Volatility is nothing new in healthcare settings with the highest incidences being reported in emergency departments. Thus, the recent incident at Ridge Hospital though eyebrow-raising, is not unique to Ghana.
According to a survey by the American College of Emergency Physicians and the Emergency Nurses Association, about 70% of nurses reported being physically assaulted at work while 50% of physicians reported same. This alarming data raises a very important question; why does this happen?
A combination of stressful situations brought on by injury/illness, a stressful ED environment, mental health issues, and alcohol and drugs create a perfect storm for such escalations. Healthcare workers have reported anything from insults being hurled at them, being spat on, slapped/beaten up and to extremes of gun violence.
From the health care worker’s view point, it is frustrating and seen as ungrateful, inappropriate behavior by the very people they serve whereas the patient/relative may see some healthcare workers as unempathetic, uncaring, rude and all the colorful descriptors one can think of.
Though both sides may believe that their opinions are absolute truths, the truth may actually lie somewhere in the middle. The issue should however not be allotting blame, but rather developing strategies to help decrease these occurrences. Why? Because incidents like this gradually wipe out trust between patients/clients and health care workers which may end up snowballing and worsening an already bad situation.
Given the negative impact of these occurrences on both patients and health care workers, many institutions have developed different strategies which have helped in many situations to prevent violence. Ridge Hospital and other health institutions in Ghana may have strategies or well laid plans to decrease or avert these, but the question is, are these being implemented? If yes, how effective have they been? With the continued reports of these incidents, maybe we should take a second look at our strategies or look into other tried and tested measures that may be helpful.
Many different communication and patient engagement strategies have been explored to help prevent these conflicts, and these are taught and refreshed annually to help keep staff always equipped. Did I hear this is too much training? Well, we can all see that the alternative is not too pleasant so let us see what else can be done.
These training sessions include aspects of clear communication during the emergency room triage process. Staff members are taught to clearly explain wait times based on illness/injury severity or stability of the patient’s condition. Reasons for delays should also be communicated in a transparent manner as being uncertain of a situation may exacerbate one’s frustration.
It is possible that sickness or injuries and its concomitant fear and uncertainty may decrease awareness of one’s surroundings, but it is helpful to also have posters on the walls that explain wait times and the triage process as repetition of this information may solidify understanding. Additionally, though staff may not have all the answers to a patient’s questions, we can agree that having someone listen to our concerns makes one feel cared for. Therefore, training staff members on active listening should be part of our strategies to help decrease the patients’ frustration.
It is well known that not all aggression can be prevented or resolved with communication alone. Sometimes, even with one’s best efforts at clear communication, anger still flares up, so what can we do when that family member is in all in your face or has a phone/camera in your face and yelling? How do you de-escalate this situation?
This is where non-violent crisis intervention techniques come in. Though hard, maintaining a calm demeanor, exhibiting non-confrontational behavior, using calming body language, employing empathetic listening, using clear language while avoiding medical jargon, and respecting personal space and feelings is very important in preventing further escalation. Sometimes, one may even have to step away for a bit, but wait… don’t just walk away! One can say, I think I may have to give you a little space. I will come back in a few minutes so we can talk. Please don’t forget to come back though!
Now, one has tried communicating and being calm, but the patient or family member is still not calming down. What does the staff member do? This is where a patient support team comes in. Hospitals may set up patient complaint channels or patient support teams whose services may be offered when patients/families have concerns or grievances. This team may serve as patient advocates which will help make patients feel heard by someone other than a healthcare worker.
Okay, the situation escalates and the family member is now threatening violence. Scary situation for staff members no doubt. This is where the hospital’s security is summoned to come and escort the patient or family from the facility. Hospitals and emergency departments should have a clear policy on violent behavior visibly posted all around. One example of such a policy may be a Zero Tolerance for Violence policy. This should spell consequences of verbal and physical aggression towards staff members, and may include being kicked out of the hospital by security or the police being called.
To help ground this policy, security presence should be visible though maintaining a respectful distance at all times. This may serve as a deterrent to violence. There is a caveat though, not all escalations can be taken care of by security or the police. In some cases, the aggressive behavior is a mental health crisis which requires intervention by trained personnel. Hospitals should therefore have behavioral emergency response teams who should be specialized teams trained in psychiatric and behavioral intervention.
As mentioned earlier in this write up, the hospital environment and by extension, the emergency room setting is a generally stressful environment for staff members. This may lead to staff burn out which can lead to poor interactions. Now, imagine a staff member trying to deal with their own stress and suddenly assailed with insults and yelling. How situation do they take this kindly? Very difficult situation if you ask me. This can however be helped or prevented by Hospitals providing staff with coping strategies which may include training on mindfulness and how to maintain a healthy lifestyle.
Just like any new program or system, the above strategies may be challenging to implement if not already being practiced, but we must acknowledge that a change or a “reset” (as many of our country men call it), comes with a will to forge ahead regardless of the challenges. Together, we can help decrease these conflict situations, build trust and improve health outcomes for all.
David Leo-Nkoah
CEO of Adage Health Consult – Ghana
