You can read my bio online, I have been an occupational health nurse for about 30 years, prior to that I was a staff nurse, nurse midwife in the UK, my big passion was delivering babies, still the happiest job on earth I think, and I've also worked as a manager in healthcare. But as I started in industrial, occupational health in the industrial environment in Texas, I really got interested in industrial engineering and went back to grad school to get my degree in ergonomics and human factors. So my passion has been designing work systems so that we can prevent worker injury and error, and obviously in healthcare then that produces better outcomes for our patients. So you might think about, what is an occupational health nurse and an ergonomist talking about violence prevention? Well I think this falls under the umbrella of designing work systems to prevent injury and error. So I do want to ask you, how many of you have been victims of physical violence in a healthcare setting? Okay, a couple of you. I was at a session with about 200 folks, nurses and some physicians a few weeks ago, I hadn't even finished my question and pretty much everyone's hand went up, unfortunately. What about victims of verbal violence in a healthcare setting? A few more of you, right? Let's just keep it to that verbal level, hopefully. Obviously a growing and very worrying trend. My last question to know a little bit more about you is, who is actually a physician that's treating healthcare workers with occupational injury or supervises treatment? So some of you, great, because I do want to talk to that as well. So, here are my disclosures. I have no financial interests or relationships to disclose. And photographs that we're going to see today are stock images and the video is in the public domain. So we're going to talk a little bit about the scope of this issue in healthcare. Now I realize you're from different environments, not everyone is affiliated with acute care. So, you know, take whatever I'm telling you today about programs, culture, the scope of the issue, the cost of the issue to our patients, healthcare organizations and staff, and scale this for your facility. And I'm around afterwards if anyone has specific questions, because I'm going to talk about a program approach that seems sometimes overwhelming, but we can scale this to the size of facility. What we have to remember with this topic is that we don't know a lot. We really don't know what combination of interventions will prevent and control violence in healthcare. And I'm using the term control because we can't prevent all violence, and we'll get to that a little later. But we do have to control and mitigate the severity or outcomes. We're still learning, but we don't have 15 years to wait for the research. Unlike, I remember the days when we started coming out with hearing protection, I've been around that long, blood-borne pathogen standards. You know, we had 20 years of prior research to support that before we had laws and regulation. We don't have that time in healthcare right now because this is such a serious issue. I hope you agree with that. So what I've done at the end of this PowerPoint, there's a lot of different resources for you. I like to put a lot of information on slides, we're not going to read all of them. But I've also provided a handout with a lot of reference material that's been updated through this month. And I'm going to talk to you about some of the project that we did in Oregon between 2015 and 2017 with five hospitals. It was a joint effort between hospital association and unions, and we really wanted to know what does a workplace violence prevention program look like. So I'm going to refer to that a little bit as we go through today. And as a result of this, we have developed a toolkit that's in the public domain for non-commercial use that's part of your resources. So just if I say the toolkit, that's what I'm referring to. Now, this is a depressing topic for a Sunday morning. I'm sorry, guys. So let's start off with something a little lighter. I'm from Boring, Oregon, and we're partnered with Dullin, Scotland. This is the trivia you wanted to know today, right? 89 people live in Dullin, Scotland, and then I was in Australia just before COVID and the Shire of Bland wanted to join in as well. So there you go. August 9th every year, you're welcome to come to Boring. The state declared it the Boring and Dull Day in Oregon. There wasn't a lot to do in the legislature that day, so we now have a state regulation. Boring and Dull Day, August 9th every year. We have a party, lots of beer and ice cream, so you're welcome to come, and a few bagpipers. Okay, so I'm going to show you a couple of very brief videos that kind of set the stage for what we're talking about this morning. They are reenactments of violence, so I hope they're not too disturbing for you. I chose the ones that were a little bit more on the mild side, so let's see if this works. The first one is going to be in an emergency room. The second one is going to be really a synopsis of the aggression we're seeing in the public right now, not just in health care, but in other workplaces. So let's see. Sarah, can you hear me? Sarah, wake up! It's okay, I'm here. It's okay, I'm here. So you're going to have to wait. I'm not going anywhere, I'm staying here. She's okay. We're looking up. I'm just waiting for you. I'm not going anywhere, I'm staying here, okay? Don't hurt her, Kiernan! Dave, stop. She's just trying to help me. Assault isn't part of their job. It's a crime. Authorised by the Queensland Government, Brisbane. Let me see if I can get to the next one here. I've been waiting for ages. What the hell is going on? Come on. What's the issue? Leave! Idiot. I didn't even ask for that. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I'm sorry. No, no, no, no, no. What the hell are you... Sorry. You know you can't be here. What do you mean I can't be here? These were obviously shot not in the US. Did you notice the accent? They're from Down Under. Right? G'day. These were made in 2018. Several of their provinces in Australia, Canada's done the same, other countries have. We felt that we needed to tell the public to stop assaulting healthcare workers and others in other industries. This is prior to COVID. Obviously things have got a lot worse since then. What's the difference between... This is a global problem in healthcare. It's not unique to the US. What's the difference between the US and all these other Western countries that are dealing with violence in healthcare? Guns. Unfortunately, we take it to another level. So because of the access to firearms, and I don't know about you, but on the West Coast, we haven't seen an increased incident of active shooter. I'll get back to that later. But we are seeing more gun violence around our urban hospitals, which then causes us to lock down and have to deal with these events because of gang violence and access to guns. So, you know, I would love to see a kind of public awareness campaign made in the US. And I have talked to some large systems about doing this. We'll see. But should we accept this kind of behavior in healthcare, whether it's your office, your practice, or a hospital, or long-term care? We would all like to say zero tolerance. But the challenge we have in the US is we have a duty to care if it's for emergency care. And when I've been fortunate enough to teach this topic around the country in different states, the hospital leadership will tell me it's all about patient experience, especially post-COVID, because we need the income, and accreditation. So if we're going to turn someone away because they're aggressive or violent, we've really got to think this through and what's the impact on accreditation. So we're in a jam right now. I think we need to be far stricter about this. We've had enough. I know as a nurse, having worked through COVID with my colleagues and physicians, we've had enough. But I don't know. I'm not quite sure where we're going. We'll talk about legislation a little later. And we're all finding our way through this topic and really deciding what's going to work best and how to control this issue. So I want to start very quickly before I go into a few brief stats about defining violence and why that's important. I'm sure you all know how to define violence. This is the OSHA definition. It's very broad. It's verbal, physical violence perpetrated by our patients, visitors, co-workers, and so on. However, how many of you are aware that OSHA is now pushing forward a standard for all healthcare industry in the U.S.? And they've just finished their hearings with the smaller business entities in healthcare. Unfortunately, right now, and I am in contact with OSHA about this, their definition of violence is going to be patient violence only, so type 2 violence only, and physical assault. I think that's a challenge because when we're looking at these programs, we have to define all levels of violence, all types of violence. We have such underreporting. Fifty to 90% of violence is underreported in healthcare. You need a clear definition as a foundation of your program so that staff know what violence is clearly. It has to be communicated so they report it. The other side of this definition, for those of us particularly who are nurses, if my patient, I work with pediatric patients and some of our teenagers are brain injured, very difficult to know what the triggers are for violence. They don't mean to try and swipe at me as I'm trying to ambulate them safely. And I don't always know what those triggers are. So if they do hit me, they didn't mean it. You know, our elderly with dementia, Alzheimer's, they don't mean to hurt us. Nurses are reluctant to report particularly if it's not intentional violence. And they're also worried about that the patient may be criminalized if charges were brought against them. So we really have to be clear to all staff that this is intentional and non-intentional violence. And actually in Oregon, we've had a violence prevention law since 2007. It is only for intentional violence because we got bogged down in criminal law. And I can tell you it's not been very effective. I'll get back to how effective laws are in a little bit. With our definitions of violence, we need one definition so we're all on the same page. CMS really focus on patient violence. The Joint Commission have a broader definition. And then we have state laws for workplace violence and they're all variable. So California, Nevada, Washington, and Oregon, for example, all have different violence prevention laws and their definitions are different. So this is pretty confusing. Especially when you're trying to design an effective program and get your staff to report. So this is the definition from Joint Commission. I'm sure you're aware that this standard became effective January last year. I was on the technical expert group that helped guide development of this standard. We'll touch base on that when we talk about legislation in a second. But again, this is a very broad definition. It's verbal, physical violence perpetrated by anyone. This is what I think our program should be based on. And then you're probably familiar with these four levels of violence. So Type 1 is where our perpetrator has no relationship to the employer. Type 2 is our customer or client, i.e., our patients, visitors, family members. Type 3 is that repeated health-harming mistreatment by a co-worker. So it can be lateral or vertical bullying or lateral violence. And Type 4 is domestic, for example, domestic violence where the perpetrator has a relationship with an employee at an employer's work site. When we talk about active shooter, which we have to address and be prepared for in health care in all environments, unfortunately active shooter can fall in any of these categories. So my concern with just focusing on patient violence is that we now know there's a relationship between Type 2 and Type 3 violence. Where bullying is allowed to thrive, we have more patient violence. So we really have to look at violence with a bigger lens. And when we're developing our programs or enhancing our existing programs, we have to address all of these levels or sources of violence. So I don't want to throw too many statistics out there, but here's a few for you. That's why I have my notes this morning, so a little early on a Sunday to remember numbers. This is from the Bureau of Labor Statistics. This is a graph. The orange bar is the increase in violence, intentional violence, in private health care in the U.S. since 2011. So you can see there's been a fairly dramatic increase. And again, this is the tip of the iceberg. This is just intentional violence with days away from work. Obviously, when we compare that to other industries, we have a huge concern. When we're looking at health care and social assistance together, psychiatric behavioral health facilities are going to have higher levels of intentional, non-intentional violence, followed by long-term care, and then our acute care medical surgical environment. So just to give you an idea of that dramatic increase, most of the violence reported is hitting, beating, shoving types of episodes, resulting in bruising, soreness, strains and sprains, and pain. And most of the victims are female, which is not surprising. And I'm just going to say something before COVID that struck me is the increase in violence in our educational institutions as well. They have seen a very dramatic increase in violence just prior to COVID. Now, that's leveled off, but it's starting to increase again. So we're not the only industry where we have, unfortunately, this concern. So what happened during the pandemic? I'm just going to throw these up here for you. You probably know there was a dramatic increase in injuries with days away from work in acute care, long-term care to nurses and CNAs between 2019 and 2020. Most of that was related to exposure to disease, i.e., COVID. But what we don't talk about was the dramatic increase in violence and muscular skeletal disorders associated with manual patient handling to nurses and aides in those environments. What's interesting now is that the Bureau of Labor Statistics is no longer reporting case rates every year or descriptions of cases such as intentional, non-intentional violence by persons or other people. We have to wait until November this year to get the updated data for 2021 and 2022, unfortunately. But from my practice, in the last two years, I've seen a decline in injury reporting, or I'm going to say a decline in injuries in health care, acute care, to lower levels, lower than we saw in the pre-COVID era. And I'm wondering why we're not seeing those injuries. And I have to wonder if it's to do with the traveling staff and temporary staff that we're now hiring in the acute care environment. I don't know what you guys think, but there's something a little odd going on with the data. So we'll have to see what the BLS come out with towards the end of the year and see if we see a dramatic drop in injuries, because I think it's going to be kind of a false sense of security there. So just to give you an idea of why nurses thought the violence increased during COVID, this is a study from Byron et al in 2021. In the first half of the year, they asked the ICU nurses, why are you seeing an increase in violence? And they put this down to oxygen deprivation due to COVID in their patient population. But in the medical surgical units, they said that the violence was related to political issues and social issues, such as asking about vaccination status, mask wearing, and restricted visiting hours, sadly. The American Nurses Foundation have conducted several surveys throughout COVID. This was published in November last year, and 53% of nurses reported increase in verbal abuse since the pandemic began. But they also backed up the Byron study and said that they felt that there wasn't a reporting mechanism for violence in acute care. They did not feel supported by their employer organization, and 84% said they were stressed or dealing with burnout and don't feel safe at work. Now, I'm going to produce a lot of stats around nursing today, partly because that's one of the biggest populations that's been researched. Doctors behind that, physicians behind that, but for our other workers, such as MAs and CNAs, we don't have a lot of data, unfortunately. So, OSHA has recently updated this five times to nearly six times, as I was looking at the SBREFA data with the recent hearings. Nearly six times more likely to be injured with days away from work in health care and social assistance than other industries, no surprise there. But when we look at the location of violence, the obvious locations are the emergency room behavioral health units or freestanding units. But we also saw in our project in Oregon, it occurs in the ICU, medical surgical units, pediatrics, and obviously we have those higher rates in long-term care. When we look at professions that are impacted by violence, Press Ganey released this data last year. Two nurses an hour assaulted in U.S. hospitals. This was a survey of over 480 hospitals. I was catching up with my notes here. That equated to about 57 assaults per day and over 5,000 per quarter. We've seen similar numbers with physicians, not quite as high as that, when the American College of Emergency Physicians have surveyed physicians. But what we don't know is about other professions. EMS workers, home health care workers, the violence occurring in outpatient settings, we don't have a lot of accurate data. There's one or two studies. So we know more about acute care. We know more about nurses and physicians. A little bit more about CNAs, psychiatric aides being vulnerable, but not much else. Our perpetrators are mostly patients, usually male, but in the labor and delivery environment in pediatrics, they found it was mostly female. And we have mostly female perpetrators. This is the Press Ganey study. And then, as I said earlier, we have a huge issue with underreporting and also inaccuracies when we look at the OSHA 300 log. When I look at the employer's 300 log, very few of them are coded. They have the source of injury coded well on the log. So whether that's violence, musculoskeletal disorders, and what was the underlying concern for the MSD, this data is not well kept overall. One point I wanted to make about bullying, because we are going to get back to the type 3 violence, is that 90% of new graduate nurses report being bullied. There's a disturbing study that just was published in the last couple of months around nursing students and sexual harassment and assault while they're nursing students on clinical rotation. I'll get back to that topic. I told you it was depressing, right? It really is. It really is depressing for a Sunday morning. So sexual harassment and abuse. We don't know. I think this is something we haven't talked about in healthcare, in all areas of healthcare globally. There's just one meta-analysis I'm showing the data from here. In this analysis, they looked at harassment in healthcare worldwide. There was a range of 10 to 87%. When we did our surveys in Oregon, so when we looked at injury data at our five hospitals in Oregon, the injury data didn't tell us anything about workplace violence. It just was insufficient. We didn't know why violence was occurring, who the perpetrator was, what the cause was. So we had to survey staff. We had over 1,400 responses at four hospitals. At one hospital, and this was a critical access hospital, 10% of staff reported being sexually assaulted by a patient since they'd been at that hospital. We were astounded. We had no idea. And as I'm talking to nurses and aides now, because I do work at the bedside in another capacity at a level one trauma in Portland, and I do a lot of training with staff, I ask them about this. And it's alive and well, unfortunately. We have to address this within the scope of our violence prevention programs. Again, the American College of Emergency Room Physicians did a poll of 3,500 physicians in 2018. 96% of females and 80% of males said that they had endured inappropriate remarks and unwanted advances by patients and visitors. And this is prior to COVID, so I haven't seen any data since then. So if you're treating a health care worker that's a victim of violence, our hot topic right now is trauma-informed care. We've got to know about the patient's past, their trauma, so it informs us about why they may be aggressive. But I want you to think about the health care worker, because I've worked with a number of staff who have been sexually assaulted or abused as a child or had similar types of trauma. And when they experience even verbal abuse at work, they're traumatized again, and all those memories come back, especially if it hasn't been dealt with. So I'd like to think of trauma-informed care for our injured workers as well. I think that's just as important. And then the last depressing statistic, active shooter. We're not here to talk about this in detail, so I'm just gonna throw all the stats up for you. The incident hasn't really increased. I know of six last year in hospitals, but if you look at statistical trends over a decade, there hasn't been a significant increase, but again, it's the gun violence around our healthcare facilities that's the issue. But a couple of things to think about. Up to 10% of the perpetrators got their guns off a policeman or security once they entered the facility. So I have this conversation a lot with hospitals about hiring security. Nurses want lots of security. They think that's the solution to violence. It's part of the solution, but it's not the whole solution. And could we give them guns or tasers? Well, we'll get back to state law about that a little later. I was co-presenting with an FBI agent from LA, so don't mess with me. I know people in the FBI, right? That's what I like to tell my husband. I have to remind him occasionally. But this was prior to COVID, and he's trained for active shooter scenarios. That's what he responds to. He said, if we go into a facility, hospital or otherwise, and we see anyone with a gun, we assume they're the perpetrator, we shoot to kill. So, and that has happened to security in non-healthcare environments in the last couple of years. So we really have to be cautious about how we use security in this field, and if we're gonna arm them or not. I work at a hospital where we have full police force that are armed with tasers and guns. We're the only ones in Oregon. But they have special training, and we have very specialized and strict laws in Oregon about use of security, especially if they're armed. So what's the full cost of workplace violence in healthcare very quickly here? The reason I'm going to talk about this, I'm sure you're familiar with this iceberg picture, is because when I work with senior leadership and C-suite, I realize they have no idea what the cost of healthcare worker injury is to patients, patient outcome, and their bottom line profit margins. They rarely get data presented in this way. They get the work calm data. They might get injury numbers, rarely rates, because a lot of hospitals don't calculate incident injury rates, unfortunately. And Liberty Mutual back in 2017 reported that if we took care of slips, trips, and falls, workplace violence, musculoskeletal disorders in healthcare, we'd address nearly 80% of lost time injuries and 80% of workers' comp costs. So we really have to look at all those three facets. So the top of the iceberg, as you're probably very familiar with, is our workers' comp costs, medical costs, time away from work for occupational injuries related to violence in this case. And then we have indirect costs to replace that nurse or CNA who is on modified duty or lost time. Now, in the hospital that I'm working at, where I run the Ergonomics Safe Patient Handling Program, we actually calculate those indirect costs for every nurse, aide, anyone that is away from work or on modified duty related to patient handling injuries. And these costs are at least double the direct costs. So that's great. That might be enough to justify a program. It's not enough to manage a safety program because of underreporting. So unfortunately, with workplace violence, as I just mentioned in Oregon, we have to get under the iceberg and look at indirect or operational losses and costs. And these can be hard to capture. So I usually advise hospitals and other systems to look at one or two of these and measure it well. So we know that with exposure to violence, particularly bullying, we have increased sick leave and intention to leave. So that present tears and the stress, PTSD, which is particularly associated with bullying or type three violence, burnout, presenteeism, contributes to sick leave and staff turnover, which as we know is a huge issue right now across the continuum. It also contributes to reduced quality care or service. And I don't know how many of you are familiar with ECRI, the Research Quality Institute, but number two as a concern for patient safety in this country this year is verbal and physical violence against healthcare workers. And the number 10 concern that's gonna impact patient safety is actually missed nursing care. Does anyone know what I mean by missed nursing care? So this is a passion of mine. We've been studying it for about 10 years. James Reason, you know, the father of the Swiss cheese model when we're looking at error and mitigating and improving patient safety, said that missed nursing care or where we omit total or partial care is one of the biggest threats to patient safety. So missed nursing care occurs worldwide by nurses and CNAs. There's many reasons why we miss or omit care. A lot of them are to do with staffing, teamwork, communication, staff mix, not having the right lift resources, for example. And the outcomes to patients are varied, but most of the care that we miss is actually activities of daily living and medication administration. You all know the consequences of not doing that correctly and completing it. Two of the tasks that are missed are repositioning in bed, ambulating from the bed. And if we don't do that early mobility, we know we have increased falls, pressure injuries, length of stay and early immortality in our patients. And of course, any hospital-acquired pressure injury and so on is non-compensable for the healthcare organization. So this has been tied, bullying particularly has been tied with missed nursing care and omitting care. And when I talk to nurses anecdotally over the last 10 years, I've talked to hundreds of nurses and aides. They tell me at the end of a 12 hour shift, if my patient is combative, aggressive and or a patient of size or is acutely ill and I just can't find the staff to go move them or finish that treatment or care, or I don't have the right resources, I'm just going to omit it. This is a very pervasive issue that we really have to address. And it has a direct link to patient outcomes and error. The last one I'm just going to mention on error here is PTSD that's associated with type three or bullying is also associated with cognitive tunneling and cognitive error, which leads to clinical and medical error in nursing. And this has been fairly well researched. And when nurses are asked, well, why would bullying lead to PTSD and error versus patient violence? They'll tell you the patients didn't mean it. It wasn't intentional, but this is my coworker. They intentionally were violent, verbally nasty over a period of time or whatever was going on. And this causes more stress and harm than actual physical violence from patients. And then we have the increased insurance costs, property damage, litigation, regulatory non-compliance, especially with CMS. CMS got a pretty big stick. Who's got the biggest stick for hospitals? OSHA or CMS, what do you think? CMS and the fire marshal, right? In Oregon, the two of them walk around together, they can shut down your facility. So we pay attention when they come around. After that, I think it's DNV and joint commission, your accrediting agencies, but don't tell OSHA this. Sorry if there's anyone from OSHA, but here. They're aware of this. So we have some significant impacts, indirect impact from workplace violence that we have to try and capture if we're gonna really address this successfully. Then we overlay the pandemic. I don't have to read statistics about turnover in all staffing areas right now is of extreme concern. I'm dealing with training staff who were maybe on site for a day, three days, three weeks, three months. How do you keep up with workplace violence prevention training or any other safety training when we have this constant rotation of staff right now in all environments? And then I want to add, because I also work in that MSD world. If you overlay the cost of musculoskeletal disorders, which when I've looked at 25 facilities in the Northwest and I've looked at five years of their work comp data, the number one cost for healthcare organizations is not violence. It's back injuries from manual patient handling. It's still the leading cause of injury to healthcare workers in this country. And it is related to this topic because if we're manually handling patients, we know that we have more violence. When we use equipment, we have more control and distance and there's research to support that. So if we add the MSD costs in this, we have a big problem. This is not a great way to run a business. The cost to employees here, no surprise, which is why violence is taking our focus. Of course, the death, the psychological, physical injury. I've talked about PTSD already and unfortunately, suicide. And I don't know if most of you know, as physicians, you had double the rate of suicide in the general population prior to COVID. That has significantly increased in COVID. It also has in nurses as well. We just had a testimony at our state legislature about nurses have been committing suicide in Oregon through burnout and the COVID, long haul COVID for a myriad of reasons we won't get into. It's a very serious issue. The one thing I also want to note with this cost is, did any of you get training on workplace violence prevention in medical school? So we, you know, healthcare students across the continuum in this country get training on blood-borne pathogens, PPE. That's it. It's not on the exams. We're fighting to get safe patient handling on the exams because unless it's on the licensing exam for nurses, we can't get it taught in schools. But I'd like occupational health and safety in every school in this country for healthcare students, whether it's for medical students, CNAs, and so on. But we have a huge gap here. So if any of you got any influence, could you go forth and change that for me, please? So, and then lastly, the costs for healthcare industries. I'm not going to read this data. We really don't know. This is costing billions a year. And the question then when I talk to C-suite is, how much reimbursement do you have to make to offset the costs of violence alone? Now add the pandemic and add MSDs and slips, trips, and falls, and you're going to have to make millions more in profit to be able to stay in business. This is not a good way to run a business. So let's just switch to guidelines and standards just to give you a very quick overview here. And I say, this is a very broad topic. So I hope there's something for everyone as I'm going through. Obviously, we do not have federal legislation for workplace violence prevention right now. So we've got the general duty clause. Whether we agree that's very effective or not, we could have a whole debate about that. We have legislation that was introduced two years ago. AECOM supported it. There was a bill that passes at the house and now went to the Senate and it sat in committee for 18 months. And to be honest, from what I hear from my lobbyist colleagues at ANA, it's not going anywhere. So this is partly why OSHA is focused on infectious disease and workplace violence right now. But as I said earlier, the OSHA standards as it's proposed, if you're not involved with this, please go take a look at it. And when it's appropriate, provide comment and feedback. I hope your organization does as well. I do have some concerns with what they're asking employers to do, partly because we can't be too prescriptive because we don't have all the answers for this right now. But they are on a fast track to pass some kind of legislation in this current administration. That's what I've heard. So if you're interested in that, definitely kind of provide that comment and from your perspective. We have state laws where we have OSHA state level. We have a lot of state laws that are all different. Are they effective? No one really knows. We have 40 states with assault felony laws. I know that the hospital administration asked the Department of Justice last year to make it a felony to assault healthcare workers as they did with airline employees. Well, nothing's happened. But New York did an extensive study of their law and their felony assault law. And they found that neither were effective. So we can debate all day whether we need legislation, how effective it is. It might set that bottom parameter for a healthcare organization. It kind of sets a priority. I have to do something about this. Hopefully they're already doing this with CMS and Joint Commission. But just some things to think about. We have the accreditation entities. We'll talk about Joint Commission in a minute, but DNV and CARF for long-term care do not have specific violence prevention standards, but they will look, they use the ISO quality approach when they're looking at accrediting facilities. They will look at worker safety programs and look at if you have an ongoing process to protect workers as it relates to patient safety. So we may see more with those agencies as we go forward with workplace violence prevention. And then lastly, if you weren't aware of this, and if you're involved in advising clients or developing these programs, you have to know about the laws in each state and each city around the use of security personnel. We learned the hard way in Oregon who we shouldn't and should hire. And we have pretty prescriptive laws on training for security personnel in healthcare that came about after our project because we were hiring nightclub bouncers and mall security, and they're not always appropriate in healthcare. We usually get them on board. We go through all the OCH health vaccinations, immunizations, and they're there for a month. And my OCH health colleagues tell me they then leave because it's not for them. So we don't have enough security to man every unit in every hospital or other environments in this country. So just be aware of those laws and standards. It's hugely variable in every state and whether they can carry weapons or not. So in the joint commission, how many of you are aware of this standard from last year or may impact your practice? This is a very non-prescriptive programmatic approach, which I like. It talks about identifying hazards for violence, addressing them, education and training, policy and procedure, and a continuous improvement using a continuous improvement model. And you have to have a point person to run this program with a multidisciplinary team. And I totally agree with this. But they didn't get too prescriptive. So I think this is definitely doable. It gets it on the healthcare. For hospitals and critical access hospitals, it gets it on their radar if they're accredited by joint commission. And so, you know, I'm kind of alluded a little bit to culture here. I'm watching my time because obviously I always have a lot to say as my husband says. So let's talk a little bit about culture and why violence occurs. And again, this is a huge topic, but this is how I like to kind of give you a background in this. And it relates to what OSHA and NIOSH have published as well. I like to look at this from the point of view of what can the employer control and not control. And I don't believe, as I said earlier, we can prevent all violence from occurring in healthcare because our patients arrive in the emergency room or some of your clinics, they're already escalated. Maybe they're having a behavioral health crisis, they're intoxicated. I mean, in Oregon, we dealt with the police dumping intoxicated members of the public at the ED on a Saturday night in our rural hospitals. We've addressed that now, but when we started the program, it was quite eye-opening. So when we would look at the patient behavioral factors, we have so many patients are violent because of their medical condition, they're impaired in some way, they're demanding to leave, they've lost the control, they feel powerless. They may have a poor experience. We know poor patient experience is related to increased rates of violence. They may be, their aggression is due to physical transfers. I just mentioned pain, needles, and so on, or situational events. And I see a lot of violence related to having to move, reposition patients who are in restraints, particularly related to ICU delirium. And we obviously saw quite a bit of this during COVID. So again, a big topic, there's a lot of good information out there that I've provided if you're interested in this. We have to really focus as employers or healthcare organizations on how do we assess, know that our patient's escalating, look at the root cause of violence, and then address it so that we can mitigate the severity. And that's about the best we can do in a lot of cases. Oh, and I want to mention history of violence. There's a lot in the literature about if our patients have a history of violence, they're going to be more prone to violence in the future. We don't know that. The jury's out on that one. The research is kind of 50-50. It is an indicator. It's often flagged in your like Epic, your electronic health record, but it shouldn't be the only thing we hang our hat on. We've got to do more than that to save that patient's escalating. It might just be a red flag, but it's not always a predictor. I work with parents of dying children in pediatrics, and believe me, they can get really aggressive and upset, and I totally get why. But are they going to do that in the future? Maybe, maybe not. So you really got to look at context here and the situation. The things that the employers can control, organizational risk factors and environmental risk factors. So we know understaffing contributes to violence, rotating shifts, night shift, working alone. You know, there's a lot of different factors that have been well-published. So can we control that? Absolutely, by work process design. This is the employer's responsibility. We can also control the design of the work environment. So where we have furniture that can be used as weapons, we have poor lighting, noisy, crowded waiting rooms, poor egress situations, or not open visibility when we're treating patients. All of these can be impacted by design, and we can be more proactive. The fourth bucket then is our social and economic risk factors. These are things, again, we can't directly control. But as I just told you about our local law enforcement leaving our intoxicated public at the ED on a Saturday night, we then worked with sheriff, and the sheriff and the local police actually weren't getting along at the time. It's different now. We worked with them, behavioral health providers in the community, and really had the hospital integrate into the community about how we were going to manage this situation. So there was a lot of good communication around when we bring a patient in that's intoxicated, having a behavioral health crisis, what do we know about triggers? How are we going to treat them? And the same when we're discharging them back to the community. And as you all know, behavioral health support in the rural communities particularly has declined over the last 10 years. So we treat our behavioral health patients in the ED. We let them go. There's no support for them. They come back. That's the revolving door syndrome. And we certainly have seen that a lot in Oregon, especially in our rural areas. Often our behavioral health patients sit in the ED with someone monitoring them for two or three days before we can get them to Portland for care because there's nothing in Eastern rural Oregon. I'm not going to read these. These are the joint commission kind of root causes of violence from their Sentinel event database. They've divided these root causes into human factors, which is failure of supervision, staffing levels, complacency, leadership. This is the culture we'll get into. Communication failures and lack of patient assessment for risk of violence. And I want to get back to that with prevention in a second. And then just to circle back to why we have to address all types of violence, because we know that if we have a poor organizational climate of safety, we have more type two, type three violence. And there's some early research in behavioral health environments that say where we allow bullying to exist, we have more patient violence. And bullying exists when we look at poor leadership, where we have laissez-faire leadership, very autocratic leadership, where we have psychosocial demands such as low perceived control of the job, overloading with workload, nursing competency. All these have been related to type three where we're working in environments and related to type three violence. And of course there is a relationship between bullying and musculoskeletal disorders and psychosocial risk factors as well. So this is where I get back to this. We don't want to silo violence. We really need to look at that interrelationship with other occupational issues or hazards. So some of the barriers to successful programs. Why am I putting this up here? Because if you don't assess your culture and readiness for change before we start any patient or worker safety program, it's not going to be successful. And I've just learned this over the years. It's in the literature. OSHA talks about it. And some of those factors that we need to look about, we need to look at is, you know, the way we do work around here. What is that culture for that particular organization? And our leaders really create and allow the culture. So when I talk about assessing culture, there are some resources in the toolkit, a gap analysis tool that has an assessment piece in there. AHRQ have some assessment of culture pieces and I provided some resources for you. But when we're assessing organizational culture to see if we're going to have a successful program and if it's going to stick or sustainable, we have to look at the C-suite culture. We have to look at the unit culture, the management department level. And we've got to look at the culture between professions. So nurses and rehab staff, nurses and physicians, what does that look like? Do they work together well as a team or is there friction, operational friction somewhere? So assessing that leadership style really can tell you a lot about what can I address in workplace violence? And if there isn't the support there for changing culture and the resources, you may just have to look at the high hazard risks and try and address them. And you're not going to have a program that's sustainable. And until we change that culture. The focus on patient safety only, I'll get back to that in a second, are competing demands. Obviously, I don't have to explain this. It's worse tha pherthynas. Ddifrif systemau, ymdrech i'r gwasanaethau, lle rydyn ni'n edrych ar ymdrechu ar ymddygiad ac nid eisoes yn edrych ar sut mae'n gysylltiedig ag ddysgwyr sgiliaid musgwyr neu'n ymddygiad amlwg yn ein poblogaeth patient. Ac yna'r broblemau sy'n cael eu datgoli, lle rydyn ni'n ymddygiad â'r weithwyr. A oes unrhyw un yn ei weld hwnnw yn eu prasau pan mae'r weithwyr yn cael ymddygiad ar unrhyw un? Nid ydyn ni'n edrych ar ymddygiad â'r weithwyr ac yn ymddygiad â nhw fel rydyn ni'n ei wneud ar ddiogelwch patient, diogelwch adfer. Felly os yw'r gweithwyr yn y stryd gyda'r patient ac mae'r patient yn ymddygiad â'r gweithwyr, mae'r gweithwyr yn cael ymddygiad am nad ysgolio'r patient, nid ysgrifennu i'r hyfforddiant, yn hytrach na edrych ar y system lle nid oedden nhw'n darparu'r ymddygiad iawn ac nid oedden nhw'n darparu'r hyfforddiant i wneud yn ddiogel i'r ysgol sy'n golygu am y patient. Felly, eto, ddifrifio'r dynion. Ac yna, rydych chi'n gwybod, ynglyn â hyn, yw nad ydych chi'n deall y cost cyffredinol o hyfforddiant. Rydw i wedi dweud hynny o'r blaen. Y sgôp gyffredinol o'r rhaglen hwn. Felly pan ysgrifennwydon ni hyfforddiant ym mhob ysgol yng Nghymru, rydyn ni wedi ysgrifennu i'r holl staff. Felly rydyn ni'n ddod o hyd i hyfforddiant a chyfrannu a'r adnoddau ariannol, roedden nhw'n cael ymddygiadau o'r ffôn, o'r llythyrau. Mae hynny'n ddod o hyd i Covid hefyd. Felly rydyn ni'n cael gweithwyr eraill sy'n ymddygiad ag ymddygiad mewn fforddau gwahanol a dydyn ni ddim yn gallu ei gofio ac yn rhaid i ni ymddiriedu. Ac yna ymddygiadau staff. Y unig ffordd rydw i'n gwybod i'w ymddiriedu o flynyddoedd o wneud rhaglenau ergonomeg yw bod gennych ymddygiad mwyfasodol sy'n cael ei ysgrifennu yn y diwydiant, fel y byddwn ni'n cael rhaglen pan fydd un aelod yn mynd, ac nid yw'n mynd gyda'r un person sy'n mynd o'r sefydliad. Mwy eisiau i'w ddweud na'i wneud, os oes unrhyw un ohonoch chi wedi rhoi'r rhaglenau hynny i le. Pan ddweudwn am bariau i'r adroddiad, mae'r bariau'n gyffredin yn adroddiad y llyfrgell. Rydyn ni'n troi'r tri gyda'r un yng Nghymru pan ysgrifennwyd staff. Os nad oes gen i rhaglen ffysig, dydw i ddim yn adroddi adroddiad. Os nad yw'r patient yn ei golygu, dydw i ddim yn sylweddoli, dydw i ddim yn adroddi'r rhaglen. A oes unrhyw un arall yn adroddi'r rhaglen? Rhai o'r pethau eraill. Nid oes polisi glir ar adroddiad. Broses adroddiad cyfathrebu. Mae'n mynd i mi 30 munud trwy 10 ffyrdd ar y cyfrifiad i adroddi'r broblem hwn. Nid ydyn ni'n mynd i'w wneud, dydych chi'n nodi'ch golygau. Os allwn ni wella hynny, byddwn ni'n wella hyn ar gyfer pob rhaglen ddiogel. Fears of retaliation internally and in our rural communities we found externally. A nurse wanted to file charges against a patient who assaulted her in eastern Oregon. The family knew her and threatened her. The family of the patient because everyone knows everyone else. So we have to consider that as well. Poor management response, poor response by the co-workers, suck it up, violence is part of the job, just get on with it. I've heard that over and over again in all environments, not just acute care. And again, if management don't respond when you file an incident and there's no visible preventative action to prevent it from happening again, no communication, it's going to drive under reporting underground. And then we also have a problem with law enforcement and the district attorneys. They don't know what to do with these cases. And in a lot of incidents, in a lot of cases, our patients are not mentally competent to stand trial. But we in Oregon and Washington, we've dealt with this. They really don't know what to do if we're going to file charges against a patient that's assaulted a physician or a nurse. And you're often on your own as that worker. The hospital's not going to do this for you. We've actually tried to pass that into legislation in Oregon, but we haven't been successful. The hospitals would like to do more, but that's not been passed into law yet. So is it just OK to come to work and be hurt, be injured? I think that's what we think in health care. When I came to health care from industry, I was blown away that we're 20 years behind general industry with worker safety, and we expect to be hurt on the job. This is not OK. And I can say that is also fairly unique to the US. I hate to say that, that things are a little different in other countries. So we've got a lot of work to do. I'm not going to read this for the sake of time, but because we don't have research into this topic, a lot of research, these are some of the areas we need to know more about. One of my passions is assessment of patients using user friendly tools that take about 10 minutes for their risk of violence that can be used by any staff member, not just nurses and physicians. There are tools out there. We have a validated tool in the toolkit. The Canadians have done some great work around this, but I'm not seeing this proactive approach in health care. And we really need to move to that. So I just thought, after all that depressing information, I'd show you some sunsets. I was going to do some funnies, but, you know, the copywriters, so I didn't do that today. But anyway, we've got a night. We've got some nice sunsets. We have some beautiful beaches on the West Coast. If you haven't been there, plug for tourism, come and spend some money in Oregon and Washington. So, OK, let's talk about prevention. I know I have about 15 minutes left here. What how are we going to really address preventing control violence? Well, we're going to need to look at the culture. And I'm just going to catch up with my notes here, because, again, I like to make sure I've got my my statistics are accurate. So we know that safety culture is directly linked to incidents of violence and a good safety culture for patient worker safety mitigates the type two and type three violence. There's some pretty good research around this in long term care and in acute care. We need to do some more work, but but that's kind of the bottom line. You're all familiar with high reliability organizations. So, you know, I like to about 10 years ago, we started looking at patient safety in the US. We weren't doing very well since that 1999 IOM report to Air is Human. We were kind of trying to figure out what how can we improve patient safety? We're not number one in the world. So we started looking at clinician burnout and incorporating health care worker safety. Covid, if there's a silver lining to this awful pandemic, has really shone a spotlight on worker physical and psychological well-being of workers worldwide. And if we take care of our workers, we have better patient outcomes because the data for patient outcomes in covid was pretty awful as well. And I like the work of Deming, Edward Deming, if you're familiar with him, my kind of father, a total quality movement in the US. He was a very savvy businessman. And in a nutshell, he took care of his workers. He engaged them. They were experts in their job. He gave them that joy and work, the passion for work. He increased quality, productivity and its profit margin. It's not that hard, I don't think. We need to do that with our health care workers because it benefits everybody. So if you're not familiar with this, the IHI worked with 27 organizations in 2020 and developed their new patient safety initiative in the US. And there's four foundational elements to this culture, leadership, governments, patient family engagement. And number three is workforce safety. Finally, we're starting to see that movement forward. Number four is a learning system as part of that high reliability tenants. They published their implementation guide last year in the National Academy of Medicine is doing the same. They have a similar initiative around workforce safety and clinician burnout right now. They also specifically both organizations call out that we have to address violence, patient handling, needle sticks, slips, trips and falls. But there's not a lot of meat around this. I have to say that for me and my colleagues who are on the ground level, the sharp end applying research to practice, we haven't been at the table. So I'd like to see a little bit more on how we actually do this. So if anybody's involved with those organizations, that's a call out to you because we'd like to be at the table for how when the rubber meets the road, how do we really implement these programs and make them stick and change that culture? There's some other organizations that are focused on this. How many of you've heard of joy and work from IHI? Oh, good. If you haven't seen this and all of these are in the public domain, please take a look at the joy and work, work, joy and work, work. It's based on Deming's work and they have some excellent tools, training tools about how to engage workers and take care of them. And there are some other things here if you're involved with the NIOSH Total Worker Health. So just some resources for you. So to wrap up, how do we address this issue? We have to try and prevent it. We're not doing a great job at that right now. We're tending to respond and hopefully control the severity or outcome of violence. I'd like to see more response based on the cause of violence, not a one size fits all. Let's just get security in there and deal with it because not all violence needs security. It needs a medical intervention and then the care and support for all the victims of violence. Those are witnessing it. And then that ongoing, continuous learning that we have to do. So very quickly, I'll talk about the components of what we think works right now, but we really don't know. And this is based on the OSHA approach. It will be familiar, but I've added in some program facets as well that I've learned work over the years. So our program foundation and management starts with management, commitment, leadership and employee engagement. You're all familiar with that. And I do want to just flash a couple of slides up in a minute on what that looks like. But where we have transformational leadership, clear communication, transparency, excellent communication with our staff. We empower managers and our caregivers. We tend to have those just cultures, high reliability organizations, better culture of patient worker safety. We these programs can be sustainable and they stick for a while and success and they're successful. And then that means ongoing engagement of employees. Written policies, though, and this gets back to what I said earlier about zero tolerance for violence. If we're going to have a zero tolerance policy and some hospitals want to do this, you need legal and risk at the table to say, OK, if we're going to do this, how do we deal with CMS? Because in Missouri a few years ago, CMS were going after hospitals that had developed these policies because they perceived it as not providing emergency care. So you really need to know what you're getting into as an organization and what's going to sit for that organization. But zero tolerance for all other forms of violence, including bullying, is absolutely fine. But it's a little difficult with this patient violence right now. And you can't write a policy till you know what the program is. What's the strategic and tactical plan? And then make sure it's well communicated and updated regularly. I like to add program management. You need a champion. I do this for musculoskeletal disorder programs, whatever the topic is. So this is usually the nursing executive for me who has direct line to C-suite, who is visible to the staff and has excellent communication skills. They support a program manager. And as we said earlier, joint commission requiring the programs to have an individual to organize them. And that person doesn't need to be an expert in violence prevention. Very few of them are. We don't have the expertise, but make sure in your multidisciplinary committee you have behavioral health experts in our small hospitals in Oregon. We even went out to the community and said, could you be part of our committee? We don't have internal help in our critical access hospitals, and they were willing to come and work with us. And then we have to have a program plan. What are we going to do? What's the scope of this program? And it's, you know, we have that strategic, tactical plan that we evaluate in an ongoing way and improve. Lastly, and I rarely see this in programs, we need a communications plan. Who are the stakeholders that are impacted by violence prevention? Or it could be any other safety topic. What do they need to know? When do they need to know it? How are we going to deliver it? Who's delivering it? And was it successful? And then again, this is ongoing. So this is helping with that culture change, getting people ready for change. And then it's a foundation for your education and training program. So multifaceted programs are much more effective than any single intervention. We know that in safety generally. And I know I'm watching my time here. I'm going to just put these up very quickly. This comes from the gap tool that I mentioned before. And it's the first part of the gap tool that I have all my committees look at. What is the culture at the unit level, organizational level? And these are some of the questions to ask. And again, this comes from evidence based, not something we made up. But we did add a few things from our project in Oregon as well. So do senior leaders know what workplace violence is? That's the first thing. Do they know the scope? Do they know what's going on in their own facility? So we start with that. Do they declare it a priority and do they back that up with visible support? So you can have the verbal declaration, but if there's no action, then employees see right through that. Is this aligned with patient quality and other safety plans? And then, you know, is there that clear policy that's communicated? Well, do you have ongoing resources, ongoing being the operative word here for everything that we need for these programs? These programs are not small. You can scale them to your facility, but there are a lot of different elements if you're going to be successful. Do they set clear safety goals and expectations? I know there's a lot on here. You have this in the handout, but again, what are the expectations of patients, visitors, roles and responsibilities for staff? And then do we recognize our frontline staff if they come up with suggestions? Are they recognized for their efforts? Employee participation is ongoing and it's in a lot of different facets of the program, but employees have a responsibility to report hazards, to attend training. And they also, in this context, need the responsibility to know if they're making the situation worse. So a lot of my programs, they have a code word, like they'll go up to an employee who's obviously escalating the patient. Things are not going well. And they'll say, Dr. Armstrong needs to see you. And that's their code word for you need to step out of this situation. So this again is part of that, that the response protocols. And they need to know how they're going to react to patient aggression. And is it going to trigger trauma for them? So there's some insight needed there as well. So there's lots of different ways we can get our employees participating in these programs. There should be nothing new to any of you. But then we get on to our hazard identification and assessment. Worker injuries are not, reporting is not enough to manage these programs because it's a lagging indicator. We have underreporting, miscoding. We found we had to survey workers. That was how we really found out what was going on in our facilities. And the survey is in the toolkit. It can be, it's been adapted by a lot of hospitals across the country. The other evaluation tool is the gap analysis. Where are we right now? Where do we want to go? And this is an evidence-based tool that looks at all facets of the program that you can have your committee review. And then lastly, we need to get onsite to do a safety security assessment. This is not security rounding. This is looking at onsite at the physical environment, risk for violence, the organizational culture, the patient population, engaging staff, what do they want to see fixed at their unit level and what needs to be addressed. And these tools we can use to evaluate these programs. And then we get into our controls. And unfortunately we can't substitute. If you know the hierarchy of controls, we can't substitute and eliminate in this world. And a lot of our controls are focused on work practice changes, which is tough because we have to supervise for those. We do know something about the evidence based on engineering controls. So closed circuit video surveillance, lighting, weighted furniture that can't be used as a weapon. There's evidence to support this can help prevent violence. We really don't know much about panic alarms. We have no data to say panic alarms prevent violence, but obviously they're an important tool. We just don't have the evidence. But if you're gonna have panic alarms, make sure they're accessible, salient, user-friendly, especially if you don't have a caregiver population that speaks English well or is a very diverse population. And then noise barriers and so on. So metal detectors are very prevalent right now and popular. But again, we have no data to say that they will prevent violence. So it's very much a sharing of best practices. Where we do have to hang on hat with these programs are the administrative work practice controls. We have to supervise for them. And what we have evidence for is effective incident reporting. If it's user-friendly, quick, it gathers enough information so you can be proactive and address the issue. If we identify patients and visitors at high risk for violence with a validated tool, there's something called the BROSET tool. I don't know if some of you are familiar with this. We use it in behavioral health. It's been adapted for acute care. We used it in our project and it was used very well in ICU, not just the emergency department. And we identify the patient at risk for violence in the next 24 hours. And then we have standardized protocols to response depending on the level of risk. We then have to look at communication and there's evidence to support that flagging the patient chart and communicating between caregivers can be a proactive approach. But a lot of hospitals are very hesitant to flag the employee's chart or their door because of stigmatization. So you really have to have a clear process on how you're gonna do this and if you're gonna keep the flag in that chart. In Washington, we have a database now. If you have a history of violence, that database is available to all hospitals. Nurses and doctors love it in the ED because they know if there's a history of violence, they know that before the patient comes in. But I think there's some ethical issues around that that we still haven't really worked our way through. And then behavioral health rapid response teams. There's good evidence to support that I've seen this in our hospitals in Oregon where we have like a medical response team. They get in there early before we have full escalation of that episode. They help support the staff, give them confidence in de-escalation skills. And they don't always have to be staffed by behavioral health experts. So in the toolkit, there's a lot of kind of pearls on how to set up a behavioral health rapid response team. There's many other interventions here, none of which have been really surveyed well or studied well, including how many security do you need in an emergency room? We really don't have the data. So our nurses in Oregon wanted laws passed that we have security in every department. Well, there's not enough security to go around in every hospital. So again, they're part of the solution, but you have to manage hiring security and their scope and their role very well. So just to give you some ideas of some of the things out there for controls. And then lastly, to finish up here, education and training. This concerns me a little bit with OSHA's proposed standard right now. They're proposing, I believe, at least a minimum of eight hours training for everyone that would be interfacing with a patient. They do talk about stratified training. So depending on if you're that behavioral health rapid response team, or you're a caregiver, or maybe you're the EVS staff, and you're gonna interact with that patient on occasion, you stratify that training. But I think you'd agree, if you went to two days of training, or listen to me for two days, you're not gonna remember everything I said, right? Stop laughing there in the front rows. And could you apply those skills that you learned to your patient population in your environment? And I would hesitate to say, no, you can't. So hospitals are spending thousands of dollars with external consultants who have great programs, don't get me wrong, but aren't even looking if they're customized for their facility and meet state law. So you gotta know there's knowledge, skills, and abilities, and design your training accordingly. What the evidence supports is online training for foundational information with classroom tabletop exercises with a multidisciplinary team, using case studies from your environment. But there's not a lot of good free training out there right now, and I'm gonna challenge OSHA and NIOSH to update what they've got and really help us with some training resources. And then ongoing program evaluation that is designing, you know, conducting environment care rounds that incorporate worker safety and patient safety goals, not just patient safety. And then looking at proactive design for remodels, new builds where we incorporate for violence prevention and ergonomics. And there's a lot of good resources out there that are free of charge from the Center of Healthcare Design around that. So I don't need to talk about the hierarchy of controls, but I just will point out training is down the bottom of the list. You can't train away this problem. PPEs are things like bike guards, face shields, bulletproof vests, if that's appropriate. We have those at the hospital I work at. But again, we have to supervise for all of these lower level interventions, and that can be a problem. And we've seen the safety world that when we've just intervened with work practice controls and safety programs and in ergonomics, injuries go down because there's emphasis on it. But after about 18 months to two years, they start creeping up again because there were no engineering controls. We didn't isolate the employees from the hazard. Just to point out on your handout, there are some outcome data. We don't have a lot, but there's some outcomes in our toolkit on the Joint Commission website, and the VA have done some excellent work in this area for you. There are some meta-analyses there. And then I've given you a lot of resources. This is the toolkit that was developed with our hospitals in Oregon. Again, it's in the public domain. We updated it again in 2020, and you've got many other resources that are supplemental to this. So please take a look at it if you're not familiar. And I'm going to skip through these. These, again, a variety of resources, hotline numbers for suicide prevention and some other resources for dementia care and so on, if they might be useful. And then I will just finish up with, for any program, whether it's patient safety, worker safety, have a plan, set goals, evaluate them often, use economic modeling to show ROI. Whether this is a law or not, you have to look at that cost justification. Start small, test and pilot, demonstrate successes. Don't reinvent the wheel. Use the resources that are out there. I see this all the time with hospitals. And then involve all of those stakeholders, plan for sustainability, engage your employees, and maintain that management support. Keep marketing, and then ultimately, treat patient and employee safety with equal emphasis. And I think I'm just about a little bit over. So thank you for staying, all of you. I appreciate your time and attention. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

workplace violence

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