Background: Workplace violence in healthcare is a growing and global problem with verbal violence as the most prevalent form of workplace violence experienced by nurses. For ambulatory care nurses, verbal violence may also occur over the telephone while triaging and providing patient care. Calls may manifest as yelling, cursing, and threatening (reactive expressive) but may also be comprised of snide remarks, personally or professionally attacks, and language containing sexual or racial slurs (passive aggressive). To de-escalate and manage these violent calls real time in a professional manner can be challenging. The purpose of this program was to establish organizationally approved de-escalation scripting tools, develop support structures to terminate a call if necessary, and expand documentation procedures to include verbally violent telephonic events.
Methods: Development of scripting phrases, call termination procedures, and documentation were created with support from ambulatory care leaders, patient experience, behavioral health, patient and family advisors, security, and risk and legal consults. The scripting and the decision algorithm were trialed and revised several times over the course of a year. Algorithm starts with service recovery (addressing the problem), de-escalation attempts, back-to-service recovery OR call termination, post-event documentation, and staff support. Process includes management of threats, those which are categorized as “imminent danger” requiring emergency response or “non-imminent” addressed by organizational security. Nurses were extensively involved and contributed to the final scripting product, development of electronic documentation, and reporting. Post-event self-care was built into the process for nurses to recover after these difficult calls.
Results: Initially, nurses were reluctant to set limits with verbally violent callers and would “just take it,” or they transferred to a clinic leader who was, in turn, exposed to the verbal violence. Nurses needed reassurance and empowerment to manage the calls professionally and terminate the call if necessary. A third of the nurses reported they received one to four verbally violent calls per week to more than three a day. 88% of nurses reported being emotionally impacted by these calls with more than a third reporting being upset more than an hour, affecting their productivity. However, nurses rarely terminated calls; three calls were terminated in three months with more than 100 nurses using the algorithm. Post-event documentation included call content, call outcome, and event reporting, which increased by 33% from before the process was initiated. Self-care after verbally violent events allowed for debriefs, peer support, a break for breathing, taking short walks, or chair yoga.
Discussion: Verbal violence, even verbal violence over the telephone, is negatively impactful on nurses and nursing care. Considering verbal violence is a precursor to physical forms of violence, managing and de-escalating telephone verbal violence is essential for proactive management of workplace violence. Providing nurses the structure to de-escalate and manage verbally violent calls in a professional manner allows for individual critical thinking and empowerment without exposing others, such as leaders, who are transferred angry callers, to the violent events. This type of structure and process is integral to a culture of zero tolerance within ambulatory care when addressing workplace violence.