1 Workplace Violence Awareness and Prevention in Health

1 Workplace Violence Awareness and Prevention in Health Care Mary L. Hill, BSN, MA, JD Executive Vice President of Mission Avera

2 Violence in Health Care: Overview, Trends and Cases

3 Workplace Violence Definitions: • The National Institute for Occupational Safety and Health (NIOSH): ". . . any physical assault, threatening behavior, or verbal abuse occurring in the work setting" (NIOSH, 1996). • The World Health Organization (WHO) and the International Council of Nurses (ICN): ". . . incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health. " Centers for Disease Control & Prevention, National Institute for Occupational Safety and Health

Workplace Violence in Healthcare Understanding the Challenge Workplace violence risk factors vary by healthcare setting, but common factors include the following: • Working with people who have a history of violence or who may be delirious or under the influence of drugs • Lifting, moving, and transporting patients • Working alone • Poor environmental design that may block vision or escape routes • Poor lighting in hallways or exterior areas • Lack of means of emergency communication • Presence of firearms • Working in neighborhoods with high crime rates • Lack of training and policies for staff • Understaffing in general, and especially during meal times and visiting hours • High worker turnover • Inadequate security staff • Long wait times and overcrowded waiting rooms • Unrestricted public access • Perception that violence is tolerated and reporting incidents will have no effect Workplace violence is a serious problem. Different organizations have defined workplace violence in various ways. The National Institute for Occupational Safety and Health defines workplace violence as “violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty. ” Enforcement activities typically focus on physical assaults or threats that result or can result in serious physical harm. However, many people who study this issue and the workplace prevention programs highlighted here include verbal violence—threats, verbal abuse, hostility, harassment, and the like—which can cause significant psycho- logical trauma and stress, even if no physical injury takes place. Verbal assaults can also escalate to physical violence. In hospitals, nursing homes, and other healthcare settings, possible sources of violence include patients, visitors, intruders, and even coworkers. Examples include verbal threats or physical attacks by patients, a distraught family member who may be abusive or even become an active shooter, gang violence in the emergency depart- ment, a domestic dispute that spills over into the workplace, or coworker bullying. Healthcare workers are at an increased risk for workplace violence. From 2002 to 2013, incidents of serious workplace violence (those requiring days off for the injured worker to recuperate) were four times more common in healthcare than in private industry on average. In 2013, the broad “healthcare and social assistance” sector had 7. 8 cases of serious workplace violence per 10, 000 full-time employees (see graph below). Other large sectors such as construction, manufacturing, and retail all had fewer than two cases per 2013 Data source: Bureau of Labor Statistics (BLS), 2013 data. These data cover three broad industry 10, 000 full-time employees. sectors: ambulatory healthcare services, hospitals, and nursing and residential care facilities. Source categories are defined by BLS.

5 Incidence of Workplace Violence in Healthcare: Violent Injuries Resulting in Days Away from Work, by Industry, 2002– 2013

6 Workplace Violence Classifications: The National Institute of Health and Safety classifies workplace violence into four types: 1. Criminal Intent: Person/perpetrator has no relationship to the business or its employees. 2. Customer, Client or Patient: Person has a relationship to business and becomes violent while receiving services. 3. Worker on Worker: Employees who threaten or attack another employee. 4. Personal Relationship: Person who has interpersonal relationship with the intended target but no relationship to the business. Centers for Disease Control & Prevention, National Institute for Occupational Safety and Health

Workplace Violence by Type, 2012 - 2016 4% 4% 90% 3% 3% Type 1 Type 2 3% 3% Type 3 Type 4 For hospitals that had at least one charge under an existing “Assault on Healthcare Worker” law, 15% of Workplace Violence Type 2 incidents (assault or aggravated assault by a patient or visitor) resulted in a charge in 2016. The second question asked how many employees worked at the hospital. The responses (n = 160) to this question allowed us to calculate the number of Workplace Violence Type 2 incidents per 100 employees. Since this question is unique for this year’s Healthcare Crime Survey, the graph below displays the 2016 rate of assaults and aggravated assaults against employees by patients or visitors per 100 employees. Workplace Violence Type 2 per 100 Employees, 2016 1. 4 Type 2 Assault Type 2 Aggravated Assault 0. 7 International Healthcare Security and Safety Foundation, Healthcare Crime Survey, https: //iahssf. org/assets/2017_Crime_Survey_-_IAHSS_Foundation. pdf , April 12, 2017.

Sources of Violence in Health Care* Other client or customer 12% Student 3% Patient 80% Coworker 3% Placeholder Photo Other person (not specified) 1% Assailant, suspect, inmate 1% *The numbers above only include incidents that led to time away from work. 2013 Data source: Bureau of Labor Statistics (BLS), 2013 data. These data cover three broad industry sectors: ambulatory healthcare services, hospitals, and nursing and residential care facilities. Source categories are defined by BLS. 2

9 2017 Survey of Healthcare Professionals: In a July 2017 Medscape survey of 2389 health care professionals: 1. Experienced Verbal Abuse and Intimidation: 88% said they have personally experienced verbal abuse, while 76% said they have personally experienced intimidation. 2. Witnessed Verbal Abuse and Intimidation: In comparison, 92% and 81% of respondents said they've witnessed verbal abuse and intimidation in the workplace, respectively. 3. Witnessed Physical Assault: 55% said they had seen a physical assault occur in the workplace. 4. Victims of Assault: Nearly 50% of all nurses surveyed said they were victims of assault, compared with physicians (36%), pharmacists (18%) and other providers (24%). 5. Training: Almost 70% of respondents said they received no or minimal training on how to cope with workplace violence. 6. Filed Incident Report: While 77% of nurses in emergency medicine settings said they had experienced physical violence, nearly 60% of emergency room nurses said they sometimes, rarely or never filed a report detailing the incident. http: //www. staging. medscape. com/viewarticle/886230#vp_1

10 Violence in Healthcare is Underreported: • While some data are available for other violent incidents, surveys show that many incidents go unreported, even at facilities with formal incident reporting systems. • A survey of 4, 738 Minnesota nurses found that only 69% of physical assaults and 71% of non-physical assaults were reported to a manager, while one medical center found that half of verbal and physical assaults by patients against nurses were never reported in writing. • Bullying and other forms of verbal abuse are particularly prone to underreporting. Reasons for underreporting include lack of a reporting policy, lack of faith in the reporting system, and fear of retaliation. OSHA Workplace Violence in Healthcare report, 2013 Data source: Bureau of Labor Statistics (BLS), 2013 data. These data cover three broad industry sectors: ambulatory healthcare services, hospitals, and nursing and residential care facilities. Source categories are defined by BLS.

Underreporting of Workplace Violence Healthcare‘s unique culture factors may contribute to underreporting or acceptance of workplace violence: 1. Duty: Caregivers feel a professional and ethical duty to “do no harm” to patients. 2. “Part of the Job”: Some will put their own safety and health at risk to help a patient, and many in healthcare professions consider violence to be “part of the job. ” 3. Absence of Malice: Healthcare workers also recognize that, in many cases, violence by patients is unintentional, and so this behavior is accepted as routine or unavoidable. 4. Lack of Access to Needed Care: Healthcare is also evolving in ways that increase the challenge. For example, because of reduced funding for mental health services, severely mentally ill patients are increasingly using emergency departments rather than psychiatric facilities for treatment. 2013 Data source: Bureau of Labor Statistics (BLS), 2013 data. These data cover three broad industry sectors: ambulatory healthcare services, hospitals, and nursing and residential care facilities. Source categories are defined by BLS; Data source: Bureau of Labor Statistics (BLS), 2013 data. These data cover three broad industry sectors: ambulatory healthcare services, hospitals, and nursing and residential care facilities. Source categories are defined by BLS. 2

2017 Healthcare Crime Survey IAHSS-F CS-17 April 12, 2017

Hospital Crime Rates The first graph below compares the 2016 crime rates per 100 beds for each crime (n = 222). The subsequent graphs in this section display the crime rate trends from 2012 to 2016. For analytical purposes and consistent with FBI practice, Murder, Rape, Robbery and Aggravated Assault were aggregated into one group called Violent Crime. 2016 Crime Rates per 100 Beds by Type of Crime 35. 0 30. 0 34. 1 25. 0 20. 0 9. 3 15. 0 10. 0 5. 0 Disorderly Conduct 0. 0 8. 0 Assault Theft 3. 0 Vandalism 1. 0 Violent Crime 0. 6 Burglary 0. 4 Motor Vehicle Theft Violent Crime Rate per 100 Beds 3. 0 2. 5 2. 0 1. 5 1. 0 0. 5 2. 0 2012 2. 5 2013 2. 8 2014 0. 9 1. 0 2015 2016 0. 0 International Healthcare Security and Safety Foundation, Healthcare Crime Survey, https: //iahssf. org/assets/2017_Crime_Survey_-_IAHSS_Foundation. pdf , April 12, 2017.

Disorderly Conduct Rate per 100 Beds Assault Rate per 100 Beds 12. 0 40. 0 10. 0 39. 2 8. 0 25. 0 21. 4 20. 0 28. 0 4. 0 2. 0 15. 0 2012 2013 2014 2015 2016 2012 2013 4. 0 8. 0 6. 0 1 1. 0 4. 0 0. 7 2016 Vandalism Rate per 100 Beds 2. 0 5. 0 1. 0 2015 3. 0 7. 0 2. 0 10. 0 2014 5. 0 0. 0 Theft Rate per 100 Beds 9. 0 34. 1 30. 0 6. 0 0. 0 35. 0 2012 2013 2014 2015 2016 0. 0 Burglary Rate per 100 Beds 2012 2013 2014 2015 2016 Motor Vehicle Theft Rate per 100 Beds 0. 5 0. 4 0. 3 0. 2 0. 1 0. 0 2012 2013 2014 2015 2016 International Healthcare Security and Safety Foundation, Healthcare Crime Survey, https: //iahssf. org/assets/2017_Crime_Survey_-_IAHSS_Foundation. pdf , April 12, 2017.

15 International Association for Healthcare Security and Safety • Between 2012 and 2014, health care institutions reported a 40% increase in violent crime, with more than 10, 000 incidents directed at employees. • Many factors contribute to the increasing incidence of violence: 1. Increasing violence within society 2. Addiction to opioids and other substances 3. Serious, untreated mental illness 4. Caring for “justice involved-individuals” International Healthcare Security and Safety Foundation, Health Care Crime Survey, April 12, 2017

16 Factors Contributing to the Increasing Incidence of Violence 1. Increasing violence within society 2. Addiction to opioids and other substances 3. Serious, untreated mental illness 4. Caring for justice-involved individuals International Healthcare Security and Safety Foundation, Health Care Crime Survey, April 12, 2017

Nurse stabbed multiple times in Southbridge hospital By Andrew Grant Globe Correspondent June 14, 2017

18 1. Increasing Violence Within Society: 1 -20 -15 Murder at Brigham and Women’s Hospital • January 20, 2015, Boston, Mass • 55 -year-old son of a deceased cardiac surgery patient presented at Brigham and Women’s Hospital in Boston demanding to speak with Dr. Michael Davidson, the cardiac surgeon who had operated on his mother. • During a 1: 1 meeting with Dr. Davidson, son shot surgeon with a 44 -caliber handgun. • Dr. Davidson fled from meeting room and collapsed in hallway. Dr. Michael Davidson https: //www. nytimes. com/2015/01/22/us/dr-michael-davidson-brigham-womens-dies-after-shooting. html

19 1. Increasing Violence Within Society: 1 -20 -15 Murder at Brigham and Women’s Hospital • Shooter committed suicide in meeting room. • Dr. Davidson died despite eight hours of emergency surgery to save his life. • Suicide note left by shooter indicated that he was seeking revenge for his mother’s death and that a lawsuit would have been insufficient. https: //www. nytimes. com/2015/01/22/us/dr-michael-davidson-brigham-womens-dies-after-shooting. html

20 1. Increasing Violence Within Society: 6 -30 -17 Murder at Bronx Lebanon Hospital • June 30, 2017, Bronx Lebanon Hospital • Family physician Tracy Sin Lee Tam was killed when Dr. Henry Bello, a 45 -year-old former family physician at Bronx Lebanon Hospital, pulled out an AM-15 assault rifle hidden under his lab coat and began firing. • Six others were wounded in the shooting. • Bello then fatally shot himself after attempting to set himself on fire. • Tam had been scheduled off for the day but agreed to cover for a colleague who was out of the hospital. http: //www. huffingtonpost. com/entry/tracy-sin-yee-tam-identified-as-doctor-gunned-down-by-former-colleague-at-bronxhospital_us_5957 e 884 e 4 b 02734 df 32 c 2 d 2 “

21 1. Increasing Violence Within Society: 6 -30 -17 Murder at Bronx Lebanon Hospital • Just two hours before the shooting, Bello sent an email to staff at the New York Daily News blaming former colleagues for his termination in February 2015. • “This hospital terminated my road to a licensure to practice medicine, ” Bello wrote to NYDN. “First, I was told it was because I always kept to myself. Then it was because of an altercation with a nurse. ” • During his rampage, police officials said Bello at one point shouted out “Why didn’t you help me out when I was getting in trouble? ” while firing at a nurses station. Dr. Bello’s History of Problematic Behavior: • Bello was arrested in 2004 after being accused of imprisoning and assaulting a woman. • In 2009, two women accused him of trying to look up their skirts with a mirror. • The 2004 arrest resulted in a felony abuse charge that was dismissed after Bello pleaded guilty to a misdemeanor charge of unlawful imprisonment, The New York Times reported. http: //www. huffingtonpost. com/entry/tracy-sin-yee-tam-identified-as-doctor-gunned-down-by-former-colleague-at-bronxhospital_us_5957 e 884 e 4 b 02734 df 32 c 2 d 2

22 1. Increasing Violence within Society: 9 -10 -17 Police Shoot and Kill Armed Irma Evacuee at North Carolina Hospital • September 10, 2017, Huntersville, NC • Police were called to Huntersville Medical Center after reports of multiple shots fired inside the facility. • When police arrived, they encountered a 76 -year-old armed man who had been evacuated from Hurricane Irma. • Police fired several rounds at the man who was pronounced dead at the scene. • The North Carolina State Bureau of Investigations is investigating the incident. http: //www. wsoctv. com/news/local/police-investigating-after-shots-fired-inside-novant-health-in-huntersville/607108782

23 2. Addiction to Opioids and Other Substances: 7 -26 -17 Physician Murdered for Declining to Prescribe Opioids • July 26, 2017, Mishawaka, Indiana • Man accompanied his wife to appointment with wife’s physician. • Wife requested opioid prescription which physician declined to write. • Husband became upset and started an argument with physician before he and wife left premises. Dr. Todd Graham https: //www. 953 mnc. com/2017/07/27/mishawaka-doctor-shooter-identified-details-released/

24 2. Addiction to Opioids and Other Substances: 7 -26 -17 Physician Murdered for Declining to Prescribe Opioids • Two hours later, husband returned and waited for physician to emerge from office. • After instigating an argument, husband shot and killed physician in parking lot • Husband fled the scene and went to home of a friend. • Husband committed suicide at friend’s home. https: //www. 953 mnc. com/2017/07/27/mishawaka-doctor-shooter-identified-details-released/

25 3. Serious Untreated Mental Illness: 6 -14 -17 ER Patient Repeatedly Stabs Nurse at Mass Hospital • June 14, 2017, Harrington Health. Care, Southbridge, Mass • 24 -year-old patient who had been registered into ER. • While being directed for care, patient cornered 65 -year-old nurse in a small room, punched her then stabbed her 11 times. • Nurse airlifted to U of Massachusetts Medical Center for treatment. • Patient has a history of mental illness. http: //boston. cbslocal. com/2017/06/15/nurse-stabbed-conor-oregan-worcester-southbridge-harrington-hospital/

26 3. Serious Untreated Mental Illness: 6 -14 -17 ER Patient Repeatedly Stabs Nurse at Mass Hospital • Patient/perpetrator fled the hospital and was later apprehended off hospital campus. • Charged with aggravated assault and battery with intent to murder. • Motive for stabbing was perpetrator’s dissatisfaction with care he had received three weeks earlier at the hospital. Elise Wilson one month following her injuries http: //boston. cbslocal. com/2017/06/15/nurse-stabbed-conor-oregan-worcester-southbridge-harrington-hospital/

27 3. Response to Attack on Elise Wilson at Mass Hospital • Proposal of “Elise’s Law” by Massachusetts Nurses’ Association. • Increased security measures implemented at hospital, including: 1. Walk-through metal detectors in ED, more cameras and panic buttons; 2. Security personnel now armed with batons, pepper spray and handcuffs; 3. Limiting number of visitors in ED; and 4. Training of staff in de-escalation and defensive techniques. Elise Wilson had worked at the hospital 43 years http: //boston. cbslocal. com/2017/06/15/nurse-stabbed-conor-oregan-worcester-southbridge-harrington-hospital/

28 3. Serious Untreated Mental Illness: 7 -17 -17 Two Murders at Florida Hospital • July 17, 2017, Titusville, Florida • 29 -year-old man entered hospital through ED at 2: 00 am on a Sunday morning, then proceeded to 3 rd floor via elevator. • Man walked down hall and into patient room where he shot and killed an 88 year-old patient and a 36 -year-old sitter. • There was no relationship between shooter and victims. http: //cdanews. com/2016/07/random-shooting-at-floridas-parrish-medical-center-leaves-two-dead/ http: //www. floridatoday. com/story/news/crime/2016/07/17/police-deadly-titusville-parrish-hospital-shooting-motiveupdate/87218528/

29 3. Serious Untreated Mental Illness: 7 -17 -17 Two Murders at Florida Hospital • Shooter had a long history of arrests including illegal drug possession/sales, robbery, and battery on a law enforcement agent. • Shooter had also been taken into custody on two previous occasions for mental health evaluations. • Shooter, who appeared disheveled and confused at the time of the incident, was later found incompetent to stand trial. http: //cdanews. com/2016/07/random-shooting-at-floridas-parrish-medical-center-leaves-two-dead/ http: //www. floridatoday. com/story/news/crime/2016/07/17/police-deadly-titusville-parrish-hospital-shooting-motiveupdate/87218528/

30 3. Serious Untreated Mental Illness: 9 -12 -17 Man Shoots and Kills Hospitalized Mother • Sept 12, 2017, Lebanon, NH • A 48 -year-old man went to ICU of Dartmouth-Hitchcock Medical Center to visit his 70 -year-old mother, Pamela Ferrier, who was being treated for an aneurysm. • Man asked stepfather (Pamela’s husband) to leave room so he could visit with Pamela alone and she agreed. • Husband re-entered room after hearing Pamela’s screams. • Son was pointing a gun at Pamela then shot and killed her. http: //www. nydailynews. com/newswires/new-york/cops-man-asked-stepdad-leave-shot-mom-hospital-article-1. 3492845 follow-up

31 3. Serious Untreated Mental Illness: 9 -12 -17 Man Shoots and Kills Hospitalized Mother • The medical center issued a Code Silver alert, evacuated ambulatory patients and staff, and went into lockdown. • The shooter was apprehended by police as he attempted to exit hospital. • More than 100 first responders attended to the area. • The shooter had a history of TBI and PTSD from service in the US Marine Corps. • In 2013, shooter’s ex-wife and 3 -year-old son were found dead in a running car at an apartment complex but foul play was ruled out. Pamela Ferriere with her Husband http: //www. nydailynews. com/newswires/new-york/cops-man-asked-stepdad-leave-shot-mom-hospital-article-1. 3492845 follow-up

32 4. Caring for Justice-Involved Individuals: 5 -13 -17 Inmate Treated at Delnor Hospital • May 13, 2017, Delnor Hospital, Chicago, Illinois • Inmate taken to suburban Chicago hospital for treatment in ER. • Sheriff deputy unshackled inmate who requested to use restroom. • While unshackled, inmate grabbed attending sheriff deputy’s pistol and took two female hospital employees hostage in a room near the treatment area. • Hostages were both threated by inmate. One female hostage was repeatedly beaten and sexually assaulted. • ER evacuated and hostage negotiators talked for several hours with inmate. • After negotiations broke down, SWAT team entered the room, shot and killed inmate. • One hostage was also struck in the arm by the bullet that killed the inmate. http: //www. nbcchicago. com/news/local/More-Nurses-Join-Lawsuit-After-Hostage-Situation-at-Suburban-Hospital-425913003. html http: //wgntv. com/2017/05/25/nurses-file-lawsuit-over-delnor-hospital-hostage-standoff/

33 4. Caring for Justice-Involved Individuals: 6 -7 -17 Inmate Treated at Joliet Presence Hospital • June 7, 2017 • Convicted murderer had been taken from Illinois state prison to Joliet Presence St. Joseph Medical Center for treatment. • While at the hospital, the inmate displayed a makeshift weapon and informed the assigned officer and a nursing assistant that they were being held hostage. • The Joliet police responded to the incident and apprehended the prisoner. • Hostages were released unharmed. http: //www. wsiltv. com/story/35612226/inmate-takes-hostages-at-will-county-hospital

34 4. Caring for Justice-Involved Individuals: 7 -26 -17 Utah Nurse Arrested for Upholding Hospital Policy and Patient’s Rights • July 26, 2017, U. of Utah Medical Center, Salt Lake City • Police officers arrived at hospital intending to obtain blood from a comatose patient injured in a MVA. • Per hospital policy, nurse refused to allow blood draw because: a. Officers did not have a search warrant; and b. Patient was unable to give consent. • After one officer challenged nurse, she called her supervisor to report the situation. Supervisor validated nurse’s understanding of policy and refusal to allow blood draw. http: //www. nydailynews. com/news/national/arrested-utah-nurse-sexually-harassed-police-staffer-article-1. 3499314

35 4. Caring for Justice-Involved Individuals: 7 -26 -17 Utah Nurse Arrested for Upholding Hospital Policy and Patient’s Rights • While nurse was speaking with her supervisor, Officer Jeff Payne yelled, “We’re done” then grabbed her and dragged her out of hospital. • At the direction of his supervisor, Lt. James Tracy, Payne told nurse she was under arrest. • In the parking lot, Payne slammed the nurse against the hospital, handcuffed her and placed her in the police car. http: //www. nydailynews. com/news/national/arrested-utah-nurse-sexually-harassed-police-staffer-article-1. 3499314

36 4. Caring for Justice-Involved Individuals: 7 -26 -17 Utah Nurse Arrested for Upholding Hospital Policy and Patient’s Rights • The incident was investigated by the FBI. • Prosecutors opened a criminal investigation into the officers’ conduct. • Two internal investigations found that both officers’ conduct violated department policy. • One report stated that Payne’s conduct was: “inappropriate, unreasonable, unwarranted, discourteous, disrespectful and has brought significant disrespect on both the officer and the department as a whole. ” http: //www. nydailynews. com/news/national/arrested-utah-nurse-sexually-harassed-police-staffer-article-1. 3499314 http: //people. com/crime/utah-nurse-arrest-investigation-alex-wubbels/ http: //www. chicagotribune. com/news/nationworld/ct-utah-nurse-arrest-investigation-20170914 -story. html http: //www. springfieldnewssun. com/news/national/police-mayor-apologize-utah-nurse-arrested-for-refusing-draw-blood -from-unconscious-patient/a. I 7 Vl. Xt 0 qg. FXnc. KVptx. CTL/

37 4. Caring for Justice-Involved Individuals: 7 -26 -17 Utah Nurse Arrested for Upholding Hospital Policy and Patient’s Rights Both the Salt Lake City Mayor and Police Chief have apologized to the nurse. Salt Lake City Police Chief Mike Brown and Mayor Jackie Biskupski http: //www. nydailynews. com/news/national/arrested-utah-nurse-sexually-harassed-police-staffer-article-1. 3499314 http: //people. com/crime/utah-nurse-arrest-investigation-alex-wubbels/ http: //www. chicagotribune. com/news/nationworld/ct-utah-nurse-arrest-investigation-20170914 -story. html http: //www. springfieldnewssun. com/news/national/police-mayor-apologize-utah-nurse-arrested-for-refusing-draw-blood -from-unconscious-patient/a. I 7 Vl. Xt 0 qg. FXnc. KVptx. CTL/

38 4. Caring for Justice-Involved Individuals: 7 -26 -17 Utah Nurse Arrested for Upholding Hospital Policy and Patient’s Rights Detective Jeff Payne, who arrested the nurse, dragged her out of hospital and forcibly handcuffed her, has a history of disciplinary action for violating police department policy: a. 2013 Sexual Harassment of Female Employee: “Your harassing behavior was severe and persistent and created a hostile, intimidating work environment for this employee, significantly interfering with her ability to work, ” the chief wrote. b. 1995 Ethics and Rule Violations: Payne was suspended for 80 hours without pay for violating the police department’s code of ethics and vehicle pursuit policy in connection with a late-night car chase. Detective Jeff Payne http: //www. nydailynews. com/new s/national/arrested-utah-nursesexually-harassed-police-stafferarticle-1. 3499314

39 4. Caring for Justice-Involved Individuals: 7 -26 -17 Utah Nurse Arrested for Upholding Hospital Policy and Patient’s Rights • On Sept 6 th, Payne was fired from his part-time paramedic job after the arrest video went public. • On September 26 th the patient died as a result of the injuries sustained in the accident. • On October 10 th, Detective Payne was fired from the Salt Lake City Police Department. • Lieutenant Lacey was demoted to the rank of officer. • Mayor Jackie Biskupski applauded the Police Department’s actions stating, “The decision … is in keeping with the highest level of accountability we owe the people of Salt Lake City. In making his decision, I am confident that Chief Brown balanced the unique stresses each of our police officers deal with daily, and the responsibility they have as leaders in our community. ” http: //www. nydailynews. com/news/national/arrested-utah-nurse-sexually-harassed-police-staffer-article-1. 3499314 http: //people. com/crime/utah-nurse-arrest-investigation-alex-wubbels/ http: //www. chicagotribune. com/news/nationworld/ct-utah-nurse-arrest-investigation-20170914 -story. html http: //www. springfieldnewssun. com/news/national/police-mayor-apologize-utah-nurse-arrested-for-refusing-draw-blood-from-unconsciouspatient/a. I 7 Vl. Xt 0 qg. FXnc. KVptx. CTL/ http: //www. cnn. com/2017/10/11/health/utah-officer-fired-after-nurse-arrest/index. html

40 Violence Against Nurses in the News

41 Washington Post Story: 9 -11 -17: “What’s One of America’s Most Dangerous Jobs? It’s Not What You Think. ” • Nurses are routinely yelled at, spat at, pummeled, kicked, scratched and even stabbed by people they’re trying to save. • In many states, being a nurse is more dangerous than being a police officer or prison guard. • Beyond the cases reported in the media, nurse assaults occur at most hospitals and clinics every month. • After a spate of workplace violence in 2016 that included a patient in South Carolina who attacked 14 nurses, the American Nurses Association issued a zero-tolerance policy on workplace violence. https: //www. washingtonpost. com/local/whats-one-of-americas-most-dangerous-jobs-its-not-what-youthink/2017/09/11/71 eae 4 d 8 -9715 -11 e 7 -87 fc-c 3 f 7 ee 4035 c 9_story. html? utm_term=. 2 b 8422 e 6 f 289

42 American Nurses Association Policy: Zero-Tolerance for Workplace Violence • “Health care professionals have a duty to provide care that keeps people safe, alleviates suffering and restores health, ” wrote Pam Cipriano, president of the American Nurses Association. “But when health care workers fear the threat of personal harm from attack and injury, their focus on patient care is undermined—and so is the U. S. health care system. ” • More than 75% of nurses questioned in a recent survey reported being physically and verbally abused by patients, persons trying to get to patients and family members. • Many states are enacting legislation making it a felony to assault a nurse. • To date, there are no broad federal standards or laws protecting healthcare workers. https: //www. washingtonpost. com/local/whats-one-of-americas-most-dangerous-jobs-its-not-what-youthink/2017/09/11/71 eae 4 d 8 -9715 -11 e 7 -87 fc-c 3 f 7 ee 4035 c 9_story. html? utm_term=. 2 b 8422 e 6 f 289 http: //www. nursingworld. org/Main. Menu. Categories/Workplace. Safety/Healthy-Nurse/bullyingworkplaceviolence/ANASets-Zero-Tolerance-Policy-for-Workplace-Violence-Bullying. html

43 “When the Hospital Fires the Bullet” New York Times, February 12, 2016, Elisabeth Rosenthal

44 “When the Hospital Fires the Bullet” New York Times, February 12, 2016, Elisabeth Rosenthal • On Aug 26, 2015, Houston, Texas • Alan Pean, a 26 -year-old college student drove to St. Joseph Medical Center in Houston for treatment of worsening symptoms of his bipolar disorder. • He accidentally crashed into several cars while pulling into the parking lot. • Following the car crash, Alan was examined in the ER by the trauma team who were informed of his psychiatric diagnosis by family members. • Although the hospital had a psychiatric unit, Alan was transferred to a surgical floor for observation. • He was ordered Flexeril for back pain, a muscle relaxant that can exacerbate psychiatric symptoms. • Alan was held overnight and became increasingly restless and delusional. https: //www. nytimes. com/2016/02/14/us/hospital-guns-mental-health. html? _r=0

45 “When the Hospital Fires the Bullet” New York Times, February 12, 2016, Elisabeth Rosenthal • The trauma team planned to discharge him on the morning of Aug 27 th, but when his parents arrived at 10: 00 am, they insisted that a psychiatrist see him. • As the parents waited for doctors to discuss their concerns, they went to a nearby hotel to rent a car to drive their son to a psychiatric facility. • During the parents’ 30 -minute absence, the nurses called security because of Alan’s escalating behavior. • The two security officers to arrive at the scene were Houston police officers who moonlighted at St. Joseph. • One officer reported being struck in the head by Alan. He shocked Alan with a Taser to no apparent effect. • The other officer then shot Alan in the chest. https: //www. nytimes. com/2016/02/14/us/hospital-guns-mental-health. html? _r=0

46 “When the Hospital Fires the Bullet” New York Times, February 12, 2016, Elisabeth Rosenthal • The medical team responding to the incident placed him on ventilator and inserted a chest tube. • Scans revealed bullet fragments throughout his chest which caused extensive bleeding. • Alan was taken to surgery and later admitted to ICU. • Prosecutors charged Alan with felony assault of a police officer and reckless driving. • A grand jury investigation found the police shooting to be justified, but dropped the felony assault charges against Alan. • Alan and His Parents After the incident, federal health officials conducted an emergency investigation and faulted the hospital for the shooting, saying that St. Joseph had created “immediate jeopardy to the health and safety of its patients” and ordered that it restrict use of weapons and provide more training in dealing with mentally ill patients. “I thought of the hospital as a beacon, a safe haven…. I can’t quite believe that I ended up shot. ” https: //www. nytimes. com/2016/02/14/us/hospital-guns-mental-health. html? _r=0 https: //www. nytimes. com/2016/03/19/us/alan-pean-hospital-guns-mental-health. html? mcubz=1

47 “When the Hospital Fires the Bullet” New York Times, February 12, 2016, Elisabeth Rosenthal • Patient Shot in Ohio: On the same day that Alan Pean was shot, a patient with mental illness was shot by an off-duty police officer working security at a hospital in Garfield Heights, Ohio. The patient had first tried to take the officer’s gun, then during the ensuring struggle, grabbed the officer’s Taser and used it on two other officers and a nurse. • Patient Shot in Virginia: In January 2016, a hospital security officer shot a patient with bipolar disorder in Lynchburg, Virginia after the patient started an altercation, grabbed the guard’s Taser and ran down the hall. As a result of the shooting, the patient is paralyzed from the waist down. • Patient’s Tased in PA and IN: In Pennsylvania and Indiana, hospitals have been disciplined by government health officials after guards used stun guns against patients, including a woman bound with restraints in bed who was Tased by an offduty police officer working security because she wouldn’t be quiet. https: //www. nytimes. com/2016/02/14/us/hospital-guns-mental-health. html? _r=0 https: //www. nytimes. com/2016/03/19/us/alan-pean-hospital-guns-mental-health. html? mcubz=1

48 The Debate Over Arming Hospital Security Personnel • According to the International Healthcare Safety Foundation’s, in 2014, the following percentage of medical centers reported that security personnel were armed with: ▫ Handguns: 52% ▫ Tasers: 47% • 23% of shootings in emergency rooms involve someone taking a gun from a security guard, according to a study by Gabor Kelen, MD, Director of Emergency Medicine at Johns Hopkins University. International Healthcare Security and Safety Foundation, Health Care Crime Survey, April 12, 2017; Hospital-Based Shootings in the United States, Annuls of Emergency Medicine, 2012, https: //www. hasc. org/sites/main/files/03 -hos 1_0. pdf

49 The Debate Over Arming Hospital Security Personnel Potential Advantages Potential Disadvantages • Stopping an active shooter, as active shootings have gone up; • The liability that is associated with arming officers; • An armed presence can increase staff confidence; and • The possibility a gun being stolen; • If done right, hospital can build high-quality security officers. • High training costs; and • Increased recordkeeping. http: //www. securitymagazine. com/articles/86822 -the-debate-over-arming-security-officers-in-a-hospital-situation

50 A Distinction • Violent patient management: the patient/health care provider relationship remains intact; VPM is part of a treatment plan for patients who, as a result of their medical condition, are combative. • Self-defense: a self-defense situation exists when a health care provider believes s/he is in imminent danger of physical harm.

51 Survey of Today’s Participants: 1. Experienced Verbal Abuse and Intimidation: 2. Witnessed Verbal Abuse and Intimidation: 3. Witnessed Physical Assault: 4. Have been Assaulted: 5. Received Training: 6. Filed Incident Report: http: //www. staging. medscape. com/viewarticle/886230#vp_1

52 Next Steps: Ways to Implement New Learnings from this Presentation into Your Practice 1. Be informed about your organization’s policies and procedures concerning workplace violence prevention and reporting. 2. Participate in training about workplace violence awareness and prevention. 3. Notify your leaders of all verbal abuse, threats, intimidation, disrespect, disruptive behavior and/or violence. As a leader, discuss workplace violence prevention during orientation and regularly at staff meetings.

53 Questions and Discussion

54 References for Workplace Violence Awareness and Prevention in Health Care Articles and Publications Lisa Sowle Cahill, “A Church for Peace, ” Commonweal Magazine, September 2016. S. G. Gerberich, et. al. , “An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study, ” 2004; 61: 495 -503. Occupational Safety and Health Administration, Caring for our Caregivers, Preventing Workplace Violence: A Road Map for Healthcare Facilities, U. S. Department of Labor, December 2015. Occupational Safety and Health Administration, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, U. S. Department of Labor, 2015. International Healthcare Security and Safety Foundation, Healthcare Crime Survey, https: //iahssf. org/assets/2017_Crime_Survey_-_IAHSS_Foundation. pdf , April 12, 2017. Gabor Kellen, MD, “Hospital Based Shootings in the United States, ” Annuls of Emergency Medicine, 2012, https: //www. hasc. org/sites/main/files/03 -hos 1_0. pdf.

55 References for Workplace Violence Awareness and Prevention in Health Care Online News Stories about Workplace Violence in Health Care https: //www. nytimes. com/2015/01/22/us/dr-michael-davidson-brigham-womens-dies-after-shooting. html http: //www. wsoctv. com/news/local/police-investigating-after-shots-fired-inside-novant-health-in-huntersville/607108782 https: //www. 953 mnc. com/2017/07/27/mishawaka-doctor-shooter-identified-details-released/ http: //boston. cbslocal. com/2017/06/15/nurse-stabbed-conor-oregan-worcester-southbridge-harrington-hospital/ http: //cdanews. com/2016/07/random-shooting-at-floridas-parrish-medical-center-leaves-two-dead/ http: //www. floridatoday. com/story/news/crime/2016/07/17/police-deadly-titusville-parrish-hospital-shooting-motiveupdate/87218528/ http: //www. nbcchicago. com/news/local/More-Nurses-Join-Lawsuit-After-Hostage-Situation-at-Suburban-Hospital 425913003. html http: //wgntv. com/2017/05/25/nurses-file-lawsuit-over-delnor-hospital-hostage-standoff/ http: //www. wsiltv. com/story/35612226/inmate-takes-hostages-at-will-county-hospital

56 References for Workplace Violence Awareness and Prevention in Health Care Online News Stories about Workplace Violence in Health Care http: //www. nydailynews. com/news/national/arrested-utah-nurse-sexually-harassed-police-staffer-article-1. 3499314 http: //people. com/crime/utah-nurse-arrest-investigation-alex-wubbels/ http: //www. chicagotribune. com/news/nationworld/ct-utah-nurse-arrest-investigation-20170914 -story. html http: //www. springfieldnewssun. com/news/national/police-mayor-apologize-utah-nurse-arrested-for-refusing-draw-blood-fromunconscious-patient/a. I 7 Vl. Xt 0 qg. FXnc. KVptx. CTL/ https: //www. washingtonpost. com/local/whats-one-of-americas-most-dangerous-jobs-its-not-what-youthink/2017/09/11/71 eae 4 d 8 -9715 -11 e 7 -87 fc-c 3 f 7 ee 4035 c 9_story. html? utm_term=. 2 b 8422 e 6 f 289 http: //www. nursingworld. org/Main. Menu. Categories/Workplace. Safety/Healthy-Nurse/bullyingworkplaceviolence/ANA-Sets-Zero. Tolerance-Policy-for-Workplace-Violence-Bullying. html https: //www. nytimes. com/2016/03/19/us/alan-pean-hospital-guns-mental-health. html? mcubz=1 http: //psychnews. psychiatryonline. org/doi/full/10. 1176%2 Fappi. pn. 2016. 7 b 3 http: //www. mcall. com/news/local/investigations/ http: //www. beckershospitalreview. com/quality/the-number-of-armed-security-guards-in-hospitals-is-growing-so-is-the-debateover-their-necessity. html http: //www. securitymagazine. com/articles/86822 -the-debate-over-arming-security-officers-in-a-hospital-situation

57 References for Workplace Violence Awareness and Prevention in Health Care Online News Stories about Workplace Violence in Health Care • http: //www. staging. medscape. com/viewarticle/886230#vp_1 • http: //www. huffingtonpost. com/entry/tracy-sin-yee-tam-identified-as-doctor-gunned-down-byformer-colleague-at-bronx-hospital_us_5957 e 884 e 4 b 02734 df 32 c 2 d 2 • http: //www. cnn. com/2017/10/11/health/utah-officer-fired-after-nurse-arrest/index. html