Again, this is a first in a series, where we begin our discussion on violence in the healthcare setting. And I'm very excited and pleased to introduce our guest today, Monica Cooke. Monica is the founder of Quality Plus Solutions. She is a national leading expert and behavioral health risk professional with over 40 years of clinical administrative and executive experience in the industry.
She is a recognized expert and leader in the field of behavioral health risk management. She's also a registered nurse and certified as a psychiatric mental health nurse. She's certified professional in healthcare quality, certified professional in healthcare risk management, and a distinguished fellow with the American Association for Healthcare Risk Management. Welcome, Monica, we are so glad to have you join us.
MONICA COOKE: Thank you, Joan. It's just an absolute pleasure to be here. You and I have such stimulating conversations that I'm really looking forward to today.
JOAN PORCARO: Well, I want to start off with just a little background information. So, you've been a national leader in working to reduce workplace violence and you're often heard at the national and local level. And you're a welcome speaker. So, I want to ask first, why is this topic so interesting to you? What became the first thing that possibly stimulated you to go in this direction?
MONICA COOKE: I think my long history in behavioral health well over 45 years and working with this population, as well as substance abuse patients. I think we're quite proactive in that arena and managing aggression. And while I've been doing behavioral health risk assessments around the country for a very long time, probably about five years ago, I moved into the arena of workplace violence because it became very clear to me that organizations were extremely challenged with how to manage workplace violence.
And we have very little evidence-based literature or research on this topic. I know that because I've been involved in extensive OSHA litigation around workplace violence issues and have sat in weeks and weeks of trial. And really learned not only what was not out there but also what we needed to do and what if we didn't do it, what would be coming down the pike from a regulatory perspective.
And unfortunately, I think that that's already going to happen. We've had House Bill 1195 passed through the House in April of 2021 that's going to really require all health care settings to follow various federal regulations that have been OSHA guidelines for many, many years. So, I think my interest in this topic in particular is that while we can manage behavioral health patients, they're not the bulk of the violence that occurs in healthcare.
The bulk of violence really is coming from patients, and visitors, and vendors. And of course, we still have lateral and vertical violence in healthcare. But the bulk of it is really, what I call, the nasties and people that come into the organization and believe that it's their way or the highway or feel that they have a right to be threatening and abusive of people that are caring for them.
So that's really my main impetus to do this. And I think that as I continue to do workplace violence risk assessments around the country, I see more and more how little resource and how little direction organizations have to really focus on the root causes of this very serious issue. So that's pretty how I got to where I am right now, Joan.
JOAN PORCARO: I appreciated a couple points that you raised. One, that in the behavioral healthcare settings, there has been just a different type of approach to working with these individuals. And when we go outside of behavioral health, we're challenged a bit more. So why do you think we've not been able to stop or at least reduce healthcare workplace violence? What's some of the reasons for the persistence?
MONICA COOKE: Well, I think there's lots of reasons. I think when I speak to this topic, I really talk about what's been going on in the last 15 years when this rate has just gone off the chart. I think, people have become less regulated in the last many years and in society, in general, not just in health care but in general.
And if we just look around what's going on in the world itself, we can see the chaos and the dysregulation that people have and the lack of filters, just in terms of when they say something, how they say it, and the kind of behaviors on how they say it. So, I think that that's something that's been progressing for a number of years. And then we don't have clear codes of conduct in healthcare.
People come in and they really don't know. What is the culture here? How am I supposed to behave? And there's reasons for that as well, which maybe we'll get to speak to a little more. But I think the other piece of this really is the lack of immediate action.
And when we have patients or visitors that are getting agitated or anxious, we are very poor in healthcare recognizing the cycle of violence and pre-attack indicators of violence. When we see patient's behaviors, we, in general, in healthcare do not jump to the next step and conclusion that, oh my, here's this patient that is really anxious or agitated and if I don't do something now, it's only going to escalate.
We're not good at that. We've never been good at that. And historically, we don't have time to deal with that a lot in healthcare. We're so busy. Staff are pulled in so many just different directions that having to just stop and really look at what's going on and then intervene often can become very difficult.
We've also failed to understand the impact of violence on not only the well-being of our staff but the quality of care. If we had looked at this many years ago, and really, had we listened to staff many years ago-- and you yourself know as an old ER nurse what was going on many, many years ago. And if leaders had listened to staff back then and responded when staff were concerned or worried or scared of patients and looked at it really as a highly potential liability type event, we might be in a different direction. But we didn't listen.
And we're still not listening in healthcare. It's unfortunate but at most organizations, leaders are at a loss on how to move forward with this. And there's a lack of really hearing what people are saying and dedicating resources to mitigate the risk that we'll talk more about. You know I can go on and on, Joan.
You and I have wonderful conversations about this. And we get quite deep. But I think that those are the main reasons, I think, on how we've gotten here and why we can't get rid of harm to staff and how can we protect them like a baby cub?
JOAN PORCARO: Excellent points, excellent points. And when I think about it out there in the world today, all businesses that face the public are dealing with some of the same issues. And I often wonder, how is it that healthcare obtained the distinction of having the highest rate of workplace violence in all industries? Any thoughts about that?
MONICA COOKE: Yeah, I think we are required by law, all industries are required to report data to OSHA. And those are what we call reportable events. Typically, staff that have needed treatment and have lost days at work.
So that is the data that OSHA collects in general. And they also have reporting of other data. But for the most part, we've gotten this distinction from OSHA. And essentially, we are deemed as the most violent profession, having the highest rate of workplace violence of any industry.
And that's really a horrible thing to say in my brain, just to even say those words, that healthcare is the most dangerous profession to be in. But I think, the OSHA data doesn't even include all the daily abuse that staff deal with. So unfortunately, I'm very sorry to say that while we have the highest rate of reportable events, we also have extremely high rates of non-reportable events that isn't captured at any federal level or even necessarily at any state level.
I think another reason is when we talk about healthcare, we talk about staff that are compassionate. And they go into the field because they're compassionate and they care. And they don't necessarily go in with strong skills in managing violence. It's not what they go into the field for.
And I venture to guess from risk assessments I've done and all the work I've done on this is that probably about 50% of staff that work in healthcare, both clinical and non-clinical, have a real hard time managing conflict. And when you can't manage conflict well, you can't manage aggression and violence well. And there's lots of reasons for them not having those skills to manage conflict. But a lot of it just comes from their own internal mechanisms of functioning, and their own traumas, and their own backgrounds, and their own personality types.
So, these are the people that are working in healthcare. And how do we get people who really are here to take care of people, be compassionate, care, do their job follow the rules to then break out of that and have to manage people that are disruptive, and dangerous, and threatening, and antisocial? These are antisocial behaviors.
It's a hard question. I think we need to throw in there the patient experience. And that started back in 2008, where it became an outcome measure and organizations got very heavily focused on the customer experience and the patient experience.
And our job isn't to make people happy all the time. And on the other hand, we have the patient experience, where staff are almost afraid to set limits on patients or not be nice to patients. What I hear around the country is, oh, we got to be nice because of the patient experience.
So being nice means not setting limits. It means not intervening in a firm, consistent manner with some patients. And ergo, they just continue to escalate and continue to disrupt the environment and cause difficulty for staff that ultimately is traumatizing when it keeps happening over, and over, and over, again, every day you go to work. So, I think that those are probably the main reasons how we got to where we are.
JOAN PORCARO: I thought you brought up the aspect of the patient experience and for someone like myself who had responsibility for risk management and patient relations, the patient relations side is where you get to hear the stories that the patients are telling you about that experience. When there's the compelling event that creates a violent episode and I'm interviewing maybe nurses or other members of the care team, they bring up that concern. They think, well, if we don't score a certain way, we might impact this or that or even a raise or some type of benefit that could happen.
And it's not that that's a bad thing to have a good approach to how the patient should experience their care. But part of the experience, I would say, has to do with, sometimes, the day doesn't go well and we have to be able to work with individuals who essentially are going to be troubled about different things.
And I'm glad you brought up limit setting. I think that it's a phenomenal tool that if we haven't learned it in nursing school or other places, we should probably take time to learn it now. So when we think about the key strategies, what are some of the things that healthcare system or a physician practice, a small physician practice that doesn't have a team of security officers that can come in when someone is aggressive, in different settings, whether it be long-term care or an outpatient surgery center, what strategies can work to mitigate the situations we're seeing?
MONICA COOKE: Ahh, loaded question. And there's lots of them. I think from all my research and all my work in this field, we've basically discovered that we really have no evidence of what works. And people can propose all kinds of ideas about this. But when it comes down to evidence, there is no evidence with one exception and I want to bring this out because I think that this is really the only thing that we know. There is literature based on nursing that the therapeutic relationship mitigates risk. That's an easy thing for me to say, the therapeutic relationship. Because in psychiatry and substance use and those types of settings, the primary job of the clinical staff really is to establish and then develop those relationships with patients because we know that if we do that, we mitigate our risk of harm. We also engage the patient in treatment.
But particularly, in a behavioral health arena, when we understand that patients, if they know us and if we are therapeutic with them, they are less likely to harm us either verbally or physically is key. So that is the only thing we know, it's that therapeutic relationship. Hard to do in healthcare these days and in any kind of setting. Because of the acuity, because of the fast pace, very hard for people to say, hey, let's just talk for a couple of minutes, let me learn who you are and find out what you're about. Not an easy solution.
But other solutions, we need to work to shift the culture. And how do we shift the culture in healthcare when we've really embedded violence in it, and we are the most dangerous profession out there? I think that our focus needs to be on the root causes.
And what are the root causes of workplace violence in healthcare? Good question. How do we dig down to those areas that can help us identify interventions to move forward? So, for instance, we need to conduct a risk assessment.
We need to know, what is our current state? What is the data telling us? Are the data going up? Are the data going down? All those kinds of things we need to look at. And there's tools out there to do that.
Another strategy is we need to assess patients. We're not even assessing patients to find out what their risk is. We just look at everyone the same. Everyone's going to be fine. Everyone's going to be comfortable wherever they are in the setting. And there's no risk. So, we just deny the risk.
I think that assessing patients, there are evidence-based tools out there to do that. And I do believe that it's going to be required down the line. So, I encourage organizations to begin that process, so that at least we can identify these patients upfront and then have standardized interventions to manage them.
The other thing, I think, in healthcare is that staff don't understand what violence is. So, when we say the word violence in healthcare, we think about active shooter, or we think about somebody getting seriously hurt. And we don't think about all these little aggressive moments or little threatening moments that happen on a day-to-day basis.
And we don't call that what it is. And we blame it away on the etiology. So, if we have a patient who is psychotic-- let's take a behavioral patient who's being aggressive, and loud, and threatening. And we go, oh well, that's just because they're psychotic, but they're doing that. Well, we've essentially blamed it away on etiology.
And sometimes, we don't attend to it. So, we just leave it alone. For instance, in the ED, if the patient isn't being too disruptive, we might just leave the patient alone and not treat that behavior. So, naming the behavior when it happens is very important.
When a person puts their finger in your face, that's antisocial behavior, that's aggression, that needs to be attended to. Or a family member that's yelling at you and we blame it away by saying, oh, they're just upset about their loved one being ill, or dying, or whatever it is. And therefore, we don't confront the person.
So, it's the behavior that staff need to know how to name. Because once we name it, we then have to attend to it. We can't ignore it. So, I think that's key.
I think we need immediate interventions for aggressive behavior. We need protocols. If a staff, say, in a primary practice setting has a patient that yells at them or threatens them, there needs to be an immediate protocol that's followed and the provider is involved in that.
And we let providers off the hook to a large extent. But they are key in mitigating this risk because they hold the power. And sometimes, people, patients, visitors feel like they can yell at the peons. But they're not going to behave the same when we pull in a provider, or we pull in other leaders into the intervention or the confrontation with the patient.
I think simple things, we need to communicate risk after we've assessed it. We need to use medication in inpatient settings and Eds and we're not. We are using them when the crisis is happening or has happened.
We need to be proactive in our use of the only tool that we have in healthcare that can really effectively mitigate this risk. So, patients that are anxious, patients that are agitated, patients that are annoyed or threatening, we need to use medication in the inpatient side for that. I think other keys, we can have behavioral health rapid response teams, which probably will take a whole other podcast to talk about. But I'm going to throw that out there.
And then I think a key here is the use of debriefing. A lot of organizations claim to be on this high reliability journey. But one of the key components of high reliability is looking at every single defect and every single failure and figuring out what happened, how it happened, what needs to change, and what are we going to do now to manage either the patient or the situation.
We are not good at being transparent in healthcare. We absolutely must start talking about these events and debriefing them for multiple reasons. One, it gives staff a learning opportunity, wonderful learning opportunity. Secondly, we can identify needed change in processes or the environment or a policy or procedure, so that we can get better at managing the types of behaviors that we're seeing out of patients.
So that is really a key strategy that can help, if we're willing to be transparent enough. Because a lot of organizations are not. And a lot of people are not. And a lot of healthcare workers are not. So, they have-- again, that's a culture shift. They're going to have to get comfortable with talking about events that happen and being critical, critically analyzing the event to determine what needs to change as a result.
Joan, I can go on and on. We need to engage the community. A lot of organizations don't want the word out in the community that healthcare has the highest rate of workplace violence of any industry. That's a word the community needs to know because the community is bringing it in.
We've talked about having signage and having code of conduct that we can hand patients when they come in or when they're admitted, so that they understand, what's the expectation in this environment and how am I supposed to behave? And what are the consequences if I don't behave?
So where can you go, and curse, and threaten, and point fingers, and even physically harm people without having consequences? And really, we think about healthcare because people walk in and don't believe that there are consequences for their behavior because we rarely provide them unless it's a devastating event. So, these small day-by-day, minute-by-minute actions by people that come in that we're servicing do not get attended to. Need I go on, Joan?
JOAN PORCARO: Well, I think you touched on something really important and it's sort of a continuum, so those microaggressions, if you don't attend to them, I know you mentioned earlier, the pre-attack symptoms of violence, recognizing them, and training staff to have a response plan. And I want to go back now to the staff for a moment.
Supporting staff in working in the ER, there was like, well, you work in the ER, of course, you're going to get spit at. Of course, somebody is going to yell at you. And so, we've normalized it in many instances. And so, staff feel a little bit maybe uncomfortable about what should they talk about. But when we have situations, how best can we support those staff who've been harmed and are being harmed with even that level of bullying or microaggressions?
MONICA COOKE: Yeah, I've met with a lot of ER nurses. And I've met with a lot of victims of workplace violence. And they say things like, oh, it's not a good day if I haven't been spit at or somebody didn't yell at me. They feel like their job's not done, that they have to stick around for more hours to get that to happen.
And that's a sad testimony to the work that we do. That is not the work we do. And when staff are harmed, sometimes, they don't even know they're harmed. And then what happens is that they just begin to behave very differently.
And we're also not good at picking up on staff that are traumatized from these abuses either. The burnout, the frustration, the inability to concentrate on the job or are easily distracted, all those things, which, of course, affect care. So, I think in terms of staff that are harmed at any level, verbal, physical, we don't know what harms a person.
We don't know what we could say to somebody that opens up their box and gets them retraumatized, so to speak. So, we need to always debrief these events with staff. And that's done better in some places than others.
But if they don't need emergency medical care and they're still there, there needs to be an immediate debriefing of these events. And in order for that to happen, you got to have people at the manager level that buy into this. Leaders can institute these cultures.
But if we don't have people buying in at the unit level where they see it every day and where staff come to them and tell them that these things are happening, where they can then respond and say, oh my gosh, we need to do something with this patient right now and let's debrief the situation, staff are going to just throw it by the wayside. They're not going to be invested in it because there's not a culture of doing it. So, in the initial phases of developing that, we need to get staff to understand that the manager at that level is going to ensure that we are paying attention to these events the way that we should be.
I think the other thing in terms of staff that are harmed, a lot of organizations have EAPs. And most staff don't utilize EAPs. It's really not in their comfort zone to do that. They're not people that they know.
There's still a lot of stigma and bias around mental health and getting care for yourself and care for the caregiver. And so I think having a peer support program is what's being done in many organizations around the country, where staff that have been harmed and particularly nurses that have been in the field for a long time, the ED or other settings, where they've experienced it repeatedly can then be available to help support that person.
And the staff person that's been a victim can understand what that program is and that we have people here, we have a group of 10 people that have been through healthcare violence and are here for you to talk to or for you to engage with to see if they can help you minimize the impact of this on your life, basically. And that is a very, very good program staff report that have been involved in those programs, that it really is quite helpful and much more so than EAPs.
JOAN PORCARO: Thank you. Thank you very much. Now, we're coming to a close to our session. And if you had just the opportunity to only share one thing with the audience today, what one thing would you want to close our session out with?
MONICA COOKE: Oh, good question, Joan. There's so many things and so little time. I think the one thing is that leaders in healthcare need to really embrace the concept of shifting this culture and begin to take baby steps, if that's all they can take to do it. Staff need to see that they are cared for, that people respect what they're doing, and that they're not going to tolerate them being abused by the people that they are caring for.
And I think how that can happen is by leaders really getting educated on this issue and understanding that if they do not begin to turn this around, that they won't have staff, and they won't be able to provide good care for patients because staff are not going to want to work with patients that are abusive. So those patients are just not going to get the care that they deserve.
So I think that I would just tout for leaders to really listen to what staff are saying and to begin to integrate some strategies into the organization that will help minimize this risk other than bringing in more security guards, because there are things that can be done at the unit level, at the basic direct care staff level-- everything from establishing protocols to having adequate medication orders for patients, engaging providers in these efforts to talk to patients instead of the nurse having to go in and confront the patient.
Again, I don't think that it's one thing. But I do think that it starts at the leadership level. And it starts at the investment level. And it may mean more resources. And that's why we need them involved.
JOAN PORCARO: Thank you. Thank you very much. I mentioned, we're at the close of this session. And again, I want to extend my appreciation to you, Monica, for joining us on this topic, this very important topic today.
MONICA COOKE: Thank you, Joan. It's been an absolute pleasure. And we can always talk more anytime you want; you just give me a ring.
JOAN PORCARO: All right, well, thank you. And a big thank you to our audience for listening in to WTW Vital Signs podcast series. Thank you.
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