How Parkview Behavioral Health Reduced Workplace Violence

Added on Mar 9, 2020

From “Worst to First”: How Parkview Behavioral Health Reduced Workplace Violence
By Audrey Doyle

By using evidence-based patient experience strategies to combat workplace violence, leaders at Parkview Behavioral Health transformed the facility from being the most dangerous place to work among Parkview Health’s 11 hospitals to being the safest in just one year. The culture transformation was so successful that Parkview Health leaders have asked the team to help them identify ways to improve workplace safety systemwide.

Located in Fort Wayne, Indiana, Parkview Behavioral Health (PBH) provides intensive inpatient and outpatient hospitalization services for patients struggling with mental illness. With 34 youth beds, 55 adult beds (18 for high-acuity patients), and 20 geriatric beds, PBH is the largest inpatient psychiatric hospital in northeast Indiana and the only high-acuity care provider in the region.

Paula Bostwick, RN, is vice president of behavioral health hospital services at PBH, former director of patient experience for Parkview Health, and one of the leaders who launched the culture transformation. She’s also no stranger to workplace violence in health care. During her more than three decades of nursing experience, she was often verbally and physically assaulted by patients who were disoriented due to illness or medication. And when she was nurse manager at Parkview Regional Medical Center (PRMC) prior to joining PBH, she led efforts to tackle workplace violence there by training her staff to de-escalate and resolve difficult situations with patients and visitors through proper communication and empathetic listening techniques.

Notwithstanding this experience, Bostwick says her first weeks on the job as PBH’s director of nursing in March 2017 were “eye-opening.” Extreme verbal and physical aggression toward staff by patients, especially high-acuity patients, was common. Parkview Health police were always visible in the halls, and they intervened the moment a patient became aggressive. The staff interacted with patients in a paternalistic manner, which caused power struggles and violent outbursts that required the use of restraints and seclusion and usually resulted in staff being emotionally traumatized or physically injured, often to the point where they had to seek medical treatment and take time off from work to recuperate.

“It was a culture of violence that was accepted and expected,” Bostwick said. “Because our culture wasn’t supporting a positive patient experience, patient violence was escalating, and staff safety was in jeopardy. To fix this, we had to completely transform our culture.”

Improving the Staff–Patient Relationship

According to Katherine Avery, RN, manager of Adult Services at PBH and a co-leader in the initiative, the culture transformation comprised several changes based on Press Ganey best practices for improving the patient experience.

One change was to encourage nurses to take more personal responsibility for their patients’ care and outcomes. “Our nurses were constantly waiting for a patient to act out or a co-worker to get hurt,” Avery said. “They’d given up ownership of the patient because they were so afraid. We had to help them feel safe so they could take it back.”

To do this, the leaders increased their visibility on the floor to build a sense of teamwork. They also started helping the staff manage difficult patient situations. As an example of how important this was, Avery recounted the time she and Bostwick responded to a panic alarm on the adult unit. A one-to-one patient was actively suicidal and combative. Bostwick and Avery helped the staff and the patient’s physician safely restrain the patient, but as Bostwick was talking to the patient to de-escalate the situation, the patient spat in her hair.

“Everyone stared at Paula, waiting for her to react, but she stayed focused,” Avery said, adding that Bostwick not only gained a tremendous amount of respect from the staff that day, she showed them that leaders aren’t just there to impose rules and standards, but truly are part of the team.

Bostwick and Avery also began coaching the staff on how to connect with patients instead of trying to control them. “When a patient is admitted to a psychiatric hospital, everything is taken from them and they get privileges only if they’re good,” said Bostwick. “Just by walking the halls, Kate and I could see the effects of this paternalistic culture. Staff were telling patients what they could and couldn’t do, and as a result, they were fighting over just about everything. And because the staff’s mindset was ‘we think we know what’s best for these patients and we’ll exercise control to make them comply,’ there were lots of power struggles that ended in violence toward staff.”

To change this dynamic, Bostwick and Avery encouraged the staff to find ways to partner with patients and meet them halfway in getting to have or do things they typically weren’t allowed to have or do. Similarly, they taught staff to pause when patients begin to act out and to give patients time to calm down, instead of automatically resorting to restraints and seclusion.

Shifting the staff’s mindset from reactive to proactive is another change Bostwick and Avery implemented. For example, at the start of each shift and at staff change-out, oncoming staff meet with one-to-one patients and read a copy of their care plan with them. Because care plans may be amended based on patients’ needs, reviewing them at each shift change/change-out guarantees that every staff member is following the proper plan and removes inconsistency and confusion as triggers that could cause patients to become aggressive.

The team also coached the staff on being more proactive in de-escalating patients and teaching healthy coping skills. “Anytime we restrain or seclude a patient or have come near that point, we gather the team afterward to discuss what went well and what we can improve,” said Bostwick. “This helps us identify how we can intervene earlier for that patient or similar patients next time.” Along these lines, the staff also began implementing aggression scales on the adult and youth units to better predict and prevent aggressive behavior.

Finally, because a hospital’s physical environment can influence both the patient and caregiver experience, the high-acuity unit received a makeover. Prior to this, patients’ rooms were small and plain, with walls made of concrete blocks. The doors sounded like prison doors when they were closed and locked, the nurses’ station was enclosed in concrete blocks and shatterproof glass, and the unit had only two windows with outside views.

A behavioral health architect oversaw the remodel, which eliminated the use of concrete blocks and incorporated other improvements, including an activities room, a lounge with a fireplace, and a redesigned nurses’ station that allows patients and staff to interact more freely, which builds trust, Bostwick said. In addition, patients’ rooms were expanded, colorful murals now adorn the walls, and 12 of the rooms were converted to private rooms, each with its own bathroom and a window overlooking an open courtyard.

“This unit is for patients who are at the highest risk for violence,” said Bostwick. “Transforming it into a more homelike, welcoming environment changed the atmosphere from punitive to therapeutic for patients and staff.”

Positive Outcomes Inspire Systemwide Improvement

Since the team began implementing these strategies in 2017, instances of workplace violence and worker injuries have dropped dramatically. To wit, the number of workplace violence calls to Parkview Health police dropped 90%, from 120 calls in 2017 to 12 in 2019. During that same period, the number of staff injuries dropped by almost 70% (from 25 to eight). And the number of staff injuries that were OSHA-reportable, meaning the injury was serious enough that the person had to seek medical intervention and take time off from work, fell by 88% (from 17 to only two).

Patient experience has also improved significantly. According to Press Ganey survey results for the first eight months of 2018, PBH’s rank for patients’ perceptions of overall care increased from the 41st to the 75th percentile. Furthermore, as the team has changed how they practice, the use of patient restraints has dropped—from 0.05 hours of restraint per 1,000 patient hours in Q4 2017 to less than 0.01 in Q4 2018. “Now it’s the nurses, not the Parkview Health police, who initiate restraint use, and only as a last resort,” Bostwick said, adding that the police get involved infrequently now and are less visible in the halls.

Finally, nurse turnover has plummeted. At the beginning of 2018, PBH’s first-year nurse turnover rate was 80%. For 2019, it was 12% (the industry standard is 19.4%). Moreover, interest in working at PBH has been so great that the hospital now fields multiple job applicants per week, many of them from inside the system.

At press time, Bostwick and Avery had begun working with Parkview Health on ways to improve safety systemwide. In addition, a newly formed behavioral response team was being piloted on two med-surge units at PRMC. The team members change based on who’s working that day and include Bostwick along with nurses, physicians, social workers, chaplains, and personnel from public safety and nutritional services. If a patient’s behavior escalates, the staff can request immediate assistance from the team, who will work directly with the patient to understand the root cause of the escalation and help the staff by developing a mutually agreeable solution with the patient.

Prior to joining PBH, Bostwick hadn’t worked in a behavioral health setting. “But when your goal is to provide a positive experience for your patients and keep your staff safe, it doesn’t matter where you’ve worked,” Bostwick said.

“Violence in health care is a universal problem; it happens in every hospital, and for many it’s now considered part of the job,” she concluded. “The strategies we used can be applied everywhere, not just in behavioral health. We’re eager to see how they’ll make a difference for patients and staff throughout the Parkview Health system.”