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December 10, 2020/Nursing

Workplace Violence in Pediatrics: A Patient Experience Issue

New program encourages families and caregivers to work together to promote a healing environment

patient safety

Being in the hospital can create anxiety and fear for patients and their family members. Occasionally, these feelings can put caregivers in unsafe situations. By launching a new program they call Speak Up for Safety, leaders at Cleveland Clinic Children’s hope to change that.


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“When we have challenges with patients or families, we try our best not to let it impact the care we deliver. However, these situations can really weigh heavily on us as caregivers,” says Amy Cox, RN, CPN, Inpatient Nurse Manager at Cleveland Clinic Children’s. “This [Speak Up For Safety] project gives caregivers the tools they can use to escalate concerns so they may provide safe care to their patients and go home without feeling physically and/or emotionally exhausted.”

Aggression in the hospital setting

Aggression in the pediatric hospital setting may be anything from hair pulling, scratching, hitting or biting, to verbal abuse or intimidation. “For example, I once cared for a combative teen patient with altered mental status. As caregivers, we were literally trying to keep the patient off of each other while we were in the room. Somehow my arm got in front of the patient, who yanked it down and bit into it. The bite didn’t break the skin, but those physical altercations can be frightening and stressful,” reports Ms. Cox.

Now, with Speak Up for Safety, there are communication and escalation protocols in place to help alleviate some of the stress in these situations. “We want caregivers to know that we take these incidents very seriously, whether it’s a child who has no control over certain behaviors, another who is just plain combative, or a parent who is verbally abusive,” says Amrit Gill, MD, Patient Safety Officer for Cleveland Clinic Children’s.

“The Speak up for Safety project is first and foremost about patient safety. We must acknowledge that patient safety cannot be maintained without our caregivers having a sense of psychological safety. We began this work about decade ago when we sought to establish a culture of safety by developing programs to encourage people to speak up when they see something concerning. We now use the acronym ARCC: Ask a question; Request a modification; express Concern if the team member does not modify the plan; following the Chain of command and inform leadership immediately to prevent an event. We also documented escalation routes that clearly lay out the chain of command. ARCC and the escalation of care guidelines have been effective in creating an environment where caregivers feel free to speak up and advocate for their patients. Next, we really wanted to take these safety concepts to the next level by ensuring that parents felt comfortable speaking up if they had a concern,” Dr. Gill explains.

A phased roll-out that keeps patients first

In 2019, Cleveland Clinic Children’s partnered with parents to roll out the first phase of Speak Up for Safety. The project team also included inpatient nursing, behavioral health physicians and child life specialists. In this first phase, the team explored parent expectations of caregivers and identified ways to improve the patient experience.

“The patient experience is an important component of these efforts,” states Christine Traul, MD, Patient Experience Officer at Cleveland Clinic Children’s. “We want to understand the family’s expectations for their child’s hospital stay, and to thoughtfully and empathically communicate the healthcare team’s expectations of the patient and family during the hospitalization. By working with our Healthcare Partners, who are parents of Cleveland Clinic Children’s patients, we were able to understand the most important elements that allowed them to feel safe and ultimately have the best experience.”

A document is posted in each hospital room that gives parents the information they need to advocate for their children, including who to call to escalate a situation, if needed. The document describes patient expectations for caregivers, such as:

  • We will introduce ourselves when we walk into the room.
  • You will know who is on your care team.
  • The nurse will be included in rounding.
  • We are going to wash our hands.


In the second phase of Speak Up for Safety, the team explored caregiver expectations for patients and their families. The team produced an updated document for families that also addresses caregiver concerns, such as:

  • Parents/patients should maintain unobstructed entry/exit to the patient’s room and maintain a clutter-free environment.
  • Verbal and physical abuse will not be tolerated.
  • The nurse should be notified when you leave the room.

The team created a separate document that is available on-line for caregivers with helpful communication tips and links to de-escalation strategies, as well as guidance should one feel threatened or unsafe.

Working together for the best possible outcomes

“Speak Up for Safety is a structured and effective way to remind families and caregivers that we need to work together as a team to provide the best possible outcomes for our littlest patients. Ideally, we want to be able to de-escalate situations before they become concerning or risky, and to ensure that caregivers have information as proactively as possible about the potential for risk. We want to empower patients and families to speak up with any concerns related to their care, as well as establish clear guidelines and processes for situations when patients or families may be less than cooperative,” states Allan Cohn, Quality Director for Cleveland Clinic Children’s.

Now that these processes have been rolled out, the team plans to conduct education and training with caregivers and will begin to measure outcomes via parent and caregiver surveys.


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