Violence in the Workplace for Emergency Nurses
Steps Hospitals Can Take to protect Nurses
Years ago, Julie Crawshaw, RN, BSN, was a new nurse, asked to cover the triage desk for 10 minutes. It turns out that was more than enough time for something to happen that would remain vivid in her mind throughout her 20-year emergency nursing career. “I was held at knifepoint,” says Crawshaw, who was working in a hospital in Los Angeles at the time of the attack. “A man asked, ‘How long will it be?’ I had a bad feeling about him — he was encroaching on my space. I turned my back to call security, and he pulled a six-inch blade on my throat.” (She says the man had pulled the knife out of his Bible, of all places.)
Crawshaw ended up falling backwards onto a rolling chair as the man continued to pursue her. Luckily, another employee arrived just in time, and was able to grab the man. Crawshaw says she found out later that he was a psychiatric patient. According to the Occupational Safety and Health Administration (OSHA), the assault injury rate for nursing and personal care facility workers in 2000 was 25 injuries per 10,000 full-time workers, whereas the injury rate for the private sector overall was only two injuries per 10,000 workers.
Check Out Toolkits and Guidelines
A November 2011 report from the Emergency Nurses Association (ENA) found that a common factor in assaults on nurses was the aggressor being under the influence of drugs or alcohol. In nearly half of reported assaults, a psychiatric patient was the aggressor.
For example, Lillian Briones Arredondo, RN, MSN, who worked as an emergency nurse in a level 1 trauma center in Los Angeles for over four years, recalls an incident in which a coworker was attacked by a psychiatric patient who lost control and threw a sharps container and large trashcan at Briones Arredondo’s colleague.
The violence cited in the ENA study included not only physical abuse, but also verbal abuse, such as yelling and cursing. “That [verbal abuse] happens all the time,” Crawshaw says. “There are people hysterically crying. Patients or family scream, especially when you are working with children. I take it with a grain of salt. I have never felt bodily danger from this.”
Briones Arredondo also perceives verbal abuse as being just part of the job, certainly not something one would report to hospital safety professionals as an incident. “I think verbal abuse is typical for most service-type jobs, but more so with nurses because we are at the front line — and even more so with the emergency room,” she says.
Current ENA President Gail Lenehan, Ed.D., MSN, RN, FAEN, FAAN, says training emergency nurses can help. Nurses should have a good understanding of risks, security procedures and how to de-escalate a situation. The entire workplace must also support its employees with a “comprehensive violence mitigation program” — one that is supported by nurses, physicians, administrators, security and facilities staff alike.
ENA has made available a tool kit and other resources to help emergency departments initiate such a program. Also, OSHA has published guidelines for preventing workplace violence for healthcare workers.
“Clearly, given the data, we need to do more to protect emergency nurses from violence,” says Lenehan. “Our research shows that an enforced zero-tolerance policy can cut violence rates by nearly half.” She goes on to state that a zero-tolerance policy isn’t a complete solution in itself, but is more an indication of an institution’s commitment to a safe work environment. “Without that cross-departmental input and buy-in, it is very difficult to address the issue effectively,” she says.
Make Sure Security is Trained and Available
Lenehan advises emergency nurse candidates to screen potential workplaces before being hired, to get an understanding of their security and safety programs.
“While overall there needs to be improvement, not all emergency departments are alike,” Lenehan says. “Some have admirable, well-trained professional security right on site, as well as panic buttons and other concrete measures that should certainly be a consideration for any nurse.”
Crawshaw agrees that having reliable security staff could help — at least, it would make her feel more secure.
Arrowhead Regional Medical Center (ARMC) in San Bernardino County is a level 2 trauma center and designated facility for patients on involuntary psychiatric holds. With more than 3,000 employees, ARMC requires all hospital staff to complete situational awareness and safety training. Additionally, all security, behavioral health and emergency room staff must complete a management of assaultive behavior (MAB) program, which features a team approach for handling assaults.
ARMC has a police officer onsite at all times and a staff of up to 90 security personnel available. Three or four security members may be stationed in the emergency department, depending on patient census. And yes, the security staff is required to meet the physical expectations of the job.
“They must be physically able to intervene, as needed, using the team techniques — it is a job requirement,” says Kurt Sawatzky, supervising security technician at ARMC. He explains that if someone becomes assaultive or has escalating behavior, a “code grey” is called and those personnel who are MAB-trained attempt to de-escalate the situation, which Sawatzky likens to an “orchestra playing their instruments.”
“We are not all prizefighters,” he jokes, “but we can take on a patient very effectively as long as we work together.” ARMC also has metal detectors and inspections at all hospital entrances, controlled access to the emergency room and emergency registration windows and colored wristbands to clearly identify people going to inpatient and outpatient areas.
Streamline the Triage Process
“We relied heavily on security guards,” Briones Arredondo says, of her workplace. “They would de-escalate problems from patients and family who were irate after waiting long hours and not understanding the triage system.” She reports that patients have a hard time accepting that a burn victim or person involved in a motor vehicle crash has to be treated ahead of them. After waiting several hours, seeing others “cut the line” can cause tempers to flare.
To help mitigate wait time as a potential risk factor for escalation, ARMC implemented a rapid assessment protocol to decrease door-to-doctor wait times. This approach postpones the registration process so patients can be triaged more quickly. To help reduce aggravation, ARMC also installed cubicles for the triage to be performed more visibly for those waiting.
Hold a Post-Incident Debriefing
Another consideration for emergency nurses when screening future employers is to ask what their response is to nurses who are threatened or injured. Crawshaw, now a critical care transport nurse and an instructor at Long Beach City College, said that after the knife incident, she was not debriefed, but actually chastised for not being able to prevent the incident using psychiatric nursing skills.
“Some hospitals do not take care of their nurses when something mental or psychosocial happens — when it’s physical, they take care of it,” she says.
Police officers are always debriefed by management after a violent incident with a citizen, but it is not common practice for nurses to do so. Putting a mandatory post-event discussion process into place could turn a scary situation into a learning experience and make the emergency department a safer place for everyone.
Report from the Emergency Nurses Association: www.ena.org/media/PressReleases/Pages/WorkPlaceViolence.aspx
ENA tool kit for reducing workplace violence: www.ena.org/IENR/Pages/WorkplaceViolence.aspx
OSHA guidelines for preventing workplace violence for healthcare workers: www.osha.gov/Publications/OSHA3148/osha3148.htm
Daria Waszak, RN, MSN, CEN, COHN-S, is a freelance writer with extensive clinical and administrative nursing experience.