Responding to Abusive Patient Behavior Part 1
By Judith Schubert
3 Pitfalls to Avoid When Training Staff
Healthcare workers, police and security personnel greatly benefit from training that shows them how to appropriately deal with patients, visitors and even other employees who may become disruptive or violent. But if that training isn't delivered properly and to the right people, problems can result. This first part of our series on managing abusive patients discusses how hospitals can avoid the mistakes often made when developing their education programs.
Earlier this year, a 19-year-old man was brought into a hospital in the Louisville, Ky., area suffering from apparent cardiac arrest. When emergency room staff members were unable to revive him, several members of the man's family began throwing furniture and attacking hospital staff. In all, seven people were injured, including a security guard who had to be admitted to the intensive care unit.
The Bureau of Labor Statistics (BLS) reported in 2000 that nearly one-half of all nonfatal injuries from occupational assaults and violent acts occurred in healthcare and social services settings. Whether working in an emergency room, a psychiatric ward, a nursing home or any other healthcare facility, staff members face patients and others who exhibit disruptive, assaultive and violent behavior. Healthcare facilities are often places of great anxiety, stress, grief and anger. Patients, their family members, and even co-workers can lose control of their emotions and become verbally or physically aggressive.
Administrators often choose an educational approach as a logical starting point for examining issues relating to workplace safety and minimizing risk. Proper training can provide employees with a consistent framework for identifying warning signs of violence, as well as techniques they can use to respond appropriately to differing levels of disruptive behavior. Training will also teach them how their own behavior significantly affects the behavior of others.
If training is to be successful in achieving the goals of minimizing risk and creating a safer workplace, however, it must be implemented in a way that gives it the highest possible chance of success. There are three key pitfalls that administrators can avoid in order to increase training effectiveness.
Pitfall No. 1 — Training Only Your Security Staff
One of the strategies often used in human service organizations is to train security personnel or a crisis response team to respond to potentially violent incidents. This strategy allows a relatively small group of workers to specialize and become experts in responding to threatening situations. While this is a good strategy, it is an incomplete one.
Staff members who are not part of the crisis response team are often interacting with an individual before the response team is called and until they arrive. Their responses and attitudes can be critical in diffusing the stress and anxiety of irrational individuals. In fact, if they respond appropriately, the crisis response team might not be needed at all.
When untrained staff members are confronted with potentially dangerous behavior, it is more likely they will respond instinctually with a "fight or flight" response. Neither fighting nor fleeing is consistent with one's duty of care. The body's fight response will usually cause a disruptive person's behavior to escalate further. A flight response from staff — admittedly the best option in some situations — may create an even less safe situation as the disruptive individual is left alone. Training helps to transform those instinctive responses into more appropriate interventions.
By training all staff, every employee gains the skills and confidence to intervene safely. Staff who are closest to a given patient or situation are often in the best position to diffuse escalating behavior and eliminate the need for a crisis response team call. Therefore, it is best if all employees have a foundation in the same training, even if a crisis response team or security staff has more specialized training in responding to violence.
Pitfall No. 2 — Using the 'One and Done' Approach
Providing training on a one-time basis is unlikely to produce lasting effects, yet it is the approach chosen by many organizations, due to time and cost constraints. If training is to be more than just a Band-Aid for workplace violence, it must be part of a process that includes opportunities for review, practice and drills. Just as with other emergency responses procedures, such as CPR, regularly scheduled refresher training prevents skills from eroding.
Albert Bandura's Social Learning Theory and other supportive research explains that training staff in ways to de-escalate and manage aggressive behavior increases staff confidence and self-efficacy. Without an ongoing process to reinforce learning, however, staff will gradually lose both the confidence and the competence gained in the initial training.
Pitfall No. 3 — The Administrative Disconnect
Training does not stand alone as a solution to the problem of workplace violence. Best practices call for the integration of training into a culture of care that includes an organizational commitment to a values-based philosophy. Mission, values and goals must be clearly stated to all and reinforced through policies and procedures that reflect organizational philosophy. Staff development is then seen as a tool to help staff members put philosophy into daily practice.
Administrators who take the time to participate in training take a huge step toward ensuring the effectiveness of that training. By their very participation, the following outcomes are realized:
Employees take the training more seriously when they see administrators are also taking the time to participate
Administrators learn more about the day-to-day realities faced by their staff members
Administrators themselves gain skills they can use when confronted with disruptive behavior
Any disconnect between policy and training content will be apparent and can be adjusted, as necessary
Administrators gain a greater understanding of the need for an ongoing training process in order to sustain the learning and momentum generated by the initial training sessions
Training's Return on Investment Is Significant
Clearly, addressing the problem of workplace violence through a comprehensive training program requires an investment of time, energy and human resources. It is an investment, however, with many returns. Data has clearly demonstrated a decrease in the use of physical restraints when facilities implement staff training that includes strategies for preventing, de-escalating and safely responding to disruptive or assaultive behavior.
A decrease in violent incidents can also mean a decrease in liability-related concerns. The less often restraint is used, the less likely an organization is to be brought into litigation, either by the individual who was restrained, or by anyone else who may have been injured during an incident. A decrease in workplace violence may also result in a decrease in employee injuries and workers' compensation claims, as well as a reduction in lost time due to injuries.
When organizations are successful in creating a safer work environment, added benefits can be assumed. With a decrease in workplace violence and an increase in staff confidence, employees are more likely to maintain their employment, lowering turnover rates.
Empowerment Through Education Reduces Burnout
In a recent article published in the Canadian Journal of Nursing Leadership, nursing researchers Greco, Spence-Laschinger and Wong examined efforts to improve working conditions for nurses through their leaders' empowering behaviors. The study found that when nursing administrators provided empowering behavior, nurses felt better about their jobs and experienced less burnout.
"It is reasonable to expect that when leaders empower nurses to accomplish their work in meaningful ways, nurses are more likely to experience an empowering workplace that fosters a fit between their expectations and their working conditions," the study reads. "That is, they will feel that they have reasonable workloads, control over their work and good working relationships; that they are treated fairly and are rewarded for their contributions; and that their values are congruent with organizational values."
More satisfied employees are more likely to assist in recruiting other quality employees seeking a more positive work environment. And improved worker satisfaction also leads directly to improved customer satisfaction — and helps your organization fulfill its care-giving mission.
Judith Schubert is president of the Crisis Prevention Institute (CPI).
This article originally appeared in Campus Safety Magazine, May/June 2007.