Ep72 | Before Violence Happens : Using Anticipatory Guidance to Prevent Escalation

If you work in healthcare, you already know this. Conflict is everywhere. In the OR, in labor and delivery, in committee meetings, between physicians, nurses, administrators, and teams that are all trying to do the right thing. But here's the problem. Most of us were never trained to handle conflict well. We learned procedures. We learned Diagnostics, but we didn't learn how to navigate the moments when 2 professionals strongly disagree. That's why I developed the SPARK framework. SPARK stands for stop, pause, ask, don't assume, reflect and respond, and create a path forward. It's a practical system designed specifically for high shakes healthcare environments. Through keynote talks, residency workshops, and Spark Masterclasses, I teach physicians, nurses, and healthcare teams how to turn destructive conflict into productive conversations that strengthen teams and improve care. If your hospital, residency program, or medical conference is looking for a speaker on conflict, Communication and leadership in healthcare. I'd love to work with you. You can learn more in the show notes because in medicine, conflict is inevitable, but handled well, it can make teams stronger. In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power. Hello, my peaceful warriors, and welcome to the Scalpel and Sword podcast. I'm your host, Dr. Lee Sharma, physician and conflict analyst. I saw a story on the news probably about a month ago of a nurse who is at UAB in Birmingham, just 2 hours north of me. That was working at the bedside and was assaulted by a patient that she was caring for. And while I may say that story hit close to home, that's one, unfortunately, of hundreds of healthcare workers, of people who are caring for patients, who are literally afraid because of the risk of violence in the workplace. And it's not something that's just limited to what you see on the news. This can happen anywhere. And the question then becomes, if we know it can happen anywhere, what can we do to raise our awareness of it? And even more, what can we do to actively prevent this from occurring? On Scalpel and Sword, we talk about conflict being a vital sign, and nowhere may it be more important to recognize that vital sign early than workplace violence. And today, this is a first for Scalpel and Sword if you're a regular listener, because we have this amazing team that's going to help us talk through this today, and I'm so excited to introduce them to you. First, I want to introduce to you Dr. Emmanuel King. Dr. King is a professor of clinical medicine in Penn Medicine's Division of Hospital Medicine and a physician leader at the Hospital of the University of Pennsylvania. With extensive experience in quality improvement, patient safety, and interdisciplinary leadership, he works closely with nursing and operational partners to advance initiatives that improve both patient and workforce safety. I'm happy to introduce Natalie Plastino. Natalie is a patient safety manager at the Hospital of the University of Pennsylvania and a former interdisciplinary patient safety officer. Her work focuses on risk identification, event analysis, safety culture, and workplace violence prevention. I'm so happy to introduce Christina Vo. And Christina was the person I first reached out to, and I want to thank her for facilitating all of this. Because I reached out to her with a cold email and she was so kind and generous to respond to me. Christina is a nurse practitioner on the Advanced Lung Disease Service at the Hospital of the University of Pennsylvania and serves as an interdisciplinary patient safety officer. She leads initiatives focused on workplace violence prevention, quality improvement, and interdisciplinary education. Karen Brooks, We're so happy she's here. Is the nurse manager for advanced medicine at the Hospital of the University of Pennsylvania, where she leads nursing teams in a complex academic healthcare environment. Her experience includes workforce development, nurse wellbeing, and operational leadership. And last but absolutely not least is Scott Crespi, PhD. Scott is a master improvement advisor at the Hospital of the University of Pennsylvania, With more than 25 years of experience in healthcare quality, safety, and operational excellence, he has developed workplace violence prevention strategies using anticipatory guidance, which we're really going to get into today, and empathy-based approaches. Welcome all of you to the podcast.

Thank you for having us. We're super excited.

So glad. You guys are here. This is absolutely such an urgent challenge right now. We have to be addressing this. Dr. King, tell us, how significant is workplace violence today?

Thanks for having us here today, Lee. We're so excited to share about our work. We think that workplace violence is one of the most pressing challenges in healthcare today because even beyond its effects on each individual, It has long-term effects on the way we provide patient care. It has effects on the culture of our organization. And we think that there's also a real opportunity to shift from after-the-event response to trying to really prevent events before they happen.

And this is huge, right? Because a lot of times I think with them, sometimes we look at events as not necessarily something that's rare. But something that's such an unusual event that we may never see it again. But in effect, really what we're talking about is something that we are at risk for every single day in medical practice.

Correct. Like when we started looking into this and looking at the background, we were really astounded to see that most studies show that up to 40 to 70% of healthcare workers will have an event occur. And in particular, our nurses that are new to practice. Younger physicians, many of which are in my hospital medicine division, people that don't have as much experience with conflict resolution. Our patient populations are boarding in emergency rooms. Tempers are high, expectations are high. But I think one of the reasons that this is something that has only recently gained attention is that we feel that there's a large opportunity in terms of reporting. There's lots of underreporting, which I think limits our understanding.

This is a huge number, right? 2/3 of healthcare workers at some point are gonna experience workplace violence. And I think this is a really important point because we tend to think about workplace violence as an assault, as an attack, but workplace violence can be verbal. It can be emotional. It doesn't just take the form of physical contact.

You're totally right. The most common forms of workplace violence are classified as verbal. Or psychological, which may be even harder to put our brains around. And a lot of times as healthcare workers like physicians, nurses, CNAs, phlebotomists, we're really taught to just go through our shifts, get our heads down, get the work done, be patient-centered almost to a fault. So when these things occur, we feel like we don't want to be the complainer. You know, patient's going through something. We shouldn't be getting them in trouble in some way. And I think that the thing that really makes us great as a profession and gives me a lot of respect for all my colleagues across disciplines, it ends up like causing an issue for us because we're just kind of letting it all like fester inside of us and it can be a real challenge.

I'm so glad you're talking about this, and I think this is going to be a recurring theme for us as we're going through this episode. It's this idea that patient safety and clinician safety are exclusive. That we have to have one or the other. But this is about a culture of safety. This is about everybody feeling safe as they practice. And so I agree with you. I think as clinicians, we have a heart for our patients and we want to support them. And so we have empathy and sympathy for them. So we're willing to accept a lot. Like you said, we're willing to say, well, this is just part of the job. This is just kind of what I signed up for. But it's not, right? This is something that we should have an idea that we are safe where we work.

Yeah, we really need to get past the point where any form of violence is considered part of the job and normalized. I think that's very hard to do. As you know, culture is the last thing that will change despite a lot of commitment across disciplines from executive leadership. But really not tolerating this is the most important thing we need to take away.

This is such an important point, and I really want to bring this out. Is that part of underreporting may be this idea that we should tolerate it or it's inherent in our jobs. But what we're really talking about is that we can't address a problem that we're not bringing out into the open. And the only way, maybe one of the most important ways to bring it out into the open is to verbalize it.

Yeah, you're totally right.

So if you have a young clinician on your service, You know, like you said, you're in an academic institution, so you always have young learners. Do you actively talk with them about existence of workplace violence and how to deal with it and report it?

Yeah, I definitely use debriefing as a big part of my teaching strategy, like in-the-moment type of debriefing. So that could be anything. We've done this for decades with codes and rapid responses. Like, what could we have done better? What broke down in communication that maybe made this not go so smoothly. But more recently, rather than just shaking our heads as we leave a room when someone has mistreated one of us on the team, I usually will take the team aside and just ask everyone to talk about how they felt about that and really encourage normalization of the debriefing as opposed to normalization of the behavior that we were subject to.

I'm so glad you do that. And I'm so glad you're exposing them to that at an early part in their education. And I think that's a really important idea, that the idea that we have to set up processes to actually address workplace violence. And so I think there definitely are hospitals that have policies. And Natalie, I wanna kind of come to you on this, that a lot of hospitals, institutions talk about policies, but those policies don't always work. I think this comes to underreporting as well, but I think it also comes to the question of the policies that maybe we have in place aren't working. So is that something that you guys are also seeing as you work on this?

Yeah, thank you, Lee. I think that's a very important point. So the literature suggests that the biggest gap isn't necessarily in policy existence, but rather in the implementation of policies and The policies that exist, which most organizations, to your point, do have workplace violence guidelines, policies, but they are not always standardly operationalized across the health system, across different units in the hospital setting. So, despite many organizations having policies and reporting systems and training programs, frontline staff don't always see consistent follow-through or action. or implementation of these policies. And I think that's a major gap in certain organizational systems.

That's huge, right? Because if we have a policy that's in place and maybe people don't see actionable progress coming from the policy, maybe they don't see the policy encouraged. Let's say somebody has an issue with workplace violence, and let's just say for the sake of argument, this was a verbal assault in a workplace situation. And maybe this gets reported. And within the confines of that reporting system, maybe the clinician gets told, oh, nothing really happened to you. You just got yelled at. It wasn't like the patient pushed you or shoved you. And unfortunately, the next time that occurs, or let's say a colleague witnesses something similar, they're going to be reticent to report this. They're not going to want to use the system again because they didn't see it work for their friend. I love this point that you're talking about, this idea that we can have policies. But unless these policies are functional and consistent, they're not encouraging reporting.

You're right, Lee. And so, one of the largest gaps, as both you and Emmanuel have spoken to, the fact that workplace violence events are significantly underreported. So, up to, the literature shows up to 88% of workplace violence events are not reported, and it's mostly for 3 common themes. But the first we've already addressed. Unfortunately, workplace violence is normalized. In the healthcare setting, and we do feel like it's often just a part of the job. But there's also contributing factors such as healthcare workers feel like the confidence in the system or there's inconsistent leadership response. So if there's lack of visible organizational action to their reporting, then they're going to disengage in the system and they're not gonna want to report And then if the events are not reported, then the scope of the problem can't be validated by the health system, which would ultimately lead to actionable change. So, there's sort of this spiral from the lack of reporting, but people also have fear and there's a psychological safety piece sometimes surrounding reporting. They feel like it could be burdensome or they might be blamed for the workplace violence events are often think that people might think they can't manage their patients. And so, there are all these different factors that go into the underreporting, and those all contribute to those gaps in active policy.

You brought up a really important point, and I really wanna take a second on this because this is something that I think, as professionals, is really good to hear. The idea that one of the reasons why we may be afraid to report a workplace violence incident Is because it actually reflects upon us and our professionalism, that we are afraid that someone's going to think that we're not a good doctor and not a good nurse. I'm not a good clinician. If I had this interaction, if I had this happen, what did I do wrong? And if I did something wrong, I don't want to tell anybody because I don't want anybody to find out that I'm not good at what I do.

That's huge.

And I think you're really great to mention that because I think that's probably a huge component to reporting. A lot of Female clinicians, we walk around with imposter syndrome all the time. If this is going to feed into that, then I'm not going to want to talk about it. And unfortunately, that's going to put not just me at risk, that's going to put somebody else at risk because I haven't reported those statistics effectively.

Yeah, that's right. I think there's this whole concept of psychological safety from the patient perspective. So, you know, we're fearful of the workplace violence events themselves. We're fearful of how our colleagues might perceive us or how leadership might take action. And so, I think workplace violence reporting and culture of safety are hand in hand. And so, we have to ensure that we are set up to allow our colleagues to feel safe to report these events when they occur.

There's an inherent trust we're building in the system as we build this good policy. And I think that's such a thing for institutions. I once had a guest tell me, we were talking about psychological safety. And one of the things that he said was, you know, what hospital systems or sometimes systems in general don't realize is that if they're not investing on the front end to establish a safe environment later on, you're going to pay for it later on, but you're going to pay for it in different ways. And that's something that I think is very illustrative is we're trying to talk with big institutions about instituting effective policy, not just policy, not just something on paper, but something that actually is protecting our patients and our staff. I think That is incredibly insightful. I love that. You know, we talk about the idea of creating a culture of safety. Natalie, you speak to that so beautifully that this is about a, basically this whole region of psychological safety. So we talk about safety and other things in healthcare, in operating rooms. We talk about counts. We talk about doing timeouts. We talk about these things. So Christina, I wanna kind of turn to you. Why don't we treat workplace violence like we treat other safety issues that we treat in hospital systems?

And that's a phenomenal question as well. And it's similar to what you have said and Natalie has said and Emmanuel has said. It's definitely a culture of staff feeling it's a part of the job. It's the psychological safety in reporting, and then it's the significant underreporting. That doesn't give the leadership eyes to be able to say, this is what is going on. Without the numbers, without those concerns being brought up in a way that they can be acted upon, it definitely hinders the growth that's needed in being able to manage this. And I love how Natalie and Emmanuel have spoken about staff feeling psychologically safe. So it's not only in the reporting, and we will be able to address this a little bit as well, but not only within the culture. What we had learned was, as we try to talk to the staff about saying we should really prevent workplace violence from happening in the first place, like we shouldn't get to a point where you need to restrain chemically, physically, and you need security and everyone, but how do we get Staff to accept anticipatory guidance? How do we get staff to say, yeah, there's this like novel idea of anticipating a patient's emotions, and we can then begin to say, let us talk to them, let us have an understanding of what's going on. It's not going to work until we ensure that the staff feel psychologically safe. And so part of what we can delve into a little bit later on is that is why we really put an emphasis on our crisis emergency response, which brought restraint and medications and the recovery provider all in a timely manner. Because once we were able to speak to them and say, we heard you, we saw the safety nets, we've rounded, we've discussed it with the staff who who unfortunately were victims of workplace violence. And we learned where were the gaps. We heard the gaps in security arriving, restraints not available, medications not there. And we listened to the fear that was in their voices and how traumatized they said they were. And so we said, we're going to work on it as a leadership team here at Penn, at HUP. We're going to say, we're going to fix this. How can we fix this? Where we gathered experts from psychiatry, pharmacy, nursing providers, security. Everybody came together and said, this is the problem. This is what our staff need. This is what we should do. And we built it. We built it and we had it go through, unfortunately, a couple of times, but we'll, you know, definitely be able to chat. But once we built something like this that showed, one, our system or our health Our hospital cared enough to be able to say, dedicated a team, built this process, listened to the staff, and said, how do we ensure that the restraints get there? How do we ensure that you have enough security? How do you have the meds? How do we make sure that the provider is there? We built them all and we had it happen. And now we can tell them, how do we make that culture change? Because now we've showed them that we listen, and now we've shown them that The safety nets or how they are reporting did matter, right? So they entered the safety net. We listened to them. Someone interviewed them. Someone went to go talk to them and someone heard what they were feeling and what happened and we built it. And so now with that, we're beginning to say at our system, please report it. Please tell us. Please let us try to work on this. And then after we have that, Then we can start building in the early preventative measures that we have, the anticipatory guidance, the de-escalation techniques. Now we're saying, we have a way to keep you physically safe. We think this is gonna work, but let us also ensure that we never get there. And these are some of the things that we can do. And I'm like really excited for the team to be able to delve into it like a little bit more.

Wow.

Okay. I'm about to cry. I mean, that's phenomenal. There's so much that I wanna talk about and so much that you guys have done that I think deserves praise and celebration, but also really taking it apart. The first one is the switch from saying, report this, to, please report this. That you actually looked at this culture where workplace violence was occurring and you weren't trying to— because this happens, right? We all know this happens where hospitals don't want anybody to say that this is happening.

Yes.

They don't want to report. They don't want to make it public. Oh, we had a nurse who was assaulted on med surg. They don't want that. Oh, we had a physician who was mugged on the way out to his car. They don't want to talk about that. So the idea that you made this switch to, please tell us, we want you to tell us, I think number one is a lesson for every institution. The second thing that I think is so cool that you did is that you started with very concrete things that you could measure. How fast can we get security there? How fast can we get the meds there? I mean, these are things that you can measure. And as people are coming to you and as you're encouraging people to talk about workplace violence, these are measurable gains you can go back to them and say, we are working on this problem. And we're going to start with the things that we can easily quantify. Because as you move into things like psychological safety and creating a safety culture, those are things, and Dr. King, you had also mentioned this, That take longer to change. They can be changed, but they take longer and maybe in some ways harder to measure or quantify. So you start with the things that you can measure, you make very targeted change, and then you get buy-in from the other people in the system because they see what you're doing. And then they're going to be more likely to come to you and be part of this culture of change to create safety. That's phenomenal. So was this the impetus for writing the paper as well? Is the work that you had done?

Yes, partly it was. We were already known within different groups and committees, the work that we were trying to do. And it's because, as you know, like it's a multidisciplinary effort. It's not, you know, solely nursing or solely providers or psychiatry. We really leaned on everyone to be able to work on this. Really, the training and everything that we were trying to do just really caught the attention of a lot. And when they needed a paper, it was like, we think we'd love for you to share. A little bit about what you're doing, just so that people have an understanding of the progress that has been made. And if I can chat a little bit about training with it, I think there was a lot of back and forth about how do people even learn how to de-escalate? How do you learn to manage emotions that are so volatile at a time like this? Yeah, when we were starting and we were doing simulations, To simulate what a crisis emergency response would look like, how it would react, how providers would come, what nursing would do, how security would come, how they would get there. And when we reviewed it with residents, and I still remember it, Scott and I were rounding, or we were talking with the teams, and the gentleman actually had said, I'm 6'2. I am baseline intimidating. I had not realized that my own, like, body and my own tone is scary to the patient when they're already volatile. And so when we were able to just review it and talk about, oh, this is what we can do. Other studies have shown that it's not just clicking through a PowerPoint on de-escalation. Like, you're not gonna learn how to do that by clicking. You're gonna be able to learn by really seeing it simulated and then viewed and then talking about it with your teams to the point that what we've done, again, when we built what the crisis emergency response or our CERT is, we added the anticipatory guidance, we added the de-escalation. And then when we went back to these same units that we did these sims on, and Natalie and I like did it afterwards as a follow-up. Verbatim. The staff were able to almost tell us verbatim the steps on how to deescalate, on how to provide anticipatory guidance, on how to ensure that they were physically safe in situations like this. And we were like little proud mamas. Like, we were just so enthusiastic that it was, you know, time well spent in not only did we create this process. We trained on it. We stimulated. We had partners come to this, and the lessons were maintained. And that we were just so happy with. And again, please report, increase the numbers, let us track it, let us learn from them. After every CERT or every time something like this escalated, we reviewed it. We touched base with the staff that were involved. Were there areas to improve, or there's things that we could have done. And so if there's anything that we can say is de-escalation and training, it's not clicking, not a slide deck, not PowerPoint. It's really conversations and simulations truly helped our work with this. Just love it.

That's amazing. I love the iterative nature of how you've done this, how you've learned as you've applied, but also that you actually create this as a simulation. We simulate codes. We simulate shoulder dissociation codes. We do XELS. Why would we do anything less with this? It's absolutely beautiful, the work that you're doing. And the fact that you've been able to go back over and over, and you should be proud mamas after you're watching people do this because you're giving them such a powerful skill. It's incredible. And we talk about being in these situations, but of course, ultimately what we'd like to do is give people the skills to be able to deescalate before it gets to a situation where we're having to run this. So, Karen, I'm going to turn to you. Ideally, we'd like to look at our workplaces and hopefully prevent these situations from getting to a level where we're actually escalating to workplace violence. Are there interventions that have worked in terms of helping people learn how to do that?

Yes, there is a lot of evidence that shows what is the most effective. And just to piggyback off what Christina just described, our program really tries to emulate what is reflected in the literature, but the literature shows us that the most effective workplace violence prevention programs are comprehensive and proactive rather than reactive. And a really great program, a leading example, is the Workplace Violence Prevention Program that was developed by the VA, and their program combines staff training, event reporting, multidisciplinary threat assessment, and real-time communication of safety plans. And success comes from identifying risk factors early and creating systems that support consistent communication and coordinated action using a multidisciplinary approach that involves nursing, physicians, security, executive leadership, and patient safety teams.

So, what kind of risk factors are we looking for? If we're looking to try to prevent workplace violence, what kind of risk factors are playing into that?

So workplace violence prevention extends just beyond basic security measures, right? And the evidence shows that overcrowding, prolonged wait times, and communication breakdowns are all key contributors to patient and family frustration that can sometimes escalate into aggression. And I just wanted to take a minute to highlight that in addition to the work that we're here to talk about today, our hospital in the last year and a half has really made significant strides to address these risk factors here within our organization. We've done quite a bit of work this year to geographically cohort our medicine patients by team, and we've also implemented a robust multidisciplinary rounding process, which has definitely improved communication amongst teams. It's also improved our HCAHPS scores, and we hope that those efforts, though separate from our workplace violence project, has helped to promote a safer, more efficient environment for patients and staff.

That's huge because it's this idea of we have to, as we're creating teams, and one of the things I love about, especially the students and the residents who are coming up through the system, they are much more being brought into a team mentality. I don't know, I may be the oldest person here, but I think when I was going through medical school, we were definitely in the lone wolf mentality. It was you and you alone. Everything falls on you. The idea of being in a team, working together, in a team-based system, which is not something that was in our educational process. And I think the younger people coming in get that much more. And I love this because especially when we talk about topics like workplace violence, like you're talking about, Karen, this is a team approach. And that also leads to shared communication and accountability, that we're all being accountable for what's going on in this clinical interaction with the patient and the family. And as a result, we all play a role. in providing good communication and hopefully maintaining some type of relationship that we're not getting to this escalated process.

Definitely. And I think, you know, you made a statement earlier that people coming in before had this lone wolf mentality. And we've seen in the literature that workplace violence prevention is not the responsibility of any one department, and that the most successful programs really utilize a team-based approach where every discipline has a defined role in identifying risk, in improving communication, and ultimately preventing escalation. Like, for example, the nurses being the ones closest to the patient throughout the day, they're identifying those early warning signs. Physicians, they're partners in helping to set expectations and explain the care plans. Security can provide those, their safety expertise and provide onsite support when needed. And then the executive leadership really creates a structure for accountability and the availability of resources and training for everyone.

And I love how everybody's playing a part in that. And I absolutely think, especially for physicians, we don't realize how big a role we play in terms of communication expectation setting and how far that can go in terms of avoiding escalation. I don't think doctors sometimes understand how key we are in that. And I love how you're talking about that, that we are one part of a team, but a lot of times if we are setting that expectation or even just a clinical arc for a patient, that becomes something that can actually make this process much easier for the patient. And as we're communicating that with the rest of the team, make it easier for the team. So what kind of things in terms of team mentality, as you're building these teams, how are you encouraging them to communicate? How are you encouraging them to check in and communicate these shared goals?

I think multidisciplinary rounds have been huge for us. That really gives us dedicated time to touch base about whatever pressing item might be happening during any particular shift or during an admission. It might be an ongoing issue. We use Epic, so we have secure chat and we're in communication really all the time. And I think, like I said, it really is a team-based approach. And like Christina was describing our program, there are mechanisms at every level To help team members communicate whatever appropriate information needs to be sent down the line to prevent, but also react if needed to a workplace violence event.

I love that you mentioned that because I think that's something we don't always think about. We have secure messaging on almost every platform. Almost every physician, every nurse, every clinician has that on their phones. I can shoot somebody a message if I have somebody who's rounding after me, or if I'm turning a patient over, then I can actually say, hey, just so you know, I think we may need to just make sure that we touch base with this family because I think they're a little frustrated about what's going on with this particular situation. Giving that person a heads up, which I can do in 2 seconds on a secure messaging platform. I may think about shooting somebody something about an X-ray, but I may not think about shooting them something about a potential conflict situation. And I think that's where technology can really be utilized.

Definitely. And I also want to highlight something that our organization does that Scott and Natalie, as members of the safety team, can definitely speak to more in detail, but What we're doing in the foreground on SecureChat, like the frontline, that communication, there's also communication happening behind the scenes in our event reporting system. The patient safety managers are going into events, reviewing them, and then hashtagging them, flagging them as potential workplace violence events for tracking and trending. So it's happening on, in the foreground and in the background from a communication standpoint.

That is incredible. So you've got multiple ways you can surveil. to see if something could be potentially a concern. I love that. That's incredible. Scott, I wanna turn to you because we kind of briefly talked about technology in terms of how we're using technology for prevention of escalation and prevention of workplace violence. Do you feel like technology's helping us? Are there ways maybe we're underutilizing technology in terms of prevention of escalation?

Yeah, I'll get to that, but I do wanna say something about data and build off of what Natalie said. It's almost impossible to know the scope of the issue, and it's impossible as a quality improvement professional to know if you're effective, if your interventions are effective. So it's really easy, I would think, programs to peter out if you're not able to quantify and show that it's actually having an effect. And I think this is nationally a big issue because Unlike falls or infections or skin breakdown, even though the Joint Commission has a great definition, we're not all using one definition. And the nurses here definitely know that a skin breakdown, it might sound easy, like a pressure injury, but I mean, there's wound ostomy continence nurses that know how to stage, and how much harder is it to define? Things like bullying, harassment, verbal abuse. So having a definition that we could all agree on, and then reporting. If things aren't reported nationally, the incentive isn't really there. And even if we report and we show, like, we're doing maybe well, a low number of them, it could be underreporting, like Natalie said, up to 88% of the events not being reported. Or we might have a great prevention program, but when Joint Commission and others come in and talk to us, I think you can flesh out kind of how well an organization's doing, even if their numbers are low. So I think technology, we all have event reporting systems, but like, are we all utilizing them? How do we know we're utilizing them? And there's a lot of other sort of Technology, I think that's there that could kind of raise awareness, but I don't think necessarily solve the problems. For instance, there's a lot of work happening with people measuring aggression in patients, maybe in the ED, and sometimes folks are using FLAG, but without the rich information of things like what triggers a patient, And what kind of approaches we could take with that patient that could be helpful. Those flags are not going to be that helpful, even if the technology is helping us to raise the awareness, if we don't have that human detail, the information about what's setting this person off and how we could potentially address it. And I think that's where trauma-informed care comes in and checking in with the patient. You know, have they struggled with Being in the hospital before, struggle with interacting with the healthcare system, and find out where those struggles are. And we'll talk a little bit more about it, but how we could anticipate how we can make it more comfortable for them or address some of those struggles by helping them know what to expect or what's next or meet whatever those needs are. One other piece of technology I'll just add, and Christina said Simulations are great, but they're labor intensive and they're time intensive. There's some virtual reality programs out there that have been started. I don't know if the technology is quite as good as some of the gaming that programs have out there, but what they're starting to do is put people with virtual reality goggles and put them in situations and giving them chances to Try over and over again how to react. And so they're actually getting to practice. So I think those might be some opportunity.

That's huge. I want to emphasize this, Scott, because I think this was a beautiful point, that as we are learning and using technology, it still comes down to humanity. We still have to be human with our patients, and we still have to be very, very intentional about expressing trust and helping build trust back in the system. That we can have all the tech tools, but it still comes down to that connection we have with the patient and with each other. And I think it's always going to be paramount for us to talk about that. So I'm really glad you said that. And I also think that while we use technology, I love the idea of using VR simulations. No doubt if we turn this into a gaming scenario, my son would absolutely kick my butt if I actually had to do this in a gaming scenario. My son's girlfriend, who is a valid listener to the podcast, Ms. Goldsmith, and please tell my son that I said that. But I also think about like, we're seeing sort of influx of using AI as an analytic tool for looking at, say, phrases that come up as we're interviewing patients. And if we see phrases, the AI will trip us up. Okay, maybe this is a potential. We're starting to see this a lot in just the conflict resolution literature as a whole and in healthcare as well. And I want to know if that's something that you have thought would be of benefit if institutions, especially large institutions, are trying to scan for potential workplace violence issues.

Yeah, we have a behavioral health team called MEND on the medicine unit, and they have an algorithm that sort of highlights patients that could potentially be at risk. And then they'll reach out to the attending or other team member to say, hey, would you like me to reach out to them? I think that's one useful way of doing it, but I think we might be able to use it, and the literature is suggesting that some people might be trying it, and that is if it looks into their medical record to get a sense of what are the situations that sort of set them off in the past. And so what types of triggers might we be on the lookout for? And also, what kind of responses have been successful? So give staff some clues about what to look for and also how they could potentially be effective. So things hopefully in the future we could use and help us out.

Yeah.

No, thank you for that, because I think that's a really important point that we're maybe seeing more of that. So I want to move on because I want to talk about something that Christina brought up earlier. And that is this concept of anticipatory guidance. Just, I'm going to throw it out to the group, so anybody, please jump in. Explain to us what anticipatory guidance is.

It prepares patients and families for predictable emotional and operational stresses that occur during hospitalization. The goal is to reduce uncertainty, promote coping, establish realistic expectations, And address emotional distress before it escalates into conflict. But I will tell you that 3 and a half years ago, I'd never heard of that term before. We were sitting in a meeting. Some of the nurses indicated that, you know, we're having a lot of workplace violence. So we got the best experts we could find within the hospital of the University of Pennsylvania. Psychiatry, security, medicine, social work, and our psychiatrist, Eleanor Anderson, she named a few things. She said, yeah, trauma-informed care, anticipatory guidance. And I'm taking notes, and then afterwards I'm looking them up and I'm trying to find out, like, what are they and how could we use them? And I wasn't really finding anticipatory guidance being used. In this way. Like I saw it for things like helping retirees prepare for retirement. I saw in prenatal care, like talking to mothers about what to expect during their pregnancy and then after childbirth, what are some of the milestones to look for? And so we got together, put all our heads together. to try to flesh out how could we help patients recognize that we know it's not easy being in the hospital. And we even built a handout which has different faces on it of different emotions that they could feel. We know that being in a hospital could bring up big emotions— anxiety, fear, uncertainty, being overwhelmed. And we also know that patients don't have their coping resources. They can't walk their dog. They don't have their cat. They can't take a glass of wine. So we wanted to give them some ideas about what could you do that could potentially be helpful. And then we wanted to end with what makes you overwhelmed. And when you're overwhelmed, we want to know early because we want to partner with you. to be as comfortable as possible during your stay. So that's how we took that concept, which we— I hadn't heard before. I know our women's health, Natalie, heard of it before, but— and how do we apply it to this situation?

Wow. This is incredible because I think this is something that I think we all sort of acknowledge, That healthcare situations are very scary for our patients. I think we all understand that. But to be able to give them a way to express that in something that's very concrete and combining that with setting expectations, with giving them a way, and also, again, this permission, we want you to tell us. We want you to tell us if you're, you know, we're giving you all of these tools and all of these ways to express how you're feeling and express how being in this situation is affecting you. But then we want to know if you're feeling overwhelmed. This is something that's very, very powerful. And as you've started to introduce this concept of interdisciplinary guidance, how has this been received by patients and people going through the healthcare system?

That is a great question. I'm going to ask maybe Karen and Emmanuel.

I'll set my screen. So this is briefly, and I'm going to have to share it because now I can't see you all, but this is just what it looks like.

Oh, okay. Yes.

This is the handout that was developed before Karen delves into like how patients and staff have received it, but it is exactly as Scott had explained. It gives patients a visual. It gives staff the language to communicate with patients on how they are feeling during a very, at times, like overwhelming, stressful time of their lives. And then as you see on the bottom, there are ways that we are telling our staff, and we're sharing with everyone, to say, here are things that we can offer patients. There's journaling. We have coloring books. We have a chaplain. There's social work. And there's so many other things that we've done to be able to help mitigate some of these very real and very normal feelings that patients have.

Thank you for that. And if you don't mind, I will put that in the show notes so that people can have access to that. So thank you. I think that's incredible because it's really hard for us to express ourselves sometimes when we're very in this situation and you're giving them very, very specific ways to do that. And as you are offering this idea of anticipatory guidance and you're giving them ways to express themselves, how has this been received by patient populations and their families? How are they receiving this?

Do you mean how are they physically receiving it or how are they reacting?

Both.

Yeah.

So we went through, when we were initially piloting, we partnered with our Drexel Co-op program and our EVS colleagues, and we were able to, Scott, correct me if I'm wrong, but get about 4,000 one-pagers put into our patient welcome books for patients to receive on admission. And then another thing that we did once that was that ended and we didn't have support to continue stuffing these welcome books was we created more permanent signage for the patient rooms. So we converted the one-pager into a vinyl cling that was distributed to all of the units participating in our pilot. And so no matter how many patients are cycling through admission, like the nurse can just be like, here it is.

I wanna go over this with you. Right.

But something I really wanna mention, it's obviously great for patients to have that and get that education from the staff and that support. But I think another thing that's been great about it is it's a reminder for the staff. We are here every day. We're living and breathing the hustle and bustle of the hospital environment, and it's very easy to forget that it's normal to us to be here and to be encountering all of the things that we encounter in a day. For some patients that come through the door, they've never been in the hospital.

Sure.

Or they're contending with a potentially really serious, you know, new diagnosis or a new chronic disease. And so it serves as a nice reminder for all of us that this can stir up some pretty serious emotions, and it's important that we all just take a minute to acknowledge that.

I'm so glad you said that, Karen, because I do think it's very easy for us if we have spent all of our time in educational process in hospital or medical arenas that we do sort of take for granted how we feel and how we look at it. Both of my parents were doctors, so I spent a lot of time in hospitals as a kid. And so when my friends would tell me that they had to go to the doctor and it was really scary, I'm like, why? Doctors are fine. I can go to the doctor's lounge. I can get food, man. This is great. Why are you scared? And I think when I was 15, 16, 17, and I started to realize, oh, well, I have insight that they don't have. But also too, I'd been in hospitals as a not sick person. It's very different when you're in the hospital as somebody who has an illness or a process or something that you're doing. It's a very, very different way of looking at the situation. And so the fact that you're giving not only something very concrete for patients to look at, it's okay to be overwhelmed. I think that's part of what's brilliant about what you're doing is that you're saying it's okay to feel this way. Because I think sometimes, oh, I'm not supposed to feel this. Yes, you are. You're supposed to feel this way. It's okay. But then also too, you're raising people who are in that water all the time that other people may not look at that environment the way they do. I think that's always a win when you can have somebody look at a situation differently than they otherwise. I think you're already halfway there to resolving a conflict when you do that. So one of the things that I think you can definitely say is as you have introduced these interventions, especially at Penn, that you're seeing a reduction in workplace violence events. So how big has this reduction been?

Yeah, since I collect a lot of the data, I could share some of that. You know, it is kind of an interesting thing to capture workplace violence. So, as was mentioned earlier, for a 3.5-year period, we were— our safety managers were Hashtagging events using standard definition, but how do you measure it over time and see a difference? So we used a measurement that we use for falls prevention, which is you know events over patient days times a thousand to sort of standardize it, and we saw a 58% reduction between our baseline fiscal year 23 and. fiscal year '26, and in our pilot units. And that compares with a 5% increase in the units that aren't yet in the pilot. So during the same period where one has gone down pretty dramatically, the other has basically been flat or went up a little bit.

That is tremendous. And I think that's something that not only We should really look at and look at what you guys have done. We should also celebrate that you have made real progress in decreasing workplace violence. And this is the kind of stuff that we want to disseminate. This is the reason why I'm so glad you guys were here. These are the things that people need to know about, especially if they're feeling like we don't know how to make these changes, because I feel like the way that you guys have addressed this is very deliberate. And in terms of building trust in the system of people who are depending on you to do it, you have— really devoted yourselves to building that trust. And I think the way that you look at this is understanding. And I think this is part of what, in my work on conflict, conflict is going to happen. It is a vital sign. It is a sign that something is going on. And I think rather than just closing your eyes to it and saying, well, we're just going to say that conflict's not going to exist. That's not reality. That is not what we see. But what you have done is you have said, not only are we going to understand that this is going to happen, we're going to prepare. We're going to exercise empathy. And you will develop a system with interdisciplinary guidance to actually help raise awareness to it and make it easier for patients to accept the idea that they have a way to express how they're feeling before it gets to a point that they feel like they have no other way to express it than through violence.

I'd reinforce what Christina said, though. It's really important to listen to the staff and so that they know we're Putting into place a way for them to be safe. And then I think once they know they are being listened to and cared for, I think you could bring in the other thing, the de-escalation and the anticipatory guidance. I think they'll be open to that and they'll be more receptive to it, I think.

I think it's that the overall empathetic and like humane component of hospitalization and being sick is not only are we We're trying to be empathetic towards the patients and understanding that they need psychological safety. Like, while they are hospitalized or sick or their loved one is, how are we addressing their concerns? It's the same thing for the staff, right? It's the same thing saying, how do we address their concerns? Do we want them to be afraid to come into work? You know, if they know they're going to be taking care of a volatile patient, like, are they going to be at their best if they're scared? Right? And then they're afraid of getting harmed or physically assaulted or verbally assaulted. And so those are the things that we thought about and said, what's the language? What's the commonality? How do we enable the staff to communicate with patients and the patients to communicate to the staff to say what their needs are and how do we meet them?

The thoughtfulness that you all put into this Really shows. And one of my mentors, Javi Marin, she's a PhD JD, has a wonderful phrase that I love in conflict resolution. And she says that trust is the coin of the realm. And what you guys have done is you have physically created trust, not only with providers, not only with staff, but also with patients as well. You have literally used anticipatory guidance to build trust in a system. It is phenomenal what you all have done. So, people who are listening to this, let's say they're walking into a shift, let's say they're walking into a 12 or a 24, what are some things they can do on their next shift? You know, obviously we want them to share the work that you guys are doing, but what are some things that they can put into action just right away?

I think, like I had spoken about earlier, I think just the dialogue. To me would be the most important thing. If something difficult just happened, instead of just going back, moving on to the next patient, find a moment when it's appropriate and talk about it before the shift is over. Make sure your manager knows about it. Make sure it's reported. I think just opening up that dialogue is a change that will happen, I think, with the right leadership, with the right culture change.

100%.

I was going to say something similar just to Take care of yourselves. Hopefully we can prevent these events from occurring, but if they do occur, make sure you're taking care of yourselves. Make sure you're utilizing resources that are available to you. This is impactful and we know about secondary trauma and we hope that ultimately people aren't victims of this in the future, but really sort of taking care of yourself just as you take care of your patients and leaning on your colleagues and your leadership. As Emmanuel mentioned. And then from the other sort of end of the coin, I think really just meeting your patients where they are, like we've talked a lot about, sitting with them 5 minutes, even the literature shows that's really impactful, just sitting, holding their hand, listening. And when patients feel heard, then you also feel this sense of we're working together and So hopefully we can prevent these events from occurring, but take care of yourself and take care of your patients. That would be my message.

I love that, Natalie. And I think that's a really huge message. I'm so glad you said that because I think sometimes we get caught in this idea that we don't have time to do those things. And that 5 minutes that you invest holding that patient's hand or hugging them or crying with them, whatever happens to be going on in their journey, Maybe the next 10 years that they trust the system, maybe a whole family or a whole group of friends that will trust healthcare because you took the time to do that. So, 100%.

I attended a conflict resolution workshop a few years ago that really changed my practice and changed how I view conflict in general. In my position, I'm often put in positions where I'm Dealing with people who are very upset about a variety of things. And one of the things that the instructor of this workshop taught us is that oftentimes maladaptive behaviors are often a symptom of some unmet need. So if someone is acting out, be curious. And the curiosity has made inroads with so many different situations, just keeping that curiosity and really working to understand, like, Okay, I understand what you're saying, but what's really underneath that? What is it that I can do beyond what you're asking for? Like, what is it that you need to feel seen or feel heard or feel acknowledged or feel some sense of power over the situation? So I would just encourage people to be curious. Don't take people at their word or their behavior. There's more to what you see or hear.

Oh my gosh, I love that so much. Thank you so much for saying that. And I think that curiosity is one of the most beautiful practices we can employ. And if there's one phrase that I wish I could banish forever in the field of medicine, it's the difficult patient. Wish I could throw that phrase away forever because there's no such thing. There's a patient we're just not curious enough about that we don't know what the backstory is.

Yeah.

And so I love the exercise of curiosity and conflict resolution is probably one of the most valuable things you can learn.

And I'm really glad that was something that If I could build on the curiosity theme, I think we do a pretty good job when we evaluate an event after the fact in terms of making sure the staff are safe, care for the care provider. We've crossed the T's and dotted the I's. But I think something that we may not be as curious about that could be helpful is, what did the staff learn? was setting the patient off and looking for themes because there might be something in our operations, delays, the ways that we're approaching patients that we could potentially work on. If there are patterns, maybe there are elements of our system that we could improve.

I love that. I love the idea that the exercise of curiosity isn't just a one-on-one, it's actually systemic. I think that's amazing, Scott. Absolutely. Christina, one thing that maybe people can take away?

I think from what Karen and everyone here has said, it's a lot. I truly believe that taking care of yourself, and I think for myself, learning in with the work that we've done here is the curiosity is super important, but also understanding like that trauma-informed approach. approach because there's a reason why sometimes patients or family members are exhibiting certain behaviors. It's a learned response or a maladaptive response. And I think that has what changed me as I now myself go into rooms when I go see patients. And if I'm having, like, as Karen says, like she had that conflict resolution course and says, be curious. I'm curious, but I'm also thinking in the back of my head, like, I wonder why. I wonder why, like, this patient or this family is being like this. Like, did something happen? Did they have a misunderstanding? Was there a medical error? Is there mistrust? And I think it's the curiosity that builds, but then we've delved into also, like, how are we truly understanding? Like, we're in the inner city, we're in Philadelphia, right? And so— Mm-hmm. Really having an understanding of that has truly changed my perspective and the way I interact with my patients. And I think if where it was a takeaway for anyone to come in here is be curious, take care of yourself, and then not only be curious, kind of also understand where the patients and families are coming from. It's not necessarily that they're just problematic, right? There's something most of the time also underlying those concerns.

Thank you so much.

I want to thank all of you for being here today. This has been an amazing conversation, and the work that you're all doing and the way that you have shown us how we can absolutely make progress in terms of workplace violence, and especially the work with anticipatory guidance, I think is incredible. I really can't even thank you all enough.

Thank you, Lee, for having us. This was a great experience. Thanks so much.

That is all I want. Honest to goodness, that is all I want is to have a way for you guys to share the wonderful work that you're doing. But I hope you all had fun doing it because I definitely am so grateful for this opportunity. I had a great time talking and meeting with all of you. This was fantastic. For all of our listeners on The Scalpel and Sword today, if this conversation resonated with you, I hope you'll take a moment to Please share it with a colleague, share it with your hospital system, take it to an administrator. Absolutely find out ways that you can start to use anticipatory guidance in your healthcare system. Listen to your patients, be curious, practice self-care, take care of yourself. And more than anything, peaceful warriors, until next time, be at peace. Every episode is an invitation To speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.