Pilot Program Sees 78% Reduction in Workplace Violence

By Matt Phillion

Workplace violence in healthcare continues to increase with few signs of slowing down. A new nurse-led pilot program aimed at mitigating workplace violence in the hospital setting using communication enhancements, tools for early risk identification of escalating behaviors, and increased accessibility to de-escalation resources has shown a 78% reduction in workplace violence incidents over its first year.

The pilot results also found significant cost savings in reduced staff injuries and the establishment of site-specific guidelines in the hospital system.

Sheryl-Lyn Quijano, MSN, RN, ONC, and Jennifer Hill, BSN, RN, ONC, authors of the Strength in Safety: Preventing Workplace Violence and Supporting Staff study, recently presented their findings at the American Nurses Credentialing Center’s (ANCC) Magnet & Pathway Conference™ in October. Both work at Advocate Health in Park Ridge, Illinois.

“When we started this work, our reporting increased, but our injuries decreased. To us, that was profound, having simply asked the question,” says Quijano.

The study came out of Quijano and Hill’s own first-person experiences in the workplace.

“That was the fire that led us to saying we can’t let this happen to our teammates,” says Quijano.

It was pivotal in their research to look at the issue specifically through a nursing lens. Work was being done in areas like duress response or installing metal detectors, but what about the nursing side of workplace violence?

“There are processes in the behavioral health realm providing tools to walk through things like a de-escalation process, but we need to challenge the norms and bring those tactics to the inpatient nursing side,” says Quijano.

As a part of the study, reporting of workplace violence is riding with a larger number of incidents but Quijano and Hill note, this is also a sign that the teammates are sharing that they feel supported—that they can report incidents of violence.

“It’s multifactorial,” notes Hill. “There’s more awareness surrounding workplace violence, so we’re talking about it more and that’s driving up the numbers. We’re also starting to report some of those ‘minor’ incidents that people used to just write off as part of the job as that awareness increases. They’re reporting those incidents of verbal abuse that we’d just let go in the past, small scratches. And while the number of incidents is going up, the number of incidents with injuries is going down” with the implementation of the tools in the pilot program.

Clarifying how to report a teammate’s injury or experience of workplace violence helped drive the study, and then taking action based on the incoming data helped demonstrate to staff that something was actually being done with that data.

“That’s really where we got started with this work,” says Hill. “We were involved with our workplace violence committee, but we were sharing more from the public safety side of things, making the environment safer. But we had a few profound examples that made us pause: What can we do on the nursing end? We’re the sharp tip, the ones who are arguably most personally affected. What can we do to keep us safer?”

Implementing tools that make a difference

It’s one thing to collect data, but the next step is doing something with it. One such implementation the pilot program used was a patient intervention bag that can be applied in the event of a violent patient.

“Nurses are often the one applying restraints, so what can we do to make this process easier and more readily available?” says Hill.

“We have a rapid response team, and during COVID we had a kind of go-bag, which was essentially all you need for a patient declining with COVID,” says Quijano. “Jen talked about her experience as a bedside nurse deescalating a patient and [how] it took time for help to arrive. The patient was aggressive, hitting his father. We thought, ‘If we’re holding someone down because someone could get hurt, what can we get into people’s hands that is like that ‘go-kit’ but for situations involving violence?”

They examined what tools such a go-bag for these incidents would require—such as soft and locked restraints—and taking precautions such as storing the restraints in the unlocked position to save invaluable time instead of fumbling to unbuckle the restraints. This takes a bit of anxiety out of an already very high-stress situation. They also considered if a spit hood was appropriate but eventually dropped that from the kit because it requires a different level of training to use.

“We do rounds annually on the bags to remind people they’re there and ask what their experiences have been like,” says Hill. “It’s surprising: We only found one unit that hadn’t needed to use it, and that was in women’s health in the postpartum area. It’s unfortunate that it’s needed, but this shows that there’s value. People are happy the bags are there, and what we’ve heard from bedside nurses is overwhelmingly appreciative that they know these tools are ready when they need them.”

They have also worked to make sure the bags are easily restocked and replaced so they are always there when staff need them.

They’ve made sure to implement proper training to go with the bags as well.

“We want to make sure nurses were educated and they understand the why behind it. These situations can be scary and it’s unfortunate we’re in a world where we need this type of tool. We wish you’d never have to use it, but if you do, we want to give you that level of security to protect yourself,” says Hill.

Additional training, such as how to identify behaviors that may indicate the patient is becoming violent so staff can intervene before it happens, was another important addition, she notes.

“We want the bedside nurse to be able to identify those behaviors themselves and know what to do next,” says Hill.

Next steps and further improvements

Violent incidents in the healthcare setting are unlikely to go away any time soon.

“Most nurses will say absolutely, it’s been getting more frequent,” says Hill. “In our larger workplace violence committee that’s what we’re hearing, from public safety, from employee health, and from our data collection.”

Their organization has a best practice act for violent patients, where nurses are enabled to identify patients exhibiting violent behavior and include this in the electronic record, so it appears when you open the record as an alert.

They’ve expanded this process through signage and tools, such as for transportation staff moving patients between units.

“Our organization has a robust workplace violence committee, and I can only imagine how much this can grow,” says Quijano.

Working in a large organization meant implementation could be a challenge.

“Sometimes it works to our advantage and sometimes you have to bust through a lot of red tape to implement these things. It’s just being steadfast and persistent and partnering with the folks around you,” says Hill.

They teamed up with areas of the organization like clinical informatics to demonstrate how these changes would work throughout the enterprise.

“In the example we discussed where the patient was hitting his dad, looking at the room, we noted that there was a bedside tray with a metal knife and fork. We were able to push through changes where our organization already used safety trays for patients demonstrating suicidal or homicidal ideation, so we asked if we could expand that to folks we identify as potentially violent,” says Quijano. “Why would we give them tools to hurt themselves or someone else?”

“This felt like it should be the easiest to implement but was one of the hardest things to push through. It comes down to dollars and ordering more of those trays, but we kept pushing,” says Hill.

“A barrier is only a barrier if you don’t have support,” says Quijano. “That’s what you need from all your partners.”

Quijano and Hill are hoping to see their work toward better preparing nurses for intervening with and preventing workplace violence to go even further.

“There’s a lot of work that still needs to be done in this space, but we were excited to present at the Magnet Conference and join forces with other nurses throughout the country and the world,” says Hill. “It was a chance to put our heads together to see what we can do to keep expanding this work. Everyone deserves to feel safe in the workplace.”

“I wanted my peers to not be afraid to ask why or why not, and challenge the status quo,” says Quijano. “It’s about our teammates. We’re driven by what we’ve experienced, and by our ‘why.’”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.