By Christopher Cheney
A new training program for workplace violence in healthcare settings emphasizes de-escalation and addressing four distinct stages of crisis situations.
Healthcare staff carry a heavy workplace violence burden, with about three-quarters of workplace assaults occurring in healthcare settings. Workplace violence is prevalent in the emergency department—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
“What we teach is that you can’t control what is happening with a person—their backstory or the neurocognitive challenges they might be facing—but you can absolutely control your responses to escalating behaviors. We train that changing your approach can change everything about an encounter,” says Susan Driscoll, president of the Milwaukee, Wisconsin-based Crisis Prevention Institute.
She says CPI has developed a four-stage framework to describe and address workplace violence situations.
1. Anxiety: “The first stage is anxiety, where somebody is showing they are agitated. They might be pacing. They might be clenching their hands into fists,” Driscoll says.
In the early stage of a crisis, she says how staff members say something or what they say make a difference. Staff members need to be empathetic and listen. They need to allow agitated patients and family members time to vent. Those principles can usually get someone back to a normal state.
2. Defensiveness: “The second stage is when someone gets defensive. At this stage, someone is likely to verbally challenge a staff member. They’re starting to lose control. They may refuse to do something they are asked to do,” Driscoll says.
The new CPI training program features a “verbal toolkit” to address defensive patients or family members, she says. “One of the strategies is to distract the patient or family member who is in crisis. If they are escalating and getting irrational, you change the subject. A specific example is if somebody challenges you with an inappropriate comment, you can say, ‘I understand that, but we need to get back to what we are trying to do.'”
3. Risk behavior: “The third stage is risk behavior, where someone might try to intimidate a staff member. They literally are losing control such as looking for something to throw or punching. This is where the situation becomes dangerous,” Driscoll says.
“Our most advanced programs include restrictive practices. So, if someone is out of control and is a danger to themselves and other people, our advanced programs teach the physical holds to safely control someone or move them out of a location.”
4. Tension reduction: “The fourth stage is tension reduction. After someone goes through a crisis episode, there tends to be a release of energy. They might appear to be exhausted. They might cry. They generally apologize profusely,” she says.
What happens after a crisis is just as important as what happens during a crisis, Driscoll says. “We teach what we call therapeutic rapport—the techniques for getting you as a staff member and the person who was in crisis back to a normal functioning state.”
Documenting workplace violence incidents is essential in the healthcare setting, she says. “Having a strong policy about incident reporting is critically important. Sometimes, there are patterns in a person’s behavior that are not readily apparent. But when incidents get documented, you see those patterns and better quality of care can be delivered.”
Incident reporting can identify solutions to workplace violence situations, Driscoll says.
“In a crisis, we believe that every behavior is a sign of distress, and the goal should be to prevent that distress through early intervention. When incidents are reported—even when the person in crisis was not aware of what they were doing—sometimes you can identify an underlying trigger.”
Delivering bad news
One of the aspects of the new CPI workplace violence training for healthcare workers that distinguishes it from CPI’s other training programs is guidance for breaking negative news to patients and family members.
“Doctors and nurses in healthcare often have to deliver bad news to a patient or family member. That is a time when escalation can occur quickly,” Driscoll says.
The CPI training for healthcare workers provides seven strategies for delivering bad news:
- Keep yourself safe
- Get to the point
- Remain objective
- Rationally detach, which is a concept presented in all CPI training programs
- Listen with empathy
- Offer something
- Bring closure
Christopher Cheney is the senior clinical care editor at HealthLeaders.