The threat of violence is always present for home-based staff
The threat of violence is always present for home-based staff
Managers need to develop programs to minimize risk
Although it’s not a subject that hospice managers want to think about, the fact remains that staff face the risk of violence every time they go out to a patient’s home. While violence against home care and hospice workers is rare, it’s not unprecedented. For example, home care nurse Edna Lorraine Hooks of Loveland, CO, was shot and killed without warning in 1996 by an enraged wheelchair-bound patient after she changed his wound dressings. A home care aide in New York City was bludgeoned with a barbell by a client’s son, resulting in permanent brain damage to the aide.
Various guidelines for promoting workers’ safety in the home setting are available from government sources (see resources in box on p. 32). Hospices serving urban or high-crime areas often have their own policies on how to minimize risks to staff, even specifying neighborhoods to avoid after dark or without a colleague or police escort. But the most important challenge for managers is to encourage staff to trust their own judgment and intuition to avoid situations that don’t feel "right" and for their managers to honor that judgment.
How widespread is the danger?
According to the federal Occupational Safety & Health Administration (OSHA), violence is a fact of life for American workers, 1,063 of whom were victims of job-related homicide out of a total of 6,271 fatal workplace injuries in 1993. More workplace assaults occur in the health care and service industries than any other. In home care, the rate of all workplace injuries involving lost work time is 474 per 10,000 workers, and 6 of these are due to assaults and violent acts.
The perpetrator of the assault usually is the patient. Patients don’t just strike health care workers, they also bite and scratch. Patients with dementia or psychosis secondary to their terminal illness, who often forget someone is coming to see them, may respond fearfully to visits by hospice workers, says Elise M. Handelman, RN, COHN-S, MEd, director of OSHA’s Office of Occupational Health Nursing.
OSHA identifies other violence risk factors for home care, such as working in the following situations:
• after hours;
• alone;
• high-crime settings;
• any situation involving extensive contact with the public.
Guns, hazardous materials, or dangerous pets may be present in hospice patients’ homes, while in some areas the primary hazard lies in getting to the home through rough neighborhoods. Hospice’s association with narcotic pain management may also make its workers targets for drug theft.
Actual incidents of workplace violence may go underreported, experts say. Staff may feel that assaults are "part of the job" in health care or that "the patient comes first," especially in hospice, where the personal commitment to service is so strong. "What I see is that hospice people misunderstand the danger and ignore what their instincts tell them," observes Sherri Weisenfluh, LCSW, associate vice president for counseling services at Hospice of the Bluegrass in Lexington, KY. Plus, these usually are people with very little experience in violent situations, she adds.
Mary A. Cooke, RN, MA, director of Cabrini Hospice in New York City, says some of her staff have been mugged in the past, although more serious incidents have not occurred. "Our policy is that we spend time talking about safety, and I try to instill in staff a common-sense attitude. If they get somewhere and don’t feel safe: Don’t go! Call your supervisor," Cooke says.
Cabrini staff are often familiar with neighborhoods where an escort is required, and police precincts can provide data on specific apartment buildings known, for example, to be "crack houses." Families also know when safety is an issue. On-call operators screen calls in terms of safety, and staff may take taxis to make after-hours visits, Cooke adds.
"We’re moving toward a policy where each case is handled individually," away from one based on specific areas deemed "daylight only," says Jeanne Dennis, MSW, ACSW, director of hospice program services for Hospital Home Health Care Agency, Torrance, CA, an affiliate of Little Company of Mary Health Services. The hospice serves greater Los Angeles. "We tell staff: Follow your instincts. We trust you on that," Dennis says, although some staff might prefer clearer direction from the agency. In some cases the patient’s neighborhood may be safe, but the route to get there is not; in others, sending two staff together may not be much safer than one.
Dennis’ agency is wrestling with how to balance staff safety with the delivery of good patient care in a non-discriminatory manner. In some neighborhoods, it is just not possible to attend when a patient dies after dark, "until dawn’s early light," she explains. Also, some staff are more willing to "go anywhere," but it isn’t fair to burden them with all of the cases in unsafe neighborhoods.
Christine Spencer, RN, a nurse case manager with the Torrance hospice, tells Hospice Management Advisor that she takes safety very seriously. "I was on the freeway once, in the middle of the afternoon, and had a gun pointed at me," she says. Spencer used to work at another hospice, "where they made nurses go out no matter what time, regardless of neighborhood. Another time I tried contacting the police [to request an escort for an on-call visit] and got laughed at over the phone. I went down to the station and they still gave me a hard time. The dispatcher said it’s not a bad street, although I was more concerned about the neighborhood I had to drive through to get there. Then he told the officer who was going to drive in front of me [as an escort] to put on a [bulletproof] vest," Spencer relates.
"I guess I would say to hospice mangers: Take it seriously. People behind the desk don’t go through what we go through they don’t feel what we feel. Safety is an individual perception, and it’s more than just a specific neighborhood. It has to do with putting yourself in unsafe situations."
Although assaults such as the murder of Edna Hooks may be difficult to anticipate, hospice managers owe it to their agencies’ precious human resources to adopt a risk-management approach to violence prevention in the home setting. An effective violence prevention program, according to OSHA, includes these basic elements:
• management commitment, with employee involvement;
• a written program for job safety and security;
• step-by-step, common-sense work-site analysis;
• hazard prevention and control;
• safety and health training and education.
(Some of OSHA’s recommendations for field-based workers are found in the box on p. 30.)
A more comprehensive approach is detailed in a recent article in Home Healthcare Nurse.1 Author Ella Hunter, PhD, RN, professor of psychiatric nursing at Eastern Kentucky University in Richmond, argues that "an effective violence prevention program requires the client’s willingness to provide a safe environment and the home care worker’s ability to assess for potential risks in this environment." This assessment should begin from the moment a referral is made.
Hunter has developed an "Aggression Toward Others Assessment Scale" to identify low, moderate, and high risk of violent behavior. If the patient and family are identified as high-risk, various procedures would automatically be followed, such as consulting with supervisors prior to making a visit, arranging for another person to be present, or asking the client to agree to a "no-harm contract." The client’s reluctance to do so is itself a significant risk factor, she states.
Other recommendations for hospice managers, culled from interviews, OSHA documents, and a September 1996 article in American Health Consultants’ Homecare Education Management newsletter, include:
1. Bring potential problem situations to team meetings for group assessment and problem solving.
2. Watch for "red flags" indicating that something isn’t right, such as frequent turnover of aides on a case.
3. Teach case managers to trust aides when they report incidents.
4. Teach staff about sexual harassment and about assessing domestic violence in the home. Take every report seriously.
5. Investigate providing self-contained burglar or "panic alarms," noise-making devices, or pepper spray for staff.
6. Emphasize reporting and documentation of all incidents.
7. Instruct staff in how to recognize potentially dangerous situations, and use role-playing techniques to teach assertiveness.
8. Keep close track of home-based staff members’ schedules. Make sure someone at the agency knows where they are and when they are expected to return.
9. Make available critical incident stress debriefing sessions and post-trauma counseling for staff who have been assaulted.
10. Don’t forget your patient care volunteers in safety prevention programs.
But most of all, emphasize that staff need to protect themselves first, to leave unsafe situations immediately, or to call the police when situations in the home become violent. "Just empower your employees to determine whether or not it’s safe to go," OSHA’s Handelman insists. "One home care nurse told me about a time when she felt really uneasy, and she called back to the office. She was told, We’re responsible to make the visit. If you can’t do it, we’ll get somebody else,’" she relates. Handelman preaches the mentality: "If you feel unsafe, you probably are. Back up and re-evaluate."
Reference
1. Hunter E. Violence prevention in the home health setting. Home Healthcare Nurse 1997; 15:403-409.
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