Bill Klaproth (host): This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. And joining me today, we have Kathy Barnard, we have Stephanie O'Bryon, and we also have Cy Amoin. Thank you so much for all being here. I appreciate it. We're going to be talking about Calm the Storm: Strategies For Ensuring Physical Safety in Healthcare. Welcome.

Kathy Barnard: Hey, Bill. Thanks for having us today.

Stephanie O'Bryon: We're glad to be here.

Host: Absolutely.

Kathy Barnard: So excited to be here. Thank you so much.

Cyril Amoin: I have been looking forward for this.

Host: I have been looking forward to talking to all three of you as well. So, the feeling is mutual. This is great. Well, this is such a big issue, workplace violence and how do we keep our nurses safe? So, let me start with you, Stephanie. Why is workplace violence still one of the biggest, most pressing issue nurses are facing?

Stephanie O'Bryon: A great question, and I would say it's not only still a problem that some would argue it's actually getting worse across the nation if you are seeing national headlines of serious injuries, and lot of us are just trying to figure out what's happening with these violence against the healthcare workers.

And several years ago, we had injuries in our emergency department. We work in the emergency department. We noticed that about 19 of our staff members were getting injured. And then, the year after, about 27. And this was keeping us up at night. I mean, I would say of all things that leaders have on their plates, quality outcomes, patient experience, really nothing is more important than our team and our patient's safety. There's really nothing more important. So, we knew we had to do something and start. But where do you start? Where do you start? So, we assembled a workplace violence task force team.

We also knew our reporting was low. Our teammates were saying that our injuries were high. We're seeing that environment was unsafe, but the reporting was low. Out of a about 120,000 visits per year, we had about 69 violent event reportings, like near-misses for the year. So, it's really low. And we knew that was an issue. And statistically, across the nation, we see that about 19% reporting. So, nurses, frankly, were tolerating it. They were saying, "Nothing's going to happen if I do press charges against this person. I'm going to take it all the way to court. Nothing's going to happen. It's part of the job."

Host: Part of the job. So, just deal with it. It is what it is.

Stephanie O'Bryon: So, we put together a Workplace Violence Task Force Team, and we went over a bunch of conversations. Some of the conversations were let's change our Charlotte-Mecklenburg Police Department's way of doing things too. And we had to really land on some tangible items. And from there, we were able to put together a model. And the rest is history, it really took off. I mean, workplace violence in a lot of ways will never be done. So, you have to really engage your frontline teams. You have to engage all your stakeholders. It's never going to be over. We're looking at it really like a never event like CAUTIs and CLABSIs and our team should never be injured, right?

And so, you know, I think the model that we put together, we were able to present here at AONL, which is amazing, it hopefully helps other people to have something tangible, because we've already done a lot of the hard work of where do you start and with some great outcomes.

Host: Yeah. So, you talked about tangible things, actionable things you can do. Cy, can you explain some of those things that you came up with?

Cyril Amoin: Well, it's a very comprehensive model, I would say, because it is three years work of a really strong partnership. I think one of the key element that made us successful in our emergency department is the partnership between the nurse leaders and the frontline team, which this whole workplace balance task force and the things we've instituted would not have worked.

You have like leaders always consistently asking, how can we do better? Always listening to the frontline team and the frontline team before this whole culture shift was just, "Oh, it's another day. It's another day to get injured." It's not great. But I think Stephanie and Kathy really brought out a really good culture of this is not tolerable, so we're going to change this.

And one of the key things, one tactic, and it's a four-pronged approach that we did, but one of the key things that we really started with was instituting a mechanism by which we're able to capture those aggressive or potentially aggressive behaviors, one of the hardest things earlier. Because one of the hardest thing for us nurses is that we know something's wrong. We know someone is going to cause something wrong, but we couldn't really tell what that is. And so, we rely on just intuition or some thought. But it's hard to explain that to another nurse like there's something wrong here.

And so, we started identifying, of course, a tool to determine that and we decided on STAMP. And that is actually a professional governance work because the frontline team decided on that. We had a lot of options, but we realized that STAMP was very straightforward. It was very black and white, and we can do that in less than 10 seconds and determine what we can do moving forward. And there's a lot of steps after that. But that was very empowering for the nurses to be able to finally call or name what we thought was wrong, we didn't have a name before.

And then, we also looked at changing the culture of reporting in terms of it was so much paperwork. It was you got injured or there was like a threat to you or a workplace violence situation. I wouldn't want report it because of the paperwork that I had to do. I'm already exhausted. I already got punched or something. I don't want to do that. So, it's under-reported to Kathy. To Stephanie's point, it's under-reported because of the workflow that comes along with it, in addition to the workload that you have in the emergency department. The next thing you know, there's another trauma, so you completely forget about it.

So, we did a very good support in that. We have a quality outcomes nurse that helps with plugging in that information. And we also have our rover security who helps also with that reporting. And I think Kathy could speak to it. And that actually improved the reporting because it offsets the workload from the nurse and then we get a confirmation that, "Hey, this has been plugged in for you. Let us know if it's correct or there's missing information.'" So, it's a dynamic approach by which we're able to really authentically capture data. Because if you're oblivious to the situation of injuries happening or workplace violence happening in your department, that's a big issue. You can't change what you don't know.

Host: Right. Well, the under-reporting, the no reporting, huge issue. Kathy, can you speak to that, what I was talking about?

Kathy Barnard: Yeah, absolutely. So, just to kind of elaborate from what Cy was saying, that STAMP tool that we instituted, as soon as the nurse says that patient is exhibiting signs of potential violence, then the nurse has the autonomy to put that patient in a safe area. And then, as Cy mentioned, let security know. And that designated security officer that we call a rover literally will rove the department and round on these patients that we identify as STAMP positive.

And then, all of those patients are put on their shift report that comes to all of us, and then capturing that data to Cy's point. That dedicated nurse takes that report from the officer and puts in those care events for the nurse. That nurse now doesn't have to worry about that. They can focus on their patients or go home and that type of thing. But really, the one thing that we had to stress to our team, it's not just getting punched, it's the act of violence. It can just be them threatening you, "I'm going to follow you to your car when you get off work," or "I know where you live. I know your name now." It can be the fun things of working in the emergency room, a urinal being thrown at you just, being cussed at being touched inappropriately when you're trying to start an IV.

It is not okay. And the culture shift that we had to do was, "It's not okay. We're not going to accept this. Now, what are we going to do about it?" And then, we really had to push the team to press charges like, "This is not okay anymore." And so, part of that model that we developed was the screening tool, getting safety at the front of our work, but now pressing those charges. And then, that is where we as a leadership team really have developed. And part of that model is the wraparound support of that teammate. You want to press charges now? We are going to be with you every single step of that way. We're going to go with you to the magistrate's office and file those charges. We're going to go with you to every court appearance that you have to do. And we talked about this yesterday in our presentation, how that's probably the most exhausting piece of this work. Yes, it's taken us two, three years to get to this point. But just the teammate feeling supported. Because before, as Stephanie mentioned, it takes too much. "I'm not doing this. It's going to take six months to be handled through the court system." But now, you're not alone. We're going with you. We're paying you to go to court. We're going to pay for your lunch. We're going to pay for your parking. And then, we encourage our team to go with that nurse--

Host: In scrubs.

Kathy Barnard: Yeah, in scrubs. Even if it's a physician or a tech, a paramedic, it could be any. It doesn't matter your job title. Nobody deserves to have any type of act of violence towards them.

Host: Absolutely. I think you kind of just presented a really good roadmap. First, you have to let the nurses know this is not okay. If you're touched or grabbed, or somebody spits on you or whatever, it's not okay. So first, you have to say, "We hear you. We hear what you're going through. These things are not okay. Just don't live with them." Not like, "Eh, just part of a day's work. You can't do that."

And it sounds like you made reporting easy. So, they don't have to go through all the paperwork. And then, you're supporting them through the whole process. So, that is kind of a roadmap, if you will. Stephanie, you were going to say something.

Stephanie O'Bryon: Yeah. And putting safety front and center. And just to elaborate a little bit for those that don't know what STAMP is, I just want to elaborate on that. STAMP means staring, tone, anxiety, mumbling, and pacing. So, it's an evidence-based tool that comes from a review of violent events in 155-- I believe it was-- violent events. And every single one of those events had one of those characteristics.

So, we really looked at that as predictive. And like Cy said, we can see it in 10 seconds. So as the person intently staring at you, not just like kind of glaring, but intently staring at you. The tone of voice, like Kathy was saying, are they threatening? Is their voice escalating? Anxiety? Are you seeing these things coupled in that uncomfortable anxiety? Are they mumbling under their breath and just making you uncomfortable? And are they pacing? Which was almost the largest factor when you're looking at pre-violent episodes.

So now, not only do the nurses have an opportunity to say the person is STAMP positive, which is a universal language now. We can clearly say it right off the bat now that people in our department, like EVS, environmental services, transport, security, they don't have access to their electronic medical record, they can actually understand what you're saying. And when you say STAMP positive, it is now a universal language and not gestalt or I have a bad feeling. And so, it has two actions. And like Kathy was saying, you move the person to a secure location, which is very hard in the ED when you have a hundred people in your department.

Cyril Amoin: Quite secure, right?

Stephanie O'Bryon: Yeah. But, you know, you give that clinical decision-making or judgment. But the bottom line is you move the person away from the general population. You move them away from other patients and other teammates, and you intervene earlier. And it might just be security going and talking to the person, trying to calm them down. It might be a quicker medical screening evaluation just to get that process going faster. Whatever it is, just moving them to a secure location and getting that care or that intervention started earlier.

I think that's super important. Because before we went live with STAMP, we would have things going on in our waiting room that were making us very uncomfortable. And just like Cy said, uncomfortable for our teams that just are out there with patients.

Cyril Amoin: And it's very empowering to the nurses too, wherein you are able to name what the phenomenon is and you're able to do something about it instead of just having to deal with it and you're just like waiting for a bomb to explode.

Kathy Barnard: Yeah. And I think it's sometimes it's not even the patients that are doing these things. It could be the visitor. So, another piece of this work was looking at all of our access points into the emergency department, who's coming in our department that doesn't belong there.

So, deactivating what was a pin code to get in the door where our EMS partners would come in because it was the same code across-- we don't know how many states-- to get into that door. So just turning that off, it's badge-entry only, or security has to let you in. Every patient, every visitor goes through a magnetometer. If you come in by an EMS, you're, we get the stadium search with the wanding device. So, we don't want the visitor to be the one who's hurting us either. The patient sometimes may be the calm one, it's the loved one who's upset about what's going on. So, just knowing who's in your department.

Host: Yeah, that makes sense. This has really been a great discussion. I love talking about all of this. And thank you for sharing all the great work that you've done. This has really been great. Can you talk about the results that you've seen so far, Stephanie?

Stephanie O'Bryon: Absolutely. Absolutely. Well, from the beginning, we've talked about how our injuries were going up, and then where do you start? So since we've gone live with this, we've had a significant reduction. We went from 19 a year to 27 a year. Then, that following year after STAMP and the security reports and putting safety front and center and changing our culture, we went down from, I believe, it was eight to six down to two. And this year from the beginning, we've only had one when we pulled up our results from this year.

And again, our work is not done. We still have situations that are struggles as the patients are holding in our departments. We've instituted this work in the front end and triage, so we have more work coming in the future where we're partnering with our physicians and creating a scoring tool that is associated with order set. So maybe next year, we'll come back and talk about that. But that'll be new for us. And we're partnering with Wake Forest. But just, again, the work is never done. So, that's the biggest thing is our teammates are not getting injured as much.

When we talk about our patient scores for our culture of safety work that we have for our teammates that fill that out every year. We have about 174 nurses that fill that out for last year, and employee safety as high priority was 82%. I think that was that 18% or 19% above the benchmark. Super high, a bunch above the benchmark. And then, our, patient safety as high priority was also super high in the 90%. So, our teams are feeling that the patient safety and employee safety is extremely high in our department, which comes with a lot of conversation.

Again, as you're chasing a train, having that dialogue with your frontline team, having those workplace violence task force teams, communicating patient safety and employee safety is our number one priority at all times, whether it's in our meetings, our town hall meetings, our huddles, constantly talking about that with our teams is really important.

And so, I think the biggest thing for us too is we went years and years and years without any convictions, because people were not pressing charges and they were not going through the process, which we're not going to lie to our team. It's still not great and easy to go through the process of pressing charges. You still have to deal with a lot of legal challenges. But we had three convictions in a year. And that was awesome when you went year over year over year with no convictions at all. We had one dismissal. It was a magistrate error on the paperwork, one checkbox was not clicked. That changed our culture of having someone look at dotting their I's and crossing the T's at when you're filling out that paperwork. It was super frustrating. But to have three convictions in a year was really awesome, which encourages people. And then, when we do have a teammate that goes through this process, we ask their permission to share that information with the team. The good, the bad, the ugly. Like, what was it like to be up on the stand? What was it like to face the perpetrator in front of you? What did you learn? How did the legal team support you? And we send that information out via email. We talk about that in huddle. "Hey, just so you know, don't necessarily talk to the defendant's attorney without a legal present because this might happen," or they give them all the ins and outs and the tips.

Kathy Barnard: What to expect.

Stephanie O'Bryon: That's been super inspiring because people are starting to ask us, "Can we go in scrubs? Can we show up?" Not just the leaders, but can we all stand in the back? And so, I think people are just getting sick of it, wanting to really support that culture of pressing charges. And we're starting to see that as well.

Host: Yeah. Knowledge is power, and that's what you're doing. You're informing your staff. Well, the successes are amazing. And I would imagine for your nurses, they feel supported, heard, seen, and it's more enjoyable for them to come to work. And nurse retention, I'm sure, has risen as well, which is a huge thing. If they feel supported and safe, they don't feel like they have to leave the profession. Would that be right, Kathy?

Kathy Barnard: Yeah, absolutely. And I think this could be a direct result of feeling safer. We currently have a vacancy rate of less than 5% I mean, we have a waiting list. Most of our vacancies are from our healthcare techs. But nurses, as soon as we have a position open up, we've got someone ready to enroll into that. So, I think it's the message and the culture that's changing, people are staying longer than what they were.

Host: Well, that's a great byproduct. A great result of this.

Cyril Amoin: Things are thriving. Last year, we presented for our professional governance conference because of our thriving professional governance culture. And you wouldn't be able to execute that if you don't feel safe where you work, because you don't feel like you can't thrive in a place wherein you feel like something's going to happen anytime. So, I would say in a frontline perspective, the transparency, the partnership, the collaboration is a key element for this.

Host: Absolutely. Well, I want to thank you all for coming by today. This has been a great discussion. Thank you for sharing with us all the. Great work that you've done. I'd love to go around the table and get final thoughts from each of you. Kathy, can we start with you? Any key takeaways or final thoughts?

Kathy Barnard: I think, as a leader, it's very important to know that safety doesn't happen by accident. You have to be intentional as a leader with the work and making sure the teammates are at the table. They're the ones who are out there day in and day out. And I tell these guys all the time, you all are my eyes when I'm not there. So if they're not at the table, the work's not going to get done. So, just safety does not happen by accident. You have to be intentional with your work.

Host: Absolutely. That's a great thought. Thank you for sharing that. Stephanie, how about you?

Stephanie O'Bryon: Make sure you have all the key stakeholders at the decision table. Pull in your nurses, your bedside nurses. Have them help you make these decisions, because they are leaders. They're going to be using these tools every day. They're going to be doing the work every day. So, fully engaging with them and not forgetting-- you really have to think about who are your stakeholders in this. You have EVS, anybody in your area. For us, transport, EVS, security. Even at night, not just nurses from the day shift, but make sure your meetings that you have, the night shift nurses can go to them as well. So, just thinking through the stakeholders and pull them in is important, your physician colleagues.

Host: Yeah. Really important stuff. Cy, wrap it up for us. Final thoughts or key takeaways from you?

Cyril Amoin: Workplace violence is not and will never be okay. And as frontline nurses, I know, we've been hearing about it. Social media, it's all over. People are complaining about it. So, one solution for this is a key partnership with the frontline team and nurse leaders. And we need to be able to group together and really attack this seriously. Understanding, orchestrating together that this is not okay. And we got to do something about this, and we got to be very strategic about this and we have the capacity to do this. It's going to be a problem, yes. But we can't sit here getting punch, getting cussed out, getting workplace violence, because it's never okay. It will never be okay. But guess what? We can do something about it.

Host: Yeah. Change the culture. And that's what you all did. You said this is not okay. We're not going to put up with this anymore. Our numbers are too high. And you talked about it. You put procedures in place, and you're seeing the results of that. And now, you've got a safer workplace for employees. It's just wonderful. So great job, really.

Kathy Barnard: Thank you.

Cyril Amoin: Great.

Stephanie O'Bryon: This has been awesome. Thank you.

Host: Thank you so much for stopping by. I really appreciate it.

Kathy Barnard: Thank you.

Cyril Amoin: Yeah, thank you so much.

Host: Once again, that is Kathy Barnard, Stephanie O'Bryon, and Cy Amoin. And for more information, you can always 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.