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Home Care Nurses at Unique Risk for Workplace Violence


Safety risks for nurses exist in homes and neighborhoods

Workplace violence is a recognized hazard in healthcare that is defined as any act or threat of physical violence, harassment, intimidation or other disruptive behavior that occurs at the workplace, according to the Department of Labor's Occupation Safety and Health Administration. For home care nurses whose workplaces are patients' homes in sometimes unfamiliar or unsafe neighborhoods, the threat of violence is real.

Trust your own intuition

Six months ago, the International Association for Healthcare Security and Safety Foundation issued an evidence-based healthcare security research series, one focusing on best practices for preventing violence in home health. According to its findings, a home health manager's most important challenge is to encourage staff members to trust their judgment and avoid situations that don't feel "right," and for managers to honor that judgment. Jill Goldstein, MS, MA, RN, vice president, nursing, Mount Sinai Queens, Long Island City, N.Y., and Robert Wood Johnson Foundation Executive Nurse Fellow, who worked at the Visiting Nurse Service of New York for nearly 10 years, agrees with this practice. "If at any time before, during or while departing a patient's home, a nurse sees or hears something that is or feels unsafe, he or she should immediately escalate the concerns to his or her immediate supervisor," Goldstein said. VNSNY has detailed and rigorous standards of neighborhood safety, which include its security and safety department assessing areas of concern, both on foot and with local police precincts, to determine what level of support should accompany a staff member, according to Goldstein. "Safe home care visits are an imperative for all agencies," Goldstein said. "Some organizations, like the VNSNY, provide different levels of support staff to accompany a clinician such as escorts or security personnel." If your agency doesn't support you when it comes to unsafe circumstances, then you need to find another, said Kelly Tracy, RN, case manager, Bayada Home Health Care, which has offices throughout the United States as well as overseas locations. "No one should judge you if you feel a situation is more than you can handle," she added. There's reason for concern. Study results have varied widely, but an IAHSS survey of a number of reports found at least 5% and perhaps as many as 61% of home care nurses have experienced some form of workplace violence. Also, 18% to 59% reported verbal aggression as most pervasive. Other studies found that approximately 30% of home care workers reported being sexually harassed.

Assess and be prepared

After working at Brandywine Hospital in Coatesville, Pa., for 25 years, and then WellSpan Ephrata (Pa.) Community Hospital for five, Tracy joined Bayada. Now as case manager, Tracy said she makes sure the home environment is safe for the nurses she supervises. She asks specific questions when assessing a neighborhood for staff members and trains them to consider the factors: Is the area well lit at night? Is there parking close to the client's home? Does the nurse have the proper equipment to meet the client's needs, for example, transfer lifts? Is the neighborhood known for criminal activity? "Our nurses know they should always have fully charged, working cell phone; dress in scrubs with the stethoscope visible; carry only what is needed into the home and if, for any reason, they feel unsure or unsafe in any way, they know to call the agency and ask for help or an escort," Tracy said. Consistent adherence to donning the home care organization uniform and prominent placement of the staff identification badge are some of the most effective interventions as well, as visiting in the early part of the day, Goldstein added. NIOSH provides 19 best practices for home health workers to use in preventing and managing violent situations.

Training is needed

The Bureau of Labor and Statistics estimates that home healthcare employment grew 55% in the 10 years between 2006 and 2016, making it one of the fastest growing healthcare sectors of the past decade. Goldstein and Kelly recognize the growing number of home care workers need training in environmental awareness, as well as workplace violence prevention, whether veteran or new staff. OSHA issued the latest revised version of its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers in 2015. The guidelines are based on industry best practices and feedback from stakeholders, and provide recommendations for developing policies and procedures to eliminate or reduce workplace violence in healthcare and social service settings. In the training process, OSHA recommends organizations create a zero tolerance policy for workplace violence; require employees to report every incident; develop a written plan for ensuring personal safety; report violence to the police; educate staff on the risks of their assignments and how to assess the safety of their environments; and educate staff on the cues of drug use and threatening body language. According to IAHSS research, if the patient and/or family are identified as high-risk, specific procedures should automatically be followed, such as consulting with supervisors prior to a visit; arranging for another person to be present; asking the client to agree to a "no-harm contract"; or providing police as escort services, both inside the home and/or outside in the community, as needed.

Use effective resources

Along with smart phones and all of its capabilities and safety checklists, other commonly used tools help keep home healthcare staff safe and enable close communication between the staff and the agency. For example, some staff members have immediate access to their agency or an emergency responder by pressing an access button inserted on the identification badge. A voice activation tool can be added to the ID badge as well. Risk assessment tools are some of the most important safety resources, according to IAHSS, because they can help to determine whether it is safe to make a home visit. One tool uses a map that denotes crime occurrences in a specific community by using a scoring system. The map can be viewed on a daily basis, which Tracy said is especially helpful in knowing the crime rate and the number of police calls. The "windshield survey" also helps assess risk. By driving around a community, staff learns to differentiate between ordinary and unusual activities or suspicious behaviors. According to Goldstein, VNSNY's security team would speak with local precincts to verify any unusual activity in an area that was brought up by a field RN. The team also had a female officer in plain clothes walk through the area "to gain a sense of how safe it felt," said Goldstein. "From this evaluation, they make recommendations to the nurse administrator to provide the nurse with an escort or higher level of support such as a guard. Or they recommend that the nurse [makes home visits] early in the day."  

Courses Related to 'Home Care'

CE109-60: For Nurses New to Home Care (1 contact hr) More than 60% of RNs are employed in acute care settings. The need for home care nurses will continue to grow as the U.S. population ages and the number of chronic conditions that the elderly must manage increases, which will help them stay out of acute care facilities and reduce re hospitalization. This continuing education activity will provide nurses with an overview of the homecare nurse practice and introduce them to another career option. This activity will help acute care nurses understand how a referral to home care can benefit patients who qualify for home healthcare services. 60050: Managing Legal Risks In Home Healthcare (1 contact hr) The demand for home health services continues to rise as the population ages and more and more healthcare is delivered outside of acute-care hospital settings. In 2010 alone, 3.4 million Medicare and Medicaid beneficiaries were provided with home health care of some type. The demand for providers of home health services, especially RNs, continues to increase as well. The 2013 National Workforce Survey of Registered Nurses found 6% of nurses in the United States work in home care. While some legal risks for nurses translate across all settings, the home care setting has some unique situations nurses should be prepared to recognize and manage.