30 Volume 82 • Number 1 A D V A N C E M E N T O F T H E PRACTICEA D V A N C E M E N T O F T H E PRACTICE  D I R E C T F R O M C D C E N V I R O N M E N T A L H E A L T H S E R V I C E S I ntroductionEmergency response and recovery work-ers might be exposed to multiple hazard- ous conditions and stressful work environ- ments when responding to a public health emergency. Previous emergency events have demonstrated that significant gaps and defi- ciencies in responder health and safety con- tinue to exist (Michaels & Howard 2012, Newman, 2012). Ensuring the health and safety of emergency response and recovery workers who might be exposed to hazardous conditions and stressful work environments when responding to a public health emer- gency should remain a top priority (Kitt et al., 2011). The National Response Framework contains a Worker Safety and Health Annex detailing responsibilities for safety and health during major emergencies, including roles for the National Institute for Occupational Safety and Health (NIOSH) such as exposure assessment and personal protective equip- ment determination. The NIOSH Emergency Preparedness and Response (EPR) Program was created in 2002 following the events of 9/11, which included attacks on the World Trade Center and Pentagon, and the anthrax letter terrorist attacks. The goal of the NIOSH EPR Program is to coordinate emergency preparedness and response within NIOSH and improve NIOSH’s ability to respond to future emergen- cies and disasters. The NIOSH EPR Program protects the health and safety of emergency response and recovery workers through the advancement of research and collaborations to prevent diseases, injuries, and fatalities in anticipation of and during responses to natu- ral and human-induced disasters and novel emergent events. The NIOSH EPR Program participates in response planning at the local, state, national, and international levels to ensure the timely identification of health hazards associated with emergency responses and implementa- tion of adequate protection measures; support the Centers for Disease Control and Preven- tion’s (CDC) emergency response efforts; and use the Disaster Science Responder Research Program to identify research needs to protect emergency response and recovery workers while identifying solutions to rapidly support research during emergencies. Training for emergency response and recovery workers is an integral part of the NIOSH EPR Program. This column highlights the NIOSH EPR Pro- gram training opportunities and activities. E d i t o r ’s N o t e : NEHA strives to provide up-to-date and relevant information on environmental health and to build partnerships in the profession. In pursuit of these goals, we feature this column on environmental health services from the Centers for Disease Control and Prevention (CDC) in every issue of the Journal. In these columns, authors from CDC’s Water, Fo.

1. 30 Volume 82 • Number 1
A D V A N C E M E N T O F T H E PRACTICEA D V A N C
E M E N T O F T H E PRACTICE
H E A L T H S E R V I C E S
I ntroductionEmergency response and recovery work-ers might
be exposed to multiple hazard-
ous conditions and stressful work environ-
ments when responding to a public health
emergency. Previous emergency events have
demonstrated that significant gaps and defi-
ciencies in responder health and safety con-
tinue to exist (Michaels & Howard 2012,
Newman, 2012). Ensuring the health and
safety of emergency response and recovery
workers who might be exposed to hazardous
conditions and stressful work environments
when responding to a public health emer-
gency should remain a top priority (Kitt et al.,
2011). The National Response Framework
contains a Worker Safety and Health Annex
detailing responsibilities for safety and health
during major emergencies, including roles
for the National Institute for Occupational
Safety and Health (NIOSH) such as exposure
assessment and personal protective equip-
ment determination.

2. The NIOSH Emergency Preparedness
and Response (EPR) Program was created
in 2002 following the events of 9/11, which
included attacks on the World Trade Center
and Pentagon, and the anthrax letter terrorist
attacks. The goal of the NIOSH EPR Program
is to coordinate emergency preparedness
and response within NIOSH and improve
NIOSH’s ability to respond to future emergen-
cies and disasters. The NIOSH EPR Program
protects the health and safety of emergency
response and recovery workers through the
advancement of research and collaborations
to prevent diseases, injuries, and fatalities in
anticipation of and during responses to natu-
ral and human-induced disasters and novel
emergent events.
The NIOSH EPR Program participates in
response planning at the local, state, national,
and international levels to ensure the timely
identification of health hazards associated
with emergency responses and implementa-
tion of adequate protection measures; support
the Centers for Disease Control and Preven-
tion’s (CDC) emergency response efforts; and
use the Disaster Science Responder Research
Program to identify research needs to protect
emergency response and recovery workers
while identifying solutions to rapidly support
research during emergencies. Training for
emergency response and recovery workers is
an integral part of the NIOSH EPR Program.
This column highlights the NIOSH EPR Pro-
gram training opportunities and activities.

3. E d i t o r ’s N o t e : NEHA strives to provide up-to-date and
relevant
information on environmental health and to build partnerships
in the
profession. In pursuit of these goals, we feature this column on
environmental
health services from the Centers for Disease Control and
Prevention (CDC)
in every issue of the Journal.
In these columns, authors from CDC’s Water, Food, and
Environmental
Health Services Branch, as well as guest authors, will share
insights and
information about environmental health programs, trends,
issues, and
resources. The conclusions in these columns are those of the
author(s) and
do not necessarily represent the official position of CDC.
Kerton Victory is an environmental health specialist and
emergency
coordinator with the National Institute for Occupational Safety
and
Health’s (NIOSH) Emergency Preparedness and Response
Office (EPRO).

4. Jill Shugart is a senior environmental health specialist and the
Emergency
Responder Health Monitoring and Surveillance coordinator with
NIOSH
EPRO. Sherry Burrer is a senior epidemiologist and emergency
coordinator
with NIOSH EPRO. Chad Dowell is the NIOSH deputy associate
director for
emergency preparedness and response. Lisa Delaney is the
NIOSH associate
director for emergency preparedness and response.
Insights Into the National Institute
for Occupational Safety and
Health’s Emergency Preparedness
and Response Program
1 figure, 1 table, 1 photo, 1 sidebar, 5 authors
Kerton R. Victory, MSc, PhD, REHS
Jill Shugart, MSPH, REHS
Sherry Burrer, MPH-VPH, DVM, DACVPM
Chad H. Dowell, MS, CIH
Lisa J. Delaney, MS, CIH
National Institute for
Occupational Safety and Health
JEH7.19_PRINT.indd 30 6/14/19 9:53 AM

5. July/August 2019 • Journal of Environmental Health 31
A D V A N C E M E N T O F T H E PRACTICEA D V A N C
E M E N T O F T H E PRACTICE
Training Opportunities
and Activities
The NIOSH EPR Program has trained over
1,000 public health professionals and emer-
gency responders through its Emergency
Responder Health Monitoring and Sur-
veillance (ERHMS) training courses from
2015−2018 (Table 1). ERHMS is a health
monitoring and surveillance framework
that includes recommendations and tools
specific to protect emergency responders
during all phases of a response—prede-
ployment, deployment, and postdeploy-
ment (Shugart, 2017). The goals of ERHMS
are to prevent short- and long-term illness
and injury in emergency responders and
to ensure workers can respond safely and
effectively to future emergencies. ERHMS
principles are scalable to both small and
large events, including federal-, state-,
local-, tribal-, and territorial-level responses
(Figure 1).
In addition to ERHMS, the NIOSH EPR
Program also created a responder health
and safety training module for CDC’s En-
vironmental Health Training in Emergency
Response and Public Health Readiness

6. Certificate Program courses. These courses
are offered to CDC staff, as well as to other
federal, state, and local health agencies, and
have trained over 450 public health profes-
sionals from 2015−2018 (Table 1). The re-
sponder safety and health training module
highlights the importance of critical per-
sonnel, equipment, training, and other re-
sources needed to ensure that all workers
are protected from all hazards during a pub-
lic health emergency. While space is limited
to attend these in-person trainings, anyone
wishing to attend this course can contact
CDC’s School of Preparedness and Emer-
gency Response.
The NIOSH EPR Program also developed
a number of free courses that are offered on
NIOSH’s website. Recognizing that many re-
sponse and recovery workers are required to
work long hours during responses, NIOSH
developed the Interim NIOSH Training for
Emergency Responders: Reducing Risks As-
sociated With Long Work Hours to describe
personal strategies to promote good sleep
and other safe work practices during a pub-
lic health emergency. Additionally, the NIOSH
EPR Program developed the Anthrax: Instruc-
tor Training in 2014. The training is a collec-
Overview of the Emergency Responder Health Monitoring and
Surveillance Info Manager software tool developed by the
National Institute for Occupational Safety and Health’s
Emergency
Preparedness and Response Program

7. FIGURE 1
Number of Public Health Professionals Who Completed the
ERHMS
and Responder Health and Safety Training Modules for EHTER
and
PHRCP Courses, 2015−2018
Year ERHMS EHTER PHRCP Total
2015 255 19 − 274
2016 255 85 61 401
2017 225 70 83 378
2018 210 72 59 341
Total 945 246 203 1,394
ERHMS = Emergency Responder Health Monitoring and
Surveillance; EHTER = Environmental Health Training in
Emergency Response; PHRCP = Public Health Readiness
Certificate Program.
TABLE 1
JEH7.19_PRINT.indd 31 6/14/19 9:53 AM
32 Volume 82 • Number 1
A D V A N C E M E N T O F T H E PRACTICE
tion of train-the-trainer resources including

8. a slide presentation, videos, and handouts to
teach responders how to collect, decontami-
nate, and ship samples. Sampling procedures
taught in the training follow CDC’s recom-
mended gold-standard surface sampling pro-
cedures for Bacillus anthracis spores (Photo 1).
Through course feedback and program
evaluation, the NIOSH EPR Program con-
tinues to refi ne and update its trainings and
preparedness activities for the next genera-
tion of public health professionals and emer-
gency responders. The program also actively
works with other federal agencies such as
the Federal Emergency Management Agen-
cy, as well as state and local health agencies
and other stakeholders, to integrate key
components of responder health and safety
into new and existing trainings and provide
technical assistance to these agencies. More
information about the NIOSH EPR Program
can be found on its website (see Quick
Links).
Corresponding Author: Kerton R. Victory,
Environmental Health Specialist, Centers
for Disease Control and Prevention/National
Institute for Occupational Safety and Health,
1600 Clifton Road, MS E-20, Atlanta, GA
30329. E-mail: [email protected]
References
Kitt, M.M., Decker, J.A., Delaney, L., Funk,
R., Halpin, J., Tepper, A., . . . Howard, J.
(2011). Protecting workers in large-scale

9. emergency responses: NIOSH experience
in the Deepwater Horizon response. Jour-
nal of Occupational and Environmental Med-
icine, 53(7), 711–715.
Michaels, D., & Howard, J. (2012, July 18).
Review of the OSHA-NIOSH response to
the Deepwater Horizon oil spill: Protecting
the health and safety of cleanup workers.
PLOS Currents Disasters, Edition 1.
Newman, D.M. (2012). Protecting disas-
ter responder health: Lessons (not yet?)
learned. NEW SOLUTIONS: A Journal of
Environmental and Occupational Health
Policy, 21(4), 573–590.
Shugart, J.M. (2017). Utilizing the Emer-
gency Responder Health Monitoring and
Surveillance System to prepare for and
respond to emergencies. Journal of Envi-
ronmental Health, 80(4), 44–46.
• National Institute for Occupational
Safety and Health’s (NIOSH)
Emergency Preparedness and
Response Program: www.cdc.gov/
niosh/programs/epr/default.html
• Emergency Responder Health
Monitoring and Surveillance: www.
cdc.gov/niosh/erhms/default.html
• Interim NIOSH Training for
Emergency Responders: Reducing

10. Risks Associated With Long Work
Hours: www.cdc.gov/niosh/emres/
longhourstraining
• Anthrax: Instructor Training: www.
cdc.gov/niosh/topics/anthrax/
training.html
Quick Links
Photo 1. The National Institute for Occupational Safety and
Health’s (NIOSH) Emergency
Preparedness and Response Program staff demonstrate how to
sample for Bacillus anthracis spores.
Photo courtesy of NIOSH.
A credential today can improve all your tomorrows.
Choosing a career that protects the basic
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people in your communities already proves
that you have dedication. Now, take the
next step and open new doors with the
Registered Environmental Health Specialist/
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JEH7.19_PRINT.indd 32 6/14/19 9:53 AM

11. Copyright of Journal of Environmental Health is the property of
National Environmental
Health Association and its content may not be copied or emailed
to multiple sites or posted to
a listserv without the copyright holder's express written
permission. However, users may
print, download, or email articles for individual use.
10 American Nurse Today Volume 13, Number 5
AmericanNurseToday.com
ROBERT, a 78-year-old patient, re-
quests help getting to the bath-
room. When the nurse, Ellen, en-
ters the room, Robert’s lying in
bed, but when she introduces her-
self, he lunges at her, shoves her to
the wall, punches her, and hits her
with a footstool. Ellen gets up from
the floor and leaves the patient’s
room. She tells her colleagues what

12. happened and asks for help to get
the patient to the bathroom. At the
end of the shift, Ellen has a
swollen calf and her shoulder
aches. One of her colleagues asks
if she’s submitted an incident re-
port. Ellen responds, “It’s all in a
day’s work. The patient has so
many medical problems and a his-
tory of alcoholism. He didn't in-
tend to hurt me. What difference
would it make if I filed a report?”
These kinds of nurse-patient in-
teractions occur in healthcare set-
tings across the United States, and
nurses all too frequently minimize
their seriousness. However, accord-
ing to the National Institute for Oc-

13. cupational Safety and Health, “…
the spectrum [of violence]…ranges
from offensive language to homi-
cide, and a reasonable working
definition of workplace violence is
Patient violence:
It’s not all in a day’s work
Strategies for reducing patient violence and
creating a safe workplace
By Lori Locke, MSN, RN, NE-BC; Gail Bromley, PhD, RN;
Karen A. Federspiel, DNP, MS, RN-BC, GCNS-BC
AmericanNurseToday.com
May 2018 American Nurse Today 11
as follows: violent acts, including
physical assaults and threats of as-
sault, directed toward persons at
work or on duty.” In other words,
patient violence falls along a con-
tinuum, from verbal (harassing,

14. threatening, yelling, bullying, and
hostile sarcastic comments) to
physical (slapping, punching, bit-
ing, throwing objects). As nurses,
we must change our thinking: It’s
not all in a day’s work.
This article focuses on physical
violence and offers strategies you
can implement to minimize the
risk of being victimized.
Consequences of patient
violence
In many cases, patients’ physical vi-
olence is life-changing to the nurses
assaulted and those who witness it.
(See Alarming statistics.) As a re-
sult, some nurses leave the profes-
sion rather than be victimized—a
major problem in this era of nurs-

15. ing shortages.
Too frequently, nurses consider
physical violence a symptom of the
patient’s illness—even if they sus-
tain injuries—so they don’t submit
incident reports, and their injuries
aren’t treated. Ultimately, physical
and psychological insults result in
distraction, which contributes to a
higher incidence of medication er-
rors and negative patient outcomes.
Other damaging consequences in-
clude moral distress, burnout, and
job dissatisfaction, which can lead
to increased turnover. However,
when organizations encourage
nurses to report violence and pro-
vide education about de-escalation

16. and prevention, they’re able to alle-
viate stress.
Workplace violence prevention
Therapeutic communication and as-
sessment of a patient’s increased
agitation are among the early clini-
cal interventions you can use to
prevent workplace violence. Use
what you were taught in nursing
school to recognize behavioral
The statistics around patient violence against nurses are
alarming.
67% of all nonfatal workplace violence injuries occur in
healthcare, but health-
care represents only 11.5% of the U.S. workforce.
Emergency department (ED) and psychiatric nurses are at
highest risk for patient violence.
Hitting, kicking, beating, and shoving incidents are most
reported.
25% of psychiatric nurses experience disabling injuries from
patient assaults.
At one regional medical center, 70% of 125 ED nurses were

17. physically assaulted in 2014.
Sources: Emergency Nurses Association (ENA) Emergency
department violence surveillance study 2011;
ENA Workplace violence toolkit 2010; Gates 2011; Li 2012.
Alarming statistics
Effective communication is the first line of defense against
patient violence. These
tips can help:
• To build trust, establish rapport and set the tone as you
respond to patients.
• Meet patients’ expectations by listening, validating their
feelings, and respond-
ing to their needs in a timely manner.
• Show your patients respect by introducing yourself by name
and addressing
them formally (Mr., Ms., Mrs.) unless they state another
preference.
• Explain care before you provide it, and ask patients if they
have questions.
• Be attentive to your body language, gestures, facial
expressions, and tone of
voice. Patients’ behavior may escalate if they perceive a loss of
control, and
they may not hear what you say.
• Control your emotions and maintain neutral, nonthreatening

18. body language.
• Strive for communication that gives the patient control, when
possible. Example:
“Which of your home morning routines would you like to follow
while you’re in
the hospital? Would you like to wash your hands and face first,
eat your break-
fast, and then brush your teeth?”
• Offer a positive choice before offering less desirable ones.
Example: “Would
you prefer to talk with a nurse about why you’re upset, or do
you feel as
though you will be so angry that you need to have time away
from others?”
• Only state consequences if you plan to follow through.
• Listen to what patients say or ask, and then validate their
requests.
• Discuss patients’ major concerns and how they can be
addressed to their sat-
isfaction.
Despite these strategies, patients may still become upset. If that
occurs, try these
strategies to de-escalate the situation before it turns violent.
• Nonverbal communication. “I see from your facial expression
that you may
have something you want to say to me. It’s okay to speak

19. directly to me.”
• Challenging verbal exchange. “My goal is to be helpful to you.
If you have
questions or see things differently, I’m willing to talk to you
more so that we
can understand each other better, even if we can’t agree with
one another.”
• Perceptions of an incident or situation. “We haven’t discussed
all aspects of
this situation. Would you like to talk about your perceptions?”
Communication strategies
12 American Nurse Today Volume 13, Number 5
AmericanNurseToday.com
changes, such as anxiety, confu-
sion, agitation, and escalation of
verbal and nonverbal signs. Individ-
ually or together, these behaviors
require thoughtful responses. Your
calm, supportive, and responsive
communication can de-escalate pa-
tients who are known to be poten-

20. tially violent or those who are an-
noyed, angry, belligerent, demeaning,
or are beginning to threaten staff.
(See Communication strategies.)
Other strategies to prevent work-
place violence include applying
trauma-informed care, assessing for
environmental risks, and recognizing
patient triggers.
Trauma-informed care
Trauma-informed care considers the
effects of past traumas patients ex-
perienced and encourages strategies
that promote healing.
The Substance Abuse and Mental
Health Services Administration says
that a trauma-informed organization:
• realizes patient trauma experi-

21. ences are widespread
• recognizes trauma signs and
symptoms
• responds by integrating knowl-
edge and clinical competencies
about patients’ trauma
• resists retraumatization by being
sensitive to interventions that
may exacerbate staff-patient in-
teractions.
This approach comprises six
principles: safety; trustworthiness
and transparency; peer support;
collaboration and mutuality; em-
powerment, voice, and choice;
and cultural, historical, and gender
issues. Applying these principles
will enhance your competencies

22. so that you can verbally intervene
to avoid conflict and minimize pa-
tient retraumatization. For more
about trauma-informed care, visit
samhsa.gov/nctic/trauma-interventions.
Environmental risks
To ensure a safe environment, iden-
tify objects in patient rooms and
nursing units that might be used to
injure someone. Chairs, footstools,
I.V. poles, housekeeping supplies,
and glass from lights or mirrors can
all be used by patients to hurt them-
selves or others. Remove these ob-
jects from all areas where violent
patients may have access to them.
Patient triggers
Awareness of patient triggers will
help you anticipate how best to in-

23. teract and de-escalate. (See Patient
triggers.) Share detailed information
about specific patient triggers dur-
ing handoffs, in interdisciplinary
planning meetings, and with col-
leagues in safety huddles.
What should you do?
You owe it to yourself and your fel-
low nurses to take these steps to
ensure that your physical and psy-
chological needs and concerns are
addressed:
• Know the definition of work-
place violence.
• Take care of yourself if you’re
assaulted by a patient or witness
violence.
• Discuss and debrief the incident
with your nurse manager, clinical

24. supervisor, and colleagues.
• Use the healthcare setting’s inci-
dent reporting to report and doc-
ument violent incidents and in-
juries.
• File charges based on your
state’s laws.
Your organization should pro-
vide adequate support to ensure
that when a nurse returns to work
after a violent incident, he or she
is able to care for patients. After
any violent episode, staff and nurse
leaders should participate in a thor-
ough discussion of the incident to
understand the dynamics and root
cause and to be better prepared
to minimize future risks. Effective

25. communication about violent pa-
tient incidents includes handoffs
that identify known risks with spe-
cific patients and a care plan that
includes identified triggers and clin-
ical interventions.
Influence organizational safety
You and your nurse colleagues are
well positioned to influence your
organization’s culture and advocate
for a safe environment for staff and
patients. Share these best practices
with your organization to build a
comprehensive safety infrastructure.
• Establish incident-reporting sys-
tems to capture all violent inci-
dents.
• Create interprofessional work-

26. place violence steering commit-
tees.
• Develop organizational policies
and procedures related to safety
and workplace violence, as well
as human resources support.
• Provide workplace violence-pre-
vention and safety education us-
ing evidence-based curriculum.
• Design administrative, director,
and manager guidelines and re-
sponsibilities regarding commu-
nication and staff support for
victims of patient violence and
those who witness it.
• Use rapid response teams (in-
cluding police, security, and pro-
Recognizing and understanding pa-

27. tient triggers may help you de-esca-
late volatile interactions and prevent
physical violence.
Common triggers
• Expectations aren’t met
• Perceived loss of independence
or control
• Upsetting diagnosis, prognosis,
or disposition
• History of abuse that causes an
event or interaction to retrauma-
tize a patient
Predisposing factors
• Alcohol and substance withdrawal
• Psychiatric diagnoses
• Trauma
• Stressors (financial, relational, sit-
uational)

28. • History of verbal or physical vio-
lence
Patient triggers
tective services) to respond to
violent behaviors.
• Delineate violence risk indicators
to proactively identify patients
with these behaviors.
• Create scorecards to benchmark
quality indicators and outcomes.
• Post accessible resources on the
organization’s intranet.
• Share human resources contacts.
Advocate for the workplace you
deserve
Physically violent patients create
a workplace that’s not conducive
to compassionate care, creating
chaos and distractions. Nurses
must advocate for a culture of
safety by encouraging their organ-
ization to establish violence-pre-
vention policies and to provide
support when an incident occurs.
You can access violence-preven-

29. tion resources through the Ameri-
can Nurses Association, Emergency
Nurses Association, Centers for Dis-
ease Control and Prevention, and
the National Institute for Occupa-
tional Safety and Health. Most of
these organizations have interactive
online workplace violence-preven-
tion modules. (See Resources.) When
you advocate for safe work envi-
ronments, you protect yourself and
can provide the care your patients
deserve.
The authors work at University Hospitals of Cleve-
land in Ohio. Lori Locke is the director of psychiatry
service line and nursing practice. Gail Bromley is the
co director of nursing research and educator. Karen A.
Federspiel is a clinical nurse specialist III.
Selected references
Cafaro T, Jolley C, LaValla A, Schroeder R.
Workplace violence workgroup report. 2012.
apna.org/i4a/pages/index.cfm?pageID=4912
Emergency Nurses Association. ENA toolkit:
Workplace violence. 2010. goo.gl/oJuYsb
Emergency Nurses Association, Institute for

30. Emergency Nursing Research. Emergency
Department Violence Surveillance Study.
2011. bit.ly/2GvbJRc
Gates DM, Gillespie GL, Succop P. Violence
against nurses and its impact on stress and
productivity. Nurs Econ. 2011;29(2):59-66.
National Institute for Occupational Safety
and Health. Violence in the workplace:
Current intelligence bulletin 57. Updated
2014. cdc.gov/niosh/docs/96-100/introduc
tion.html
Occupational Safety and Health Administra-
tion. Guidelines for Preventing Workplace
Violence for Healthcare and Social Service
Workers. 2016. osha.gov/Publications/osha
3148.pdf
Speroni KG, Fitch T, Dawson E, Dugan L,
Atherton M. Incidence and cost of nurse

31. workplace violence perpetrated by hospital
patients or patient visitors. J Emerg Nurs.
2014;40(3):218-28.
Substance Abuse and Mental Health Servic-
es Administration. Trauma-informed ap-
proach and trauma-specific interventions.
Updated 2015. samhsa.gov/nctic/trauma-
interventions
Wolf LA, Delao AM, Perhats C. Nothing
changes, nobody cares: Understanding the
experience of emergency nurses physically
or verbally assaulted while providing care. J
Emerg Nurs. 2014;40(4):305-10.
• American Nurses Association (ANA) (goo.gl/NksbPW): Learn
more about
different levels of violence and laws and regulations, and access
the ANA posi-
tion statement on incivility, bullying, and workplace violence.
• Centers for Disease Control and Prevention

32. (cdc.gov/niosh/topics/vio-
lence/training_nurses.html): This online course (“Workplace
violence preven-
tion for nurses”) is designed to help nurses better understand
workplace vio-
lence and how to prevent it.
• Emergency Nurses Association (ENA) toolkit (goo.gl/oJuYsb):
This toolkit
offers a five-step plan for creating a violence-prevention
program.
• The Joint Commission Sentinel Event Alert: Physical and
verbal violence
against health care workers (bit.ly/2vrBnFw): The alert,
released April 17,
2018, provides an overview of the issue along with suggested
strategies.
Resources Screen & Intervene:
Addressing Food
Insecurity Among
Older Adults
FREE Online Course
Check out

33. the course today at
senior health and hunger.org
Hunger is a
health issue.
People experiencing food
insecurity are more likely to
suffer from chronic
conditions such as
diabetes, heart disease and
depression. In just 60
minutes, health care
providers and community-
based partners can learn
how to screen patients age
50 and older for food
insecurity and connect
them to key nutrition
resources.

34. This Enduring Material activity, Screen and
Intervene: Addressing Food Insecurity
Among Older Adults, has been reviewed
and is acceptable for up to 1.00 Elective
credit(s) by the American Academy of
Family Physicians. AAFP certification
begins 10/28/2017. Term of approval is
for one year from this date. Physicians
should claim only the credit commensurate
with the extent of their participation in the
activity.
AmericanNurseToday.com
May 2018 American Nurse Today 13
http://www.feedingamerica.org/research/senior-hunger-
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individual use.
1/27/2020
Hiring a coder: How to recruit and retain the
right candidate

36. PART 1: SUMMARY.
According to Kimberly Clark, the main cause of o lost revenue
in medical practice is inaccurate coding which shows just how
significant it is to have a professional coder on the staff.
Because of the demand available for skilled coders, it is a
challenge to find and recruit the right candidate due to the
competition available for the employers. Ms. Clark therefore
suggests training an internal employee within the organization
or company who the company preferentially wants to retain to
have those coding skills instead of hiring an outsider. However,
if this option is not available, Ms. Clark suggests 5 tips to help
recruit a coder: determine your coding needs, describe your
ideal candidate, create a compelling job advertisement,
recruiting from the right place and asking the right questions.
These tips are meant to establish the roles and responsibilities
of the coder, their qualifications, where to find them as well as
the right questions to ask so as to identify if you are hiring the
right person for the job. She particularly emphasizes on the
need to focus on the skills that the person has and not just
hiring anybody to fill up the position.

37. PART 2: PROBLEM.
I have previously worked at the North-western memorial
hospital in the position of a nurse on internship. During my
internship, I noticed several documentation issues that arose at
the hospital. There was only one coder who was often
overwhelmed by the magnitude of the work from the patients.
Some documentations went missing from the patient files or
were simply not documented due to poor follow up. In some
cases, the information provided to the coders was not enough
leading to the problem of not coding to the highest level. The
coder sometime reported less expensive or more expensive
medical services than was actually performed hence leading to
the problem of under coding or over coding due to lack of
system audits.
PART 3: HR INITIATIVE.
The HR team needs to take initiatives to change their perception
of the importance of a coder in the health care sector. As Ms.
Clark puts it in her article, it is very important to have a
professional coder as part of the medical staff. They therefore
need to hire more professional coders to be part of the medical
staff. Hiring coders from outside would help to manage the huge
volume of information that needs to be coded at the healthcare
facility and enable a smooth flow of work. A better solution that
the HR team can come up with is training part of their staff in
coding so that they avoid the high costs of hiring a coder from
outside. The HR team may still hire a professional coder from
outside but they need to change their hiring criteria so as to hire
the right person by following the five tips given by Ms. Clark in
her article. The HR team needs to focus not just on the skills
but also the ethics of the coders such that they are able to
record the true values of the medical services in order to
eliminate the problem of under coding and over coding. The HR
team might also introduce human resource assessment and audit
plans so as to get reduce the instances of infidelity or doing
substandard work than is required. This would prevent the
providers from giving incomplete or less information to the

38. coders hence eliminating the problem of failing to code to the
highest level. Automating the process and using up to date
protocols would also help to fast track the speed of the work
hence reducing piling of information that needs to be coded.
PART 4: IMPLEMENTATION CHALLENGE.
The implementation challenge that is likely to emerge include
ethical challenges. If the hired person has no ethics, they may
increase the problem of under coding or over coding as well as
not coding to the highest level. Furthermore, if part of the
employees is trained to code, they may have a conflict of
interest between their initial work and coding. Apart from the
training interfering with their initial work, trainees may also opt
for another job in the more lucrative coding field.
PART 5: EVALUATION.
To evaluate the impact of the HR initiative, the organization
may use statistical tallying of the number of recorded cases of
over coding, under coding or failing to code to the highest
level. Self-appraisal of the employees including the coders and
the providers of information can also help to ensure accuracy in
coding.
References
Heywood, N. A., Gill, M. D., Charlwood, N., Brindle, R.,
Kirwan, C. C., Allen, N., ... &Forrest, L. (2016). Improving
accuracy of clinical coding in surgery.
Sehjal, R., & Harries, V. (2016). Awareness of clinical coding.

39. Scoring Guide (20% for each section)
Part 1: Article Summary
In 3 or 4 sentences the student correctly and clearly summarizes
the key points in the chosen article. Make sure the exact title of
the article and the author(s) is identified in the first sentence or
in the heading above this section.
Part 2: Problem section
In a paragraph or two the student briefly describes their current
or former company. Then the student describes a problem or
issue this company is having that relates to the article in part 1.
The student’s writing is clear, complete, and professional.
Part 3: HR initiative section
The student comes up with a HR initiative that addresses the
problem described in part 2. The student’s writing is clear,
complete, and professional.
Part 4: Implementation challenge section
The student identifies a major implementation challenge
associated with his/her initiative described in part 3. The
student’s writing is clear, complete, and professional.
Part 5: Evaluation section
The student describes how he/she would evaluate the success of
his/her initiative. The criteria that will be used and when the
data will be collected is also described in this section. The
student’s writing is clear, complete, and professional.
Please make sure you use these headings in your paper so it’s
clear to me when one section ends and the next one begins.