THE MAGAZINE

Nurses On Guard

By Ann Longmore-Etheridge

Baystate Health, headquartered in Springfield, Massachusetts, is a three-hospital, multiple-treatment-center system with nearly 10,000 employees. The hospital considers customer service as important as good healthcare—so much so that Baystate Health has measured customer satisfaction since 2001 through patient studies that are conducted by an outside consultant. But when family members or other visitors exhibit threatening behavior, security, rather than service, needs to be central in the minds of staffers.

Perhaps because stress is high, verbal abuse or threats of violence occur fairly regularly in hospital settings. Sometimes family members are demanding more or different care for the patient, but that’s not always the cause of the bad behavior.

“Sometimes it doesn’t have to be about the patient’s care at all. It can be, for example, caused by a brother and a sister who are estranged. Now mom or dad is in the hospital, and the two of them end up in the same place at the same time. Whatever sparked the original separation boils up and suddenly you have two people arguing over the bed,” says Thomas Lynch, Baystate Health’s director of security.

Lynch says that, in addition to abuse directed at staff, he has seen confrontations between just about every combination of family members.

When problems occur, security should be called in to lay down expected standards of behavior and address the specific situation—for example, by setting up separate visiting hours for each party in the dispute. But Lynch discovered that nurses at his facility were hesitating to call security in, thinking instead that they should bear the abuse and focus on customer service.

To address that issue, the hospital developed a new program of staff training and a new security mind-set of eliciting incident information about how nurses were being treated on a daily basis rather than waiting for some misbehavior to balloon into a more serious problem.

Problem Child
The need for the program became clear in August 2005, when an elderly man was brought from a nursing facility to a hospital to treat a chronic ailment. The man had three children who regularly visited. One son and a daughter usually dropped by during the day, and their interactions with staff were without incident. That was not the case with the second son, who visited at night. He became “more and more insistent about certain things, and more and more critical about almost every aspect of care,” says Lynch.

The floor nurses could not appease the son, nor could the nurse manager. When the father’s condition worsened, necessitating his transfer to another ward, the son’s behavior grew worse. For example, he would lean out of his father’s room, snap his fingers, and yell, “Here, puppy!” to summon the nurses.

Finally, says Lynch, “He went over the top completely. A nurse came in and tried to address his concerns about a treatment issue. As she was leaving, he threw the bedpan at her.” At this, the unit staff finally called security, and officers swiftly ejected the son.

The next day, as per security policy, a meeting about the incident was convened with the staff to determine whether the son should be allowed back. Baystate Health’s strong customer service position maintains that if a patient wants or benefits from a visitor, that individual should not be excluded.

Lynch was expecting to hear the details of a lone incident and to set the son’s visitation boundaries proportionately, but instead he heard about a string of aggressive encounters that had been taking place since the father’s admission to the hospital. Lynch was flabbergasted. “They didn’t call security. They were trying to manage this situation on the unit with the resources that they had.”

The nurses rationalized that it is not uncommon for people to be demanding—and for some to be much more demanding than others. Lynch suspected, however, that the son was abusive by nature, and interacting with female nurses exacerbated his tendencies. He was not, for example, equally abusive to the mostly male doctors.

The hospital was able to control the son’s behavior by setting clear rules for him to follow as a condition of retaining visiting privileges.

Before he could return to the hospital for regular visits, he was asked to meet with a security supervisor and a nurse manager. They told him that if he had a problem with his father’s treatment in the future, he should speak only to the nurse manager. If he was not satisfied with the information provided by the nurse manager, he was instructed to contact a specific staffer higher up the administrative ladder.

The son accepted the security supervisor’s terms without argument. “He agreed and behaved himself until his dad was discharged. He wasn’t happy, but he behaved,” Lynch states.

Problem Assessment
With the critical situation managed, Lynch turned his attention back to the staff, trying to ascertain why they had not called security in on this and other incidents. A meeting was convened that included staff nurses and managers from the unit, members of the workplace violence committee, and personnel from employee assistance, psychiatry, risk management, human resources, and security.

Information from the meeting, and from additional personal interviews that security conducted with staff, revealed that this was not an isolated incident. There had been many other occasions in which staff had tried to deal with abusive or threatening visitors without security’s—or anyone else’s—help.

Lynch discovered that nurses were confused by the mandate that customer service to patients and families was paramount. “It was an eye-opener for me,” says Lynch.

In addition, there was a lack of staff understanding about the resources available to help manage difficult situations. “There was a perception that this was a situation requiring a clinical solution as opposed to getting a broader group involved that could assist in managing the problem to a desired outcome,” he recalls.

Security’s own weakness was also pinpointed. It had been security’s past practice to meet annually or semi-annually with each unit’s staff. During the meetings, security representatives asked a question such as, “Are you having any problems?” If staff said nothing, the meeting agenda moved on. The problem with this approach was that staff tended not to volunteer information when presented with that type of question.

These findings led to changes in training and in security’s approach to information gathering.

New Training
New training on boundary setting has now been instituted for the nurses. It is led by Bob Oldenburg, director of Baystate Health’s employee assistance program (EAP), and is based on a session he was already delivering to new resident doctors. Information about how setting boundaries can be reconciled with customer service has been added for nurses.

For example, nurses may think that they are required to answer any question asked of them. The boundry-setting training teaches staff that it is okay not to share information or to say that while they are glad to be helpful, they don’t have the requested information.

Another major point is that customer service does not include accepting disrespect or aggression. Now if staff encounter abusive behavior, they are taught to express the desire to help but to be firm that the person asking for help must be respectful.

Oldenburg counsels nurses to use short, clear sentences that invite the other person to accept the boundary, such as “I hear that you’re upset, but to continue this conversation I need you to stop using profanity. Can you do that?” or “I want to help you, but I won’t be able to if you don’t lower the volume of your voice. Will you do that?”

The training also advises nurses to listen to their own bodily clues as a way to determine when a boundary needs to be set. “Nurses are used to dealing with people in distress, but when they themselves start feeling anxiety and fear, they need to recognize it as a sign that a particular situation is too much,” he says.

Where boundary lines lie can vary from person to person in various settings, Oldenburg explains. For example, in a clinic where the same patients are frequently seen during extended treatment, a relationship has been established with a nurse and in that situation, placing a hand on her shoulder or arm may be acceptable. If, however, that nurse feels that it is not, then Oldenburg’s training teaches her to make a statement such as, “I’m sorry, but I’m not comfortable with you touching me. Would you please stop?”

If the person chooses not to accept the boundary, then nurses are trained not to defend their line in the sand alone. They are instructed to move to the next level of intervention. To do so, they must be empowered by knowledge of the resources available to them—such as calling in supervisors, security, or others.

Even before this program was instituted, all of Baystate Health’s security personnel received crisis intervention training, as did behavioral health and clinic staff; but nurses did not. Now, the hospital is beginning to provide all nursing staff with this same crisis intervention training. Twenty-six nurses have already been trained and will now serve as the trainers of other nurses.

The crisis intervention training includes such issues as looking for physiological clues that an individual’s aggressive behavior might escalate—for example, sweating, a lack of eye contact, or the smell of alcohol—as well as psychological signals, such as watching for changes in behavior or signs of emotional or substance-induced impairment in familiar visitors.

Nurses are also taught physical behaviors of their own, such as not allowing themselves to be cornered, maintaining a safe distance, and standing in loose, flexed positions that make it harder to be knocked over. “The message is, the more you can feel responsible for the outcome of the intervention, the better the outcome is likely to be,” Oldenburg says.

Information Gathering
Staff training was only half the problem; the other was overcoming the staff’s reluctance to report incidents and ask for help from security. To overcome that reluctance, security representatives decided to change how they went about gathering information. Rather than just asking if staff had any problems, security personnel determined to get a conversation going that would elicit information, Lynch states.

Now, during meetings, security representatives ask questions such as “Do you ever have circumstances where people yell at you?” or “Do people sometimes make excessive demands of you?” or “Has anyone constantly criticized you?”

Lynch explains, “We pull out threads by asking how these situations made the staff member feel, and then ask, ‘Do you know there are ways that people can help you with this kind of problem?’”

Staff are reminded before the meetings that they are free to bring up any incidents that have occurred. The new approach is helping staff, who are speaking up without trepidation. “They seem to be willing to do it because it’s something they now see that we see as important,” Lynch says.

Security is also coordinating its activities with EAP services. After an incident occurs, security calls Baystate Health’s EAP, which works with staff to manage their thoughts and feelings about what has happened.

The Big Picture
The new training and information-gathering initiatives do not take place in a vacuum. Those efforts are part of a larger proactive workplace-violence prevention program. The hospital has a committee that oversees this program, and security is a participant.

“Every year, the committee assesses the risks that the staff are experiencing by looking at records and reports of incidents both in the hospital and the nation to determine whether our countermeasures were appropriate,” he states.

An example of the success of this approach occurred when a clinical decision was made to care for adolescent patients up to 18 years of age in the pediatric intensive care unit (ICU). “That meant that some of the gunshot victims who we see here in the city and who used to go to the normal ICU, are now in with 8 and 12 year-olds,” he says.

The young patients and the pediatric ICU staff would be at risk from drug-related or gang-related retaliation, as well as a “completely different community” of visitors. The pediatric ICU staff, Lynch states, “were not accustomed to that kind of potential violence,” nor to wondering whether visitors might be a threat to everyone’s safety.

The committee conducted training for pediatric ICU staff, bringing in adult ICU personnel to share their experiences and lessons learned from these types of patients. Security now also meets with the unit’s managers to discuss individual case threat issues and can provide increased patrols and visitor controls when merited or requested.

Results
The changes have yielded results. Many are intangible, but Lynch offers one concrete example of how the program is working. Five months after the original incident, he says, the same unit received an elderly female patient whose son was particularly insistent about his involvement in treatment decisions. Lynch says that the son wanted to be involved in every treatment decision and wanted to stay in the room for all examinations and procedures, as well as maintenance care such as bathing.

That’s not necessarily a problem, but “It got to the point where it was beginning to interfere with appropriate care,” he states. When he began to threaten and demean staff, the unit manager called security.

An evaluation team was convened that included nurses, physicians, social workers, and others to evaluate the behavior of the son and its effect on the patient. A coordinated plan was formed that addressed the importance of the son to the ongoing treatment of the patient, the behavioral limits to be set, and the response to noncompliance. The team also decided who would be in attendance at the meeting with the son and when it would occur.

After an initial meeting with unit supervisors and security, a consistent message on standards of behavior was delivered to the son by the nurses caring for the elderly woman. The son’s behavior improved and for the remainder of the hospitalization, he focused only on the patient’s condition and comfort.

SYNOPSIS
Baystate Health, headquartered in Springfield, Massachusetts, is a three-hospital, multiple-treatment-center system with nearly 10,000 employees. Its mission statement is, in part, “to improve the health of the people in our communities, every day, with quality and compassion.” Customer service excellence is an important aspect of that mission’s success. But there were times when security’s mission needed to be central in the minds of staffers, and—much to security’s chagrin—was not. This revelation, brought about by the threatening behavior of a visitor, led to a change in staff training and a new security mind-set of eliciting incident information rather than waiting for it.

When the son of an elderly patient escalated from treating nurses with disrespect to yelling at and threatening them and then to throwing a bedpan at one of them, security learned about a string of aggressive encounters that had been taking place for some time without its awareness. The nurses had not been notifying security because, to them, the line between patient service and their own safety was indistinct. There was also a lack of staff understanding about the resources available to help manage difficult situations.

In response, new policies and procedures were developed that included a more assertive security practice of information gathering about incidents. Security has also improved coordination with the company’s employee assistance program (EAP). After an incident occurs, security calls an EAP representative who works with staff to manage their thoughts and feelings about what has happened.

Nurses now receive training in boundary setting, crisis intervention, and the resources available to them in dealing with verbal abuse and threats of violence from visitors.

Ann Longmore–Etheridge is associate editor of Security Management.

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