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PICOT- or on duty (OSHA, 2013). They

PICOT- For healthcare staff in the Emergency Department at Hackensack University Medical Center, would the implementation of a workplace violence program, compared to the current HUMC policy and normal practice, decrease the incidence of workplace violence and injury to staff within an eight week time frame?

1.    Practice problem- Being that I work in a high paced, fast moving, acute care, extremely busy emergency room environment for the past twelve years, I have seen firsthand nurses and staff being victims of direct violence from both patients and their family members. This violence is both physical and verbal, and both types can have lasting detrimental effects on the employee. Most of the time this violence can be avoided with proper education and training of the employees to help them identify and react to situations that are escalating. I have concluded that this training is lacking in most hospitals and thus needed further research and attention. Healthcare has been consistently identified in the literature as having high rates or workplace violence (WPV), more so than any other profession. Due to this, there needs to be a strong effort made by hospitals to reduce violence and protect its staff. Healthcare workers are nearly four times more likely to be injured and require time off of work as a result of workplace violence as compared to all workers in non-healthcare combined (Bureau of Labor Statistics, 2013). WPV is a public health problem of increasing proportions. Different organizations have defined workplace violence in various ways. WPV is defined by The National Institute for Occupational Safety and Health as violent acts, including physical assaults and threats of assault, directed towards persons at work or on duty (OSHA, 2013). They further define verbal violence as threats verbal abuse, hostility, harassment, and the like which can cause significant psychological trauma and stress even without physical injury (OSHA, 2013).

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2.    Practice change- The goal of my research project is to compare the literature on the components of workplace violence and current interventions implemented in hospitals across the country, identify the most commonly implemented program elements that have been effective, and identify gaps in existing programs that can be remedied for future practice and for practice change. This study was a cross sectional survey of existing literature on workplace violence in the United States. Once the gaps have been identified and the effective interventions have been singled out, the goal is to use these interventions to effectively educate employees for safety.

3.    Population- Healthcare workers, most specifically acute care and Emergency Department Employees at Hackensack Meridian Medical Center. Inpatient hospital settings are receiving much of the attention regarding workplace violence programs (Blando, 2015). According to mortality data, victims who experience violent injury shows that these patients often have long term effects of alcohol and substance abuse and often have limited support systems (Fischer, 2014). In the US, 60% of new nurses leave their first position within six months as a result of horizontal WPV (Townsend, 2012). Bullying and WPV can disrupt professional performance increasing the risk of medication errors and patient falls (Townsend, 2012). I do not feel the population is too narrow for my research study. WPV effects healthcare workers, of all races, any gender and all ages, in all healthcare settings across the country. The literature examples have been taken from facilities across the country representing various facility sizes, setting and approaches to addressing workplace violence.

4.    Intervention- Referring to the current literature offers real world examples of how healthcare facilities have put workplace violence policies and procedures into practice. For example, The New Jersey Department of Health and Senior Services (NJDHSS) regulations for covered healthcare facilities and require the formation of workplace violence prevention committee, the utilization of reporting systems to track violent incidents, annual security reviews of the hospital environment, specific training requirements for all staff, and a comprehensive policy and workplace prevention plan (NJDHSS, 2012). The state of New Jersey implemented WPV intervention regulations to ensure appropriate employee representation on WPV committees by requiring that 50% of the committee members have direct patient contact (NJDHSS, 2012). The most common causes of violence in the literature included environmental, policy and procedure, technology and equipment, people, and communication (Beard, 2017). Environment; space restrictions, patient placement issues, forensic patients, volume surges and mentally unstable or intoxicated patients. This can be remedied by redesigning ER spaces and triage areas, add panic buttons, addition of internal communication capabilities in the ER, have designated ER overflow spaces and house supervisor involvement, create an ER surge team and have specific areas for unstable or intoxicated patients (Beard, 2017). Technology and equipment; security cameras lacking, secure entry/card swipes lacking, inadequate panic buttons and lack of handheld metal detectors and presence of security and entrances and exits. This can be remedied by ensuring all card readers are functioning, add metal detectors, and engage local law enforcement. Communication; unreported incidents, non-awareness or adherence of policies, acting without collaboration and security that has a hands off policy. This can be remedied by developing a comprehensive workplace violence policy, revise a 1:1 observation policy, include security as a part of the intervention team in regards to restraints, and develop a patient code of conduct policy. This can be achieved by educating ALL staff how and when to report, form a workplace safety committee, and use of daily huddles to identify potential unsafe situations and issues on the unit (Beard, 2017) People; lack of teamwork, lack of appropriate training and accountability, lack of support, burnout, and lack of security presence (Beard, 2017). De-escalation training protocol education for all staff, enhanced training to all current staff and new hires, and work place safety committee with senior leadership support (Beard, 2017). Additional strategies that can be implemented to reduce the threat or workplace violence include the following: implementing comprehensive prevention programs that involve employers and employees and include risk assessment, safety training, reporting systems, and intervention for at risk employees (US Department of Labor Occupational Safety and Health Administration, 2015). Zero tolerance policies regarding threatening, harassing and violent behaviors and create a culture that encourages prompt reporting of threats and violence (Townsend, 2012). Employee education and training to promote recognition of warning signs of workplace violence and increase the ability of health care workers to appropriately respond to violence (US Department of Labor Occupational Safety and Health Administration, 2015). Moving forward first we need to learn about workplace violence in order to be able to correctly identify the violence and then appropriately respond to threats of violence. Promote respectful communication, zero tolerance policies in the workplace without regard to position or role, written policies and procedures on WPV that include definitions of unacceptable behavior, personal accountability, and procedures for appropriate response and reporting (Ramacciati, 2016).The above are examples within the literature and will be used as stepping stones for my proposed similar interventions. For my specific project and research I plan to use the literature findings to create in-service education, handy pocket guides, e-learnings, in class hands on education and training to ALL hospital employees on workplace violence and protecting their wellbeing. In addition, employees will be educated on proper reporting procedures and how to access references and resources related to workplace violence occurrences and potential occurrences in the workplace.

5.    Comparison- The current hospital Violence Intervention Programs for patients presenting to the ER are not currently covered under Medicaid in any state, and there is currently no standard as to what exactly would qualify as reimbursable service (Fischer, 2014). Hospital based violence intervention programs use a chronic disease model to prevent violent injury and improve patient outcomes, but this services struggle to stay afloat because they are currently not reimbursable through health insurance providers (Fischer, 2014). After reviewing the literature, it was found that seven common themes are major barriers to effective violence prevention programs: a lack of action after an incident has been reported, varying perceptions of what constitutes violence, bullying and retaliation due to reporting, focus on customer service over employee satisfaction, lack of management accountability and profit driven models for management, and lack of or weak social service approaches to mental health and mentally ill patients (Blando, 2015). The above barriers will be compared to the current violence reporting policy and procedure at Hackensack Meridian Health ( which follows a JCAHO model) which states as follows: Reporting Procedures: (for onsite) Call 3535 for security office, press the panic buttons in your area and activate a Code 61 for immediate security assistance. Notify supervisor, if injured seek medical attention immediately, submit an Employee injury report and an occurrence reports ASAP, if the incident involves a patient then a clinical assessment by a mid-level provider or physician must be performed to determine if the action was a direct consequence of the patient’s condition or disability, and thus, not intentional (JCAHO, 2017). If the incident is deemed to have been intentional, then HUMC is mandated to reports the incident to local authorities who will contact the employee to determine whether the employee wishes to file a criminal complaint against the patient (JCAHO, 2017). Security will be responsible for identifying and detaining the person who has committed the assault. Security will then assist the employee in filing a criminal complaint, with the original report being submitted to the police. Copies of the reports will be retained by Security and Risk Management. Taking into consideration the current Policy, the literature, and my stated proposed interventions I hope to help streamline and improve the current facility policy.

6.    Outcome- The ultimate goal is to decrease episodes of reported violence, educate employees on potentially violent situations and what actually constitutes “violence” as reportable, streamline reporting procedures, and increase awareness of violence resources. This will all be achieved through employee education and training to promote recognition of warning signs of workplace violence and increase the ability of health care workers to appropriately respond to violence (US Department of Labor Occupational Safety and Health Administration, 2015). Moving forward first we need to learn about workplace violence in order to be able to correctly identify the violence and then appropriately respond to threats of violence. Promote respectful communication, zero tolerance policies in the workplace without regard to position or role, written policies and procedures on WPV that include definitions of unacceptable behavior, personal accountability, and procedures for appropriate response and reporting (Ramacciati, 2016). Development of an employee assistance program (EAP) that incorporates a panel of human resource professionals, mental health clinicians, and emergency service personnel for assistance not only with strategy development but also for support of employees who are victims of workplace violence. Combining role playing case-based scenarios and lectures to teach nurses how to address violence in the workplace, promotion of residency programs and preceptorships for new or transitioning nurses, training management in providing support associated with aggression, and require managers to monitor aggression risk from patients during busy times and periods of suboptimal staffing ratios (Ramacciati, 2016). The purpose of this research is to establish a protocol in compliance with The State of New Jersey and Hospital policies in regards to assault on a healthcare employee. There does not seem to be a current existing tool, however my intervention can simply be measured by a decrease in the amount of reported violent incidences and a decrease in the amount of employee injuries at Hackensack Meridian Health.

7.    Timing- Mandatory violence training for all hospital employees as a practice change. I expect to see a decrease in reported violence and employee injury over the course of eight weeks. This is an ongoing and dynamic process within healthcare workers daily practice.

8.    Feasibility- This problem, practice change, and project is very significant to the hospital (Identified here as the stakeholder). Decision makers at Hackensack Meridian Health are very supportive of this project and research as they recognize its increasing popularity in the literature. Healthcare workers experience injuries resulting from workplace violence at twice the rate of workers in other fields, and nurses experience nonfatal assaults at twice the rate of other health care workers (March, 2017). According to mortality data, victims who experience violent injury shows that these patients often have long term effects of alcohol and substance abuse and often have limited support systems (Fischer, 2014). In the US, 60% of new nurses leave their first position within six months as a result of horizontal WPV (Townsend, 2012). Bullying and WPV can disrupt professional performance increasing the risk of medication errors and patient falls (Townsend, 2012). For this reason, the hospital stakeholder can save money on employee injury claims, workman’s comp claims and out of work injuries related to WPV.

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