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October 6, 2022

Conflict in a Childrens Hospital

Conflict in a Childrens Hospital - interview with Gerard O'Dea

Gerard: I'm Gerard O'Dea, Director of Training here at Dynamis, and I'm going to be talking to you today about one of our recent training courses.

Vanessa: What was the training course and how did you prepare for it?

Gerard: We were asked to help by providing a trainer program which would address the Conflict in a Childrens Hospital. Essentially, we were there to prepare their training team so that they could deliver an in-house training program to help all the different staff at the hospital in the different ways that they might have to interact with visitors or patients coming in and at varying levels of cooperation with the demands of the hospital, keeping everybody safe.

Vanessa: What particular problems and challenges were the team experiencing in managing Conflict in a Childrens Hospital?

Gerard: When you first start doing a training needs analysis at a hospital, you could be forgiven to expect that many of the issues you're going to have are between the clinical staff and the patients. For example, difficulties in asking people to take their meds or finding confused people in the corridors who need to be helped to go to where they're going. But at this hospital we quickly found, and it is true at many hospitals - which you find when you do the trainings analysis - is that there's so much going on!

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There's so many people who visit our hospitals that you end up considering all sorts of scenarios when you look at conflict in a childrens hospital. To start with there's various levels of staff. So you have what we might call the gatekeeper staff, people whose job is to make sure people get to the right place or that things get to the right place. You've got your porters, you've got your reception staff, things like that.

Security often fill that role as well. Then you have clinical staff and nursing, doctors and specialists. They all fulfill different roles, and so the types of conflict they get into are also really varied.

We did some surveys with the team and found out some of the challenges that they're having. And then of course, what we like to do is when we start the training, we always start with a fairly in-depth discussion really about what are the most common, most risky, most challenging 'conflict in a childrens hospital' situations that the teams are getting into. And then we use those as the curriculum for the training programme.

Vanessa: So it's quite specific to the experiences that the team themselves were telling you about?

Gerard: Yeah, absolutely. We have to do that, to make sure that the training is relevant, appropriate and beneficial.

Often we talk about having four or five core (in this instance 'conflict in a childrens hospital') scenarios that we will use with a team, but with this team (and because they are trainers as well,) they are going to have to cover everything that goes on at the hospital, all the different kinds of encounter. I think we ended up isolating nine different scenarios that they would work on to be able to deliver training sessions based around one of those scenarios or all of them for some of the staff.

Vanessa: It would be good to hear an example of one of those scenarios. So a common problem that was being experienced by the teams in the hospital?

Gerard: Going back to one of the earlier points, one of the things you find at the children's hospital in particular is that the staff are always having to deal with parents. So parents who are stressed out, afraid, scared, worried about their kids, and then maybe they also have very high expectations of what the hospital can do, what the staff can do.

So in this instance, one of the key 'conflict in a childrens hospital' scenarios that we worked on very early in the course was a staff member coming across a parent who wanted to have an extra bed put into the child's room so that they could stay over, so that they could rest when they needed to and be there when the child wakes up, and situations like that.

Of course, you can't have every room at a hospital able to have another bed put into it, (you wouldn't have enough beds!) you wouldn't have enough space and so on. So the facts are, the rules of the hospital are “that can't happen”. The tricky bit comes then when sometimes the staff have to make exceptions for that - quite justifiably as well in some cases.

So that's a really good scenario for us to work on because there are things the staff can do before they arrive into that situation to prepare themselves and achieve what we call emotional equilibrium, so they can be better prepared in a better space, in control of themselves as they walk into that situation. So there's actually quite a bit of work to do on that end of things.

And then as they come through that doorway and they encounter the parents, we have a set of tools called non-escalation. So how do you present yourself? How do you introduce yourself? How do you make first contact with somebody in such a way that the interaction is more likely to go in a good direction?  We know that people respond to clinicians' use of language very strongly.

And then there's listening carefully and empathizing with the person, and trying to find a solution, even though there might be rules, procedures, policy that you have to navigate in doing that. So that by itself, that one scenario was really, really useful for us to start putting in sort of a foundation of managing conflict effectively and professionally communicating.

Vanessa: Most inspiring or the best moment on the 'conflict in a childrens hospital' training, from your perspective as the trainer?

Gerard: As a person leading a train the trainer course, one of the key moments you have is when you realise that these people who walked in on first day of the training course to become trainers - often they come in and they're quite anxious really about the pressure about becoming a trainer, and especially about becoming a trainer in conflict, and then even more so in becoming a trainer in physical interventions. Not everybody has the background in doing physical skills training.

So the key moment, I suppose, is when you turn around maybe halfway, two-thirds of the way through a hospital violence reduction trainer course and you start giving instructor candidates more opportunities to teach. Now on our courses, an instructor candidate gets an opportunity to teach on day one, which I think is relatively unusual, but that's the way we do it. But maybe half or two-thirds of the way through when you give them maybe a longer block of the course to teach, and then you see them stand up in front of a group and actually start doing the work of being a trainer, instructing the skills, having the practices going on in front of them, and then providing feedback - that's a really good moment.

I think it's testament to being able to take people on that journey from being unsure if they can do it, to then actually doing it for the first time really competently. That's really good.

Find out more about our Hospital Violence Management courses:   https://www.dynamis.training/hospital-violence-management/  

To learn more out about our Trainer-level courses:  https://www.dynamis.training/trainers/

Vanessa: Did they have any particular challenges or particular parts that they appreciated very much?

Gerard: Well, what we covered with them in order to make the hospital violence reduction training program they're going to deliver as robust and as broad as possible (albeit limited to conflict in a childrens hospital) was we covered off a full suite of conflict management methods. So we covered things like non-excalation, deescalation. So non-excalation means how to have everyday interactions with people at the hospital, whether they be visitors or patients or other people, colleagues from different departments even, and how to have these everyday interactions with them in such a way that they don't become something that then deteriorates, if you like, how we treat people in that initial contact and listen to them and empathize with them.

Another topic in that conflict management methodology is deescalation. Many of the more senior staff will only be called to talk to a patient after something's gone wrong, after a complaint's been declared or an issue's been disclosed or somebody's getting upset. So they literally have to turn a corner and immediately go to work by slowing things down and deescalating a situation, forging a compassionate connection with the person in front of them.

And then especially for the mental health staff, for some of the emergency department staff, some of the time, they need to be able to recognize when somebody's in crisis, when we've got an emotionally disturbed person standing in front of them and they need a slightly more specific and a slightly more empathetic methodology to deal with them. We call it crisis management or dealing with people with cognitive difficulties. So that was the foundation - how do you, with your words and with your behavior, make sure that we're keeping everybody safe?

On top of that, we build a whole platform of physical skills. We call them protective physical interventions - from low level prompting and guiding where somebody just needs help to understand where they need to go and maybe a physical touch would be the best thing to do for them. We work on personal safety tactics, how to protect yourself if somebody's, for want of a better word, lashing out. And then moving towards holding tactics for some lower risks situations with children. And then beyond that, looking at holding tactics and physical interventions and how to stabilize somebody if there's more risk, these higher-risk encounters which we talk about. A full spectrum of those protective physical interventions would be needed to cover all of the potential conflict in a childrens hospital.

Because this was an instructor course, the third pillar was the scenario driven training approach (scena). Very unique to the way we do things and based on work we do with Professor Chris Cushion at Loughborough University. We teach the trainers how to deliver the training in-context. So that's why we talk about scenarios all the time, and it is a very specific, very high level methodology for trainers to create really engaging, efficient, and effective training sessions.

Throughout those three things - I was just reviewing the comments from the learners today - the guys found that in all three of those domains, there was something that really helped them in their work. How to talk to people, how to keep yourself and others safe. And then for this team who were going to have to teach a training programme, the scenario driven methodology was really helpful. So I've started talking about the three pillars of our approach, and I think they support each other really well. It creates effective training, so I think they appreciate many aspects of it.

There's probably one area that stands out and a little pet topic of mine, which is breakaway skills and self-protection, personal safety training. We've really boiled that down into something that's very simple, can be learned relatively quickly. It can be learned well in any block of time that you give me. So if you give learners for an hour, I can teach them something very simple that can help them to stay safe in the context of conflict in a childrens hospital. Now, if you give them to me for three hours or a full day or two days just to focus on personal safety, then we can build on that. But it's building on their ability to do those simple things as opposed to building it out wider in terms of more skills.

A lot of the breakaway skills that we see, they're kind of on a one to-one relationship with what the assault is, being grabbed by the lapel, and then there's a technique for that. So it's a one-to-one ratio.

Vanessa: So a lot of content, in other words, because there's numerous different ways you could be assaulted as a member of a healthcare or hospital team...

Gerard: That's right. So historically, there's been about 15 techniques - somebody decided that somewhere in the teens was the right number of different ways that you could be assaulted, being hit, being grabbed, being grabbed by the arm, grabbed by the hair are the types that we see - somewhere along the way, it evolved into having 15 different techniques for 15 different assaults, or more!

But we've been able to break that down and really look at the way those assaults develop, and then the way the human body works and put that together in such a way that the breakaway system we teach is really, really quick to learn initially. And then it can be refined over time, but most of the learners, and definitely the trainers really appreciate that because it cuts down the amount of things the learners have to try and remember when learning how to deal with conflict in a childrens hospital.

As we know, in a real, serious physical confrontation, you can't stop to “try and remember”. You just have to act - and get free, and break-away and get to safety. So I'm really proud of the work we do on that particular skill set because it always produces really good results and people walk out of the room feeling much more confident.

Vanessa: Were there any particular challenging moments for this particular training or any surprises?

Gerard: I suppose the constant challenge when you look at conflict in a childrens hospital anywhere in the world, is that you have language barriers and then you've got cultural differences, and then you might even have other things that pop up that are somewhere between the two. So language is one thing, but then how people communicate is another. So what's persuasive in one culture can appear aggressive in another. What's a redirection in one culture can look like fobbing somebody off in another, or be very triggering for somebody.

One of the key strategies we teach in a redirection is that if somebody's being abusive or resistant with you, or they're throwing a few insults your way, "You're slow, you're too slow, you're not good at your job," whatever it might be, that you would say to them that you understand that they're feeling frustrated at the situation they're in, but that you're doing your best to help, and you might suggest some solutions, but actually, recognizing that somebody is frustrated and then saying it out loud, in some cultures that can actually be seen as quite a trigger.

So there were some issues around language and culture, which we've been navigating for many years now, really. But when you look at trainers who are considering these things for the first time, it can be pretty tricky to navigate.

Vanessa: So are there any recommendations that you would make to other healthcare organizations, based on your observations and experiences with this particular group?


Should hospitals be working on communication skills with their staff? I think the answer is yes.

On this course, we actually brought in a group of novice learners. On one afternoon, about two-thirds of the way through the course, we actually got a bunch of the ED nurses to come up and stand in the room, and then we let our new instructors loose on them. But what was really interesting is that many of them had never had any in input on communication skills or personal safety skills, probably since they'd done their initial training (if they'd done any of that during their initial training!).

So small things like being aware of their distance and positioning, their body language, how they make that first interaction with a patient when they come into the hospital. There's an awful lot there that sets the tone for how things will progress from that point. Of course, we get a lot of those ideas from our partners at Vistelar. This is a core idea, of setting the social contract and reinforcing the social contract to reduce conflict in a childrens hospital at every touch point.

Our colleague, Joe Lashley tells this story about the library principle. Very simply, people who arrive into a library…we can assume that they know how to behave. Everybody knows the rules in the library, but people turning up in the emergency department or hospital, they have many expectations. They're very stressed and they don't necessarily have an awareness of or previous learning about how to behave in an emergency department. So our staff have to help them.

If they raise their voice, our staff need to help them to understand that that's perhaps not the best way to get what they need at this time. And so the idea that hospitals would just hope or assume that their nurses, clinical staff, even their gatekeepers, can effectively communicate with all of the visitors and the people coming in to the hospital, some of them for the first time, I think that's a real issue, that if we're trying to improve our patient satisfaction scores, if we're just trying to reduce conflict, if we're trying to bring our number of restraint incidents down, that can be the first place to start, rather than looking at personal safety as a first topic or even physical interventions.

So really how do you set up the social contract? How do you educate the people coming into your hospital as to how we're going to treat each other, how we're going to do business? As my colleague and mentor, Gary Klugiewicz says, we have to set this supportive atmosphere from the very beginning, and we have seen training can really help with that.

Find out more about our Hospital Violence Management courses:   https://www.dynamis.training/hospital-violence-management/  

 To learn more out about our Trainer-level courses:  https://www.dynamis.training/trainers/

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Gerard O'Dea

Gerard O'Dea is the Director of Training for Dynamis. Training Advisor, Speaker, Author and Expert Witness on Personal Safety, Conflict Management and Physical Interventions, he is the European Advisor for Vistelar Conflict Management, a global programme focussing on the spectrum of human conflict.

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