Workplace violence against nurses has surged in recent years, but that doesn't mean it has to be part of the job. Proper protocols and de-escalation tactics can go a long way in preventing violence in health care.
An estimated 81.6% of nurses will experience physical assault, verbal abuse or disruptive or combative behaviors in their careers. Unfortunately, according to OSHA, only 30% of health care professionals report these incidents to a supervisor or manager.
It is important to educate staff and develop and implement well-defined behavior management programs and safety protocols to mitigate the risk of violence.
Health care workers may:
- Believe that violence is part of the job
- Be uncertain about what constitutes violence
- Often believe their assailants are not responsible for their actions due to conditions affecting their mental state
Why are safety protocols needed in hospitals?
All staff should be aware that violence could occur but can be avoided or mitigated through preparation.
Health care professionals are frequently required to respond to individuals demonstrating challenging behaviors. These could be more appropriately managed with well-defined processes and resources. How health care professionals respond to challenging behaviors can impact several aspects of patient care and organizational operations, including:
- Improved patient outcomes
- Reduction of workplace violence
- Improved employee engagement and turnover
Common causes of violence in health care
Violent behavior can stem from various factors, including mental disabilities, frustration, fear, substance abuse, trauma or unmet needs. It is vital that nurses understand how to identify possible causes and triggers, utilize de-escalation techniques and manage maladaptive behaviors.
The most common characteristic among those who initiate violence is altered mental status, often associated with:
- Dementia
- Delirium
- Substance intoxication, abuse or withdrawal
- Decompensated mental illness
How to mitigate risk
Workplace violence is a complex issue that requires an interdisciplinary approach to create a safer working environment for patients and health care professionals. Some of the mitigation techniques could include:
- Shifting from reactive approach to proactive approach to behavioral management
- Reporting, tracking and trending of workplace violence events
- Educating and setting clear expectations with staff, patients and visitors
- Conducting hospital-specific workplace violence and safety risk assessments
- Conducting hospital-specific “interdisciplinary” violence prevention programs/plans
- Leveraging EMR capabilities to effectively capture patient behaviors, which streamlines communication across the team and enables quick collaboration to create a plan of care for behavior management
Patient verbal de-escalation techniques
Understanding patients’ needs and utilizing de-escalation techniques are key. Strategies could include:
- Distraction: Ask the patient to take a walk with you to burn energy, find a lost item or introduce them to someone who can help with their concern. Offer food, drinks or activities to give patients a job or duty to help you with. Reduce environmental stimulation.
- Get Assistance: Find someone familiar with the patient or situation. Use familiar names when the patient can’t find a loved one or is wanting to leave.
- Choices: Instead of saying “no” or “you can’t,” provide patients with various options.
- Element of surprise: Use disarming or vulnerable responses like, “You’re right;” “Let’s try that again;” “I’m sorry that happened;” or “Let me help.”
What is dysphagia?
Like aphasia, it can be caused by neurological conditions such as brain injuries and stroke, but it also can stem from muscle disorders, certain cancers and blockages/strictures in the throat.
Depending on the cause, dysphagia can be temporary or long-term.
Conditions commonly associated with dysphagia include:
- Parkinson’s disease and multiple sclerosis
- Neck and throat cancers
- Late-stage Alzheimer’s disease and other dementias
- Cervical neck surgeries
Stages of dysphagia
There are three phases of swallowing that are impacted with dysphagia:
- Oral: This is the process of chewing food and mixing it with saliva to form a bolus in order for it to be moved from the front of the mouth to the back of the mouth. A person with dysphagia in this phase could have trouble breaking down the food enough to properly move it to the back of the mouth to trigger the swallowing reflex. This stage is also where tongue weakness or decreased sensation may impact the ability to clear food from the sides of the mouth causing it to pocket in the cheeks.
- Pharyngeal: This is where the swallowing reflex begins, and pharyngeal muscles push food down the throat to the esophagus. The epiglottis (a cartilage) inverts to protect the airway and sends the bolus towards the esophagus. This is when the upper esophageal sphincter opens to allow food to travel into the esophagus. A person with dysphagia in this phase might feel like the food is “entering the wrong pipe,” Delashaw said, because the muscles in the pharynx and/or larynx are not operating properly to prevent food or liquids from entering the airway.
- Esophageal: This is when the bolus is taken from the upper esophageal sphincter that has opened, allowing it to enter the esophagus. Peristalsis (muscle contractions) carries the bolus from the upper esophagus towards the stomach. In this phase, a person with dysphagia may feel like food is stuck in their throat or chest.
Symptoms of dysphagia
Dysphagia symptoms could include:
- Coughing or choking during or shortly after eating or drinking
- Heartburn or indigestion
- Feeling that food is stuck in the throat or chest
- Painful swallowing
- Regurgitation
- Food sitting in the mouth or being pocketed in the cheeks
- Unexplained weight loss
- Reduced desire to eat
Diagnosing dysphagia
Dysphagia is diagnosed by a healthcare provider. Speech-language pathologists diagnose dysphagia with a comprehensive oral exam and swallowing examination, which should include swallowing tests such as a FEES or MBS exam.
- FEES: FEES stands for fiberoptic endoscopic evaluation of swallowing. This is an exam where a speech-language pathologist inserts a small thin scope with a camera through the nose and allows visualization of the throat, larynx and vocal cords to assess swallow function as you eat and drink certain foods.
- MBS: During a modified barium swallow study, a speech-language pathologist will give you food and liquids covered in a small amount of barium. As you swallow, X-rays are performed to view your swallow in real-time.
Treatment of dysphagia
After a dysphagia diagnosis, a speech-language pathologist can help determine what consistency of food and liquids is safest to eliminate risk of choking or aspiration. They can also provide therapy and exercises to help strengthen the muscles used during the different stages of swallowing.
Treatment should always involve a discussion with the individual to determine their wishes regarding oral intake and development of dysphagia treatment.
“If difficulty is noted in the oral phase, we can design an exercise program to target movement for the muscles used when breaking down the food,” Delashaw said. “Say you had a stroke that impacted lip muscles, and you can’t hold food in your mouth. We’re going to work on increasing the control and strength of the lip muscles, so you do not lose liquids or foods out of the mouth.”
In addition to exercises, Delashaw said neuromuscular electrical stimulation could also be used to increase muscle awareness in the different stages of dysphagia.
In the esophageal stage, your speech-language pathologist could suggest obtaining a referral from your primary care doctor to a gastroenterologist for further evaluation.
Recovery from dysphagia
Depending on the diagnosis and related conditions, dysphagia could improve over time. If swallowing difficulty is related to a neurological condition, inpatient rehabilitation could help develop adaptive techniques and diet plans to meet your needs and quality of life standards.
The multidisciplinary approach in this setting also allows for other symptoms related to your condition to be addressed through intensive therapy. In addition to working with a speech-language pathologist, your therapy team would also include a physical therapist and occupational therapist to address mobility and strength as well as activities of daily living and quality of life.
