The Unthinkable: Violence in Healthcare from Bullying to an Active Shooter

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The Unthinkable Violence in Healthcare From
Bullying to an Active Shooter
Susan Strauss, Ed.D RN Violence, Bullying
Harassment Consultant
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Dr. Susan Strauss Dr. Susan Strauss RN Ed.D is
a national and international speaker, trainer,
consultant, and recognized expert on workplace
and school harassment and bullying. She conducts
harassment and bullying investigations and is a
consultant to attorneys and an expert witness in
harassment lawsuits. She has served on workplace
violence task forces and conducted violence in
the workplace training. Her clients are from
business, education, healthcare, law, and
government organizations from the public and
private sectors.   Dr. Strauss has conducted
research, written over 30 books, book chapters,
and journal articles on sexual harassment and
related topics. She has been featured on 20/20,
CBS Evening News, and other television and radio
programs. She has been interviewed for newspaper
and journal articles such as Harvard Education
Newsletter, Lawyers Weekly, and Times of London.
  Susan has worked as an RN in the OR,
pediatrics, medical-surgical, psychiatry, and
public health. She has also been the director of
quality improvement, education and development,
and other healthcare leadership roles. She
researched physician abuse of RNs in the OR to
determine if the abuse varied based on the gender
of the nurse.   Susan has a doctorate in
organizational leadership. She is a registered
nurse with a bachelors degree in psychology and
counseling, a masters degree in community
health, and a professional certificate in
training and development. She has been involved
in the harassment and bullying arena since
1985.   Dr. Susan Strauss Strauss
Consulting 952.937.1991   www.straussconsulting.ne
t susan_at_straussconsulting.net
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Objectives
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Definitions of Workplace Violence (WV)

• Any physical assault, threatening behavior, or
  verbal abuse occurring in the work setting. It
  includes, but is not limited to beatings,
  stabbings, suicides, shootings, rapes, near
  suicides, psychological traumas such as threats,
  obscene phone calls, an intimidating presence and
  harassment of any nature such as being followed,
  sworn at, or shouted at. (National Institute of
  Occupational Safety and Health NIOSH)
• Any act against an employee that creates a
  hostile work environment and negatively affects
  the employee, either physically or
  psychologically. These acts include all types of
  physical or verbal assaults, threats, coercion,
  intimidation and all forms of harassment.
  (Workplace Violence Research Institute)
• Rape, sexual assault, homicide, robbery,
  aggravated and simple assaults (U.S. Bureau of
  Justice Statistics)
• Violent acts directed towards a person at work or
  on duty (i.e., physical assaults, threats of
  assault, intimidation or bullying). (U.S.
  Department of Labor Statistics). The BLS further
  classifies WV into 4 situations Criminal (85),
  Customer/client, co-worker (7), domestic
  violence (5)
• WV encompasses any conduct that is sufficiently
  severe, offensive, or intimidating as to cause an
  employee to reasonably fear for her or his safety
  or the safety of her or his family, friends, or
  property, such that employment conditions are
  altered or a hostile, abusive or intimidating
  work environment is created. This includes
  actual acts of violence such as shooting, hitting
  and other forms of physical abuse as well as
  threats of violence including surveillance and
  stalking. (Littler Mendelson Law Firm)

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Impact of Violence
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Violence May Take Place During Times of High
Activity

• Interaction with patients, such as admission to
  ED
• Patient transportation
• Patient involuntarily admitted
• Billing
• Hospital Rules
• Explaining re grave situation
• Poor prognosis
• Costly surgery or treatment
• Anaphylactic reactions
• Unexpected consequences of treatment
• Complications of diagnosis, surgery, treatment
• Death
• Patient dies before or during shifting

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Nurses Dont Report Physical Abuse

• 66 filed no formal report-physical abuse
• 66 did not notify security
• 64 did not inform supervisor
• 63 did not inform colleagues
• 55 did not inform MD
• 86 did not report verbal abuse
• (yet 50 report hospital requires mandatory
  report of violence)

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Why Are Nurses Not Reporting?
https//www.ena.org/education/onlinelearning/wvp/P
ages/default.aspx
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Warning Signs

• Fascination with weapons
• Alcohol or drug abuse
• Severe stress
• Anguish over employment decisions
• History of violent incidents
• Implied/direct threats
• Threatening gestures
• Paranoia, depression, delusional
• Extreme adverse reaction to coaching, discipline
• Possession of weapons
• History of violence
• Disregard for co-worker safety

• History of negative interpersonal relationships
• Few family or friends
• Views the workplace as a home and coworkers are
  family
• Has obsessive involvement in his or her job
• Psychological deterioration
• Decreased or inconsistent job functioning
• Social isolation
• Marked deterioration in personal hygiene
• Other major personality changes

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Warning Signs (cont.)

• Suspicious of others
• Sense of entitlement
• Unable to take criticism
• Marked changes in mood or behavior
• Extreme or bizarre behavior
• Irrational beliefs or ideas
• Marked decline in work performance

• Argumentative
• Displays unwarranted anger
• Uncooperative, impulsive, easily frustrated
• Challenges peers and authority figures
• An unreciprocated romantic obsession
• Serious family or financial problems
• Recent job loss

• Acts of violence
• Demonstrated violence towards inanimate objects
• Evidence of earlier violent behavior
• States intention to hurt someone
• Holds grudges
• Excessive behavior (phone calls, gift giving,
  obsessions)
• Preoccupation with violence

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Tips to De-escalate

• Be empathetic nonjudgmental
• Respect personal space (1 ½ to 3 feet)
• Use nonthreatening body language
• Avoid overreactingstay calm rationale
• Focus on feelings
• Ignore challenging questions
• Set limits
• Be honest
• Be firm respectful
• Choose wisely what you insist upon
• Allow silence
• Do not be defensive
• Explain rules and limits

• Assess the situation in your mind
• Project calmness
• Encourage the person to talk
• Focus your attention on the person so they feel
  that you are interested in what they have to say
• Maintain a relaxed yet attentive posture,
  position yourself at a right angle instead of
  directly in front of the person
• Ask for small specific favors, such as if you
  could talk in a quieter area
• Arrange yourself so that your exit is not blocked

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Increased Risk of Employer Liability

• Federal State Discrimination laws
• State laws employer may be liable if knew or
  should have known about employees situation
• Tort laws claims for negligent hiring,
  supervision, gross negligence, negligent
  retention and more
• Vicarious liability
• Guns at Work laws
• OSHA can cite employer under General Duty Clause
• Requires safe healthful workplace
• Workplace hazards caused by DV are not an
  exception

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Steps to Prevent DV in Workplace

• Provide training to supervisors regarding DV in
  workplace
• Provide DV resource information in private areas,
  HR, and bathrooms
• Take appropriate steps to limit or bar abusers
  access to workplace if employee provides info
  regarding her/his abuser
• Consider additional security steps including
• escort to parking lot
• provide parking space close to building
• offer flexible/varied work hours
• remove employees name from office directory
• screen calls
• Change employees work e-mail address

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Responding to the Unthinkable A Shooting

• Hit the floor
• Scramble for cover
• Determine, if possible, where shooter is located
• Evaluate surroundings and examine options
• Hit panic alarm if able
• Get to exit, if possible
• Warn/help others if possible
• If get out of building run in winding manner to
  get as far away from building as can

• If cant get out
• Hide in closest room that can be locked or
• Barricaded bar door, close window blinds, turn
  off lights, stay quiet
• Place as many large objects between you and door
  as possible
• Do not open door even if someone says they are
  police or someone says trying to hide from
  shooter
• Hide behind or under something even if just a
  chair

• If several people hiding in same room spread
  out
• To create confusion and
• Make it harder for shooter to hit target
• Last resort fight
• Attack subject as a group, use body to hold down
• Find weapon
• Book
• Stapler
• Fire extinguisher
• Use group to distract, scream and throw items

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What Can Organizations Do?

• Prepare employees for downsizing
• Implement humane termination policies
• Provide job skills training
• Provide counseling
• Conduct threat assessments

Better use of pre-screening and background
investigations!
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Respond

• Your zero tolerance policy includes responding
  100 of the time
• Administrative support
• Fair and consistent procedures
• Culture of support, not punishment, for victims
  of violent occurrences

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Policy Recommendations

• Domestic Violence
• Tie into other specific polies such as code of
  conduct, harassment
• Renewed annually
• Communicated and distributed annually
• Prohibit weapons
• Disciplinary procedure
• Establish and disclose employee resources such as
  EAP
• Zero tolerance (and define)
• Make policy easy to understand translate into
  pertinent other languages as needed

• Definition of violence
• Organizations commitment to safe environment
• Examples of prohibited conductthreats, pushing,
  shoving, unwanted touching, verbal abuse
• Prohibition of weapons on worksite (notice should
  be posted)
• Reporting process
• Statement encouraging employees to report
• Investigation process
• Consequences to the perpetrator
• Anti-retaliation clause

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Anti-Bullying Laws

• No federal
• 3 states
• Utah focuses only on public employees
• Tennessee focuses only on public employees
• California employers with 50 employees
  training
• None create private right of action

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Training

• Warning signs
• Examples of WV
• Policies and procedures
• Definition of WV
• Reporting mechanism
• Documentation record keeping
• Steps to take if confronted by actual or threat
  of violence
• Facility safety measures
• Nexus of violence with bullying and harassment
• Workplace violence prevention policy
• Risk factors that cause or contribute to assaults
• Early recognition of escalating behavior or
  warning signs
• Ways to prevent volatile situations
• Standard response action plan for violent
  situations
• Location and operation of safety devices
• Policy and procedures

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Recordkeeping

• OSHA Log of Injury and Illness (OSHA 300)
• Medical reports of work injuries assaults
• Incidents of abuse, verbal attacks, or aggressive
  behavior
• Information on clients and employees with history
  of violence
• Minutes of safety meetings, records of hazard
  analyses, and corrective actions
• Records of all training programs with sign-in
  sheets

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Program Evaluation

• Establish uniform violence reporting system and
  regular review of reports
• Review reports and minutes from staff meetings on
  safety and security issues
• Analyze trends and rates in illnesses, injuries
  or fatalities caused by violence relative to
  initial or baseline rates
• Measure improvement based on lowering the
  frequency and severity of workplace violence
• Keep up-to-date records of administrative and
  work practice changes to prevent workplace
  violence to evaluate how well they work
• Survey workers before and after making job or
  worksite changes or installing security measures
  or new systems to determine their effectiveness
• Tracking recommendations through to completion
• Keep abreast of new strategies available to
  prevent and respond to violence as they develop
  
• Survey workers periodically to learn if they
  experience hostile situations in performing their
  jobs
• Comply with OSHA and state requirements for
  recording and reporting injuries, illnesses, and
  fatalities
• Request periodic law enforcement or outside
  consultant review of the worksite for
  recommendations on improving worker safety.

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