Larry Beresford
Douglas Brant, age 56, an experienced home healthcare nurse with Providence VNA in Spokane, WA, was shot and killed by his patient’s grandson during a home visit on December 1, 2022. It was his first visit to the patient’s home, and the grandson was said to have a history of mental health issues and physical aggression.
Although this is one of only a few known instances of fatalities for home-visiting staff of home care, hospice, or palliative care teams, there have been many more cases of verbal or physical abuse, aggression, intimidation, or harassment. Data are spotty, but cases of gun threats, aggressive dogs, known psychiatric issues, criminal activity such as drug dealing, theft of property, dangerous or unhygienic conditions, heated conflicts between family members, and the like do happen. And we know that healthcare and social assistance workers overall are five times more likely to experience workplace violence than workers in other industries.1
This violence might be considered the other side of the coin from the dilemmas of the elder abuse silent epidemic described in the last Quarterly newsletter. It can greatly impact staff, causing burnout, depression, anxiety, post-traumatic stress disorder, and decisions to leave the field. But it can also make it harder for hospice teams to ensure equal access to care for all eligible patients if fears for personal safety limit the team’s ability to respond to patients in unsafe neighborhoods or problematic living situations. How do agencies balance these competing demands?
Bethany Snider, MD HMDC FAAHPM, senior vice president and chief medical officer of Hosparus Health, a hospice and palliative care organization based in Louisville, KY, said her agency has experienced instances of threatened or actual violence. “Historically, in hospice care, we knew there was some inherent risk in this work, but it really wasn’t top of mind 15 years ago, 10 years ago even,” Dr. Snider said.
She recalled instances where she was accompanied on a home visit by a police escort, but that was rare. “I think over the past 4 years, this has become a much bigger challenge for our patients and our staff, where we’ve had to take proactive approaches to try to address concerns about safety and even violence in the workplace.”
Prepare for the Worst
“Some advice I give to colleagues at hospice and palliative care organizations is that you need to prepare for the worst,” Dr. Snider said. “You need good processes that you have developed and tested. What do staff do when they’re in a situation where they don’t feel safe? Who do they call? What do they say? And you need to practice those things, not just hope that they will work after you’ve taught them once in orientation.”
Dr. Snider described a situation where a Hosparus staff member called in to the office using the protocol taught to staff some years before—with a designated catch phrase to serve as a crisis signal for help. “The people who were supposed to be able to respond just didn’t remember the process,” she said. “So that’s something we learned along the way. Safety and security need to be an essential part of the culture of postacute organizations like hospices. I also think we have to think differently about how we prepare our staff.”
Based on its experience, Hosparus Health has invested more robustly in active aggression training and de-escalation training for the entire organization. According to Dr. Snider, “we brought in experts who had experience with the FBI and in law enforcement for the active aggressor training.” These experts taught Hosparus employees how to respond, what to do, what to look for, and what should be considered red flags. “We have a cycle by which this education occurs at a set frequency to keep it top of mind, and then we do simulations,” she explained. “You have to be prepared at any site for anything to happen.”
“Step two is de-escalation training. We sent staff from our education department to get trained in teaching de-escalation techniques, how to react in those situations, trying to gauge (in a challenging encounter) whether this is grief…[or] anger—figuring out what is driving it and then how we can de-escalate the situation.”
Dr. Snider said the underlying concepts of de-escalation are inherent to hospice clinicians. “It’s about how you listen to people, how you validate emotions. What we had to do is to take the skills they already had, from their experiences [of having] difficult conversations with people, and then help them see how to apply this to the emotions of safety and security when those are under threat.”
The underlying concepts of de-escalation are inherent to hospice clinicians. “It’s about how you listen to people, how you validate emotions.”
The coursework also helps staff better understand the grief and trauma they have experienced in their own lives. “It’s different for everybody, but until you have some awareness of what those triggers look like for you, it’s harder to successfully de-escalate, because you may find yourself in a situation that is a trigger for you,” she said.
“The other thing we’re doing is investing in technology that will [help] staff to feel safe and [allow them to] notify someone for help if they should find themselves in difficult situations—not just threatened violence but other kinds of emergencies as well.” Hosparus is preparing to implement a new system, which a few other hospice organizations have adopted, that uses a stand-alone button to silently call for help, with the notification going to EMS or the police to be dispatched to wherever the caller is. These services can also offer 24-hour access for staff as an employee benefit, even when they’re not working, Dr. Snider said. “They’d still have an easy way to call for help when they are in a scary situation.”
A New Generation of Staff
Bluegrass Care Navigators, based in Lexington, KY, is committed to promoting staff safety, says Eugenia Smither, vice president for quality and compliance for the diversified hospice and palliative care agency. “We’re in a place today where a new generation of healthcare workers is coming in without experience of providing care in the home and not comfortable going into patients’ homes.”
“We’re in a place today where a new generation of healthcare workers is coming in without experience of providing care in the home and not comfortable going into patients’ homes.”
These new employees are not as ready for what can happen in the home, where the patient and family have much more control, Smither said. That is in contrast to experienced hospice staff who sometimes say they’ve seen everything in their professional work life. The hospice patient’s home is inherently a chaotic, dynamic situation because at its center is a dying individual.
“If they’re yelling, you lower your voice. If they’re challenging you, you try to redirect them. If you are being verbally abused, tell them if that behavior doesn’t stop, you’re going to leave. You have to trust your judgment when you’re out there alone; you know when something doesn’t feel right.” And all incidents should be reported—including near misses. “We ask clinicians to report information into our system, so we can track how often this is happening,” Smither said.
Samuel Weisblatt, MD HMDC, a hospice team physician for VNS Health in Brooklyn, NY, is also involved in his agency’s extensive hospice and palliative medicine fellowship training. Roughly fifty fellows from numerous academic programs do rotations annually with VNS Health, which serves New York City, the ultimate urban environment. Fellows are expected to spend a minimum of 4 weeks going on home visits with the hospice team, observing how physician and nonphysician members of the team do their jobs.
“When fellows come to us, by and large, they’ve never been in a home of someone that they are taking care of. So I start with safety, because that’s critical. Of course, we want them to have a wonderful and educational experience, but without safety, there’s nothing. Years ago, I worked as a paramedic, and in that job the first thing you do when you arrive on the scene is to check for safety,” Dr. Weisblatt said.
“I also think it’s critically important to ensure that you have some degree of emotional awareness of your own experience in the home. I haven’t encountered violence per se, but in my experience, when things have escalated, it usually starts with a verbal altercation and voices being raised,” he said. “Then we have our own emotional response, and our sympathetic nervous system gets activated. But you really need to be able to think critically and tamp that down so that you can lower the heat of the encounter,” he said.
“Here we are extensively trained on safety tips, how to navigate spaces,” Dr. Weisblatt said. The training is interactive, with case discussions on how to make safe choices, things to look for that suggest you need to be acutely thinking about your safety, listening to your gut. “If we sense that there is a lack of safety, either in the home, or in the elevator or lobby, or even before getting to the building, we’re trained in how to navigate that safely, including not making the visit if we’re really concerned about our safety.”
Treating All Addresses the Same
VNS Health does not treat any NYC zip codes as too unsafe to visit and tries to view every address the same. “I can think of two occasions where I was uncomfortable enough with the surroundings that I did not enter a building because I was acutely concerned about my safety,” Dr. Weisblatt related. “And in homes, I’ve had to use that same sense of having to decide: Do I need to leave right now? Is this enough of a safety threat? Was some illegal activity taking place in another room, and was that a direct threat to me? In one such case I was able to finish the visit without concerns for my safety,” he said.
“But it led to a multitiered discussion with our team, our manager, and our senior leadership about whether this was a situation where we could no longer continue to provide the care. Ultimately, we were able to provide the care to the person, who died comfortably in their home.” That was done by making all subsequent visits jointly, with at least two clinicians present, and everyone who went to that home was offered the availability of a security guard to accompany them.
VNS Health also offers a great deal of staff support such as an employee assistance program, access to mental health professionals, and opportunities to join support groups. “It wouldn’t be unusual that one of their expressed concerns would be: ‘You know, I visited a home, I was terrified. I’m trying to sort that out.’”
Staff wear agency uniforms, which clearly display its logo, identifying the person as a health care worker. That can be a protective factor in safely entering and exiting some locations, he said. “Our agency does a good job of getting our name out there in the community.”
And there is a safety app from AlertMedia, an emergency alert notification system, loaded onto agency work phones; when clinicians activate it, the information goes directly to local police. All VNS Health staff can also receive alerts via text, email, and voice messaging, with a template for safety check messages and alerts regarding violent crimes and other civil unrest that impact their service area.
Know Your Community
Michael E. Knower, MD FAAHPM, is a family medicine–trained physician and retired medical director of St. Charles Hospice in Central Oregon. “We’re for the most part very rural,” he said, and gun ownership is common locally. “One of our newer social workers was told that some patients had firearms in the home, and [they] had a problem with that. This is an area where a one-size-fits-all approach isn’t going to work.”
First and foremost, Dr. Knower said, hospice and palliative professionals need to know their community, know their patients, know their environment, know the risks. “For example, if you know the person has mental health issues or a proclivity to violence, you need to take steps.” In this case, gun ownership was normal for this community. “But when one of our team feels unsafe going into a home, they are not obligated to continue making home visits there.” And the agency’s administration needs to take staff at their word, he said.
First and foremost…hospice and palliative professionals need to know their community, know their patients, know their environment, know the risks.
A nurse who was an Army veteran was visiting a patient who was also a vet and who lived 20 miles out of town on property surrounded by six-foot high deer fencing. “When he arrived, the patient said to him, ‘I was just now sitting here with my [hunting] rifle. I could see you at my gate through the scope.’” The agency had an interdisciplinary team meeting, and the consensus was to discharge that person because staff did not feel safe—which is one of the recognized criteria for discharge from hospice.
What Else Can Hospices Do?
What else can agencies do to protect their staff? To the extent possible, consider limiting visits to daytime hours. Use communication systems to inform the agency’s command center when each visit starts and finishes and where and when visiting staff are going next. Let the family know when you’re coming so they can look out for you.
Develop closer working relations with local law enforcement agencies. When visiting apartment buildings, try to check in with a desk clerk or security clerk or any other available staff. Have detailed, accurate directions to each patient’s home before you leave the office. Make a habit of paying close attention to surroundings, and know where the nearest exits are. Keep your parked car locked and as empty as possible.
Some hospices insist that weapons be secured in the patient’s home before staff will come to visit. Others ask screening questions about firearms and a history of violent behavior before visits are made. There are various violence and aggression assessment tools2,3 that can be used with patients, who can also be asked to sign a “No Harm & Safe Environment Contract.”
Physical self-defense training (eg, how to extricate yourself from a choke hold) may be helpful in some situations, although we shouldn’t expect hospice staff to become fighters. Depending on local ordinances, some hospices might consider permitting staff to carry firearms for self-defense, just like a few EMS services do today4—but that is not likely to be a comforting solution for most hospice professionals.
“I think having multifaceted strategies for safety is really important,” Dr. Snider said. “It’s a real issue that organizations cannot ignore. We need frontline staff to help create part of the solution so we can actually build something that works for them.”
“I think having multifaceted strategies for safety is really important…It’s a real issue that organizations cannot ignore.”
One key to understanding the issues is that hospice teams are invited in to care for people in their homes, which are a big part of what defines them. “I’ve absolutely been in homes where guns are present and visible. And part of the challenge is that some communities are dangerous for the patient and family, so that gun represents safety and security for them. They don’t feel threatened by me,” she said. “But it comes down to awareness of those things, right?”
Dr. Snider recommends that hospice and palliative medicine administrators make a point of going on home visits with their staff to see these kinds of situations in person. “And I’m not just talking about one visit. Get in a routine where you regularly experience what it feels like as a care provider to be vulnerable and not in control of a situation in the home when emotions are already high,” she said.
Hospice staff “do an extraordinary job across the country in trying to manage really difficult situations with flexibility and creativity and compassion. Where I see organizations fail to meet the needs of their staff is when administrators don’t walk alongside them to see what the work really looks and feels like. That’s why I still make joint home visits today, even though I’m in an executive position, so I can see the challenges that our staff face.”
References
- Lim MC, Jeffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: the risk factors, implications and collaborative preventive measures. Ann Med Surg (Lond). 2022;78:103727. doi:10.1016/j.amsu.2022.103727.
- Violence Risk Assessment Tools. The National Institute for Occupational Safety and Health. Updated May 16, 2024. Accessed December 19, 2024. https://wwwn.cdc.gov/WPVHC/Nurses/Course/Slide/Unit6_8.
- Sammut D, Hallett N, Lees-Deutsch L, Dickens GL. A systematic review of violence risk assessment tools currently used in emergency care settings. J Emerg Nurs. 2022;49(3):371-386.
- Lawrence R. Arming the EMS workforce. EMS 1. Published February 21, 2020. Accessed December 19, 2024. https://www.ems1.com/tactical-ems/articles/arming-the-ems-workforce-vs415d0LXsJDATkW/.
Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.