Minnesota Hospital Association


July 08, 2013

Protecting patients and staff from aggressive behavior

Health care professionals are committed to providing the highest quality, safest care possible to patients. Yet this deep-seated commitment to caring for others often leads health care workers to endure violent or aggressive behavior from patients as simply “part of the job.” This reluctance to speak up or report incidents puts employees at risk as well as patients and visitors.

Following a series of what it deemed “significant” events of aggressive behavior within a six-month period, CentraCare Health decided it needed changes that empower staff to address violence and/or aggressive behavior on inpatient units.

“The hospital experienced significant damage to equipment, and employees were subject to terrifying and emotionally straining situations,” said Joy Plamann, care center director of medicine at CentraCare’s St. Cloud Hospital.

After reviewing all the cases, Plamann discovered a common denominator that all the patients had some sort of “escalation” symptoms that staff either did not identify or did not know how to intervene properly. “Many of these skills are taught and practiced regularly on mental health units, but nurses and staff on medical-surgical units don’t have the opportunity to execute these skills every day,” said Plamann.

Upon further investigation, Plamann discovered that similar incidents were happening across CentraCare’s campus; essentially every department had a story to tell of a patient who had displayed aggressive or violent behavior to staff. Armed with this information, Plamann went to the performance improvement group to ask for support for a failure modes effects analysis (FMEA), a process used to define, identify, prioritize and eliminate known or potential system, design or process problems. She understood that in order to address the issue, they had to first fully understand it. During this process, the performance improvement team identified 96 immediate failures to systems and processes in place. They prioritized these failures and identified focus areas.

“At the same time this analysis was taking place, an incident in the emergency room helped the group realize that immediate education for staff was needed,” explained Plamann.

All staff received general training on safety principles from the security department and direct patient care staff received additional education to alert them to the warning signs of escalation as well as how to intervene non-verbally if an incident is happening. A main take-away of the education sessions was to inform staff of the need to speak up about these incidents and report them.

Following the education sessions, the hospital found the number of Code Green calls, indicating an incident in progress, were decreasing and calls for security were increasing. Often the presence of security is enough to moderate the behavior before it escalates to a violent incident.

CentraCare also made several process changes to help staff better identify patients who might be at risk of aggressive behavior. It can be difficult to identify all risks as some patients display aggressive behavior in the hospital when they otherwise would not. It may be caused by a reaction to medication or stress of their condition, for example. However, if a patient is known to have a past history of multiple aggressive behaviors or the nurse determines they may have a current potential risk for aggressive behaviors, a spiral-shaped magnet is placed outside the patient’s room, similar to how many hospitals identify patients at risk of falling with a “falling star.” This common symbol replaced other signs such as “check with nurse before entering” that staff didn’t always think applied to them. “This reminds staff to be thoughtful about every move they make; to knock first, be aware of their position in the room and so forth,” said Plamann. In addition, an alert can be added to the patient’s record in the electronic health record so all staff can be informed of the risk.

For patients where multiple episodes have occurred, Plamann said a unique treatment plan is recommended. A unique treatment plan is a consistent care plan that is developed with input from the patient to try to mitigate risks of escalation. “Whenever possible, the patient is involved so they know if they are displaying certain behaviors the nurse will call them on it and there may be certain restrictions. It’s a way to set expectations for their behavior while they are receiving care,” she said. Once the unique treatment plan is established, it will trigger a “best practice” reminder every time the patient’s record is opened.

According to Plamann, each organization needs to find the resources that can assist in these situations. “Build relationships with internal resources, the police department or security team because when you need help, you need help now,” she said. She also said it’s critical to know which patients are at risk. “Many hospitals have patients who come back for care or are seen in another setting. You must flag those persons as a risk so staff can be aware,” she advises.

Changing hospitals’ approach to managing aggressive behavior can be difficult because it requires a change in mindset that any patient can pose a risk. “We weren’t trained that way; we were trained to care give,” said Plamann. “We just haven’t been trained to think of hot coffee as a potential risk or weapon.”

CentraCare is working to change that mindset and has made a long-term commitment to involve staff at the bedside to try to mitigate the risks of this issue. As with many safety and performance improvement efforts, a strong safety culture is at the foundation. Staff must recognize that aggressive and violent behavior by patients does not have to be tolerated, and they must feel that the hospital will support them in putting their own safety first.

“We’ve come a long way,” said Plamann. “But we still have significant under-reporting of events. We know staff expects some level of aggressive behavior to happen and just take it as part of the job. We’ll continue to advocate for staff. We want to create a culture where staff feels safe to speak up and show them that actions are taking place as a result.”