Workplace Violence Module (CDC)

 Types of Workplace Violence

o Type 1: Criminal intent
 the perpetrator has no legitimate relationship to the business or its employees, and
is usually committing a crime in conjunction with the violence (robbery, shoplifting,
trespassing). For example: a nurse assaulted in the hospital parking garage; a home
health care nurse is mugged while conducting a home visit.
 In health care settings Type I violence occurs less frequently compared to other
types of violence.
o Type 2: Customer/client
 the most common in healthcare settings. This course considers the customer/client
relationship to include patients, their family members, and visitors, and will be
referred to as CLIENT-ON-WORKER VIOLENCE. Research shows that this type of
violence occurs most frequently in emergency and psychiatric treatment settings,
waiting rooms, and geriatric settings, but is by no means limited to these. Prevention
of Type 2 violence is a primary focus of this course.
o Type 3: Worker-on-worker
 between coworkers is commonly referred to as lateral or horizontal violence. It
includes bullying, and frequently manifests as verbal and emotional abuse that is
unfair, offensive, vindictive, and/or humiliating though it can range all the way to
homicide. Worker-on-worker violence is often directed at persons viewed as being
"lower on the food chain" such as in a supervisor to supervisee or doctor to nurse
though incidence of peer to peer violence is also common. This course explores the
roots of worker-on-worker violence in healthcare settings.
o Type 4: Personal relationships
 the perpetrator has a relationship to the nurse outside of work that spills over to the
work environment. For example, the husband of a nurse follows her to work, orders
her home and threatens her, with implications for not only this nurse but also for her
coworkers and patients. This course does not specifically address Type 4 violence but
many of the concepts, techniques and protocols presented here for violence Types 2
and 3 are applicable.
 Workplace violence consequences
o Crisis is an acute emotional upset; it is manifested in an inability to cope emotionally,
cognitively, or behaviorally and to solve problems as usual
o Manifestations of crisis
 Biophysical manifestations
 rapid heart beat, increased blood pressure
 hyperventilation, sweating
 rash or hives
 stomach pain, nausea, vomiting
 diarrhea, frequent urination
 chest pain
 involuntary shaking
 release of stress hormones
 decreased sleep

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 Emotional manifestations
 fear: of injury, loss of life, losing control, or of going crazy
 high anxiety: about what to do, how to escape, stopping the abuse
 shock/disbelief
 guilt, embarrassment, or shame
 fight-flight impulse toward self-protection
 post-trauma sequelae: e.g., nightmares, re-play of the frightening incident,
crying
 Cognitive manifestations
 Inability to focus or concentrate
 Interference in ones usual problem-solving ability
 Behavioral manifestations
 cannot perform usual work demands
 becoming withdrawn
 crying easily
 lack of sleep
 avoiding usual social interaction
 losing temper easily - yelling, getting angry at family members, etc.
 acting impulsively
 driving hazardously as a result of anxiety and emotional upset
 Risk Factors for Type 2 Violence (Customer/client)
o Staff shortages, increased patient morbidities, exposure to violent individuals, and the
absence of strong workplace violence prevention programs and protective regulations are all
barriers to eliminating violence against healthcare workers
o Clinical risk factors
 Patients who are at risk of perpetrating violence include those who:
 are under the influence of drugs or alcohol
 are in pain
 have a history of violence
 have cognitive impairment
 are in the forensic (criminal justice) system
 are angry about clinical relationships, e.g., in response to perceived
authoritarian attitude or excessive force used by the health provider
 have certain psychiatric diagnoses and/or medical diagnoses
o Environmental Risk Factors
 those that are attributable to the layout, design, and amenities of the physical
workspace
 Environmental risks fall into four categories and include factors that:
 Provide opportunity to gain access or avoid detection such as unmonitored
entries or stairwells, insufficient lighting, blind corners, unsecured rooms or
closets
 Increase stress such as signage that is confusing, poor weather conditions,
difficulty parking or accessing a building, insufficient heat or air conditioning,
and disturbing noise levels

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Provide opportunities to be used as weapons such as unsecured furniture,


fixtures, decorative items, office or medical supplies
 Limit staff's ability to appropriately respond to violent incidents such as the
lack of security systems, alarms, or devices
o Organizational Risk Factors
 Organizational risk factors are those that result from the policies, procedures, work
practices and culture of the organization. Such risk factors include:
 Careless management and staff attitudes toward workplace violence
prevention;
 Inadequate security procedures and protocols;
 Lack of staff training and preparedness;
 Cumbersome or nonexistent policies for reporting and managing crises;
 Low staffing levels, extended shifts, overtime requirements.
o Social and Economic Risk Factors
 High concentrations of poverty
 Diminished economic opportunities
 Socially disorganized neighborhoods
 High levels of family disruption
 Low community participation
 Social and cultural norms that encourage violence
 Health, educational, and social policies that help to maintain economic or social
inequalities between groups in society
o “Revolving Door” Syndrome
 There is a vicious cycle that sometimes links workplace violence, psychiatric
treatment, and the "revolving door":
 Stage 1: The intensive psychiatric hospital treatment for some mentally ill
patients may be cut short because of insurance pressures for early
discharge;
 Stage 2: Community-based follow-up treatment and medication monitoring
are inadequately staffed and supervised;
 Stage 3: Patient enters general hospital Emergency Department when in
crisis;
 Stage 4: De-escalation and/or chemical restraint is applied;
 Stage 5: Patient is discharged with minimal or no psychiatric follow-up;
 Stage 6: Patient experiences a repeat crisis episode and admission to ED—
and the "revolving door" continues.
 The rate of recidivism (return for treatment) is extremely high and these patients
may be referred to as "frequent fliers." Some end up in the criminal justice system
where psychiatric treatment is minimal or non-existent.
 Risk Factors for Type 3 Violence (worker-on-worker)
o Contributing factors
 The Joint Commission describes root causes for worker-on-worker violence:
 "Systemic factors stem from the unique health care cultural environment,
which is marked by pressures that include increased productivity demands,

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cost containment requirements, embedded hierarchies, and fear of or stress

from litigation
 These pressures can be further exacerbated by changes to or differences in
the authority, autonomy, empowerment, and roles or values of professionals
on the health care team … as well as by the continual flux of daily changes in
shifts, rotations, and interdepartmental support staff
o Oppressed Group Behavior
 Nurses as a group display some characteristics of being oppressed including low self-
esteem and feelings of powerlessness
 When an individual or group not only feels but is relatively powerless compared to
another, they can take it out on one another within the oppressed group, especially
on someone even less powerful
 Prevention Strategies for Organizations
o OSHA’s five major elements of an effective workplace violence prevention program are:
 Management commitment and employee involvement;
 Worksite analysis;
 Hazard prevention and control;
 Safety and health training;
 Recordkeeping and program evaluation.
 Prevention Strategies for Nurses
o Dress for Safety
 Long hair should be tucked away so that it can't be grabbed;
 Jewelry - avoid earrings or necklaces which can be pulled;
 Overly tight clothing can restrict movement;
 Overly loose clothing, or scarves can be caught;
 Glasses, keys, or name tags dangling from cord or chains can be hazardous; make
sure to use breakaway safety cords or lanyards
o Indicators of possible violence
 Verbal cues
 Speaking loudly or yelling
 Swearing
 Threatening tone of voice
 Non-verbal or Behavioral Cues
 Physical appearance (clothing and hygiene neglected)
 Arms held tight across chest
 Clenched fists
 Heavy breathing
 Pacing or agitation
 A terrified look signifying fear and high anxiety
 A fixed stare
 Aggressive or threatening posture
 Thrown objects
 Sudden changes in behavior
 Indications of drunkenness or substance abuse

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 Intervention Strategies
o Stages of Crisis Development
 Stage 1—normal stress and anxiety level
 The background of crisis development brought about by the minor
annoyances and frustrations of everyday life. Individuals at this stage are
rational and in control of their emotions and behavior.
 Stage 2—rising anxiety level
 A heightened condition typically including rapid heart rate and respiration.
The person might appear lost or confused about how to solve a problem.
Voice may be pitched higher or quaver with accelerated speech patterns.
Small nervous habits such as finger or foot tapping may be manifested.
 Stage 3—severe stress and anxiety level
 A person's reasoning capacity is seriously diminished, with fixation on the
here and now. Behavior typically becomes boisterous or disruptive.
Communication may include shouting, swearing, argumentation, and
threats. Physical indications include pacing, clenched fists, perspiring, and
rapid shallow breathing.
 Stage 4—crisis
 Characterized by unbearable anxiety and loss of cognitive, emotional, and
behavioral control, with urgent need to end the emotional pain. A person in
crisis is unable to solve problems or process information rationally without
help. Behaviors of persons in crisis are erratic and unpredictable to a point
that they may pose a danger to themselves and others.

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