Background/Significance: PES nurses are highly skilled in crisis de-escalation and management of violent and manipulative patients. Because of their focus on the recovery model and trauma-informed care, PES nurses are poised to directly influence the culture of safety through the nursing role of the BERT team. The BERT team has been serving the hospital since July 2013 and has positively impacted safety throughout the institution.
BERT is a multidisciplinary team consisting of a PES nurse, a security officer, and a clergy member. Although any BERT team member can take the lead role on a BERT call, the PES nurse is frequently the team leader and the team member who enters documentation into the medical record. BERT is available throughout the hospital 24/7 and team members respond within fifteen minutes of receiving the call. This behavioral team can be likened to a medical Rapid Response team.
Through their role in BERT, PES nurses are able to role model de-escalation techniques, motivational interviewing, crisis de-escalation, and collaborative problem solving with security, clergy, social work, and the healthcare treatment team. Petska, et al, (2012) emphasizes the importance of the role of the psychiatric nurse and states that the psychiatric nurse often will serve as the team leader. PES nurses often lead a debriefing after the call to empower staff with tools to manage challenging patients and to encourage staff as they provide excellent care to patients and families.
Methods: BERT is based on the medical Rapid Response team model, which means that early intervention is key and safety is priority. The team contains a security officer, clergy member, and a PES nurse who has been specially trained to be a BERT nurse. There is a BERT Algorithm to assist staff in prioritizing safety and implementing patient and family centered care. Loucks, Rutledge, Hatch, & Morrison (2010) discussed their development of a BERT activation as a tool for staff to use; however, they mention that even after the development of tools and the BERT team, staff remained uncomfortable with psychiatric patients on the medical units. This shows the importance of PES nurses acting as role models to other healthcare team members to show them how to best de-escalate patients.
By utilizing Substance Abuse and Mental Health Services Administration’s (SAMHSA) trauma informed care and the recovery model, PES nurses are able to teach and role model how to build rapport with challenging clients and their families. Using motivational interviewing techniques to guide their interactions, PES nurses attempt to identify the reason behind a client or family member’s behavior and work to identify mutually beneficial solutions. SAMHSA’s four dimensions of recovery help PES nurses to best identify areas impeding the clients progress toward their goals (2017).
In addition, PES nurse have shown their commitment to the MANDT training system and have been instrumental in role modeling these techniques and encouraging other hospital disciplines and units to be trained in MANDT. MANDT training is mandated as yearly training for all PES nurses and teaches staff the importance of implementing de-escalation techniques. Richmond, et al (2012) discusses the importance of verbal de-escalation to engage the patient and to manage agitated behavior. Because of PES’s role in embracing MANDT, there are now MANDT champions throughout hospital units and disciplines.
Armed with all of these tools and models, BERT nurses focus on collaborative problem solving with the goal of strengthening and supporting the interdisciplinary team to deliver high-quality and patient and family centered care and to reduce workplace violence from patients and visitors.
Results: In 2016, PES BERT nurses responded to 103 BERT calls. Most recently, PES BERT nurses responded to 115 BERT calls in 2017 with an average time of twenty-four minutes spent on each call. Weinberg 7 (MICU) was the highest utilizer of BERT services with 21 calls (18% of total calls) in 2017. 27% of the 2017 BERT calls were based on responding to aggressive or violent behavior, and 17% of calls were to assist unit staff with patients who were confused.
In a study on the effectiveness of BERT implementation, Zicko, Schroeder, Byers, Taylor, & Spence (2017) found that after BERT was implemented, unit staff experienced fewer assaults from patients and had a decreased incidence of seclusion and restraint. While no specific data has been collected, PES nurses have reported that they have intervene and de-escalate patients who had previous history of assault and were threatening to harm staff.
Conclusion: Violence toward healthcare workers has become so prevalent that the Joint Commission recently issued a Sentinel Event Alert in April 2018 that addressed the widespread violence that healthcare workers experience. This violence is unacceptable and BERT is one of the ways that this inner city hospital is addressing it. BERT has been instrumental in creating and maintaining an environment of increased safety for patients, families, and staff throughout the hospital. 31/115 BERT calls in 2017 were for aggressive or violent behavior and 6/115 BERT calls were to intervene after a patient had assaulted staff. This data shows the value and role of BERT in helping to de-escalate and support staff when managing patients who are aggressive or violent.
As part of BERT, PES nurses apply their expertise of de-escalation, crisis management, trauma-informed care, and MANDT knowledge on BERT calls. With this needed presence on each BERT call, PES nurses serve as leaders in helping to manage violence and aggression. The BERT team works with the interdisciplinary treatment team to enhance overall environmental safety, accomplish clinical goals, and empower patients to safely participate in their care. PES nurses often act as advocate for the patient and assist the patient in effectively communicating concerns to their treatment team. PES nurses are also working closely with the Workplace Violence Prevention Committee to identify opportunities to collaborate with other units and to advocate for the utilization of BERT.
Next steps for BERT include implementing hospital-wide re-education about the benefits and uses of BERT. Also, PES nurses should follow up with patients and/or unit staff to determine additional benefits of BERT response and additional opportunities to assist unit staff to provide quality patient and family centered care and improve patient satisfaction.