Bill Klaproth (Host): This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. With me today, we have Eric Clay, we have John Voight, and we have Leah Blackwell as we talk about Creating Safe Spaces: Addressing Workplace Violence in the Healthcare Setting. Thank you all for being here today. Appreciate it.

Eric Clay: Thank you very much for having us, Bill.

Host: You bet.

John Voight: Yeah. Thank you very much. Glad to be here.

Leah Blackwell: Yeah. And thanks for giving us a platform to talk about something we're all so passionate about.

Host: Well, it's an important platform, and we've done several podcasts on this, so I'm glad you're here that we can talk about this a little bit more and address this issue. So John, let me start with you. As I just said, this is a huge issue, very important. Why do we need to keep working on this? Why do we need to keep working on building safe spaces?

John Voight: Yeah. Well, I think that, when we look at workplace violence nationally, workplace violence in healthcare occurs 73%. So when compared to other industries, it's the number one industry affected by workplace violence. And I think as clinicians, this is something that is very important to us because we want to keep nurses and physicians and clinicians in the hospital safe at all times.

Host: Absolutely. So, the number one industry for workplace violence?

John Voight: Yes.

Host: I didn't know that. So, that's why this is such a big issue.

John Voight: Yes.

Host: For sure. So, now that we know that this issue is out there, let me ask you this, Leah, so what are you doing to address or solve this issue? How are you looking at this and what are you proposing?

Leah Blackwell: Yeah. So when we started this work back in 2021, we realized that it was going to take multiple work streams to address the concern. So, two work streams that we can talk about today are the clinical work stream or work group, and then the security one. So, I'll address the clinical ones just from a chief nursing officer perspective.

So, there were several things that we did. We started with a comprehensive workplace violence prevention plan. We really wanted something in writing that would really articulate our organizational stance to our teams that this is not okay. And this is the process to report them that we want them reported and what our approach to workplace violence was going to be. We also outlined in that plan escalations and how to escalate and how to respond to aggressive behavior.

Several other things that we did is that we added a behavioral health nurse practitioner and social worker to our ERs. We refined and optimized our Code Green Process for that aggressive behavior and how we escalate it, and implemented really mock drills on how staff can respond so that they get practice in a safe space. To do that, we implemented code of conduct signage as well as an externally facing kindness campaign that humanizes our workforce. We revisited our visitation policy, recognizing that we had created a lot of maybe more openness than we wanted to into some of our areas of our hospital. We hardwired our deescalation training, and then our accountability and attendance for that, kind of reset those expectations with our teams, worked on inner team communication and how we respond, and engaging our security officers with people who we think may be risk for aggressive behavior.

We added a workplace violence icon to our variance reporting system to make it easier for staff to report. Worked a lot around boundary setting conversations with patients and families, so that we can set those boundaries and help them understand what our expectations are in this kind of mutual care relationship.

And I think a really big thing that we did is partnering with, our law enforcement officers and DA offices around charges. There's a perception from our team that we weren't as supportive of them reporting charges or wanting to press charges. And so, really creating a process for that, but also engaging those offices around picking up the charges. And so, I had heard from our staff that, if they wanted to do those things and then were sort of deterred by law enforcement from doing that or that the DA wouldn't move forward with the charges. And so, engage our system risk management partners and legal partners to have those conversations and share the statistics like John shared about what's happening in the hospital setting and really encouraging them to do that. And then, we maintain that relationship ongoing. And so if there's ever any opportunities, we're able to connect with them and because we have that ongoing relationship. So, I think that was a big win for our teams to feel that the organization is supporting them, that there's a clear process for them to be able to do that. And if for any reason the charge doesn't get picked up, that we're going to have a followup conversation.

Host: That's a long list. It's a very long list. Did you put a committee together? How did you come up with all of these touch points?

Leah Blackwell: We did. So, we actually have a workplace violence steering committee at the system level. And then, this was one of the clinical work streams, and it had nurses on it who provided feedback, helped with solutioning. We would show them drafts of things and they would say that's not enough, we need more. And so, really, we're able to refine a lot of the processes, pilot them in smaller areas, and then roll them out across the enterprise, as we were able to hardwire those things.

And then, Eric led a security work group. And so, we've been able to put a lot of things in, and that's what I tell people is we probably don't have the full solution, but we continue to layer on the things that we need as risk presents itself, or we see opportunities to strengthen our overall plan.

John Voight: Yeah. And I would add that I think that this approach is a multi-pronged approach. And I think that ultimately we're building the toolkit. When you look at workplace violence, it's not a singular approach. It's multifaceted. And I think that, in partnership with our security partners, with our clinicians, with our executive teams, and mainly with the frontline clinicians who do this every day, that's how we've evolved to where we are now.

And to Leah's point, there's more work to be done. It's never going to stop, cause it's ever-changing as well. So, I think recognizing that it's multifaceted is key, and really tapping into every component that you can to solve for each problem as it comes along.

Host: So, you said multifaceted, multi-pronged, and you said two main points, clinical and security. Is that what you said?

Leah Blackwell: Yeah. They were work streams. But I think that these are the two biggest that really drove a lot of the initiatives that we're feeling at that frontline level, and that they're able to see changes in how we're supporting them.

Host: Okay. And Eric, what kind of results have you found with this after all of your efforts?

Eric Clay: I think it's been very positive. We've seen around a 9% decrease in workplace violence, reportable workplace violence incidents over the last year. We've seen our engagement survey scores go up, where staff feel better protected. And I think one of the things that is kind of unique about Memorial Hermann is that Leah alluded to some of the workplace violence committees we have. But we have campus-level workplace violence committees. We have a system task force that looks at workplace violence at a very high level. And then, we also have a workplace violence committee that's made up of line staff that's system-wide. So, we engage with them to see what their issues are, what the solutions that they've come up with. And then, we take it back to the larger committee and we work on how can we address these concerns, what can be done today, what can be done in the future. And we communicate that back so they feel like they have a seat at the table. They feel like their voice is being heard. And quite often, they're the ones closest to the problem. They're the one experiencing workplace violence on a daily basis. So, their perspective is valued because of that, because we can come up with an idea and say, "We think this is how to fix it," but it may not be feasible, may not be effective. Whereas when we take their words and we listen to them and we work with them collaboratively, we have such great, benefits from that.

Host: I was going to say, and I'm sure the nurses feel supported and heard and seen, which is really a big part of this.

Eric Clay: Most definitely.

Host: You know, so we've been doing these podcasts for a while. I know there was issues where nurses wouldn't report things, they would just hold it inside. It sounds like with the programs you've put in place now with the results you're getting, people feel safe to speak up to say what's happening to them. Would that be right?

Eric Clay: Yeah, I would agree with that. I think though it's still an ongoing work to try to make sure that nurses, other caregivers feel comfortable reporting. Quite often, people who get into the healthcare industry are very servant-driven. They want to help people. They're very tolerant of issues around workplace violence. And again, as Leah alluded to, we kind of can try to make the reporting process as simple as we possibly can. We provided multiple avenues for them to report, which I think is critically important that they have all these different ways so it's convenient for them and it's important for security to know exactly what's going on from a workplace violence standard, because we need to be able to address that.

We need to build, put our mitigation plan together. And if we don't have all the data, then we're just assuming and we're trying to do things that we think, again, are effective, but may not be as effective as if we had the actual data from our team.

Host: Absolutely. Yeah, go ahead, John.

John Voight: I think you raised a good point too. I'm an ER trauma nurse by background, and I think there's this perception and has been a perception for decades that this is just part of the job. You know, in the ER, we see patients like this all the time, and it becomes a second nature where they think that this is just what I have to do because that's what I do every day.

I think it was an important stat to recognize 62% of ER nurses and 52% of ER physicians reported being physically assaulted at work in a 12-month period. That was from the Emergency Nurses Association and American College of Physicians in 2022. So if you think about that, that's a huge number of assault. And an assault doesn't necessarily mean physical, it's psychological as well. It can be verbal abuse, it can be spitting, it can be any number of things. And 70% or so of those are from patients, but 30% are from visitors and family members and others as well. So when you think about that, it's hugely impactful to what we do every day. And I think you raised a good point, reporting is critical, right? We can't solve a problem that we don't know. And I think that Eric is right. I think that we have made great progress because they see that we're making a difference. We're trying our hardest to make their workplace safe.

And I think that we still have work to do though, because underreporting is still around. And I think people still want to, continue the work that they've done in the past without changing and bringing it forward. But I think recognizing that they have a voice and that we're willing to listen to solve for these problems is critical.

Host: Absolutely. That makes a lot of sense as we were talking. So Leah, if somebody wants to do-- that was a long list. That was a lot of stuff you're doing. So if somebody is listening to this and says, you know, "I want to do this at my hospital," or "I need to do better at this at my hospital," what are your suggested tips for starting? Not that it will be as robust as what you explained, but give us your thoughts on that.

Leah Blackwell: Yeah. I mean, I think us breaking it into chunks, when you look at the problem, it feels trying to eat the whole elephant. And when we broke it into chunks, it made it easier for us to sort of chop away at the issue. I don't know if you want Eric to share all the things they're doing on the security side, but I mean, they've done a lot too. That has been impactful. And so, I think just even that relationship between security leadership and nursing leadership is critical. I know that I can reach out to him or any of his leaders anytime that I have a concern, and they're going to jump in and support. We've seen a lot more visibility of his team and to our teams, through this partnership. And it really has helped, I think, the nurses, that visibility just feeling safer and more supported.

Host: So, Eric, jump in on that as far as the security angle of that Leah said, your team is seen more often. Can you talk just a little bit about some of the changes you've made to address this problem?

Eric Clay: You know, our mission in security, I think, is typically twofold. It's to reduce incidents of violence, reduce incidents of crime being committed. And then, it's also to reduce caregiver anxiety. So, a lot of the things that we put in place also have that component. We want the caregivers to feel better protected. We want them to be very visible measures so that they understand, we communicate that to them in town hall meetings to make sure that they see what we're doing, the investments we're making.

And some of the things we've done in security have been probably one of the biggest things I think was the concealed weapons detection. that has really reduced the anxiety that a lot of our ED staff feel. Last year alone, we stopped around, I think, 1500 knives, cutting instruments from coming in. We stopped around 500 guns from coming in. And then, we stopped a lot of other types of weapons like pepper spray, mace sticks, things like that. And that's just really at five of our campuses where we've started out. So, we know that this is a big problem. We know there are a lot of weapons we're getting in. And we were able to stop that. So, I think that's one of the biggest things that we've been able to do.

We have a program called Purposeful Rounding, which is where the officers are up and engaged. They have a minimum number of interactions that they will have with a caregiver, minimum number of actions with a patient and their visitors. So, they're typically supposed to make about three contacts with each of those demographics. And what that is, is they go onto the unit, they will meet with the charge nurse and say, "What's going on today? You know, here my name's such and such. I'm here to help part of the care team. Then, they find out about problem patients or patients with agitation. They speak with that person. They try to develop a rapport with them so that they are, you know, seen as a friendly type level. We're not just the enforcer that comes in. We meet with the visitors for the same purpose, to make sure they see us. We're very visible. They understand there's a security presence. We're very engaged. And that is another thing that I think has been great, is that whenever we do have an agitated patient or a violent patient, we can come in and talk to them and be like, "Hey, you know, we were talking about baseball earlier," and get back into that conversation.

Another thing I think we've done that not a lot of organizations are doing is we've incorporated Kevlar, the bullet-resistant material that's used in vest and helmets for the military and law enforcement. We've incorporated that into the walls of our EDs. We're incorporated into the millwork of the desks so that if we do have an active shooter or an armed intruder type event, those materials will help keep our staff safe. They'll help keep our patients safe, our visitors safe. We have also added a significant number of armed officers to our program. We have around 450 officers, and we're about 63% armed right now, with a goal of being a hundred percent armed. And we think some of these things are ways to deter crime from happening, because we are ready, we are able to address these issues. The staff, again, feel better protected.

We have a canine program, the first canine healthcare program in the state of Texas, where we have dogs that are trained specifically to look for firearms, explosives, bullets, solvents, lubricants for guns. And that I think is another thing that we're doing just in this multi-pronged approach to try to make sure everybody feels safe, is that we're looking at all these different innovative ways to do things that maybe other organizations aren't using.

And I think the benefit for us has been just everybody feels better protected. Caregivers are able to focus on providing the quality care that we know that they're able to do. Patient outcomes, I think, get better at that point because they're solely focused on keeping their patients taken care of. So, it's been great. And the organization has just made a tremendous investment in our department. We have a training center now that is built specifically for us. We can put about 50 officers through training at any given time. We have a firearms training simulator. We have our own firing range now. So, this organization has made just tremendous investments in making sure our staff feel better protected.

Host: Do you think there is this level of protection at most hospitals around the country? It sounds like you're on the leading edge of security and what's happening. Because I don't think I've ever heard of somebody taking action this in depth to make sure that not only the staff, but also the patients are safe like this. This is amazing.

Eric Clay: I think from, you know, my role on the board at IHSS, which is the International Association for Healthcare Security and Safety, I have pretty good visibility across the country on what other organizations are doing. I think we are leading edge. And I think that the organization, again, has made a deliberate attempt to make sure that we have the things that we need.

And one of the ways that a lot of security departments are looked at is just a cost center. You know, as money goes in, we're not getting anything back for it. We've taken a different approach and we feel that we can show return on investment by keeping our nurses, keeping our caregivers there. We know it costs about $60,000 for us to train and field a nurse. If we're able to keep 10 of those each year, we know we save $600,000. So, that's how we look at our return on investment. When we ask for different things that we may need in the security department, that's how we catalog how we're going to see that money come back to us.

Host: I love that you said that nurse retention is such a big issue, but that's so important for somebody to feel safe when they come to work. They're able to really just do their job and feel protected. Why would they want to leave? I know some people still would leave. But I mean, really does help with nurse retention. I'm so glad you brought that up and how you look at the ROI of it. Because there might be some people listening to this podcast saying, "Wow, that's great, but I just don't have the funds to do as much as Memorial Hermann is doing." But I'm glad you brought that up, Eric. Thank you for bringing that up.

John Voight: Yeah, yeah. I would just add, you know, to Leah's point, these things can be done incrementally. It's not an all-in requirement, but I think starting with the dialogue breaking down barriers, making sure that nursing is working collaboratively with our security partners with others within their hospital or their system. That's the first step. And as Eric has mentioned, there's many things that don't require money. They just require a change in how you do things, right? Perception, awareness, situational awareness, things like that are critical.

I'll share a stat. You know, the cost of workplace violence in the U.S. hospitals is estimated to be over $2.7 billion annually, and that's from the AHA in 2023. So if you think about the cost of workplace violence, as Eric alluded to, we're going to have to do something, right? One event will cost the same as all of the things we put into place at Memorial Hermann.

Host: Good point.

John Voight: So, if you don't do anything, you're not going to attract nurses and others because they want to be safe. They want to go home to their families at the end of the day. And they want to come back tomorrow.

Host: Yeah. Great point.

Leah Blackwell: And I think, you know, the other thing we've been able to capture is lost time from work from injuries. And so, being able to capture that and say, "Okay, well, now this nurse is out for six weeks from a workplace violence injury, and now I'm going to have to back fill her role with other high-dollar supplemental staffing." I think that helps your finance partners start to understand the impact it can have. And then, you hope that they come back after an injury. Because we have had people just leave the profession because they just don't want to put that risk on themselves anymore. And so, I think when we start talking about it in terms like that, it makes it much more clear for our finance partners and our COOs and CEOs who sit at the table with us and have these conversations.

Host: Yeah. Great point. Well, I want to thank all three of you for coming in today. This has been a great discussion. Before we wrap up, I'd love to get final thoughts from each of you. Leah, let's start with you. Anything else you want to add?

Leah Blackwell: I think, I think the one thing we've also talked about a lot is how this is a community health issue. It is a hospital problem, and it is certainly a staffing problem, but it has an impact on other patients in the community that we serve when we have these risk points in our hospital, and so I think I would just encourage anybody to also think about it from that approach. It's also the patients who aren't aggressive and violent that are impacted when their nurse is distracted and pulled away by those patients. And so, how do we just create an overall safer environment, not just for the care team that's a priority, certainly for us, but also our patients and visitors in totality in the community we serve.

Host: Yeah. Good points. John, how about you? Final thoughts?

John Voight: Yeah, I would just add I think that your staff or your number one asset in any organization. And we have an obligation to keep them safe at all times as much as we possibly can. We won't mitigate all risks, but we should try to mitigate, as much risk as possible. And I think that's our duty as leaders within healthcare.

Host: Yeah. Well said. Your staff is your number one asset. Very well said. Eric, how about you? Wrap it up for us. Final thoughts?

Eric Clay: I think workplace violence in a healthcare setting is not solely a healthcare issue. It is a community issue. And that in order to ensure our communities are going to have access to quality, affordable healthcare, we really, as healthcare leaders, need to prioritize the care and safety of our nurses.

Host: Yeah. Good thoughts. Well, thank you all. I really appreciated this discussion, and thank you for bringing this important issue to light and sharing what you're doing to address it. Thank you all for your time. I appreciate it.

John Voight: Thank you.

Eric Clay: Thank you.

Leah Blackwell: Thank you.

Host: Yeah. And once again, that is Eric Clay, John Voight, and Leah Blackwell. And for more information, please visit aonl.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.