Working in Hospital Emergency
Departments:
Guidelines for Crisis Intervention Workers -
Chapter 3.
Instructor: Jeff Garrett Ph.D.

Problems Patients Face in ER
• Medical Emergencies (physical injuries, illness,
and death).
• Isolated from natural support systems.
• Unfamiliar surroundings and hospital
procedures.
• Acute emotional disturbance.

SCOPE OF THE PROBLEM
• Increased Visits to the ER
• Overcrowded, long waiting periods.
• Nonmedical issues can often be
neglected.
• Nonmedical issues can be quite severe
and may influence recovery from the
medical issues.

New Challenges
• Differentiating accidental injuries due to abuse
(e.g., domestic violence, child abuse, and elder
abuse).
• Making these judgments requires knowledge
and takes time.
• With an already overworked staff, these types of
patients can be easily over-looked.
• Some hospitals have developed special in-
service training to identify these types of
problems.

New Challenges
• Other hospitals rely on outside programs developed
to work with these types of populations.
• Crisis workers can minimize the chance that
victims of abuse are overlooked.
• Medical personnel have become aware that nonmedical
issues are essential factors to be reckoned with in
patient care.
• Thus, the demand for crisis services in emergency
departments is clear.

REVIEW OF THE LITERATURE
• Training, unfortunately, has not kept pace
with increased awareness of the psychological
and emotional well-being of patients in recovery.
• Even though some medical personnel receive
minimal instruction in crisis theory, most hospital
staff simply do not feel comfortable dealing
with patients in psychological or emotional crisis.
• Many hospitals do recognize the value
of trained crisis intervention workers in the
emergency department.

Crisis Intervention in ER
• Medical personnel have become more receptive to
services that address these psychological and emotional
factors in recognition of the impact that treatment of
these issues has on physical recovery.
• Psychiatric Nurses
• Chaplains
• Social Workers
• Counselors and crisis intervention specialists.

Four Advantages of Crisis
Intervention in ER
• First, crisis intervention services help
prevent additional psychological
problems and complications that may
accompany hospitalization.
• Second, crisis intervention in emergency
departments may serve to alleviate
possible exacerbation of physical trauma.

Four Advantages of Crisis
Intervention in ER
• Third, crisis intervention may serve to make
patients more responsive to treatment
(e.g., psychological problems can interfere with
patients' ability or desire to perform the
behaviors necessary to control a medical
problem).
• Fourth, crisis intervention in emergency
departments can identify abuse victims
(e.g., records indicate that 22-35 percent of
women who present at emergency departments
do so because of symptoms related to physical
abuse).

CRISIS THEORY
• Robert’s Model is Flexible
• Roberts' seven-step model for crisis
intervention provides an excellent guide
for crisis workers in hospital emergency
departments.
• Crisis workers, however, should recognize
that this model is not set up to be rigidly
followed in a step-by-step fashion.

CRISIS THEORY
• The model should be viewed as fluid
and adaptable for work in emergency
departments.
• Crisis workers must be attentive to changes
in clients and the environment that might
influence reactions to the crisis event.
• As changes occur, crisis workers must be
flexible in moving to that part of the model that
best corresponds with current circumstances.

Accurate Assessment (a key
element).
Assessment should be holistic, taking into
account affective, cognitive, and behavioral
reactions.
Affective reactions to crises fall into three
primary types:
• (a) anger/hostility;
• (b) fear/ anxiety;
• (c) sadness/melancholy.

Accurate Assessment (a key
element).
Cognitive perceptions of crisis events are
experienced as these impact four areas:
(a) physical - food, water, shelter;
(b) psychological -identity, emotional well-
being;
(c) relationship -family, friends, coworkers;
(d) moral/spiritual - personal integrity, values,
and belief system aspects of patients and their
family.

Accurate Assessment (a key
element).
Cognitive reactions to crises are:
• (a) transgression, which occurs when
patients' or their families' rights have been
violated;
• (b) threat, which occurs when a person judges
the event as having potential harm or damage to
themselves or others;
• (c) loss, which involves the belief that an
irretrievable loss has occurred.

Accurate Assessment (a key
element).
Behavioral reactions to crises are:
• approach, in which individuals make overt or
covert attempts to address the crisis;
• avoidance, in which active attempts are
made to ignore, evade, or escape the crisis
event; and
• immobility, in which nonproductive,
disorganized, or self-canceling coping
behaviors are displayed.

Accurate Assessment (a key
element).
Assessment should be Continuous
• Ongoing assessment is essential in
determining the needs of patients and their
families at that moment.
• New information may result in crisis workers
adjusting their approach to match the current
state of patients and their families.

Robert’s Seven-Step Model

1. Make psychological contact and
rapidly establish the relationship.
Establishing rapport involves active listening skills
including …
• Attentiveness.
• Reflection of feelings.
• Restatements of content.
• Asking open and closed questions.
• The use of minimal encouragers.

1. Make psychological contact and
rapidly establish the relationship.
• Show respect.
• Show interest.
• Show care and concern.

1. Make psychological contact and
rapidly establish the relationship.
Gather information important to the
assessment process.
This information will help crisis workers to
judge the affective, cognitive, and
behavioral reaction along with the severity
of these reactions.

1. Make psychological contact and
rapidly establish the relationship.
To gauge the reactions, three basic questions need to
be answered.
• First, what are the feelings that patients and their
families have about the crisis event?
• Second, how have they perceived the crisis event
affecting their lives?
• Third, what have they done to overcome the impact
of the crisis event?

2. Examine the dimensions of the problem
Steps 1 and 2 frequently blend together.
Do not assume that the crisis reaction is concerned with
medical issues.
Crisis workers should ask themselves: "Will the affective,
cognitive, and/or behavioral reaction interfere with
the day-to-day activities and if so, how and to what
degree?"
Also important during step 2 is to assess patients' and
families' potential to harm themselves or others.

3. Encourage an exploration of
feelings and emotions.
• At times, this step can be overlooked as crisis
workers attempt to focus more on the crisis
event rather than the reaction to that event.
• Active listening skills along with the
demonstration of a nonjudgmental attitude,
empathy, and genuineness are invaluable in
this step.

3. Encourage an exploration of
feelings and emotions.
As patients and their families perceive they are being supported,
they will be more open to expressing their feelings.
This catharsis is therapeutic and can lead to a healthy resolution
of the crisis.
Assess the patients' and their families' affective reactions to the crisis
event.
This assessment will determine the primary affective reaction and the
severity of the reaction.

4. Explore and assess past
coping attempts.
• The shock of an unexpected visit to a hospital
emergency department may result in the
inability of patients and their families to cope.
• Simply exploring coping skills used in the
past may be all that is needed.
• In more severe cases the crisis worker may
have to teach coping skills.

5. Generate and explore alternatives and
specific solutions.
• Generating and exploring alternatives and
solutions to crisis events depend on the
severity of patients' and their families'
reactions.
• The more severe the reaction, the
more directive the intervention
needed.

5. Generate and explore alternatives and
specific solutions.
• Mild types of crisis generally require a more
non-direct level of intervention.
• This intervention level uses active listening
skills to support and demonstrate caring.
• Moderately severe crises necessitate a
collaborative intervention level. In this level of
intervention, crisis workers, patients, and their
families work together as a team.

5. Generate and explore alternatives and
specific solutions.
• Crisis workers are compelled to use a
direct level of intervention for patients
and families who have suffered a severe
crisis.
• This intervention level requires crisis
workers to use directives with patients
and their families.

5. Generate and explore alternatives and
specific solutions.
• Care must be taken with intervention levels not
to foster undue dependence on crisis
workers.
• After the initial shock of the crisis is over, crisis
workers might then retreat to a more
collaborative rather than a direct intervention
level.

6. Restore cognitive functioning through
implementation of action plan.
• To Restore Cognitive Functioning.
• Patients and their families must have a realistic
understanding of the crisis event . (e.g., if the patient has just
suffered a massive stroke, it is unrealistic to believe that he/she will
return to work in a short period of time).
• Patients and their families should understand the meaning of
the event and its likely effect on their lives (how the injury will
influence their lives on a short- and long-term basis e.g.,
rehabilitation, doctor visits).

7. Follow up.
• Follow-up is important to ensure the
well-being of patients and their families.
• Follow up is useful to evaluate the
effectiveness of the services, and
subsequently, to improve those services.

7. Follow up.
• Follow up may involve visits to the
hospital room if the patient is admitted.
• If the patient is not admitted, crisis workers
may telephone or correspond with
patients and their families.

GOALS FOR CRISIS INTERVENTION
IN EMERGENCY DEPARTMENTS
• Returning to former level of
functioning.
A primary goal is to return patients and
families to their state of functioning prior
to the onset of the crisis.

GOALS FOR CRISIS INTERVENTION
IN EMERGENCY DEPARTMENTS
2. Adapting to the hospital setting.
ERs are a new environment, one that very few
persons would choose willingly.
A goal of intervention would be to facilitate a
tolerance of the hospital environment
so that the hospital becomes a familiar place in
which functioning can take place.

GOALS FOR CRISIS INTERVENTION
IN EMERGENCY DEPARTMENTS
3. Setting up a referral network.
Provide patients and families with a list of
support sources and groups that
can ease the sense of isolation
accompanying the emergency.
Show how these can be contacted and
utilized.

GOALS FOR CRISIS INTERVENTION
IN EMERGENCY DEPARTMENTS
4. Mobilizing coping skills
Patients’ established coping skills may be
inadequate with the chaos of the crisis.
A goal is to help patients adapt their inherent
coping skills to the new environment and
situation which allows them to tolerate and
respond to the demands of the new situation.

GOALS FOR CRISIS INTERVENTION
IN EMERGENCY DEPARTMENTS
5. Providing psychoeducation.
Serious psychological ramifications can be associated with
crisis events of a medical nature.
These can often manifest after the initial shock has
passed.
The crisis worker's aims to inform patients and families to
expect certain psychological consequences such as
depression, despair, and anxiety as appropriate
to the situation.

GOALS FOR CRISIS INTERVENTION
IN EMERGENCY DEPARTMENTS
6. Establishing lines of communication.
A smoothly operating communication network
should be established between crisis worker(s),
staff, patients, and, families.
This minimizes confusion for all concerned and
provides a sense of order and organization.
This network can be structured in such a way as to
allow a policy of who talks to whom, when, and
under what circumstances.

GUIDELINES FOR WORKING IN
EMERGENCY DEPARTMENTS

Role of Crisis Workers
Many professionals typically interact to assist in
the over-all care of patients and their families.
One part of a multidisciplinary team (e.g.,
physicians, nurses, x-ray technicians,
phlebotomists, respiratory therapists), and the
other is support staff (e.g., receptionists,
clerks, chaplains, social workers).

Role of Crisis Workers
To function effectively multidisciplinary teams should demonstrate a
sense of mutual trust, collaboration, and
willingness to compromise when needed.
The crisis worker's primary role is that of mental
health specialist to specifically address the psychological
and emotional effects of trauma on patients and their
families.
Part of their role is also to enlighten other team
members regarding such phenomena.

Functions of Crisis Workers
Function within guidelines established by the
hospital.
Some hospitals may have vague guidelines while
others may have precise rules about contact with
patients and their families.
These rules may be written or unwritten and typically
involve procedures and/or lines of authority to be
followed.
A knowledge and understanding of these guidelines
promote the effective performance of crisis workers.

Five Functions of Crisis Workers
First, crisis workers function as advocates.
Second, crisis workers function as case coordinators.
Third, crisis workers function as counselors.
Fourth, crisis workers function as educators.
Fifth, crisis workers serve to mobilize resources and provide referrals.
Crisis workers will seldom perform all of these functions with
any one case. Instead, functions are performed on the basis of the needs,
both immediate and necessary, of patients and their families.

Training Crisis Workers
Knowledge of this nature is gained through
two interrelated methods.
1. Didactic training
2. Supervised experience.

Eleven Desirable Qualities of
Crisis Workers
1. Quick Thinking.
2. Creativity and Flexibility.
3. Parallel Process.
4. Quick and Easy Rapport Building.
5. Tolerance of Medical Trauma.
6. The Ability to Maintain Calm and Inspire It in
Others.
7. Self-Awareness.
8. A Sense o f Reconciliation with Death.
9. Ability to Maintain Objectivity and Derole.
10. A Sense of Humor as Appropriate.
11. Space Allocation.