Workplace Violence Incident Report

Final Version January 23, 2024

The following data collection tool has been developed by the Maine Hospital Association Workplace Violence Subcommittee to quantify the number of workplace violence incidents occurring in Maine hospitals. The data collection tool has been broken down into two sections: Phase I and Phase II.

Phase I data collection are the essential elements that hospitals should collect from any employee impacted by workplace violence. These are the minimum data that can provide insight into the volume and impact of workplace violence. The collection of the information is critical to developing an appropriate response to violence in hospitals, which may include policy change, advocacy, education, and training.

Phase II data collection are elements that allow hospitals to better understand contributing factors to violence and provides more detailed information around the specifics of the incident including those involved. Phase II data will assist MHA member hospitals in understanding the steps that will be necessary to help prevent future incidents and support victims through the short -term and long-term impact of these events. Phase II data collection would be completed upon further investigation of an initial report. Hospitals may choose to collect this information for each report or select a subset of the total reports to collect additional information.


PHASE I DATA COLLECTION:
Information about Location of Event and Individual Impacted:

• Facility Type [dropdown]
  • Acute Care Hospital (Department noted below)
    • Emergency Department
    • ICU
    • Med/Surg/Inpatient
    • Psychiatric
    • Other
  • Ambulatory Care Center
  • Long-Term Care
  • Home/Home Care
  • Skilled Nursing Facility
  • Assisted Living Facility
  • Psychiatric Hospital
  • Other
• Occupational category of person impacted [dropdown]
  • Nurse (RN, LPN)
  • Physician/ Advanced Practice Provider
  • Allied Health/Technologist
  • Rehabilitation/ Therapy Services
  • Case Management/ Social Work
  • Education
  • Administration/Support Services
  • Facilities/ Plant Operations
  • Nutrition
  • Security
  • Other
• Department/office where incident took place.

Incident Report Information:

• Aggressor [dropdown]
  • Patient
  • Visitor
  • Employee (Lateral)
  • Other
• Type of Violence [multi-check option]
  • Physical
  • Verbal
  • Attempted Violence (near miss)
  • Written and/or Digital
• Primary Assault Description [multi-check]
  • Biting
  • Choking
  • Grabbing/Pinching/Scratching/Hair Pull
  • Harassment
  • Kicking/Hitting/Beating
  • Other
  • Posturing
  • Punching
  • Pushing/Shoving
  • Sexual Assault/Rape
  • Shooting
  • Spitting
  • Stabbing
  • Stalking
  • Throwing an Object/Breaking Object
  • Verbal Assault
• Assault Description (Free Text/Description)
• Primary Contributing Factors [multi-check]
  • Abandoned by Guardian
  • Altered Mental Status
  • Ambulance/Transport Unavailable
  • CCSU Bed Unavailable
  • Coming Out of Anesthesia
  • Community Services Unavailable
  • Crisis Services Unavailable
  • Detox Bed Unavailable
  • Homelessness/Lack of Housing
  • Inpatient Bed Unavailable
  • Jail / Corrections placement unavailable
  • Long-Term Care /SNF Bed Unavailable
  • PNMI / Residential Placement Unavailable
  • Psychiatric Bed Unavailable
  • Removal Of Personal Belongings by Security/Care Team
  • Resource (Foster) Home Placement Unavailable
  • Self-Injurious Behavior
  • Under Influence of Substance(s)
  • Unknown
• Severity of Assault [dropdown]
  • None- No Contact / Unwanted Contact w/ no injury
  • Mild – Mild Soreness / Abrasions / Scratches / Small Bruises
  • Moderate – Major Soreness / Cuts / Large Bruises
  • Severe – Laceration / Fracture(s) / Head Injury
  • Death or loss of limb
  • Unknown
• Emotional and/or Psychological Impact [dropdown]
  • None – No emotional and/or psychological impact
  • Mild – Upset / Angry / Scared / Humiliated
  • Moderate – Moderate emotional and/or psychological impact with no missed work but return to work with modifications.
  • Severe – Significant Emotional and/or psychological impact resulting in missed or inability to return to work, interventions required.
  • Unknown
• Level of Care Needed
  • None
  • First Aid
  • Employee Health
  • Emergency Department
  • Unknown
• Response Action Taken [multiple checklist]:
  • No Security or Law Enforcement Called
  • Security Called
  • Law Enforcement Called
  • Police Report Completed
  • Physical restraints used
  • Chemical Restraint/Medication administered
  • Seclusion of Patient
  • Pepper Spray Used
  • Handcuffs/Shackles Used
  • De-escalation Techniques
  • Emergency Call/Code

PHASE II DATA COLLECTION:

• Job Title of person impacted.
• Years in occupation (not in specific job or at facility) [dropdown]
  • <1 year
  • 1-2 years
  • 3-4 years
  • 5-9 years
  • 10-15 years
  • 16-20 years
  • 21-25 years
  • 26-30 years
  • 31+ years

Information about Aggressor:

• Gender of Aggressor [dropdown]
  • Male
  • Female
  • Transgender
  • Nonbinary
  • Other
• Age of Aggressor (in years)
• County of Residence [dropdown]
  • Maine Counties Listed
  • Other

Prolonged Impact of Violence:

• Emotional and/or Psychological Impact [dropdown]
  • None – No emotional and/or psychological impact
  • Mild – Upset / Angry / Scared / Humiliated
  • Moderate – Moderate emotional and/or psychological impact with no missed work but return to work with modifications.
  • Severe – Significant Emotional and/or psychological impact resulting in missed or inability to return to work, interventions required.

Additional Contributing Factors to Violence:

• Aggressor’s length of stay [dropdown]
  • Upon Arrival
  • <24 hours
  • 25-48 hours
  • 2-7 days
  • 7-14 days
  • >2 weeks