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Are you losing nurses due to violence in your ED? You should take action now!
Emergency nurses at high risk for assaults, study says
If you’re having trouble retaining and recruiting ED nurses, it may be time to closely examine your violence prevention strategies. The University of Alberta (Canada) Faculty of Nursing surveyed more than 9,000 nurses. The survey revealed that 22% of ED nurses reported being assaulted during the previous five shifts, and 62% reported emotional abuse.1 Both percentages are higher than those reported by psychiatric and medical-surgical nurses.
The report found that nurses who reported emotional abuse and at least one other form of violence had the lowest job satisfaction, while nurses who reported no violence were most satisfied.
This study clearly shows that the nursing shortage is a powerful motivator to immediately address the problem of violence and abuse in your ED, says Kayleen L. Paul, RN, BS, CEN, director of emergency services at McKay-Dee Hospital Center, a 300-bed facility based in Ogden, UT. "We strongly believe that a violence-free workplace will help us retain our experienced and valuable ED nurses," Paul says.
Confront this problem in your ED, urges Rosemary Kucewicz, RN, BSN, ED manager at Northwest Community Hospital in Arlington Heights, IL. "For many years, we accepted aggression as part of our environment and never did anything to prevent or control it," she says. "Every ED manager has to come up with strategies to prevent violence."
As an ED manager, implement a "zero-tolerance" policy for abuse and violence, says Sherlene Stepp, RN, clinical nurse supervisor for the ED at University of California-Irvine Medical Center in Orange. "No staff member should be threatened or harassed," she emphasizes. "We need to let the public know we will not tolerate violence in the ED."
To prevent violence in your ED, use these strategies that work:
• Develop specific policies to address violence. The ED at Northwest Community has detailed policies and procedures for violence prevention, and staff members are regularly inserviced on these, reports Kucewicz. Your policies must address violence in the workplace, management of psychiatric patients, and security policies, she says. The ED’s policy outlines a "show of force" procedure by security known as "Mr. Strong," says Kucewicz. "In this policy, you do not wait until the patient does something," she points out. "At the first sign of a potentially violent situation, you page security staff for a show of force."
Often, security stands by as the nurse de-escalates the situation verbally, but the show of force prevents a violent outburst, says Kucewicz.
A "no tolerance" procedure was implemented at Covenant HealthCare in Saqinaw, MI, reports Marc Augsburger, RN, BSN, BC, manager of the emergency care center. "If any threatening remarks are made toward our staff, security is immediately notified and responds," he says. "They stand guard at the doorway until a clinical decision can be made concerning the patient."
If any visitor is heard or visualized making threatening comments, security is notified to respond to the ED immediately, says Augsburger. "The visitor is politely asked to leave the property," he says. "If the visitor does not willingly leave, they are escorted out by security."
No tolerance’ policy includes staff
The Canadian study reported that a significant number of incidents were from co-workers. The ED’s "no tolerance" policy also is in effect for co-worker abuse, notes Augsburger. "The co-worker is escorted out, and a thorough investigation of the account is conducted and documented," he says. "Termination is a real possibility."
To notify security, staff can call the five-digit emergency security number or use one of several push buttons throughout the ED that alert the security office, he explains. "These are mostly mounted under desktops within easy reach of staff members," says Augsburger. The push buttons are not visible, so they can be hit without the patient knowing it, he adds. "The actual button also is protected so that there is little chance of a false alarm," Augsburger says.
If staff members observe a patient or co-worker being threatening, they use the push button or verbally call for help, and security is immediately notified, he says. "Depending on the situation, the observer may assist in a de-escalation," Augsburger says.
• Limit the number of people in the department. "We now allow only one visitor at the bedside, unless the patient is a child," says Stepp. The ED also has locked-door access, she adds. "This means that anyone who wants to enter has to first check with our greeter, who calls the ED to receive clearance for him or her to enter," she explains.
• Address high-risk patients. The ED has a very high psychiatric population, notes Stepp. "Most of our violence does occur with this population of patients," she says. Two beds are designated for psychiatric patients in a secluded area of the ED, says Stepp. "This is helpful because it takes [most] disruptive patients out of the main ED, and it also decreases stimuli that may escalate the patient," she says.
• Assess potential for violence. A level system was implemented so that ED staff could convey the degree of risk posed by a patient, says Stepp. "To communicate the potential for violence was very difficult, so we developed a system so everyone would be on the same page," she says. The levels are as follows:
The ED nurse decides the patient’s level based on his or her behavior, and security is notified, she explains. "The level number is placed on the patient tracking board so the entire staff will know which patient to watch for," she says. With this system, security and ED staff are aware of a patient’s potential for violence, says Stepp.
• Invest in a security dog. When a disturbing trend was noticed of an increase in assaults on staff and patients coming in with weapons, ED staff knew something had to be done, says Paul. A committee was convened, and drastic measures such as metal detectors and armed security guards were considered, she says.
However, patient satisfaction was at issue, she notes. "We are not a large inner-city ED, and we knew that many of our patients would not expect or accept a lockdown’ atmosphere," Paul says. Instead, a security dog was purchased at a cost of $5,000 from a kennel that raises police dogs in Germany. "Any hospital considering a dog program would be best advised to have a close working relationship with their local police agency, so training can occur," she says. "We used their contacts with kennels and their selection and testing criteria to choose the dog."
The hospital’s security officer agreed to become the "canine officer" and patrols the ED during night hours with the dog, she explains. When the first dog was retired, a second dog was purchased from a kennel in the United States, says Paul. "We have had none of the problems we were worried about, such as infection control issues or the dog behaving inappropriately," she reports.
The dog is occasionally brought in when staff members feel threatened by a patient and is an excellent deterrent to violence, says Paul. "I have seen patients refuse to respond to armed police officers, but when faced with a growling dog, they immediately back down," she says.
1. Hesketh KL, Duncan SM, Estabrooks CA, et al. Workplace violence in Alberta and British Columbia hospitals. Health Policy 2003; 63:311-321.
For more information on violence prevention in the ED, contact:
• Marc Augsburger, RN, BSN, BC, Manager, Emergency Care Center, Covenant HealthCare, 700 Cooper Ave., Saginaw, MI 48602. Telephone: (989) 583-6259. Fax: (989) 583-7181. E-mail: firstname.lastname@example.org.
• Rosemary Kucewicz, RN, BSN, Manager, Emergency Department, Northwest Community Hospital, 800 W. Central Arlington Heights, IL 60187. Telephone: (847) 618-4010. E-mail: email@example.com.
• Kayleen L. Paul, RN, BS, CEN, Care Center Director, Emergency, Critical Care, and Trauma Services, McKay-Dee Hospital Center, 4401 Harrison Blvd., Ogden, UT 84403. Telephone: (801) 387-7006. E-mail: firstname.lastname@example.org.
• Sherlene Stepp, RN, MICN, Clinical Nurse Supervisor, Emergency Department, University of California-Irvine Medical Center, 101 The City Drive, Route 128, Orange, CA 92868. Telephone: (714) 456-6549. Fax: (714) 456-5390. E-mail: email@example.com.