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Workplace violence: Occupational health nurses can be 'early alerts' to trouble
VA Tech, other scenes of violence show warning signs
Occupational health experts say there are some lessons in workplace safety that can be gleaned from the April 2007 shootings at Virginia Tech. To make those lessons effective, however, we first have to stop believing that workplace violence only happens to other people, they say.
"It's human nature to say, 'Oh, that only happens at other worksites,' but occupational health nurses know that it can happen anywhere," says Louann Beck, BSN, MS, COHN-S, occupational health nurse for Pacificorp in Portland, OR, and a frequent author and speaker on workplace violence. "In 23 years in occupational health, I have worked at a variety of worksites, and I have intercepted many cases," says Beck, referring to people on the brink of violent acts at work.
In fact, the American Association of Occupational Health Nurses (AAOHN) in 2003 conducted a survey on workplace violence, and some results clearly indicate a degree of denial among American workers and their attitudes toward workplace violence.
The AAOHN Workplace Violence Survey revealed that while one-fifth of the U.S. workforce has experienced an episode of workplace violence within their own working environment (as opposed to hearsay about incidents occurring in other locations), 61% said they are not concerned about workplace violence in their worksite. Twenty-seven percent said they were concerned; 8% said they were "very concerned," and 4% said they were "extremely concerned; " (See resources at the end, for information on how to see the entire AAOHN survey report.)
AAOHN past President Susan Randolph, MSN, RN, COHN-S, says the survey indicated that most workers do not know what to look for in recognizing potentially violent offender characteristics. "These findings alone define a significant need for companies to commit to and implement workplace violence education and prevention programs," said Randolph. "Without employee education, a company will be far less able to defuse a potential violent situation before it arises."
Take danger signs seriously
Ignoring the early warning signs that so often precede violent acts is easier than confronting them, points out W. Barry Nixon, executive director of the National Institute for Prevention of Workplace Violence, an Orange County, CA-based consulting group that helps employers create workplace security programs.
Nixon says many employees fall victim to ignoring early warning signs. "The earlier you identify the problem and start taking steps to intervene, the more likely you are to prevent violence from occurring," says Nixon.
Experts say warning signs can include escalating, out-of-proportion anger toward co-workers, employers, or family members; an obsession with perceived injustices; altercations with co-workers; inappropriate responses to normal changes; expressions of feeling targeted or conspired against; and a refusal to accept feedback, particularly if it is critical. More lethal signs include verbalized threats or physical violence; a new, and possibly obsessive, interest in weapons; and expressions of sympathy for the perpetrators of violence.
"If someone is reading about the Virginia Tech shootings and says, 'I can understand why that guy did that,' that is a huge, very dangerous sign," Beck points out.
The AAOHN survey on workplace violence found the vast majority of respondents did not recognize many of the key workplace violence warning signs that have been identified by the FBI and other agencies. When given a list of "red flag" behaviors, less than 4% of respondents were able to identify some of the most common warning signs usually seen in potential offenders. The warning signs referred to in the survey included: changes in mood, personal hardships, mental health issues (e.g., depression or anxiety), negative behavior (e.g., untrustworthy, lying, or bad attitude), verbal threats, and past history of violence.
"We like to think that the people who do these [acts of violence] are psychotic, but the truth is, very psychotic people aren't out there holding down jobs," Beck stresses. "The people who are likely to commit these acts are people with symptoms resembling borderline personality disorders."
Beck says she is familiar with a recent episode involving a male employee who became increasingly threatening toward his female boss. He was suspended from his position for one offense, but disregarding orders that he stay off the premises, returned to the office with a video camera and began filming his boss while he made threats to her. Later, he mailed her an envelope containing a photo of a woman who resembled her, and the photo had been cut into pieces.
"These were such dangerous signs. They tell me that not only is he mentally ill, he hates his boss and is harboring violent thoughts about her," says Beck. "But when she kept going to human resources, they kept responding that they didn't believe he was actually capable of committing violence." In fact, Beck says, the human resources staff recommended mental health counseling — for the female boss, to help "calm her down."
Worker defensive about time off?
Another sign to watch for is an employee who is missing a lot of time at work, and becomes defensive when confronted about it, according to Karen Vesterby, RN, BSN, COHN-S/CM, an occupational health nurse with the U.S. Department of State medical services office in Washington, DC. "Occupational health nurses are in the position of being able to see these signs early, maybe during a health screening, hearing test, or other encounter," says Beck. Also, employees tend to trust occupational health nurses, she says. "We're not the boss," Beck says. "And one of the things we're able to do for the employer is to be an arms-length resource for the employee. We can talk with them about things their managers can't, and if there is a problem, we can go to the supervisor and say, 'He's going to be off work for about a month,' and that's all they need to know."
When the worst happens, however, Vesterby says occupational health nurses must address the risks left in the wake of a violent incident. Occupational health and safety professionals must think of all groups of people who should be protected from exposure to bloodborne pathogens — not only anyone present at the incident, but also housekeepers and workers who deal with cleanup and repair, she says. (See "Occupational health addresses the aftermath," below.)
Occupational health addresses the aftermath of violence
Sometimes overlooked in the wake of an incident of workplace violence is the exposure risk that might result.
Karen Vesterby, RN, BSN, COHN-S/CM, an occupational health nurse with the U.S. Department of State medical services office in Washington, DC, worked at one federal agency where a man came to the office and shot and killed a woman there. In the midst of the shock and chaos, Vesterby says, her occupational health experience kicked in.
"We had to then consider that we had a bloodborne pathogen exposure and had to make sure that all people who were exposed were protected," she says. "They had to replace all the flooring, so we had to make sure the carpenters and flooring people were protected. It went far beyond just the people who were present that day [of the shooting]."
Housekeepers need protection in the aftermath of an exposure, as do security officers and even visitors, Vesterby adds. "This is when you see how effective your exposure control plan is, because in this case, there were 14 buildings at this facility, so there's no way an occupational health nurse could be the first one on site [to ensure immediate compliance with the plan]," she explains. "So have an exposure control plan ready and in place, and make sure that security and risk management includes occupational health nurses at the table while it's being drawn up."
W. Barry Nixon, executive director of the National Institute for the Prevention of Workplace Violence, says that if he tries to find a positive outcome that can be pulled from the aftermath of the Virginia Tech shootings, it is the indication that colleges and other employer sites with large numbers of employees scattered over an area are looking at how to communicate threats of violence when they occur.
"One of the issues being debated is how to connect with the information that someone might be about to do harm to himself or others and get that information directed to the right parts of the organization," he says. "There are privacy issues, but put that aside and ask how can occupational health identify what they perceive as a danger and communicate that to security or human resources or even a threat-assessment committee.
"Because of their interaction with employees, it's very possible that occupational health might be one of the early alert systems in a crisis."
Violence and health care not natural partners
The facts about health care workplace violence have been well documented. Health care leads all other sectors in the incidence of nonfatal workplace assaults, according to the Emergency Nurses Association (ENA), which recently adopted a position statement on violence in the workplace. (For information on how to access that statement, see resources, below.) In a recent survey of more than 1,000 emergency department nurses, the ENA says 86% reported being the victim of violence in the last three years by patients or patients' family members, and 19% experience violence in the workplace on a daily basis.
"A lot of times, we've said, 'Oh, they can't help it; they're psychotic,'" says Beck. However, a lot of times, the violent patient or family member is in control of what they're doing, she says. "They're angry, or they have abused drugs or alcohol."
Nixon says nurses — and for that matter, anyone who works in health care — have long worked under the misconception that violence is part of their jobs. "But that notion is starting to change, and nurses are starting to be clear that it's not part of their job, they shouldn't have to put up with it, and more institutions are coming to terms with that," he says.
For more information on workplace violence, contact:
The Emergency Nurses Association position statement, "Violence in the Emergency Care Setting" is available for free at the association's web site, www.ena.org. Click on "About ENA" and "Position Statements."
The American Association of Occupational Health Nurses, Workplace Violence Survey (2003) is available for free at www.aaohn.org. Click on "Pressroom" at left of screen. Click on "Archived Releases" to right of screen. Scroll down to "Critical Warning Signs of Workplace Violence Not What Employees Expect: AAOHN and FBI Deliver Workplace Violence Prevention Tips and Tools to Prepare Workforce (12/1/03)."