EXECUTIVE SUMMARY
Hospitals have made strides in addressing violence, but still are not proactive enough. Even small incidents of violence should be addressed thoroughly.
- Policies and procedures should focus on prevention and de-escalation.
- Staff must be trained and given the necessary resources.
- Documenting a patient’s history of violence can prevent future incidents.
Hospitals are focusing more on violence and how to prevent it in the healthcare setting, but they still need to adopt a more proactive approach that includes all forms of violence, not just the big notable incidents, experts say.
More hospitals have addressed violence in recent years, partly to comply with requirements or guidelines from The Joint Commission, OSHA, and other regulatory bodies. Most are not going far enough, says Monica Cooke, BSN, MA, RNC, CPHQ, CPHRM, FASHRM, a behavioral risk management and quality improvement consultant with Quality Plus Solutions in Annapolis, MD.
“Healthcare organizations are beginning to get more of an idea that they need to take a stand on workplace violence, but we’re still pretty far behind,” Cooke says. “They’re developing workplace violence programs and policies, but they still tend to be reactive. They are all about how to respond when the event happens, as opposed to a more proactive approach to violence prevention and mitigation.”
Organizations often make the mistake of focusing their efforts on Sentinel Event violence, the unusual incidents such as an active shooter or hostage-taker, Cooke says. Just as important, and perhaps even more so, are the far more common smaller incidents of violence, she says.
“These are the daily incidents of aggression and abuse that staff have to tolerate from patients, visitors, and even staff to staff. This occurs all the time and sometimes doesn’t get the attention it deserves,” Cooke says. “You need the plans in place for the big Sentinel Events, but you also need plans for mitigating the day-to-day aggression. I have not seen a whole lot of that.”
Time to Act
Failing to address those more common incidents can lead to the bigger incidents when aggression is left unchecked and people see there are no consequences for bad behavior, she says. In addition, people are unlikely to be effective in addressing serious incidents of violence if they have not been provided the training and resources to respond to more common everyday incidents, she says.
Hospitals have taken a big step forward in awareness of the problem, Cooke says, and they have changed the healthcare culture so that violence is not seen as an unsolvable problem or a byproduct of clinical work that must be tolerated. The next step, she says, is to produce a meaningful effect on violence.
“It’s time to implement practices, and programs, and systems that can work to minimize the level of aggression in your facility, to prevent it or minimize it,” Cooke says. “We don’t want to wait until the patient is screaming and banging the walls or throwing things before people get alarmed and take action. We need to develop training and promote competency in this among all staff, including receptionists, housekeeping, maintenance, and anyone else that comes into contact with the patients and the public.”
That training should include issues such as what the hospital expects of them when they encounter an aggressive or violent person, methods for de-escalation, and the steps to take before calling for help from security or others, she says.
Response Teams for Violence
Knowing at what point to step back and call for help is a key component of staff training, Cooke says. Also, the organization must determine who is going to respond to that call for help and it’s not always going to be security officers. It might be co-workers or a supervisor, and many hospitals employ rapid response teams (RRTs) similar to the clinical RRTs and code teams that nurses rely on when a patient’s medical condition needs immediate attention.
The violence RRTs include various staff members who have advanced training in de-escalation and physical defense, as well as behavioral health professionals who can talk to the violent person and, if necessary, provide medications.
Without such a resource, the same nurses and other clinicians who depend on clinical RRTs are left with few options in a different kind of emergency, Cooke notes.
“Too many hospitals have a policy that essentially says, ‘Call security.’ In reality, security should be the last resort because their presence often escalates a situation and it can turn into something bigger than it had to be,” Cooke says. “There should be an effort to de-escalate and prevent the violence that will need a security response, and that can only happen if staff are given the right training and resources.”
Code Violet Brings Help
Nationwide Children’s Hospital (NCH) in Columbus, OH, takes a proactive approach to violence, which is especially necessary because the facility treats a high number of young people for behavioral health issues. The hospital’s response plan for violence uses the name “Code Violet,” notes Dan Yaross, MSM, CPP, CHPA, director of security at NCH. A violent patient will prompt staff to call a Code Violet, and that brings representatives from several different departments to help.
The Code Violet response alerts a security offer, nurses, a member of the hospital’s behavioral health crisis management team, the attending physician, and a pharmacist who can provide sedation if necessary.
“Everyone has a role, and we also have enough people to implement safe holds if necessary,” Yaross explains. “De-escalation is the goal, but if we have to go hands-on, we need a number of people with the right training to do that. There’s a specific procedure for controlling each limb and securing the head so they don’t slam it on the floor, and the people on the response team have that training.”
NCH uses a broad definition for violence or aggression that may require intervention, Yaross says. In addition to physical violence, aggression includes verbal threats or passive aggressive comments suggesting a threat, yelling, throwing objects, and body language. All NCH employees have been trained to recognize the signs of potential violence and are authorized to call for help.
“Every employee is authorized to activate Code Violet whenever they see the need,” Yaross says. “We don’t restrict that to just certain people like supervisors or someone else with authority.”
Violent History Documented
For violent persons other than patients, the staff calls a “Code Violet — Security,” which alerts a security officer and, in the evening, the nursing supervisor who is in charge of the hospital at night when administrators are away. These incidents may involve siblings and parents, other visitors, and people who have no business at the hospital but come in off the street and cause a disturbance, Yaross says. (See the story in this issue for information on how NCH screens visitors for security.)
The hospital also notifies the social work department after an incident with a non-patient so they can follow up with family members if they were victims, or with unrelated patients or visitors who may have witnessed the violence.
NCH made the program more proactive over the past couple of years after witnessing harm to employees that could have been mitigated if staff had known certain information beforehand, Yaross says. The hospital now documents any Code Violet in its electronic medical record (EMR) system, and that puts a purple warning banner on the patient’s record. In the notes section, the hospital details the nature of the incident, what triggers to avoid, and anything else that might prevent or de-escalate violence.
“If that record indicates that the only way to control the individual and prevent him or her from verbally abusing staff is to have security present, we will have a security officer right there when the parent arrives with the child,” Yaross explains. “The child sees the officer and behaves. We don’t do that with every child with a history of violence, but we know that’s what works for this family.”
To be even more proactive, the EMR system produces a list every Monday of patients scheduled for appointments at the hospital in the coming week who have a history of violence, Yaross explains. That list is seen by several administrators, including security, which reaches out to the clinic where the patient will be seen. Security alerts the staff that the patient could be violent and offers to have a security officer present with the patient or available nearby, whichever the clinic staff prefer.
“That has been useful in reducing the number of employee injuries because we can anticipate the problem and prevent it, rather than responding after the fact,” Yaross says.
SOURCES
- Monica Cooke, BSN, MA, RNC, CPHQ, CPHRM, FASHRM, Quality Plus Solution, Annapolis, MD. Telephone: (301) 442-9216. Email: [email protected].
- Dan Yaross, MSM, CPP, CHPA, Director of Security, Nationwide Children’s Hospital, Columbus, OH. Email: [email protected].
Hospitals are focusing more on violence and how to prevent it in the healthcare setting, but they still need to adopt a more proactive approach that includes all forms of violence, not just the big notable incidents, experts say.
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