Aug 1, 2004 12:00 PM

Lantana, Fla., the barefoot skiing capital of the world, is a small sunny town located 60 miles north of Miami. Sun and fun are not the only treatments available because Lantana, population 10,000, is also home to the last original tuberculosis sanatorium in the nation.

Built in 1950, A.G. Holley State Hospital was one of four state tuberculosis sanatoriums built between 1938 and 1952 to care solely for tuberculosis patients. Today, the hospital's 35-50 patients are comprised of voluntary admissions and those who have been court-ordered to receive treatment after failing to take their prescribed medicines voluntarily.

Dana O. Vogelsang, mental health security chief for the hospital, says the unique mixture of patients requires special care for the patients and improved training for hospital staff. "We get the most complex cases of TB at the hospital," he says. "A.G. Holley serves all 67 county health departments in the state, and some patients become non-compliant with their treatment and are court-ordered to the hospital. Therefore, it is vital that we take great care in balancing security and treatment," he says.

Employee training is a favorite subject for Vogelsang. Three years ago, he was chosen to attend the Public Health Leadership Institute of Florida, held at the University of South Florida. State public healthcare workers are selected annually to attend the Institute; they meet in numerous conferences and training sessions during the year.

Each attendee is required to prepare a comprehensive presentation; Vogelsang chose workplace violence. "I wanted an assignment that had to do with security," he says. "As I started out at South Florida State Hospital, one of the largest psychiatric hospitals in the state, I could see first-hand how many experienced staff members we were losing, especially nurses. We have a nursing shortage in Florida and, after my research, I am absolutely convinced that workplace violence is a contributor.

"Nurses and other people in the healthcare field are getting beaten up," he continues. "They're getting hurt and they don't need to. They need information; they need to be trained."

Once he started doing the research, Vogelsang discovered this was a much larger issue than he first realized. "The numbers were staggering," he says. "It costs American businesses $36 billion annually to deal with the issue of workplace violence. I figured if I could bring attention to the issue, combined with a system to help prevent it from happening, it would be extremely beneficial to everyone in healthcare."

Today, Vogelsang's "Violence in the Workplace" program has been adopted by the Florida Department of Health's Intranet site and is available to all state employees. It is a required portion of employment training at A.G. Holley State Hospital. He also presents the program annually to the new members of the Public Health Leadership Institute.

"I find that people who don't do security for a living don't think security," Vogelsang says. "What the program does is bring a different perspective to everyone, and it's needed."

The numbers are alarming. In 2000 alone, there were 674 murders in the American workplace. Every year, the workplace is the setting for 51,000 rapes, 84,000 robberies, 396,000 aggravated assaults and 1.5 million simple assaults. Plus, Vogelsang learned, healthcare workers are more at risk for assaults than are law enforcement officers.

Workplace violence is any physical assault, threatening behavior, or verbal abuse occurring in a work setting. The phenomena is further divided into four types:

  • Criminal intent, in which the perpetrator does not have any legitimate business with the establishment. The primary motive is often theft.

  • Customer/Client, in which the perpetrator is a customer or client. This category often affects healthcare workers, and accounts for 30 percent of all workplace homicides.

  • Worker on Worker, in which the perpetrator is an employee or former employee, and the motivation is often one or a series of interpersonal or work-related disputes.

  • Personal, in which the perpetrator is not an employee. This category covers the overflow of domestic violence into the workplace.

A patient's relative attacking a hospital receptionist in a fit of rage; an ex-husband who injures his former spouse at her place of employment; the two co-workers who allow a feud to erupt into violence ! each is an example of workplace violence.

Vogelsang, in his presentation, also covers an often-ignored issue: healthcare workers without a fixed office who must visit homes to provide care.

"That is unbelievably dangerous," he says. "When I was at the Institute, we worked with some people who did exactly that ! treated sexually transmitted diseases in homes ! and they said 'we have nothing, no resources or training, and you should see some of the neighborhoods we go into.'"

Employees at A.G. Holley receive training in workplace violence; and all employees who will have contact with patients are trained in Techniques for Effective Aggression Management (TEAM), by Vogelsang and Norman Raiford, the lead unit treatment rehabilitator at the hospital.

Because of the 16-hour TEAM training, repeated annually, "we have had no injuries to patients or staff even during physical altercations," Vogelsang says. "TEAM teaches you what to look for in people's behavior, so you can hopefully avoid an incident before it becomes physical. Secondly, it teaches you how to get away safely if you are by yourself (and facing a physical altercation); and finally, it teaches you what to do when you respond with a large group of people."

All employees at A.G. Holley are expected to act as security professionals, watching for and reporting any suspicious activities. This involvement is crucial for a newly developing security department, Vogelsang says.

"When I came here, I was asked if I could enhance the existing security department, and we've made great leaps and bounds," he says. "But because of budgetary constraints, I have six officers and 164 acres. (Security is) absolutely impossible unless you have buy-in from management and all the other employees. Their eyes and ears are helping me make them more secure."

Vogelsang's research into workplace violence allowed him to contribute further to the hospital's interdepartmental workplace violence committee. "Whenever an employee is confronted by a workplace violence incident ! and this could mean someone who is having a problem with a spouse, because domestic violence in the workplace is becoming a huge problem ! they'll report to their supervisor who then alerts someone on the committee," he says.

"The committee will hold an emergency meeting with the individual involved and then come up with a plan to keep that employee and all employees safe."

The committee is made up of 10 members, including the staff psychiatrist, the general service manager, the quality and assurance person, the lead dietician, the nursing director and the risk manager. The committee's recommendations are sent to the hospital's CEO for a final decision.

Common responses to the threat of domestic violence overflowing into the hospital environment could include changing the specific employee's office location and distributing a photo of the spouse to the hospital grounds crew and the switchboard operators, Vogelsang says.

The workplace violence prevention training and TEAM classes also help the security team work with the outside groups who lease facilities on the hospital grounds. For example, the foster care program adjacent to the hospital, by nature, involves parents who may be extremely anxious. "It's difficult to talk to people in that frame of mind unless you've had very good training," Vogelsang says. "We can calm people. In fact, we've probably done more with verbal intervention than we've ever had to do physically, and that's because of this training."

Technological security measures are expected to support the security efforts undertaken by the A.G. Holley staff. Proximity readers by Sonitrol protect all public and employee entrances. Employees are permitted to enter 30 minutes before their shift through 30 minutes after their shift. At other times, they must enter through the main lobby and sign in with the switchboard dispatchers.

All visitors after 5 p.m. must approach the locked lobby door, guarded with a motion detector light, and show their faces to the surveillance camera to be buzzed in. Employees must then use their Sonitrol proximity cards to enter the hospital from the lobby.

CCTV cameras monitor some patient rooms. "A lot of our patients are court-ordered and that brings up behavioral problems, so we have a timeout system," Vogelsang explains. "When someone's behavior is unacceptable or they have become violent, you offer them alternatives to stop acting as they are. If they choose not to calm down, they are put into timeout."

If the misbehaving patient enters his room voluntarily once asked, the room door is allowed to remain unlocked. If the patient requires subduing, he is locked in the room and monitored by the behavioral medicine department every 15 minutes until a re-evaluation is conducted in four hours.

Pelco Spectra III Integrated wireless pan/tilt/zoom cameras in the patient rooms allow one behavioral medicine staff member to observe the rooms of up to four timeout patients on one monitor. In times where there is no behavioral issue, the monitors and cameras are turned off in the rooms to preserve patients' privacy.

The cameras also are focused on hospital entrances, the recreation area, the water tower that supplies water to the hospital and all roads leading from the facility. The phone dispatchers control these cameras.

Hospital dispatchers play an important role when a patient escapes, or in "hospital-speak," elopes. As the dispatchers have a digital view of the hospital entrances and much of the campus, they can report an escape, including the patient's attire and the direction of departure.

Color armbands, earned in a point system, tell hospital employees which patients belong where. Patients placed in isolation during their contagious period wear a red band. An orange band means the patient is restricted to his unit. Other color bands signify chaperoned and unchaperoned access to hospital grounds.

For a patient or employee to leave the patient unit, which occupies one full floor of the hospital, they must use a key to summon the elevator. "If a patient jumps in behind an entering nurse and tries to send the elevator down, the nurses will hit the emergency override button in the secured nurses' station across from the elevator. The elevator stops and an alarm sounds; then there's no other means of escape," Vogelsang says.

When a patient escape is discovered, the first observer uses his Nextel phone to contact the 20 employees who compose the 911 Group. The 911 Group Talk feature allows the first observer of the escape to announce the details of the escape to all 20 members simultaneously.

"So what happens is you get an instantaneous hospital-wide response to wherever the occurrence is," he says.

Vogelsang tells of a recent attempted escape discovered first by a member of the hospital grounds crew. "Normally you wouldn't think of engineering (the grounds crew) as part of the security department," he says, "but we train everyone that security is everyone's job."

"I got in a cruiser with a Lantana Police Department deputy and was able to relay employee observations through the Group Talk 911 to the officer in real-time. We were able to find the individual with no one getting hurt, and it was because of the initial response of everyone at this hospital using 911 Group Talk."

Special code words protect other patients and their families from experiencing unnecessary fear if they overhear a 911 Group Talk call. Code Red is fire; Code Blue is a medical emergency; "Paging Dr. Strong" signifies a physical altercation; and "Paging Dr. Armstrong" indicates someone has entered the hospital with a weapon.

The recent escape attempt demonstrates the importance of cooperation among hospital employees, and between the hospital and the community law enforcement agents. Vogelsang has instigated several partnerships designed to benefit both the two local police departments and the A.G. Holley Hospital.

To deter the homeless people who attempt to find homes in the wooded area of the hospital campus, Vogelsang offered the campus to the Lantana Police Department as a training camp for officers with all-terrain vehicles. He also offered the hospital as a training facility for the neighboring Lake Worth Police Department's drug dogs.

Though some hospital employees were apprehensive about all the new security precautions, any fear has transformed into relief, Vogelsang says.

"Now they're feeling a lot safer and they're telling the guards, 'This is a good thing,'" he says. "We've got total buy-in, which is the key to making this system work. In a place like this rumors are like DSL (or high-speed Internet). If you do something right, it goes around as fast as if you do something wrong. So we want the right rumors flying around here."

Contributing Factors to Workplace Violence

  • A weak or non-existent policy against all forms of workplace violence.

  • No mechanism for reporting violent or threatening behavior.

  • Failure to take immediate action against those who have threatened or committed acts of workplace violence.

  • No clearly defined rules of conduct.

  • Failure to educate managers, supervisors, and employees in workplace violence awareness, early warning signs, emergency procedures, hostage survival, and workplace violence reporting and prevention measures.

  • Negligence in hiring, training, supervision, discipline, and retention of employees.

  • No in-house employee support system.
  • Inadequate physical security.

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