VIRGINIA A. BARTHEL, RN, MA

VIRGINIA BARTHEL is vice president of clinical operations at Advocate Lutheran General Hospital in Park Ridge, IL.

Hospitals are inherently stressful places, but no one should have to work in an abusive environment. Here's how one facility helps nurses deal with disruptive behavior—before it turns into something worse.

It's a sad reality, but all too many of today's nurses find themselves in a workplace where verbal abuse, threats, and physical assaults are commonplace. The attacks seem to come from all sides: unruly patients, volatile family members, abrasive doctors, and angry colleagues.

According to the Bureau of Labor Statistics, healthcare workers are at high risk of violent assault at work, and nurses are among those most frequently attacked.¹ Almost half of all non-fatal injuries from occupational assaults and violent acts reported in 2000 occurred in the healthcare and social services industries, according to the Bureau's latest compilation.¹

And the injury rate for nurses is among the highest—25 of every 10,000 full-time nurses were injured in workplace assaults in 2000. This compares to an overall private sector injury rate of two per 10,000.¹

These statistics, however, tell only part of the story. According to the Occupational Safety and Health Administration, such incidents are probably underreported because healthcare workers believe that it's all part of the job.

But it shouldn't be. When erratic behavior and the threat of physical violence become part of the clinical setting, staff RNs and nurse managers alike feel unsafe and uncomfortable, and everyone suffers. In my experience, though, equipping professionals with the skills to identify disruptive behavior early on and to prevent or de-escalate tension goes a long way to create confidence and enhance job satisfaction.

I've seen an improvement in staff morale since we implemented a protocol for dealing with disruptive behavior at Advocate Lutheran General, a 600-bed tertiary medical center in the Chicago metropolitan area. Prompted by staff complaints, nursing administrators took a proactive, systematic approach to the problem that can serve as a model for other facilities, as well.

Identifying a need for early intervention

Since 2000, our hospital has had a Central Access Team—a group whose primary function was to assess the behavioral health of disruptive patients and to determine whether there was a need for psychiatric care. When it became apparent that a similar process was needed for relatives of patients, the Access Team provided the framework that led to the creation of a formal procedure for responding.

We set out to establish a Family Triage Team whose job it would be to respond to potential or actual volatile situations by de-escalating disruptive behavior and assisting in family interventions. Early involvement of the triage team, we hoped, would avoid the need for a more dramatic response.

We decided to start with the ICU staff because of its frequent encounters with emotionally overwrought or abusive family members. Nurses in the ICU felt that they had to muddle through difficult situations on their own.

To be sure we addressed the nurses' concerns, we compiled an interdisciplinary team. Members included the critical care and behavioral health directors, ICU managers, care coordinators, clinical psychologists, and social workers from the ICU. Together they pinpointed ways to assess the risk of disruptive individuals and, when necessary, to intervene.

Handling explosive family members

Any significant change begins with admitting there's a problem. With that in mind, the team's first several meetings were filled with war stories: ICU managers described numerous instances in which staff nurses had been the targets of verbal abuse and physical threats. They expressed frustration over their frequent inability to take control.

One example involved a patient with end-stage renal disease (ESRD) whose adult children wouldn't accept the doctor's recommendation that treatment be withheld and palliative care initiated. The daughters became irate, threatened to sue, and demanded that their mother receive dialysis.

The hostility mounted for days, with the daughters repeatedly accusing nurses of not knowing what they were doing. The crisis came to a head when one daughter demanded that another patient be removed from dialysis so her mother could be placed on the machine.

The ICU staff warned the daughters that they would have to leave if they continued to act aggressively. Family conferences and ethics consults were held but the behavior continued. In the meantime, the nurses were upset when the doctor agreed to initiate dialysis despite the obvious medical futility.

These "storytelling" meetings turned out to be constructive: They created an understanding between critical care and behavioral health clinicians, provided a safe environment for nurses to air their frustration and sadness, and demonstrated the urgent need for earlier intervention. Had the Family Triage Team been in place when the ESRD patient was in the ICU, for example, its members would have intervened days earlier to address the conflict before the hostility had time to escalate.

At first, the two groups differed dramatically in their approach. The critical care nurses leaned toward an action-oriented strategy, like removing hostile family members, while the behavioral health clinicians opted for conflict-resolution meetings. Eventually, the two sides came together and forged a team approach.

Part of the plan took the form of a four-tiered observation tool intended to help staff members properly identify behavior that might lead to confrontation. A companion tool (you'll find key elements of both tools in the "When hostilities rise, don’t go it alone'" chart) delineates the types of interventions that are appropriate for each hostility level and the specific actions that are needed.

So, for instance, if the situation is a Level III (verbal conflict and the threat of a lawsuit), the nurses are advised to alert the physician, nurse manager, and other designated personnel as soon as possible. The group can then choose whether to bring in support services, such as pastoral care or social work, or the Family Triage Team, which is always available by pager.

On the lookout for warning signs

To prepare the ICU staff to recognize the need for intervention, clinical psychologists held training sessions. There the nurses were taught to identify early warning signs of stress among patients and families—excessive fidgeting, shouting, pounding a fist, or rapid pacing, for example—and how to perform (and document) an objective assessment.

The nurses were told of ways to remedy tense situations: Often an agitated relative needs only to be led to a safe, quiet area to be calmed. Or perhaps a supervisor must intervene to answer a distressed family member's clinical question. More threatening scenarios might be handled by calling in uniformed security officers, whose mere presence could defuse a volatile situation.

Personal reflection was an important part of the educational program. Each nurse was encouraged to examine how her responses might affect the outcome of a confrontation. The staff was taught that it's possible to listen to and affirm the feelings of a family member who's very upset, for instance, without becoming defensive—and without agreeing with or attempting to refute the individual's understanding of the situation.

Learning to deal with difficult staff

We didn't stop there. While the family behavior intervention program was being developed, a group of clinical managers identified their own most difficult challenges in creating an effective work environment. In their case, it was disruptive behavior by those they work with. To address the problem, the behavioral health specialists developed an educational program for managers.

Role-playing, which helped give participants insight into the way their own responses under pressure may contribute to the problem, was a key component. The scenarios involved such potentially volatile situations as responding to a disruptive physician and announcing an unwelcome change in hospital policy to their staff. Participants practiced management conflict strategies.

In responding to difficulties with a physician, for example, the managers were given advice on how to cultivate healthy relationships with doctors and avoid key triggers when communicating with them. There was an emphasis on following the chain of command to report chronic problems. A nurse working with a physician who repeatedly becomes angry or defensive whenever, say, an order is questioned, would be advised to stop arguing with the physician and use the chain of command in seeking a resolution.

Though it's too soon to gauge the success of our program (it was just introduced to general units over the past year), feedback thus far has been positive. Comments from the staff have led us to believe that our goals of staff retention, enhanced job satisfaction, and a safer environment for patients and families are well within reach with the program we've developed. Perhaps a system like ours could benefit your facility, too.

REFERENCES

1. U.S. Department of Labor, Occupational Safety and Health Administration. "Preventing workplace violence for health care & social service workers," 2004. www.osha.gov/Publications/osha3148.pdf (21 July 2004).

 

Helen Lippman, ed. Virginia Barthel. We STOP AGGRESSION as soon as it STARTS. RN Oct. 1, 2004;67:33.

Published in RN Magazine.