Protecting our Caregivers and Patients from Workplace Violence Patti Boucher RN, MHSM, BHSC(N), COHN(C), CRSP, CDMP 1
Who we are … • We serve Ontario’s public service sector • We assist over 9,000 organizations to achieve safer and healthier work environments for their one million workers • Our highly skilled staff are located across the province, providing ready access and timely response to all our clients 2
Types of Violence in the Workplace • Type I External • Type II Client/customer • Type III Employee related • Type IV Personal relationship 3
Types of Violence in the Workplace Type II: Client/customer Violence versus Aggression Violence (Predatory) • ‘Willful intent’ to cause harm • No contributing physiological or psychological conditions rendering person incompetent Aggression/Responsive Behaviours (Affective) • No intent to cause harm • Underlying physiological/psychological condition • Often results form inability to communicate a need – response to stimulus 4
Prevalence In Mental Health • Rates of violence in mental health facilities increasing (Decaire et al., 2006; Almvik, Woods & Rasmussen, 2000 ). • > 90% of physicians and nurses working in mental health have been subjected to violence • Highest risk during initial days of hospitalization • Assaults on health care staff by psychiatric patients constitute a sizeable proportion of violence – good body of evidence internationally over a 30-year period has documented prevalence An investigation of 1,144 incidents within a secure mental health facility revealed that 61% of • violent events were categorized as serious and 31% as life-threatening to either staff and other clients (Decaire et al., 2006) • Incidence of violence in a locked inpatient psychiatric unit was higher during the daytime within 1 st week of admission and when unit exceeded its max. capacity • Violence directed at staff members and other clients as opposed to visitors (Brasic & Ainsworth, 2007). • Study in UK reported that most violent episodes occurred in lounges and corridors at night and on weekends – where staffing numbers were lower (Brasic & Ainsworth, 2007) 5
Lost Time Injuries due to Workplace Violence or Client Aggression Date Source: PDM Injury Analysis by SWA cube Data Source: Injury Analysis Snapshot Jun 2009 Snap Shot Date: Aug 2009 Jun 2009 Snap Shot Date: Aug 2009 6
Lost Time Injuries due to Workplace Violence or Client Aggression 7
Mental Health – Triggers of Violence • Disrespect (real or perceived) • Unmet needs – hunger, pain, • Rude and/or condescending inability to communicate staff • Sedative drugs in high doses Police presence Poor surveillance • • • Long waits • Frequent medication changes • Lack of privacy • Long hospitalization Fear Anxiety • • • Frustration • Loss • Excessive noise • Restraint use • Crowded environment – lack of • Approach to Care Giving personal space 8
Workplace Violence Prevention • To-date, focus of research on prevention in healthcare has remained outside clinical practice. • Much of existing literature has examined internal factors (i.e.type of mental illness; age; gender) and external factors (i.e. environmental conditions; staff behaviours) One recent study examined societal factors and safety climate in addition to internal and • external factors (Sheilds & Wilkins, 2009) • Traditional approaches to managing violence focus on methods to contain or reduce impact (de-escalation, medication, seclusion and restraint) • No studies have looked at clinical practice as a determinant of violence prevention. Adoption of evidence-based interventions to avert aggression/violence – safety must be • considered a priority; integrated into client care • Research has shown quality client care is dependent on the health and safety of the caregiver and an organizational culture where safety is a priority (Boucher, Sikorski, & Nichol, 2009). 9
Clinical Practice Assessment Tool • Employee safety considerations • Patient safety considerations Two Tools – management • and front-line staff • Incorporates safety strategies and infrastructure for: – Collaborative Recovery Model – Therapeutic Alliance – Reduction of Seclusion and Restraints 10
Clinical Practice Assessment Tool Caregiver Tool Management Tool • Leadership Commitment • Leadership Commitment Supporting Program Infrastructure Program Infrastructure • • • Environmental Considerations • Client Admission and Assessment • Client Admission and Assessment • Staff Development • Client Engagement • Security & Emergency Response Client Care & Communication Environmental Considerations • • • Staff Development 11
Questions? Concerns? Comments? 12
www.pshsa.ca esao.on.ca mhsao.com osach.ca 13
An Innovative Interdisciplinary Model for Managing Relationships Through the Crisis Continuum Debra Churchill RN MHScN Director Professional Practice & Clinical Informatics 14
Ontario Shores Centre for Mental Health Sciences
The Background and Context (Setting the Stage for Change) • Staff injury rates (2 nd highest in province) • Jeffrey James Inquest Recommendations – Least restraint/seclusion • Code White prevalence • Operational Assessment – Review of Policies & Procedures • Need for changes to practice – Incorporation of best practices
The Background and Context (Setting the Stage for Change) • Staff preparedness and training in preventing and de-escalating aggression • Lack of standardized philosophy of care provision - Recovery Focused Organization – Therapeutic Relationship • Staff injuries correlated with Code White occurrences in which restraints were used • Ministry of Labour
Getting Started……..Building the Foundation Introduced Recovery Philosophy • Shared Journey Project: Recovery and Rediscover • Rediscover – Clinical Practice, Level of Knowledge and Skill in Mental Health • Recovery – Collaborative-Recovery philosophy of care Introduced Interprofessional Standards of Care based on Recovery and Best Practices to identify expectations of practice
Multidimensional Model for Managing Relationships • MMMRCC emphasizes that a comprehensive approach is required to effectively prevent aggression & promote client & staff safety • Shift from a reactional approach to a preventative approach • Shift from a Biomedical Model (chemical, environmental, physical restraints) to a Multidimensional Model
Six Core Strategies 1. Leadership towards organizational change 2. Use of prevention/proactive tools 3. Workforce development 4. Debriefing techniques 5. Patient/client roles in an inpatient setting 6. Use of data to inform practice **Adopted the recommendations from the Six Core Strategies to Reduce The Use of Seclusion and Restraint Planning Tool National Association of State Mental Health Program Directors (NASMHPD, 2008)
Outcome Measures • Monitoring Code White Incidents • Use of Mechanical Restraints • Positive Patient Outcomes – Goal IQ ( MAP Collaborative Goal Setting) • Promote Well-being and Strengths ( Psychological Well-Being , Maslach Burnout Inventory,
Code White Incidents 4000 500 3000 400 300 2000 489 200 303 2,579 3,101 328 1000 202 1,714 100 561 0 0 2006/07 2007/08 2008/09 2009/10 2006/07 2007/08 2008/09 2009/10 Total # of Mechanical Restraints # of Code White Incidents
Patient Outcomes Goal IQ total score significantly increased from 23.78 to 27.04 (t(96)=-3.119, p=0.002). Goal IQ measures goal setting in patients’ charts as a means of examining integration of patient’s goals into the plan of care. t(96)=-3.119, p=0.002
Staff Outcomes – Psychological Well-Being PWB (Environmental Mastery) scores significantly increased from 16.69 to 17.97 (t(119)=-4.513, p<0.001). The environmental mastery scale measures mastery and competence in managing the environment, control over complex array of external activities, extent of effective use of surrounding opportunities, and ability to choose or create contexts suitable to personal needs and values. t(119)=-4.513, p<0.001
Staff Outcomes – Maslach Burnout Inventory MBI (Emotional Exhaustion) scores significantly decreased from 15.71 to 13.50 (t(119)=2.718, p=0.008). The emotional exhaustion scale measures mental and emotional overextension and exhaustion by one’s work. It describes states of emotional exhaustion and overextension due to work demands. t(119)=2.718, p=0.008
In Summary… • The MMMRCC recognizes that client aggression and violence occurs as a result of various factors, some of which may be separate from the client • Increasing staff awareness of the compounding dimensions in managing relationships will have a positive impact in safety of staff and patient and the quality of care
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