Staff need to know when and how to get help

A comprehensive manual containing up-to-date policies, procedures, and referral information, as well as on-going staff training in de-escalation, medical triage, and crisis management is essential. Program operators must ensure that staff are sufficiently trained and that the necessary supports are in place. Crises are easier to manage when staff feel competent and supported.

When dealing with crises, there is a need for immediate, secondary, and follow-up responses. Effective responses not only defuse the particular situation, but also contribute to a safer environment for residents and staff. In a crisis, the first staff member to respond usually becomes the crisis manager and directs other staff and residents. Staff should observe and "size up" the situation before taking action. While there is often more than one correct way to respond, drills can help staff develop and practice appropriate responses.

Threatening/escalated behaviouris the most common crisis that a Safe Haven will face. This type of behaviour includes: raising of one's voice, yelling or screaming, subtle or veiled threats, cursing, increased psychomotor activity, irritability, accusations, intrusions, and gestures or positioning with or without objects that suggest throwing or hitting. It has several possible causes: a mental illness; response to being close to others after having been isolated; interaction between two or more people with untreated mental illness; substance abuse, adjustment to new structures and routines; and perceptions of intrusion by staff and other residents. Threatening behaviour may pose a danger to other residents or staff. In cases of threatening behaviour, staff need to attempt to calm the resident through body language, a soft, low voice, and comforting, empathic language. De-escalation may also include attempts to distract the resident; persuade the resident to leave the area or ask the persons causing the behaviour to leave; request the person who is "bothering" the resident to leave the immediate vicinity for a time; or address the escalated resident's perceived needs. If de-escalation does not work, staff need to get help. Safe Havens should have a code system that alerts staff to a crisis. With a code system, a staff member would announce via intercom or in another way, "Code One in the dining room." Staff would know that there is a crisis in the dining room.

If a particular staff person is the target of the escalation, he or she should ordinarily leave the immediate vicinity once another staff member arrives. Only one staff member should ordinarily talk to the escalated resident. With sufficient staff, a "show of support" is often useful It may allow the resident to submit without losing face.

Staff, however, should look for signs that the resident is escalating even more due to the increased number of staff. In that case, the extra staff should remove themselves from the resident's view, but be close enough to respond if needed. The crisis manager will direct staff according to the resident's response. In cases where danger is clear and imminent, the crisis manager should ensure that, 911is telephoned immediately.

A secondary response would be gently guiding other residents who witnessed the crisis to a different area and assuring them of their safety. One follow-up response would be debriefing sessions, one with the residents and another with the staff. A few staff members may want to avoid the debriefing because it may be misperceived as a process of criticizing each other's interventions. When debriefing is done collegially, however, it builds the Safe Haven team and assists staff to develop insight and skills. Other follow-up responses include communicating the incident via progress notes, shift reports, or other means, and reviewing the escalated resident's care plan. A report on a crisis incident should include: 1) nature of the event and persons involved; 2) precipitating factors; 3) the chosen intervention; 4) information/alternatives/choices given the resident; 5) staff response; and 6) suggestions for responses to any future situation.

Staff generally should accompany the resident back to the Safe Haven upon discharge and ensure a smooth transition and welcome home.

On-going suicide assessment and a plan for intervention will be critical elements in the care plans of more than a few residents. While "suicide rounds" are generally inappropriate for Safe Havens, the Safe Haven and its staff need to be sensitive to the condition of residents in this situation. If program staff observes symptoms indicating an increased risk of suicide, it may increase staff monitoring and support, relay information to the resident's psychiatrist for a medication adjustment, or refer the resident to a crisis shelter or program.

If the resident is at high risk for self-harm, staff may need to attempt to persuade the resident to enter a hospital for a psychiatric evaluation. Obviously, a voluntary admission is preferable to an involuntary one. If a voluntary admission does not take place, the Safe Haven may have to initiate an order for involuntary transport. Ordinarily, staff should wait to tell the resident about the order until the transporting authorities have arrived in order to reduce risk of the resident fleeing the facility. When the authorities arrive, staff should assure the resident that they care about the resident and that a staff member will visit them at the hospital. Safe Haven clinical staff or the resident's psychiatric care provider will communicate pertinent information to the hospital.

Prior to visiting a resident, Safe Haven staff will in­quire of the resident if he or she needs any clothing or personal items, and then will bring the requested items. This kindness expresses to the resident the staffs com­mitment and esteem. Prior to discharge, the appropriate Safe Haven staff member will consult with the resident, hospital staff, and the care plan team to update the resident's care plan. Staff generally should accompany the resident back to Safe Haven upon discharge and ensure a smooth transition and welcome home.

Medical Emergencies are also likely to occur. A Code One and immediate call to 911 is warranted for any of the following:

- loss of consciousness;

- seizures lasting more than one minute or any seizure for a person without a history of -seizures;

- choking;

- deep lacerations;

- significant bleeding;

- appearance of confusion or significant person­ality change;

- severe numbness or tingling in or inability to move extremities;

- difficult breathing; or

- fainting.

If a Safe Haven has 24-hour on-call medical consultation, staff should call and receive direction for the following: inability to urinate or incontinence in a resident who usually does not have this problem, vomiting blood (looks like black coffee grounds), blood in their stool (looks like black tar), burns, severe abdominal pain, copious diarrhea and vomiting, allergic reactions to food/medication, sudden appearance of rash, or resident eats or drinks something not meant for consump­tion. If medical consultation is not available, staff should help the resident seek emergency treatment. The general rule is to err on the side of safety.

During a medical crisis, staff should attempt to distract other residents away from the immediate area of the crisis and advise them that an ambulance is on the way. If residents witness an incident, a debriefing meeting should take place. Communication is critical in emergency situations: communication between Safe Haven staff, administration, and collateral staff; communication of medical history and information to emergency and hospital staff; and receiving information from hospital staff on the course of treatment and discharge. After the emergency, the resident's care plan may need to be adjusted.

Safe Havens may also experience a missing person crisis. Occasionally, a Safe Haven resident may "disappear" for one or several days. This situation becomes a crisis when any of the following occur:

- The resident does not usually leave unannounced and is missing for an unusually long period of time;

- The resident does not return to pick up checks, food stamps, other entitlements, or allowances;

- Collateral contacts, including family, have not seen the resident;

- The resident has left important belongings behind;

- The resident needs to take medication for pressing health reasons.

In this type of situation, staff usually will contact hospitals, jails, police, diversion teams, crisis shelters, emergency shelters, and the coroner's office. Staff may also increase outreach efforts and collaborate with other outreach and social service providers in attempting to locate the resident The Safe Haven may also "get the word out" on the street that it is looking for the resident, if this approach would be in the resident's best interest The Safe Haven could also contact an agency that specializes in locating missing persons.

An outsider attempting to victimize a resident is an other type of crisis. This problem will vary depending on the location of a Safe Haven. Many Safe Havens are located in urban neighborhoods, which persons who are homeless frequent Many, if not most, Safe Haven residents have been victimized on the streets or in shelters. Predatory behavior and abuses of persons who are homeless and who have serious mental illnesses can include threat of or actual physical or sexual assault; financial abuse; persuasion of residents to use illegal substances to provide more income to dealers; and "setting up" residents to handle illegal drugs or drug-related money. Predators may be subtle about these activities and lead residents to believe that they are not in any danger by associating with them.

One prevention is to only allow approved visitors into Safe Haven facilities. Another is to have a single, monitored, and secure point of entry. A Safe Haven that has a drop-in center or in which screening or intake for services take place in the hours of operation should be sure to limit entrance to the residential areas of the facility.

A Crisis and A Response

The Scenario:

A resident, John, hears voices that command him to hitanother resident, Sarah, because she has planted a microchip in his brain so that the enemy can track him. Sarah gets a black eye.

Immediate Responses:

1) The staff member who witnesses the incident or who arrives at the scene first calls a Code One. Other staff respond;

2) The first staff member:

a) in view of other staff, asks John to come with her to a different location, to "cool off;"

b) assigns a second staff member to accompany Sarah to another area to calm her and assess her injury;

c) and, assigns a third staff member to assist and debrief other residents.

3) Based on John's care plan and staff assessment of the situation, staff request John to seek a voluntary psychiatric evaluation. John agrees and a staff member accompanies him to the hospital.

4) Staff administer appropriate first aid to Sarah and offer her the option of additional medical attention.

Secondary Responses:

1) Staff communicate relevant information on John to the appropriate hospital personnel;

2) Staff continue to comfort Sarah and assist her to process the incident;

3) Staff debrief the other residents who witnessed the issue;

4) Staff record and communicate information on this incident to other staff as appropriate;

5) Staff debrief the incident in a staff meeting.

Follow-up Responses:

1) Staff visit John in the hospital and work with him, hospital personnel, and care plan team to revise his care plan. Staff accompany John back to the Safe Haven upon discharge.

2)Staff prepare Sarah for John's return by listening to her concerns and assuring her that staff believes that John is safe.

3)(It is my experience that residents are very forgiving of each other's "incidents.")

4) Staff and residents warmly greet John upon his return and reassure him that, he is welcome.

5)Staff monitor John and Sarah, their interactions, and other residents' response to John.

6) Staff praise positive behaviour. If new medication seems to be a key factor in improved behaviour, staff point, out this benefit to John.

As a Safe Haven limits visitors and educates residents about issues of safety, predators may view staff as a threat, and staff may be at risk. If a non-resident enters the Safe Haven and escalates for whatever reason, staff should attempt to deescalate the individual with the goal of having the individual leave. If this does not work, a Code One should be called and 911 contacted.

All staff should be aware of any particular outside person who may pose a threat to residents or staff. The Safe Haven should have a set plan for responding to predictable incidents. For example, a resident has been harassed by a man about her entitlement checks. He comes to the Safe Haven on the day she receives her check and asks for her. If she is not there, or if staff are unwilling or unable to locate her for him, he escalates.

An immediate response may be for the person at the front desk to call for assistance as soon as the individual approaches and to have all staff present collectively inform him that they will not get the resident for him at that time or in the future. Secondary responses include informing the resident that the man is not an approved visitor. Staff may also accompany the resident on errands around the neighbourhood to send a message that the staff are watching out for the resident (While this approach may seem intrusive, residents are usually thankful for intervention because they often may have difficulties in setting boundaries themselves.) Follow-up responses may include seeking a court injunction against the outsider and addressing safely issues in house meetings or in the resident's care plan.

In conclusion, Safe Havens should expect that crises will occur, prevent them whenever possible, and intervene in an effective and client-centered manner. Programs should provide staff with training, structure, and support to handle crises. Effective crisis management can enable Safe Havens programs to serve residents even more compassionately and successfully.