Tim Lahey

In this episode Dr. Tim Lahey describes how he helped his institution curb violence against health care professionals.

Here’s an open access copy of Tim’s article describing his work on combating workplace violence:  

https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.13355

Transcript

0:00

Before we begin, Please note that the names and specific details of the clinical cases we discuss in this episode and in all of our episodes have been altered to protect patient confidentiality.Now on with the episode.Welcome to this episode of Bioethics for the People, the most popular podcast on the planet according to Grandma Nancy.

0:21

I'm joined by my Co host Doctor Tyler Gibb, who if he weren't here recording right now, would probably be golfing.And I'm joined by my Co host Doctor Devin Stahl, who dutifully completes the same 5 New York Times puzzles every day.All right, Tyler, we have another exciting success story to share today.

0:49

Great.These success stories are so much fun because they're such different kind of perspectives of what benefit clinical ethicists can have on a lot of different people in the healthcare settings, so.Absolutely.And I don't have to sit in silence for an hour after the podcast like I had maybe last season where I was just in existential.

1:12

Like that was the hardest thing I've ever heard.This is more like great.We are such great people doing great work.Yeah, so so far I've been taking a lot of notes about like ideas or projects or like tweaks that I want to incorporate into my practice.

1:29

So I think it's been really helpful.So today we've got a a repeat customer, a repeat guest on the podcast.So, Tim, do you want to introduce yourself again?Well, thanks for having me on the podcast again.It's, it was a pleasure the first time and, and also since I think I was a contributor to doom and gloom my last time through.

1:49

I'm happy to finally show the other side.So I'm Tim Leahy.I am the director of ethics and an infectious diseases physician at the University of Vermont Medical Center in Burlington, Vt.Great, Tim.So what's the entry into your success story?

2:05

Is it a case?Is it a policy?Is it some education before you launch into the of course the success?How did it start?This success starts with a failure, which exemplified a pattern of failures that our institution was experiencing having to do with violence.

2:22

We had a young nurse who was a couple years out of training who was taking care of vulnerable patient who suffered from a major mental illness and was hospitalized for for a life threatening medical condition.

2:38

And then what felt like a fairly routine moment of care, she was leaning over the bed to adjust something on the the patient and IV the patient took a swing at her and fractured her jaw.Her her perception was that this sort of came out of the blue.

2:59

But as we, the institution dug into what had happened, there have been some signs that this patient had a pattern of violent behavior previously.And the more we heard about this case, the more we heard from the nurses on that floor and then in other units and then other forms of clinicians that man, they were facing a lot of violence in their clinical practice more than before.

3:26

And to distressing disagrees.And and so that sort of caused us to embark on an institution wide response to the problem of violence directed at healthcare workers.How long ago did this happen that.

3:42

Particular catalyzing event was four years ago.OK.You know, and I think many institutions have experienced rising rates of violence for several years, actually rates that were rising before the pandemic and then took a steeper increase during the pandemic.

4:01

And and and so there is that kind of sense of this was a catalyst because it was so bad, but certainly part of a pattern.For some people, this will be old news, still alarming, but.But they have heard of this.But some people might be shocked that healthcare providers are routinely hit or hurt by patients.

4:20

Do you know what the rates of that are?You know, it, it, it, it is a little bit hard to capture with perfect accuracy because we know that violence in healthcare settings is underreported.And so, you know, I think we know, for instance, overall rates of employee injuries in healthcare settings are on the order of 20 times higher than in other industries on average.

4:49

Then the, the, the rates are really quite differently distributed in different locations.You know, so for instance, psychiatric hospitals and inpatient hospitals see a lot more violence directed at healthcare workers than say outpatient primary care clinics.

5:06

Or different healthcare workers will face different rates of violence.Nurses overwhelmingly experience the bulk of violence, whereas physicians and other healthcare workers just sort of drop into the room more episodically during the day, experience far less.

5:25

So the, the numbers are sort of tough and, and I suspect all of our numbers are underestimates because a reasonable number of times people will have one of these tough experiences of, of being verbally abused or being physically threatened or being actually hurt that are not reported because they they may view it as part of their routine clinical practice.

5:48

Yeah, and, and do you think the rates of nurses is just because they have more interactions with patients?Or do you think there's something about nursing itself it's more intimate or it can't be that people don't like their nurses as much 'cause all the data I've seen is that people really like nurses.

6:04

So what is it about nursing that sort of opens people up to that kind of violence?It is an interesting contrast to the fact that nurses are among the most respected groups in our society.So why would we, why would our members of our society also be hitting them?You know, I, I think it has to do with two things that that you pointed to. 1 is just the frequency of contact.

6:24

Nurses have many more hours in the day with the patients, particularly inpatient nurses.And so naturally just their, their degree of exposure can be greater.I do think, however, that there are some other social dynamics that play a role.Power dynamics is, is a piece of it.

6:41

I think, you know, those of us in healthcare certainly will recognize that people will treat nurses differently than they treat physicians in many different ways.Perhaps physicians are treated with a different level of respect, whether or not they deserve it.And so I, I wonder if that maybe stays the hand of somebody who might be otherwise a little disinhibited.

7:02

And then I also wonder about gender dynamics.You know, while increasingly equal numbers of men and women are in position roles, nursing is still predominantly a female role.And women experience more violence directed at them than men do.

7:20

So I I wonder if it's some mixture of all of those.Yeah.Well, so the incident you raised, even if we might be somewhat familiar with it, it sounds like this nurse was really hurt by this patient.And so it sort of was the catalyst to a bigger conversation.

7:37

You can imagine that there's a, a, a tough mixture of challenges in there.You know, of course, anybody confronting violence has has to deal with whatever physical injury happens and and then of course, the other versions of trauma that might happen.

7:55

I do think it's worth thinking about how it's a special kind of of experience of, of violence to do it when trying to minister to somebody in one's workplace.And, and the way that that can have, can bring in that, you know, this is very different, for instance, from, say, the experience of trauma in a war where one expects for conflict to be there and maybe sort of showed up ready for that.

8:26

Whereas this nurse, like many healthcare workers, described being completely shocked that suddenly this person who she thought she was in a therapeutic relationship with would, would strike out at her.I, I think also there is this conflict between our expectations of ourselves.

8:43

How much are we supposed to sort of subordinate our own needs in order to take care of others with processing this trauma?You know, naturally, if somebody's going to threaten me at my first response might be to protect myself in some way to get away or do it.But if I'm trying to, you know, sort of put that patient's needs above my fatigue or other needs, might I be a little bit less likely to protect myself?

9:07

And might that compound some of the sense of trauma of that experience?Yeah, 'cause it does seem like it's different if I'm walking down the street minding my own business and get assaulted.And part of that is just like wrong place, wrong time, like I'm minding my own business.Like it's just kind of the the randomness of that type of action.

9:24

But if I'm engaged in the thing where I'm doing something selfless and trying to help somebody, and then because of that interaction I'm the victim of violence, it feels like another layer of assault or harm.Feels to me like it's kind of in a similar space to intermittent partner violence, where violence is is bad to experience no matter what.

9:46

But if it's the person that's supposed to care for you, I think that that gets particularly complicated and it and it naturally leads to questions about is this relationship good for me?What does it mean if this, if I don't have this relationship in my life?And I think there are some interesting parallels to the experience of healthcare workers who have had to go through violence and the questioning they do about, well, can I still come back to work?

10:10

Do I feel safe to do that?Am I has this hurt my passion to, to help with people?Is it OK for me to say that I need help at work?Are other people's going to say, oh, you're just supposed to buck up and deal with it?It's a very complicated way of thinking, and I think it certainly has the risk of compounding healthcare worker burnout, the problem of nursing attrition, which is huge at many medical centers, a really complicated problem.

10:39

Yeah, and one that I wouldn't necessarily think is like the job of the ethicist to fix.How did you get contacted?Like how did you get involved in the case?Yeah, great question.You know, it turns out that we our door into this conversation had to do with the question of professional obligations.

10:57

You know, if a patient who has exhibited a pattern of threatening or fully assaultive behavior still needs a given form of clinical care, are we obligated to still provide that clinical care?Or is it OK to step back and consider withdrawing certain forms of clinical care in response to that behavior?

11:18

So that was the the door that I had.You know, ordinarily when when violence happens in a healthcare space, you call security.You don't, you don't say where's the Ephesus don't fix this.I am uniquely unhelpful in those types of situations.Yeah.

11:34

Yeah.So I, I think it was an absolutely a post hoc response to that experience of, of violence that as the team was taking care of the affected nurse, they were seeing pattern of repeated behavior and starting to feel out with their institutional and personal obligations to that patient.

11:56

And, and honestly, we, we were getting asked that question repeatedly with many cases.And I think it was that pattern of repeated consults and, and just how impactful these cases were on our healthcare workers that led us to implement a, a, a bigger response.

12:14

And that's, that seems like a tough ethics question to me because on the surface of it, any, most any other profession, if your client hit you, there would be no question that you would not be obligated to serve them anymore.But we have a different sense in health care because the reasons which people might become violent might have to do with the very thing that brings them into the hospital, right?

12:38

Or regardless they are sick and in desperate need, like they wouldn't be in the hospital unless they had to be.So there's a different kind of sense of like what we owe them.But even from like a, a legal perspective, if I'm a public defender assigned to a client that has a constitutional right to an attorney and dude cold cocks me, like I, I can say I'm no longer this guy's attorney, right?

13:03

So there are really different duties based upon the roles.But the healthcare worker role is, I think, unique in that way, in a way that I, I can't, I can't even imagine and I can't, I can't envision a different profession that would have that same sort of hesitancy of is it OK if I don't engage any further with this individual?

13:23

I, I, I think those are great, great reasons why this is so complicated.And, and I think just a layer in another dynamic that, that, that still further complicates it is patient centered care that I think we've had this rolling conversation over the last, you know, 1020 years about redressing some of the paternalism or, or I'm on this campaign to, to invert those letters and call it parentalism.

13:53

So it's not sexist that, that we, that we're trying to fix the parentalism of yesteryear and the kind of doctor knows best approach, but instead to sort of partner with our patients and to deliver the sort of healthcare that they most want.

14:09

And I think that good trend toward better responsiveness to individualized patient needs is, is I think another thing that puts people back on their heels.And so the, the reflex to say, no, you can't do that.The rules are, are a little bit atrophied.

14:26

I think actually in, in what is overall a good way, you know, that we may have been a little too willing historically or arguably presently just say my house, my rules and this is how you're going to get your care.And I think we're still working through how to how to do better as a system to meet each person's needs where they best need them met.

14:49

But but yeah, it's it's tough to transition from that conversation to, wow, I just got hit, what am I going to do?So what are we going to do?So I'll try to tell you a story of an accumulation of interventions that started with that sequence of ethics consultations and A and a team we brought together to address them and ended up becoming an institution wide response that ultimately was out of ethics control.

15:21

You know that we we pass it on to people who are better positioned to do it, but I think helped help that come to pass.So in response to that pattern of what we sort of generically called unsafe patient behavior, we formed a task group task force to deal with the question of one, what sort of policy language might we put to these balancing acts of of about professional obligations toward patients who are threatening or violent and, and really just sort of use that as a platform to do a needs assessment for what else beyond a policy needs to be done.

16:00

And I say it that way because I think a lot of us put time into creating policy documents with full knowledge that they can grow dust on a shelf that that, you know, sometimes a little, you know, word file is not the answer to the world's problems.

16:18

But we did feel like the bringing together the task force of of the right stakeholders to work on that first was sort of a, a low risk team forming process that would help us move in the direction of additional interventions that might be a little bit more tangible.

16:35

And so the the first piece was trying to get a stakeholder group just like we would with any policy creation, making sure, for instance, that we had outstanding representation from nurse leaders and nurses who spent a lot of time at the bedside, but all of the, you know, clinician groups that you can imagine from nurses, physicians, social works, chaplaincy and beyond.

17:00

We also wanted to make sure that the partnership with security was intact right up front.And we also built in some representation from facilities because we knew that security is intimately related to facilities concerns like locks and magnetometers and other interventions that the institutions do.

17:23

And we ended up using that group over the course of several months, drafting a document that was partly attempting to frame some of the ethics and tension around the space.Because honestly, I think our discussion on this podcast mimics the conversation we had in that multi stakeholder group where we were essentially focusing on the ethical values that would lead you not to inhibit care and response to violence.

17:52

All the reasons why we expect our patients to be nice to us and then tolerate it if they're not.And so we wanted to make sure we first developed an ethical vocabulary around some of the reasons that might move us to create boundaries.And that was, I think, useful for the policy document, but but also has been informative for subsequent institution wide and and even local conversations about our response to violence.

18:21

Because we knew that if we were going to make some boundaries or sometimes say, say, that that form of care was going to be withdrawn in response to a given behavior, that that we wanted to be able to justify it and make sure it was clear to our neighbors that that wasn't some draconian response, but actually something anybody would do.

18:40

This all sounds like good process, right?And and I'm glad to know that Tyler and I had some good instincts on the kinds of considerations you I feel reassured.Yeah.I mean, this, this issue is it, it happens across the country, right?It's not unique to your institution or our institution.

18:57

I think part of it is an overall maybe erosion in the trust or the respect of the healthcare professions.I think the pandemic had a lot to do with that, but I don't think that it was only because of the pandemic.I think that that level of discourtesy and disrespect and distrust was well on its way developing or progressing, and the pandemic kind of tipped it over.

19:19

We struggle a lot with this idea of professional violence that is tolerable versus intolerable, and particularly because, like you said, the people who are often committing the ones the violence are the ones who need our care the most.So it is this catch 22 that has this emotional slash professional slash like personal identity overlay to it.

19:42

That that feels like a really important point to emphasize that it's much more likely that somebody who behaves violently toward a healthcare worker is experiencing a mental health illness.It's more likely that they have substance use disorder, for example.And I do think we need to grapple with our contribution.

20:03

To the emergence of violence in the healthcare space that that there is kind of a natural presumption that anybody who strikes a healthcare worker fully created the violence themselves.And, and I think we can recognize that it is always wrong to hit or threaten a healthcare worker while examining some of the contextual features that may have made that violence more likely.

20:28

So one of the things that we tried to sensitize our or, or sort of to develop within our stakeholder group and then sensitize our institution to were some of the ethical justifications for making boundaries.For instance, we not only have an obligation to deliver the standard of care to everybody no matter what, but there are also institutional obligations to protect workforce safety.

20:53

And so how do we satisfy those obligations at the same time?Or if we know that the experience of violence is not equitably distributed and leads to, for instance, greater experience of harm on the part of nurses, then how would we make sure that there's not an unjust response at the institutional level to the experience of violence?

21:23

You can imagine that if you had maybe just to be a little bit stereotypical about it, if you had wealthy, well respected physician leadership of an institution who decides to Pooh, Pooh the nursing experience of violence, you could imagine how that exactly perpetuate some of the maladaptive power dynamics that we've seen in healthcare.

21:47

And whereas if we say, well, wait a second, we're noticing that not only is it our nurses who are experiencing more violence, but it's our nurses of color who are experiencing violence.Then the the, the healthiness of our response to that violence is partly about protecting our our institution from nursing attrition and from nursing burnout and supporting the well-being of our staff and also rather intimately connected to our DEI efforts to make sure that everybody who works here feels like they belong.

22:17

So that I think was helpful to us.And then of course many of our clinicians were really helpful in characterizing clinical situations in which they would or would not be comfortable making some boundaries.So for instance, if a clinician is trying to perform life saving therapy on a patient, the example would be in an intoxicated patient who's just been brought to the emergency room after a motor vehicle accident, was sort of lashing out and disinhibited because of their intoxication, but also has, say, a pneumothorax from a rib fracture.

22:55

You know, that that person is their life is in danger and we really want to save their life.And we'd hate to say, hey, buddy, why don't you get a better attitude and come back to us at risk?You know what I mean?I mean, that's the last story nobody wants to be part of.

23:11

And so, so we started talking about, well, in that case, we might be more aggressive in our use of say, sedation to address that person's pain and perhaps to help them calm down.Or maybe to if there were an antidote of the substance that intoxicated them, help them reduce their disinhibition while also making sure we never flinch from providing life saving care.

23:36

On the other hand, if the same level of violence were directed at a phlebotomist who's drawing a routine yearly cholesterol for somebody, well, come on, the stakes are much higher.We could certainly say, hey, come on back when you're in a better mood.

23:52

We'd love to care for your cardiovascular disease by drawing this blood, but it can wait.Yeah.We, we've run into a similar type of conundrum where we have patients who are exhibiting problematic behaviors and there's no question that the behaviors are problematic.

24:10

They're either verbally or physically confrontational or aggressive.But the patient is a dialysis patient and the outpatient dialysis clinic has a very low threshold of what kind of shenanigans they're willing to tolerate.And they're very quick to say, Nope, you're done, you're cut off and leaving these patients who sometime, you know, there's mental health concerns there, there are other things going on in their life that may help to give some context to the behavior.

24:36

But then they are reduced to dialysis through the emergency room, hopefully, if that's an option or sometimes not.But yeah, it's contextualizing the severity of the behavior with some sort of plausible explanation for the behavior makes us a lot, I think, more complicated.

24:53

I do think the receipt of chronically indicated, potentially life saving care like dialysis or cancer chemotherapy is another example, can make these situations even more complicated.We will feel sort of an obligation to deliver the right frequency of dialysis despite outbursts of violence that happened or the right dose of chemotherapy.

25:17

We want to deliver the standard of care.And so I think a lot of our conversations started focusing on what degree or amount of responsibility can the patient hold for a health outcome that's maybe not suboptimal in response to their behavior.

25:37

I think we can think of it in the space of patients who miss appointments or do not adhere to medications that we expect, of course, that they own some responsibility, assuming they have the, you know, cognitive and logistical capacity to to hold their up their end of the bargain.

25:53

We expect people to shoulder the responsibility of health outcomes that happen from non adherence to care.We give them the dignity of risk in other hands.And, and so part of this was identifying what piece of, of the perhaps temporary withdrawal of medical care might be understood as the patient's responsibility that they have capacity to shoulder.

26:17

Is that ever tricky?I mean, I imagine I can imagine patients who, you know, the capacity is waning.They, you know, it's, it's hard to pinpoint exactly like how how culpable they are for their actions in any given moment.Absolutely agree.And I think maybe that gets to a piece of our work that went beyond policy.

26:37

You know, that, that our policy essentially gave people a language such as we've been discussing to, to weigh the pros and cons of either continued provision of, of life saving care despite violence.

26:52

With some, you know, protective measures put in place like security presence versus temporary withdrawal until the patient can and improve their behavior, along with other preventive things that we'll get back to.But that we realized that there were so many contextual features of each story that it was impossible to kind of, you know, prefigure in advance what, what to do in a given case.

27:18

And that that partly our clinicians were doing this on a day-to-day basis and appreciated sort of the, the wording to be able to deliberate more effectively, but also needed to be able to call more effectively on leadership responses.And that the experience of our clinicians was huge variability in what happened.

27:38

You know, that some nurses, for instance, were told by their nurse supervisors, this is part of the job, just suck it up and deal with it.This is part of being a nurse.Whereas other nurses got really quite different, I would say more adaptive responses of, wow, that's really difficult.

27:53

Let me make sure you have connection to the support at work.You let us know if you're willing to care for this person.Again, if you prefer not, we're going to put these measures into place.You know, why variation?And so norming what best institutional practices are, I think was important.And then we found that for the hardest cases where each team with or without unit support really still felt they were not sure how to strike the right balance in a given patient's care, we wanted to have an institutional resource to call upon.

28:23

And so we were able to catalyze with a collaboration between ethics and medical psychology and one of our associate chief medical officers who ended up being sort of the motive forces in that initial policy and needs assessment work.

28:39

We were able to successfully advocated our institution for funding for a behavior response team that essentially would drop into these cases led by a medical psychologist, but bringing together whatever stakeholders were appropriate to that case to essentially adjudicate what the particulars of that situation would dictate as a plan ahead.

29:03

And as you can imagine, kind of analogous to an ethics consultation, this was partly just about getting the different viewpoints in the room and syncing up the different professions despite different experiences.But also the medical psychologists had expertise in not only management of some of the mental health issues that might be contributing to the situation, but also in directly intervening with the patient so that some of those drivers might help, and connecting any affected clinicians to needed psychological care.

29:43

So I've seen in some hospitals like a.It's almost like a call overhead call, like a Code Blue for a violent patient, like a Code Gray, I think is the one that I'm most familiar with.Is that the type of like activation that would, you know, trigger the response from this team?

30:02

You know, this was a wholly separate pathway.We had an emergent, you know, get security of the room right away.Code 8, we call it, that was already running, but the hope was that this behavior response team would not only sort of deal with the the clean up that happens after that blow up happens and sort of decision making about, well, what now do we do to deescalate that conflict or, or make decisions about boundaries.

30:37

But that might even be enlisted when there's a concern about the future likelihood of a code aid happening and how could we kind of prevent it from happening.So this was less emergent, but both preventive and responsive.Interesting.It seems almost like I've heard of some like local police departments have social workers or mentor mental health professionals respond to certain type of mental health calls as the, you know, mental health first responder.

31:03

But it sounds kind of similar to that, having somebody with particular training maybe in trauma informed care or some of the psychological issues, but also like somebody who's cool in a in an emergency and can talk through hot activated people.

31:20

Absolutely.And you know, we we're very fortunate that our security personnel are quite skilled and de escalation and really good at using force as a absolute last result resort.But but yeah, having a multidisciplinary sort of slower acting, including preventive approach has been critical.

31:42

So that was really helpful in it and it did sort of, you know, to your point, Devin, it sort of changed the role of the ethicist a little bit because we went from sort of naming the pros and cons of different ethical responses to advocating for systems responses, you know, assisting in the drafting of the the ultimately successful proposal that added FTE to medical psychology and got somebody to catalyze this behavior response team.

32:10

Oh, and I this is, this is so crucial.So you can bring people together to talk about the issue.You can write a new policy and that's kind of part of most people's work.And they think of it as like the kind of the volunteer work to improve the hospital.But you can't have a responsive team that reviews cases, acts in current cases, and that's just their volunteer time.

32:28

You can do that, but that's asking a lot of people who have, you know, a lot of work to do.So you got them paid to do it.You got them time within their their work day to actually do that thing.That's huge.It was I was really proud of that success that, you know, I was part of, but I don't want to claim sole credit.

32:48

That was, it was a team that made this happen.And, and, and I think I do want to call out that that required a really sensitive tuned in senior leadership team.And so we were very fortunate to have a chief medical officer and a chief nursing officer who fully understood the impact of violence on their healthcare workforce and we're troubled by it and wanted to visibly make responses.

33:11

And and you can imagine that partly that was because they are outstanding leaders and also those were sensibilities that we had worked to cultivate so that they were regularly receiving the data on the number of employees going for help after injuries and etcetera.

33:29

What do you think that your role and background as a clinical ethicist added to the team or to the project?Like what was the value add of you being there?I think there were.There were three things.One was that values laden language was really important in part because different people, different stakeholders have really diametrically opposed instinctive responses to these situations.

33:55

Some said you do whatever the patient needs, Others said that's not safe, I'm not going to do that.And they're both really reasonable but knee jerk reactions.So I think it was helpful to help everybody have more balance responses and and maybe just sort of move from the the domain of emotion into that thinking about what is a good boundary.

34:19

I think the other piece is that it was important to think about not just ethical speech, but ethical action.We really wanted to make sure that since this was a recurring plan, this was clearly a systems issue that we, you know, the ethics maybe was not perfectly poised to say what the nature of the intervention was.

34:40

We're not, you know, experts in managing mental illness, but saying there is a contribution to this of mental illness or, or this needs to be multidisciplinary cause security needs to be partnering with these specialties.I think was a piece of, of our perspective, I think partly from a clinical ethics perspective, seeing the recurrent pattern, but I think also from an organizational perspective and seeing the wide impact of it.

35:07

I think the third piece of our contribution to the the success, such as it was, was trying to tell the stories of, of the impact that we were not only hearing from a wide array of stakeholders about the many ways this was impacting people.

35:26

Not just the person who got hit, but the concerns people had about sort of withdrawal from the therapeutic alliance and subsequent provision of kind of half assed healthcare or whether certain patients whose behavior were seen as threatening were actually just being confronted with violence.

35:48

You know, as we dug into this, we kept on hearing lots of different versions of this story that complicated the balancing act.And I think our ability to be in the room both with the frontline stakeholders and with the senior leaders and to say, hey, this is a good response.

36:06

But for example, there are some equity issues that are that this case is calling up that we need to make sure we have a good response to.I think was really helpful because it, I think it helped generate institutional momentum for a multi modality response that there was no single fix.

36:25

You know, that we needed this team, but there needed to be other responses.And I think that was helpful too to tell those stories.I did want to emphasize the role of bias and, and diversity in some of our deliberations because it led to some unexpected successes from the behavior response team.

36:44

So, you know, by design, we were planning this team to be an aid to our healthcare workers who were dealing with difficult cases.And, and I and I think what we definitely heard from some of our clinicians, what they call difficult patients, you know, it's a problematic phrase, but I understand why people use it.

37:01

I've heard much worse.I've heard much worse phrases used.That's right, difficulties is a.Is a much more.Powerful word.So what we found as the behavioral response team launched Burst as a a three unit pilot and then ultimately across the entire inpatient institution was that there were times when the healthcare team had clearly increased the risk that there was an outburst.

37:30

We didn't want to say that they were to blame for violence because of course our at least our patients with capacity own responsibility for this.But but there were times when we could see that healthcare speech or institutional policies were perhaps flaming the fans of a potential conflict and and that there were some real preventive opportunities that not uncommonly intersected with our diversity, equity and inclusion efforts or with our efforts to combat healthcare worker bias.

38:03

So to give you an example there, we had a a patient who was from the sub-saharan African country who was a large man who was understood by the healthcare worker to be behaving in a threatening fashion.

38:20

When we, our behavioral response team, sort of engaged in that case, it turned out that that patient spoke a language for which a local interpreter was not available 3D and investments in video interpretation had been a little slipshod so that the patient was not being fully understood when he was talking about unaddressed pain.

38:45

And he began to quite frustratedly talk about his UN addressed pain with a raised voice in a fashion that once those facts became clear, you'd say, well, gosh, I can imagine myself doing that.But since what he was saying was not well understood, the nurses at that time who came from different races started perceiving him as more threatening than I think he actually was.

39:13

And it was an understandable reaction.This was a a big man speaking in a raised voice to a smaller woman.But also this was a healthcare worker facing a patient whose names were not needed, who is quite appropriately advocating for needed care.

39:29

It was incredibly helpful for us to realize that there was a little bit of a pattern of events like that of either racial or language or other differences.A similar perception of threat came from a a patient who could not hear a worker who was speaking perfectly fluent English with a bit of an accent.

39:50

And the worker thought that they were being discriminated against in a somewhat threatening way because of their accent.But it was the worker saying, they were repeatedly saying, I cannot read your lips, but if you'd wear one of those masks, I can.I can understand you and I want to understand you.

40:06

And so coming into these situations that were coming to a head might have gone to violence.And helping healthcare workers see their contribution to it and to modulate it was helpful.And, and I think we were lucky in that, you know, I think if we had pitched the team to be, hey, we're the people that you call so that you can identify your contribution to a violent situation and fix it, nobody would call, right?

40:32

But we were called to help.And largely we were helping make boundaries with people who are just being violent.But we did identify as a bonus these cases where we could help our people have better de escalation training.That's a that seems like, yeah, the the other side maybe that I wouldn't have immediately thought about.So super helpful to talk to people and see patterns.

40:50

So have you been able to see a decrease in incidents of violence or at least people are more happy with the response to violence, sort of what has been the success on the backside?Yeah.So Fast forward, this effort has a nucleated process that other institutional leaders have properly taken over from the small ragtag team that started it.

41:12

And so the there had been other responses to violence across the institutions, for instance in our ER and they were sort of happening in little pockets without much mutual awareness.So we a great thing that our security and facilities leaders did was brought together a task force to improve mutual awareness of all of those responses from the behavior response team that we help create to some of those the DEI output of that to what they were security was doing in the ER and beyond.

41:45

And fortunately, that multi modality response has been followed by a 3540% depending on the month reduction in the average number of code 8 calls, the average number of employee outreach for responses to physical violence experiences in healthcare.

42:06

So we've seen a lot of a lot of improvement.And, and I think the improvement goes beyond the numbers.You know, I, as you pointed out, Tyler, I suspect that some of this was due to forces outside the institution, you know, election season stress I'm sure was contributing or some of the pandemic stress.

42:25

And, you know, our institution can't fix that.But I do think that not only can we do a better job with our responses to violence when it washes up on our shores, I think also we've been able to show people that the institution is taking meaningful responses and that we do care.

42:41

You know, that there is somebody who has your back from somebody to care for you if you're dealing with PTSD from the experience to somebody you can call if you're just worried about such a thing happening.And I think that has been helpful for people who are not directly involved in the response to feel cared for by their Co workers.

43:00

And then also, I think for those of us dismayed by healthcare workers, facing violence gave us a sense of agency 'cause there really were things that we could do to make a difference.Yeah, that seems so helpful because in cases that I've tangentially been aware of or been involved in, that's my biggest, I don't know, the struggle I guess is like I'm like, I can empathize and I can listen, but I don't have any solutions.

43:25

But having not only just resources but a team seems like such a great thing to be able to offer to people in in teams in these situations.Yeah, I bet people who are listening are going to really be taking notes on this podcast.

43:40

I mean, this is something every hospital deals with.And a 30 to 40% reduction in violent acts is is huge.That's really big.Yeah, I think it's it's really a huge success both for the people like medical psychology helping defuse some of these situations before they come to a head to the great de escalation work that our security and now an increasing percentage of our nursing leadership force are engaging in.

44:06

We, we also got some senior leadership support for enhanced de escalation education.It's, it's, it's taken a lot of work for people to deal with this different manifestation of illness, but I think it's been gratifying for them to, to see the results of their intervention.

44:23

And, and importantly, you know, you don't call ethics when somebody's being violent.I don't have training in that.You also don't necessarily call ethics to de escalate the violent event.But I think it was helpful for us to help name the nature of the problem and to bring together the group to have the solution 'cause they're out there and and we work with really skilled people who can implement them.

44:45

Great.Well, thank you so much, Tim, for sharing that story and that success.Thanks for hosting, I'm really glad you guys are helping change the dialogue.I think we all could use a little sunshine on our day, so thank you.Awesome.Great.Thank you, Tim.Thanks for tuning into this episode of Bioethics for the People.

45:03

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45:22

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