Violence prevention training helps deal with threatening situations
Combine an abusive, out-of-control patient and an untrained home health care worker, and the result can be disastrous. Some workers have been injured and even killed in such situations. Training employees to deal with threatening situations can make a lifesaving difference, says Judy Jacobs, RN, MA, president and chief executive officer of Professional Health Care Systems in Troy, MI, and co-author of The Workplace Violence in Healthcare Toolkit: A Guide to Establishing a Prevention and Training Program.
Jacobs has seen the dangers of workplace violence in her own nursing career. There was the biker she cared for who was recovering from a knife wound and whose threatening behavior escalated to the point that he struck another home health care worker. She says many agencies don’t know how to assess potentially violent situations properly. "People are likely to blow somebody off, saying, Oh, they’re just going postal today.’ That is a really dangerous stance to take."
That approach can carry dangerous consequences. In 1996, home health care workers reported 435 nonfatal, lost-worktime injuries caused by assault or other violent acts, according to the Department of Labor’s Bureau of Labor Statistics. While nationwide fatality figures for the industry weren’t available, homicide was the second leading cause of death on the job in 1997, trailing only highway crashes, the bureau reported.
Along with the threat to life and health are the financial consequences of workplace violence, from penalties imposed by regulatory agencies to the threat of lawsuits. The key to preventing such incidents, Jacobs says, is for employees to know what behavior might pose a threat and to have a system in place to correct it immediately. Sometimes, that’s as simple as contacting a patient and laying down the law, she says.
In more serious cases, the agency may need to terminate a relationship with the patient. "You cannot abandon the patient," she says. "But you can discharge [patients] if you have reasonably accommodated them and they have been noncompliant in their behaviors."
Jacobs says a good safety plan starts well before any specific threat has been identified. Establish a workplace violence prevention policy that spells out employees’ and supervisors’ responsibilities in the event of a threatening incident. An important part of that policy, she notes, is requiring continual violence assessments as part of the physical assessment of every patient. Physical exams should note any previous knife or gunshot wounds or bruises. Workers should be aware of the behavior not only of the patient but of caregivers or family members in the house.
"Are they victims of elder abuse or domestic violence situations?" she asks. "Do they live in a neighborhood that’s in the middle of gang warfare?"
The assessments should be completed by every worker, on every visit, because a patient’s behavior can change over time. "Even if they don’t have histories of violence, medication interactions and the progression of disease processes can make somebody violent," she says. "They can act out just from the frustration of their medical regimen, and their caregivers can act out just from the frustration of long-term care."
Sudden events can trigger problems, as well. For example, a patient may receive bad news, such as a letter from an insurance company curtailing coverage: "All of a sudden, you’re the one that’s there the next day, and they take it out on you."
Inform employees, contractors, patients
Many threats or violent incidents aren’t reported, Jacobs says, even by the home health worker on the front line. Part of the problem is the worker’s belief that he or she can handle the patient. "A lot of nurses feel that they’re not good enough if they’ve not been able to take care of the patient," Jacobs says. "You have to educate employees about what workplace violence is, what we expect of you: If you receive a threat, these are the actions you need to take. You need to report it.’"
Supervisors and administrators also must be trained to take reports seriously and to take action quickly when a threat is made or violent act has occurred, Jacobs says. The system should have mechanisms in place so an employee who feels that his or her concerns aren’t being addressed has another outlet.
Communication is vital between the home health agency and contracted workers such as physical therapists, Jacobs says. Therapists should be performing the same assessments and should notify the agency immediately if a problem develops.
Finally, patients and families must be informed about what’s expected of them at the beginning of treatment, she says. "When you go out to do the admission, you let the patient know what behaviors are acceptable and what behaviors won’t be acceptable."
Such rules would include locking up any guns or weapons in the house, warning against threats or violent actions, and removing family members or other caregivers during visits if a problem develops. The rules should be part of the patient’s rights and responsibilities agreement that he or she signs before treatment. "You contract with a patient and let him know what the consequences are," she says. "You set up the parameters before anything happens."
Act quickly if a threat or violent act does occur, but the response should be proportionate to the action. "If the patient threatened to kill the nurse because she ripped the dressing off and it hurt him, and that was just his way of complaining about the pain, you need to look at that," she says. "That needs to be addressed. A supervisor needs to call back to the patient and say, What happened here? We’ll work with the doctor on pain control, but this behavior will not be allowed anymore.’ Then you can send another nurse in there with a guard or a buddy system of some sort. You don’t send that same nurse back in again."
Armed escorts are becoming more common in the industry, Jacobs says, but an agency considering one needs to realize it is responsible for that person and should make sure guards are bonded. When providing care in dangerous neighborhoods, agencies should note previous problems and be ready to provide a guard or buddy if needed.
If a patient or family member refuses to change objectionable behavior, patient care can be terminated, Jacobs says. In that case, the patient’s doctor must be notified, and the patient must be informed in writing as to where he or she can go for needed care.
The ultimate goals of a good safety plan are to protect the employee, the organization, and the patient, while continuing to treat the patient, if possible. "Part of the conditions of providing health care is that the patient is safe in the home and that you’re going to be safe going there," Jacobs says.
source
• Judy Jacobs, RN, MA, President and Chief Executive Officer, Professional Health Care Systems, 3911 Rochester Road, Troy, MI 48083. Phone: (248) 740-7888. Fax: (248) 689-0611.
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