A Quality Improvement Project to Reduce Events of Visitor Escalation in the Intensive Care Nursery

Abstract

Background: Escalating and aggressive visitor behaviors have become increasingly common in healthcare settings nationally, negatively impacting staff and patients alike. Most healthcare providers do not innately possess the specific skills to manage such behaviors. Management of escalating and aggressive behaviors presents a particularly bedeviling challenge when staff safety must be balanced with the needs of parent–neonate bonding. Purpose: In the Intensive Care Nursery (ICN), the frequency of aggressive and hostile incidents from visitors increased such that the staff felt frustrated by and uneasy about their work environment. Methods: The ICN convened an interprofessional team to strategize interventions aimed at consistently managing aggressive behavior and supporting the staff after aggressive and/or hostile visitor encounters. Findings: Following staff education and training, the unit launched a de-escalation management algorithm in July 2018 that assisted in identifying high-risk families at admission and drove consistent action and management of all visitor behaviors. In the 12 months following the intervention, the frequency of behavioral escalation decreased by 75% and staff perception of safety increased by 25%. Implications for Practice: Collaborating with staff to design consistent strategies to manage aggressive and escalating visitor behavior can improve safety and improve employee satisfaction in the ICN. Implications for Research: Additional research on the effectiveness of the algorithm in other ICNs and alternative areas of practice is needed. Furthermore, validation of a staff perception survey measuring the impact of escalating visitor behaviors on employees would be an important next step in this research. Video abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=43

No excuses, no exceptions except with compassion: A narrative review of visitor aggression in pediatrics

“…Eleven records ultimately met the criteria for presenting best practices, strategies, policies, education, and any other interventions to mitigate visitor aggression in pediatric health care systems as elucidated in Figure 1. [6][7][8][9][10][11][12][13][14][15][16] IRB or ethics approval was obtained across 11 studies that involved both quality improvement and research. 6,[10][11][12][13][14][15] A consolidated breakdown of each study's design, intervention components, and outcomes can be found in Table 1.…”

“…Nurses, pediatricians, medical technicians, respiratory therapists, paramedics, patient care assistants, other visitors, and patients were recipients of aggressive behavior by visitors 6,8,10,12,16 and were primary targets for de-escalation training efforts. 6,7,8,13,16 Multidisciplinary workgroups were implemented to formulate a comprehensive incident reporting system and develop hospital-wide recommendations to mitigate risk and increase staff, patient, and family safety while ensuring optimal patient care. 6,7 Some efforts utilized existing, embedded safety measures, primarily deploying security staff, to mitigate verbal and physical aggression.…”

“…6,7,8,13,16 Multidisciplinary workgroups were implemented to formulate a comprehensive incident reporting system and develop hospital-wide recommendations to mitigate risk and increase staff, patient, and family safety while ensuring optimal patient care. 6,7 Some efforts utilized existing, embedded safety measures, primarily deploying security staff, to mitigate verbal and physical aggression. 9,12,16 The community police department worked closely with the hospital security team in one study 16 .…”

“…Peer-reviewed journal articles were included that involved practices, interventions, and strategies to de-escalate visitor aggression in any part of a children's health care system. [6][7][8][9][10][11][12][13][14][15][16]…”

“…Two hospitals established multidisciplinary workgroups to address visitor aggression on a systemic or organizational level that could reach all parts of their respective facilities. 6,7 Establishing a workgroup of this nature can certainly be beneficial in first reviewing existing visitation policies with respect to behavioral expectations as the basis to then revise as needed to assure that safety in a healing environment is preserved for patients, their families, and staff at all times. Ensuring that this workgroup is multidisciplinary will also account for the differing viewpoints of health care professionals within patient treatment teams.…”