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ASSESSING AND MANAGING DISRUPTIVE PATIENTS

KATHRYN GIFT DNP, RN, CEN

Beyond Customer Service

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Objectives

Discuss the 3 elements that interact in a violent situation with emphasis on the most unpredictable element.

Summarize the different levels of stress and intervention that can be used at each level of stress.

Demonstrate customer service, verbal/nonverbal interventions, and limit setting techniques that may be deployed to de-escalate disruptive behavior.

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Workplace Violence

“ Violent acts ( including physical assaults and threats of assaults) directed toward persons at work or on duty” National Institute for Occupational Safety and Health (NIOSH)

2011-2013 workplace assaults ranged from 23,540 and 25,630 annually, with 70-74% occurring in healthcare and social service settings.

Assaults comprise 10-11% of workplace injuries for healthcare workers compared to 3% in private sect0r Bureau of Labor Statistics and National Crime Victimization Survey (www.bjs.gov/content/pub/pdf/wv09.pdf)

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Workplace Violence

Health Care workers are 16x more likely to experience violence than other service workers.

Over 50% of workplace aggression claims come from the health sector. Workplace Violence in the Health Sector- State of the Art World Health Organization 2002

24% of all female deaths in the workplace are the result of homicide National Crime Victims Survey; Workplace Violence, 2006

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Subtle Forms of Violence

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Predatory vs. Affective Violence

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Decrease Increase

Values/beliefs against violence

Intact thought processes/ judgment

Appropriate emotional control

Non-violent resolution skills

Undesirable outcomes

Predisposing Factors Internal qualities/ characteristics Things we bring into

the situation ( our baggage)

Precipitating Factors Elements external to

us in the environment or situation

Violence Risk Factors

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Predisposing Factors

History of Past ViolenceActive Substance AbuseWeapons AccumulationFinancial StressViewing the World as HostileSocial History, Past ExperienceLoss of InhibitionConfusion or Disorientation

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Predisposing Factors

Inability to Bond with OthersMisperception of DangerProblems Regulating BehaviorHopelessness or “Nothing Left to Lose”Means to an End

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Precipitating Factors

Loss of ControlLoss of IdentityLoss of PrivacyLoss of DignityLoss of IndependenceLoss of ChoicesFear of Pain

Today’s Precipitating Factor May Become Tomorrow’s Predisposing Factor

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Ongoing Interactive Assessment

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Other’s Body Language: Non-Verbal

Fearful or Anxious AppearanceAgitated or Angry PostureLewd or Inappropriate StaringActing Suspicious or HostileAppearing Stressed or ThreatenedAngry or Sexually Inappropriate GesturesBehavior Doesn’t Match What is Being Said

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Other’s Verbal Behavior

Talking Loudly/ShoutingCursing/SwearingTone of VoiceClaims of MistreatmentSexually Inappropriate CommentsChallenging, Threatening OthersBlaming Others for ProblemsStating a Plan of Intent to Harm Others

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Stress Levels

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Stress Levels

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Normal/ Mild Stress Level

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Normal Stress Level Intervention

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Normal Stress Level Intervention

Allow Person to Express ConcernUse Shared Problem Solving ApproachDemonstrate EmpathyBe Active ListenerAvoid Being DefensiveApologize if AppropriateFollow Through with Their ProblemAvoid Blaming Others or “Not My Job”

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Moderate Level of Stress

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Signs of Moderate Stress

Looking Anxious, Lost or ConfusedMild Voice Changes

Higher/louder/faster speechSmall Nervous Habits

Drumming fingers Tapping foot

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Moderate Stress Level Intervention

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Moderate Stress Level Intervention: Verbal De-escalation

Encourage Person to Talk and Share Experiences

Validate the Person’s ExperienceAsk Open Ended QuestionsRestate, Reflect, ClarifySuggest CollaborationLISTEN

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Moderate Stress Level Intervention: Verbal De-escalation

Present Reality SupportivelyIdentify the ProblemFocus on Problem SolvingGive InformationProvide AlternativesSummarizeCreate an Action Plan

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Moderate Stress Level Intervention: Verbal De-escalation- NON VERBALS

Remain Calm and in ControlMaintain Personal SpaceSupportive Body LanguageDemonstrate EmpathyConvey Willingness to HelpShow Open HandsNon-threatening Eye Contact

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Severe Level of Stress

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Verbal Signs Non Verbal Signs

Threatens othersIncreasing loud or

boisterous behaviorCursing, swearing ,

argumentative

Approaching/avoiding others, pacing

Invading personal spaceNonresponsive to

directionsUncharacteristic behaviorsSlamming doors/pushing

furnitureBehaving inappropriately

for the situation

Signs of Severe Stress

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Severe Stress Level Intervention

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Severe Level Intervention: Limit Setting

Limits are:Simple and DirectDescribe the Desired Behavior- Giving

OptionsAppropriate to the Situation- Stating

Consequences if NeededProgressive in NatureEnforceable

You need to be clear, calm in demeanor, nonthreatening, encouraging, firm yet supportive, respectful and civil, AVOID POWER STRUGGLES

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Severe Level Intervention: Limit Setting

Is an Advanced form of Verbal De-Escalation Skill

Different than customer serviceTakes PRACTICERequires keen self-awareness

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Panic Level of Stress

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Panic Stress Level Intervention

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Panic Stress Level Intervention

Personal Safety Skills“Take Down” Follow facility policy/training

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Tension Reduction

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Tension Level Interventions

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Tension Reduction Intervention: Therapeutic Rapport

Support De-escalation/CalmingProtect Dignity- help “Save Face”Monitor Stress LevelRemember

Even if you never see this patient again, SOMEONE ELSE WILL!!

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Scenario

A customer walks into your workplace. His/her face is flushed and jaw is clenched. S/he states, “ I can’t believe this place! My doctor tells me I may have to go into the hospital for more tests & keeps me so late. I need to go to the lab, bet anything it is closed or another long line. I can’t even find it and no one will help.

What level of stress, What can be your response?

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Scenario

You hear a loud voice in your workplace. You go to see if you can help, and you see an angry person pointing his/her finger at your co-worker’s face, stating “listen, I don’t need a map, I just need to know where my appointment is!! What is wrong with you people? Can’t anybody find anything around here?! Your co-worker appears frozen and stunned by the outburst, unable to get the angry person to calm down.

What is the level of stress and what is your response?

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Resources

Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, Occupational Safety and Health Administration (OSHA), OSHA 3148-04R 2015

Hills, D.J, Ross, H.M., Pich, J., Hill, A. T., Dalsbo, T….. Martinez-Jarret, B. (2015). Education and training for preventing and minimizing workplace aggression directed toward healthcare works. The Cochrane Library.