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FSHP 54th Annual MeetingAugust 7-9, 2020
FSHP 54th Annual Meeting – August 7-9, 2020
Workplace Aggression in Healthcare
Joshua Caballero, PharmD, BCPP, FCCPProfessor and ChairDepartment of Clinical and Administrative SciencesLarkin University, College of Pharmacy
Disclosure
FSHP 54th Annual Meeting – August 7-9, 2020
• I do not have (nor does any immediate family member have):– a vested interest in or affiliation with any corporate organization
offering financial support or grant monies for this continuing education activity
– any affiliation with an organization whose philosophy could potentially bias my presentation
Objectives
FSHP 54th Annual Meeting – August 7-9, 2020
• Discuss the definition and types of workplace aggression
• Identify risk factors for aggression and responses to risk factors specific to the healthcare industry
• Outline components of a workplace violence prevention program and strategies for implementation
Violence vs. Aggression
FSHP 54th Annual Meeting – August 7-9, 2020
Beck DL. Hazardous to Your Health: Violence in the Health‐Care Workplace. December 1, 2018. Available at https://www.ashclinicalnews.org/spotlight/hazardous‐health‐violence‐health‐care‐workplace/ (accessed May 20, 2020)Rahim H, Shah B. Pharmacy students’ perceptions and emotional responses to aggressive incidences in pharmacy practice. Am J Pharm Educ 2010;74(4):Article 61
• Workplace violence• Behavior intended to harm a target person• The Health & Safety Executive (HSE) defines violence as “any incident in which
a person is abused, threatened or assaulted in circumstances related to their work
• The World Health Organization (WHO) defines violence as “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.”
Violence vs. Aggression
FSHP 54th Annual Meeting – August 7-9, 2020
•However, the term “violence” is mostly associate with physicality
•The term aggression is generally more encompassing (e.g., verbal, emotional)
Beck DL. Hazardous to your health: Violence in the health‐care workplace. December 1, 2018. Available at https://www.ashclinicalnews.org/spotlight/hazardous‐health‐violence‐health‐care‐workplace/ (accessed May 20, 2020)Rahim H, Shah B. Pharmacy students’ perceptions and emotional responses to aggressive incidences in pharmacy practice. Am J Pharm Educ 2010;74(4):Article 61
Why Should We Care?
FSHP 54th Annual Meeting – August 7-9, 2020
Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med 2016;374(17):1661–9.
• According to the Bureau of Labor Statistics (BLS) data records• Healthcare workers > 11,000 assaults by persons in 2010• Approximately 70% of incidences go unreported
• American Hospital Association workplace violence cost US hospital and healthcare systems approximately $2.7 Billion• Injuries• Loss of productivity
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Why Should We Care?FSHP 54th Annual Meeting – August 7-9, 2020
Beck DL. Hazardous to your health: Violence in the health-care workplace. December 1, 2018. Available at https://www.ashclinicalnews.org/spotlight/hazardous-health-violence-health-care-workplace/ (accessed May 20, 2020)
• Healthcare settings had higher incidence than police protection or correctional institutional settings
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Nursing/Ressidential Care Facilities Hospitals Correctional Institutions Police Protection
Incidence of Intentional Injury per 10,000 Full time Workers
Incidence of Intentional Injury per 10,000 Full time Workers
Sources of Aggression
FSHP 54th Annual Meeting – August 7-9, 2020
• Patients
• Co-workers
• Superiors
• Student/Interns
Phillips JP. Workplace Violence against Health Care Workers in the United States. New England Journal of Medicine, 2016, 374(17): 1661–1669. doi:10.1056/nejmra1501998Beck DL. Hazardous to Your Health: Violence in the Health-Care Workplace. December 1, 2018. Available at https://www.ashclinicalnews.org/spotlight/hazardous-health-violence-health-care-workplace/ (accessed May 20, 2020)
Displays of Aggression or Violence
FSHP 54th Annual Meeting – August 7-9, 2020
• Verbal face: face
• Verbal abuse on the phone
• Refusal to cooperate with aspects of instructions/service
• Thrown objects at with/without contact
• Physical assault
Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med 2016;374(17):1661–9. Beck DL. Hazardous to your health: Violence in the health-care workplace. December 1, 2018. Available at https://www.ashclinicalnews.org/spotlight/hazardous-health-violence-health-care-workplace/ (accessed May 20, 2020)
Handling Verbal Aggression
FSHP 54th Annual Meeting – August 7-9, 2020
Berger BA. Communication skills for pharmacists: Building relationships, improving patient care. 2nd ed. Washington, DC: American Pharmaceutical Association; 2005:527 steps for dealing with angry customers. August 2, 2013. https://www.forbes.com/sites/thesba/2013/08/02/7‐steps‐for‐dealing‐with‐angry‐customers/#5c97c18c6d27 (accessed May 20, 2020)
• Steps• Listen• Remain calm• Control body language• Allow them to vent and listen carefully • Realize most of the time it is nothing personal• Actively sympathize/gracefully apologize• Use their name when responding
Handling Verbal Aggression
FSHP 54th Annual Meeting – August 7-9, 2020
• Steps• Ask constructive questions• Stand firm• Find a solution • Avoid the hold button (if phone)• When all else fails, contact security or supervisor
• Special notes for supervisors• Listen to all sides before acting
Berger BA. Communication skills for pharmacists: Building relationships, improving patient care. 2nd ed. Washington, DC: American Pharmaceutical Association; 2005:527 steps for dealing with angry customers. August 2, 2013. https://www.forbes.com/sites/thesba/2013/08/02/7‐steps‐for‐dealing‐with‐angry‐customers/#5c97c18c6d27 (accessed May 20, 2020)
Robbery Prevention
FSHP 54th Annual Meeting – August 7-9, 2020
Burke J. Rising pharmacy violence. Pharm Times. 2011. Available at :https://www.pharmacytimes.com/publications/issue/2011/August2011/Rising-Pharmacy-Violence (accessed May 20, 2020).
• Security review• Local crime prevention officer• Be aware of surroundings• Care with opening/closing pharmacy alone
• No need to be a hero• Provide the criminal with what they came for• Pay attention to what they are wearing, tattoos/piercings, transportation • Call 911 after the incident
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Violence Prevention
FSHP 54th Annual Meeting – August 7-9, 2020
OSHA. Guidelines for preventing workplace violence for healthcare and social service workers. https://www.osha.gov/Publications/osha3148.pdf (Accessed May, 19, 2020)
• Inspecting the workplace• Peak workload times• Workplace environment evaluations• Security systems• Properly designed waiting areas• Staff restrooms and emergency exits
• Education• Clear policies in place (e.g., general, sexual, racial)• Protocols for eliminating or reducing risk (e.g., zero tolerance policy)• Rapid medical/emotional evaluation availability• De-escalation, break away techniques
• Transparency
Violence Prevention
FSHP 54th Annual Meeting – August 7-9, 2020
OSHA. Workplace Violence. https://www.osha.gov/SLTC/workplaceviolence/ (accessed May 25, 2020)
• Making it an issue or priority• Provide prevention strategies• Create clear policies
• Defining violence and aggression• Coordinated vocabulary/approach
• Develop strategy• Training plan • Perhaps focus on ER first, or high-risk stores
• Emphasize the need to report incidences• Having refresher courses (not 1 and done)
Staying Proactive
FSHP 54th Annual Meeting – August 7-9, 2020
• Excessive jewelry
• Overly tight/loose clothing
• Comfortable footwear
• Keys, name‐tags dangling from chords
• Watching behaviors
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
Cues to Watch Out For
FSHP 54th Annual Meeting – August 7-9, 2020
• Verbal cues• Raised voice• Yelling
• Non‐verbal cues• Neglected physical appearance• Folded arms/clenched fists
• Heavy breathing• Fixed stare• Threatening posture• Indications of drunkenness or substance use
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
In SummaryFSHP 54th Annual Meeting – August 7-9, 2020
• S (staring and eye contact)• T (tone and volume of voice)
•A (anxiety)
•M (mumbling)
•P (pacing)
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
Avoid Saying...
FSHP 54th Annual Meeting – August 7-9, 2020
• Come here!
• Calm down!
• You just need to relax
• That’s just how it is
• What do you want ME to do about it?
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
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Defusing Incidents
FSHP 54th Annual Meeting – August 7-9, 2020
• Respect all individual’s personal space
• Be aware of your language and body position
• Be empathic to other’s feelings
• Use DESC during conflicts and try to de-escalate challenging questions
• Set and enforce reasonable limits
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
What is DESC?
FSHP 54th Annual Meeting – August 7-9, 2020
D Describe the specific situation (objective, factual)
E Express your concerns/feelings about the situation or action
S Suggest/Specify other alternatives and why it may be important
C Consequences should be stated (both positive and negative)
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
Defusing Incidents
FSHP 54th Annual Meeting – August 7-9, 2020
• Permit verbal venting when possible
• Identify real reason for trigger (brief/huddle/ and debrief)
• Stay composed, avoid over-reacting
• Provide task assistance as needed
• Use physical techniques as last resort
OSHA. Workplace Violence. Hospital Education. https://www.osha.gov/dsg/hospitals/education_training.html (accessed May 22, 2020)AAHRQ. Workplace Violence Prevention Resources. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/ (accessed May 22, 2020)
Threat or Limit Setting
FSHP 54th Annual Meeting – August 7-9, 2020
• The way you talk to me will not be tolerated! What’s wrong with you?
• Mary, I know you are frustrated, but can you lower your voice and give me a chance to see what is happening.
• Stop calling over and over again. You are not the only floor I enter orders for. The more you call the longer you will be without the medication.
• This is the third call in five minutes. Please stop calling. I am trying to enter the order properly and make sure there are no errors.
Threat
Threat
Limit Setting
Limit Setting
Lessons We Learn
FSHP 54th Annual Meeting – August 7-9, 2020
• Pharmacy programs teach• Sensitivity• Empathy• Assertiveness• Ethical responsibility• Tolerance
Rahim H, Shah B. Pharmacy students’ perceptions and emotional responses to aggressive incidences in pharmacy practice. Am J Pharm Educ 2010;74(4):Article 61
End Result
FSHP 54th Annual Meeting – August 7-9, 2020
References:
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The Need
FSHP 54th Annual Meeting – August 7-9, 2020
Limited data on stress and the emotional impact on pharmacists’ health
Consequence
FSHP 54th Annual Meeting – August 7-9, 2020
Sibbald B. Workplace violence is not part of a doctor’s job. CMAJ 2017;189:E184
Aggression or violence becomes part of the job… that we just have to deal with it and accept it
In other words…
Suck it up, buttercup
FSHP 54th Annual Meeting – August 7-9, 2020
Emotional Response to Aggression
FSHP 54th Annual Meeting – August 7-9, 2020
Decrease in mental
well-being
The Reality…
FSHP 54th Annual Meeting – August 7-9, 2020
• Frustration • Angry• Helpless• Disgust
Leads to…
FSHP 54th Annual Meeting – August 7-9, 2020
• Lack of pride regarding work
• Increased stress related outcomes
• Burnout
• Turns into a “job”
Sibbald B. Workplace violence is not part of a doctor’s job. CMAJ 2017;189:E184
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End ResultFSHP 54th Annual Meeting – August 7-9, 2020
References:
• Lack of productivity
• Increase in errors
• Depression
• Anxiety
• Substance use
• Turnover
Burnout
FSHP 54th Annual Meeting – August 7-9, 2020
Jones GM, Roe NA, Louden L, et al. Factors associated with burnout among US hospital clinical pharmacy practitioners: results of a nationwide pilot survey. Hosp Pharm. 2017;52(11):742‐51. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2:99‐113McQuade B, Reed BN, DiDomenico RJ, et al. Feeling the burn? A systematic review of burnout in pharmacists. J Am Coll Clin Pharm. 2020. doi: 10.1002/jac5.1218. [ePub ahead of print.]
• Psychological syndrome that encompasses personal feelings of emotional exhaustion, depersonalization, and decreased personal accomplishment
• Recognized by WHO as an emerging problem in healthcare
• Criteria defined in 11th revision of the International Classification of Diseases (ICD‐11) as a syndrome resulting form unsuccessfully managed chronic workplace stress
• May use the Maslach Burnout Inventory‐general survey (MBI‐GS)• Three scales (exhaustion, cynicism, professional efficacy)
Burnout Prevalence
FSHP 54th Annual Meeting – August 7-9, 2020
Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists. Am J Health Syst Pharm. 2018;75(23):S93-S100. Dyrbye LN, Shanafelt TD, Sinsky CA, et al. National Academy of Medicine. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine. https://nam.edu/initiatives/clinician-resilience-and-well-being. Updated 2017.Jones GM, Roe NA, Louden L, et al. Factors associated with burnout among US hospital clinical pharmacy practitioners: results of a nationwide pilot survey. Hosp Pharm. 2017;52(11):742-51.
Healthcare Provider Prevalence (%)
Nurses ~37
Physicians ~50
Pharmacists ~55
Physician assistants ~60
Reasons for Burnout
FSHP 54th Annual Meeting – August 7-9, 2020
McQuade B, Reed BN, DiDomenico RJ, Baker WL, Shipper AG, Jarrett JB. Feeling the burn? A systematic review of burnout in pharmacists. J Am Coll Clin Pharm. 2020. [ePub ahead of print.]
• Younger age
• Increased workhours per week
• High volume and demand workflow
• Staffing inadequacy
The CycleFSHP 54th Annual Meeting – August 7-9, 2020
Aggression/ Violence
Depression, Anxiety,
Substance Use, Hopelessness
Burnout
Depression, Anxiety,
Substance Use, Hopelessness
Need to Educate
FSHP 54th Annual Meeting – August 7-9, 2020
Lifelong learning is not just about therapeutics and pharmacy knowledge
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Need to Educate
FSHP 54th Annual Meeting – August 7-9, 2020
Stoffel JM, Cain J. Review of grit and resilience literature within health professions education. Am J Pharm Educ. 2018;82(2):6150. McQuade B, Reed BN, DiDomenico RJ, Baker WL, Shipper AG, Jarrett JB. Feeling the burn? A systematic review of burnout in pharmacists. J Am Coll Clin Pharm. 2020. [ePub ahead of print.]
• Resiliency• Grit• Handling difficult situations• Managing stress (individual vs. small group)
• Diet/nutrition• Exercise• Financial literacy• Mindfulness‐based methods• Spiritual/emotional• Network (shared experiences)
Mindfulness
FSHP 54th Annual Meeting – August 7-9, 2020
• Avoiding judgement and focusing on the moment
• Identify negative moods and triggers
• Adjusting the thought process when negative situations arise
• Topics include:• Acceptance of feelings/current state of environment
• Breathing techniques• Letting go of judgement
• Hatha/chair yoga• Self‐compassion meditation
Williams JM, Kuyken W. Mindfulness‐based cognitive therapy: a promising new approach to preventing depressive relapse. Br J Psychiatry. 2012;200(5):359‐60
What Institutions Can Do
FSHP 54th Annual Meeting – August 7-9, 2020
El‐Ibiary SY, Yam L, Lee K. Assessment of burnout and associated risk factors among pharmacy practice faculty in the United States. Am J Pharm Ed. 2017;81(4)7West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burn‐out: a systematic review and meta‐analysis. Lancet. 2016;388(10057):2272‐81.
Clear Role Delineation
Reward System
Mentorship
Workload Evaluation
Thank [email protected]
FSHP 54th Annual Meeting – August 7-9, 2020
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