RESPECTING  OURSELVES  AND  OUR  PATIENTS:    IMPROVING  PATIENT  SAFETY  BY  IMPROVED  

HANDLING  OF  VIOLENT  PATIENTS  Timothy  I.  Morgenthaler,  MD    

Mayo  Clinic  Chief  Patient  Safety  Officer  |  Co-­‐Director,  Center  for  Sleep  Medicine  |  Pulmonary,  Critical  Care,  and  Sleep  Medicine  |  Professor  of  Medicine,  Mayo  Clinic  College  of  Medicine  

|  tmorgenthaler@mayo.edu|  mayoclinic.org  |  twitter.com/DrTimMorg  

Workplace  violence  in  the  healthcare  setting  is  increasing  in  prevalence  in  nearly  all   locales.  In  this  session,  we  will  work  together  to  better  understand  the  prevalence,  scope,  and  down-­‐stream  effects  of  the  problem,  along  with  programmatic  elements  that  begin  to  address  violent  patient  handling.  

Workplace   violence   has   several   definitions,   nearly   all   of   which   are   more   inclusive   than   merely  counting  physical  harms  visited  upon  the  healthcare  worker.    Some  of   the  definitions  of  workplace  harm  include:  

• World   Healthcare   Organization   (WHO):   “The   intentional   use   of   power,   threatened   or  actual,  against  another  person  or  against  a  group,  in  work-­‐related  circumstances,  that  either  results  in  or  has  a  high  degree  of  likelihood  of  resulting  in  injury,  death,  psychological  harm,  mal-­‐development,  or  deprivation”  

• National   Institute   for  Occupational   Safety   and  Health   (NIOSH):   “Workplace  violence   is  any   act   or   threat   of   physical   violence,   harassment,   intimidation,   or   other   threatening  disruptive  behavior  that  occurs  at  the  work  site.  It  ranges  from  threats  and  verbal  abuse  to  physical  assaults  and  even  homicide.”(Note:  Threats  may  be  conveyed  via  verbal,  physical  or  electronic  means,  or  physical  assault)  

It  may  be  useful  to  consider  these  different  types  of  violence:  

• Assault/attack:  Intentional  behavior  that  harms  another  person  physically,  including  sexual  assault    

• Abuse:   Behavior   that   humiliates,   degrades   or   otherwise   indicates   a   lack   of   respect   for   the  dignity  and  worth  of  an  individual  

• Harassment:   Any   conduct   based   on   individual   characteristics   or     other   status   that   is  unreciprocated  or  unwanted  and  which  affects  the  dignity  of  men  and  women  at  work  

• Threat:  Promised  use  of  physical  force  or  power  (i.e.  psychological  force)  resulting  in  fear  of  physical,   sexual,   psychological   harm   or   other   negative   consequences   to   the   targeted  individual  

Given   such   definitions,   the   following   figure   depicts   the   proportion   of   healthcare   workers   who,  according  to  surveys,  have  experienced  violence  at  work.  

 

It   is   also   useful   to   consider   the   source   of   the   violence,   and   by   convention,   the   source   has   been  categorized  in  the  following  way:  

• Type   I:   Criminal   intent   by   perpetrator   with   no   legitimate   relationship   to   worksite   (e.g.,  robbery)  

• Type   II:   Perpetrator   is   a   customer   receiving   services   from   the   company   (e.g.,   patient   or  visitor  at  a  hospital)  

• Type  III:  Perpetrator  is  employed  by  the  establishment  (e.g.,  worker  assaults  co-­‐worker)  

The  majority  of  violence  against  healthcare  workers  is  of  Type  II,  hence  the  topic  of  this  talk.    At  Mayo  Clinic,   we   had   initially   embarked   on   a   Violent   Patient   Handling   Project.     This   project   is   nearing  completion  and  will  transition  into  a  sustainable  program  with  ongoing  learning  and  improvement.    We  will   discuss   aspects   of   governance   and   ownership   as   important   characteristics   of   an   effective  program.  

The   underlying   causes   of   Type   II   violence   extend   well   beyond   the   condition   of   the   patient,   and  encompass  societal  and  organizational  factors.    In  designing  programs  to  violent  patient  handling,  it  is  important  to  consider  these  factors  (Figure).    On  the  left  are  the  several  “systems”  influencing  the  likelihood  of   violent  behavior   in   the  healthcare   setting.     In   the  middle   is   an   approximation  of  how  much  those  systems  may  be  under  your  organizational  influence,  along  with  an  estimated  timeline  to  anchor   expectations   for   program   development,   though   faster   would   be   better.   On   the   right   are  examples  of  activities  that  might  influence  the  systemic  causes  of  Type  II  violence.  

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The  program  we  have  been  working  on  thus  far  includes  significant  activities  in  the  following  areas:  

• Safety  Coordination  

• Accurate  and  concurrent  reporting  

• Facility  and  Culture  Accountability  

• Education  for  all  staff  

• Linked  activities  

Useful  references  are  listed  below.  

Yao  S,  Zeng  Q,  Peng  M,  Ren  S,  Chen  G,  Wang  J.  Stop  violence  against  medical  workers  in  China.  Journal  of  Thoracic  Disease.  2014;6(6):E141-­‐E145.  doi:10.3978/j.issn.2072-­‐1439.2014.06.10.  

Bigham   BL,   Jensen   JL,   Tavares   W,   et   al.   Paramedic   self-­‐reported   exposure   to   violence   in   the  emergency   medical   services   (EMS)   workplace:   A   mixed-­‐methods   cross-­‐sectional   survey.   Prehosp  Emerg  Care.  2014;18(4):489–494.  

Nelson,   Roxanne,   Tackling   violence   against   health-­‐care   workers.     The   Lancet,   2014,   Volume   383  ,9926  ,  1373  –  1374  

Martino  DV.  Workplace  violence   in  the  health  sector.  Country  case  studies  Brazil.  2002.  Available  at:  http://cdrwww.who.int/entity/violence_injury_prevention/violence/activities/workplace/WVsynthesisreport.pdf.    

Violent   Patient   Program   Gap   Analysis:  http://www.health.state.mn.us/patientsafety/preventionofviolence/preventingviolenceinhealthcaregapanalysis.pdf    

NIOSH  report.    https://www.cdc.gov/niosh/docs/2002-­‐101/    

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