New legislation aimed at decreasing workplace violence in health care settings in Washington state went into effect in January 2020. The new law expands the scope of a pre-existing statute passed in 2008 in three major ways, according to a breakdown from the Violence Prevention Institute.
RCW 49.19 extends required workplace violence training to more health care settings, requires volunteers and security personnel to receive this training in addition to health care employees, and expands the scope of the workplace violence training itself to include more education on violence prevention.
For help updating existing training modules, the Washington State Nurses Association, the leading voice and advocate for nurses, turned to frequent collaborator Dr. Annie Bruck, academic retiree in the University of Washington Bothell’s School of Nursing & Health Studies. Although no longer graduate faculty, Bruck arranged for Master of Nursing students to work on the project.
“I got really excited about this opportunity because workplace violence prevention is an area of passion of mine,” said Jenna Mathies, who received her MN in June. “I’ve had a lot of personal experience with workplace violence, as have my friends and colleagues. It seems to be plaguing our discipline.
“In addition, I teach the de-escalation and workplace violence and self-defense classes at work, so this project tied into everything that I’ve been interested in.”
Pandemic exacerbates violence
Anna Callen, who worked alongside Mathies at Virginia Mason in Seattle during the pandemic and who also received her MN in June, was eager to get involved for similar reasons. She, too, has witnessed and experienced workplace violence firsthand and says she has seen violence — particularly from patients — worsen during the pandemic. This, she adds, then exacerbates burnout among doctors and nurses.
“The most significant thing is that during the pandemic family members or the visitors who can usually be a resource for the patients and the nurse could not be there, so the information flow decreased — and we didn’t have the people who could help us out if a patient got violent,” said Callen. “From the patients’ standpoint, they already had heightened anxiety as a result of the pandemic, and they didn’t have their support system at the hospital. Simultaneously, the nurses were feeling the need to stay safe physiologically while dealing with the psychological factors during their 13-hour shifts.
“Anxiety, anger, burnout and stress in general increased for everyone.”
To address the legislative mandate to expand workplace violence training, Callen and Mathies needed to know where knowledge of the issue currently stood. They developed a survey that was sent to all members of the WSNA in February 2021. The questions revolved around the nurses’ definition of violence, their grasp of de-escalation tactics and their understanding of their basic legal rights when faced with violence from a patient or a colleague. The two researchers assumed that, because existing training was required each year, there would be high recall.
Instead, what they learned was that respondents didn’t believe they had even taken the training. In 2020, many organizations pivoted to an online module, which, according to Mathies, was not conducive for such an important and sensitive topic.
“Pre-pandemic at my organization, we would do an interactive, four-hour, in-person class on workplace violence prevention and de-escalation,” said Mathies. “Checking a box online that you read the module just isn’t the same experience.”
Workplace violence commonplace
The general survey response to the definition of workplace violence also worried Callen and Mathies: Many nurses replied that they withstood certain acts of violence because they believed it came with the job.
Violence, said Mathies,should never be tolerated.
“If a patient tries to hit you or says they’re going to hurt you, you don’t have to continue caring for them,” she said. “There’s a lot of moral distress around that concept because some of these verbally and physically aggressive patients may fall or rip out critical medical devices. You’re torn ethically.
“I think this stems from nurses being natural-born caregivers and always assuming positive intent.,” she said. “It’s part of our nature. Through the new training, however, I really want to empower the nurses to stand up for themselves.”
The lack of knowledge about workplace violence basics meant that Callen and Mathies not only had to incorporate legislated changes to the existing virtual trainings, but they also had to refresh the current content. To ensure some of the interactive portions of in-person training were represented virtually, for example, they developed scripts for nurses and caregivers that they could use to practice setting boundaries when faced with violence.
“I’m proud to say that the scripts will go beyond the work of the WSNA,” said Callen. “They will be used across the University’s medical facilities and in nursing programs, so new nurses will be well prepared to protect their patients and themselves.”
As part of the content upgrades, Mathies and Callen also added hands-on de-escalation training to thee revised program.
Protecting the future of nursing
Callen and Mathies are now advocating that the expanded training be used early in a nurses’ careers, while they are still in school and before they have begun working in a clinical setting.
“I noticed a lot of the nursing students we hired this year didn’t get full clinical exposure,” said Mathies. “They weren’t allowed in the hospitals and came into this high-stress environment with little bedside experience. I know of some new nurses who have had incidents of workplace violence and didn’t even recognize it as such. It’s really heartbreaking.”
The new virtual curriculum, which includes objectives and a short quiz, will go live online in the next few months. With the project behind them, both Callen and Mathies are hopeful the new training will better serve their colleagues and will help to curb the violence and burnout that’s plaguing their discipline.
“In the end, it’s like the analogy of the oxygen mask on the plane,” said Mathies. “To help others, you have to put yours on first before you can put it on anyone near you.”
