By Stacey Paul, MSN, RN, APN, PMHNP-BC, project director, clinical, The Joint Commission and Lisa Wilson MBA, RN, CEN, NE-BC, project director, clinical, The Joint Commission
As part of our ongoing discussion of workplace violence prevention, two Joint Commission staff with nursing experience in different clinical areas—behavioral health and academic medical centers—discuss ways that violent episodes manifest in different health care settings, and share winning practices for workplace violence prevention.
While the issue of violence in hospitals is finally getting the attention it deserves, there’s still little conversation on the problem in outpatient settings—and even fewer standardized solutions.
For instance, pediatric behavioral health outpatient offices see more than their fair share of violence. Children, by nature, tend to be more impulsive than adults. Some children seen in behavioral health outpatient offices are being treated for disorders such as Oppositional Defiant Disorder, a diagnosis characterized by anger/irritability, vindictiveness, and argumentative behavior. Add factors like longer-than-expected wait times, busy offices, or the expectation of a prescription that the provider won’t order—and tempers can flare quickly. Other diagnoses seen commonly in the pediatric and adolescent population, such as bipolar disorder and major depressive disorder, can also present themselves with anger and irritability as symptoms.
Reality of Response Training
Many people who’ve worked in behavioral health clinics have seen patients become agitated, even to the point of physical aggression towards staff, yet few outpatient clinics have the kind of detailed workplace violence prevention plans that exist in hospitals.
Some outpatient clinics require staff to partake in de-escalation training. While it lacks the detail of a full restraint/seclusion simulation, even the way the front desk responds to an agitated patient can make a huge difference. If a receptionist uses de-escalation techniques, or has access to help from those trained in de-escalation, a violent situation can often be avoided. On the contrary, a busy receptionist may give a short response to an upset patient in order to remain efficient and serve the next person in line, causing the situation to escalate further.
De-escalation training works equally well in hospital settings. A multi-disciplinary team, including non-clinicians, can calm potentially violent individuals. Anyone skilled at having a therapeutic conversation or even others who just have strong communication skills would be an asset for undergoing de-escalation training, regardless if they’re part of the patient care team or work in environmental services, the facilities’ team, etc.
In fact, it’s often most helpful to employ de-escalation techniques as an adjunct to the security department intervention. All too often—in both inpatient and outpatient settings—the training provided to the security team covers different techniques than what hospital staff has learned. This can be confusing to patients, and even staff who are leading the de-escalation. Other times, the presence of a uniformed security officer can exacerbate a tense situation.
Violence Preventing Policies
By now, many hospitals have a comprehensive violence prevention policy including active shooter protocols but there may not be existing policies for violence that doesn’t involve a weapon. Some clinics provide new patients an orientation with ground rules, expectations for behavior, and policies regarding prescription medication.
Some of the most intense arguments stem from the fact that a patient (or his/her parent) expects a medication that the clinic won’t prescribe. Prescription monitoring goes a long way toward knowing a patient’s history with having certain medications filled at various offices. Some clinics have strict policies on benzodiazepines, so individuals are clear on the expectation that they won’t get a prescription for a certain type of anxiety medication from the time they make their first appointment.
Others publicize a “lost prescription policy”, outlining the number of times they’ll fill a lost prescription. Outpatient clinics who spell out such a policy may say they’ll refill once if a prescription is lost, but not twice, for instance.
True Safety Culture
Oftentimes, violence in health care facilities stems from staff conflict. This happens not just in behavioral health but in hospitals, home care and virtually every health care setting. Unfortunately, many hospitals say they have a “just culture reporting environment” but, it’s often in name only. In reality, lateral violence is still a real issue in most healthcare settings.
True healthy work environments support transparency and encourage staff to report events and injuries supporting a culture of safety. With this philosophy, organizations can identify, improve, and enhance work environments for their teams at the front lines. Until the reporting is genuine, there’s no way to tell how serious a problem is. Leaders and charge nurses in the acute care setting influence staff with their immediate response to an injury or escalating event. Engaging transparent and supportive leadership is a must to improve the safety of our front-line caregivers. Furthermore, they are instrumental in initiating real-time debriefing for those involved; a tactic proven to be an instant stress reliever regardless of the setting.
While a culture of safety won’t necessarily stem the tide of workplace violence in health care, it’s a start. More resources can be found in our online workplace violence prevention portal. In the meantime, we’d love to hear what works in your organization.
Stacey Paul, MSN, RN, APN, PMHNP-BC is a project director, clinical in the Department of Standards and Survey Methods at The Joint Commission. She has experience in inpatient, partial hospitalization, residential, and outpatient settings in psychiatry. Prior to this position, she has worked for Lurie Children’s Hospital, Children’s Home and Aid, and Mount Sinai Hospital. Most recently, she has worked as a nurse practitioner in Psychiatry at Alexian Brothers Behavioral Health Hospital.
Lisa Wilson, MBA, RN, CEN, NE-BC, is project director, clinical standards and survey methods, in the Division of Healthcare Quality and Evaluation, at The Joint Commission. Prior to this position, Wilson managed emergency departments at Presence Health, Loyola University Medical Center and Rush Oak Park Hospital. Most recently, Wilson managed patient care services in surgical care and oncology for Advocate Health Care.