​Several years ago, at a Milwaukee-area hospital, a patient came into the emergency room for treatment. The patient was flagged in the hospital's system for a history of violent behavior; he was known to carry weapons. However, the attending nurse ignored the warning to involve hospital security and proceeded to provide care to the patient. During the triage process, the patient made several comments to the nurse, including threats to cut her with a knife. Instead of disengaging for her own personal safety and notifying hospital security, she continued triaging the patient. The nurse later filed a complaint about an unsafe work environment, and when asked why she continued triaging the patient even though he threatened physical harm, the nurse responded, "I have a job to do, and I had to triage him."       

Healthcare is one of the most violent professions in the private sector—the number of violent events in the healthcare workplace is on par with law enforcement and corrections. According to the U.S. Bureau of Labor Statistics, in 2015 all private sector industries experienced workplace violence at a rate of 1.7 incidents per 10,000 full time workers. However, those numbers jumped to an alarming rate in the healthcare industry—6.7 per 10,000 full-time workers at psychiatric or substance abuse facilities. At hospitals, the rate was even higher, with 8.7 per 10,000 full-time workers experiencing workplace violence. In such settings, security practitioners face the challenge of protecting both staff and patients—who are often the ones committing the violence. 

With the focus on patient satisfaction, caretakers often forgo their own safety to produce results, creating a more unsafe work environment and potentially providing a lower level of care—when staff do not feel safe, they are less likely to spend time working with their patients, instead focusing on getting to the next patient as quickly as possible. 

An unsafe work environment doesn't just affect employees. Hospital surveys show that when patients choose a hospital, they base that choice on their experiences and what they have seen in emergency rooms or waiting rooms. When a patient feels comfortable and safe in a hospital that has subpar care, they will choose it over a hospital that has good care but a reputation that it is unsafe. When workplace violence is not well managed, it can jeopardize not only the staff, but the reputation in the communities served.

Because caretakers themselves are on the front lines when it comes to patient-perpetrated violence, a healthcare facility's security approach must extend beyond top-down security management and physical security. Security directors should foster among staff the importance of a clear and uniformly enforced social contract—an agreement for how individuals treat each other and how they behave within a community—that providers and patients alike should adhere to. 

Social contracts are designed to manage low-level, disrespectful "gateway behaviors." When behaviors such as sarcasm, name calling, yelling, and swearing are not properly managed, they can lead to more threatening behaviors that often escalate to violence. Task-oriented staff often appease these behaviors to quickly and efficiently get on to the next patient. However, the message is sent that bad behavior is rewarded and the person displaying those behaviors learns it is okay to act in that manner. When these behaviors are properly managed, and the social contract is consistently enforced, the cycle of violence can be interrupted. Many organizations, however, have an ambiguous social contract that is often inconsistently enforced, creating a pattern of learned behaviors that empower disruptive individuals to act violently to get what they want. 

In addition to physical security and crisis response protocols, healthcare facilities should also train caregivers in nonescalation and de-escalation approaches. Adopting conflict management techniques can increase awareness and safety and achieve positive outcomes for staff and patients.

A concept known as the Six Cs of Conflict Management, developed by consultant and training institute Vistelar Inc., can be applied to the healthcare setting for better staff and patient relations.

The entire spectrum of human interaction can be broken down into six distinct concepts: context, contact, conflict, crisis, combat, and closure. Each of these concepts can impact interactions and influence the creation of an environment of care that is incompatible with conflict and violence. 

Context

The concept of context encompasses all aspects of preparation for interaction within hospitals and clinics. Context begins with an understanding that, to produce positive outcomes, all people must be treated with dignity and respect, regardless of their background. Context also refers to knowing the inherent risks within the healthcare environment and planning for those risks through awareness of surroundings and escape routes. 

Along with this awareness comes the possibility of encountering verbal abuse and conflict. To respond professionally, healthcare staff must understand that hot-button words can trigger an emotional response in the heat of the moment, leading to negative interactions resulting in workplace violence.

To set and enforce a social contract, a facility's staff must identify triggers and develop safeguards to protect against an unprofessional response.

Keeping context in mind can help staff maintain a professional mindset by beginning interactions with patients on a positive note—if an individual or situation creates an uncomfortable atmosphere, healthcare workers should take a step back, take a deep breath, and conduct positive self-talk to encourage confidence.  

Contact

Caregivers should have a foundational understanding of a situation's context to be mentally prepared to have positive interactions, which begin long before that first word is even spoken. Staff must take into account what message they are sending with their own body language and expressions. Understanding how nonverbal communication such as posture and facial expressions affects verbal communication can mean the difference between a positive and negative outcome. 

Oftentimes caregivers focus on the task at hand and overlook crucial nonverbal warning signs from the patient, such as preattack postures or targeted glances at items the caregiver might be carrying such as pens, clipboards, or stethoscopes around the neck. Along with body language, understanding personal space has an equally important role in positive contact—entering an individual's personal space begins to put pressure on them, and if individuals are angry and upset, encroaching on their space may begin to escalate their behavior because they feel that they are being cornered.

A real-life example of this happened not too long ago in a psychiatric facility when a nurse announced to several patients in a common area that it was time to head back to their rooms for bedtime. Most of the patients complied, but one woman began backing herself into a corner. Instead of retreating and attempting to verbally persuade the patient to come to her room, the nurse got closer to the patient, who then barricaded herself with a table. Two additional nurses came in, causing the patient to move into "fight" mode—she flipped the table, threw a chair at one of the nurses, and physically attacked another. This example demonstrates that when people are in conflict, managing distance and maintaining appropriate personal space can help avoid a potential physical attack.

However, as part of routine care, doctors and nurses have to touch, poke, and prod patients without regard to their physical or emotional state, developing what is known as presumed compliance. This approach leads to a staffer's complacency, giving them a false sense of security. If a caregiver has been assaulted, it is common to hear them say, "I've done this a thousand times and nothing ever happened before." Before entering a person's personal space, caregivers need to determine if it is safe and appropriate to do so. 

When a caregiver approaches an individual, they should conduct an assessment at specific distance intervals (such as 10 feet, five feet, and two feet) to determine their own level of risk at each stage, allowing them to either continue or disengage. As they engage physically, a caregiver's relative position comes into play. Standing directly in front of someone or towering over them can imply dominance, so caregivers need to be positioned in a manner that allows them to stay safe, as well as make the patient feel comfortable. Positioning at an approximately 45-degree angle to the patient and communicating at his or her eye level helps avoid an unintentional show of dominance and continue positive contact.         

After establishing a comfortable position, caregivers should use professional language to introduce themselves and communicate effectively. Verbal interaction begins with a proper greeting—beginning contact with informal greetings like "hey" or "hi" may send the wrong message to the other person. Proper greetings should be professional and tactical to begin the interaction on the right foot without unintentionally escalating the situation. After the proper greeting, caregivers should introduce themselves, state the reason for the contact, and bring the other person into the conversation by asking a relevant question. These four steps to a proper greeting help mitigate potential conflict. 

Verbal communication, however, is a two-way street. When gathering information to better meet the needs of their patients, caregivers need to go beyond active listening and understand the emotions behind the words, allowing them to use empathy to find the hidden meaning of the words being spoken. By combining the knowledge gained through observations of body language, personal space, and relative positioning, caregivers can make assessments that allow them to remain safe and communicate effectively. Positive contact fosters a supportive atmosphere, and when done well allows the interaction to move into closure. When done poorly, contact can move into conflict.  

Conflict

Simply defined as "emotional violence," conflict can lead to stressful work environments and contributes to high staff turnover, leading to negative patient outcomes. Conflict typically begins when the expectations of individuals are not met, and in the healthcare environment usually arises because of someone's perceived lack of dignity and respect.

A few years ago, one of the security staff in a local hospital was watching a patient on a psychiatric hold. The attending nurse came in and offered to get the patient something to drink, suggesting apple juice. The patient told her that she hated apple juice and didn't want it. The nurse insisted on giving her apple juice, to which the patient said that she would throw it in the nurse's face. However, the nurse proceeded to bring her a carton of apple juice and, after handing it to the patient, had it thrown in her face, as promised. Conflict is more likely to occur when healthcare professionals fail to listen and forget that all people should be treated with dignity and shown respect. 

When involved in conflict, a caretaker's goal is to de-escalate tensions, return to normal conversation, and end with a positive outcome. De-escalating conflict begins by deflecting verbal abuse and redirecting it, focusing on managing gateway behaviors. Caretakers should then take the context they have gathered and put it into action by asking relevant questions, providing explanations, offering options, and finally giving a second chance. This technique is more likely to generate voluntary compliance, cooperation, and collaboration, which will lead to closure in conflict situations. 

It is important to incorporate all elements of context and contact when involved in conflict. This allows caregivers to maximize their safety and conduct themselves in a professional manner that gives them the ability to set limits and reinforce the social contract. However, if staff members do not manage conflict properly, they can unintentionally escalate a situation into a crisis.    

Crisis

Some events have the potential to lead to an unstable or dangerous situation affecting an individual's ability to make good decisions. Anything can be a crisis—sudden bad news, a traumatizing event, a physical injury, or withdrawals from alcohol or substance abuse. Individuals with brain-based disorders may display rumbling or self-stimulating behaviors such as rocking back and forth, flicking fingers, making unusual noises, or displaying uncontrollable or unexplained twitching. Individuals with psychological disorders may experience visual or auditory hallucinations. 

Any of these may be warning signs that the individual is entering a crisis. If these behaviors are observed quickly and caretakers intervene effectively, they can begin to bring the individual back to normalcy. If the behaviors are not recognized for what they are, the individual may escalate to rage behaviors—self-destructive behaviors such as slapping their own faces or banging their heads against a wall. Other rage behaviors include physically lashing out and causing injury to others or damaging property. At this point, the primary goal is safety for everyone, including the individual displaying rage behaviors. Once safety is achieved, the goal is to work with the individual to move them into recovery. 

Combat

The term "combat" sounds intimidating to most people, but combat is common in the healthcare environment. Combat can be physical violence that has escalated from other unmanaged behaviors. A patient can become combative when verbal skills have failed to de-escalate conflict, when the intervention during a crisis event was not effective, or when staff safety is threatened with potential for physical harm. Sometimes caretakers can be their own worst enemies by creating combat scenarios through their actions—or inactions. 

For example, a patient was discharged from the surgical floor of a local hospital. This patient refused to leave until she spoke with her doctor, so hospital security was called to intervene. However, before security personnel could respond, the decision was made to physically dress the patient and remove her from the room. When physical contact was initiated by the nursing staff, the results were disastrous. One caregiver was pushed over a table, injuring her back, while others struggled to control a now violent individual.  

Staff response to combat is dependent on the totality of each of the circumstances they encounter. When appropriate action is taken, rules of engagement such as policies and procedures, training and experience, and current laws and court rulings must be taken into consideration. As demonstrated by the story above, caregivers must be careful not to create their own combat scenarios. The primary goal in combat is to maintain everyone's physical safety, but if staff can take their time, communicate professionally, and have a preplanned and practiced response, they can take the appropriate action. In combat scenarios, staff members must always have the mindset of being the victor and not the victim. When action is taken, it must be done in a safe and efficient manner with the goal of re -establishing control to chaotic situations with minimal injury to all involved. 

Closure

Closure is a personalized tactic that changes from situation to situation. When caregivers end their encounters with patients—whether good or bad—their goal is to establish a stronger foundation for future interactions. Closing encounters should summarize the events that took place, reinforce the social contract, and establish a plan for future interactions without inadvertently reigniting a previous conflict. 

A longtime member of a hospital security department shared an example of this after completing nonescalation training. Previously, he closed every encounter by telling the person to have a nice day, regardless of the circumstances. What he did not realize was that his closure statement was received in a negative light—it could be viewed as a parting shot—and often resulted in re-escalating the situation. Phrasing that treats the person with dignity and respect—such as "I'm sorry this happened today. Next time let's work together so that we don't have to go down this path. Sound okay?"—puts both the staff member and visitor on the same level, provides closure, and establishes an equal foundation for future interactions.

To reduce incidents of workplace violence, caregivers need to know they are supported in the actions they take. This begins with support from their leaders, encouraging caregivers to report workplace violence incidents when they happen. Additional support can be gained through partnerships with local and state law enforcement and legislatures, and development of a comprehensive training program.

Through these mechanisms, healthcare professionals can learn the skills to effectively manage and reduce incidents of workplace violence. By adopting a comprehensive conflict reduction plan into healthcare, caretakers can establish an environment of care that is incompatible with conflict and violence.

 

Ryan Weber is Training Assistant, Loss Prevention Security at Aurora Health Care, and is trained by Vistelar as an organizational instructor of the Six Cs concept. His colleague Dennis Hafeman, Training Coordinator, Loss Prevention Security, contributed to this article.