By Will Stewart, MSN, RN, CEN, EMT-LP, NE-BC
There are multiple safety concerns in society today, and one unfortunate headline is the frequency of violence in healthcare settings. If you are a healthcare provider, it is safe to say that you have been or will be exposed to violence in the workplace, whether from a coworker (lateral violence), a patient, or a patient’s family member.
Healthcare institutions often respond to situations of violence by implementing new policies and rules, and most require some type of de-escalation training for their staff. A less frequently discussed method of reducing episodes of violence in high-stress situations is unconditional positive regard, a concept developed by psychologist Carl Rogers. I have found this approach to be very successful and encourage you to try it yourself.
Unconditional positive regard is a learned methodology of increased acceptance and respect for all patients. It requires a fuller awareness of people (patients) as human beings with the right to choose how to respond to their situation. It necessitates a non-judgmental approach so that no matter how dangerous or dysfunctional patients may seem, one accepts that they are doing their best. This is a difficult mindset to achieve, and until it is tested and successful, it is often difficult to adopt.
Let’s turn to a common example in emergency departments (ED). A patient is brought in by law enforcement and is resistant to care. A urine sample for a drug screen is needed prior to completing the evaluation, but when approached, the patient says, “Don’t touch me; I won’t give you one.” Often, the response from the caregiver is, “Either you will do this or I will make you” or something similarly coercive—such a response further disempowers the patient and could escalate the situation.
Patients who feel a loss of control regularly attempt to exert power and act out with verbal threats or violence. Of course, this creates an unsafe situation for staff and others and could become more dangerous if not quickly controlled.
Unconditional positive regard is best implemented in a collaborative manner. In a healthcare setting such as an ED, the following steps may prove effective:
- Establish a goal—The caregiver takes a moment to discuss with patients what they are feeling and what they want, thus establishing a goal.
- Provide options—The caregiver then provides options the patients can take, even though some may be unpleasant, and allows them to make a choice (collaboration in care).
- Identify steps required to meet the goal—Continuing the example above, many patients want disposition from the ED. With this approach, the caregiver would calmly discuss the situation and explain that certain steps are required to be released from the ED. For example, a caregiver might say, “One of the steps is a urine test. Could you help me by collecting that sample?” This establishes a common goal between the caregiver and the patient. While it is true that the patient may not be able to be discharged or evaluated prior to the test, clearly and calmly explaining this fact often yields positive results. Of course, it may be necessary to discuss why a patient is reluctant to provide the sample; perhaps it is due to fear of legal action or other complications. Discussion of the situation, with the caregiver maintaining calmness and respect but focusing on the goal of disposition and providing the urine sample, allows the patient to participate in making a self-determined decision. This builds trust and improves the overall situation.
In one example, during an interim leadership project in a freestanding ED in the Pacific Northwest, a department was cited as having a high frequency of restraints. Security would make the decision to place a patient in restraints, often opting for restraint after any resistance by a patient as well as after verbal outbursts. Restraints were used at least daily, sometimes multiple times a day. After consultation with the organization’s director of behavioral health, unconditional positive regard was used as part of education that was delivered to all staff, along with a policy change stating that only the caregiver could request to place a patient in restraints with support from security. The result was a decrease in restraint usage in the behavioral health population, resulting in less than two restraints per month.
Overall, approaching situations in a collaborative manner with unconditional positive regard takes the caregiver out of a role of authority and demonstrates a collective relationship with the patient. I have experienced positive results by doing so. Some caregivers may think this approach takes too much time, but it should take less time than an escalated situation that poses safety issues to everyone involved.
Will Stewart is consulting principal of ED services at Philips.