Peds RN Disruptive Behavior in a Healthcare Setting

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Disruptive Behavior in a Healthcare Setting

Michael Van Vleet

Security Manager

Mercyhealth

OBJECTIVES

• Define the purpose, importance, and barriers for dealing with disruptive behavior

• Identify key risk factors for violence

• Early recognition of escalating behavior

• Describe methods for defusing volatile situations

• Importance of a post incident response

Workplace Violence (WPV)vs.

Disruptive Behavior (DB)

Is all Workplace Violence (WPV) Disruptive Behavior?

Is all Disruptive behavior Workplace Violence?

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What is the Importance of Dealing with Disruptive Behavior?

Disruptive behavior and WPV come

with a high cost.

• Most importantly, it harms workers!!!– Physically & Emotionally

• It makes it more difficult for staff to do their job ‐ which in the long run can effect patient care

• Injuries can lead to lost time and thousands in worker compensation losses.

No Harm, No Foul?

Disruptive behavior and WPV can also have hidden costs.

• Increased job stress

• Family turmoil

• Deteriorating moral

• Diminished productivity

• Absenteeism.

• Increase in employee turnover.

• Loss of reputation for quality care.

The Bureau of Labor Statistics show the magnitude of the problem:

From 2011 to 2013, U.S. healthcare workers suffered 15,000 to 20,000 workplace‐violence‐related injuries every year that required time away from work for treatment and recovery (i.e., serious injuries). Healthcare accounts for nearly as many injuries as all other industries combined.

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Preaching to the Choir

• Violence is a more common source of injury in healthcare than in other industries. From 2011 to 2013, assaults constituted 10–11 percent of serious workplace injuries in healthcare, compared with 3 percent among the private sector as a whole.

How Dangerous is Healthcare?

• Healthcare and social assistance workers experienced 7.8 cases of serious workplace violence injuries per 10,000 full‐time equivalents (FTEs) in 2013. Other large sectors such as construction, manufacturing, and retail all had fewer than two cases per 10,000 FTEs.

Does this Surprise You?

• These statistics do not include the many additional assaults and threats that do not lead to time away from work.

• Studies also show that violence in healthcare workplaces is underreported; thus, the problem is considerably larger than the official statistics suggest.

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Johns Hopkins Hospital (Baltimore) –September 2010

Offender: Paul Warren Pardus, 50 years old

Offender, upset over news about his mother's medical condition, opened fire on a physician, shooting him in the abdomen

Offender barricaded himself in his mother’s hospital room where he fatally shot his mother and then turned the gun on himself, killing himself

• Source: http://articles.baltimoresun.com/2010‐09‐17/news/bs‐md‐ci‐shooting‐hopkins‐20100916_1_mother‐hospital‐staff‐east‐baltimore

•

Johns Hopkins StudyU.S Hospital‐base shootings, 2000 to 2011

• Open source search, 9,360 hits, 154 shootings identified (avg. 14/yr.).– 59% (91) Inside hospital

– 41% (63) Outside on hospital grounds.

• Perpetrators, 91% men.

• The most common site– E.D., 29%

– Parking lot, 23%

– Patient rooms, 19%


• Most events involved a determined shooter with a strong motive.

– Grudge, 27%

– Suicide, 21%

– Euthanizing an ill relative, 14%

– Prisoner escape, 11%

– Ambient society violence, 9%

– Unstable patients, 4%

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• The most common victim was the perpetrator 45%

• Of the 106 perpetrators who were shot, 84 (79%) died.– 59 by suicide

• Hospital employees composed 20% of the victims– Physician, 3%

– Nurse, 5%

– Pharmacists, 2%

– Non‐medical (other), 10%


• The E.D. was a little different (isn't it always?)

– Younger perpetrator

– Most likely in custody

– Unlikely to have personal relationship with victim

• Fifty percent (50%) of guns used in the E.D. were not brought in by the perpetrator, but rather involved security personnel’s firearms.


• Fatality rate

– E.D., 19%

– Other sites, 73%

• Authors judged that only 30% to 36% of events were likely preventable by the use of metal detectors.

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Barriers for Dealing with DB &WPV

• Fear of – Retaliation

• Staff

• Physicians

• Administration

– isolation

– embarrassment

• Lack of management support

• Afraid it will show up on performance evaluation as not being able to handle patient.

Barriers for Dealing with DB &WPV

• Restrictions imposed by regulatory & accreditation agencies.

• Perception that reporting would have a negative impact on customer services scores.

• There is a persistent perception in healthcare that assaults are part of the job.– By management

– By Co‐workers

– By the criminal justice system

• Until the culture of tolerance at hosptials changes, violence inside of healthcares is not going to change.

What is WPV?

• Defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.

• The workplace may be any location, either permanent or temporary, where an employee performs any work‐related duty.

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General Duty Clause

Section 5(a)(1) of the Occupational Safety and Health Act (OSHA) of 1970, employers are required to provide their employees with a place of employment that "is free from recognizable hazards that are causing or likely to cause death or serious harm to employees."

Disruptive Behavior Defined

There is no standard definition of disruptive behavior.

• Any inappropriate behavior by a patient, family, friends, or patient representative, that is confrontational, intimidating, threatening, or disrespectful of others or any behavior that interferes with the safe and effective medical care for any patient or impedes facility operations.

• Disruptive behavior does not include non‐adherent behavior – Patient may not comply with recommended treatment plans.

Verbal Abuse Examples

• Name calling

• Racial or ethnic epithets

• Sexually inappropriate comments

• Loud or profane language

• Direct, indirect, implied threats

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Physical Abuse Examples

• Bumping

• Shoving

• Slapping

• Striking

• Inappropriate touching

• Kicking

• Biting

Social Media

• Online comments by co‐workers may constitute lateral violence.– Even if posted from home during nonwork hours.

• This disruptive behavior parallels the characteristics of verbal abuse, only via the Internet.– Name calling

– Sexually inappropriate comments

– Threats: direct, indirect, implied

– Demeaning personal comments

– Intimidation & bullying, commonly referred to as “Cyber Bullying”

Social Media

• Negative comments:

– Can adversely effect team‐based care

– May result in sanctions against the healthcare worker

• Additional word of Caution on Social Media:

– Online contact with patients or former patients can blur the line between a professional and personal relationship. Regardless of who initiates the contact.

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Key Risk Factors for WPV‐Related to Patients, Clients & Settings‐

• Working directly with people who have a history of violence, people who abuse drugs or alcohol, gang members, or distressed relatives or friends of patients or clients.

• Working alone in a facility or in patient’s homes.

• Working in neighborhoods with high crime rates.

Key Risk Factors for WPV‐Related to Patients, Clients & Settings‐

• Poorly lit corridors, rooms, parking lots, and other areas.

• Prevalence of firearms, knives, and other weapons among patients and their families and friends.

• Poor environmental design of the workplace that may block employees’ vision or interfere with their escape of a violent incident.

Key Risk Factors for WPV‐Organizational‐

• Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff.

• Working when understaffed.

• High worker turnover.

• Inadequate mental health personnel on site.

• Inadequate security on site.

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Key Risk Factors for WPV‐Organizational‐

• Long wait for patients and overcrowded, uncomfortable waiting rooms.

• Unrestricted movement of public in clinics and hospitals.

• Perception that violence is tolerated and victims will not be able to report the incident to police and/or press charges.

• An over emphasis on customer satisfaction over staff safety.

5 Core Elements of WPV Program

1. Management commitment & employee participation

2. Worksite analysis & hazard identification

3. Hazard prevention & control

4. Safety & Health training

5. Record keeping & program evaluation

Management & Employee Participation

Managers demonstrate commitment & set example

Communicate commitment

Establish goals & objectives

Provide adequate resources & support

Employees involved in all aspects of program & can report their concerns with fear of reprisal

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2. Worksite analysis & hazard identification

• Process & procedures to continually identify workplace hazards

• Formal re‐evaluations after incidents

• After‐action reviews

3. Hazard prevention & control• Process, procedures, and programs to eliminate or control workplace hazards and achieve workplace violence goals and objectives.

4. Safety & Health training• All employees have education and training on hazard recognitions and control

• Their responsibilities under the program, including what to do in an emergency

5. Record keeping & program evaluation• Accurate records of injuries, illnesses, incidents, assaults, hazards, corrective actions, patient histories and training.

• Identify patterns or trends

• Evaluate methods

• Identify training needs

Engineering & Design

• Deploy emergency signaling, alarms, and monitoring systems.

• Consider the use of metal detectors.

• Provide security escorts to parking lots.

• Utilize access control systems

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Provide good lighting & install mirrors to view corridors and hidden spaces.

Utilization of video monitoring equipment


• Design waiting areas to accommodate patients and visitors who may have long waits.

• Arrange furniture and other objects in a way that minimizes their ability to be used as weapons.


• Design patient rooms/areas so most tasks can be performed without placing patient between staff and the exit.

• Always have an escape route.

• CPTED – Crime Prevention Through Environmental Design

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7/38/55

Theory by Albert Mehrabian

Verbal Escalation Warning Signs

• Threats– Direct

– Veiled

– Conditional

• Increase in voice pitch, forced or strained speech.

• Nervous laugh at inappropriate times

• Person speaks to others about someone as if they’re not present.

Verbal Escalation Warning Signs

• Yelling or screaming

• Non‐stop profanity

• Boasts of prior violence

• Talk of hurting/abusing animals

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Non‐Verbal Warning Signs

• A change in eye contact– Person refuses eye contact

– Person stares through you

– You should not maintain constant eye contact

– You should maintain the same level or higher eye contact

• Standing toe to toe

• Finger pointing

• Flaring nostrils

Non‐Verbal Warning Signs

• A violation of personal space – at least an arms length in distance

• Clenched fist or tightening & untightening of the jaw

• Pacing , fidgeting

• Blading of their body

• Flipping you off

Verbal Do’s

Use the person’s name

Ask “How may I help you”

Use active listening skills– Give full attention

– Use restatement for clarification

• Get them to yes

– Reflective questions to understand feelings

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Verbal Do’s

Give options

Ask for their idea or solution

Speak slowly

Use simple words

Allow time for reflection

Remember – You are in charge of how you react.

Don’ts

Don’t allow long waits (easily said)

Don’t fake attention

Don’t roll your eyes

Don’t make fake promises

Don’t cut people off

Don’t get in a power struggle

Don’t raise your voice

Don’ts

Don’t argue

Don’t allow more than one person to talk

Don’t ever meet an angry person one on one

Don’t say “calm down”

Don’t lose temper

Verbal de‐escalation takes patience, tact, and the ability to control one’s ego and pride.

Remember – You are in charge of how you react.

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Safety Tips

• Evaluate each situation for violence.

• Be vigilant throughout your encounter

• If the disruptive person is in a public area or waiting room, try to move them to another location. Sometimes an audience emboldens them.

• Do not turn your back on the person.

Safety Tips

• Do not isolate yourself or be alone with the person.

• Always have an exit strategy.

• If you are unable to defuse, remove yourself from the situation and seek help.– Different personalities click

– This does not mean the patient or family dictate who they will behave for.

Safety Tips

• Listen to your body and intuition!

– Heart rate

– Perspiration

– Nausea

– Feeling indecisive

– Hair raising on the back of your neck

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Situational Awareness

• Plain & Simple

Know what is going on around you!!!

• What is going on in my environment?

• Is it changing? What is the norm?

• What do I sense?– Danger

– Challenges

• Do I need to adapt and how?

De‐escalation Training Programs

(This list is alphabetical and not all inclusive)

Crisis Prevention Institute (CPI)

Management of Aggressive Behavior (MOAB)

Managing Aggressive Behavior (MAB)

The Mandt System

Oregon Intervention System (OIS)

Pro‐ACT

Professional Crisis Management Assoc. (PCMA)

De‐escalation Training Programs

Right Response

Safety‐Care (SC)

Safe Crisis Management (SCM)

Safety First (Early childhood)

Therapeutic Alternatives in Crisis Training (TACT)

Therapeutic Crisis Intervention (TCI) System

Eastern Oregon Behavior Intervention System (EOBIS)

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Setting Expectations

Termination of Provider/Patient Relationship


• Every practice should have a patients rights and responsibilities document posted in a visible place.

• It should outline the types of behavior expected.

– Respect for providers and staff

– Refill request protocol

– Arriving for appointments on time


• Also outline which behaviors will not be tolerated including physical and verbal abuse.

• One of the biggest issues when dealing with disruptive behavior is the unwillingness of the staff to be consistent with the application of behavioral limits.– Nurse to nurse

– Shift to shift

– Doctor to patient

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• In some cases, termination of the provider/patient relationship may be an appropriate response. This should be considered as a last resort.

• If care has already been initiated, or a provider/patient relationship is established, specific steps should be taken to terminate that relationship.


• The first step should be an attempt to alter the behavior through two aspects of communication.

– Informal

• Describe to the patient or family member how their behavior impacts their care.

• Establish clear expectations and limits.

• Fully document in medical record.


– Formal communication

• A written Provider/Patient Agreement or Contract.

• Describes a clear and consistent process.

• Reinforces expectations and limits.

• Clearly states the provider/patient relationship will be terminated if the behavior continues.

• Must be signed by the disruptive patient and/or family member.

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• The AMA Council on Ethical and Judicial Affairs have established guidelines.– The physician has an obligation to cooperate in the coordination of medically indicated care with other health care providers treating the patient.

– The provider may not discontinue treatment of a patient as long as further treatment is medically indicated without giving patient reasonable assistance and sufficient opportunity to make alternative arrangements for care.


• Its imperative that you consult your Legal Dept and Risk Management Group when considering the dismissal of a patient.

Post Incident Response

• De‐brief – Review facts of what happened– Can be informal, immediately after incident

– Formal Critical Incident Stress Debriefing (CISD) for traumatic experiences

• RCA

• EAP

• Incident/Work site analysis– Notifications/communications

– Response/Resources/Effectiveness

– Environment/Engineering

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What about Criminal Charges?

• What can be expected from the Criminal Justice System

Definitions– Battery – Aggravated Battery

– Assault – Aggravated Assault

• “Emergency medical technician” includes a paramedic, ambulance driver, first aid worker, hospital worker, or other medical assistance worker.

Battery (720 ILCS 5/12‐3)

• A person commits battery if he or she knowingly without legal justification by any means

– (1) causes bodily harm to an individual or

– (2) makes physical contact of an insulting or provoking nature with an individual.

• (b) Sentence

– Battery is a Class A misdemeanor.

Agg. Batt. (720 ILCS 5/12‐3.05)

• A judge, emergency management worker, emergency medical technician, or utility worker:

• (i) performing his or her official duties;

• (ii) battered to prevent performance of his or

• her official duties; or

• (iii) battered in retaliation for performing his or her official duties.

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Aggravated Battery

• A nurse while in the performance of his or her duties as a nurse.

• Sentence

– Unless otherwise provided, aggravated battery is a Class 3 felony.

Assault (720 ILCS 5/12‐1)

• A person commits an assault when, without lawful authority, he or she knowingly engages in conduct which places another in reasonable apprehension of receiving a battery.

• (b) Sentence. Assault is a Class C misdemeanor.

Aggravated Assault (720 ILCS 5/12‐2)

• A peace officer, community policing volunteer, fireman, private security officer, emergency management worker, emergency medical technician, or utility worker:

• (i) performing his or her official duties;

• (ii) assaulted to prevent performance of his or

• her official duties; or

• iii) assaulted in retaliation for performing

• his or her official duties.

• Sentence. Class A misdemeanor

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Who Files the Charges?

• The victim must be the one to press charges.

• There are 102 counties in Illinois and 102 State’s Attorneys.– Each State’s Attorneys office may interpret the law differently.

• You (Legal, Risk, or Security) may need to meet with a representative from your State’s Attorneys office and the local law enforcement agency to discuss what elements must be present to charge.

Managing disruptive behavior is a Risk Management, Security, and

patient safety challenge.

QUESTIONS???

Be Prepared

Be Calm

NEVER GIVE UP YOUR RIGHT TO SURVIVE

Peds RN Disruptive Behavior in a Healthcare Setting

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