For the past decade, Jasmin Orange has worked on the front lines of critical care nursing, witnessing firsthand the impact of aggressive behavior and violence on nurses. Now, as an assistant nurse manager in a medical ICU in Delaware, she has dedicated herself to fighting the rising violence against healthcare providers.
In her role, she leads an interprofessional committee tackling workplace violence, aggression, discrimination and harassment, while also working to improve workplace civility for everyone. She and her team use evidence-based practices to create a culture of respect and safety in their organization.
Jasmin led a session about mitigating workplace violence at the 2024 National Teaching Institute & Critical Care Exposition (NTI). Afterward, she spoke with us about combating the epidemic of violence in healthcare, as well as the tools and strategies her team has employed to help maintain a safe environment for their caregivers.
Please introduce yourself.
My name's Jasmin Orange. I am an assistant nurse manager in a medical intensive care unit at Christiana Care in Delaware. We are the only Level I trauma center in the state. I have been a member of AACN my entire nursing career, so 10 years. I’ve been certified since 2017.
What led you to address the topic of workplace violence against healthcare workers?
Anyone can look at the news and get the sense that workplace violence against healthcare workers is on the rise. It's an epidemic in our field, and it's something that's going to take a big team and a strong voice to combat. I was fortunate enough to be involved in shared governance in my organization and was tasked with finding a workplace violence mitigation strategy to implement. It was a very large feat but luckily I had a great team, including nurse scientists to help me with the research, as well as behavioral health and psychiatric partners to ensure we were addressing the problem from all angles. The more I've learned about workplace violence … the more driven I am to find a way to where nursing isn't a profession where people think it's normal to get hurt at work.
How does workplace violence contribute to unhealthy work environments, staff turnover and moral distress?
I've talked to nurses who have been afraid to return to their unit, because there was an assault that took place and the patient was allowed to return. We shouldn't work in a profession where people are afraid to come to work. It's not acceptable in other industries. I often worry that because nursing is female-dominated, it's part of the reason we're facing this. It's something we need to address if we want to attract and retain people in this field.
How do you address safety concerns not just from patients, but also patients’ family members, or incivility among nursing colleagues?
Part of my shared governance work focused on workplace incivility among nurses. We developed toolkits to provide nurses with the skills and tools to talk to one another. When these conflicts arise, it takes someone willing to say, "Hey, you talked to me that way and I wasn't OK with that." Through mentorship, we have to develop our nurses to know it's OK to have those conversations with each other. We are here to rise together, and we need to build up our workforce that way.
In terms of workplace violence from family members or other visitors in the healthcare setting, I'm lucky I work in an institution with a zero-tolerance policy. As a manager, I'm able to independently make decisions to restrict or modify visitation for family members who do not treat my staff with the level of respect they deserve. We have strong policies in place regarding behavior contracts, and we will press charges. We encourage our caregivers to do that in these instances, which is really hard for nurses. People don't go into banks and treat the employees the way they treat their nurses. It’s about sending the message that this behavior isn't going to be accepted in our institution.
You successfully piloted a screening tool that helps nurses proactively assess aggression risk in patients. Tell us about that.
The workplace violence screening tool we're using is called the Dynamic Appraisal of Situational Aggression, or DASA. It screens patients based on seven behaviors that the nurse assesses as either present or absent. If there are more than three of these behaviors present, the patient is at high risk for aggression.
Once a nurse realizes a patient is at high risk for aggression, we develop a care plan. We flag the patient in our electronic medical record, so anyone who accesses the record knows this patient is potentially violent. From that flagging, they're also referred to the Interdisciplinary Plan of Care (IPOC), which has interventions tailored to keep nurses safe. We reference our de-escalation training within the IPOC.
We also have door signage that goes into place, because we want our caregivers to know they're interacting with a patient who could potentially become aggressive. This enables them to put those situational awareness tools into practice - such as not positioning themselves in a way that they could be trapped in a room, alerting members of the care team that they’re going into the room and, if possible, implementing team care for the patient that's at risk for aggression.
The DASA provides a way to assess the patient, but the tool itself isn’t meant to be used in isolation. We ask people to use those care planning techniques and take a full, compassionate look and collaborative approach to care for the patient.
What kind of results have you seen in units using the DASA tool?
Since implementing the DASA tool in our organization, we've found there is a correlation between high DASA scores and patients at risk for violence, but we're also finding we might need to screen patients more frequently than we initially anticipated. We're currently developing forward-facing dashboards to help our clinicians see how DASA scores correlate with IPOC utilization, as well as risk flags or risk events.
We've also integrated a great deal of bias training into the DASA tool education to raise awareness about some behaviors we might think of as aggressive but could be cultural. For instance, if a patient talks in a loud voice, it doesn't necessarily mean they're going to be violent or aggressive. So we really try to be mindful of integrating bias training into education on the DASA tool.
How does using an objective tool to screen for potentially aggressive behavior help reduce the amount of bias nurses might have when interacting with patients?
Initially, I think there was a lot of anticipatory excitability because we were expecting to see a lot of aggressive behavior. In the region where I live, we have a high rate of substance misuse disorder, and some behaviors these patients exhibit can mimic violence. But having a tool that gives nurses objective measures of the specific behaviors we’re looking for helps them reflect on how they're interacting with patients and how the patients are interacting with them.
An objective tool is also helpful in how we communicate with one another. For example, when communicating with our physician colleagues, the tool makes it easier to say, "I looked at these behaviors and this patient could be potentially aggressive. I need help in developing the care plan for this patient so we stay safe."
What are some other de-escalation tools and strategies that can help nurses identify and minimize the risk of workplace violence?
When nurses identify that their patient's behavior is escalating, it's important to first think of what they can do to mitigate the risk of violence. We ask that people are direct and firm in their communication once they realize the behavior is escalating. We also encourage situational awareness – what kind of risk the patient is posing, where the nurse positions themself in the room and what kind of risk they’re putting themselves at. Part of our strategy includes having our behavioral health specialists round on patients. They not only help the nurses with the stress of dealing with these difficult patients, but they also help the patients develop coping skills. We also have some highly skilled nurses who are really good at having those conversations with patients to help them identify their triggers, as well as what we can do to minimize those triggers during the patient’s stay.
It really is a partnership. When we talk about “aggressive patients,” we typically think of avoiding those patients. But if we can get to know our patients and understand why they're being aggressive, it can be so helpful. For instance, we've had family members tell us a patient has PTSD as a result of long hospitalizations, and there are certain things we can do when entering the room, like having our hands forward so they can see them when we’re coming in.
Even after a violent event, we try to reestablish that therapeutic rapport with our patients. If it's unsafe and we have to dismiss the patient, that happens. But in critical care, we know these patients are often too sick. They have to stay with us. So how can we reestablish that relationship with them and let them know if they're remorseful for their behavior, we're not going to judge them for it? We're going to move forward, partner in their care - together.
What role do soft skills, such as communication and establishing rapport with patients and families, play in mitigating the risk of workplace violence?
As nurses, we are often the person at the bedside, talking to our patients and getting to know them. Getting to know our patients and their families is how we form a deeper bond and really develop that trust.
But we need to mentor our newer nurses who've learned clinical skills through simulation environments on how to have those conversations and form those bonds. It's a lot different when they walk into a room with the patient and family. They have to make small talk; they have to learn how to get to know someone. That's a lot different than in the sim environment where it's just skill-based. For me, it was going into the room with our intensivists when they were having end-of-life conversations where I learned to connect with families and how to tie in what’s important to them to the care we're providing. So it's a lot of role modeling and shadowing, and knowing who's skilled at that and letting the new nurses learn from them.
What other ways can hospitals help make work safer for nurses and all other healthcare professionals?
Beyond the bedside, nurses have a strong voice and an ability to guide the way policies move. In Delaware, for example, it's now a felony to assault a healthcare worker. Nurses need to be the voice that says this behavior is not going to be tolerated. As a collective, we have a lot of strength. We have a lot of numbers. The public trusts us. So we have to be vulnerable and use our voice to tell the public this is something we’re experiencing, because I think people don't know. Again, most people go to work and they don't have to worry about these kinds of events.
What else can organizations such as AACN do to help promote workplace safety?
AACN is doing a great job promoting workplace safety by having a platform like [NTI]. It was great to see the number of people who came to the session [at NTI about workplace safety] wanting to talk and engage about what they're doing at their institutions for workplace violence. It's that collective voice of nurses, where we can learn so much from each other and what other practice areas are doing. AACN providing conferences where we can talk and exchange ideas is a great way. AACN is also a powerful voice to help drive policy throughout the system to change workplace violence against nurses.
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