NURS 6226 Week 10 Implementation Analysis Example

Implementation Analysis: Where the Workplace Violence Prevention Rule Was Remade

Student Name

College of Nursing, Walden University

NURS 6226: Introduction to Healthcare Policy

Instructor Name

Month Day, Year

Implementation Analysis: Where the Workplace Violence Prevention Rule Was Remade

The Final Rule

The composite state's health department adopted its final rule a year after the workplace violence prevention law passed. The rule defines a reportable incident broadly, including verbal threats as well as physical contact; requires each covered facility's prevention plan to include a worksite risk assessment, security measures, a post-incident response and annual training; and requires an annual report of incidents by category to the department. By the first reporting deadline, every covered hospital had a plan on file. Nurses surveyed by their association six months later reported little change on their units.

The Implementation Chain

The rule passes through three layers before it reaches a patient care unit.

Table 1

How the Rule Travels From Agency to Unit

Street-Level Discretion

Lipsky (2010) argued that public policy is in large part made by street-level workers: the people who apply rules to individual cases under heavy workloads, limited resources and ambiguous guidance, and who develop routines to cope. Their discretion is where policy is effectively remade. In this case, the street-level workers are not public employees but hospital staff carrying out a public rule, and the pattern is the same.

A charge nurse on a busy night must decide whether a patient's threat to hit a nurse is an incident under the rule or ordinary behavior from a patient in withdrawal. A security officer called to restrain an agitated patient may record a use-of-force entry but not a workplace violence incident. A clerk may code a bite during restraint as a patient injury rather than violence against staff. Each decision is reasonable in the moment, made with little time and less guidance, and together they mean that threats, the category the rule deliberately added, are classified as behavior rather than incidents and never counted.

This matters because the rule's annual reports will look like evidence of the problem's size while systematically understating it. Underreporting was already the norm before the law: in one U.S. hospital system, most workers who experienced violence did not document it in the incident system (Arnetz et al., 2015), and in a national survey of nurses in Slovenia, formal written reports were made for only a small fraction of violent acts (Kvas & Seljak, 2014). The rule has not changed the conditions that produce underreporting; it has added a definition that frontline staff must apply without support.

Two Levers the Department Holds

First, a simpler reporting form: a one-screen report with the rule's definition built into the choices, including a specific option for verbal threats, which takes less than two minutes to complete. Second, feedback: the department could require each hospital's committee to return a quarterly summary to units showing what their reports led to, such as a security change or a revised care plan. When staff see that reports produce action, the reason to classify events away from the incident system weakens.

References

Arnetz, J. E., Hamblin, L., Ager, J., Luborsky, M., Upfal, M. J., Russell, J., & Essenmacher, L. (2015). Underreporting of workplace violence: Comparison of self-report and actual documentation of hospital incidents. Workplace Health & Safety, 63(5), 200-210. https://doi.org/10.1177/2165079915574684

Kvas, A., & Seljak, J. (2014). Unreported workplace violence in nursing. International Nursing Review, 61(3), 344-351. https://doi.org/10.1111/inr.12106

Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services (30th anniversary expanded ed.). Russell Sage Foundation.