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Comprehensive Clinical Care

Position/Job Title

Clinical Nurse Specialist


Background: Workplace violence, patient, and staff safety continue to be a top priority and concern for Henry Ford Jackson Health (HFJH). Evaluating the current process at HFJH, there was no formal process to support clinical staff members to maintain patient and staff safety during acute behavioral health crises on medical inpatient units prior to the activation of a “Security Assistance”, or security personnel response to situations involving an actual or potential physical threat to patients, staff, visitors, or property. Maintaining patient and staff safety, decreasing workplace violence, and mitigating sentinel events is critical. Significance: Violence against health care workers is 20 percent higher than violence amongst other professions and is estimated to be exceptionally underreported. The Joint Commission and OSHA recommend the development of policies, programs, and response teams to decrease these potential violent acts. It is estimated that at least 50% of healthcare workers have experienced verbal abuse from patients and up to 25% of health care workers have been exposed to physical violence. Synthesis of Evidence: Based on level I through level VI evidence, it is recommended to implement activation criteria, de-escalation techniques, debriefing, and evaluation strategies with defined response personnel to promote workplace safety and decrease adverse events. It is predicted that the implementation of a behavioral emergency response team (BERT) will maintain patient and staff safety by applying evidence-based techniques and interventions to appropriately de-escalate patients. Through de-escalation, a BERT can decrease workplace violence, decrease security intervention, decrease restraint use, increase staff perception of workplace safety, and ease in caring for behavioral health patients on medical units. Aim: To improve patient and staff safety through the implementation of an evidence-based BERT, with dedicated, trained, team members, on medical inpatient units through rapid assistance to clinical staff members during acute behavioral escalating situations. Plan: Led by a clinical nurse specialist (CNS), collaborating with multidisciplinary key stakeholders, the project encompassed selecting metrics to track, creating activation criteria, de-escalation techniques, identifying members of the team, creating a policy and flowchart, a debriefing form, a BERT tracking tool, education for the clinical staff, electronic health record (EHR) integration, and an evaluation and sustainability plan. The BERT activation team members consist of a House Shift Manager or CNS, Security Officer, Unit specific Clinical Unit Leader, and Behavioral Health RN with the primary RN caring for the patient. CNS collaborated with behavioral health physicians, pharmacists and EHR liaisons to add a BERT medication order set for streamlined medication prescribing and administration. Do: Literature search, synthesis, and proposal for a BERT process. Key stakeholder buy-in obtained from Nursing Executive leadership. BERT team members identified, policy, education, debriefing form, and tracking tool created. Policy presented & approved, electronic health record implementation for BERT medications. Education provided to all clinical staff members. BERT process go-live 10/1/23. Check: Mock activations trialed prior to process go-live 10/1/23. Debriefing forms and internal reporting processes reviewed. Tracking forms included date, time, and location of the activation, if medications or restrained were utilized, if further security assistance was required, incidence of staff were harm, and opportunities for improvement. Act: Opportunities for improvement included streamlining the activation process with internal paging. Ongoing improvement monitored through activation debriefing forms, internal reporting processes, and an anonymous survey sent to the clinical staff members who activated the BERT. Implications for Nursing: A BERT process will improve the quality of care provided to patients by preserving patient and staff safety during behavioral health crisis events, while meeting the needs of the patient. To date, no staff have been harmed during a BERT activation. Staff have voiced their appreciation and support they have received from the BERT members. Strengths to this program include the ease of integration by utilizing current resources, creating a process when no formal process was in place, and supporting clinical staff in real time, at the bedside. Limitations include no physician oversight for the program. The BERT process will be continued at HFJ and operationalization at additional Henry Ford sites is being explored.

Publication Date


Combating Workplace Violence: The Implementation of a Behavioral Emergency Response Team