Bill Klaproth (Host): This is a special episode of Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership, recorded live at the AONL 2024 Conference. I'm Bill Klaproth, as we talk about Protecting Our Nurses: Leveraging Internal Experts to Prevent Assaults. And with me is Erin Marinchak, Senior Director of Clinical Practice, and Loni Francis, Director of Behavioral Health Services, both from Reading Hospital Tower Health. Erin, welcome.

Erin Marinchak: Thank you.

Host: And Loni, welcome.

Loni Francis: Thank you.

Host: It's great to have you both here. So, assaults on Nursing, as we know, this is a big problem. So, tell us about your session and why you decided to address this. Loni, let's start with you.

Loni Francis: So, at the time, it was about 2021, Erin and I started working on this project. We're post-pandemic, or still in the pandemic, actually, and there's significant increase in assaults on Nursing, as well as severity. We started seeing our nurses being choked, punched, tackled to the floor, so a little bit more than maybe a scratch or something that had been actually what we found to be tolerable in previous years. So, we really felt this was a call to action for us. So, that's really what motivated us to get going on this and kind of steer the ship at our flagship hospital to do something differently. And at that time, there was no roadmap. You know, it hadn't been done before. And so, we were trying to build that bridge as we were crossing it.

Host: Yeah. So, what was once something that did occur just became really a lot more common through the pandemic, and it's continued on after.

Erin Marinchak: Well said, yes.

Host: And that's why this important issue needs to be addressed. And Loni, you said, there was no road map, so we decided to create one." Erin, what is that road map? Tell us, what are the tactics, initiatives that you did to address this issue?

Erin Marinchak: Right. So, in our session, which is happening later today, we'll be talking about really four years of work. It's been a long journey for us. And what we'll be sharing is just really layer over layer and re-evaluating our data and what worked and what didn't. So, just really hitting the high points.

It all started with a very basic, and I hate to call them basic, because at the time they were huge feats trying to lift off the ground, but any workplace violence program at a hospital is going to start with a policy, and it's going to start with signage, lots of signage, which we were, I thought, a little bit late to adopt in terms of what we knew other health centers were doing, but we had no signage upon walking into our doors of this 700-bed level 1 trauma center to say we don't tolerate violence. And it's a small step, but it sent a message, less so probably to our patients, more so to our staff. That was the beginning to say", We want to let you know we support you." The signage is very basic, but it is public signage stating that our hospital and our health system doesn't tolerate violence.

The policy just kind of outlined some of the steps that we're going to talk about. And then, again, very basic measure was to initiate signage outside the patient doors to say to everybody, "Hey, certainly not labeling this patient in any way, but we're letting you know that they had had a violent episode, and we want to take precautions before walking into their room again." Early on, those were some very basic steps we took.

One of our biggest steps that took the longest was a culture change. We started by evaluating our nurses' definitions of what is violence. Because as you alluded to early in the beginning, it is something that nurses have dealt with for years, years and years and years, probably since the beginning of Nursing. And as we said, it had gotten worse, but it did become over time some part of like what we thought was part of our daily work, something we had to just take on as being nurses. And so, our very first early initiative was definition of, "This is violence." This is you being slapped, kicked, hit, punched, scratched is violence whether the patient intended it or not, whether their cognition was intact or not. And this is something that can in fact be prevented. So, those were some really big early steps. And then, what we did as kind of a phase two was leverage our internal experts to create plans of action, create plans of prevention. And I'm going to turn it over to Loni in one minute to talk about our behavioral health rounding, but we leveraged security, geriatrics, we leveraged our behavioral health nurses. There's a lot of different types of violence out there and our program kind of over time evolved to tackle every one of those.

So, I will tell you, we're going to talk about key takeaways, all of these things chipped away at our violence rates, but it wasn't until we deployed experts to the bedside that we really saw a change in our violence rates. And I'm going to turn it over to Loni to talk about our behavioral health nurses and how they helped significantly turn the corner on our assaults against nurses.

Loni Francis: Thanks, Erin. Erin had mentioned that nurses sort of just think taking it on the chin a little bit is part of the job. And something very interesting that we did initially was go to our practice council, give them multiple scenarios and say, "What do you consider violence? "What we learned from that experience was that if it was a child or adolescent or a geriatric example, they did not consider that violent. So, Erin said the word cognition and whether their cognition was intact, we actually started looking at every single RL solution or incident report that came through and looking at was the patient's cognition intact or not. And that's really where we started to evaluate as well as educate, because there's going to be different interventions depending if the patient's cognition is intact or not. And so, that's why we realized we had to leverage all of these internal experts, because everybody played a role depending on the type of patient.

So, at that time, if we could go back a couple of years ago, everyone was like, "The behavioral health patients, they're attacking everyone." Well, what we were able to glean from all of our incident reports was some internal data which we didn't have. And what that showed at that time was almost 70% of these assaults were coming from geriatric patients who did not have cognition intact. And actually, above the age of 80 and 90 was our highest offender. So, those are very different interventions, then a very small percentage of patients that were behavioral health.

Host: That's really interesting. More so the elderly geriatric patients that were causing the bigger problems.

Erin Marinchak: Correct. It fluctuates month to month, but we do see a significant portion of that pie that is definitely cognition not intact, and many of it is geriatric.

Loni Francis: So, some of the interventions that we used, we had an internal consult team. We actually don't have a behavioral health hospital attached to our hospital, yet we do have some psych social workers and a couple of nurses that work for us. So, we were able to budget neutral, reallocate a couple of FTEs to really focus in on this project.

Even though we knew it wasn't necessarily the behavioral health patient, it was similar interventions as far as how you approach someone, explaining to them what you're going to do. If they weren't ready, coming back later. These things seem so basic and simple, yet everyone was so busy at the time, and they were just rushing to try and complete all of their tasks, that they weren't considering the patient in the bed and the fact that they had some emotional and psychological needs that needed addressed before any physical need could actually be tackled.

Host: Yeah, that's really interesting. Erin, you mentioned something, you said signage, policies, culture change. You mentioned things really started to change when you brought in experts at the bedside. Could you explain that just a little bit more, what that means exactly entails?

Erin Marinchak: Exactly. So, as Loni alluded to, it's important that we did an FTE-neutral approach. Like most health systems during COVID, there was no extra room to add new positions or really to do anything that costs significant additional money. So, we're talking about leveraging internal experts. Our first partnership was with security that we developed a rounding process for our security guards to round on our highest risk patients. That made a little bit of an impact, but was very difficult. Our security guards cannot see the same things in the medical records that we see. And so, when we even talk about go round on the highest risk patients, they're all labeled, they're out there, it's in our EMR, they weren't able to see those patients. We can go into detail more probably in our session about the nuances with that. But when Loni deployed, took those two FTEs, or I think it was 1.8 FTE...

Loni Francis: 1.6 FTEs.

Erin Marinchak: 1.6 FTEs of our behavioral health nurses, took them out to the bedside while simultaneously I was working on the medical record portion of this, the EMR is a very important tool to use in identifying which patients are violent, have violent tendencies, and how to address that, her behavioral health nurses were creating individualized care plans in the record, assessing the patients, their past history of violence and essentially saying, hey, although it can seem very basic, it wasn't very intuitive to our nurses to say things like, "Take two people into the room with you for this patient. Make sure you allow them to decide when and how their care will take place as much as possible during the day. Keep the blinds open. If they were geriatrics, reorient them. These are some of their triggers. These are some of the things to stay away from." And as the nurses were developing their care plans, as I had said myself and a team of maybe more clinically and informatics focused employees, we were building these things in the medical record, what landed out of all of this is hundreds of consults now at the bedside, proactive rounding before a patient acts out. We implemented a violence risk scoring tool so they can see who is predicted to become violent in the next 12 hours. They go to the bedside, they develop a care plan. That care plan flashes up for any nurse, as soon as they open the record to take care of that patient, that care plan pops up. Those were changes that took time. Initially, that care plan was buried in the record that nobody could ever see. You'd had to click on a flag that nobody could even see it. And now, it comes right up with that individualized care plan. And that, at that point, that's when our assaults on Nursing, and most importantly, our injury assaults on Nursing, took a real nosedive in a very positive direction, cut by I would say well more than half. And we just achieved our very first green quarter. We would have never been in the benchmark nationally. And now, we're below that national benchmark for the first time in Reading Hospital history.

Host: Well, congratulations. You guys have done great work. There's no question about that. And thank you for describing all of this in detail on the steps that you took. So Loni, what are the key takeaways for someone listening to this podcast?

Loni Francis: So, Erin had mentioned, you know, really the turning point for this, and we were in a very reactive state at the time. We were flagging patients as violent after they had been violent. And security was rounding, but they didn't know who they were rounding on. So, it was sort of haphazard. And once we deployed those nurses, they guided the security rounding in partnership. They gave them talking points, so very pointed questions to ask the charge nurses or the facilitators as far as who's behaviorally giving you more challenge on your unit and how can we help you rather than just like, "You guys good? Okay, cool. Great." And that's what they were kind of getting. And so, I think the key takeaways here in order to skip four years' worth of work and kind of consolidate what we did and be able to apply it anywhere, whether you're in a small rural hospital or a large health system with a lot more resources is the people closest to the bedside, and that's house supervisors, your chair governance team as far as geriatric resource nurses, anyone that you have in the emergency department or behavioral health areas, security, they all play a part. And you have to give them the tools and the part to play in order to be able to execute this on a higher level.

Host: Everybody has a role.

Loni Francis: Yes.

Host: Yeah. Wow, that's really interesting. Can you tell us a little bit more about the results then as well, Erin?

Erin Marinchak: Yeah. So, one of the things I just wanted to add as far as a key takeaway and then the results is you cannot do enough data dive as it results in workplace violence. It's never enough. We review our violent events weekly. We keep adding data elements. It goes well beyond age of the patient, shift, time of day, whether their cognition was intact or not. These are the things that help really drive and then further define your violence program, your violence prevention program. So, we still do weekly chart reviews. We still adopt. At one point, we had some trends where it was the non-English-speaking patient. Of course, they're going to get upset. That's certainly not a generalization, but it's data kind of pointing towards, are we utilizing interpreters enough? Are we giving patients the time to process what we're doing to them before we do it? So, when I talk about data in addition to assaults and our total assaults dropped by half, our injury assaults on Nursing dropped by even more than

that. And part of that is because we take the time to adjust. Everybody wants to talk about the scariest cases. That is what sticks in their mind. But in reality, the types of violent events happening to nurses on the daily are less publicized. And so, we wanted to say to the staff, "I know you want to talk about the patient with the gun or the patient with gun violence, knife violence," less than 0.02% in our hospital of that types of violence.

Now, I just want to say very briefly, that's a different committee that will work on the safety of our campus and kind of the visitors coming in. We wanted to talk about the vast majority of violent events, which is happening from the patient in the bed to the nurse. And again, when we benchmark through NDNQI, when we talk about our benchmarking for injury assaults again, a well over 50% decrease in our injury assaults on Nursing through the work. But you have to figure out why, who the patients are assaulting the nurses before you can really make any traction.

Host: Amazing results, really. And this sounds like this isn't a set it and forget it program. You said you meet weekly and continually adding data points, is an ongoing program.

Erin Marinchak: Has to be. I'm a clinical nurse specialist by background. We generally don't recommend chart audits for a very long time, right? You want to get to a place where you can set it and forget it, but this is evolving so rapidly. We're still trying to keep up with our patients, you know, and their needs and our staff's needs. Again, four years of work and we're nowhere near done yet.

Loni Francis: And keep the culture change.

Erin Marinchak: That's right.

Loni Francis: I think frontline staff are very engaged in this, yet the executive level continuing to show them why we need to actually pull more resources to this and how important it is and how we can save money. There is an ROI on this if people aren't getting hurt. And so, showing them that data and how important it is. And also, something that we didn't mention is once there's an assault subjectively, you know, we have some great objective data, but subjectively checking in on that person and their well-being, which ultimately leads to retention or decreased turnover, and those are also things that you can put in an ROI.

Host: Very important. Very, very important. Well, this has been a great discussion. Thank you both so much for the great work you've done and leading the way on this for sure. So, as we wrap up, I'd love to get final thoughts from each of you. Loni, let's start with you. Anything else you want to add?

Loni Francis: Yeah. This has really been a passion project for Erin and I. We were very close to the teams that were getting assaulted, and we knew certain nurses or text very personally, which is what made this a personal drive. It's amazing to be here at this point and being able to look back and talk about it.

However, as Erin said, it's a lot of work, and there are many key takeaways. And we just hope from our presentation that anyone watching and wants to apply some of that to their health system, that they'll take even a couple of those things and hopefully see some success.

Host: Very well said. And Erin, how about you? Any final thoughts?

Erin Marinchak: Definitely, is just you have to utilize data to drive your program. Don't let emotions take over. We're all very emotional about this and invested in it, but you've got to use the types of assaults that are happening daily to prevent assaults that are happening daily. And so, again, those nationally-known cases, the things that are very concerning to everybody, I understand that, definitely want to prevent those too. But we need to focus on what's really wearing our nurses down, and those are those daily assaults. And it may be people who don't know what they're doing. Those are different interventions. But again, utilizing data to redirect everybody in your organization to what's happening daily and preventing that.

Host: Yeah. Well, thank you both for sharing your insights and leading the way on this. We appreciate it. Thank you so much.

Erin Marinchak: Thank you.

Loni Francis: Thank you.

Host: Yeah. And once again, that is Erin Marinchak and Loni Francis. And for more information, please visit aonl.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today In Nursing Leadership. Thanks for listening.