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Code Green and Emotional Trauma: How Nurses Help

Nurses Article   (1,722 Views | 10 Replies | 915 Words)

jeastridge is a BSN, RN and specializes in Faith Community Nurse (FCN).

5 Followers; 109 Articles; 150,275 Profile Views; 447 Posts

What is the Role of the Nurse During a Code Green?

Code Green, indicating a combative patient, can be challenging and seem to occur with increasing frequency. How can nurses help? What helps you to respond appropriately?

Code Green and Emotional Trauma: How Nurses Help

“Code Green 5th floor. Code Green 5th floor.”

The hospital operator’s voice made my pulse skip a beat even though I was far from the announced location. Code Greens [in this case meaning a combative person who may be armed] have become more common as we face more crowds, more recreational drug users, and more angry, frustrated people in our facilities. As nurses, we are sometimes part of situations that lead to the dreaded “Code Green” announcement as we call out for the necessary help. We undergo training in how to respond and follow the required steps, but we do begin to wonder if the number of these types of crises is increasing, and if so, why?

The Team Approach

Some hospitals have successfully formed specialized teams to address Code Green situations and to help de-escalate highly charged encounters. At Pinnacle Health System in Harrisburg, Pennsylvania, their Code Green Response Team, started in 2013, has saved personnel and patient injury, money and time away from work. Their example may be trendsetting as other systems look to find ways to decrease violence inside our hospitals. Code green prevents workplace violence

Trauma-Informed Care

Another opportunity for learning and forward-thinking is the Trauma Informed Care Project .The training invites participants to acknowledge that past trauma affects daily behaviors. Children are especially vulnerable to the effects of trauma and many childhood experiences accumulate to produce adverse effects leading to the term ACES (Adverse Childhood Experiences). The website goes on to explain that the goal of this foundation and this project is “organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma. It emphasizes physical, psychological and emotional safety for both consumers and providers, and helps survivors rebuild a sense of control and empowerment.”

During the training, participants are invited to re-think “acting out” and instead of asking “What’s wrong with that child?” Ask instead, “What happened to that child?” These subtle but significant shifts in thinking can help us move from finger-pointing and judging to more constructive patterns of interaction where healing can actually take place.

Emotional trauma carries over, of course, into our adult years. If unacknowledged, untreated, unresolved, it can surface unexpectedly and often explosively, leading to our current question regarding Code Green. Victims of traumatic incidents can sometimes repress or “forget” the memories of what happened to them only to have those come back during challenging or stressful times —such as times in the hospital with a loved one or being sick and in pain themselves. The post-traumatic stress of past troubles can lead to excessive anxiety, anger, and unstable emotions.

The Body Keeps the Score

In his book, The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Bessel Van Der Kolk, MD, asserts that past trauma manifests itself in actual physical disease. If unresolved, trauma will eventually lead to physical illness in a variety of diagnoses.

“Even though the mind may learn to ignore the messages from the emotional brain, the alarm signals don’t stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilize in collapse. The physical effects on the organs go on unabated until they demand notice when they are expressed as illness. Medications, drugs, and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score.”(p46)

Responding Appropriately

As nurses, we are occasionally faced with responding appropriately to challenging situations: talking an agitated patient down, listening well, knowing when to get help. How can we prepare ourselves to be even better equipped to face difficult encounters?

Be in the Know

Take mental health classes that are offered for CME; the Mental Health First Aid class is valuable as are the Trauma-Informed Healing sessions. Learning about mental illness, PTSD, and other psychiatric illnesses gives us a good preparatory knowledge base.

Responding Empathetically When Possible

This can help resolve some low-risk situations. Many people long to be heard, really heard. They may even realize that we cannot resolve their situation, but they don’t want to be brushed off. They want to know someone cares. For some, that may be the beginning of healing and just what is needed to get them through a rough patch.

Call for Help as Needed

There is simply no substitute for getting help when a crisis arises. Maybe your facility, like Pinnacle Health, can consider starting a Code Green Team which specializes in defusing and de-escalating crisis situations.

Sadly, Code Greens are more common than we would like for them to be. There are a lot of hurting people out there: both our patients and those that are surrounding them in their time of illness. We have no way of knowing what trauma might have happened to our patients or their families and loved ones previously. But we do know that they carry those hurts with them when they come in for treatment. As nurses, we are often presented with really messy scenarios. Being professionals, we do our best to make the best of even the worst of times.

What helps you to respond appropriately to tense situations?

Joy is a Faith Community Nurse who enjoys writing and maintains a blog. She is the author of two Bible Studies and a children's book. In her 35+ years of nursing, she has worked in a variety of settings.

5 Followers; 109 Articles; 150,275 Profile Views; 447 Posts

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V888 specializes in EMT.

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Please just remember this can be a very dangerous way to think. Don't let your sympathy or empathy let you put your safety at risk  

Someone in psychological crisis can, especially if armed with a weapon, kill you just as easily as a hardened criminal. I believe there was a story on here about a nurse who died after getting caught between a psych crisis patient and a clamshell shield. 

Defusing and de-escalating are things that are great...until they aren't. 

I would also push back on the idea that all outbursts or misbehavior is caused solely and directly  by trauma as that idea can be dangerous for society...(minimizing agency and free will, not accounting for rights of victims, etc)

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jeastridge is a BSN, RN and specializes in Faith Community Nurse (FCN).

5 Followers; 109 Articles; 447 Posts; 150,275 Profile Views

1 hour ago, V888 said:

Please just remember this can be a very dangerous way to think. Don't let your sympathy or empathy let you put your safety at risk  

Someone in psychological crisis can, especially if armed with a weapon, kill you just as easily as a hardened criminal. I believe there was a story on here about a nurse who died after getting caught between a psych crisis patient and a clamshell shield. 

Defusing and de-escalating are things that are great...until they aren't. 

I would also push back on the idea that all outbursts or misbehavior is caused solely and directly  by trauma as that idea can be dangerous for society...(minimizing agency and free will, not accounting for rights of victims, etc)

So well said. Thank you for your thoughtful comment and for sharing your perspective. You make some important points. Joy

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V888 specializes in EMT.

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Question for those here:

Do you think that childhood trauma can encompass things like different "emotional styles" between parents and children? Or does it purely refer to abuse?

For example a child who is emotionally expressive being raised by parents who don't believe in showing emotions or vice versa?

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HarleyvQuinn has 12 years experience as a BSN, RN and specializes in Military, ER/Trauma, Psych, Post-Partum, Med-Surg.

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As someone trained and working in the inpatient psychiatric realm, I want to caution that there is a stark contrast in how you respond to a person who is agitated and acting out and a person who has escalated to violence. This is particularly true if the person is armed with a weapon. De-escalation techniques require training and experience to work at their best. Our facility utilizes a response team for anyone presenting in a behavioral crisis where psychiatric or other trained staff respond similarly to other code situations. Our security staff also receive the same training our psychiatric staff receives on de-escalation and hand-on interventions. Unfortunately, we only offer basic level CPI at this time in our facility. 

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jeastridge is a BSN, RN and specializes in Faith Community Nurse (FCN).

5 Followers; 109 Articles; 447 Posts; 150,275 Profile Views

28 minutes ago, HarleyvQuinn said:

As someone trained and working in the inpatient psychiatric realm, I want to caution that there is a stark contrast in how you respond to a person who is agitated and acting out and a person who has escalated to violence. This is particularly true if the person is armed with a weapon. De-escalation techniques require training and experience to work at their best. Our facility utilizes a response team for anyone presenting in a behavioral crisis where psychiatric or other trained staff respond similarly to other code situations. Our security staff also receive the same training our psychiatric staff receives on de-escalation and hand-on interventions. Unfortunately, we only offer basic level CPI at this time in our facility. 

Thank you for your helpful comment. You highlight the importance of preparedness, knowledge and rapid response. Joy

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The response at a hosp where I worked was all the male staff would flood the room essentially. Some of these male staff members bought nothing to the equation and looked respectfully speaking... insipid.

 The patient (imho) usually displayed signs that they were on the “ledge” so to speak a good deal earlier than this crisis. The nature of nursing on a lot of floors (Med Surge in particular), doesn't always allow for a lot of time to be taken with ppl and in the Disney inspired customer service model we are programmed to operate under allows alot of problematic patients to be master manipulators.Some ppl who are behaving badly need to be given the “talk and look” way earlier. Not by the 85 yr old shuffling, stout but pleasant security officer. Is he really going to be effective if it “goes down”?

  Healthcare environments are out of balance.  The body needs homeostasis to operate optimally, do does working in a hosp, nursing home or clinic. Lots of passive aggressiveness, gossip and provinciality in dealing with patients and staff cross culturally. Nurses/CNA’s/RT’s are oft times overworked, disrespected, bullied and cowed into silence when trying to raise legitimate concerns about the work synergy or lack thereof. So, that behaviour seeps into the healthcare staff and then..... code green.  

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Here.I.Stand has 16 years experience as a BSN, RN and specializes in SICU, trauma, neuro.

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If past trauma isn’t an excuse to be violent on the outside, it isn’t an excuse to be violent with healthcare staff.  

And frankly as one with PTSD herself..... what the what??  If I am getting violent, staff SHOULD call a Code Green.  However, I won’t be getting violent.  While I may not have complete control over my feelings or internal physiological responses, I am adult and can certainly conduct myself as such.  

Honestly I am a bit offended by this.  

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jeastridge is a BSN, RN and specializes in Faith Community Nurse (FCN).

5 Followers; 109 Articles; 447 Posts; 150,275 Profile Views

4 hours ago, Here.I.Stand said:

If past trauma isn’t an excuse to be violent on the outside, it isn’t an excuse to be violent with healthcare staff.  

And frankly as one with PTSD herself..... what the what??  If I am getting violent, staff SHOULD call a Code Green.  However, I won’t be getting violent.  While I may not have complete control over my feelings or internal physiological responses, I am adult and can certainly conduct myself as such.  

Honestly I am a bit offended by this.  

Thank you for your honesty. You make excellent point. The staff should always call a code green whenever there is a threat. I'm sorry it feels like the article implies otherwise. That was not my intent. Joy

 

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Unfortunately programs like MANDT and CPI are not provided to protect staff or PTs.  They provide protection to the facility against liability, allowing them to claim due diligence when people get hurt.  It allows the hospital to shift blame when unrealistic techniques are not employed.

While I have found that the de-escalation training and situational awareness training is not bad, the physical restraint training ranges from silly to dangerous.

Practicing physically for 20 minutes, or an hour will not prepare anybody to defend themselves.  Look at it this way- if a 140 lb woman went to a martial arts class 3 times a week for a couple of years, she might be able to defend herself against a 200 lb man.  Giving a person the illusion that the techniques practiced for a few minutes might actually work is downright reckless.

Not too long ago I went into a scene in which 4 security guys were trying to hold a guy down, and it was dicey.  I put my full body weight on his legs, and was getting quite a ride despite the other four trying to hold him.  Another nurse asked me if she could help, I asked her to grab an ankle.  When she did, a different nurse corrected her technique, explaining that by encircling the ankle she could cause harm, and to release her thumb and use a 4 finger grip.  AAARGH!!!!! at this point this guy has over 1000 lbs of security and nursing on him, and she is worried about a thumb?

The safest thing would have been for security to tase him, but we don't have that kind of security. 

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HarleyvQuinn has 12 years experience as a BSN, RN and specializes in Military, ER/Trauma, Psych, Post-Partum, Med-Surg.

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5 hours ago, hherrn said:

Unfortunately programs like MANDT and CPI are not provided to protect staff or PTs.  They provide protection to the facility against liability, allowing them to claim due diligence when people get hurt.  It allows the hospital to shift blame when unrealistic techniques are not employed.

While I have found that the de-escalation training and situational awareness training is not bad, the physical restraint training ranges from silly to dangerous.

Practicing physically for 20 minutes, or an hour will not prepare anybody to defend themselves.  Look at it this way- if a 140 lb woman went to a martial arts class 3 times a week for a couple of years, she might be able to defend herself against a 200 lb man.  Giving a person the illusion that the techniques practiced for a few minutes might actually work is downright reckless.

Not too long ago I went into a scene in which 4 security guys were trying to hold a guy down, and it was dicey.  I put my full body weight on his legs, and was getting quite a ride despite the other four trying to hold him.  Another nurse asked me if she could help, I asked her to grab an ankle.  When she did, a different nurse corrected her technique, explaining that by encircling the ankle she could cause harm, and to release her thumb and use a 4 finger grip.  AAARGH!!!!! at this point this guy has over 1000 lbs of security and nursing on him, and she is worried about a thumb?

The safest thing would have been for security to tase him, but we don't have that kind of security. 

I completely agree. Several of our staff have pointed out the weaknesses in the CPI basic techniques, which are only directed at defensive maneuvers for staff and provide absolutely no training for how to maneuver the individual into restraint safely. This includes the fact that the maneuver for how to "break" the patient's grip on someone's neck is absolutely not realistic and does not work. All you receive is a shrug. CPI advanced is what teaches the techniques for actually taking the patient to the ground or into restraint safely and that's not even offered at our facility, but that is always what is cited to our staff as "you didn't use CPI!!" when codes are reviewed. Trauma-informed care is addressed and does have a place in how we approach and work with patients and even each other. It does help to be less judgmental of people and consider more the biopsychosocial aspects that impact how we react to situations and our environment. No, it's not an excuse, it's just another way to evaluate where behavior may come from and how to effectively work with someone to identify where it comes from and change it.

 We're lucky to have several of our security personnel with police backgrounds who are very helpful in code situations. Unfortunately, even in the inpatient psych environment staffing is horrible and we're running below what our unit even considers to be "appropriate" quite frequently, so that puts all of us at increased risk. It also, as another poster pointed out, provides less time to identify patients who are showing early signs of escalation and intervene early enough to avoid violence. 

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