Sarah had a bad gut feeling about the patient she was about to see. However, as a provider in a small primary care practice, she felt compelled to see the patient regardless of her own concerns about her safety. After all, what other options were there?
She started thinking about the worst-case scenario and then tried to think about how she might protect herself if things got out of control. All of these thoughts just made her more anxious than she already was, so she stopped. The patient, James, a large and often intimidating presence in the practice, was waiting in an exam room, talking loudly on his cell phone.
As soon as Sarah stepped into the room, he got up from his chair and cornered her, finger in her face, demanding that his medications get refilled “or else”. Sarah tried to get around him, but she was trapped. She yelled for help and her fellow staff members came to her aid. James backed off and stormed out of the exam room and the practice, yelling, “if I have to come back, you’ll be sorry.”
What might sound like a dramatic example of a medical drama playing out on TV is all too real for medical professionals and support staff working at ambulatory and outpatient care sites. Whether they are working at an outpatient surgical center or a small family practice, the staff at these sites have found that they are not immune to the increase in frequency and severity of violence happening at larger medical centers and hospitals. In fact, these ambulatory and outpatient care sites are even more vulnerable than their larger counterparts due to the lack of support they have in terms of security resources.
Even when these locations are part of a larger hospital or health system, their sheer numbers, geographic diversity and other factors make them hard to fold into the larger institution’s often limited security program. This leaves the sites with little to no professional security assistance, no one to come running around the corner to help staff when patients lash out, no one to assess threats and the patients who make them. That’s right- the staff are on their own to serve as their own security staff and to do their best to manage patients who are potentially violent.
Sounds pretty concerning, right? Well, in many cases, the folks who work at these sites do an amazing job handling problematic patients with their limited resources. They sometimes have the advantage, in a small family medicine practice, of knowing the patient for a long period of time, knowing their other family members, or both. The historical knowledge of these patients can certainly put behaviors in context as well as provide an idea of what could potentially de-escalate the patient based on what worked in the past.
However, in many settings, patients may have a limited history with the practice and the threatening behavior can be new, hard to predict and can frighten the subject of the threats in addition to the other staff working in the practice. No matter the specialty, affiliation, or the location of the ambulatory or outpatient site, patients will inevitably bring their expectations, history, and problems with them when they arrive for their appointment.
I have found, in my work as both a Security Director and as a Healthcare Security Consultant, that many staff working at outpatient and ambulatory sites feel generally safe. However, there are situations where the entire staff at one or more of these sites feel quite unsafe and are just waiting for “the worst case scenario” to unfold. They work in a constant state of vigilance and concern.
For example, at one site I visited as a consultant, the staff had deployed vehicle emergency glass break hammers in every room with a window in their practice so they could smash out the windows and escape if someone started shooting. Imagine the staff in this practice- feeling so frightened on a regular basis by the patients they serve that they feel they need to take this measure.
So, what’s the solution to this problem? How can we keep our staff working at these remote locations safe? How can we empower them and equip them to handle situations with escalating, threatening and/or violent patients?
The answer is violence prevention and response training. It’s important to recognize that employees are their own first line of defense when dealing with a patient who is getting agitated, being verbally abusive, threatening, or physically violent. This is true in both large medical centers/hospitals and at ambulatory/outpatient sites. However, with ambulatory/outpatient sites without security staffing, employees are also the last line of defense before the police arrive (if they are even called).
All staff – from the ones who feel safe to the ones who feel frightened - have one thing in common - they want training and tools to keep themselves safe in case there is an incident with an escalating, threatening or violent patient. Providing practice staff with the training to identify when things are beginning to go downhill with a patient’s behavior and how to respond to what may come next empowers them to take their safety into their own hands. Proper training can also reduce fear and anxiety in staff when dealing with these situations since they are equipped with the proper tools in their toolboxes to keep themselves and their fellow employees safe.
Sounds like a good idea and easy to pull off, right? Wrong. The biggest challenge that these outpatient and ambulatory sites face is that, due to them being scattered around one or more geographic areas with limited staffing, they can’t just all close up shop and gather in a big conference room somewhere for training. Even trying to get a training set up inside each practice is logistically difficult with the challenge of getting everyone on their lunch break to be in the same room at the same time for a training that may last an hour or more.
It’s not that these sites don’t want to provide their staff with violence prevention and response training, it’s that they have a very hard time pulling it off with their inherent logistical challenges. For these reasons, it’s not uncommon to see only some staff across multiple practices operated by the same system trained on how to recognize and respond to violence. In some cases, none of the staff are trained.
So, assuming a practice can pull off a training on a limited or widespread basis, what elements should the training contain generally? With time and other logistical constraints, the training should be right to the point and address the most common types of situations that staff may encounter. Here’s a general outline of topics that should be covered:
-Workplace Violence Overview: The definition and overview of the risk violence poses in healthcare.
-Preparing for Safety: How to prepare your mind and workspace for potential violence.
-Recognizing Aggression: The warning signs that someone may become aggressive.
-Responding to Aggression: How to de-escalate someone who is upset or angry and how to keep yourself and others physically safe if things get out of control.
-Threats: How to respond when direct or implied threats are made in person, by phone, or electronically.
-Preparing for Difficult Patients and Giving Bad News: How to plan for safety when there’s a difficult patient expected in the practice and how to plan for giving bad or upsetting news to a patient who may become volatile.
-When and How to Involve Law Enforcement: When and when not to involve law enforcement and the best ways to get the response and help needed.
-Arriving at and Leaving the Workplace: How to stay safe when coming to and going from work in the parking lot and before/after normal business hours.
-Basic Evaluation of The Workspace for Safety: How to perform a basic evaluation of the safety of each employee’s workspace from the violence prevention and response lens.
In addition, running staff through some scenarios by just talking through their responses to a variety of realistic situations with the potential for violence is also quite helpful in allowing staff to mentally apply the training concepts outlined above. It’s important to note that this training, like any other training, should be repeated, in some form, on a regular basis- every 1-2 years to keep staff fresh on key skills and techniques.
In closing, one of the most powerful and empowering tools that can be leveraged to keep staff at ambulatory and outpatient sites safe is violence prevention and response training. Staff are on the front lines every day and they are their own first line of defense. However, for training to be effective, you need the right lessons to be delivered on a realistic and repeatable timeline.
Wrapping in scenarios helps staff to think through how they might handle a threatening or violent patient in their practice and helps to mentally program them to prepare for these situations. Overall, trained and empowered staff are safe staff. They will feel cared for when they have the right training to keep themselves, their colleagues and patients safe. When this happens, everyone in the practice can focus on the number one priority- providing the best care for every patient who walks through the door.
