By VICKI ALLEN
Cindy Chaplin, a psychiatric nurse at Providence Behavioral Health Hospital in Holyoke, Mass., remembers going to work nervous and fearful of the dangers that lurked in the hours ahead to her colleagues, patients and herself.
That was before the Massachusetts Nurses Association and the hospital launched a program in 2004 to reduce workplace violence that the Occupational Safety and Health Administration recently cited as a model of labor-management collaboration.
"I don't have a knot in my stomach when I go to work like I used to," said Chaplin, who was co-chair of the bargaining unit that negotiated with the hospital to confront threats from stressed patients and others in a workplace environment that is prone to violence.
In nurse contract negotiations, psychiatric nurse Cindy Chaplin, standing, worked with Providence Behavioral Health Hospital administrators on joint initiatives to prevent workplace violence. Here she talks with nurse Jeanette Christian in the "sensory room" of the Holyoke, Mass., facility. The room is a soothing place for patients.
"When I would go to work before I was like, 'Oh my God, how many restraints and how many staff am I going to have in the ER?' I don't have that anymore," Chaplin said.
From 2002 to 2013, the rate of serious violent incidents in hospitals, nursing homes and other health care settings was more than four times the rate in private industry, OSHA said in its report, "Worker Safety in Hospitals: Caring for Our Caregivers." Health care accounts for almost as many serious violent injuries as all other industries combined, the report said.
Mutual goals
The Massachusetts Nurses Association brought the issue to the bargaining table, and the result at Providence Behavioral Health Hospital was an evolving, comprehensive program involving staff training, rapid response teams, physical changes at the facilities such as improved lighting and metal detectors in some areas, and approaches to calming patients to prevent incidents from arising.
The joint effort has "led to more than a decade of collaboration on preventing workplace violence, a multidisciplinary task force, an open dialogue, a greater emphasis on prevention and de-escalation instead of restraint, and ultimately a decrease in the number and severity of assaults caused by patients," the OSHA report said.
Roger Ringuette, labor relations manager at the Sisters of Providence Health System in Springfield, Mass., described the program as "an evolution over a significant period of time that started with the collaboration of the union and management." Some measures to reduce violence were "being done in pieces, but putting it together in a committed labor-management agreement I think really defined what we were trying to accomplish, what the roles and responsibilities were."
Figures from the hospital's risk management department showed a dramatic drop in workers' compensation claims from violent episodes, from 64 claims costing $69,196 in 2011 to 32 claims costing $14,541 the following year. By 2015, there were seven claims costing $735.
Code yellow
Chaplin said it took a few bargaining sessions for the issue to take hold. "At first I think they didn't see the day to day things that the nurses saw. But I think they saw that we were really, really scared and people had been hurt."
There could be "punches, kicks, bites, hits with an object, a chair or anything they had, toward staff or toward another peer. Sometimes it was patients attacking patients," Chaplin said. Violence at that time was particularly prevalent at the facility's methadone clinic and children's units.
Now, she said, upper management joins leaders of safety teams on weekly walk-throughs, "and sometimes they're in the midst of a code yellow when they're walking through, and they understand, I think, the impact it can have on patients."
When a code yellow is called, either by intercom or a silent code, staff from various units who have been assigned to the response team converge to try to defuse a potentially dangerous situation, some to deal with the agitated or violent person, others to calm or protect other people. Nursing staff on these response teams, which are available around the clock, have received extensive training. Other support staff such as dietitians and maintenance workers also can get training to deal with a volatile patient or situation and in self-defense.
Panic buttons
There were incidents of patients bringing weapons to the facility's methadone clinic, prompting the hospital to install metal detectors and signs warning that weapons would be taken.
The hospital also installed panic buttons, security cameras for public areas and parking areas, better lighting, controlled access to buildings and other safety measures.
Chaplin recalled her car was stolen from the hospital parking lot. Now the lot is well lit and is patrolled by a guard who also is available to walk staff to their cars.
"My everyday working conditions are, I would say, 100 percent improved," Chaplin said.
OSHA noted the program's reliance on communication and trust between management and staff. Safety is the topic of quarterly meetings of a workplace violence task force, of monthly meetings of managers and frontline staff and a daily "flash meeting" for staff and managers to discuss strategies to deal with specific patients.
Trust building
"Staff is trained in situational awareness, reading behavioral signs for escalation, things like that," said Ann Shea, emergency preparedness/environmental care coordinator at Mercy Medical Center in Springfield, also part of the Sisters of Providence Health System.
The program also encourages staff to report violent incidents, Shea said. "We used to have employees who said 'Well, it's just part of the job,' and we'd say 'No, it's not part of the job.' It's not okay if you get kicked or whatever. It should be reported. The only way we can mitigate or prevent it from happening is knowing that it happened in the first place," she said.
"We've got so many different people at the table, they develop relationships and trust," Ringuette said. "It's getting down to skill sets so people who are actually delivering the care are getting the support they need. If something happens, because we can't control everything, they get reinforced that, wow, we really care." If there an incident, senior management "is there, on the spot," he said.
The program goes hand in hand with an effort to reduce the use of restraints and to instead try to soothe stressed patients that has greatly improved their care.
Chaplin said when she became a psychiatric nurse in the 1990s "there were six to eight restraints every day. You didn't have a lot of options to offer patients as far as calming things, medications."
With relaxing music, weighted blankets, "geriatric chairs" with built-in trays to prevent patients from wandering, a "sensory room" with a cabinet full of activities and other strategies, the aim is to keep patients from becoming agitated.
"We're not thinking restraints, we're thinking how can we help this patient, and that is a totally different focus," Chaplin said.
Be prepared
But the hospital has taken steps to protect staff and patients when its violence prevention measures don't work. Providence Behavioral Healh and Mercy Medical Center participated in an active shooter drill with scenarios including gang violence, a behavioral health incident and an estranged ex-boyfriend in the maternity unit. The drill was coordinated with the state and local police and other local emergency officials and private security companies.
Reducing the risk of workplace violence requires vigilance, Shea said. "We can never rest on our laurels. We have to work on it constantly, the relationships as well as the concrete work that goes into it."
Andrea Fox, the Massachusetts nurses union's associate director for the division of labor action and a participant in the workplace safety negotiations, said she hopes the industry studies the OSHA report. "I feel like it's got a lot of great information. You don't have to start from scratch, you can see what's already working. I hope people use the tools in there to make their situations better."
The union is pushing for a law to require the state's health care facilities to adopt violence reduction programs.
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