Working together toward safety

The National Safety Council, the nation’s leading nonprofit safety advocate, recognized June as National Safety Month, focusing on saving lives and preventing injuries. In honor of National Safety Month, @TheU is sharing a story the originally appeared in U Health’s 2019-2020 Nursing Report, “Building Momentum: A Virtuous Cycle of Success.”

Safeguard your staff

Deploying de-escalation for aggressive patients

Keeping employees safe in the workplace is a priority, and can be especially challenging in healthcare, where aggression from patients and visitors is on the rise across the globe. Over the past few years, University of Utah Health has intensified their focus on keeping staff safe, and after a couple of particularly worrisome events, chief nursing officer Margaret Pearce and Thomas Miller, chief medical officer, asked two key leaders to create a formal program to deal with workplace aggression.

One of those asked to lead the effort is senior nursing director Laura Adams. “It’s not physician-to-nurse, or nurse-to-therapist, or nurse-to-nurse aggression,” states Laura. “Where these tensions may have existed in the past, clinical teams have really come together to support each other in the face of increased aggression from patients and visitors.” Joining Laura in the effort was Dustin Banks, director of support services, which includes hospital security services. Together, Laura and Dustin engaged the nursing and security teams to create a program of non-violent de-escalation.

BERT alert

“When we were asked by Laura and Dustin to work on this program, we knew that within our organization, we were already doing great things,” said Scott Christensen, an acute care nursing director. “Patient aggression has been seen commonly in psychiatric care settings, and our psychiatric hospital already had a program for deescalation called Code White,” said Scott. “In addition, our Emergency Department used crisis prevention training, so we called in those experts to join our efforts so we could incorporate that knowledge.”

Scott and team members visited Boston Massachusetts General and Piedmont Athens Regional to observe how de-escalation programs worked in other large facilities. One of their key findings was around the culture. “When it comes to patient violence, you need to create a zero-tolerance culture,” said Scott, “because a lot of nurses are good-natured, and they accept that a patient might hit them, or kick them, or say mean things to them. We realized that we needed to change this mindset.” Newly hired security manager and team member Glenn Smith agreed. “What your nurses consider as normal behavior from a patient really surprised me,” said Glenn, bringing an important outside, objective perspective to the process.

Through the site visits and other research, the team learned about BERT—Behavioral Emergency Response Team—a general term and concept that was being adopted by a number of healthcare facilities across the country as they worked to de-escalate patient situations. BERT typically involves groups like nursing, security, behavioral health, social work, and administration, with a goal of preventing violence using de-escalation or other preventive measures. Scott and the team decided to adopt the BERT terminology and went to work developing U-specific processes and procedures.

Resetting a key relationship

As an academic medical center, many hospital services at U Health are either shared with, or provided by the academic campus. Security is one of these “purchased services.” While the relationship between nursing and security was functional, it was largely disconnected. Security staff generally visited the units when called to intervene in a severe patient escalation event, and then would often express apprehension about being in a clinical space. At the same time, calls for help to security were minimal, because nursing considered patient and family outbursts as routine and within their scope of practice.

In his new role as manager of the security team, Glenn evaluated the security team members and reviewed how they were currently interfacing with the various clinical departments. He learned that this academic campus-based team did not see proactive rounds with nurses as part of the workflow; at the same time, he learned from nurses that such interactions would be welcome.

To build a solid team that would reflect the values needed to improve the safety of patients and caregivers, Glenn recruited retired police officers with decades of experience to serve as leaders. These experienced officers had two core skillsets that were sorely needed in the new training program: communicating under stress, and de-escalation. Prevention also became a key focus, and the security team started checking in daily with charge nurses to get a “heads up” about any potential concerns that could be avoided with a little attention. With a new relationship and ally from security, nurses were able to focus on patient care from a position of safety and security.

Team training that sticks

With the help of the highly acclaimed simulation program at the U’s College of Nursing, training was created for a patient violence scenario that helps clinical teams to experience the range of emotions that surface during an event. Luckily, the project could not have come at a better time for Maddie Lassche, executive director for the simulation center, who was in the final stages of her doctorate program. “Sometimes, collaboration between academic and operational units is tricky, as the needs for each group can be very different,” explained Maddie. “In this case, I was ready to start my DNP project, and the hospital needed a customized training program–our needs were a perfect match!”

Mirroring an actual BERT code, the simulation involves a charge nurse, security officer, house supervisor, and a social worker. In the simulation, these diverse roles learn from one another and experience the same emotions together. Maddie noted that before the training, the security officers seemed hesitant to take command of the patient room, whether out of deference to the nurse or just needing permission to lead out in a clinical environment. “After the training, it was so lovely to see a security officer start moving objects around the room and away from the patient, or stepping in-between the nurse and the patient, to protect the nurse.”

After the simulation, the team comes together to debrief, which cements the skills as well as the relationships among the team members. Susan Clark, a nurse manager in neuro acute care, received overwhelmingly positive feedback on the training from her staff. “Realism was frequently mentioned in feedback, so this was clearly sticking with participants.” And when they see each other during an actual event, they instantly know they’ve got the support they need. Shegi Thomas, an acute care nurse manager, applauds the impact on her team. “The trainings they did together and the time they spent together was very meaningful. It decreased the gap that existed before. Now nursing knows who is in security, and what their vision is, what their mission is, and how they can help us.”

Formalizing improvement

In conjunction with the creation of BERT at U Health, Scott and Laura took this opportunity to conduct a formal quality improvement (QI) initiative. The QI project would yield data gathered through pre- and post- surveys that identified those project elements with the most impact on success. Their overall goal for the formal research process was to provide evidence-based outcomes that other healthcare providers in worldwide institutions could use to create their own programs.

QI project outcomes show that with the BERT training and implementation, nurse ability to effectively manage patient conflict improved significantly, as did their ability to talk with security, and their confidence in caring for aggressive patients. The strongest findings were nurses recognizing the warning signs of escalation and ability to use de-escalating techniques. “Put simply, we learned that nursing and security need to work together, we need to change our culture so nurses are comfortable asking for help, and that aggression is NOT OK,” said Scott. The QI project will soon be submitted for publication and will hopefully be published early 2020. Meanwhile, the U’s BERT project has already gained national and international interest as a result of conference presentations.

A stronger bond

Relationships are always an important part of a successful workplace, and working together, Glenn and Laura ensured a strong bond was created with nursing staff and security team members. Through daily rounds, security checks in with the charge nurses, whom they

now know personally. “Security staff has gotten more comfortable working in clinical areas,” says senior director Laura Adams. “They know they’re not coming in to take over, but rather to offer themselves as part of a team to formulate a good outcome.”

Nurses surveyed about the effectiveness of BERT now count security as part of the care team. “I feel like our security staff are empowered with the new training program, and they have gotten better and more comfortable deescalating a patient” said Eric Sawyer, a charge nurse in the neuro acute care unit. “They show up as security, know how to act with patients, and they do better than they used to.” In addition to enhanced teamwork, nurses have personally gained valuable skills in handling difficult patient situations. “Now nursing knows the signs of classic escalation,” said Laura. And a promising trend is emerging: “Teams are able to recognize and diffuse potential aggression before it starts.” The BERT process helps to move an escalating situation away from the other patients, which is always a priority on the units as nurses work to care for all of their patients. “It’s important to recognize the importance of maintaining a clinical environment as one of rest and healing for everyone.