Reducing Bad Behavior in Healthcare: the Staff Safety Continuum

By: Dick Sem, CPP       

I've assessed healthcare violence management and security programs in almost every state and often am asked by executives about how to better manage bad behavior, what the tolerance for such behavior should be and how to keep such behavior from becoming violent. 

We've all heard how hazardous healthcare environments have become, from threats and assaults against staff up to the active shooter. An underlying and contributing trend is that we're seeing more disrespectful, aggressive, intimidating, entitled and threatening behavior by patients, families and visitors. Hospitals and clinics that should be places of healing and caring are too often places of confrontation and conflict. Caregivers, especially in ER's and Behavioral Health, tell me that being sworn at, threatened and even struck are "part of the job."

And so we typically address these challenges in a piecemeal and reactive fashion. While one committee is developing a workplace violence program, another is managing EOC and the security program and yet another is researching staff training or patient relations and satisfaction. When an incident happens we tend to overreact, over study and overspend, too often will little real improvement over time.

At perhaps the most basic level we all take pride in our organization's culture, values, vision and mission. Look at the "About Us" section in virtually any healthcare system website and you'll see a statement of culture and mission using terms like respectful, quality, safe, welcoming, accountable, collaborative, compassionate, patient centric and dignity.

So how do we effectively apply and live that culture in our workplace every day and in every way? How can we exploit our most essential values to protect all people within our facilities? People tend to behave better in libraries and churches, why can't we get them to behave better in a place of care and healing?

After working with hundreds of hospitals and clinics I've evolved the concept of a continuum of behavior modification and management in healthcare. Every time we touch a patient, client or family member in any way we should be setting and demonstrating behavioral expectations from the earliest admissions paperwork, to our first greeting and engagements, and on to the mitigation of and response to violence up to the active shooter. 

Likewise, every employee's contact with patients, clients and family members should reinforce that respectful, protective and nurturing culture and should reflect the organization's policies and training regarding service, safety and security. Every employee should be an active member of the Safety and Security Team continually demonstrating and practicing ownership, engagement, involvement, accountability and vigilance. On a related note, without the Administration's clear support and understanding, the process cannot succeed.

Furthermore, bad behavior has a direct negative effect upon patient and family satisfaction. A family's delight from the wonderful care their family member is receiving can be erased in an instant by threats and f-bombs hurled from the next room. Bad behavior is toxic to every aspect of the healthcare experience.

It should be noted that, despite all of the best protective efforts, violence sometimes explodes from nothing and could not be specifically anticipated by anyone. When you routinely deal with persons with varying degrees and types of impairment, mental illness and criminality, sometimes you will face the entirely unexpected. And yet this behavioral management continuum, if properly implemented and practiced, will go far toward minimizing harm in even these situations.

A word on Scope. When we think of healthcare security and safety we tend to gravitate toward the hospitals with their ER's, Behavioral Health, ICU's, Maternity and high visibility. But let us not forget our people in the outlying facilities and functions. The healthcare industry is spreading throughout its service regions with smaller clinics, urgent care, stand-alone ER's, pharmacies, PT, MOB's, rehab, behavioral health, infusion centers, home health and family health centers. Staff at these facilities often feel like the forgotten step-children and yet may face the same sorts of confrontational, threatening and even violent behavior as the hospital without the resources of the hospital. Our safety and security planning must include these functions and locations. 

Therefore, I propose an inclusive, cohesive and strategic approach to healthcare security, safety and service planning and management where every component has a role and their effective practice, in concert, synergistically mitigate bad behavior and violence. The whole should be greater than the parts. The following addresses those components:

Setting of Culture and Behavioral Expectations>    Consider how patients and their families can begin to understand and appreciate the culture they will be encountering and the behavior that will be expected of them. This doesn't mean listings of "Thou Shalt Not's," but evoking a sense of the nurturing and respectful environment they will be encountering along with behavior that could be detrimental to that environment. This can be accomplished through the website, admissions materials and brochures along with posters and other media while within.

>The Greeting>    What will your patients, clients and families encounter when they first enter your facility? Will they be welcomed or be on their own to find their way? How many doors can the public enter into from the outside? I like to talk about the Power of Acknowledgement.  The retail industry has long known that acknowledging persons entering their stores will statistically reduce the chances they will shoplift while within. Likewise, the healthcare industry is learning that greeting and acknowledging - looking every entering person in the eye - has a positive customer service aspect as well as making it clear they've been seen. The 99% of persons who have legitimate business will appreciate the welcome and guidance, and those who may have ulterior motives might display uneasy and avoidance behavior that may deserve further attention and conversation. I was recently at a hospital where the leaders each took an hour each week to stand at the entrance and personally welcome everyone who was entering. On my arrival on my first morning I was warmly welcomed like an old friend. That made my day.  

>Engagement Within>    I've walked through hospitals, passing employees and even security officers who gave me no acknowledgement or even eye contact. They were about their business and I meant nothing to them. I was in a hospital that served many who were poor and underserved and observed behavior by many staff of exasperation, disgust and superiority. Staff created a black cloud of resentment and frustration and wondered why so many were angry at them. And I've been in hospitals and clinics where staff frequently smile and greet me as I move through the facility. In fact, the five most powerful words in security are, "How may I help you?"

>The Early Bird>   Much harmful and toxic behavior evolves and escalates from relatively insignificant acts and words. It is far easier to calm the waters when a situation is beginning to percolate than later reacting to fighting and assaults. Early reporting and intervention should be a mantra for all staff. All employees who directly interact with the public should understand the early indicators of potential violence, strategies to de-escalate (and not escalate), and the importance and responsibility of reporting early to managers and Security. I often see where the mere presence of a security officer walking through early, for example, can calm the situation rather than calling the officers ten minutes later when fists and chairs are flying and it's far more likely someone will be harmed.

>Staff Awareness and Ownership>    The most powerful, least costly and most often neglected security and safety measure is fostering a strong level of ownership, involvement, awareness, engagement, vigilance and protectiveness by all employees. Every employee should know that he and she is an active member of the Safety and Security Team and what his or her related responsibilities are. Often when security and safety fails and harm ensues, it was because some employee failed to report, allowed a stranger through a restricted door, allowed a situation to escalate or escalated a situation, or otherwise failed to reflect their training, values and culture in their dealings with others.

>Staff Training>      During an assessment close-out a hospital CEO asked me, "Out of all I was recommending, what was the one most important thing?" I thought and had to say staff training. When I interview nurses and other front-line staff the most frequently mentioned need was better training. Can your people recognize the warning signs of violence? Do they know strategies to manage and de-escalate aggressive behavior and conflict? Do they know how and why to report? Do they know what to do when they feel at risk? Nurses often tell me that as caregivers they may not be particularly confrontational and may allow situations to escalate too far rather than confront. They often request practice scenarios so they can feel the experience of managing aggressive behavior.

>Don't Forget the Gatekeepers>    There are employees in healthcare who are the first encountered by the public including receptionists, registration/patient access, greeters, retail pharmacists, triage nurses, etc. I call these employees the "gatekeepers" who may be the first to encounter angry and confrontational persons and yet are too often forgotten. I seldom encounter such employees who were trained. They should be told they have the right to leave when they feel uncomfortable or at risk. Can they escape from their workplace? Can they de-escalate? Can the public come around behind them? Can they covertly communicate duress?

>Utilize your Mental Health Professionals>   One of the most valuable and often underutilized assets in many healthcare facilities is the presence of mental health professionals, whether psychiatrists, psychologists, psych techs, therapists, social workers or EAP staff. These professionals often have the skills to de-escalate, advise as to the mental state of persons, help assess threats, make care plans and assist on behavioral response teams (discussed below).  

>Threat Management and the Patient Risk Assessment>  Threat management and behavioral response processes I see are mostly reactive and kick in when a situation had become hazardous. I usually suggest, as part of the early intervention discussed above, a threat management process and multi-disciplinary team that activates when a patient, or even family member, demonstrates several early indicators of potential violence. Some systems have been built upon early indicator listings such as the Broset Scale.  When a potentially problematic person is reported, the team gathers (which could be made up of representatives of security, safety, behavioral health, risk, clinical, patient relations/safety, etc.), reviews what is known and assigns a level of risk. The level of risk will determine protective steps that may be taken during the person's care. 

>Do you Know Who Is in Your Facility?>  Hospitals and clinics typically receive heavy pedestrian traffic during days and it is not always feasible to screen every person entering, except in higher risk facilities like Children's/Women's, Behavioral Health or those in higher crime areas or with a substantial history of incidents. On the other hand, it often can be advisable in hospitals to screen all visitors entering after hours. There are various electronic visitor management systems that will scan visitor identification and generate badges and even make cursory checks against sex offender databases. Some can be tied into patient management systems to confirm the presence and availability of the patient to be visited.

>Response Teams>  Traditionally many healthcare facilities, especially where there wasn't a team of security officers to respond, have responded to confrontational or other hazardous behavior by deployment of large numbers of people, often called, "Code Manpower" or "Doctor Strong." Too often the net effect was a mass of gawkers which was not conducive to de-escalation. I often suggest, where feasible, multi-disciplinary behavioral response teams (BRT's) made up of trained representatives of security, behavioral health and clinical. All members of these teams would be trained on the organization's crisis intervention training program to include hands-on techniques and the role of each member. Such BRT's can be particularly of value in smaller facilities with no security officers.     

>Presenting Bad News>     A reality of the healthcare world is that, no matter how much care you take, bad things will happen. Violence is often set off by some event that causes heightened levels of stress, anger, loss and helplessness. Such "triggering" or "precipitating" events could be a death in the family or other negative medical news, financial demand, removal of a child or infant or, in the case of employees or contractors, a discipline or termination. In virtually all organizations I've served, the planning of such events is usually "seat of the pants" with no formalized process for safely handling such events, before, during and after. I always suggest a formalized written planning process for safely presenting bad news, especially when the individual is considered to be somehow potentially problematic. There are many mitigating steps that can be taken before, during and after, depending upon the individual and situation.

>The Security Department>   Your security program should be a consistent and meaningful thread throughout this entire continuum. Security programs differ widely in healthcare, from the sophisticated heavily staffed department led by a Vice President to a small hospital program managed and staffed by Maintenance/Engineering. In any case, the effective security program should be primarily proactive and preventive, reflect and support the culture, and address the true risks, vulnerabilities and needs of the facility. Healthcare security leaders should be knowledgeable of the field, collaboratively team with other departments and be functioning members of the Administrative Team and not just the "company cop." Security officers, whether contract or proprietary, should be competent, visible, responsive and positively engaging.

>Policies, Procedures and Plans>    It's not so just because you say it's so. Each of the components of this continuum should be reflected and supported by a policy that clearly outlines the requirements and expectations of employees, contractors, patients, families and visitors. Such policies may include those on harassment and bullying, code of conduct, ethics, hiring and termination procedures, security, customer service, reporting, workplace violence, threat management, facility access, weapons on property, etc. A proper workplace violence plan and program should include the four components of prevention, mitigation/threat management, response and recovery.

>Vulnerability and Risk Assessments>  How do you know your various protective measures truly address your current risks and vulnerabilities? I often encounter security and safety programs that are based on what happened years or decades ago, or are just collections of measures and policies deployed over the years in reaction to the latest incident. A risk and vulnerability security and violence management assessment should look at existing and planned physical and procedural measures in light of the present culture, history of incidents, area crime analyses, staff concerns and perceptions, comparable industry common and best practices, vulnerabilities of security-sensitive areas, growth and new construction, etc. Ideally, each facility and function should be assessed by competent internal staff at least annually and an objective outside perspective should be commissioned every four or five years.

>Communicate Duress>  I've served sixteen healthcare systems following deaths by shootings and stabbings. In each I interviewed employees who had lived through these traumatic events and I almost always hear, "We never thought it would happen here," followed closely by issues with internal communications ("We couldn't hear, nobody said anything to us, they forgot about us" etc.).  Perhaps the most common failing I find regarding the management of conflict is how duress can be communicated in real time. How do staff in the front like reception and registration communicate with the back treatment areas, and vice versa? How do employees in offices and treatment rooms, including human resources and therapists, communicate that they are under duress? Who and how will an active shooter event be communicated to all within those critical first five to ten minutes? What about at night or weekends? Have the safest and most effective protocols been planned for response to panic buttons?     

>Worst Case Response>   At the far end of the Behavior Management Continuum is the response to violence up to the active shooter. Despite the best efforts, violence can and does happen and must be planned for. Safe response to violence will be aided by consistent internal communications to include mass communications capabilities, partnering with local law enforcement, identifying safe rooms, staff training, incident command involvement, drills and table tops and remote lockdown capabilities.  

>Worst Case Recovery    Several organizations I served following violence dropped the ball on recovery. There were situations in which employees were more traumatized and angered by the Administration's response than the event itself. Examples of mismanaged response include administrators and managers not coming to visit the site or department to offer support, failure to explain what happened or even to say anything about the event, or giving the impression that the Administration is "talking down" to the people or treating them like children. An organization cannot do or spend too much to support those traumatized by the event, which will include everyone in the organization. Poor response and recovery measures can have a measurable negative long-term effect on employee retention, morale and productivity as well as the organization's reputation and ability to continue business. Response measures should include debriefings, assuring no recurrence, continuous communications with internal and external audiences, root cause analyses, offering counseling and support to those affected, town hall meetings, etc.

Dick Sem, CPP of Sem Security Management has over 40 years’ security and violence management experience. He serves clients across North America in almost every state performing comprehensive security and violence management assessments, targeted assessments (of Security Department/Program, Workplace Violence Program, Accessibility, Outlying Facilities, critical departments, etc.), development of related policies and plans, expert witness service and training.

Call or write if you have questions, would like to discuss an issue or would like a proposal from us.  

Dick Sem, CPP – Sem Security Management        [email protected]