assessing and managing disruptive patients kathryn gift dnp, rn, cen beyond customer service 1
TRANSCRIPT
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ASSESSING AND MANAGING DISRUPTIVE PATIENTS
KATHRYN GIFT DNP, RN, CEN
Beyond Customer Service
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Objectives
Discuss the 3 elements that interact in a violent situation with emphasis on the most unpredictable element.
Summarize the different levels of stress and intervention that can be used at each level of stress.
Demonstrate customer service, verbal/nonverbal interventions, and limit setting techniques that may be deployed to de-escalate disruptive behavior.
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Workplace Violence
“ Violent acts ( including physical assaults and threats of assaults) directed toward persons at work or on duty” National Institute for Occupational Safety and Health (NIOSH)
2011-2013 workplace assaults ranged from 23,540 and 25,630 annually, with 70-74% occurring in healthcare and social service settings.
Assaults comprise 10-11% of workplace injuries for healthcare workers compared to 3% in private sect0r Bureau of Labor Statistics and National Crime Victimization Survey (www.bjs.gov/content/pub/pdf/wv09.pdf)
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Workplace Violence
Health Care workers are 16x more likely to experience violence than other service workers.
Over 50% of workplace aggression claims come from the health sector. Workplace Violence in the Health Sector- State of the Art World Health Organization 2002
24% of all female deaths in the workplace are the result of homicide National Crime Victims Survey; Workplace Violence, 2006
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Subtle Forms of Violence
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Predatory vs. Affective Violence
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Decrease Increase
Values/beliefs against violence
Intact thought processes/ judgment
Appropriate emotional control
Non-violent resolution skills
Undesirable outcomes
Predisposing Factors Internal qualities/ characteristics Things we bring into
the situation ( our baggage)
Precipitating Factors Elements external to
us in the environment or situation
Violence Risk Factors
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Predisposing Factors
History of Past ViolenceActive Substance AbuseWeapons AccumulationFinancial StressViewing the World as HostileSocial History, Past ExperienceLoss of InhibitionConfusion or Disorientation
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Predisposing Factors
Inability to Bond with OthersMisperception of DangerProblems Regulating BehaviorHopelessness or “Nothing Left to Lose”Means to an End
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Precipitating Factors
Loss of ControlLoss of IdentityLoss of PrivacyLoss of DignityLoss of IndependenceLoss of ChoicesFear of Pain
Today’s Precipitating Factor May Become Tomorrow’s Predisposing Factor
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Ongoing Interactive Assessment
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Other’s Body Language: Non-Verbal
Fearful or Anxious AppearanceAgitated or Angry PostureLewd or Inappropriate StaringActing Suspicious or HostileAppearing Stressed or ThreatenedAngry or Sexually Inappropriate GesturesBehavior Doesn’t Match What is Being Said
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Other’s Verbal Behavior
Talking Loudly/ShoutingCursing/SwearingTone of VoiceClaims of MistreatmentSexually Inappropriate CommentsChallenging, Threatening OthersBlaming Others for ProblemsStating a Plan of Intent to Harm Others
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Stress Levels
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Stress Levels
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Normal/ Mild Stress Level
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Normal Stress Level Intervention
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Normal Stress Level Intervention
Allow Person to Express ConcernUse Shared Problem Solving ApproachDemonstrate EmpathyBe Active ListenerAvoid Being DefensiveApologize if AppropriateFollow Through with Their ProblemAvoid Blaming Others or “Not My Job”
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Moderate Level of Stress
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Signs of Moderate Stress
Looking Anxious, Lost or ConfusedMild Voice Changes
Higher/louder/faster speechSmall Nervous Habits
Drumming fingers Tapping foot
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Moderate Stress Level Intervention
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Moderate Stress Level Intervention: Verbal De-escalation
Encourage Person to Talk and Share Experiences
Validate the Person’s ExperienceAsk Open Ended QuestionsRestate, Reflect, ClarifySuggest CollaborationLISTEN
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Moderate Stress Level Intervention: Verbal De-escalation
Present Reality SupportivelyIdentify the ProblemFocus on Problem SolvingGive InformationProvide AlternativesSummarizeCreate an Action Plan
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Moderate Stress Level Intervention: Verbal De-escalation- NON VERBALS
Remain Calm and in ControlMaintain Personal SpaceSupportive Body LanguageDemonstrate EmpathyConvey Willingness to HelpShow Open HandsNon-threatening Eye Contact
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Severe Level of Stress
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Verbal Signs Non Verbal Signs
Threatens othersIncreasing loud or
boisterous behaviorCursing, swearing ,
argumentative
Approaching/avoiding others, pacing
Invading personal spaceNonresponsive to
directionsUncharacteristic behaviorsSlamming doors/pushing
furnitureBehaving inappropriately
for the situation
Signs of Severe Stress
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Severe Stress Level Intervention
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Severe Level Intervention: Limit Setting
Limits are:Simple and DirectDescribe the Desired Behavior- Giving
OptionsAppropriate to the Situation- Stating
Consequences if NeededProgressive in NatureEnforceable
You need to be clear, calm in demeanor, nonthreatening, encouraging, firm yet supportive, respectful and civil, AVOID POWER STRUGGLES
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Severe Level Intervention: Limit Setting
Is an Advanced form of Verbal De-Escalation Skill
Different than customer serviceTakes PRACTICERequires keen self-awareness
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Panic Level of Stress
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Panic Stress Level Intervention
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Panic Stress Level Intervention
Personal Safety Skills“Take Down” Follow facility policy/training
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Tension Reduction
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Tension Level Interventions
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Tension Reduction Intervention: Therapeutic Rapport
Support De-escalation/CalmingProtect Dignity- help “Save Face”Monitor Stress LevelRemember
Even if you never see this patient again, SOMEONE ELSE WILL!!
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Scenario
A customer walks into your workplace. His/her face is flushed and jaw is clenched. S/he states, “ I can’t believe this place! My doctor tells me I may have to go into the hospital for more tests & keeps me so late. I need to go to the lab, bet anything it is closed or another long line. I can’t even find it and no one will help.
What level of stress, What can be your response?
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Scenario
You hear a loud voice in your workplace. You go to see if you can help, and you see an angry person pointing his/her finger at your co-worker’s face, stating “listen, I don’t need a map, I just need to know where my appointment is!! What is wrong with you people? Can’t anybody find anything around here?! Your co-worker appears frozen and stunned by the outburst, unable to get the angry person to calm down.
What is the level of stress and what is your response?
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Resources
Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, Occupational Safety and Health Administration (OSHA), OSHA 3148-04R 2015
Hills, D.J, Ross, H.M., Pich, J., Hill, A. T., Dalsbo, T….. Martinez-Jarret, B. (2015). Education and training for preventing and minimizing workplace aggression directed toward healthcare works. The Cochrane Library.