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Questions?

Concerns?

Comments?

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www.pshsa.ca

esao.on.camhsao.comosach.ca

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An Innovative Interdisciplinary Model for Managing Relationships Through the Crisis Continuum

Debra Churchill RN MHScN

Director Professional Practice

& Clinical Informatics

Ontario Shores

Centre for Mental Health Sciences

The Background and Context(Setting the Stage for Change)

• Staff injury rates (2nd highest in province)

• Jeffrey James Inquest Recommendations

– Least restraint/seclusion

• Code White prevalence

• Operational Assessment – Review of

Policies & Procedures

• Need for changes to practice

– Incorporation of best practices

The Background and Context(Setting the Stage for Change)

• Staff preparedness and training in preventing and de-escalating aggression

• Lack of standardized philosophy of care provision - Recovery Focused Organization– Therapeutic Relationship

• Staff injuries correlated with Code White occurrences in which restraints were used

• Ministry of Labour

Getting Started……..Building the Foundation

Introduced Recovery Philosophy

• Shared Journey Project: Recovery and Rediscover

• Rediscover – Clinical Practice, Level of Knowledge and Skill in Mental Health

• Recovery – Collaborative-Recovery philosophy of care

Introduced Interprofessional Standards of Carebased on Recovery and Best Practices to identify expectations of practice

Multidimensional Model for Managing Relationships

• MMMRCC emphasizes that a comprehensive approach is required to effectively prevent aggression & promote client & staff safety

• Shift from a reactional approach to a preventative approach

• Shift from a Biomedical Model (chemical, environmental, physical restraints) to a Multidimensional Model

1. Leadership towards organizational change

2. Use of prevention/proactive tools

3. Workforce development

4. Debriefing techniques

5. Patient/client roles in an inpatient setting

6. Use of data to inform practice**Adopted the recommendations from the Six Core Strategies to Reduce The Use of Seclusion and

Restraint Planning Tool

National Association of State Mental Health Program Directors (NASMHPD, 2008)

Six Core Strategies

Outcome Measures

• Monitoring Code White Incidents

• Use of Mechanical Restraints

• Positive Patient Outcomes – Goal IQ

( MAP Collaborative Goal Setting)

• Promote Well-being and Strengths

(Psychological Well-Being, Maslach Burnout Inventory,

0

100

200

300

400

500

2006/07 2007/08 2008/09 2009/10

# of Code White Incidents

202328

489303

Code White Incidents

0

1000

2000

3000

4000

2006/07 2007/08 2008/09 2009/10

Total # of Mechanical Restraints

3,101 2,579

1,714

561

Goal IQ total score

significantly increased from

23.78 to 27.04 (t(96)=-3.119,

p=0.002).

Goal IQ measures goal setting

in patients’ charts as a means

of examining integration of

patient’s goals into the plan of

care.

t(96)=-3.119, p=0.002

Patient Outcomes

PWB (Environmental Mastery)scores significantly increased from 16.69 to 17.97 (t(119)=-4.513,

p<0.001).

The environmental mastery scale measures mastery and competence in

managing the environment, control over complex array of external activities, extent of effective use of surrounding opportunities, and ability to choose or create contexts suitable

to personal needs and values.

t(119)=-4.513, p<0.001

Staff Outcomes –

Psychological Well-Being

MBI (Emotional Exhaustion)scores significantly decreased

from 15.71 to 13.50

(t(119)=2.718, p=0.008).

The emotional exhaustion scale

measures mental and emotional

overextension and exhaustion by

one’s work. It describes states of

emotional exhaustion and

overextension due to work

demands.

t(119)=2.718, p=0.008

Staff Outcomes –

Maslach Burnout Inventory

In Summary…

• The MMMRCC recognizes that client aggression and violence occurs as a result of various factors, some of which may be separate from the client

• Increasing staff awareness of the compounding dimensions in managing relationships will have a positive impact in safety of staff and patient and the quality of care

References

Churchill, D., Chen, S., Jones, J., Saychuck, J., Henke, F., and Linder, B.

(2008). Multidimensional Model for Managing Relationships through the Crisis Continuum. Whitby Mental Health Centre. Whitby, Ontario.

Chandler, G. (2008). From traditional inpatient to trauma-informed treatment: Transferring control from staff to patient. American Psychiatric Nurses Association,

14(5), 363-371.

Duxbury, J. & Whittington, R. (2005). Causes and management of patient aggression and violence: Staff and patient perspectives. Issues and Innovations in Nursing Practice, 469-478.

Elliott, D. E., Bjelajac, P., Fallot, R.D., Markoff, L.S. & Glover Reed, B. (2005). Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology, 33(4), 461-477.

Mandercheid, R. W. (2009). Trauma-Informed leadership. Internationsl Journal of Mental

Health, 38(1), 78-86.

NASMHPD/National Executive Training Institute (2009). Training curriculum for reduction of seclusion and restraint. Draft curriculum manual. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD), National

Technical Assistance Centre for State Mental Health Planning (NTAC).