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Rules for the Unruly

​VIRGINIA MASON MEDICAL CENTER in Seattle, Washington, is a 340-bed medical center, in the heart of the Puget Sound. Its 5,000 employees provide services to approximately 3.5 million area residents and millions of tourists each year. In any large metropolitan area, a small number of individuals can become aggressive and that aggressive behavior can spill over into the healthcare environment.

To address this concern, security at the medical center developed an aggression-management training program. The program is aimed at nonsecurity staff and is complemented by two other programs that are designed to help the hospital spot trends and accurately document incidents.

The aggression-management training is just one part of the overall voluntary security training that Virginia Mason offers for nonsecurity personnel. This training, which takes a layered approach, has several courses that employees progress through. The first course, on basic security procedures at the organization, is conducted for all new hires at the new-employee orientation. The second course introduces employees to more advanced personal security issues, such as how to protect personal property from theft, how to be aware of anyone trying to get into the building by following close behind you as you use your access card (tailgaters), how to challenge those who do not belong in certain areas, and how to report any security concerns. The next course is the aggression-management training.

The aggression-management training is based on the fact that, in a healthcare setting, aggression often flows from frustration. This fact is the guiding principle on which the recommended deterrents and responses to aggressive behavior are based. The aggression-management training program teaches employees about three levels of misconduct—personal frustration, aggressive frustration, and physical frustration.

Personal frustration. The first level is the one personnel are most likely to encounter. This type of aggression is based mostly on emotional reactions from patients and is usually the result of everyday frustrations that are heightened in a healthcare setting.

Personal frustration is when a patron refuses to follow instructions or cooperate with care providers, swears during a conversation, or waves off a staff member who is trying to help. This frustration may be a result of medical or personal worries. Patients may want to go home, feel as if their needs are not met, or be upset over a treatment plan.

Other behaviors that fit into this category may include refusing to eat, pushing medicine trays aside, and hiding medication instead of taking it. Actions such as becoming overtly critical of staff members as well as threatening legal action also fall into this category.

When faced with these behaviors, staff members are trained to take specific actions. First, they note the behavior in the patient’s chart. Next, they tell fellow staff members about the incident. This is a critical step because it provides warning to others about a potentially aggressive patron.

The next step is to present a team presence. This means that staff members from various disciplines related to the patron’s care stop by to emphasize the desired behavior, such as eating or taking medication, for example. Security personnel can be part of this presence if requested by staff. Security can talk with the patient to demonstrate how seriously the hospital takes even this level of aggressive behavior. All members of the care team are trained to use caution to watch for a possible escalation to the next level.

Behavioral staff will work with family and friends to find a way to calm the patient and to explain the consequences of continued behavior.

Aggressive frustration. At the next level, aggressive frustration, the patron’s behavior becomes more intense and may result in verbal abuse or harm to staff. Examples of behavior at this level may include pushing, scratching, spitting, and throwing small items. Locking the door to the room or the bathroom is also in this category.

Staff members are trained to report these incidents to management and to security. After such incidents occur, staff members are encouraged to work in teams with the patient and may enter the patient’s room in pairs.

Physical frustration. The third, and most serious, level is physical frustration. In most of these cases, patients arrive in a highly agitated state. With these patients, the primary goal is to secure the area and prevent the patients from harming themselves or others.

The behaviors that indicate this level include lashing out and struggling due to any of several causes. Such behavior might be due to an illness that causes mental confusion. Others may be under the influence of drugs or alcohol. These patients frequently use both verbal and physical coercion to intimidate staff.
In these instances, staff members are trained to respond immediately by summoning security and other hospital personnel, such as psychiatric medical professionals if necessary, to deal with the issue. These staff members will formulate a patient-care plan on the spot to establish the next step in medical treatment. If the patient has been brought in by police, security will request that the police stay on-site long enough to ensure that proper behavior is maintained or that proper restraints are applied.

Even after the immediate crisis is over, staff members are trained to continue to enter that patient’s area in pairs. Other measures can be added depending on the nature of the problem. For example, staff may search the patient and the patient’s room for contraband on an ongoing basis. Security and the medical team may work together to provide continuous surveillance of the patient.

Oversight Programs
In addition to training nonsecurity employees, security at Virginia Mason devised two oversight programs to help guide this training and identify emerging security trends. The Security Response Review program helps keep policies and procedures up to date and the Violent Incident Report program helps track such incidents to ensure appropriate follow-up.

Security Response Review. The Security Response Review Committee was established this year and meets monthly to review all security responses to patient behavior. The committee is made up of approximately 10 volunteer members from various departments, such as administration, clinical, security, and psychology. To be eligible to volunteer for the committee, a person must be at a high enough level within the hospital to have the authority to make changes or corrections to their staff programs.

At the meetings, the security representative shares data from that month’s incidents. Then a roundtable discussion follows to review any trends and to assess whether changes to security or other hospital procedures are needed.

The committee has already made valuable changes. For example, during a recent review, it became clear that information on aggressive behavior was not always forwarded to all staff members, as required. This information wasn’t filtering down to certain employees, such as the nutritionists bringing meals. To resolve this, the committee contacted the nursing staff. The nurses developed a symbol based on an existing code used in patient charts to indicate aggressive behavior. It is used as a quick way to communicate the problem to everyone who will deal with the patient. It is placed on the door frame of an aggressive patient’s room, alerting all staff who enter that there has been a history of aggressive behavior with the patient.

Violent Incident Report. Another concern was to have documentation of exactly what aggressive behavior had occurred. Security historically responded to incidents and asked follow-up questions. However, in the immediate aftermath of an incident, it was difficult to get accurate information from witnesses and participants. To help with that, security developed the Violent Incident Report (VIR). A VIR is given to employees to fill out when they report aggressive contact. By having each employee give a first-person account of what they experienced, security can better align the sequence of events with the information in the security report.

Though the training program is currently voluntary, it has been popular, and employees are increasingly showing an interest in the training. Hospital officials find that a training program focused on aggressive behavior has helped minimize the dangers of such behavior in a healthcare setting. This training, along with oversight programs, can benefit patients and staff and assist security in keeping the total number of incidents down.

Donald C. Pilker, CPP, is the director of security and logistics for Virginia Mason Medical Center in Seattle. He is also an adjunct professor of criminal justice at ITTTech. He is a member of ASIS International.