Implementation of a Standard Process to Recognize and Respond to Unacceptable and Aggressive Behaviors in a Pediatric Ambulatory Care Setting

Introduction: To address unacceptable and aggressive behaviors in patients and visitors, could implementation of a behavior escalation readiness and response process improve an ambulatory care clinic’s culture of safety? Healthcare workers are five times more likely to sustain a workplace violence injury than other professions, and workplace violence incidents are underreported. Incivility, though less severe than other types of mistreatments, may still result in significant impacts on healthcare worker well-being and patient care. Both incivility and workplace violence in healthcare can pose great physical and psychological safety risks for patients and healthcare workers. The American Academy of Ambulatory Care Nursing (AAACN) recognizes the need for a behavior escalation readiness and response process to enhance safety in ambulatory care settings.
Methods: Data was collected from a freestanding pediatric ambulatory care clinic with 23 specialty divisions, serving nearly 1000 patients daily and employing 500 associates across four locations. A multidisciplinary continuous improvement event in December 2023 utilized results from a voluntary survey of associates to assess their knowledge of resources and reporting related to behavior escalations. Multiple perspectives were considered, including feedback from the youth advisory council, the patient experience team, associate interviews, and data from another healthcare system. A tiered process for behavior escalation readiness and response was developed, including a patient and visitor escalation (PAVE) response team to address escalating behaviors. Educational sessions, stress first aid training, and mock scenarios were conducted with the newly formed PAVE response team. After PAVE team training was completed, all patient and visitor facing associates were offered a two-hour training to recognize escalating behaviors, empower them to apply de-escalation skills, and request PAVE team support.
Results: Post-training evaluations revealed positive feedback from associates, emphasizing feeling supported, heard, and confidence in de-escalation. Post-implementation survey data showed an increase in knowledge regarding resource utilization, response processes, and event reporting specific to behavior escalations. Weekly audits of escalation events ensure appropriate utilization of the process further supporting and empowering associates. This includes debriefing with associate wellness resources and verifying event report documentation is appropriately entered.
Discussion: Challenges included protected time for training and variable staffing ratios at other sites. Training was adapted to accommodate providers’ limited opportunities to attend the two-hour training. An abbreviated process is being created for smaller sites with less leadership support. Ongoing leadership commitment and awareness are essential to sustain progress. Future educational sessions will refresh current associates and capture new ones. The goal is to make the process portable across all locations, reducing variability in processes, language, and training. In summary, implementing a behavioral response process significantly enhances safety and well-being for both patients and associates in a pediatric ambulatory care setting.