Enhancing Violence Prevention for Health Care Workers Employed in the Home Health Care Sector through Homecare-Specific Screening, Assessment and Support Tools
Summary
Workplace violence is a concerning issue within healthcare. Yet, a fourfold higher rate of workplace violence exists in healthcare than in any other profession. Most of this violence goes unreported (Arnetz et al., 2015) and undocumented (Casey, 2019). Healthcare workers have a right to do their jobs safely no matter the setting, including home care environments.
Healthcare workers employed in homecare face unique workplace violence risks compared to their counterparts who work in institutional settings. Byon et al. (2020) indicate that 50% of home visiting professionals, primarily nurses, experience verbal abuse each year, with 15% reporting experiences of physical abuse on the job. Within the homecare environment, in optimal situations, homecare employees are received by a gracious client and family who appreciate having care provided in their home. Other times, entering a dwelling incites feelings of trepidation and discomfort. Homecare workers have reported being groped, bitten, slapped, dealing with intoxicated clients, racial insults, and animal bites (Byon, 2021).
Bayshore HealthCare values compassion, respect, and dignity for all individuals in the services being provided, including how we treat one another. Approximately 13,500 professionals and paraprofessionals work at Bayshore HealthCare, of which upwards of 90% are female. When entering client homes, they are viewed as guests and, as a result, experience obstacles to imposing organizational violence and harassment policies. There is no security staff present to help should issues arise. Violence risk may be viewed as part of the work, and there may exist a lack of awareness of what constitutes physical, emotional, or psychological abuse (Byon, 2021).
Violence and harassment prevention and management policies and practices require regular review, focusing on quality improvement, thereby lessening the negative impact on workers, including physical and emotional injuries, time away from work, and its implications for health care services delivery. Subsequently, this project provided an ideal opportunity for me, a clinical practice leader at Bayshore HealthCare, to become more familiar with tools and evidence-based practices towards facilitating violence prevention and management, including a focused self-directed learning experience to develop best practice guideline (BPG) implementation knowledge and skills, within a home and community care context.
Goal and Objectives
The overarching learning goal for the RNAO Advanced Clinical Practice Fellowship (ACPF) was to increase my knowledge, skills and expertise in the prevention and management of workplace violence, harassment and bullying against health workers within home healthcare settings. Employees knowledgeable in violence risk identification, reporting, management, and prevention, assist in creating a safe and caring work environment for all (Government of Ontario, 2019), including those working in the homecare setting. The learning objectives established for this project include:
Objective 1: To enhance my knowledge of Best Practice Guideline implementation
Objective 2: To increase my knowledge and expertise in the current practice of prevention and management of workplace violence, harassment, and bullying in home health care settings
Objective 3: To increase my knowledge on the development and planning of the implementation of violence, harassment and bullying prevention tools, Best Practice Guideline, and related education
Knowledge of workplace violence and harassment was developed through several methods, including:
• conducting a review of existing literature, including a review of guidance as it pertains to occupational health and safety
• performing a current state analysis which included a review of existing policies and processes, meetings/interviews with key stakeholders, and development of an employee survey to identify perspectives on workplace violence, violence prevention and any additional areas of violence risk
• reviewing RNAO BPG implementation resources and evidence-based practice recommendations for implementation from the BPG: Preventing Violence, Harassment and Bullying Against Health Workers
• conducting a scan of existing education (internal and external to the organization), followed by updates and aligning of violence prevention education (using a client centered-approach) to support both general/non-client facing employees as well as frontline/client-facing staff
• providing feedback on and support in the development of homecare-specific screening, assessment, support, and education tools, including workflows for Bayshore-specific documentation platforms
• discussions with my Primary Mentor/other subject matter experts in both occupational health and safety and human resources occupation health business partners
• reviewing/defining/updating metrics for success with the Implementation Team and confirming existing baseline data with support from the informatics team representative
• development of a plan for education deployment
Outcomes
Outcomes for Patient/Client Population
This fellowship project focused on anticipated short term/long term outcomes of the fellowship initiatives to improve worker/employee safety along with benefits for clients and their families. Given that education initiatives have not yet been implemented due to successive waves of the COVID-19 pandemic and organizational priorities, no direct benefits for the client population are possible to provide at this time. As a result, there exists the future potential to increase client/family satisfaction in terms of:
• greater awareness of workplace safety culture at Bayshore HealthCare
• enhanced client-centered care plans to include behavioral management considerations patients/family/community will have a positive perception of organizational safety including Bayshore’s commitment to ensuring that employees have the necessary information training, and supervision (supported by evidence-based best practices), to perform their jobs safely
• continuation of care provision through greater staff retention and healthy workplace measures • an increase in the health and quality of the work environment positively impacts team functioning, leading to effective client care and enhanced ability to meet clients’ needs
Outcomes Experienced Among Colleagues/Staff, Organization, and Stakeholders
This fellowship has contributed and will further contribute (following education deployment) to the following outcomes experienced among colleagues/staff, organization, and stakeholders:
• enhanced clinical practice leader knowledge surrounding BPG pre implementation/implementation process
• built capacity towards sustaining violence management and prevention processes
• enhanced employee and organizational knowledge in violence management and prevention
• greater confidence in managing violence-related aspects of client care
• stronger commitment to evidence-based practice
• enhanced working relationships
• increased awareness of existing strengths and gaps in workplace violence, bullying, and harassment prevention at Bayshore HealthCare
• employee confidence in Bayshore’s commitment to ensuring that employees have the necessary information training, and supervision (supported by evidence-based best practices), to perform their jobs safely
• robust resources to support and enhance understanding, prevention, and management of violence, harassment and bullying in the workplace including employee education, assessment forms, toolkit for care providers, and, updated policies and processes
• enhanced tracking of violence, harassment and bullying related events within the risk management system, and subsequently, the ability to implement actions for improvement and prevent similar reoccurrences where possible
• process alignment of violence management and prevention, including workflow processes
Through extensive collaboration between branches (interviews and surveys), senior leaders, occupational health and safety working groups and the larger Clinical Practice and Informatics Teams, measures were undertaken to understand the existing and desired future states, gaps, and best practices as it relates to preventing and managing violence, bullying and harassment in the home and community care workplace settings. Based on the information gathered, resources were developed to support front-line employees and their supervisors/managers in delivering care with their safety and security as a top priority. It is essential to note that additional insights were identified through the interviews and survey responses warranting current and future education enhancement, including; communication between front line staff and managers, care plans to support behavioral aspects of care, clear client and family expectations in terms of acceptable and unacceptable behaviors, cultural sensitivity in the workplace, and consideration for personal domestic violence and active shooter preparedness. Education initiatives have not been implemented yet, and the direct outcomes experienced by staff are not known at this time. The organization will deploy a post-education survey to elicit staff satisfaction concerning the education, tools and updates in policies and processes.
Overall experience
I am genuinely grateful for learning opportunity that the RNAO ACPF has provided me in developing BPG implementation knowledge and skills relating to preventing violence, harassment and bullying against health workers. Healthcare employees are a most valuable resource and deserve safe work environments grounded in evidence-based practices. Additionally, this fellowship would not have been possible without the commitment and support of Bayshore HealthCare, numerous stakeholders and especially my mentor (Maureen Charlebois), direct manager (Tanya Baker) and project manager (Zara Von Schober).
The homecare service delivery environment is as dynamic as each client encounter in home and community care. As such, this project required unique considerations across diverse Bayshore divisions. It required consideration of violence and harassment prevention workflows, assessment tools, and education enhancements to meet our organization's decentralized model, including congregate settings, clinics, and home care offices across Canada. Furthermore, considerations relating to integration with multiple documentation platforms and applications to non-facing and client-facing staff are required to ensure content remains relevant to and efficiently utilized by the end-user.
Perhaps the most defining piece of the ACPF experience was acknowledging my own preconceived views, which included a tendency towards a higher tolerance for violence when responsive or reactive behaviours (due to an underlying condition) were the primary source. My personal family caregiving experiences further compounded this. As a nurse, one's approach to responsive or reactive behaviours is most often with primary regard for the client and utilizing mitigation strategies completed compassionately and professionally. Consequently, there can be a lesser focus on the personal implications of repeatedly overriding one's fight or flight response. A review of existing literature identified similar shared experiences amongst caregivers. These insights add to the critical nature of the role of nurses (in partnership with clients, family members, paraprofessionals, and community partners) to seek ongoing education in evidence-based violence prevention practices to reduce the risk of violence-related harm, not only where violence risk is obvious or known but also where other brain-based and/or mental health conditions exist and may be less obvious or completely invisible altogether.
References
Arnetz, J. E., Hamblin, L., Ager, J., Luborsky, M., Upfal, M. J., Russell, J., & Essenmacher, L. (2015). Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace health & safety, 63(5), 200–210. https://doi.org/10.1177/2165079915574684
Byon, H. D. (2021). Crossing the threshold: violence against home visiting nurses. STAT. https://bit.ly/3i24XYN
Byon, H. D., Lee, M., Choi, M., Sagherian, K., Crandall, M., & Lipscomb, J. (2020). Prevalence of type II workplace violence among home healthcare workers: A meta-analysis. American journal of industrial medicine, 63(5), 442–455. https://doi.org/10.1002/ajim.23095
Casey, Bill (2019). Violence facing health care workers in Canada; Report of the standing committee on health. House of Commons. https://bit.ly/3fyCOH8
