Escorts, training, duress signals improve staff safety
High-risk area visits require awareness and support
Actual scenarios: A nurse goes to check on a pediatric patient, and the mother punches her with no provocation.
An estranged husband comes into the house while the home health nurse is teaching the patient’s mother how to do enteral therapy — as he begins physically abusing the mother, he looks at the nurse and says, "You’re next."
A schizophrenic man who is not taking his medication makes advances toward the nurse as she cares for his child.
No home health manager wants his or her employees in any of the situations described above, but they are real incidents that have happened to the employees of Cincinnati Children’s Hospital Medical Center’s Home Care Services. The good news for home care employees in this organization: A comprehensive employee safety program is in place that gives employees the backup they need in these situations.
"Five years ago, we had a nurse punched in the face by a mother with no warning and no provocation," says Carrie Krueger, RN, BSN, clinical director of home care services. That incident prompted a partnership between the hospital’s protective services department and the home care agency that not only is preparing employees to avoid dangerous situations, but also gives them options to use to escape dangerous situations, she explains.
An employee safety program that relied on the use of off-duty police escorts or a two-nurse team for visits to areas or homes that were considered risky had worked to some extent, but it was not always possible to have an off-duty police officer and the two-nurse teams were costly, Krueger adds. "Luckily, we have an excellent in-house protective services staff, and after our nurse was assaulted, we teamed up to provide escorts from protective services for the nurses," she says.
The protective services escorts do not wear uniforms while escorting home care nurses because their hospital uniforms resemble the uniforms of Cincinnati police and would cause confusion or even escalate a situation, says Ron Morris, MA, CPP, CPHA, senior director of protective services at the hospital. "The escorts wear business casual clothing so that they are not confused with the police. The escort car is not marked with any logos or signs that it belongs to the hospital so that people in the neighborhood don’t think that it may contain drugs or needles," he adds.
Because home health nurses’ priority is to take care of their patients, they tend to accept some dangerous situations as necessary to provide care, Krueger notes. "When we started working with protective services, we talked with nurses about situations they encountered so that we could provide training and education they needed," she explains.
The conversations uncovered situations in which nurses have gone into homes with family members cleaning guns during the visit or male family members wearing T-shirts and nothing else during the visit, Krueger says. When asked why they had not reported these incidents, nurses stated that they didn’t think anything could be done, and they didn’t want to abandon their patients, she adds.
One of the first steps Krueger’s agency took was to reassure nurses that they were not abandoning their patients if they did not want to walk into a dangerous situation, she adds. "We emphasized that there are other ways to find care for the child, even if it means rehospitalization. Our first priority is the safety of our employees.
Nurses can leave dangerous settings
Krueger’s nurses are told they can leave a patient’s home or choose not to enter the home if they believe they are in danger. "Even if they have begun an infusion treatment, they can leave," she points out. "We remind our nurses that our goal is to teach the family how to care for the child so they should know how to complete the treatment anyway," Krueger continues.
"When the nurse calls to let us know about the situation, we call the family and explain the situation," she says.
The agency then notifies the referring physician if the patient cannot be seen by home health, and arrangements to provide care are made at outpatient clinics or physician offices, Krueger notes. "We make sure the child receives the care and that the parents receive the teaching they need to provide care for the child, but we also make sure that teaching and care happen in a place that is safe for home health employees," she adds.
"We want nurses to trust their instincts," Morris points out. "Our classes teach them that if they don’t think a behavior is natural, they need to be cautious," he says. Topics in the employee safety classes that are offered on a regular basis include how to deal with difficult people and how to de-escalate a tense or potentially dangerous situation by redirecting the person’s anger or calming them, Morris says. "We also talk about specific situations and examples of what might work for different people," he explains.
While safety classes that include self-defense techniques such as the use of pepper spray and a kubotan (a small baton that can be used as a weapon) give home health employees an extra sense of confidence that they can protect themselves, the agency also makes sure other steps are taken to provide support to employees.
"A cell phone is the simplest safety device for everyone to have, and there is no danger of it being used against you, which can be the case with [pepper spray]," Krueger notes. "We tell employees that they must keep the cell phone on their person," she says. "We don’t want the cell phone left in the car to charge the battery during a visit, and we don’t want it left in a briefcase."
That advice came in handy for one nurse who was in the home when the estranged husband came in and starting assaulting the mother of the agency’s patient.
"The husband threatened the nurse, saying that she was next," Krueger adds. When the nurse discovered that the backdoor to which she had run was locked and she couldn’t unlock it, she crawled into a closet to hide and called 911 on her cell phone that was in her pocket. The police arrived quickly and arrested the husband, Krueger continues. "We then contacted the physician and made arrangements for the child to be seen in an outpatient clinic as opposed to home care."
Another tool developed for home care nurses to use is a "duress phrase," Morris explains. "We came up with a code word that a nurse could use in a telephone conversation with someone in the office to indicate that there was a problem," he says. Within weeks of implementing the code word and educating staff members, a nurse used it, Morris notes.
"The nurse was in the home providing care to the child when the male parent started acting strangely," he explains. The nurse asked to use the phone to return a page and called the office, Morris continues. "When the office staff answered, the nurse stated that she was returning the page and that Lisa’ needed her medication," he adds. "Lisa" is the name of the agency director and is the code word to indicate a problem.
"The nurse told the office her location when she called so we knew where to send the police," Morris says. The advantage of a code word is the nurse can call for help without angering the person in the home and escalating the situation, he adds.
Another important part of the employee safety program is a debriefing whenever an incident does occur, Morris says. "By talking with the employees, we not only reassure them that we care about what happened to them, but also that we want as much information as possible so we can better prepare ourselves and other staff members to avoid that situation in the future," he explains.
Because employee safety courses always include information on the latest trends in safety, it’s important that your safety program constantly evolve, Krueger adds. "When we first started, we didn’t teach nurses how to recognize signs of meth labs or how to prevent carjackings, but crimes in our high-risk areas have changed, so our preparation has to change as well. The key is to make sure employees feel prepared and protected," she notes.
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Four tips to protect your agency’s employees Protecting employees as they travel throughout the area and into many different types of situations often means giving them trainings and tools that can help them avoid, or escape, a dangerous situation. Conversations with home health nurses and aides, as well as review of incidents that have occurred, help you discover what issues need to be addressed, explains Carrie Krueger, RN, BSN, clinical director of home care services at Cincinnati Children’s Hospital Medical Center. Some of the changes or enhancements to her agency’s protocol for visits include: 1. Use a duress signal. A code word or phrase that is known by all staff members is used when a nurse believes he or she may be in a potentially dangerous situation. "The nurse tells the family that a page must be returned, then he or she calls the office," says Krueger. "The staff person who answers the call and hears the duress signal calls the police," she explains. It is important that the nurse give the location by saying, "I’m at [patient’s name] home on [street name]" so the office staff member answering the phone knows the exact location. "It is also important that the office staff member taking the call stay on the phone with the nurse until the police arrive," she points out. If it is not possible to stay on the phone, the nurse should leave the cell phone on and in his or her pocket so others can hear what is going on, Krueger continues. 2. Communicate location. "A nurse should make sure that someone knows where she or he is going at all times," Krueger points out. "During the weekday, it is easy because we have staff in the office and it is easy to check in with each other," she says. "Nurses who go out in the evenings and on weekends need to make sure a family member knows where they are going and how long it should be until they return," Krueger suggests. "Family members should also have a list of contact numbers for managers and supervisors in the agency if the nurse doesn’t return on time and can’t be reached," she adds. 3. Establish good relationship with police. Although the nurses no longer rely upon police escorts for visits into high-risk areas, agency schedulers regularly check in with police in the different districts when a new patient with an address that is in an area that might be high risk is referred to the agency. By talking with a specific, designated contact, the scheduler is able to determine if the location is considered high risk and requires that the nurse have an escort from the protective services group at the hospital, says Krueger. 4. Don’t schedule some visits in evening. "If the patient is located in a known high-risk area, we don’t schedule night visits," Krueger says. If the patient needs care at 11 p.m., have them go to the emergency department, she adds. |
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