No Hit ZoneReinforcing a Culture of Safety through Awareness and Education

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Objectives

• History: What prompted “No

Hit Zone” policy?

• Elements of the “No Hit Zone”

Project

• Educate on how to intervene

when necessary

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• Many healthcare workers have encountered situations where parents or adults become angry, raise their voices, or hit a child or another adult in your presence without clear guidelines of what to do.

• Our goal is to help equip healthcare workers with some tools to use during these encounters.

No Hit Zone Dilemmas

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• In 2005 Rainbow Babies introduced a “ No Hit Zone” policy for their hospital

• Since then the program has been spread to over 30 hospitals across the country

“No Hit Zone” Beginning

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Goals• Assist in lowering the frequency of disruptive

behaviors in our hospitals and clinics

• Assist in maintaining a safe and caring atmosphere for patients, families, and staff

• Elevate the standard of care in all places where children interface with health care workers

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• Hitting and disruptive behaviors puts healthcare providers in a difficult situation; therefore, no type of hitting is allowed in our facilities

• Disruptive behaviors, such as, physical discipline yelling, jerking of body parts, etc. can lead to more physical and aggressive behaviors

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“No Hit Zone” Elements

• Poster– Widespread

• Brochures-Parent Resources– Available throughout clinic facilities

focusing on alternative types of discipline

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PURPOSEThe purpose of this policy is to create and reinforce an environment of comfort and safety for patients, families, and staff working in our facility.

DEFINITIONNo Hit Zone: an environment in which no adult shall hit another adult, no adult shall hit a child, no child shall hit an adult, and no child shall hit another child.

No Hit Zone Policy

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POLICY STATEMENTSWhen hitting is observed, it is everyone's responsibility to interrupt the behavior as well as communicate hospital policy.

PROCEDUREAll staff will be made aware of the clinic policy that is in place to ensure and reinforce an environment of comfort and safety. Staff will identify and respond to situations that compromise the safe environment utilizing the education they are provided. If appropriate, additional intervention will be provided by appropriate staff dependent on the level of severity.

No Hit Zone Policy

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General Guidelines• Be nonjudgmental

• Model effective interventions (such as distraction), when appropriate

• Try to have conversations with caregivers out of earshot of others (including the children) so caregivers aren’t embarrassed into being confrontational

• Thank parents for respecting our policies

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Can be used to “de-escalate” a situation in which caregivers begin to raise their voices, curse, or show other signs of stress and inappropriate behaviors that occur prior to physical discipline

Interruption

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Your calm, sympathetic, physical presence is probably the most effective response. You will need to have a variety of lead-ins that you can comfortably use, depending on the situation specifics. (use your own language to convey one or more of the example messages)

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• Scripting Examples • “Can I help you with something?”• “Would you like me to take your child to get a

book or sticker”• “You’ve been waiting for awhile. Let me see

when you can expect a doctor to see you”• “Most 2-year-olds can’t sit still/behave for long

periods. Would it help if I found something for him to play with?”

• “Do you have family here supporting you?”

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Scenario #1

You are a nurse working in a pediatric clinic. You observe a caregiver yelling at her 2 year and 3 year old children while in the patient’s room.

•What do you do?

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Discussion

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• Calmly ask if the caregiver needs any assistance.• Acknowledge how frustrating it is to wait a long

time with two young children.• Offer to see how long until the patient will be seen.• Offer something for the children to do to keep

them busy—books, movies, count stickers, snacks.• Always consider stresses the family may be under-

need to get kids off bus, need to get to another appointment (court), other family members may be ill etc.

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• Let the physician seeing the patient know the family is stressed and starting to get disruptive.

• Doctors and nurses should respond immediately to disruptive behavior to help de-escalate situations.

• It may take a few times before you are comfortable with this.

• Consult a social worker if available and appropriate

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• Situations may occur when a child/adult is hit or physically disciplined and you may need to relay that the clinic is a “No Hit Zone”.

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• “You may have seen our posters in your room/waiting room. This clinic is a “No Hit Zone”. We ask that you refrain from hitting and keep conversations quiet/private out of courtesy to the other patients and families.”

• “For the safety and protection of everyone in our clinic we participate in a “No Hit Zone”. I am obligated to say something. What can I do to help you or your family?”

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Scenario #2

• You are walking down the clinic hallway, a mother yells at her child, yanks him by the arm and hits him several times. He is a patient waiting to be seen.

• What do you do?

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Discussion

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• Intervene and notify the mother that the clinic is a “No Hit Zone”.

• Offer assistance.• Let the team taking care of the patient (physician

and nurses) know about the incident.• Provide documentation of the incident in the

patient’s chart.

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• What if the mother states “it is my right to discipline my child” ?

• What do you do?

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Discussion

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Response

“I am not trying to step into your role as a parent but this facility is a “No Hit Zone”. We do not allow hitting of any kind. This is for the safety of everyone in our facility.”

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Sympathize with the frustrations and stresses the parents may be

experiencing. Acknowledge that you respect their role as a parent/caregiver.

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Scenario #3

• You are sitting in your office and hear crying coming from the bathroom two doors down. You continue to listen and identify that it is a child and their caregiver in the bathroom. The child is crying and you hear what sounds to be the caregiver hitting the child and verbally scolding them for misbehaving.

• What do you do?

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Discussion

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• You look around your office and find a new toy. You go to the bathroom and knock. You ask the caregiver if everything is ok. The caregiver opens the door. You observe that the child is around 3 years old. The caregiver appears to be angry and worked up. The child is still crying. You bend down to the child and ask if she would like a toy. You then tell the caregiver that the facility is a “No Hit Zone”. You ask if there is anything you can get the caregiver. You then report the incident to the nurse and the medical team that will be seeing the child.

• If you get no response from your knock, request that the caregiver open the door.

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• After reporting the incident to the medical team, you returned to check on the welfare on the child. You observe the caregiver hitting the child repeatedly as she pulls her toward the bathroom. You observe the child crying and screaming.

• What do you do?

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Discussion

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• Intervene with the caregiver and child again and explain that this clinic is a “No Hit Zone”. Make a Social Worker referral and again notify the medical team who will be seeing the child.

• Depending on how you feel about the first intervention and the severity of the current situation you may want to contact security and child protective services.

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• If a person becomes angry consider calling security. Don’t make threats. If indicated by the situation, notify Child/Adult Protective Service

• Be aware of adults that go to private places to spank their children.

• Do not put yourself in a dangerous situation. Contact security when appropriate.

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Roll Out

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Continuation of Program• Refill of brochures, repair of

signage• Education of new staff• Other languages

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Acknowledgements

Erin FrazierDeonya MuhammadJamie IssisTara CockerelTherese SirlesMelissa Currie Steve Wright Michelle RobeySteve MenaughMembers of the Kosair Children’s Hospital Child Abuse Task Force

Kosair Children’s HospitalUniversity of Louisville Department of PediatricsRainbow Babies and Children’s HospitalRiley Children’s HospitalAnne Eldridge