Defuse Tensions and Protect Healthcare Workers with a Mix of Unique Tactics
Too many clinicians have become accustomed to experiencing some aggression and hostility as a daily part of their job. “This is kind of our baseline. A lot of times, we are dealing with people when they are feeling their worst,” says Monica Silva, RN, BSN, an emergency nurse at St. Mary’s Hospital in Tucson, AZ.
Since the start of the COVID-19 pandemic, Silva says the situation has become even worse. “I see that people are becoming more desperate. They are getting evicted from their homes, they have lost their jobs ... and the ED is where people go if they don’t have health insurance,” she says. “Money is tight, so they don’t go to the doctor at the first sign of something; they wait until the last minute when things are desperate, and that is when I see them.”
Silva emphasizes aggression does not just come from patients at the low end of the economic spectrum. Recently, a man verbally abused Silva because he believed staff were not meeting his needs. “I was walking down the hallway ... and a tall, older male came out, leaned over me, and right in my face started swearing,” Silva recalls.
The man, who was intoxicated, told Silva he was a lawyer and that he was going to press charges against everyone in the ED. “When people who are accustomed to being in positions of power get into a situation where they feel powerless, a lot of times those folks will get aggressive,” Silva says. “That incident really stands out in my mind because it was pretty traumatic for me.”
Perceived long wait times irritate many; some may lose it completely if they see someone who arrived later “cut the line” into an exam room. In this scenario, Silva says the best way to ease tension is a one-on-one conversation with the waiting patient. Validate any pain complaints. Make the person feel important. “It is just a matter of giving them some time and attention,” Silva explains. “It doesn’t even take that long, but there is just not enough of me when I am working out [in our lobby] by myself.”
Silva notes she and all of her colleagues have received de-escalation training, but limited time and resources make it difficult to put such skills into action. “If I am actively bandaging someone’s arm, I don’t have time to go de-escalate what is happening,” she says.
In Silva’s view, more staff would allow emergency providers to make those human connections, thereby alleviating the uptick in aggression she has seen in recent months. “I need other staff members to take care of the lobby so that people understand what is going on and don’t make their own assumptions and feel ignored,” she says.
In a nationwide survey of more than 5,000 nurses conducted by National Nurses United and published in September 2021, more than 57% of RNs said staffing has become slightly or much worse, up from 47% of nurses reporting such staffing problems in a March 2021 survey.1 Respondents indicated their facilities were using excessive overtime to staff units.
Also, 31% of hospital RNs indicated they faced a small or significant increase in workplace violence, an increase from the 22% of respondents who indicated such in March 2021. Respondents attributed the increases in workplace violence to staff cuts, changes in the patient population, and fewer visitor restrictions.
Alan Butler, director of safety and security at Cox Health, which operates several hospitals in Missouri, says while the frequency of violence-related events in his hospitals has not changed much in recent months, the severity is much worse.
“You can attribute that to all of the things that have been in our community, whether it is drug or alcohol abuse or behavioral health issues ... obviously, all of those things end up in our hospitals. The main portal for those entries into our hospitals is the ED,” Butler says.
However, Butler also observes how healthcare providers are challenging the public in ways they have not been before, including visitation restrictions and mask mandates. “We screen at every door we have open ... all of a sudden, we have set up specific pandemic ground rules,” he says. “We get lots of arguments, especially about face masks. That is really the biggie. Right down the street at Walmart, people can walk around freely without a mask.”
Regardless of the pushback, Butler says Cox Health is standing firm to protect everyone’s health. “To lose [patients or staff] to COVID because we had loose masking requirements in the hospital just wasn’t an acceptable solution,” he says.
Nonetheless, to deal with any hostility related to the mask requirement or anything else, Butler employs several risk mitigation tactics, ranging from active video management and access control to staff training. “At the end of the day, probably the most valuable tool an organization can give to its staff is training. It starts with de-escalation training and tactics ... but then leans into how [people can] protect [themselves] physically,” Butler explains.
Emergency staff members go through extra training called de-escalation and containment. “The containment piece is really about how you manage those most difficult patients. We try to recognize aggression early,” Butler notes.
In these cases, public safety and security staff members are placed on “patient standby” so they can take action quickly should the situation escalate. Security officers patrolling the ED can make this call, but so can an ambulance crew on the way to a medical facility with an unruly patient. “A lot of times, you can hear people ramping up. It is a matter of working with care providers to understand what is going on in the environment in real time,” Butler says.
One particularly novel technique leverages specially trained canines in the health system’s two busiest EDs in Springfield, MO. Typically, a security officer will appear with one of the dogs when alerted that a patient or family member has begun to show warning signs.
“Data have shown that the canines are very effective at keeping what we call a patient standby from going to a patient restraint,” Butler shares. “In fact, when we show the dog, there is a 30% less likelihood that we have to restrain that particular patient.”
In some cases, the tension dissipates because the dogs are large and intimidating; more often, the technique works because patients like the dogs. “They seem to calm the individual and the situation. We take full advantage of that whenever possible,” Butler says. “We simply call it ‘showing the dog’ in a patient standby situation.”
The canines have been trained for police work, although Butler notes Cox Health does not deploy them in the same way as law enforcement. He notes the dogs are bite-trained, bark-trained, and explosives-trained. “Their handlers are public safety officers. As part of their routine, those dogs and their handlers train eight hours a week together,” Butler reports.
The dogs have been deployed in the Springfield hospitals for almost a year. Staff members love their furry friends. “They are a pretty important part of our team,” Butler says. “We are still not far enough along to understand how we will measure [their impact], but bits and pieces are starting to fall into place that make it very clear there is value in the dogs. If nothing else, the perception of safety that staff members have when the dogs are around is very high.”
Another tool Butler has deployed is a small, wearable tracking device with two types of monitoring sensors. “The buttons are assigned individually to staff members,” Butler explains, noting these personalized panic buttons operate with radio frequency and infrared technologies.
In the ED, the buttons are tied to the call lights outside patient rooms. When a nurse enters the patient room, the light turns green outside the room. When she exits the room, the light turns off. If a nurse presses the button, the signal will immediately prompt public safety officers to respond to that specific location. “Very often, if a situation becomes violent on one of our floors or units, you don’t see one personal panic button, you will see three, four, or five of them [alarming] within seconds of each other,” Butler observes.
The panic buttons were deployed in a Cox Health behavioral health unit before expanding into other units, including EDs and urgent care centers. The device is primarily for nurses, but any staff member who works on a unit or floor covered by this technology can request the button. In addition to investing in panic buttons, Cox Health is replacing its security cameras with newer technology that includes better lenses. It also has equipped all public safety and security officers with body-worn cameras. “If you are involved in any type of incident, you engage your body-worn camera so that we not only get video footage, but we also get audio,” Butler says.
Missouri law does not require security to announce to anyone they are recording, but Butler says these cameras can be used to de-escalate. For example, if someone is acting up in the waiting room, and a security officer announces this behavior is recorded, Butler says that can be enough to defuse the problem.
To find out what security tools an organization needs, Butler says leaders should start by conducting a thorough risk assessment. “Sometimes, it is important to go outside your organization to find a healthcare security professional who has been doing this for a long time,” he says. “Let that new set of eyes come in, see what you are doing, identify where your risks and challenges are, and then [determine] what the best mitigation [tactics] available are.”
Whatever leaders decide, they must understand safety and security personnel cannot operate in a vacuum. “You have to partner with risk management, legal, nursing, compliance,” he says. “There are just so many different bodies inside the hospital. It is imperative that you work with them to build your program.”
REFERENCE
- National Nurses United. National nurse survey reveals that health care employers need to do more to comply with OSHA emergency temporary standard. Sept. 27, 2021.
The focus should be on de-escalating situations before they spiral out of control.
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