Innovative strategies for managing disruptive behaviors in health care settings [PODCAST]

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Join us on our latest episode as we explore the importance of addressing violent behaviors in health care settings. We’ll be discussing the role of Behavioral Emergency Response Teams (BERTs), trained in non-violent intervention techniques, in managing disruptive behavior and improving safety for both patients and staff. We’ll also dive into the impact of trauma-informed care (TIC) on patient well-being and discuss strategies for implementing TIC in health care settings. Our guests, Jenica W. Cimino and Samira Lopez, will share their expertise and experiences in quality improvement and psychiatric nursing, respectively. Don’t miss this important conversation on reducing violence and promoting healing in the health care industry.

Jenica W. Cimino is a quality improvement specialist. Samira Lopez psychiatric nurse and CODE Care lead.

They share their stories and discuss the KevinMD article, “Breaking the cycle of violence in hospitals: the role of trauma-informed care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Jenica Cimino and Samira Lopez. Jenica is a quality improvement specialist. Samira is a psychiatric nurse and CODE Care lead. We’re going to talk about the KevinMD article “Breaking the cycle of violence in hospitals: the role of trauma-informed care.” Jenica and Samira, welcome to the show.

Jenica W. Cimino: Thank you so much, Kevin. Great to be here.

Kevin Pho: So I’m going to ask each of you just to briefly share your story and journey to where you are today. Jenica, why don’t you go first?

Jenica W. Cimino: Sure. So I started my career in palliative care research, and for me, that model of compassionate, team-based care really set the bar for what health care could look like across the board. I then transitioned into quality improvement, and I’m now a systems improvement specialist who coaches executive leaders, physicians across specialties, nurses, and other health care workers in quality improvement and change management at an academic health system.

Kevin Pho: And Jenica, from your perspective as a process improvement specialist, from a clinician standpoint, what would you say are some of our biggest challenges?

Jenica W. Cimino: Oh, goodness. Just in general, I think solving problems from a system standpoint is probably one of the greatest challenges. And again, that comes from the perspective of somebody who has been working in quality improvement for over a decade. I think often the right intentions are there, but making systems improvement sustainable is really the biggest challenge. There are a lot of efforts that people try and fail, but for various reasons, they are not sustainable. And so I think it is really, really digging into how to make sustainable practices work for the long term.

Kevin Pho: And Samira, just briefly share your story and journey to where you are today.

Samira Lopez: Yes. So I have been a psychiatric nurse for nearly 10 years and have worked in mental health for about 20. It’s always been a passion of mine, and I’ve worked in several different capacities. I was working as a supervisor at a hospital, as a psychiatric nurse there, and I loved what I was doing. However, I wanted to get back to patient care. I had implemented a program similar to what UCSF has at another hospital and found how successful it was. So when the opportunity came to apply trauma-informed care principles in a setting, it was exactly what I wanted to do. I was very grateful to be able to have this opportunity to bring this to the hospital, because I have seen how successful it can be.

Kevin Pho: And Samira, just briefly share some of the rewards that you have from implementing trauma-informed care at medical institutions.

Samira Lopez: I would say the biggest rewards are patients feeling heard and saying that they feel their needs were taken into account in the whole treatment plan, and also nurses feeling empowered that they now have the tools and skills to be able to support a patient they previously didn’t know what they were going to do with. Overall, it leads to a more collaborative approach. For me, it’s really rewarding that after being able to support them, they feel empowered to do those things on their own.

Kevin Pho: And we’re going to talk more about that in the KevinMD article “Breaking the cycle of violence in hospitals: the role of trauma-informed care.” So Jenica, how did this article come together?

Jenica W. Cimino: Yeah. So during the 2019-2020 academic year, our improvement team, as an interdisciplinary improvement team, was working on a key institutional priority to create an optimal work environment for employees, as measured by the Gallup survey for staff and the Net Promoter Score for physicians. We developed a recognition system for physicians and nurses to help us achieve our target. But we soon learned that it wasn’t our providers’ successes, and I’m using “provider” broadly here just to include all clinically facing health care workers, that needed recognition, but instead their lived professional experiences, namely the burden of feeling unsafe at work. And the Gallup measurements, which we had relied on, were not systematically measuring provider safety.

Kevin Pho: And Jenica, what would be some examples of cases where provider safety was threatened?

Jenica W. Cimino: Oh, goodness. Well, I guess some of the things that come to mind are really just the burden of workplace violence that’s not physical assault, so the volume of events that represent other forms of mistreatment that also feel ubiquitous and underreported: the racist slurs, sexual innuendo, and threats of violence. There have been multiple accounts at our own institution of patients throwing hot coffee at nurses, throwing utensils, pulling nurses’ hair, etc. Really egregious things. And I know it gets worse from there, and Samira has probably seen more firsthand of what this looks like and can look like.

Kevin Pho: And Samira, from your experience, tell me what you’ve seen when it comes to nurses’ and clinicians’ safety being threatened in the health care setting.

Samira Lopez: I see it frequently. I feel like the hardest and saddest part about all of that is that the feedback I get is that we just have to take it, the patient’s needs are our priority, and we will sit there and listen to the verbal abuse and take it. And the physical abuse, we minimize and normalize it, so then it becomes a part of the everyday culture. That is the hardest part, and that’s the culture change we really want to work on as well, because there is a way to safely provide care for patients while still making it a safe environment and helping everybody be able to do that, and to see it in a new frame, where it is not necessarily acceptable and they don’t have to take it. There are ways to safely set limits and be able to provide all of the support that the patient needs.

Kevin Pho: So Samira, let’s walk through a scenario. Let’s say a nurse is threatened on the job. What would be the next steps?

Samira Lopez: So for the next steps, I can speak to the implementation of the CODE Care team. They would place a consult for us. I just want to start by saying that CARE is how we approach the situation: consider the facts, awareness of our assumptions, recognize others’ perspectives, and evaluate the best option to move forward. That is the mind frame with which we approach these situations. So we would take the time to hear the nurse’s perspective and what’s going on, and then the patient’s. It’s really being able to identify what the underlying need is, while still setting limits and saying what we can tolerate and what we can’t, and asking, “How can we work collaboratively to get your needs met?” But it is also for the nurse to feel safe being able to enter that room and provide the care.

Kevin Pho: And Samira, can you give us a hypothetical case study or scenario that can really illustrate that point?

Samira Lopez: Yes. There was a CODE Care placed for a patient who inadvertently slapped a nurse, or several nurses, over three days. I went to go see her, spoke to her, and explained some of the concerns that we have. She said that every time she gets woken up, she gets touched on her shoulder, and she is having a fight-or-flight response. She lives on the street and didn’t know who it was. So we talked about her trauma and what alternative ways would be safer for nursing to be able to wake her up, talk to her, and give her medications. She said touching the bottom of her foot and yelling out her name loudly was a better way and a safer way for her to be woken up in this hospital setting. Immediately after nursing got that feedback, we were able to document it and come up with a plan. That is the way nursing approached the patient, and there were no further incidents of anyone being assaulted. I felt like nursing felt safer, and the patient felt respected and heard.

Kevin Pho: Jenica, tell us, when it comes to trauma-informed care and trying to alleviate some of these assaults against nurses and threats against health care clinicians, how easy or difficult is it to implement trauma-informed programs like these?

Jenica W. Cimino: Well, I would say when we first started to gather key stakeholders at our institution, I thought, “Well, here we go. This is probably going to be a multiyear effort that may or may not result in any significant change.” But there were enough people who were really passionate. I was really passionate. This followed George Floyd’s murder and others, and there was a really mighty group of people who were really passionate about anti-racist care and trauma-informed care. I think the key was really gathering all of the right stakeholders and getting executive leadership involved. We were lucky that our executive sponsors were also really passionate about this and supportive. And so they supported training for a group of us, and then they launched this pilot, and the pilot has been really successful. We’ve collected really compelling data. It’s expanded, and I hope it just continues to expand. But I’ve been really encouraged by how quickly this all happened. It was within a year that we had a pilot launched, which was really remarkable for a very large, bureaucratic institution like ours.

Kevin Pho: And Jenica, is there any data that shows that this program has moved the needle?

Jenica W. Cimino: Yes, Samira has been collecting some data on this, and Samira, please feel free to jump in here as well. We have shown fewer calls to security; that has been very significant. The need for sitters has been reduced as well. We’re looking at length of stay, to see if this program will influence length of stay. I think some of that data are still coming in. The early data that we’ve collected have been really compelling, not to mention patient satisfaction and staff satisfaction. I think Samira can speak to this, and I certainly can as well, but there is the number of physicians and nurses who have just said, “Listen, this is the best thing our institution has funded in recent memory,” perhaps in the whole time that I’ve been employed here. And so that’s really exciting, to hear that people’s lived experiences are so positive.

Samira Lopez: Yeah, I’ll just add that the patient and staff surveys have really been, I think, the guiding force in pushing this forward, so much so that even I was surprised that I was hired on as a team lead and have been able to have the opportunity to hire one more person and expand to more units. Within the next couple of months, there’s going to be a new unit added every month. I think with the combination of the interest in it and the impact that they’ve seen, more units are getting excited and signing up to receive this service, and there are talks about expanding to other campuses. So I feel like the need is there, and the data is there to show that this is effective. I hear staff saying that they would call us first before calling security, which is really what we want, because this is a proactive, preventative de-escalation support team. So the sooner we can identify concerns, the sooner we can reduce any risk of calling security and any risk of any escalation happening. I should also add that the number of assaults has gone down as well, so that’s really important.

Kevin Pho: So Samira, a lot of medical institutions may not necessarily have the resources of UCSF, right? So for emergency departments or hospitals across the country that don’t have a formal program like yours, what are some tips that you could recommend to help them potentially de-escalate situations?

Samira Lopez: I would say one thing is to try to identify the underlying need of the patient and to see if that can be identified and resolved, to support more of a collaborative approach, and to talk with the patient to just get their perspective. I tell nurses and physicians all the time that five minutes of a conversation can feel like an hour for a patient. It’s not all the time that we take the time to just hear what they need, and to remember that this is a vulnerable environment to be in and to try to create that sense of safety. But also, your safety is important, and it is OK to let a patient know that you do not feel safe and that you need to remove yourself from that situation, so that maybe there can be time to breathe or reconvene again. Safety for everybody is important, and we really shouldn’t minimize that. It is not just the patient; it’s all of us working collaboratively together.

Kevin Pho: And Samira, what are some examples of questions that clinicians can ask patients in these situations?

Samira Lopez: I feel like they could ask them what is bothering them or what is hurting right now. Even that question can bring an answer like, “I recently lost four people, but I’m here now. I’m stressed about money things.” There could be social work needs that we just haven’t even identified. But giving them the space to talk, I think, is the first step, so that they can feel heard. You may not solve all the problems or anything like that, but the fact that you took the time to listen, I think, is the biggest thing to take away. Patients have told me several times, “Yes, the problems weren’t all solved, but you know what? I felt like they cared. They sat down and talked to me, and I felt like they cared.” And that made their responses different.

Kevin Pho: I’m going to ask each of you for your take-home messages to the KevinMD audience. Jenica, why don’t you go first?

Jenica W. Cimino: I have so many, but I guess I would just say our biggest lesson, at least for those of us who wrote the article, and really the thesis of the piece, is that there’s a diversity of phenotypes of behavioral escalation. We often blame patients for past trauma and behavioral escalation, which can include baseline dementia, substance use withdrawal, copathology, and decompensated mental health, as opposed to understanding the underlying pathophysiology and acting in a proactive and preventative way as a system.

Kevin Pho: And Samira, what are some of the take-home messages that you want to leave?

Samira Lopez: I think that regardless of the situation, you can provide trauma-informed, patient-centered care while keeping yourself safe and the patient safe. By working collaboratively, it can happen without any of the CODE Care support teams or any of those extra resources you have. Remember that this is a person here in front of you, that there are several factors outside of this hospitalization that impact the patient, and that everyone can come from a trauma in various ways. Remind yourself to look at what trauma you potentially could have that is coming forward in this situation. And so give yourself permission to make mistakes, try again, and support each other.

Kevin Pho: Jenica, Samira, thank you so much for sharing your time and insight, and thanks again for being on the show.

Jenica W. Cimino: Thank you.

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