By Thomas F. Lynch, Robert Horton, and Monica M. Wynne
When a new approach to psychiatric ward security caused resentment between security and clinical staff, a security training and shadowing program fostered teamwork and improved performance.
At Baystate Medical Center (BMC) in Springfield, Massachusetts, security and psychiatric nursing staff in BMC’s Adult Psychiatric Treatment Unit (APTU) were at odds after a radical change in APTU patient behavioral modification practices made the security department believe that its resources were being wasted. To bridge the misunderstanding between the groups, calm tensions, and foster cooperation, a staff training and shadowing program was developed and implemented.
With a staff of more than 5,000, BMC is the largest of the hospitals in the Baystate Health System; it is also the leading health facility in western Massachusetts. It includes a 653-bed academic teaching hospital that serves as the Western Campus of Tufts University School of Medicine. Additionally, it is the only Level-1 Trauma Center in the region, including an emergency department—the second busiest in New England—that handles approximately 110,000 visits annually.
The BMC security department includes 50 officers and supervisors. All supervisors and half of the officers are Springfield special police with arrest powers. Typically, one supervisor and approximately 13 officers are on duty during each shift.
Violent crimes and domestic violence can lead to security crises inside the hospital. For example, the hospital may have to deal with hostilities when rival gang members encounter each other in waiting rooms after an altercation. Because of these types of risks, providing security to the emergency department demands a large chunk of the BMC security department’s resources.
In addition are the demands created by the nature of the care provided through the Behavioral Health Department’s APTU. The 28-bed unit provides inpatient treatment for individuals aged 18 and older with psychiatric disorders. It provides specialized treatment, including pharmacotherapy and electroconvulsive therapy.
Before the new program was implemented, the security department received daily “stat” calls from the APTU that might have been only the phrase, “Send three officers.” A supervisor and two officers would respond, ready to participate in a physical intervention that included immobilizing the patient and moving him or her to an isolation area or a bed fitted with restraints. At the conclusion of the interaction, officers would leave without a debriefing. Difficult patients could generate three or four stat calls a day, each lasting up to 30 minutes and involving as many as four officers and the supervisor.
Unfortunately, during these interactions, APTU and security staff were unknowingly engaged in coercive practices that the psychiatric profession has now determined can trigger traumatic memories in patients with histories of physical and sexual abuse, as well as cause fresh trauma. Coercive tactics, it is now agreed, make therapy ineffective or markedly less effective. They also may traumatize those who carry them out.
For that reason, beginning in 2006, the APTU strictly limited the use of restraints, seclusion, forced medication, and other coercive practices in favor of “trauma-informed” services. The goal was to make the patient feel in control of his or her calming process.
The APTU’s Sensory Room is the preferred first choice for soothing out-of-control patients. The room offers sound, music, visual, tactile, and aroma therapies, and other calming processes.
While there is no doubt that trauma-informed practices are better in the long term for both patients and staff, when this new regimen was implemented by the APTU, its immediate effect on the security department was not considered. Officers were used to arriving at the APTU ready for active physical intervention. Suddenly, clinical personnel began asking security personnel to remain in the hall while counselors interacted with the patient.
After waiting for up to 30 minutes, the supervisor and officers would be dismissed without explanation. This same scenario could play out multiple times over a day with the same patient.
Security officers or supervisors who questioned the stat calls received criticism from clinical staff, who charged that security was only interested in resolutions that involved use of force and that security didn’t think the APTU staff knew what it was doing. These unhelpful responses only fueled increased frustration and resentment.
The final symbolic straw was when officers were called stat for a problem patient and then spent 20 minutes watching that patient eat. In a meeting not long afterward, an officer demanded angrily, “Why do they need me to stand there and watch him eat soup?”
This question finally brought home that security officers had never really understood trauma-informed practices or their role in them. The change to trauma-informed practices seemed like a mysterious volte-face to officers who had, until then, only seen the patients in distress. They never witnessed the normal calm and controlled environment that the APTU staff strove for, nor did they see the process of healing or the positive results.
In September 2006, Thomas F. Lynch, who is BMC’s director of security, and Monica M. Wynne, who is security manager, met with Robert Horton, who is APTU nurse educator (the three are the coauthors of this article) to discuss a possible security shadowing program that would promote understanding through on-the-job learning in the APTU. They worked together, with the support of the administrative director of psychiatry and the clinical chairman, to develop elements of the program over the following four months.
Before the program was rolled out, it was thoroughly discussed with BMC’s risk managers to seek their advice on issues that pertained to Title II of the Health Insurance Portability and Accountability Act (HIPAA) enacted by the U.S. Congress in 1996 to protect patient information. It was decided that to effectively implement what is, at its heart, a patient-safety initiative, some passive exposure to information could occur—the only reason for exposure to the information being to maximize team training to reduce risk for patients. Security officers undertaking the training and shadowing program would be cautioned not to reveal any HIPAA-regulated information they might learn.
In January 2007, presentations were made to the security staff by members of the APTU and to the APTU staff by members of the security department. It was hoped that through this mechanism both sides would perceive the program as a hand outstretched in an offer of collaboration. It also let each department identify the goals of the program from its own perspective.
The program, which is required of every member of the security team and is now included in new-officer training, includes two four-hour sessions during which security officers participate in shadowing selected APTU staff members to see how nurses, therapists, social workers, and others go about determining treatment plans and working with patients. These sessions are only conducted during times when the APTU is generally quiet. Participating officers wear street clothes to make sure that they do not frighten or agitate the patients.
During the training, psychiatric staff members explain their work to the security officers and articulate their vision of how security can best assist them in trauma-informed patient care. Officers accompany counselors on their rounds, getting the chance to see the unit’s day-to-day operations.
They see patients engaged in occupational therapy and treatment sessions in both group and individual settings. The officers are also allowed to participate in meetings where treatment courses are planned. Additionally, officers accompany staff on unit safety rounds and receive an orientation to the Sensory Room. There, they observe patients undergoing the various sensory therapies and receive a briefing on how the environment works to calm the patient.
Show of Support
Previously, security came to the APTU as a show of force directed toward the patient. Now they come as a show of support directed toward APTU staff.
The process of “stat calling” security has also been changed. While the request may still be “Send two officers,” upon arrival, security is thoroughly briefed on the situation in progress and the counselor and staff’s plan for management of the patient. Changes in approach are communicated to security officers throughout the unfolding incident. Most importantly, when the problem is resolved, there is an immediate review of all actions, and feedback is solicited from all present. Everyone participating has an equal voice in expressing how everything went and what can be improved during the next incident.
Physical intervention by officers is not entirely off the table, but it is no longer the immediate response to a patient’s outburst of aggressive behavior. Officers receive training on nonagressive, nonthreatening postures and arrive prepared to wait as staff and counselors try to resolve the situation.
As part of the training, officers are shown recorded incidents where verbal intervention successfully deescalated patients’ outbursts. The psychiatric staff point out verbal techniques for the officers to use, including direct and clear limit setting, active listening, and the redirection of conversation to focus on the issue.
Officers physically intervene only to prevent an assault; they do not intervene in reaction to an assault that has already occurred. If an APTU staffer is physically attacked by a patient or that patient tries to injure him- or herself while security is present, officers will provide a quick and appropriate response.
Questionnaire. At the beginning and the end of the training program, security officers fill out a questionnaire that queries them on their feelings toward, and perceptions about, working with APTU. After the training is completed, officers fill out a second questionnaire, reporting on their changed perceptions as well as making suggestions or asking for more detailed information.
Thus far, the officers’ feedback on the program has been positive and encouraging. They write that the training has allowed them to feel more a part of the team. The questionnaires also reflect a subtle but important change in officers’ vocabulary that reflects their exposure to trauma-informed concerns and approaches to patients.
As a result of the program, security officers have developed a greater understanding of problems facing APTU patients and, by extension, patients with behavioral issues on other units and in the emergency department. The relationship between APTU and security has improved. There is a sense on both sides that relationships have improved and that each group now trusts the capabilities of the other.
Stat calls to security have not decreased—in fact, they have risen slightly as APTU staff use all the safety tools at hand to eliminate the need for patient restraint—but calls to the APTU are no longer seen as a waste of security’s time. Officers now understand how they are contributing to the hospital’s organizational objective to serve the patient and manage each incident in the safest, least traumatizing way.
Thomas F. Lynch is director of security at Baystate Health and chair of the ASIS International Council on Healthcare Security. Robert Horton is an RN-BC with the Department of Psychiatry at Baystate Medical Center. Monica M. Wynne is security manager of Baystate Medical Center. She is a member of ASIS International.