“We Started Recognizing That the Issues Weren’t Just Patients”
My conversation with nurse educator Sara Holland of Virginia Mason Memorial Hospital was wide-ranging; she illuminated how crisis prevention in a hospital setting has to be about more than patients, and as a result our conversation touched on many facets of the Integrated Experience. Her holistic perspective makes a strong case for consistent, organization-wide training to ensure everyone is on the same page and training drift is minimized.
One of the benefits of CPI’s Nonviolent Crisis Intervention®
training is the dialog it facilitates around important issues that otherwise might go unaddressed. According to Sara, one of those issues is staff-to-staff conflict and aggression, and CPI training provides a venue where staff feel free to express their concerns. “We started recognizing that the issues weren't just patients. The people are saying, ‘I've had doctors get confrontational and screaming at me. I've had people follow me into the elevator. I had a nurse back me up against the wall.’ So it was workplace violence, too. And it wasn't just about the patients anymore,” says Sara.
Photo: Minerva Studio / Shutterstock
Sara’s observation highlights a serious and ongoing problem in healthcare: a high rate of workplace bullying and internal workplace violence that unfortunately gets absorbed by many staff, particularly nurses, as an inevitable part of the job. As Sara points out, CPI training provides a venue for staff to address all levels of conflict management and a space to escape the confines of a unilateral patient-facing focus.
The Energy We Project Is Contagious
CPI training helps to create other valuable levels of awareness at the hospital, including a concept central to CPI: the Integrated Experience. CPI describes the Integrated Experience as how my attitudes and behaviors affect your attitudes and behaviors and vice versa. According to Sara, “It's a reality check for a lot of people when they go, ‘Oh. My attitude is going to affect what's going on in front of me, how I'm behaving.’ I see people getting into power struggles all the time with patients and, ‘No, you're going to talk to me. I'm your nurse. This is how it's going to work.’”
Sara says she was struck by how often staff were fighting unnecessary uphill battles instead of looking for common ground and ways staff could better serve customers.
In the end, the concept of an Integrated Experience teaches us that the energy we project in any given situation is contagious to everybody around us, including our colleagues and teammates. In the podcast, Sara shares a story about de-escalating an extremely agitated patient who wanted to play music on her radio that was “not the general public’s desired listening,” according to Sara. Listen to the podcast to learn how Sara’s calm, limit-setting approach brought about a mutually satisfying outcome.
A Dramatic Reduction in Code Greys
A code grey is called at the hospital when a crisis situation relating to combative patient behavior arises that requires a team response. Sara describes how essential elements of CPI training including the Crisis Development Model
℠, Verbal Escalation Continuum
℠, and Decision-Making Matrix have helped staff to more effectively determine when a code grey is required and when it is not, for example when “little, old people get tackled because they won't stay in their beds.”
The hospital completed their first full year of CPI training in 2016. Code grey statistics for 2016/2017 demonstrate that CPI training can bring about a dramatic shift in outcomes over a relatively short period of time. Between comparable periods in 2016 and 2017, (January–September), there were a total of 51 code greys called in 2016
compared with only 23 in 2017—a 55% reduction over the period.
Graphic courtesy of Virginia Mason Memorial Hospital
One prominent reason for the remarkable decrease in code greys is a change in thinking about the acceptability of being hurt on the job. The hospital’s nurse manager is now pushing the message that staff injuries are no longer acceptable and should never be viewed as an inevitable outcome. “It's not okay to be hurt,” says Sara. “When you are debriefing the patient, when you are going through re-engaging, it's not okay to say, ‘It's okay’ [for a staff member to be hurt] if the patient comes up to apologize to you. ‘It's okay. I'm all right. We're fine.’ It's not okay. Don't tell people it's okay.” That shift in thinking is now part of the workplace reality at the hospital, and Sara preaches the message each time she facilitates CPI training.
Photo: michaeljung / Shutterstock
You Have to Slow It Down to Get It Right
In an age when the business of healthcare is perceived to be more focused on the shareholder than the patient, and everyone from gift shop customers to hospital administrators want everything 5 minutes ago, it can become routine and expected that hospital staff do as much work in as little time as possible. According to Sara, hospital staff can sometimes get swept up in the breakneck pace. “They [hospital staff] don’t even knock, you know, half the time. So they're just blowing through the door, making adjustments, giving meds. There's never a conversation happening. There's not, ‘This is what I'm doing. This is what you can expect,’” says Sara.
And when a patient is in great pain, or sedated, or in delirium, it can take even longer for them to comprehend what is happening around them. “How are you going to react if somebody comes in and rips the covers off when you're delirious? You know, I'd start swinging, too,” says Sara. So she takes time to remind the staff she trains that time is relevant. “We have to slow it down to get it right,” she says. (For an enlightening take on the true cost of kindness in the schedule of a busy staff, check out the CPI blog post, We Asked CPI Instructors: Is Kindness Worth It?
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.