Workplace Violence:Prevention & InterventionGUIDELINES FORHOMELESS SERVICESPROVIDERSBrenda J. Proffitt, MHA, editorHEALTH CARE FOR THE HOMELESSCLINICIANS’ NETWORKAugust 2011 Updated Edition

TABLE OF CONTENTSAcknowledgementsvIntroduction7Greater Cincinnati Behavioral Health ServicesPolicy & Procedure: Behavioral Risk Management9Community Safety Checklist27Practice Guidelines for Violent or Aggressive Clients29People’s Clinic Homeless Health Care ProgramSafety Protocol39Safety Manual41Big City Mental Health CenterViolence Policies & Procedures47Street Outreach ProjectSafety Protocols & Guidelines51Homeless Health Care Los AngelesSafety Guidelines for Outreach63Tom Waddell Health Center/Homeless ProgramsManagement of Violent or Disruptive Behavior65Resources85Appendix A: De-Escalation Tips89Appendix B: Violence As A Cause & A Consequence of TBI91DEFINITION: WORKPLACE VIOLENCEViolent acts (including physical assaults & threats of assaults) directedtoward persons at work or on duty.—CDC/NIOSH (2002)Workplace Violence: Prevention & Intervention iii

ACKNOWLEDGEMENTSThis updated compilation of policies and protocols provides practical information for creating a saferenvironment for consumers and staff in Health Care for the Homeless Projects. It is an expanded andenhanced version of the 1996 document Sample Safety Guidelines in Homeless Health Services Programs, andwould not have been possible without the essential and gracious support of many individuals.The Health Care for the Homeless Clinicians’ Network Communications Committee under the leadershipof Bob Donovan created an encouraging environment. In particular, the guidance of committee memberBrian Colangelo helped shape the parameters and content of the project. I am grateful, as well, to mycolleagues at the National Health Care for the Homeless Council, Molly Meinbresse and Lily Catalano,who made numerous contributions. Special thanks go to Amy Grassette for her thoughtful andcomprehensive review. This publication was improved by conversations with Miki Kamins on the effects oftraumatic brain injury on the health of homeless people. The Network gratefully acknowledges the generousfinancial support of the Health Resources & Services Administration.Several HCH projects generously submitted documents in response to a call for guidelines on managingdisruptive and/or violent behavior in the workplace. The Network would like to thank these agencies fortheir permission to use this material and for making this publication a reality: Clinica Family Health Services, People’s Clinic Site, Boulder, ColoradoGreater Cincinnati Behavioral Health Services, Cincinnati, OhioHomeless Health Care Los Angeles, Los Angeles, CaliforniaTom Waddell Health Center, San Francisco, CaliforniaWasatch Homeless Health Care Program, Salt Lake City, Utahplus these agencies in Seattle, Washington: Harborview Medical Center, Pioneer Square Clinic Health Care for the Homeless Network The Mental Health ChaplaincyThese contributions have been gently edited for brevity, clarity, and editorial consistency. Any errors andomissions are my own.—Brenda J. Proffitt, MHA, editor2010 – 2011 HCH Clinicians' Network Communications CommitteeBob Donovan, MD; Sapna Bamrah, MD; Brian Colangelo, LCSW; Kent Forde, MPH; KathleenKelleghan; Bill LaRock, MS, ANP, RN; Michelle Nance, NP, RN; Rachel Rodriguez-Marzec, MS, FNPC, PMHNP-C; James Williamson, MS, PA-CDisclaimerThe Health Resources & Services Administration supports the development and distribution ofWorkplace Violence: Prevention & Intervention. Its contents are solely the responsibility of the authors anddo not necessarily represent the official views of HRSA/BPHCSuggested citationHealth Care for the Homeless Clinicians’ Network. (2011). Workplace violence: Prevention and intervention.Guidelines for homeless services providers (2nd ed.). Brenda J. Proffitt, ed. Nashville, TN: National HealthCare for the Homeless Council. Workplace Violence: Prevention & Intervention v

INTRODUCTIONViolence in the workplace is a serious health and safety issue. Homicide—the most extreme form ofworkplace violence—is the fourth-leading cause of fatal occupational injury in the United States according tothe Occupational Safety and Health Administration. Although the majority of workplace homicides involvea person entering a small late-night retail establishment, nonfatal events involving assaults to serviceproviders—especially health care providers—represent the most prevalent category of workplace violence thatresults in physical injury. 1While there are no specific OSHA standards for workplace violence, a number of work settings—including agencies delivering services to individuals and families experiencing homelessness—havedeveloped and implemented strategies for reducing exposure to risk factors for violence. The Health Carefor the Homeless Clinicians’ Network gathered the policies and protocols included in this publication toprovide guidance to establishing a workplace violence prevention program. Six homeless services providersshare their expertise in preventing and dealing with workplace violence in the documents included here.Others who are responsible for establishing workplace violence initiatives at their agencies are urged to usethese resources to enhance workplace safety and to reduce and prevent disruption and violence.These collected policies and protocols provide examples of: Practical measures to identify risk factors for violence at work Basic information about employer/employee roles in prevention and protections Recommendations for response to violent incidents A checklist of safety practices for workers who go out into the communityResources at the end of the publication link to a variety of training and reference materials,including presentations, publications, sample forms, best practices, and successful methods of prevention.Appendices highlight additional information about two issues of particular concern, de-escalation ofaggressive behavior and working with brain injury survivors. Our intent is to support homeless serviceproviders in their efforts to maintain safe and healthful working conditions. Occupational Safety & Health Administration. (2007). Safety and health topics: Workplace violence. Retrievedfrom ce Violence: Prevention & Intervention 7

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICESPolicy & Procedure:Behavioral Risk ManagementGreater Cincinnati Behavioral Health Services (GCB) is the largest community-based mental health provider inHamilton County, Ohio, serving adults who have the most severe forms of schizophrenia, bipolar disorder, and majordepression. Through its PATH Program—Projects for Assistance in Transition from Homelessness—GCB is the largestlocal outreach provider to people who are experiencing homelessness. In 2010, GCB began a collaborative clinic with theCincinnati Health Network’s Health Care for the Homeless Program. GCB updated and distributed these policies andprocedures for behavioral risk management in 2010.POLICY STATEMENT GCB will provide guidelines to staff to maximize client and staff safety in our facilities and in thecommunity GCB will prohibit violence in the workplace and protect client safety through sound seclusion andrestraint procedures GCB will provide training to staff on the risks associated with providing mental health services; thetraining will focus on crisis prevention, non-physical crisis intervention, and personal safetyPURPOSE Behavior risks are risks that result from the behavior of our staff, clients, or others. GCB will strivefor a work environment that is safe for clients and staff. Since the nature of GCB’s business is such that risks to staff and clients are unavoidable, GCB willcontinue to develop strong policies and procedures to help safely manage these behavioral risksWorkplace Violence: Prevention & Intervention 9

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICESPROCEDURES Behavioral Risk Management in our Facilities and in the Community Clinical Risk Management Nonviolent Crisis Intervention Seclusion and Restraint Violence in the Workplace/Program/Settings WeaponsI.BEHAVIORAL RISK MANAGEMENT IN GCB FACILITIES & IN THE COMMUNITYA. General Use Code Yellow Procedures when indicated Use the Clinical Officer of the Day as needed Use good judgment. Do not take risks. Consult with your supervisor when you have questionsor concerns about your safety. If your supervisor is unavailable, contact your departmentdirector (or designee) and/or on-call system. Know your clients, learn their risks, and use the resources available to you When clients receive multiple services, the client coordinator manages services to assureconsistency related to staff and client safety Knowing our clients and their behaviors can help staff avoid most situations of aggressive orviolent behavior. Pay extra attention to clients who may present as anxious, agitated, or upset, andrespond in a supportive and empathetic approach. Staff is responsible for close observation andearly action.B. Co-Treatment Co-Treatment: Two staff members deliver services to one client at the same time because of riskor safety concerns (either in the office or in the community). This applies to any two staffmembers including doctors and nurses. Use co-treatment when there is a safety risk that requires that two staff be present All co-treatment must have authorization by a GCB clinical supervisor Ongoing co-treatment for safety must be authorized in the ISP. A clinical supervisor mustauthorize a one-time service. A clinical supervisor must sign all progress notes documenting co-treatment10 Workplace Violence: Prevention & Intervention

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICESC. Contacting the Police For all calls requesting police assistance, staff provides the following information:Ø Caller’s nameØ The specific location where the police are needed(generally, a street address; but when necessary,include the specific location within that streetaddress)Ø The fact that you are calling from a mental healthfacility (if applicable)Ø The nature of the specific situation for which you are requesting assistance Provide a brief, clear, and factual description of the specific situation to the dispatcher:Ø Number of individuals involvedØ Type of weapons involved, if anyØ Nature and extent of any known injuriesØ Nature of individual: Depressed? Suicidal? Apparently responding to hallucinations?Intoxicated? Known to respond negatively to police officers? If situation requires immediate police assistance, call 911 Staff should provide all information requested by the police and cooperate fullyD. Behavioral Risk Management & Quality Improvement The safety coordinator works with staff resources to include facility and community safetytopics in the agency’s orientation and annual training plan The safety coordinator ensures that the Safety Panel’s quarterly and annual reports includeinformation on facility safety and staff safety in the community Areas for improvement identified by the Safety Panel and Incident Review Panel will beincluded in agency strategic initiatives or in quality improvement plans GCB collaborates with local police to build an effective partnership to address crisesE. Resources for Managing Psychiatric Emergencies GCB’s Code Yellow Procedure When a person is threatening to hurt themselves or others or isactively hurting someone else, a Code Yellow alert sounds through the phone paging system. AWorkplace Violence: Prevention & Intervention 11

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICESCrisis Team, comprising staff that completed eight hours of Crisis Prevention and Interventiontraining, will respond immediately. Staff already at thescene should continue attempts to de-escalate theagitated person and summon additional staff includingIf situation requiresthe case manager, officer of the day, and security guardimmediate police assistance,as needed. Initial responding staff or security guardcan turn the situation over to the crisis team ifindicated, but should continue to act in a supportivecall 911. Provide allinformation requested bythe police & cooperate fully.role. Application for Emergency Admission GCB will useour psychiatrists and advanced nurse practitioners to complete Statements of Belief andObservation for emergency admissions. If one of the above listed staff is unavailable, we willuse one of our trained Health Officers to complete the statement of belief (see Health OfficerGuidelines below). Guidelines for GCB Health Officers when considering signing a hold on an individual:Ø A GCB Health Officer can sign a hold only if the individual’s treating psychiatrist oradvanced practice nurse or another agency psychiatrist/APN is unavailable to sign the holdØ If a Health Officer is needed to sign a hold, he or she must consult with a second HealthOfficer or another agency supervisory-level clinician (if a second health officer isunavailable) before completing the hold. These two clinicians must agree that a hold isrequired.Ø File a copy of the hold in the legal section of the individual’s record. If a hold is signed inthe field, keep the carbon copy for the client’s record. The original hold must alwaysaccompany the client to the hospital.Ø Anytime a hold is signed, complete an incident report. The incident reporting committeewill review every signed hold. Psychiatric Emergency Service PES is the “psychiatric emergency room” at University Hospitalwhere many clients go for psychiatric treatment. PES provides the following services:Ø Psychiatric assessmentØ Administration of psychotropic medications to stabilize a personØ Overnight observation12 Workplace Violence: Prevention & Intervention

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICESØ Admission to University Hospital’s psychiatric unitsØ Referral to hospitals in the community Persons who have physical injuries as well (e.g., overdose of medications) will be seen in theAcute Care Section before being released to PES Any time a client is going to PES, staff should call first to provide the following information:Ø Client’s name and other identifying informationØ Current prescribed medicationsØ Time of last known dose(s)Ø Any information regarding suspected overdose or substance abuse (e.g., type, quantity,time ingested)Ø A staff member’s name to contact regarding client’s status Mobile Crisis Team Operated out of PES, MCT provides on-site response (e.g., assessment,evaluation, crisis counseling, referral to PES, authorization for involuntary admission) incertain situations. Factors that rule out MCT responding include situations where deadlyweapons are involved or where the client is acting violently. In these situations, call 9ll. Theclient must voluntarily agree to talk with MCT. Note that the MCT cannot necessarily respondon short notice. Life Squad & Police Emergency For serious emergencies such as suicide or situations involvingviolence or deadly weapons, call 911. Clinical Officer of the Day GCB designates a supervisor as Clinical Officer of the Day to beavailable during business hours and gives all staff the Clinical Officer Coverage Schedule. On-Call & Clinical Backup Services GCB provides after-hours and on-call services to assistclients with emergencies when the office is closed. A clinician is on-call for consultation asneeded.F. Facility When providing services to a high-risk client within any GCB facility, plan so you are notmeeting with the client in an isolated location. Meet in open surroundings in view of others. Innonresidential facilities, if someone is under the influence, we do not want him or her in thefacility. In group homes, base decision making on the person’s behavior and use the aboveresources as appropriate. Each GCB site conducts quarterly safety drills. Program rules or guidelines are posted in each staffed locationWorkplace Violence: Prevention & Intervention 13

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICES Each facility develops and posts “house rules” that address at least the following:Ø Threatening behaviorØ Respecting other’s spaceØ StealingØ Fighting or violenceØ Weapon-free environmentØ Drugs or alcoholØ GamblingG. Crisis Intervention Protocol for GCB Facilities Staff training will be provided The goals of any intervention should be to:CRISIS INTERVENTION GOALS‣ To protect potential victims,yourself & others‣ De-escalate the situation‣ Help the individual regain controlGENERAL PRINCIPLES‣ Preventive techniques‣ No physical interventiontechniques‣ Continually assess risk factorsØ Protect potential victims, yourself, and othersØ De-escalate the situationØ Help the individual regain control Each facility should have a process for notifying other staff that a crisis is occurring or about tooccur. This is a call for help, and the Code Yellow Protocol outlines procedures. The first person on the scene should temporarily take the lead; the ideal lead person is someonewho knows the individual well and already has good rapport Depending on the situation, no more than two staff should approach and work with theindividual. Others responding should assist in clearing the area of onlookers, and take directionfrom the lead intervener. Any interventions should be progressive; i.e., do not under- or over-respond to the situation Safety of GCB employees always comes first. These are ways staff can increase safety in theworkplace:Ø Be aware: Every work environment has a routine amount of noise and energy. Theemployee, however, needs to be aware of any changes, unfamiliar noises, or unfamiliarsounds, which could be an alert to a safety issue.Ø There is safety in numbers. If you or a client feels threatened, call for help and make noise.Ø If you are involved with a client who has reached the physical action stage, scan yourenvironment for natural barriers to increase safety. For example, is there a table or chairthat you can place between the employee and the client?14 Workplace Violence: Prevention & Intervention

GREATER CINCINNATI BEHAVIORAL HEALTH SERVICESØ Survey the area for potential weapons that the client could use in the physical action stage, i.e.,utensils taken from the kitchen area, broken glassØ Always have an escape route in mind. During any crisis management intervention, be aware ofthe safest exit route. Do not let a client position him or herself between you and the door.Ø Approach the individual slowly and calmly; speak in a slow and normal voice tone; call the personby nameØ Do not approach the individual from behind or directly head on; maintain a safe distance and havean escape route in mindØ If an external stimulus (e.g., another individual) is evident, other responders should assist inseparating or removing the stimulus, as possibleØ If individual is behaving in a verbally aggressive manner (e.g., shouting threats, cursing), firmlydirect the individual to stop the behavior. If individual begins to de-escalate, continue toprovide support and redirection. Help the individual to regain control.Ø If situation escalates to physical violence—or if that has already occurred—call the police at 911Ø Never position yourself between individuals who are fighting or appear ready to fight. In afirm voice, demand that the individuals stop immediately or that you will call the police.Other responders need to clear the area of bystanders. Do not attempt to physically interveneto separate two individuals who are fighting.Ø After a crisis, the staff person in charge of the facility should see that an incident report iscompletedH. Security Measures in GCB Facilities Monitoring entrance and movement in GCB facilities GCB’s goal is to provide a safe andsecure environment while still offering a warm and friendly atmosphere.Ø All staff and clients need to work t