Strategies to prevent violence in hospitals
Two CONVERGE sessions explained how patient-behavior agreements and de-escalation training can help hospitalists avert aggressive acts by patients.
Have you ever been verbally abused at work? Nearly all CONVERGE attendees said yes at two sessions that asked this question, and a few also reported being physically assaulted on the job.
Those results are in line with the evidence, according to the experts who spoke about workplace violence at the Society of Hospital Medicine conference in Austin in late March.
Almost a quarter of physicians said they'd experienced mistreatment within the past 12 months in a survey conducted in late 2020 at an academic medical center, and the situation is even worse for nurses. While the overall annual rate of nonfatal workplace violence in the U.S. is about 8 incidents per 1,000 workers, it's 15 incidents per 1,000 physicians and 26.3 incidents per 1,000 nurses, according to the National Institute for Occupational Safety and Health.
“You would think everyone would be talking about it, every CEO and every division chief would be worried about it, with these numbers,” said ACP Member Ishaan Gupta, MBBS, an assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore. Yet, a 2015 study found that 88% of self-reported health care workplace violence is not formally documented, he noted.
Research has tied workplace violence to burnout, job satisfaction, quality of care, and clinician retention and well-being, according to Elizabeth Schulwolf, MD, MBA, FACP, chief medical officer of Dell Seton Medical Center at The University of Texas in Austin. She and other speakers described how hospitals and hospitalists can take steps to reduce violence in their workplaces.
Patient behaviors
Chief nursing officer Katie Scott, MSN, RN, knew that the Dell Seaton's existing system for dealing with patient aggression frustrated many nurses. “Security would come and de-escalate the situation, and then sometimes 40 minutes later, the same situation occurred,” she said. “They also felt a lot of moral distress because their entire day was focused on one person who probably did not need that amount of time and care, and they weren't able to adequately care for the rest of the patients.”
She joined other stakeholders, including bedside nurses, nurse and physician leaders, medical executives, and the hospital's risk manager and legal counsel, in developing a protocol for dealing with these situations: a patient-behavior expectations agreement checklist.
“This is not a part of the patient's medical record; this is really just to ensure that we are following the same process every time, that we're not deviating, and that we're doing this as safely as possible,” said Ms. Scott.
The checklist begins by noting that it does not apply to patients who have altered mental status or are under protective custody or emergency detention. For all others, though, it asks the staff person reporting the problem to start by choosing from the listed categories of inappropriate behavior.
“We thought it was important to give people an idea,” said Ms. Scott. “We saw a lot that people didn't really see verbal aggression as abuse. This was part of changing the culture and changing the mindset.” In addition to verbal and physical aggression, categories include “comments that are sexual, racially disparaging, or culturally derogative in nature” and “other.”
“‘Other’ could be really anything that is so disruptive to the care environment or the patient's care that we need to address it, [such as] … patients who might leave the facility and go to a store nearby and buy substances and come back to their room,” she said.
The checklist calls for the staff member to notify both the charge nurse and the patient's primary attending physician. In response, the attending goes to the patient's bedside to talk about the problem behavior and begins developing a care plan in case discharge is necessary.
“We can still send them out with prescriptions, wound-care instructions, follow-up instructions. We want to make sure that when we do discharge the patient against medical advice, if the behavior continues, we're doing it as safely as possible,” said Ms. Scott.
The care team then asks the patient to sign a behavior agreement (although it applies whether or not it's signed) and warns that repetition of the behavior will result in discharge. “We will alert security, [but] we don't necessarily ask them to go into the room with us,” she said. “A lot of times when you have security or law enforcement present, that alone escalates the situation, so we found it's best to have this as a clinical discussion with the patient.”
If it seems appropriate, the team seeks or offers consults with psychiatry, social work, or a chaplain. “We give [patients] every opportunity and all the support we can to try and keep them in our facility. But in the event that they exhibit that behavior again, then they're actually discharged against medical advice from the facility,” Ms. Scott said.
That is a relatively infrequent outcome, noted Dr. Schulwolf, who presented statistics gathered in the first four years of the agreement program, 2019 to 2022. Between 30 and 80 behavior agreements were enacted each year, and slightly more than a quarter of them resulted in early discharge.
About 40% of the agreements came from the inpatient medical floor, and the most common cause was verbal aggression. “The second most common was failure to comply with rules, and this is largely around substance use in the room, smoking, leaving the unit,” she said.
The discharge has no impact on patients' future ability to seek care at the hospital—even immediately, if they choose to go straight to the ED. “If they come back into our system for care, we're more than happy to continue to care for them. We had a patient just yesterday who was discharged, and we tried to tell this patient she's welcome to come back, but we would have the same expectations,” Dr. Schulwolf said.
Not every clinician supported the new system, she noted. “As a physician, you feel that this is really bad, right? You're discharging a patient that is not ready to leave the hospital.” However, physician participation in the process is critical to getting patients to respect the agreements, she added.
“For better or worse, in our hierarchical system, patients listen to physicians differently than they do their bedside nurse. … If you're at the bedside helping to support this process, it does go a long way with helping the patient to be able to complete their care,” said Dr. Schulwolf. “It's important that the physicians in general have grown to accept this process, and I think some of them really see the value in it.”
The behavior agreements are only one component of the hospital's expanded focus on preventing violence, which also includes noise alarms on badges, passive weapons detection, additional security personnel, and electronic health record systems to screen patients for risk of violence and alert clinicians.
In addition, hospital staff now use the buddy system when seeing high-risk patients. “We had an associate who was very violently assaulted by a patient who would not have been appropriate for a contract, but the associate actually ended up with subdural [hematoma] and was admitted in our hospital. So we did a deep dive into that situation and identified that he was in the room alone,” said Ms. Scott.
There are valid concerns about the risk of bias in systems that identify potentially aggressive patients, Dr. Schulwolf noted, citing recent studies finding that hospitals were significantly more likely to call security on Black patients and to place a behavior flag in their record compared with White patients.
“We do need to look at this more deeply in our process,” she said. “We need to look further to make sure that we're not introducing bias into the program, structural racism that might be impacting patients.”
Finally, the hospital also wants to help clinicians avert conflicts by training them in de-escalation strategies. “It's going to be offered to anyone. I know many times it's offered specifically to associates in the emergency department, but a lot of what we see actually happens in the inpatient areas,” said Ms. Scott.
Clinician approaches
De-escalation training for hospitalists is already a key component of antiviolence efforts at Johns Hopkins, explained Che M. Harris, MD, MS, FACP, an assistant professor of medicine there.
“We carried out a four-hour de-escalation training, and we had about 40 hospitalists that participated,” he said. “We sought to measure confidence before and after our intervention, and what we found was that in each category, there was an improvement in the post[intervention] survey.”
He described 10 key elements of the program, adapted from a 2012 consensus statement by emergency psychiatry experts. “You can take these when you when you leave this talk and apply these right away when you encounter your patient who's aggressive or violent,” said Dr. Harris.
The first step is to respect the patient's personal space, which both reduces the risk that the patient will see you as aggressive and that they are able to physically injure you, he noted. “Next, you don't want to be provocative. You want to be cognizant of the words you use, the tone of your voice, your body language, and your facial expressions,” Dr. Harris said.
The third and fourth steps are to establish verbal contact, but to do so using concise, simple language. “Because the patient's angry, they hear less, and the few words they do hear, if they don't understand the terminology, that can make them angrier,” he said. “Let the patient know who you are and what your role is in their care.”
Next, identify the patient's desires and feelings and engage in active listening. “Repeat back to the patient what they have told you. That will reassure them that you are listening to them. In addition, there's a good opportunity to confirm that you understand why they're upset and also a good opportunity to check where they might have misunderstood something,” said Dr. Harris.
Listening may lead to silence in the room. “It may seem a little awkward at first when no one's saying anything, especially if there's been recent yelling, but look at that as a time point where both parties are reflecting on and synthesizing the information that's been said,” he advised.
Then, find a way to either agree with the patient or agree to disagree, said Dr. Harris, offering an example. “So, Mr. Jones, we both agree that your pain needs to be managed in the hospital. However, with your blood pressure being on the low side, [hydromorphone] may not be the best choice for treatment. Can we agree on an alternative pain medication?”
While it's helpful to agree when you can, it's also necessary to set limits. “Patients who are harassing staff, hitting staff—we want to let them know that this type of behavior cannot be tolerated,” said Dr. Harris.
On issues that aren't deal-breakers, offer choices, for example, a reprieve from a low-salt diet for a patient with hypertension whose blood pressure has been controlled during hospitalization.
Finally, debrief with your colleagues about the situation. “Find out what happened that led up to this violent episode. Do we have all the resources we needed for de-escalation to actually work? What did work in de-escalation? What didn't work well? And how can we improve for the future?” said Dr. Harris.
Depending on the intensity of the confrontation, consider debriefing nearby patients as well. “Provide reassuring explanations to all patients following frightening episodes, such as alarms going off or announcement of codes,” said Dr. Harris.
Hospitals should also consider protocols that can prevent patients ever getting this upset, including environmental controls to minimize light and noise and regular check-ins with those who may be prone to depression or violence, he advised. In addition, Dr. Gupta recommended that hospitals track and study the events that lead to violence, because the causes may differ by unit and require individualized solutions.
It's also key for clinicians who are skilled at de-escalating these difficult situations to pass their knowledge on to others, both formally and informally, the experts agreed. “If you ask me, I think it should be part of medical school. It is a skill which you need to do the job,” said Dr. Gupta.
