Clinical staff and security staff weren’t on the same page at our hospital—and patients were getting hurt.

Last fall, I was approached by the inpatient Psychiatric Acute Care manager at my hospital. He was concerned about a recent incident where a patient was injured during a physical restraint performed by security personnel while responding to a court ordered medication assist.
Upon further investigation, we discovered that an inappropriate use of force and poor communication between security and psychiatric staff had fueled a number of incidents that could have been more safely de-escalated. Based on concerns from senior leadership regarding patient safety, there appeared to be a major disconnect between two departments in particular. Psychiatric nursing staff and security staff weren’t collaborating effectively when it came to the appropriate and safe management of patients in crisis.


We had trained the staff we thought were most at risk, but we hadn’t trained everybody. That was part of the problem.

Our hospital had implemented CPI’s Nonviolent Crisis Intervention® training program almost two years prior. We’d initially rolled out three different options for staff members to attend. Staff’s direct supervisors were to determine what class would be most appropriate for specific work environments.
We provided two-day Nonviolent Crisis Intervention® training that included physical disengagement and restraint skills for staff that we considered to be on the front lines of patient care: Emergency Room, Psychiatry, and Med/Surg. A one-day Nonviolent Crisis Intervention® training option without the physical disengagement and restraint skills was available to staff who preferred the classroom learning environment and didn’t have direct patient care contact. We also offered a blended learning option (a mix of eLearning and classroom training, with no physical disengagement or restraint training) to accommodate scheduling constraints.  
Within 18 months, we had educated approximately 1500 inpatient and outpatient staff members. We saw our Code Grey emergency response alarms decrease significantly. Both medical and behavioral restraint numbers decreased. 
But patient safety in crisis was still an issue, because even though each department had the training they needed, staff still didn’t know how to work effectively as a team when multiple departments responded to crisis behavior.


We brought staff together for short sessions to form a practical strategy that would keep everybody safer.

I began investigating practical solutions for these safety concerns with the managers from the Psychiatry and Security departments. We agreed to facilitate short meetings for staff from both teams across multiple days so that everybody could have an opportunity to attend. We called it the “Psychiatry/Security Collaboration.”
I developed an itinerary which was handed out to all participants. This itinerary included introductions and ground rules.
Using CPI’s values of Care, Welfare, Safety, and Security and keeping in the front of our minds that ALL people we encounter are our clients—not just the patients in our hospital—we agreed upon some basic expectations for our collaborative sessions.  


Learning another industry’s lingo is daunting—so using a common language helped us boost our team dynamics.

We facilitated discussion around the following topics:
  • Learning the difference between Code Greys and medication assists.
  • The importance of debriefing discussions, and how we could incorporate them into our process.
  • The appropriate use of restraints while emphasizing patient safety, and the “when, why and how” (what qualifies as a restraint) of restraint.
  • The concept of time as it applies to crisis situations.
  • How a client in crisis may present (using CPI’s Crisis Development Model and Verbal Escalation Continuum to establish common language for behaviors and responses).
  • Applying our hospital’s core values of respect, accountability, teamwork, and innovation to crisis interactions and department collaboration.
  • Applying CPI’s core values of Care, Welfare, Safety, and Security to crisis interactions and department collaboration.
We discovered that better collaboration would be reached by expanding our debriefing process into two segments our staff calls “PRE-Brief” and “DE-Brief”:
  • The “PRE-brief” discussion was organized by Situation, Background, Assessment, and Recommendation (SBAR). It was agreed that on arrival to the psychiatric unit, security would first seek out the psychiatric nurse for information that would help identify how the client in crisis was presenting, any safety risk issues for both staff and the client, goals of the interaction, and limb assignment if necessary.
  • The “DE-brief” discussion included identifying triggers, alternatives for behaviors, what went well during the interaction, any concerns for staff or patient injury, and what could be done better next time.

We tested our collaboration strategies with role-plays to make sure we could apply them in real life. 

As a team building exercise, I broke all attendees into groups that included both psychiatric nurses and security officers. I developed scenarios which were handed out to each group to read, discuss, practice PRE-brief, and problem solve for safety issues or possible patient injury considerations. Staff then came back to the large group with their scenarios and shared their collaboration ideas.

We left our meetings with better sense of trust and a practical strategy for collaboration between Security and Psychiatry. The outcome? Patients stopped getting hurt.

Upon completion of the meetings, several areas of future work were identified and agreed upon:
1. Psychiatric staff would limit the use of Code Grey calls to emergencies versus using them for medication administration assists. Should the need for additional staff be required during medication assists, security staff would determine the level and number of security personnel required.

2. Prior to alerting security of medication assist requests, staff would have all medication options arranged and would be ready to receive the arriving security personnel. Psychiatric staff would also provide security personnel with an initial description of the situation at hand, as well as their desired outcome for the intervention.

3. Upon arriving to the unit, security personnel would seek out the nurse managing the crisis situation. We determined the use of the term “in charge” was not appropriate and that “managing” would work better in supporting a team approach.

4. Security and psychiatric staff would be educated regarding the plan, limb placement, medical or safety concerns, and goal for interaction during their “PRE-brief” discussion.

5. Upon completion of the interaction, all staff would meet privately to debrief about went well, check for injuries, and determine what new proactive measures could improve outcomes in future interactions.
Our inter-departmental collaborations resulted in immediate changes to Security and Psychiatry’s interactions. There have been no further reports of client injury during security calls/assists since the collaboration meeting. Both departments have continued to make efforts to keep patient safety in the forefront of all interactions, and to act within the best practices of hospital and the core values of Care, Welfare, Safety, and Security.

Code Grey reduction is achievable, and staff, patients, and clients can all be safer in the healthcare setting. Want to learn more about the benefits of CPI training and inter-departmental collaboration at Virginia Mason Memorial Hospital? Check out Sara Holland’s interview with Terry Vittone on Episode 45 of Unrestrained, a CPI Podcast.


Learn more about facilitating successful team intervention strategies at your organization.

Sara Holland began her nursing career well before college, serving for 6 years as a certified nursing assistant in a locked dementia care unit. She completed an Associate Degree in Nursing at the Yakima Valley Community College in 2002 and eventually earned both BSN and MSN degrees. She began her career at Virginia Mason Memorial Hospital as a safety coach in the hospital’s acute inpatient psychiatric care unit. She chaired the hospital’s first shared governance council on psychiatry and in 2007 became a Professional Assault Crisis trainer (Pro-ACT®), which she taught for 3 years. In 2015 Sara became certified in CPI’s Nonviolent Crisis Intervention® training and began training hospital staff in January of 2016.

Today she facilitates CPI training across the Virginia Mason Memorial family of services. In addition, Sara writes curriculum for psychiatric specific education and interdisciplinary plans of care, as well as acting as a point of care reference for all things psychiatric and restraint. She has been with the Virginia Mason Memorial Family of Services for over 11 years.