This is an excerpt from Michael Dunning’s book, Workplace Violence in Healthcare: An Evidenced Based, Holistic Approach to Reducing Workplace Violence, available on Amazon.

People make two very important decisions within the first three minutes of meeting you. The first decision is, “Do I like you?” The second decision is, “Do I trust you?”

When forming these decisions, people rely on very limited and possibly misleading information in an incredibly short window of time. Psychologists Janine Willis and Alexander Todorov found that it takes just a tenth of a second for someone to form an impression of a stranger, usually based just on their face.

Imagine that you are at the end of a 12-hour shift in a hospital, and it has been a very draining day. Someone meeting you for the first time is presented with a lack of energy and a neutral or negative facial expression. These are the only impressions this person has of you at the moment they are deciding if they like and trust you. Add that you are in a hospital—a location of high emotional stress and trauma—and those impressions are even more impactful.

According to researcher N.A. Wyer in a research paper published in the Journal of Experimental Social Psychology, these first impressions have significant behavioral implications that are unlikely to change even if they learn those impressions were inaccurate. Those implications also carry weight when it comes to security interactions.

Consider the impression when a security officer enters a room. There may already be a negative bias towards the officer due to past experiences with security personnel or a preconditioning from other sources. And with a negative bias comes a predisposition and expectation of negative behavior from the security officer. The person automatically takes a defensive mind-set, which could devolve into an aggressive or violent act in the guise of self-defense. But when an officer enters the room presenting a warmth and genuine concern, their actions can disrupt the negative bias and begin deescalating the situation.

Biases exist and can have significant impacts on first impressions. But according to research from social psychologist Amy Cuddy, one factor generally either confirms or outweighs those biases—facial expressions. If someone has a preconceived bias that all physicians are arrogant and egocentric, but the doctor walks in with a warm smile and greeting, he or she has disrupted that bias. If someone believes all security officers are out to get them and just want to throw them out, but a security officer walks in with a warm smile and greeting, he or she disrupts that bias as well.

Beside facial expressions, a few basic factors can influence whether or not people decide that they like you: vocal inflection, attractiveness, and general emotional state.

Positive vocal inflection, tone of voice, and overall positive approach are important in the first few words that you use. Your attractiveness can be influenced by how you are dressed, the confidence you portray in your approach, but most importantly the facial expressions you use and the warmth you project from the very beginning, all of which elicit a direct response from the person you are about to address.

Taking a moment to calm or center yourself before the first contact is an important step in entering a situation and projecting the calm, warm, and trusting persona needed.

The second decision of “do I trust you?” is directly influenced by whether the person likes you.

Multiple studies (including this one studying financial analysts and forecasting accuracy) find that people essentially judge people on two dimensions: warmth and competence. They judge facilities on these same categories as well, and whether a person likes and trusts a healthcare institution or not can have consequences for their care and their behavior.

Behavior and environmental modifications start with tiny, almost imperceivable things. But through the application of systematic reinforcements, actions can start to domino. Therefore, healthcare security professionals should design programs to counter behaviors that lead to negative outcomes.

The Exterior

Arriving at a hospital can pose many challenges. Determining where to go, where to drop someone off, and where to park are all contributors to frustration, especially when a person is already under stress due to a medical situation. Hospitals can ease the pressure of those decisions with clear signage from the roadway and directions. A welcome sign or signage reinforces your commitment to care.

But not all signage is created equal. Signs that are cluttered with information do not get attention. The use of short phrases and graphics in bright or contrasting colors attracts attention. Think of this as a marketing strategy. The more you use a slogan or message, the more people will see, recognize, and understand the message, and the message you want to deliver is "safer environments, better care.”

There are multiple studies on light and color and how they impact moods and stress. Using this to the organization’s advantage, transforming parking garages to light and colorful locations can make a psychological impact to people entering a facility. Numerous healthcare facilities have experimented with the use of color and light to reduce stress and anxiety and to brighten up parking areas and entrances—with positive results.

“You obviously don’t want hospitality elements to interfere with the operation of the hospital,” said Diana Araoz-Fraser, vice president, senior interior design for HKS Inc., in an interview with Electrical Contractor magazine. “But you do want to extend them throughout the building to achieve a calming, hospitable feeling.”

Cleanliness also contributes to first impressions and stress levels. Graffiti and overflowing trash in parking areas and entrances create perceptions of dirty and unsafe conditions. Don’t confuse the effect of graffiti and murals, though—many cities and businesses have connected with local artists to turn dull, boring walls into art.

Public Entrances and First Contact

Focus and training should be paramount for employees who have initial contact with patients and visitors. Think of those places where you receive excellent customer service. Some companies are world famous for it—Disney, Chick-Fil-A, Trader Joes, and JetBlue to name a few. They don’t think of good customer service as a cost center; they realized it is a revenue generator.

Many hospitals have open entrances. Where there once was someone to greet you, there now stands a sign. While there is a cost to staffing entrances, that cost should be looked upon as a revenue generating de-escalation measure. Someone kind, courteous, trained in situational awareness and de-escalation can make a difference in the mood and tension levels of those entering and influence how they feel about being in your facility. Consider such a person a mitigation step to reduce the cost of workplace violence and increase patient and visitor satisfaction.

Some hospitals use volunteers, some use security personnel, and some use other departments for these positions. An organization’s choice should be aligned with the culture it wants to convey, basing the presence needed on risk assessments and community influences such as crime rates and traffic.

Hiring for this position can be critical because this person is the face of the hospital—the first person encountered by people seeking help. Invest in hiring the right personality and providing the training needed to fulfill this role, including situational awareness and de-escalation techniques.

Interior

Aesthetics are important if utilized to create a calming atmosphere. Lobbies, waiting areas, and behavioral health units should utilize appropriate colors to help keep patients and visitors calm. Various shades of blue, green, pink, violet, grey, and yellow have been known to have a relaxing and calming effect, whereas colors like red tend to trigger stress responses. Use furniture and décor that provides a welcoming appearance as opposed to rickety chairs that might appear unstable and cheap. This is not saying hospitals need to invest in luxurious furniture and paintings, but they should stay away from the roadside motel look.

Placement is important. In a patient’s room or triage area, many locations have the patient bed between the caregiver and the door. This can trap the caregiver if situations escalate. Configuring rooms so the caregiver can immediately exit is a best practice. This protocol should also apply to offices, counseling areas, or any other area where hospital staff meet with patients or family members.

Space is always an issue in every healthcare facility, and visitors frequently move furniture to better suit their needs when visiting. Too many chairs, IV poles, carts, and other items in a patient’s room causes a potential safety hazard and creates cramped spaces—increasing tension and providing potential weapons during a physical altercation. Consider removing any small chairs or furniture that can be easily moved or picked up.

Behavioral and mental health units have additional risks and should use specialty furniture designed for those units. This furniture is not easily moved or picked up, making it more difficult to use as a weapon. Sometimes other unauthorized furniture winds up in the unit, and it is rarely removed. Hospital staff should be on the lookout for furniture that migrated into these units from outside and return them to their proper place.

Treatment rooms in emergency departments—especially those where behavioral health patients are evaluated—should be cleared of any object that could be a potential weapon. This is a policy at many healthcare facilities, but it is rarely followed. Also consider placing signage at the door to alert those entering of the potential for violence.

Eliminate distractions through policies and training. For example, hospital employees should not be wearing headphones when entering a patient room. The headphones can distract the employee leaving them unable to hear potential warning sounds coming from the patient or others in the room. I have investigated many instances where a hospital worker injured on the job was wearing headphones and was potentially distracted in this way.

People

Most workplace violence incidents shared certain commonalities:

• Escalating environment and staff.
• Not employing de-escalation techniques due to lack of training or lack of confidence in the training.
• A lack of situational awareness.
• Not identifying or reacting to escalating behaviors prior to physical violence.
• Victim trapped with no escape routes.
• Not requesting assistance prior to physical violence.
• Lack of training or improper equipment use in physical restraint techniques appropriate to the healthcare environment.
• Staffing shortages, both for clinical and security staff.

Some of these challenges are institutional (staffing shortages, environmental design), but others are personality challenges. An organization can teach de-escalation training, but if the staff is not predisposed to stay calm and caring during stressful situations, they are likely to escalate situations despite best intentions and procedures. Too often, hiring practices emphasize certifications, years of experience, degrees, or knowledge over demeanor. While we can teach knowledge, rarely can we teach awareness, compassion, and a caring mind-set.

Hiring people with the right mind-set and approach that matches the culture of healthcare should be a major consideration. Many hires at all levels fail because they didn’t understand the environment in which they were working. Many times, the problem was largely a matter of style, not substance. The adage “It’s not what you say, it’s how you say it” is astute in these situations.

This essentially boils down to having a good bedside manner—a positive, caring approach. While this has historically applied to physicians and nurses interacting with patients at the bedside, it applies to everyone working in a healthcare facility. It can be applied to anyone—patients, family members, visitors, or staff members.

St. George’s University Medical School published an article, Developing Good Bedside Manner: 9 Tips for Doctors, that provides tips for physicians, but they can apply to anyone.

1. Strong communication is key. Your ability to communicate can quickly change a situation, for better or worse.
2. First impressions matter.
3. Sitting down means more to others than you may think.
4. Speak professionally and accurately, but in a way the person can understand.
5. Master the art of leading a productive conversation.
6. Be an active listener and be present in the conversation.
7. Don’t overlook the power of body language.
8. Value the persons time as much as your own.
9. Validate concerns.

A good bedside manner extends well beyond the bedside, though, and it can pay off for both security and operational success.

A hospital in the Midwestern United States uses a method that has been very effective in reducing complaints and increasing patient and staff satisfaction. They call it the “Anytime Anywhere Line.” It is a designated phone number that anyone can call about any issue. The line is staffed with people who have a customer-centric mind-set. When an operator receives a call, he or she becomes the facilitator of improvement. The operator documents the issue and contacts the appropriate group or department. Then he or she tracks the issue and communicates back to the caller until the issue has been resolved. Staff feel like a burden has been lifted in trying to find out who to call for different issues, and patients feel like someone is listening to them.

A popular hotel chain uses a similar technique. Upon check-in, the receptionist gets the customer’s cell phone number. After the guest has checked in and has had a little time to get acclimated, the hotel sends the guest a text asking if everything meets their expectations and if there is anything they need. The guest is told they can text anytime they need something. In a world where most communication is done over a mobile device, this works out very well and increases guest satisfaction.

But one word of warning—as with any program, once you set an expectation you must honor it. If you set an expectation and fail, you will create dissatisfaction and lose the trust you worked hard to earn in your first impression.

 

Mike Dunning, CHPA, CEM, is the principal consultant for The Healthcare Security Consulting Group, an organization providing expertise and guidance making healthcare environments safer. Previously, Dunning was the vice president of healthcare operations for the world’s largest security services provider.

© Michael Dunning, 2022