Extreme stress can lead to violent behavior
Would you know if a worker is 'crossing the line'?
Perhaps the most extreme response to unresolved stress is violence, and health care workers "are human beings just like everybody else, with the same sorts of anger and frustrations, so there does come a point where we all could go over the edge," says Carol Schober, MSN, RN, COHN-S, occupational health nurse at the 2,000-employee Presbyterian Medical Center of the University of Pennsylvania Health System in Philadelphia.
When workers lose control, Schober explains, "they go beyond the rational," often spurred by a variety of job and personal stressors. Schober is an expert in developing violence response guidelines for hospitals, and also teaches aikido (a Japanese martial art) self-defense for nurses.
On the work front, one of the main stressors is change. In hospitals, that can range from downsizing and mergers to being forced to use a different report form, Schober says.
"Employees can interpret this as loss of control," she notes. "If people feel they don't have any control over what is going on, they're going to react, and you don't know how they might react. They might sabotage a new policy by not filling out a new form or by not cooperating in a passive-aggressive way, or they might plant a bomb."
Combine pent-up work stress with any number of personal stressors such as a divorce, death in the family, or a child flunking out of school, and that employee could be a pressure cooker about to explode.
"Individual stresses can lead people to not being able to deal with things anymore, and they can cross that line into the irrational and do something they ordinarily never would do," she adds.
"Warning" behaviors can range from losing papers, being late with reports, and sabotaging computer systems, to more overt actions against managers or supervisors such as sending threatening voice mail or e-mail messages, stalking, property damage, or outright physical assaults.
Heed warning signs
How can an employee health practitioner tell if an HCW is about to cross that line into violent behavior? Schober suggests listening carefully to what the employee is saying, and "if you get a gut feeling that something is not right here, take it seriously." Some warning signs include:
* Are they saying things that don't make sense?
* Are their sentences connecting logically?
* Can you follow their train of thought?
* Are they showing visible signs of anger?
* Are they trying to intimidate other people?
* Are they talking about revenge for "wrongs" they think people have done to them?
* Are they behaving out of character? For example, someone who is normally a quiet person suddenly has become loud or aggressive, or a loud person suddenly has become quiet.
* Have their decisions become erratic or irrational, reflecting a noticeable change in judgment?
* Have they become obsessive about work?
* Have their absences or accidents increased markedly?
* Are their co-workers or supervisors concerned about them?
Schober suggests that EHPs make discreet inquiries of supervisors about employees they do not know very well but about whom they are concerned, keeping in mind confidentiality issues and policies.
One of the best ways to handle the threat of potential violence is to defuse the stress that leads to it, says Schober. This is best accomplished by involving employees in hospital policy-making.
"If you include [workers] when policies and guidelines are being written, they feel empowered and in control, so they take some ownership of what's going on. This helps to defuse a lot of problems," she explains.
If an EHP suspects an employee is or might be engaging in violent behavior, Schober advises bringing in other key hospital departments, such as human resources and security, to assess the situation confidentially.
"Do not handle this alone," she warns. "Not only could you become a target, but you need various points of view and you also need to cover yourself legally. You may need to do an intervention with a mental health professional or even the police. This must be done very carefully."
Provide guidelines, training
Every hospital should have written policies and procedures for handling violence, she adds.
"For example, what do you do if this happens at 3 a.m. on a Saturday when nobody is around? Front-line supervisors need to have guidelines and ideally some training."
Training in nonviolent conflict resolution is important for all hospital staff and can be accomplished in a train-the-trainer format, Schober says.
"It's important to learn the signs and symptoms of somebody who is about to go off and to learn appropriate ways of dealing with violent people, depending upon their level of violence," she notes. For example, responses to someone who is just yelling would be less extreme than for someone who is waving a gun or taking hostages.
[Editor's note: For more information on providing training in nonviolent conflict resolution at your hospital, call Schober at (215) 662-8278. For information on U.S. Occupational Safety and Health Administration guidelines for workplace violence prevention programs, see Hospital Employee Health, October 1995, pp. 125-128 and insert.] *
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