The best way to avoid violence is to prevent it
Staff, patient safety must be top priority
Home care employees are always shocked when they hear about a nurse or aide who is murdered during a client visit. However, in a time when the evening news brings images of school children with guns, little should surprise us.
If recent headlines have proven anything, it's that gun violence isn't limited to the big cities. That's why an expert on workplace violence recommends that every agency develop a prevention program and teach staff how it works.
"One in four homes we go into has weapons," says Kristie Brandenburg, RN, personnel and education manager at Ridgeview Home Care Community Services in Waconia, MN, a hospital-based agency that serves a 40-mile radius in South-Central Minnesota. "Between 1980 and 1990, there were 106 violence-related deaths among health care providers, and between 1983 and 1989, there were 69 home care nurses who were killed at work."
She offers these suggestions on how to establish a violence prevention program and train staff to improve their own and their patients' safety:
1. Implement staff security measures.
"We had to establish better security in our organization," she says. "We wanted to look at home care personnel's security in the patient's home, and we wanted to look at visits after 7 p.m."
The agency management, based off the hospital campus, began making changes. Manage ment developed a procedure requiring staff who come to work after hours to call hospital security and tell them when they arrive and when they expect to leave, Brandenburg says. If employees don't call the hospital security before their expected departure, the dispatcher calls them to see if they are still there. If there's no answer, dispatcher calls their homes, and if they aren't at home, hospital security drives to the office to check.
The agency created a similar system to monitor field staff who make after-hours visits. When staff make a late visit, they call the hospital dispatch office and report where they're going and how long the visit will last. Again, if employees don't call back within the allotted time, the dispatcher pages them. If there's no response within 15 minutes, the dispatcher calls the patients' homes and then calls the employees' homes.
"If dispatch still can't find the employee, they will call the on-call manager," she says. Then the last resort will be to call police in that area to tell them of the employee's last known location. All Ridgeview employees have parking stickers on their cars, and the police might locate their vehicles by looking for those stickers.
Brandenburg also recommends that agencies develop these policies and procedures:
o Require staff to stay in contact with the office.
o Provide cellular phones for staff during home visits or encourage them to buy their own.
o Encourage field staff to carry handheld alarms and noise devices.
o Encourage staff to use protective devices, such as sprays, and train them in their use.
o Advise employees not to enter locations in which they feel threatened or unsafe.
o Set up a buddy system or escort service.
o Require field staff to prepare daily work plans that keep office staff informed of their locations.
o Have office staff make follow-up calls if an employee fails to report to the office at the end of the day.
2. Make procedures to reduce threat of violence.
"Forewarned is forearmed," Brandenburg says. Education managers need to teach staff how to handle clients who exhibit sexually provocative behavior, are verbally abusive, or abuse drugs or alcohol. Since gun violence is so prevalent in American society, the agency even has a special policy regarding clients who own guns. The policy states that Ridgeview Home Care Services staff will not remain in a patient's home if it is unsafe because of unsafe storage of firearms or weapons. (See firearms policy, at right.)
Ridgeview also gives patients a statement of responsibilities that includes an item about assisting in the provision of a safe environment. (See statement of patient responsibilities, p. 113.) Brandenburg advises staff to leave a home immediately if they find themselves in a threatening situation. "Find an excuse to leave; say you forgot something in your car." If staff need to call the police without letting the patient know, they can call the office with the excuse of getting information from a chart. "When the office staff answers, they can state the client's name and say they need the `P chart,' which is our code for `Call the police,'" she explains. Employees who work in the evenings also may use the code by calling the hospital dispatcher.
The agency's emphasis on staff safety helped protect at least one nurse. The on-call nurse was called to re-insert a Foley catheter at a rural home she hadn't visited before. The call came at about 8:30 p.m. on a Saturday. "When she got to the patient's home, she saw two cars pulled out at the end of the driveway, near the road, for no apparent reason." The nurse contacted the manager on call to ask for a decision about whether an escort or another nurse should accompany her to the home. The manager contacted a nurse who lived in the area, and that nurse met her at an agreed-upon spot. When the two nurses returned to the home, a police car had parked next to the two cars.
3. Assess patients' homes for safety measures.
Ridgeview Home Care Community Services has created a safety checklist nurses use during a first visit to a patient's home. (A copy of the checklist is inserted in this issue.) "It goes room-by-room in people's homes and has a yes or no box to check," Brandenburg says.
The checklist is a good guide for nurses and patients, and it may help remind them to think about safety issues. The agency also has developed a checklist to identify high-risk patients and has established priority and hazard codes for patients.
The code contains the letters B, C, and D. The B stands for the client's behavior; the C means the community environment; and the D pertains to domain, or the home environment. When nurses assess patients' homes, they determine whether there are hazard risks in any of those three areas. If so, nurses write the appropriate letter or letters on the patients' charts. Home health aides may suggest changes to the hazard codes if they believe a patient's situation has changed.
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