Caregivers and peacemakers: Nurses Raymond Thurman, Jamie Dudley, Jody Shaw and Stephanie O'Halloran share their insight into successful de-escalation. As tense encounters with patients and families continue to rise, caregivers are perfecting their de-escalation skills. Health care is an intense environment. Patients are having rough days. Families are stressed. The conditions are right for tensions to boil over, and if they do, caregivers can be caught in the middle. When it comes to workplace safety, the best way to handle a potentially violent situation is to prevent it altogether. That’s why nurses and patient care staff are focusing on de-escalation as an essential skill. The numbers illustrate the need: In 2018, Public Safety officers in Springfield assisted with potentially violent situations more than 2,600 times. For staff in the Emergency Departments, Psychiatric Services, 700 East at Cox South and other areas, de-escalation has long been a critical skill. Fortunately, with practice, it’s a skill anyone can develop. Listening is key Jody Shaw, a nurse on 700 East, says de-escalation starts with one simple step: listening. Shaw is one of the nurses who serve on CoxHealth’s staff assist team, responding to help staff diffuse situations. Frequently, by the time a staff assist is called, a patient or family member is frustrated and feeling like their concerns aren’t being heard. “Most of the time, they need someone to listen to them and answer their questions,” Shaw says. “About 75 percent of the time, just listening works to de-escalate a patient.” Get the right people One of the main de-escalation advantages of the staff assist is that it introduces new people. That step alone can diffuse tensions. On 700 East, nurse Jamie Dudley says staff frequently work with patients who have dementia. In those cases, a staff member with a face or a voice that reminds a patient of someone from their past can be enough to trigger a negative response. “Just switching out the staff members who are talking to patients can make a big difference,” she says. “And there are times when calling a family member can help, too.” Any time staff members at Cox South are in a situation in which a patient is agitated and de-escalation tactics aren’t working, staff can call 333 and ask for a staff assist. Nurse Stephanie O’Halloran says there is a lot of adrenaline involved when a staff assist is called. “You never know what you are walking into: It could be a confused older person, an irrational patient or a family situation,” she says. “Sometimes, a new person to hear the patient’s story helps.” For a successful de-escalation, engaging patients with two staff members at a time is ideal. Adding more staff in the room can increase tensions. “You have to be confident and make patients feel comfortable,” O’Halloran says. Be flexible, be respectful When patients are in a heightened emotional state, it is key for caregivers to offer suggestions, not commands. “Nurses like to be in control. We have lives in our hands and we take that seriously. But we have to think about how we can bargain to make this work,” O’Halloran says. Something as simple as a food request can spiral into a high-tension situation. In those cases, caregivers have to pick their battles and know where they can compromise. Shaw notes that she recently worked with a patient who wanted coffee at 3 a.m. She got him decaf and sat with him for a bit, listening to his concerns. “Everyone is human and wants to be treated with respect,” she says. “Just take five minutes and take them for a walk. Talk to them,” O’Halloran says. “Talking with them earns their respect. When you talk and listen, they can trust you and they can start to give a bit as well.” Focus on common goals A successful de-escalation also requires that staffers examine their own goals in the encounter. “Ultimately, staff safety, patient safety and patient advocacy are your goals,” says Raymond Thurman, a nurse in the Emergency Department. When a patient is on the edge of being violent, it can be difficult to remember that you are on the same team. Thurman says it has been all too common in the past for caregivers to try to establish authority, rather than to listen and collaborate. The authority approach can make things worse. “You don’t want a struggle that ends with a winner and a loser,” Thurman says. “Because you won’t always be the winner.” Thurman says CoxHealth’s approach to safely handling agitated patients has improved steadily in his time with CoxHealth. “If you want to use anything clinical you learned as a nurse, you have to be able to de-escalate a patient first,” he says. “I love seeing de-escalation as a priority. It’s not just patient safety or staff safety. It’s one unified goal, and it makes empathy a priority.”

De-escalation 101: When tensions rise, try this

Work to understand the situation: Know the patient’s history. Talk to the primary nurse and find out what led to the need for de-escalation. Try to go into a situation knowing the patient’s case and what the underlying issues may be. Plan for backup: Have a game plan with other staff and Public Safety if needed. Use the buddy system: Two people in the room at a time is good. More than two can increase anxiety and escalate things. Listen and empathize: Explain who you are and that you are there to help them. Ask the patient what is going on and let them talk. Many times, a new staff member listening to a patient’s concerns can de-escalate a situation. Call for a staff assist: Any time de-escalation tactics aren’t working, staff can call their campus emergency number for a staff assist. Staffers in Monett and Barton County may contact Security.

Our approach: new RL, staff assist, training and more

Keeping staff members safe is a top priority for CoxHealth and in 2019 we are expanding our resources to do just that.

The efforts begin with a new event/concern reporting system (RL) process that offers a straightforward, streamlined form for reporting workplace violence incidents.

The new RL is the first of its kind and it represents a major commitment to preventing workplace violence. The new process will allow CoxHealth to track incidents, so we can better see trends and focus on prevention.

The online form, found on CoxHealth’s intranet, walks users through definitions of abuse and violence, with space to explain how an incident occurred and who the perpetrator is.

The new RL is only part of what we are doing in 2019. Other keys to our approach include:

Staff assist – If a situation is getting tense, any staff member in Springfield or Branson can call their emergency number and request a staff assist. Staffers in Monett and Barton County may contact Security. The staff assist team that responds to the page includes nurses who are specially trained in de-escalation.

New protocols for dementia and delirium patients – Teams are working to develop new recommendations on de-escalation tactics as well as medication and behavioral protocols to reduce outbursts that can lead to violence.

Training for staff – The Education Center at Cox North is offering de-escalation classes, which are mandatory for Psychiatric Units, Emergency Departments and the 7th floor at Cox South. The training is encouraged for anyone who may deal with an upset or agitated individual. 2019 will also include Mental Health First Aid training – designed to help staff members recognize warning signs before a situation escalates.

Crisis Care Team – CoxHealth’s Crisis Care Team (formerly known as CISM), an interdisciplinary team that includes Pastoral Care and Case Management staff members, provides one-on-one follow up with staff members affected by workplace violence.

Employee Assistance Program (EAP) – The free program, which began in 2018, offers phone consultations with professional counselors in the wake of a workplace violence incident.

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Meet the de-escalators: mastering the art of violence prevention