Objectives: Our goal was to create and implement a program, Kosair Children’s Hospital’s No Hit Zone, which trains health care workers in de-escalation techniques to address parental disruptive behaviors and physical discipline of children commonly encountered in the hospital environment.
Methods: The Child Abuse Task Force, a multidisciplinary group, along with key hospital administrators developed specific content for the policy, as well as marketing and educational materials. The No Hit Zone policy designates Kosair Children’s Hospital as “an environment in which no adult shall hit a child, no adult shall hit another adult, no child shall hit an adult, and no child shall hit another child. When hitting is observed, it is everyone’s responsibility to interrupt the behavior as well as communicate system policy to those present.”
Results: Via a multidisciplinary, collaborative approach, the No Hit Zone was successfully implemented at Kosair Children’s Hospital in 2012. Cost was nominal, and the support of key hospital administrators was critical to the program’s success. Education of health professionals on de-escalation techniques and intervention with families at the early signs of parental stress occurred via live sessions and online training via case-based scenarios.
Conclusions: The No Hit Zone is an important program used to provide a safe and caring environment for all families and staff of Kosair Children’s Hospital. Demand for the program continues, demonstrated by the establishment of No Hit Zones at other local hospitals and multiple outpatient clinics. This article offers information for other organizations planning to conduct similar initiatives.
- child abuse
- child abuse prevention
- staff development
- patient care team
- pediatric hospitals
- physical discipline
- physician-patient relations
- hospital policies
- parental behavior
- organizational policy
- crisis intervention
- multidisciplinary approach
The American Academy of Pediatrics recommends against the use of physical discipline.1 Multiple studies demonstrate the negative relationship between physical discipline and health-related outcomes. The Adverse Childhood Experiences study provides evidence that exposure to adverse childhood experiences, including physical, emotional, or sexual abuse or household dysfunction, has a strong additive relationship to the presence of adult diseases.2 The Fragile Families and Child Well-Being study showed that frequent use of corporal punishment, more than twice a month at age 3 years, is associated with a significantly increased risk of aggression when the child is 5 years of age.3 More recent data suggest a relationship between physical punishment and mental disorders4 as well as a negative association of spanking and cognitive development.5 Spanking/hitting increases aggression and anger instead of teaching responsibility, confuses children being taught that hitting is not right, and teaches that acting in a physical manner is an appropriate way to deal with anger.1,6 The very definition of discipline, which means “to teach or train,” suggests a process in which parents model behavior that children can learn from with specific goals in mind.1 The Centers for Disease Control and Prevention’s plan for reducing child maltreatment focuses on the promotion of safe, stable, nurturing relationships between caregivers and children, a key component of which is teaching positive reinforcement techniques and behavioral interventions.7 Parents need help in learning alternative, age-appropriate forms of discipline.1,7 Health professionals need training to handle heated situations that disrupt the health care environment.
Family-centered rounds starts with a follow-up visit to the room of a 5-year-old with asthma. As the team gathers outside the door, we hear hollering coming from the room. “Be quiet and sit still … if you get up again I am going to whoop your butt!” Moments later we hear several smacks against a younger sibling’s skin followed by “I told you to be quiet!” The medical students and residents look to me for guidance. Three years ago, this type of behavior was approached by multiple health care providers all looking at each other wondering, “We should do something, but what?” Do we take the kids from the room and call social work and child protective services? Do we march into the room and pretend like nothing happened? Do we bury our heads in our daily tasks and hope the problem will go away? What is in the best interest of the children and the family?
This scenario is common in many hospitals, pediatric clinics, and emergency departments across the country. The stress of having a child in the hospital often results in parents displaying disruptive behaviors such as yelling, hitting, and spanking, creating a hospital environment that does not feel safe. There are multiple publications suggesting the importance of de-escalation skills in preventing violence within the health care setting.8,9 Unfortunately, health care professionals do not have a universal requirement for this type of training.
In this article, we describe the implementation of the Kosair Children’s Hospital’s No Hit Zone, an intervention designed to create an environment where any type of hitting is not tolerated and to educate health care professionals on de-escalation techniques. We offer lessons learned that may be helpful to other organizations planning to conduct similar initiatives.
Development and Implementation
The Kosair Child Abuse Task Force was established in 2001. This multidisciplinary group includes nurses, social workers, child life therapists, public relations managers, hospital advocacy representatives, chaplains, child abuse pediatricians, pediatric psychiatrists, and general pediatricians. In 2011, discussions regarding creation of a No Hit Zone at Kosair Children’s Hospital began. To create a program unique to our hospital, we drew from the No Hit Zone experience of Rainbow Babies and Children’s Hospital and Riley Children’s Hospital. Key components to all programs can be viewed in Table 1.
Once these components were developed, they were presented to key administrators, including the Kosair Children’s Hospital medical director, hospital president, vice president of public relations, Norton Healthcare chief operating officer, and the legal department. Administration agreed the program was consistent with the mission and values of Norton Healthcare, the health care system of which Kosair Children’s Hospital is a part, and provided financial support. The Kosair Child Abuse Task Force piloted the concept at 2 Kosair Children’s Hospitals and 3 University of Louisville General Pediatric Outpatient Clinics. All facilities are staffed with physicians from the University of Louisville Department of Pediatrics. Recently, these facilities initiated a no smoking policy, which is similar in concept and design. Like smoking, we know that hitting has harmful effects on one’s health. The hospital and clinics now have signs that clearly express the No Hit Zone policy.
Before implementing the program, specific content was developed including the actual policy and protocol, as well as marketing and educational materials. Kosair Children’s Hospital has always had a general nonviolence policy; therefore, the implementation of a No Hit Zone policy was an extension of an established concept. The policy states:
A No Hit Zone is an environment in which no adult shall hit a child, no adult shall hit another adult, no child shall hit an adult, and no child shall hit another child. When hitting is observed, it is everyone’s responsibility to interrupt the behavior as well as communicate system policy to those present.
An educational PowerPoint presentation was created by the child abuse task force. A Web-based education module was also created that can be accessed remotely by all employees. Social workers, child life therapists, and chaplains presented the PowerPoint education presentation at their departmental meetings. Live sessions were promoted by the chief nursing officer and given to any interested hospital staff members by physicians and nurse educator champions. Education for physicians was accomplished via multiple noon conferences attended by residents and attending physicians. Hospital employees were alerted to the availability of online training. Although the trainings were not mandated for current staff, all new hires received training. The outpatient clinic physicians and staff were educated by using a similar presentation adapted for outpatient medicine.
The educational content provides the background and history behind the No Hit Zone concept and how it promotes a positive, safe, and caring environment. Education focuses on how to identify early warning signs of parental distress such as raised voices, pacing, and making demands. Physicians and staff members are taught how to approach these parents via scripted phrases, case scenarios, and discussion. Staff members are taught to verbally communicate situations requiring intervention to the physician of record, and written documentation is encouraged.
The financial burden for this initiative was nominal. The Kosair Children’s Hospital public relations budget provided $1884 for materials as follows: 4000 brochures, 1000 vinyl signs (dimensions 8.5 × 11 inches), and 12 posters (dimensions 18 × 24 inches). The creative design was done in house at no additional cost. Posters and brochures were distributed throughout the hospital. The No Hit Zone policy is visible on a large video screen in the hospital lobby and is accessible from all patient room televisions via the Get Well Network.
The No Hit Zone program was announced via a press conference with local print and electronic media in the lobby of Kosair Children’s Hospital in November 2012. The announcement included senior leadership from Kosair Children’s Hospital and the medical staff from University of Louisville Department of Pediatrics and featured a skit with children of staff to help illustrate the intent and meaning of the new policy. At the time of the announcement, Kosair Children’s Hospital became one of only a few children’s hospitals nationwide to implement the No Hit Zone program. We also formed a partnership with the Louisville Bats, the local professional baseball team, who shared our commitment to this initiative and designated their stadium as a No Hit Zone for the public.
A No Hit Zone is an important policy and program used to promote a safe and caring environment for all families and staff of Kosair Children’s Hospital. Support from key hospital administrators including the medical director, hospital president, departmental chairman, and chief nursing officer was an essential component for successfully implementing the policy. A multidisciplinary team can be used to develop the key components of such a program and help disseminate information.
There were several barriers to the program including nonmandated training, oversight, and personal beliefs. Currently, there are many mandated trainings for staff of Kosair Children’s Hospital, and administration did not want to increase this burden. Voluntary training sessions were widely promoted and well attended. Online training was also available. Oversight of the program is by the Child Abuse Task Force, which is a voluntary group of individuals. We discuss the No Hit Zone at monthly meetings, but there is no one who specifically has the program as part of his or her job description. This is essential for the longevity of the program.
Additionally, we were concerned that staff member’s personal beliefs about spanking and physical discipline might interfere with the acceptability and implementation of the program. Universally, staff members were supportive of the initiative and appreciative of the newly acquired skills. They expressed willingness to incorporate these skills into their daily practice. Similar to the experience at Rainbow Babies,10 there have been multiple anecdotal stories in which techniques learned during No Hit Zone training helped health care workers approach caregivers and avoid escalation of disruptive behaviors. Objective evidence, including formal evaluation of the effectiveness of the program, is a key component planned for future research.
Subjective success of the program is demonstrated by high demand for the No Hit Zone program beyond the initial pilot facilities. The University of Louisville Family Medicine Department requested the program, and all Family Practice clinic sites are now No Hit Zones. Additional facilities include multiple University of Louisville Department of Pediatrics subspecialty clinics, the local Ronald McDonald House, and a third Norton facility, the Norton Women’s Hospital/Kosair Children’s Hospital, St Matthews. A No Hit Zone toolkit has been assembled and publicized via the Kentucky Chapter of the American Academy of Pediatrics, allowing access to the educational and promotional materials necessary for community hospitals and individual practices to start their own No Hit Zones (see Fig 1).
Return with me to family-centered rounds in the hospital. After my involvement with the No Hit Zone program, I now feel more confident handling this situation. I have improved recognition of parents who are tired and stressed. At the initial sound of distress, I would knock on the door and enter immediately. I would employ the technique of interruption, asking the mom, “Is everything OK in here? Would you like our child life specialist to take him to the playroom while we round?” I would empathize with the mother about those issues that have caused her stress or anxiety. This interruption is not intuitive for most of us, who prefer to avoid conflict. We receive virtually no training during medical school in techniques for de-escalating stressful situations. However, with practice it becomes part of our seasoned repertoire. I would now intervene before the spanking occurred and model to my team of learners how to de-escalate a heated situation. Through the work of a multidisciplinary team, an environment for safer pediatric care can be promoted, 1 No Hit Zone at a time.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Kosair Children’s Hospital provided $1884 for program materials.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2014 by the American Academy of Pediatrics