Responding to Abusive Patient Behavior

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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 defuse 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.

10 Ways to Defuse Incidents

Healthcare facilities can be places of great anxiety, grief and anger. Patients, their family members and even co-workers can lose control of their emotions and become verbally or physically aggressive. This second part of our series on managing abusive individuals discusses how staff members can take action to prevent or mitigate dangerous behavior.

A comprehensive training program, like the one discussed in part I of this series, is the most effective means of preparing staff to address disruptive behavior or assaults. There are, however, some basic steps that all staff members can take to improve their interventions in potential crisis situations. The points below are not intended to replace training, but rather to provide an overview of some of the techniques and strategies that should be explored in training programs, which emphasize prevention of workplace violence.

For purposes of this article, crisis moments refer to those points in time when individuals lose physical and rational control of their behavior. Almost always, there are warning signs a person's behavior is moving toward a crisis. The following tips can aid in early interventions and increase the likelihood of staff de-escalating an incident before it becomes dangerous.
  1. Respect All Individuals' Personal Space
    Personal space is the area around us that we consider an extension of ourselves. How much space each of us requires to feel comfortable varies considerably. What is almost universally true, however, is that anxiety rises when personal space is invaded. This heightened anxiety makes it more likely a person will act out in a more serious way.

    To avoid such a response, maintain at least an arm's-length distance from a person whose behavior is escalating. In this way, you will be less likely to increase the person's anxiety. You will also reduce danger to yourself by maintaining a margin of safety that allows you time to react.

    If you must touch an anxious person to provide medical care, explain what you are about to do before you begin. If the person objects, decide if: 1) the procedure can wait until the person is less anxious; 2) someone else might be better suited to provide the care, e.g. someone who has established stronger rapport with the person; or 3) the procedure must be done by you at this very moment. This third alternative should be a last resort, chosen only due to medical necessity. If this is your decision, be prepared for the possibility of the patient reacting negatively.
  2. Be Aware of Your Own Body Position
    In addition to maintaining adequate space between you and an anxious person, avoid eye-to-eye, toe-to-toe positions, as they might be interpreted as challenging. Positions perceived as challenging can evoke a "fight or flight" response from the other person, and neither of those reactions is likely to be helpful. Standing at an angle to the person and off to the side is much less likely to escalate an agitated person's behavior.
  3. Be Empathic to Others' Feelings
    Try not to judge or discount the feelings of others. Whether or not you think their feelings are justified, those feelings are real to the other person. Pay attention to them, and don't be afraid of silence. Your supportive presence is often more important than what could be conveyed with any words you might say.
  4. Keep Nonverbal Cues Nonthreatening
    As a person begins to lose control of rational thought, the person becomes more tuned into your body language and less tuned into your words. Nonverbal communication — including gestures, facial expressions, movements and tone of voice — becomes paramount in conveying a calm, respectful attitude.
  5. Ignore Challenging Questions
    When a person challenges your authority or an organizational policy, redirect the individual's attention to the issue at hand. For example, suppose a female visitor is smoking in a waiting area. You remind her that there is no smoking allowed in your facility and ask her to put out her cigarette. She responds by saying, "Who are you to tell me what to do?" Answering this type of question only leads to a nonproductive power struggle, and it also sidesteps the issue at hand — the woman's smoking. It's better to ignore the challenge and restate your request.
  6. Set and Enforce Reasonable Limits
    If patients or family members become belligerent, defensive or disruptive, establish limits and directives clearly and concisely. When setting limits, offer simple, clear choices and consequences to the acting-out individual. Be sure the consequences are reasonable and enforceable.

    For example, you might tell a family member who is insistent about entering an emergency treatment room, "Please come back to the waiting area with me, and I'll be sure the doctor speaks with you about your husband as soon as possible. If you try to enter the treatment room again, I'll have to call security, and then it will be even longer before you can talk to the doctor."
  7. Permit Verbal Venting When Possible
    It is often the safest and best alternative to let the person shout, removing others from the area when feasible. Allow the person to release as much energy as possible by venting verbally. As a person is venting, there will be peaks and valleys in the outburst, as the person's energy expenditure rises and falls. If you cannot allow the person to continue venting, state the directives and reasonable limits during the "valleys" in the venting process.
  8. Identify Real Reason for the Behavior
    Even in the midst of an angry tirade, there is useful information to be gained about what a person is thinking and feeling. The real reason for a person's outburst is often not what it seems to be. Anxious patients and family members can be highly critical of hospital staff for reasons that are much more related to the fear and helplessness they are experiencing than to the ways staff members are performing their duties. Try to listen for the real message — the feelings behind the facts. Restate the message you think you have received in order to determine if you correctly understood the person's intent.
  9. Stay Composed, Avoid Overreacting
    It's hard not to take things personally, especially since angry people often say very personal things. But it is essential to do your best to remain calm and professional — at least on the outside. Your composed, rational response can go a long way toward influencing the person's behavior in a positive way.
  10. Use Physical Techniques Only as a Last Resort.
    Physical restraint should be used only when people's behaviors are dangerous to themselves or others. Physical intervention itself always carries some risk of injury to staff or to the person being restrained. Such interventions should be used, therefore, only when it is more dangerous NOT to intervene. Furthermore, physical interventions should be used only by competent staff members who are trained to use the safest, least restrictive methods of intervention possible and who are well-versed in any applicable regulations or laws pertaining to restraint use in their facilities.

Prevention Promotes Culture of Caring
Not every crisis situation can be successfully de-escalated, but trained staff members who know these key principles are much more likely to influence behavior in a positive way, defusing potential crisis situations before they become dangerous. Prevention is the best way to promote a culture of caring and a safe and respectful workplace for everyone.

Reducing the Risks of Restraints

Although physical intervention is considered by most in healthcare security to be the method of last resort, sometimes hospital employees are left with no alternative but to use this approach on someone who becomes a danger to themselves or others. This last part of our series on managing abusive individuals discusses how hospital personnel can appropriately use restraints.

Parts I and II of this three-part series dealt with the importance of staff training in strategies for preventing, de-escalating and safely responding to disruptive behavior or assaults. Data clearly demonstrate there is a decrease in the use of physical restraints when facilities implement such training programs. In most healthcare and mental health facilities, however, there will still be times when people lose control to such a degree that the use of restraints is deemed necessary.

To protect the health and safety of both staff and patients, various accrediting and regulatory agencies have established standards relating to the use of restraints in healthcare and mental health settings. It is also important to be familiar with state regulations related to restraints, as these vary from state to state. Some states ban certain types of interventions altogether. Others have time limits governing use of restraint.

One key element that virtually all regulatory, statutory and accrediting bodies have in common is the emphasis on staff training in de-escalation techniques that can prevent the need for physical interventions. Equally important is staff training in the appropriate use of restraints.

Know Which Interventions to Use and When
Several key points should be included in all staff training on the topic of physical techniques: When to restrain; when not to restrain; how to use safer restraint techniques; and how to minimize risks associated with the use of restraints. Awareness of restraint-related positional asphyxia and how to avoid positioning that could restrict breathing is of critical importance as this can cause death.

Through both policy and training, staff members should know there are limited circumstances in which physical interventions are an appropriate response to acting-out. The following criteria should always be met:
  • The person is an immediate danger to self or others
  • Other ways to manage the person's dangerous behavior have failed
  • Staff members are trained in the proper use of restraints

Physical restraints should never be used as a form of punishment, for the convenience of staff, or as a means to inflict pain. Instead, they should be seen as a temporary, emergency measure to take control of another person only until that person has regained control of his own behavior and is no longer a danger to others.

Key Steps To Reduce Risk
Because all physical intervention carries some risk of injury—to staff and to the person being restrained—such interventions should be used only when it is more dangerous not to intervene. Furthermore, there are several key steps facilities and staff can take to reduce the risks of restraint:
  1. Train staff members in safer ways of restraining, and provide opportunities to practice those skills on a regular basis: Physical interventions should be used only by competent staff members who are trained to use the safest, least restrictive methods of intervention possible and who are well-versed in any applicable regulations, laws or policies pertaining to restraint use in their facilities.

    Furthermore, physical restraint should be recognized as an emergency response procedure—not so different from CPR or first aid. As with any emergency response procedure, staff members need to rehearse these skills on a regular basis.
  2. Choose safer restraint techniques: Some restraints are more dangerous than others. In 1998, the Hartford Courant published a Pulitzer Prize-winning series of articles detailing 142 restraint-related deaths throughout the United States. Many of these deaths were the result of positional asphyxia, which occurs when a person being restrained is placed in a position in which he cannot breathe properly and is unable to take in enough oxygen.

    Especially dangerous positions include facedown floor restraints or any position in which a person is bent over and held in a way that makes breathing difficult.

    Staff members must be especially careful not to use their own bodies in a way that restricts someone's ability to breathe, such as sitting or lying across a person's back or stomach. When a person is lying face down, even pressure to the arms and legs can interfere with a person's ability to move his or her chest or abdomen in order to breathe effectively.
  3. Be aware of risk factors that increase the danger of restraints: Some people are more at risk for restraint-related positional asphyxia than others. Risk factors include obesity; extreme physical exertion or struggling prior to, or during a restraint; heart disease; breathing problems, such as asthma or emphysema; and use of alcohol or drugs.
  4. Monitor the person being restrained: Staff must be trained to watch for signs of distress from the individual being restrained. This can best be accomplished by assigning a staff member who is not directly involved in performing the restraint to monitor for signs of trouble, such as breathing difficulties. It's important to note, however, that there are documented cases of individuals who have gone from a state of no apparent distress to death in a matter of moments. Monitoring the person's status is not a substitute for avoiding high-¬risk positions that interfere with breathing.
  5. Debrief: When restraints are deemed necessary, a debriefing process should follow so that staff can take a closer look at the circumstances before and during the restraint. What triggered the event? Could it have been prevented? Were any warning signs missed? Is there anything that could have been handled differently? The purpose of the debriefing is not to point fingers or place blame but to creatively consider alternatives that might prevent the next restraint.

Use Physical Techniques Sparingly on Abusive Individuals
Following these guidelines will reduce the risk of injury for everyone involved in a situation requiring the use of restraints. But the very best way to eliminate injuries due to restraint—both for staff and for the person being restrained—is to eliminate the need to restrain in the first place. Remember, the safest restraint is the one that doesn't happen.

National Regulatory and Accrediting Organizations: Key Elements of Restraint-Related Standards

Centers for Medicare & Medicaid Services (CMS)
  • Requires training for hospital employees who may work with violent patients. Training must include:
    • Identifying events or factors that may trigger a need for emergency intervention
    • Using nonphysical intervention skills
    • Choosing least restrictive intervention based on patient's condition or status
    • Safe application of all types of restraints used at a hospital
    • How to recognize and respond to signs of distress
  • Requires staff to demonstrate competency in application of restraints and in caring for patients in restraint
  • Requires training to be ongoing. Training must be part of initial orientation and on a periodic basis thereafter

Joint Commission on Accreditation of Health Care Organizations (JCAHO)
  • Differentiates restraint used for an aggressive patient for behavioral reasons and restraint used for medical purposes to prevent substantial harm to patient
  • Staff using restraint to manage assaultive or abusive behavior must be trained in the following areas:
    • Identifying underlying causes of threatening behavior
    • Understanding possible links between medical conditions and aggression
    • Understanding how staff behaviors can affect patient behaviors and vice versa
    • Use of de-escalation, mediation and other nonphysical techniques
    • Recognizing signs of physical distress in persons being restrained or secluded

Occupational Safety and Health Administration (OSHA)
  • Recommends that employees receive at least annual training in workplace violence prevention
  • Encourages hospitals to make a concentrated effort to reduce identified risks factors. These could include long waits; presence of gang members, people with substance abuse problems and distraught family members; and low staffing levels during times of increased activity

This article originally appeared in Campus Safety Magazine, May/June 2007.
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“Our aim is to help you always consider the entire realm of options available to you during any crisis moment. And to help you always choose the least restrictive intervention possible.”