Good afternoon. I'm Dr. Michael Hodgson. I'm the Chief Medical Officer at OSHA and the Director of the Office of Occupational Health and Nursing. For this group, it may be of interest that we hired two nurse practitioners in the last year, both certified and DNPs. So we've thought a lot about the scope of practice issues and see that within the nurse practitioner community, there are the same issues around levels of work independent of scope of practice that exist for occupational physicians. Are you a primary care practitioner who takes care of patients? Are you a, as it were, corporate or organizational director who is responsible for population care and policy development? And as a third level, do you sit somewhere in the federal policy world or state policy world? My interest in this topic, violence in healthcare, has been passively around since 1979 when someone attacked me with a knife in the emergency room of the Washington DC VA. Didn't really think much about it, although I still have that knife, until 2000 when, as the Employee Health Occupational Health Director for the Veterans Health Administration, two of our physicians were shot and killed. And the VA then had to decide, how could we deal with this in a systematic way? So over the next hour, I'll talk a little bit about the background of all of this. What do I think you will need to walk away with? What are the elements nationally that people talk about? I'll discuss some of the work we did at the VA, which is, for me, an example of how organizational work can happen in a successful way. And then we'll talk about where we are right now. And then at the end, there are a bunch of references. You'll hear this a few times. Please look at quick safety item 47 from the Joint Commission. It's their de-escalation guide. I have no disclosures. And if there's one thing that I hope people walk away from this talk with, it's that people can evaluate whether their home institution has resources necessary to keep them safe. And if not, make sure you look for de-escalation skills on your own. It's also important to understand what the components of a comprehensive workplace violence prevention program are, because you need to be able to evaluate them, whatever level you're doing work on. And finally, we hope you learn and think about using a checklist, now the Joint Commission checklist, as you look at your own system. And we'll talk more about that in a minute. The take-home messages for personal safety clinicians need to have a framework to understand violence in health care. They must know what system resources there are, namely, what are the reporting systems? How do you make sure they, whoever they are, understand you've been assaulted, or you've seen something, and there is infrastructure to take care of that. There's some basics around violence prediction that have gotten far more successful in the last 10 years than they were back when I was at the VA. Essential for every health care provider is knowing de-escalation techniques. You should have a firm grasp of what we as clinicians do to make patients unhappy, what the systems in which we work do to make patients unhappy, and how you can deal with those. And then the issue of personal safety skills. Maybe your institution doesn't have a course on physical protection, how to get out of holes. Every police department does that. My daughter has did that with our local police department. You have to learn that. And then you have to know what the institution does, how it should. You have to know what to ask of who the program manager is and what the program is they manage, whether there's formal training on de-escalation that you can request, whether there is training and practice on breakaway personal safety skills. Some people think those should happen at least twice a year. Is there a formal risk assessment process for patients? Where is that necessary? Emergency department? Closed mental health units? Do you really need that in primary care? Or is that patient-driven? A data system? If you can't measure it, you can't improve it. And emergency response planning. What kind of therapeutic containment is there? We call that therapeutic containment. Police officers will often call that takedown. A patient died at the VA because somebody laid down on top of him to try and get him under control. And there are therapeutic approaches to control. And then understanding the Joint Commission checklist approach to standards is a really useful thing. Violence in health care. How big of a problem? What do we know about it? The first mention I've seen in the literature in 1975, a mental health hospital in Canada received a national award for having developed a program to protect its mental health providers. And it was based in martial arts. And over the last 50 years, it's become clear that the fundamental principles underlying most martial arts systems, no matter what they are, are those that help us be effective at keeping ourselves safe. The principles of getting out of holds are almost always the same. If somebody grabs your neck, you put your hands up in between and break them apart. So there are those kinds of issues. And shortly thereafter, American Journal of Psychiatry described a survey where almost half of psychiatrists admitted to having been assaulted at least once. Similarly, that year, a psychiatrist set up a violence clinic to address that. The VA in the early 80s did a system that was the rudimentary, the beginning of their prevention and management of disruptive behavior system, which included identification of threats, some verbal and physical management, again, based on martial arts theory. In 1989, Dave Drummond, a psychologist at the Portland VA, a very colorful character, a concealed carry weapon, volunteer firefighter, motorcycle driver, they randomized controlled trial of preventing violence among veterans and showed that what we'll talk about later, disruptive behavior committees are an important kind of solution component. John Howard, now the NIOSH director, in the early 90s, worked in California to deal with some regulatory approaches to violence prevention and started the efforts at classifying violence beyond the simple enumeration. Until then, people had just said, guns, knives, sexual assault. Howard said, yeah, we have to do better. We have to at least start with labeling the perpetrator. In 2005, 10 years later, a joint conference with the Department of Justice, NIOSH, OSHA, and some other federal agencies came up with a classification. Before we get to that, what is workplace violence? So NIOSH has a pretty straightforward definition that they've used since the late 90s. Their initial booklet on violence prevention used this definition. OSHA some years later thought, hmm, we could say more about that. Threats of assault. So is verbal abuse violence? Is bullying violence? Harassment and intimidation? What if no words get changed? And then the Joint Commission, a little over 10 years ago, came up with a much more detailed enumerative definition. So over time, things change. The more things change, likely the better off we are. Knowing the history makes life easier. What are the types of violence that we expect people to know? And certainly in some board examinations, this classification system is asked. Certainly for occupational physicians, it's part of core knowledge. Not clear to me that there is, since there's not yet a formal certification program for nurse practitioners in occupational health, although we hope there will be one of these days. Type one, criminal intent. Type two, customer client. For us, patient on provider. Type three, coworker assaults. Type four, personal relationships, intimate partner violence, spilling over into the workplace. And for most of what healthcare workers deal with, it's type two and type three. And depending on the system in which you work, there are very different organizational frameworks that we have to understand. So for example, in federal systems, employees are protected by very different administrative and human resources rules than our patients. And in the private sector, if somebody assaults a second time, you can discharge them from care. In the VA, we couldn't do that. Due process rights under the constitution and military service means we couldn't ban patients from care and had to figure out ways to take care of them safely. So in addition to the enumeration of events, knives, guns, hitting, assault with a deadly weapon, and the perpetrator-based classification, a far more now, I think, important way of thinking about violence is one developed by Jay Reed Malloy, a psychiatrist in Australia, who started looking at intent. Where does the intent arise? How do we think about why somebody is doing this? And so came up with this classification of predatory or instrumental violence, which is really a strategic thing, getting revenge. There's no autonomic arousal. There's no evident anger. You don't see what they're trying to do when they stick a knife in you. And it's very well planned. Often, it is quite purposeful. And we contrast that with affective or reactive violence, which we see intense arousal, autonomic system arousal with behaviors, expression of emotion, shouting, and the like. So those two extremes, and as we'll get to one of the core functions of risk assessment, is to look at violence events and think about how they happened and how to prevent them. This slide may be tricky to see. Even I have a hard time seeing the numbers. But you can see that there is a big difference between the, you know, two, three, and four per 10,000 full-time equivalents per year down here, and 60 to 80 to 160 for 10,000 workers per year. These are data that from the Bureau of Labor Statistics, the Department of Labor group that tracks injuries every year, does the SOE, the Annual Survey of Occupational Injuries and Illnesses. They send out a survey to 50,000 employers who are pre-selected. And those employers are, you know, tracked, watched. Are they doing the right thing? Under-reporting of occupational injuries is a huge problem. The SOE tries to get at that in structured ways. That all is going away because as of this year, employers with more than 100 employees who are in a halfway dangerous occupation, wind up having to send us their 300 logs. And so we're, there's a whole new world out there. But bottom line, these rates, you know, there's more than, there's almost two orders of magnitude difference in different healthcare systems. And it's important to recognize that that risk exists not just at the institutional level, but also internally within the institution. There are, from what I can tell, no data that tell us rates of assault in the emergency department and the psychiatric unit in the same hospital. So it's hard to make those kinds of comparisons. Every hospital can look at where most of their assaults happen, or the majority of their assaults happen, or where the serious assaults happen. And the Joint Commission expects that if you look at their standard. So at the individual and the institutional level, how do we predict violence? We used to say that predicting a first episode of violence is impossible, that we can't do that. And certainly through 2010, that was the belief. You could take a first episode, look at how that happened, and prevent its recurrence. And that was Dave Drummond's randomized controlled trial back in 1989, over 30 years ago. Disruptive behavior committees became standard in the VA around 2010. They're increasingly in use in the private sector. Lots of places don't do patient risk assessment in that way yet. But nowadays, we think about predicting violence as a function of both protective factors that make assaults less likely, and predictive factors that make things more likely. And so they're the things that are actually quite commonsensical. Socioeconomic issues, people who are economically marginal, will wind up more fragile and are more likely to both get angry when they're mistreated in a hospital, as a, we could get into assault theories. They have fewer resources, and they reach their breaking point sooner. Or criminals who are out after opiates. There are psychosocial issues at the individual level. So there are protective factors, and there are predictive factors. There are both institutional and individual things that certainly in the VA used to be underlying personality factors and triggering factors. List their minor things. It's not really worth knowing in that way, as long as you understand de-escalation. But it may be useful for your institution to recognize, if you don't have a robust program, that there is a Threat Assessment Professionals Association, now called the Worldwide Association of Threat Assessment Professionals. The URL to their website is in the reference list at the end. There's a formal risk assessment toolkit from Oxford University, and a number of existing organizations, like the Veterans Health Administration, or the Western Psychiatric Institute in the clinic, have tools that people can use. So if we recognize that there's a problem, and there are rates, what's going on around the country to deal with that? The major activities that you should at least know exists are a major initiative from the National Patient Safety Foundation Institute for Healthcare Improvement together with AHRQ, the Agency for Healthcare Research and Quality, and the Joint Commission that some years ago, I think now almost seven, in response to a CDC call out on patient safety, created an action plan on patient safety and incorporating employee safety into patient safety was one of the four major activities. And of the employee safety initiatives, violence prevention and safe patient handling were the two primary things that initiative focused on. OSHA had its own parallel activity. We were both part of that initiative and had pulled in organizations that were part of this in an effort to get leadership buy-in. Our initiative kind of went by the wayside, but it gave way to the CEO collaborative under this NPSF IHI initiative. And that is a collaborative activity from chief executive officers and boards of directors of large healthcare systems that are trying out different ways to implement the tools that are out there. I haven't seen any results and comparisons, people who go to the patient safety meetings done by NPSF in Orlando every December. I'm sure there will be something about those. And the third big thing is the Joint Commission's, it's not really a standard, but it's a crosswalk across their standards, listing criteria statements from four different standards to environment of care standards, a leadership standard and a training standard. The text comes up later in this slideshow and that's actually worth looking at carefully. And we'll talk about why in a minute. In addition, people should know that OSHA has proposed a standard on violence prevention in healthcare. It's been under development now for close to 10 years. OSHA standards take forever to implement. Before I took this job, I thought I had a different view of OSHA standards, put it that way. So part two of this talk is really what we did at the VA. I think examples are always useful for people. And so thinking about your role at an institution and what you can do to drive that institution forward, obviously depends on your role and position in that institution. I was fortunate, I mean, I didn't really know how to be a corporate medical director when I took that job. People snicker about doctors thinking they can do anything. And I was an academic who stumbled into that job and said, I didn't know what to do when two physicians got shot and killed. One of the things we needed to do was look at the system and figure out what went wrong. And one of the things we needed to do was figure out how big of a problem it is, because that tells us what kind of resources we need to mobilize. People may recognize in their own institution, documenting resource requirements is a primary success factor. And I think for people who deal with the corporate director level, the organizational level, whether it's in a federal system like the VA or the Indian Health Service, or a private sector system like Hospital Corporation of America or any Virginia Mason, any hospital system, you have to know what you want and how much it's going to cost. So we did a survey. We used the questionnaire that the Califano Center had used in the late 90s to look at the threat of violence among postal workers. Those of you who are old enough, I'm about to turn 75, I remember this well. Back in the mid to late 90s, they said it was going postal. So Califano Center in 97 did this survey and showed that postal workers, in fact, had an almost 10% higher rate of assaults and verbal abuse than did the average U.S. working population. So we use that survey. And this slide hasn't actually ever been published in a paper. But you can imagine that when I showed this slide, our chief operating officer, Laura Miller, brilliant, brilliant woman running the VA system in the early to mid-aughts said, oh, so it's going VA, not going postal. And that got us 10 years of management performance metrics. So every quarter, every manager in the system was asked whether they had achieved the goals that we defined. So thinking carefully about documenting the extent of the problem in your system is often worthwhile. Who suffered those assaults? We looked at not just who had been assaulted at least once in the last six months, but who the perpetrator was. That big purple thing is patients. The buff is co-workers. The blue thing down there is supervisors. There are some other things. But the bottom line is, in health care, assaults, that's a patient problem. We can talk differently about verbal abuse and perceptions of that. As you move down the income ladder in health care, co-workers get to be a problem. And in fact, as you move down the income ladder, supervisors get to be a problem. So that was a pretty striking thing, that supervisors would assault their employees. Bottom line is that that generated a rejuvenation of the system that Larry Lehman had started some, you know, tried to start quite a number of years before. And after a few years, we wound up with a set of elements that worked. A data system that tracked events that got reported, a cascade trainer system where two people at every hospital were trained as trainers for other staff, risk assessment by units to see which units and which professions needed what level of training, and the disruptive behavior committee system. That meant somebody at the hospital with mental health skills ran a committee that evaluated every violent incident. That had to be a senior mental health clinician. It could be a mental health nurse. It could be a psychiatrist. But it had to be a mental health clinician. It could not be a police chief. It could not be a safety manager. And so it had to have bunches of representation, police, security, safety, patient ombudsman, all of those had to be there. We took all the directors off to the Portland VA and did a one-week mini residency training them on threat assessment. So combining the law enforcement threat assessment systems that exist and the psychiatric mental health forensic assessments that exist. In addition, PMDB wound up doing broad education, did de-escalation, including both teaching theory and practicing on trainers. We actually had some injuries there. Somebody wrecked his shoulder. Some people were unhappy with me. Physical safety, breakaway training for individuals with practice, and then therapeutic containment. In the VA, the system back then said there had to be a way to call people together who were trained. It took four people to take down a patient in a therapeutically accessible way. So as working through this, I left the VA before this was completed. Lynn VanMale, who managed, ran this system from 2012 after I left till actually just left the VA two months ago. And I have to admit, I don't know how far the staffing training and therapeutic containment work went. Was it effective, a slide documenting what we did when the little boxes are, this is from a paper that I submitted at some point, but then went to OSHA and never got around to revising it. And so when I hadn't revised it after a year, the journal said, if you're not going to revise it, we're going to give it back. But the data system on assaults among nurses and among all staff suggested improvements. A few years ago, I asked the safety people whether I could get follow-up data. And it turns out they had done away with that data tracking system. So it's not clear that they can measure assaults these days, but that's a whole different problem. So in addition to the background and my experience at the VA, there is the issue of where I currently work. What are we doing now? And what can you learn from our stuff? So OSHA proposed a guideline for preventing workplace violence in healthcare and social services years ago in the early aughts, and reissued that with some revisions in 2015. It has the usual sections that OSHA guidance has, which the labels aren't very meaningful. The URL to that is in the references. It's probably worth looking at as you explore what your system does. Thinking about this document and the joint commission standard as a crosswalk may be very useful. Management commitment and worker participation. So how do you measure that? What is management commitment? How would you? So some people say you should have a budget. Some people say you should have a program manager. Some people say you should have reports in the hospital annual report or to the board of directors. How do you measure worker participation? Do you have joint safety committees? How do your environment of care rounds work? Locally, that's something that is worth thinking about. Worksite analysis and hazard identification. So where are their hazards? There are lots of checklists that people have for violence prevention. And sometimes they're actually tricky because, for example, the joint commission wants doors to open to the inside of patient rooms so that people don't get whacked in the hallway. But from a violence prevention perspective, you want the door to open out so that you can get out. Where's the desk related to where the patient sits and where the door is? Are you between the patient and the door or is the patient between the provider and the door? So those kinds of things. How do you recognize escalating behavior? Do you have barriers that are appropriate? Are the nursing station desks wide enough? Are there rooms that people can retreat to, to which patients don't have access? Hazard prevention and control. So we can go through each of these and we'll talk more about those in a minute. But when we started looking at cases, let me do that when I get to it. As we started looking at evaluating our own inspections, we thought we've heard about all these commercial programs. We should know how good they are, what they do, whether we think they're good, whether they meet the paper, you know, on its face, on their face criteria for an adequate program. And so a group got together to develop two things. So Jane Lipscomb, a well-known healthcare violence researcher, some representatives from the VA, Glenn VanMale, I believe Kate McFall was in at least one of the meetings. Some NIOSH researchers were part of it. So it was a working group that developed two things. One was a list of program elements for commercial workplace violence prevention programs that get sold to institutions. And the other was a checklist. I'll talk more about checklists in a minute. But I'm not going to go through each of these. I believe you can access the slides later. The bottom line is we came up with almost 30 elements that we thought programs should have and we wound up getting the training materials from 12 of those organizations. That was all we could get and we got them under the assurance that we would give them back when we were done. And whatever we published from this, we would do anonymously. We might tell them how they fared, but we wouldn't share the results of their score with anyone else. And that, you know, it's not an unreasonable request if you're doing, if you're making your money off of something. We live in a capitalist society and OSHA has to deal with people the way we find them. So we did the structured view of this. Here's the graphic documenting what happened with the results. I won't go through the details, but when you look at this, the red is the ones where there was just no evidence that they were doing that, even in their program. Teaching de-escalation. Almost everybody said, yes, they taught de-escalation. How well was it taught? We couldn't figure that out. Yellow is limited evidence and the red is just, they weren't doing it. So did anybody customize? Did anybody have a violence reporting system? You know, issues. And as we looked at that, it turned out the majority of programs did have a train the trainer approach. They did de-escalation in some way. They actually, some of them, many of them practiced de-escalation techniques. Many of them practiced extrication. Although, you know, how to do that safely is an issue. And many of them did teach a team approach to containment. But the majority of the programs did not include local risk assessment and policies with assessment, any content on predatory violence and stalking, any content on working alone, anything on host event follow-up and debriefing and EAP usage, or an analysis of program effectiveness. Sheila Arbery, occupational health nurse in this office for years, is the lead author on that paper in the reference list. One of the graduate nurse interns who did that as her project here. So what has OSHA done with healthcare violence in general? So since 2004, OSHA has done, well, by 2018, about 600 inspections. And this graphic documents what we did as outcome by year with where we issued a general duty clause citation, where we issued a hazard alert letter in red, and where we didn't do anything. And in the Yogi Berra, for those of you who remember the Yankees in the 60s and 70s, you can learn a lot by looking, seeing the shape of those lines, sending even warning letters off, and doing nothing lets you think about what happened in those years between 2016. And I don't have the newest data yet, but bottom line, we have issued general duty clause citations although not so often. So coming here from the VA, which was a deeply checklist-believing system, we developed a checklist. Again, the second thing this working group developed, the Joint Commission, the VA, NIOSH, Jane Lipscomb, we developed those criteria, and then we developed a checklist to evaluate our program. And we went back and interviewed 22 compliance officers who had gotten a general duty clause citation out of their inspection, and 22 who had gotten a hazard alert letter, and looked to see, right, so we developed a pilot to develop that. We had that working group, and then actually one of the graduate nurse interns who was a nurse practitioner, now a nurse practitioner in the VA system, did a pilot to see whether we could do that. We then identified all of those things that you saw in that graphic, classified them by Cal 581 general duty clause citation, or nothing, and then conducted these deep semi-structured interviews with compliance officers. As we analyzed those, there were statistically significant differences between these two groups, citations and hazard alert letters, except for the data stuff. Why is that? What does that mean? Well, we issue citations when we think employers should have to be doing better, and there are huge gaps. We send people nice letters saying, we really shouldn't be doing better, but we don't see enough that we could make a citation stick in court. People who have dealt with OSHA know how often OSHA loses in court as we struggle with this. But clearly the people who got cited had worse programs than the people who didn't, except for the data systems. And that I think is because they were all so bad. This is the checklist that we developed. We actually wound up recently doing that again in one of our regions where we went back in time to look and see whether we could have done something different if we had been actively using a checklist. And the bottom line in that is, it doesn't perform as well as the joint commission checklist. And more importantly, the facilities that didn't get a hazard alert letter or a citation actually did a lot worse even than the ones that got a citation, telling us that we could do better with our staff if they used checklists. Don't know where this community is around checklists and quality management. Over the last 10 years, this agency has used a checklist approach to improve our heat inspections. We started down that road and the summer I got here, there's now a heat standard well under development. We use that to improve the quality of our consultation service. The major activity of this office is to help field inspectors when they can't figure out what's going on in an inspection or when they can figure out but they can't figure out a solution. And so we thought, okay, let's see how far we can push checklists here. People may remember healthcare. People say Peter Pronovost and the Hopkins surgery, ICU stuff and airline passenger safety and checklists and why shouldn't it work for us? So our checklist worked okay. The joint commission, the year we published that checklist deep dive study, Barbara Braun at the joint commission published a crosswalk on which joint commission standards support violence prevention and two environment of care standards, a leadership standard and a training standard have specific things. And you can turn these into criteria statements without a lot of difficulty. You can talk to whoever at your institution is in charge of prepping for a TJC visit that now happened randomly. I don't know who all here is involved in that kind of systems work, but this is a powerful tool to improve violence prevention programs. So the two environment of care standards and the human resources, you know, training stuff and a leadership standard. So it's worth reading those and thinking about the statements. Is there a process for follow-up of events? Is there a process to respond to violence? What does your institution do? So it's worth thinking about these carefully. And then just some random additional thoughts. People should know that Judy Arnett's a psychologist at Michigan State had a big NIOSH grant to see whether implementing the OSHA guidelines work. She did a very complex, great study. Didn't show anything statistically significant, but it was an important piece of work. There are these known effective interventions, the Drummond Study, the Cochran Review. If you're worried about bullying, there's a project called CRU, Civility, Respect, and Engagement of the Workforce, again, from the VA that was shown to substantially reduce sick leave and improve both employee and patient satisfaction. They're the OSHA guidelines. These, the papers from Arnett's and Hamblin, if you just type those names into the PubMed search bar, you'll see about 15 studies that are really useful. And there's a great NIOSH general workplace violence prevention education program for nurses that's online. These are live URLs. Disruptive behavior committees I talked about in the VA. We had kind of did that. We called in the minutes, looked for things. One of the things that the VA did that was quite spectacular was, you know, when the VA implemented its fully electronic, universal nationwide patient record in 2003, it implemented, not in 2003, but I think in 2006 or seven, the Category 1 flag, a flag that showed up whenever you opened a chart of a patient who had assaulted a provider within the last two years. And there was a note behind that flag that was written based on the disruptive behavior committee work to say, here's what you have to do to prevent this patient from assaulting. And that's one of the few ways that in a predictable way lets you manage assaultive, violent patients. Sometimes you have to have a police officer in the room with them at all times. If that's what it takes, you want to take care of those patients, you need your staff. Some response modes that all hospitals have. Not sure I can answer questions on this mode, but happy to respond to emails. And then there's a set of references. The ones that you want, that checklist of the joint commission is worth looking at. The OSHA guidelines are worth looking at. This is one of the free risk assessment tools. Read Malloy on the waiver 21 is a commercial one that I know lots of people use. ATAP, deescalation, the joint commission tool on how do you calm a patient down or prevent them from getting worked up. That's a critical skill for every healthcare worker. One of the topics that generates both a fair amount of interest and some heartburn is the phrase deescalation. Because it sounds formal and people often don't know how to do that. Over the years, there've been lots of approaches to deescalation, but there's relatively little research showing that deescalation per se is an effective intervention. By the same token, people may remember that there is no randomized controlled trial about the effectiveness of parachutes. We insist on their use anyway. And so this is one of those things that we think is so integral to violence prevention. Certainly anybody who deals with patient-centered care and is aware of what we, as we think about patients and their, what they bring to the interaction, deescalation is critical. Those of you who have thought about the concept counter-transference, so our response to the patient may well remember, and those of you who haven't thought about it should know that the counter-transference, the way we feel about a patient is an incredibly important indicator of the threat to us. When patients are, you know, grow assaultive, they often make us afraid or angry. And we should know ourselves well enough to recognize the difference and to think about when we need help, where a minor intervention isn't getting a patient to slow down. There are no magic words. We haven't found the right phrase, having an escape line. I need to get you something, be right back. But there's really little evidence for the effectiveness of deescalation. And it's not clear how good it is, but it is supposedly there. And the Joint Commission has a bunch of stuff in that quick safe 47 that's worth understanding, reading carefully. The thing that I'd ask people to know is there are formal assessment tools. It's worth knowing those and asking your institution to get one of those. They're not all suitable for use on the spot, but they're useful to know about. There are a bunch of deescalation models. So what are the skills you can use? Understanding the different tools and knowing, for example, that some of them are, you know, evolve as you're using them. The most important thing on these are what are the actual interventions you can use to diffuse an aggressive situation? And so having read through this tells you there are some things, the verbalized communication techniques that are clear and calm. Staff attitudes must be non-confrontational in use of verbiage. We all have bad days and those bad days put us ourselves at risk. And it's worth recognizing that we can be part of the problem. And once we get down that road, being able to halt ourselves is actually, you know, a major, learning how to do that is a really important thing. You know, attitudes, limit setting, knowing what the environmental controls and resources are. And then depending on the setting, you know, are you in a closed mental health unit or the emergency department? That becomes knowing where you are and what your resources are important. So interventions worth reading, are there standards of behavior, not just for employees, but also for patients. In a closed mental health unit, you know, you can have those discussions. And Maria Luns at the Bedford VA did this really great study about community intervention and violence. And having even just a community meeting with patients regularly, where they got to voice their problems led to major shifts in patient assault rates, soft words. So it's worth reading these, thinking about them, coming up with your default statement, unless you've thought about what you might say when an angry patient shows up, because at those times we're not at our best. It's worth having thought those before. And yeah, I think that was it for resources, but this document is worth having looked at carefully. There are a bunch of references, whether it's worth going after those, or whether you use this with some colleagues to brainstorm how you and your work group could do deescalation. That's, you know, I think a place to do the work. And there are a bunch of references for people who wanna read. And that's the end of my talk. Thanks for watching and listening. I hope you not only enjoyed the session, but learned something useful. Please feel free to email me with questions. I might not respond in 24 hours. And if you don't get a response within three days, email me again. I get a few hundred emails a day, and I'm often far behind. Thanks.

violence in healthcare

scope of practice

resources for reporting

addressing violent incidents

de-escalation techniques

personal safety skills

workplace violence prevention program

OSHA guidelines

joint commission standards