Take time to consider the other hospital crisis
By Linda K. Steiger, President
Crisis Prevention Institute
Brookfield, WI
When we think about the word "crisis" in a hospital setting, we are usually thinking about a medical crisis — a serious situation requiring immediate intervention on the part of health care professionals. But there is another type of crisis that occurs in hospitals: the behavioral crisis that takes place when a patient loses rational control and sometimes even becomes a danger to himself or others.
This latter type of crisis can occur in any area of a hospital, and patient access departments are among the most common sites. The stress of upcoming surgery, concern about a relative in the emergency department (ED), or a long wait for admission can trigger difficult behavior in patients and family members.
This behavior may include sarcasm, belligerence, name calling, yelling, threats, and even physical aggression. Are your patient access personnel trained to prevent and intervene in this type of crisis situation?
Prevention
First of all, it is important to recognize that most verbal or physical aggression is preceded by signs of anxiety. These signs are usually nonverbal, but for the trained observer, they are a powerful warning that trouble is brewing. Common signs of anxiety include pacing, rocking, and fidgeting. If employees are taught to recognize signs of anxiety and intervene in a helpful and supportive way, many potentially violent incidents can be prevented.
It is also important to recognize crisis "hot spots" — areas of your hospital where anxiety is especially high and incidents are more likely to occur. Access managers are well aware that waiting areas, especially in the ED, are very anxiety-producing for patients and family members. Extra effort on the part of hospital staff or volunteers to reduce waiting times, communicate regularly with those who are waiting, and provide amenities or distractions to pass the time can pay off in lowered levels of anxiety and fewer crisis situations.
Verbal intervention
Sometimes patients move beyond the anxiety stage and become defensive. At this stage, the patient might be challenging, belligerent, insulting, or perhaps threatening. At this verbally aggressive stage, health care employees still have the opportunity to intervene in a way that can prevent further escalation of the crisis situation. They should be trained to set firm, polite limits with a patient or family member who is shouting and/or making threats.
Setting limits is an extremely useful strategy for handling the noncompliant or verbally abusive person. Such individuals are beginning to lose rational control, and setting limits is a way to help them regain control by providing choices and consequences. (See box on setting effective limits, below.)
Skilled limit-setters recognize that they cannot force anyone to do anything. Therefore, they are able to avoid power struggles and are far more likely to obtain positive results than their untrained counterparts.
Other strategies that often work well at this stage include ignoring inappropriate or challenging questions, allowing patients to vent, and letting patients and family members know that threats will be taken seriously and will be met with appropriate consequences.
Physical intervention
Although prevention and limit-setting often are successful in defusing a potential crisis situation, there are times when physical aggression occurs, and patients become a danger to themselves or others.
Research shows that health care personnel are frequent recipients of physical aggression by patients — so much so that it often is seen as "part of the job." Once again, training is extremely important if staff are to be prepared to deal with such difficult and dangerous behavior.
Two types of training are necessary to successfully cope with physical aggression. All hospital staff need to know how to protect and free themselves from a situation in which a patient or other party attempts to assault them in some way, whether by hitting, kicking, grabbing, or choking. Personal safety techniques that can protect and free the staff member without hurting the patient are key.
Secondly, a crisis response team should be trained to safely and effectively restrain an individual who is out of control and dangerous. A therapeutic physical intervention is necessary to assist the person in regaining control. Physical crisis intervention should always be performed by a team and used only as a last resort when patients are truly in danger of hurting themselves or others.
Post-vention’
In addition to the crisis stages already discussed — the anxiety level, the defensive level, and the physically acting out level — there is one crisis stage that often is overlooked. It is the time after the crisis is over when the patient experiences a reduction in tension and a return to rational thought.
In Greek, the word crisis means "turning point." Just as a medical crisis involves a turning point in regard to a patient’s physical well-being, a behavioral crisis also is a turning point. Usually, the period after a crisis is a time of increased vulnerability and openness to change. It is important for staff to use this time to re-establish rational communication with the person who has acted out, in hopes of minimizing or preventing future crisis situations. Staff members may need their own "post-vention" through a debriefing session.
The role of training
Dealing with difficult behavior is a critical skill for patient access employees, who often represent the first contact that patients have in a hospital. Effective training provides employees with a variety of strategies and tools so they can be prepared, flexible, and confident when confronted with agitated or aggressive behavior from patients or family members.
(Editor’s note: Crisis Prevention Institute (CPI) provides violence prevention training worldwide. Since 1980, more than 2.5 million individuals have participated in CPI training programs, including employees from hundreds of hospitals in the United States and Canada.)
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