How to Boost Security & Clinical Teamwork

July 11, 2019
A security officer at his post.

By improving security and clinical teamwork, hospitals are reducing violence — often by 50% or more — and you can too.

It’s easy for clinical and security teams to be disconnected from each other when their jobs seem to be at odds: caring for people, with compassion — and protecting people, sometimes with force.

But when you break down what both teams do at their core, it’s just as easy to recognize that they have the same end goals: patient care and patient safety.

And when you extend those same goals of care and safety to every staff member too — each of whom likely deals with some degree of verbal abuse or physical aggression from patients or visitors — then both teams have even more in common: a shared goal to create a culture of caring for everyone.

It’s no coincidence that the mantra of CPI training is Care, Welfare, Safety, and Security℠. As you’ll see below, when we help hospitals implement our violence prevention training — and improve teamwork and communication in the process — every skill each staff member develops is about merging care and welfare with safety and security for everyone. It’s about meeting the goals of all teams.

Tying everything to common goals is one of the most effective ways to create security and clinical teamwork. It’s also key to improving cooperation directly within care teams and clinical teams, as well as with cafeteria staff, pharmacy staff, lab staff, gift shop staff… everyone.

What research is showing about clinical care and interdepartmental teamwork

According to the American Hospital Association:

“When all clinical and nonclinical staff collaborate effectively, health care teams can improve patient outcomes, prevent medical errors, improve efficiency and increase patient satisfaction.”

Research also shows that teamwork:

  • Reduces issues that result in burnout
  • Improves communication not only among staff, but with patients and their families as well, helping them feel more at ease
  • Helps RNs, LPNs, NAs, and others feel more satisfied with their work

All this, in turn, can create real results when it comes to reducing violence against staff —

— because the more at ease patients and families feel, the less likely they are to lash out verbally or physically. And naturally the safer staff are from violence, the more satisfied they are with their jobs. The less they’re burning out, the better able they are to put patients and families at ease in the first place.

It’s a positive feedback loop that breaks the cycle of workplace violence. 

And it all starts with clinical teamwork and interdepartmental teamwork.

But let’s face it: teamwork is usually an ideal and only sometimes a reality. So how do you actually put it into practice — especially in a high-stress, fast-paced setting that has so much staff turnover that even keeping broken teams is a struggle?

Getting teamwork in a hospital setting to, well, work

We’ve shared four powerful ways to pull clinical and security teams together.

And an example of a system that’s excelling at improving teamwork is Virginia Mason Memorial Hospital. They implemented org-wide training that includes every layer of staff — not just the departments like psychiatry and emergency that usually have the highest risk of escalating behaviors.

In the process, they achieved a 55% reduction in emergency codes.

Nurse educator Sara Holland, who facilitates CPI training across the Virginia Mason Memorial Family of Services, explained on Unrestrained:

“One of the reasons we chose to do that was because at any given time, people are in and out of the hospital. And there may be an issue where someone from the lab will have to step in and help someone from the emergency room and the waiting room, or you might get someone from one of the outlying clinics who’s here for training and comes across this situation where now they can step in and help out.

“We wanted everyone to have the same skills, to have the same opportunity to learn at the same level, because, as you know, if you’ve got two people who don’t have the same training and they try to help, somebody can get hurt. It gets actually worse than not having any training at all.” 

While working extensively to implement safety training throughout her system, Sara also led a collaboration between security and psychiatry departments that involved:

  • Facilitating short teamwork skills meetings
  • Using the common language that CPI provides to boost communication
  • Discussing how patients in crisis might present
  • Applying the core values of Care, Welfare, Safety, and Security℠ to crisis interactions and department collaboration
  • Emphasizing the importance of debriefing after a crisis
  • Testing strategies with role-plays to make sure everyone can apply the techniques in real life

The results? A better sense of trust among departments, practical teamwork strategies, and “there have been no further reports of client injury during security calls/assists since.”

Sara Holland is one among thousands of professionals who lead and train multidisciplinary teams to decrease violence with strategies that you can duplicate at all levels in your setting.

Teamwork processes you can duplicate

At Bloomington Hospital in Indianapolis, the replicable work of a nurse director and a director of protective services resulted in a 52% decrease in assaults.

Together with Joe Anderson (director of protective services for IU Health’s Academic Health Center), Deb Fabert (director of behavioral health) talked with us about the study the two conducted, “Protecting the Nursing Workforce Through an Aggression Prevention Team and Behavior Alert Response.”

In the interview, they described their partnered approach and tiered Aggression Prevention Team and Behavior Alert process. When developing this process:

“We pulled together a multidisciplinary team to devise the process and come up with a very 360 look at what we needed to be bringing to the table. So, it’s risk management, quality folks, chaplains, social workers, nurses, bedside staff, nurse leaders... the chief nurse, chief operating officer, [and the] chief executive officer in support of this because it is multidisciplinary. It’s not just nursing.”  

The process they developed is this: When a staff member feels unable to successfully de-escalate a situation themselves — before any physical violence erupts and before the need for a code alert — they call in an Aggression Prevention Team (APT).

Three people who are key to this team come to help:

  1. The lead de-escalator who’s the expert in CPI training and is typically a social worker
  2. The chaplain or other support person
  3. Security, who stands by

Everyone on the team is required to have CPI training so they can come together with the staff who called using a common language, a practiced understanding of who’s doing what and when, and shared prevention and intervention strategies.

  • On arrival the team starts by asking the staff who called what’s going on and how they can help.
  • Next, the lead de-escalator gets the patient’s perspective, sets limits, and guides the patient to calm down.
  • The security team member assesses whether their presence is likely to help calm or escalate the situation, and positions themselves accordingly.
  • The support person supports the staff who called, as well as other staff, visitors if necessary, etc.
  • Together the team develops a care plan that gets documented in the patient’s medical record — and communicated to the patient appropriately, taking into consideration factors such as the patient’s state of cognition, etc.
  • A post-huddle takes place, which is crucial to getting everyone on the same page with the care plan.

Similar to this Aggression Prevention Team process, a Behavior Alert Response (BA) involves the same interdisciplinary roles. The difference is that a BA is for when physical violence is imminent or actually occurring, and it’s treated like a code. Now it’s a security-led event, with an additional clinical component — for example, the appropriate staff having access to auto-dispensing meds to treat a patient who’s escalating because of withdrawal.

Deb and Joe started this work in November 2017, and within a little over a year they achieved a 52% decrease in assaults with injury and a 43% decrease in violent restraint use.

And, as Deb puts it:

“Any hospital in the country could take this program with assistance in the customizable piece of it, for who’s going to play the roles, and see good results.” 

Also worth noting is that one unit — a Level 1 trauma unit — in an urban hospital in their system doesn’t even need to call the response team often because all staff are trained in the Nonviolent Crisis Intervention® program. Joe says:

“Prior to that, [the nursing director] had significant turnover in her nursing staff and a lot of acting out that was happening. Since she rolled this out, because they are early practitioners, and they can gauge at the point of grievance... they started using APT and BA quite a lot, but now they’re not using it anywhere near as much because... nurse contact with the patient has already resolved those situations.”

If violence is a reality in your hospital, that doesn’t mean it has to be. Hospitals are using teamwork to reduce it, they’re preventing it from erupting in the first place, and you can too.

At Yale-New Haven Hospital, one goal was to reduce the use of restraint while safely managing and preventing violent patient behavior AND keeping staff, patients, and visitors safe in the process. They managed to not only reduce restraint application by half, they reduced staff injuries too.

“Almost immediately with the mindset of just using our verbal skills, the adolescent psych unit experienced at least half the restraint application,” says Don Costa. “I don’t have the exact numbers on the adult side, but I would say easily from half to two-thirds reduction in restraints.”

A retired police detective, Don is lieutenant and manager of the Protective Services Department at Yale-New Haven. As a Master Level CPI Certified Instructor, he trains some 2,000 hospital staff members annually in our Nonviolent Crisis Intervention® program.

On Unrestrained, he explained:

“We started initiating the team right away, right from the beginning, because we recognized a good coordinated team effort usually has a better result, a safer result.”  

One of Don’s favorite things about training team members is seeing them go from thinking, “Oh, this stuff is all lovey‐dovey. This is great, but it’s not going to work” to realizing that this approach is evidence-based and it exists to help them make sure they get home safe every day.

In fact, staff routinely stop Don in the hall and say, We used it today and it worked again! And everybody was safe.”

Here are a few of the team strategies Don implemented to get security officers, nurses, social workers, chaplains, and others on the same page:

  • Using a hand signal system to communicate next steps — instead of escalating a patient’s panic with words like “I’ll get her right arm.”
  • Letting someone else on the team take over when a patient isn’t responding well toward you.
  • If you don’t know what to say to someone who’s acting out and you’re nervous, just calmly and quietly say, “I’m here to keep you safe.”
  • Using the CPI COPING Model℠ to debrief after a crisis, asking questions such as:
    • Everybody good? 
    • What happened?
    • How did we handle it?
    • Could we have handled it better?
    • How do you feel about what just occurred?
    • What can we learn from this?

“We discuss it openly,” Don says. “And we have a checklist. We also have a staff member that’s dedicated to speaking to the patient or the visitor and their perception of what just occurred. And by reviewing this whole process, we’ve gotten better at it. And this is something... we use because we realize that what affects the patient also affects the staff.”

Collaboration across departments requires letting go of long-held assumptions about how to prevent violence.

When security staff start their careers in healthcare, they often say their new roles can be a mindshift if they’re coming from a background in law enforcement.

Don Costa of Yale-New Haven teaches his staff this core CPI principle: “Going hands‐on never is the best option. The best option is always when you can verbally de‐escalate… We’re all trained, experienced officers, and we realized that the best skills are the verbal skills.”

Don and the leadership at Yale feel so strongly about this that some of Don’s advanced training with CPI is in enhancing verbal skills. He met our Global Professional Instructor Dave Vargas in his verbal skills training. Dave also has a law enforcement background, and built a strong rapport with Don when facilitating one of our train-the-trainer programs. Dave says:

“When I train persons from law enforcement, corrections, and security, they realize, ‘Wow — I have more tools than just my muscle or more tools than just what’s around my belt.’ And if they use their relationship as opposed to their authority... they're like, ‘Finally, I have something more and I feel even more confidence, and I can prepare my staff members to respond effectively to whatever situations might arise.’”  

No matter your role in your setting, you can take fast action to improve teamwork and collaboration. Try these 4 tips.

If you want to increase teamwork and communication at any level, you can take these steps immediately (and see below for the most powerful way to take action if you’re in a leadership role):

1. Share best practices with your coworkers that you can all use right away.

The Joint Commission recommends CPI’s Top 10 De-Escalation Tips as an immediate tool that anyone can use to stay safer on the job. These are simple strategies for effectively defusing challenging and disruptive behavior before it can escalate into physical violence.

Do you face verbal abuse from patients? Check out CPI Verbal Intervention™Training.

2. Find out what other organizations are doing to measurably reduce incident rates, cut lost time, and keep staff and patients safer for the long-term.

As agencies like OSHA continue to assess org performance when it comes to violence prevention, security directors and hospital administrators have led results that your teams can replicate. You’ve seen some of the strategies and results above. And getting more firsthand insights and the metrics that document their success is a solid way to lock in your leadership’s attention and make the case for teamwork across departments.

3. Get informed about the training solutions that fit various departments’ levels of risk.

Training is the best way to foster collaboration and get staff on the same page about violence prevention. But who’s really at the most risk, and what type of training solutions will be the most effective for them? Knowing these answers will guide a conversation to a conclusion where decision makers can take action.

4. Lead by example. If you want your colleagues to improve their teamwork, make sure you do, too.

Your organization’s culture can exist by default, or by design. If you want to enhance a culture of true safety and caring, even the simplest choices can have a profound impact on your peers. Your behavior has the power to impact what others say and do — have you owned your side of the Integrated Experience?

Regulatory bodies recommend — and in many cases require — staff-wide training because it’s crucial to teams working together to stop violence.

As you likely know well, years of data show that healthcare and social services workers are stuck at the top of the charts for illness and injury from workplace violence.

The AHA estimates that medical care, staffing, indemnity, and other costs of violence against hospital employees set hospitals and health systems back $429 million in 2016.

Because of statistics like this, it’s not only fiscally wise to invest in prevention. It’s also critical because people are priceless.

The human factors that embody the statistics are starkly personal. Lives can be changed, sometimes permanently, by physical harm and psychological trauma. These lives belong to nurses, social workers, security officers, chaplains, administrators, assistants, patients, families, bystanders — all kinds of precious human beings.

We all know that’s why the American Nurses Association and other groups advocate for mandatory, comprehensive training to prevent workplace violence.

It’s also why regulatory bodies are requiring it more and more.

And it’s why we provide it.

If you’re in a leadership role, you likely need to fulfill standards, guidelines, and requirements such as:

  • OSHA’s Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. CPI can help you fulfill these in any state.
  • Cal-OSHA’s Workplace Violence Prevention in Health Care regulation. CPI sets the standard for meeting these regulations in California.
  • Other state-level OSHAs are following California’s lead, requiring workplace violence prevention training for all healthcare workers.
  • More and more states are passing laws requiring health care settings to provide violence prevention training for every staff member. Search for your state to see why CPI is the smartest choice to help you comply with the laws and regulations that apply to your setting.
  • CMS requires training to “identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion.”
  • The Joint Commission suggests seven actions your facility can take to reduce verbal or physical violence. CPI can help you meet them, as well as numerous additional TJC standards, such as their Environment of Care standards.

At San Francisco Kaiser Permanente, part of emergency management planner Bob Durand’s role involves managing their compliance program. As he explained in his interview on Unrestrained, by incorporating Nonviolent Crisis Intervention® training into their compliance program:

“We were able to virtually eliminate injuries within our emergency department from violent, unpredictable patients. And we are now into our fourth workplace safety year with no lost time from injuries.”  

And, according to Bob, a clinician told him that “one of the biggest things that has led to our safety results is that our team is more confident... Everybody now goes to the environment, and then they’re able to function as a team to either de‐escalate, regain control, whatever the requirement is to keep everybody safe.”

As patient-centered care moves from best practice to regulatory requirement, a meaningful culture of safety is more critical than ever.

Standards are evolving to require a truly person-centered approach in achieving optimal outcomes for patients and clients, instead of just recommending it. Providing services that are maximally responsive to every person’s unique needs, values, and preferences requires a supportive team dynamic among care professionals and all staff.

“We have a lot of regulatory agencies that come here. And as soon as they hear that we’re CPI-trained, everybody feels very comfortable. It sets the standard.”  


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