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Reduce ED violence with training, diligent reporting to avoid harm
Don't let staff accept assaults as unavoidable part of the job
Violence in the emergency department (ED) is such a common occurrence that staff can become complacent about the risks they face daily. Nowhere else in your organization would employees accept the idea that they may be assaulted at any time, but that attitude can be common in the ED. Risk managers should emphasize to ED staff that violence does not have to be just a routine part of their work.
The Emergency Nurses Association (ENA) in Chicago recently surveyed 1,000 ENA members and found that 86% had been the victim of workplace violence in the past three years, with nearly 20% reporting that they experience workplace violence frequently. The potential for liability is enormous, not to mention the effect that ED violence has on employee morale and retention. Reducing the risk and effects from ED violence depends first on a good reporting system, says Steve Albrecht, PHR, CPP, a security consultant and expert on workplace violence based in San Diego.
"When it comes to health care violence, my biggest concern is that staff and physicians are reluctant to report threats or actual assaults, somehow thinking it is part of their jobs to take these behaviors," he says. "When I teach classes, the ED members all report being threatened or assaulted, because they work in the patient's intimate space, yet these are not reported."
Without knowledge of incidents, the leadership of the organization cannot respond effectively, write new policies or change existing ones, or create new protocols, Albrecht says.
"Without consequences for patient behaviors, we can expect more of the same," he says. "People who work with patients who often have high stress and high emotions, like in the ED and neonatal, tend to minimize patient actions even when it is quite severe. They get the idea that it is part of their job to be mistreated and assaulted."
Good reporting also can improve your threat analysis, says Amit Gavish, a security expert with SSC Inc., a security consulting company in Shelton, CT, who previously was deputy director of security for the office of the president of Israel. He says it is easy for people to focus almost exclusively on what they perceive as the big threat a murder or rape in the ED and devote little attention to preventing the far more common acts of violence.
"You have to categorize the different types of threats and plan a response for each threat," he says. "What you need to do to prevent a knife attack from a gang member is not the same thing you need to do to prevent a disgruntled former employee from walking into the ED and assaulting someone."
It is a mistake to be hasty in implementing security improvements without knowing what the real threats are, Gavish says. EDs are not all the same, and the type of potential violence will vary, he says. Urban EDs may have different concerns than rural facilities, and pediatric EDs may have their own concerns. Each will require an appropriate prevention and response plan.
When improving security in the ED, it is important to remember that fortifying the facility is not necessarily the answer, Gavish points out.
"A lot of times we see people say they're going to improve security, usually after a bad incident, and they spend a lot of money installing cameras and metal detectors and posting more guards," he says. "But if you haven't analyzed your risks and identified the threats, it can be a total waste of your money. You say you've increased security, but you really haven't done anything useful."
Promote zero tolerance
Risk managers can improve reporting by emphasizing that they want to hear about all incidents of ED violence and that those reports will not be viewed as whining or complaining, Albrecht says. Staff must understand that the hospital leadership does not consider ED violence an unavoidable job hazard. The relatively minor incidents can reveal security issues that can help prevent more serious incidents, he says.
Nurse saved from possible rapist
Police in Longview, WA, report that a nurse at St. John's Medical Center recently was saved from an apparent rape attempt by a hospital security guard who came to her defense.
Hospital officials reported that the incident began when a man walked into the hospital and asked for medical attention. He was taken to an exam room and asked to change into a gown. Then two nurses entered and began asking questions. That was when the man became violent, according to a statement from the hospital.
Police say the man jumped off the bed and attacked one of the nurses. He pinned her against the wall, ripped her shirt, and told her he was going to rape her, according to the police report. Hospital security guard Joel Reeder heard the nurses' screams and ran to the exam room. Reeder told police he saw the patient on the nurse and yelled at him to back up, and the man complied. The guard then called for more help and several guards took the man into custody.
A statement from the hospital noted that it had conducted a thorough review of security procedures and improved some measures about a year ago after someone entered the ED with a gun. Police say the man may be charged with attempted rape and assault, pending a mental evaluation.
"Don't wait until a nurse is beaten unconscious before you decide to act," Albrecht says. "No matter what you identify as why that happened, I can almost guarantee that you could have identified the same issues after previous, much less severe incidents took place."
Albrecht says ED staff also should be encouraged to call for help from the local police department whenever there is a threat of violence without feeling as if they are being overly cautious.
"The police don't necessarily arrest anybody, but they show up and lower the emotional temperature of the situation," he says. "I would let ED staff know that hospital leadership will not frown upon staff calling for help when they feel threatened, before the violence occurs, whether that help comes from hospital security or the local police."
Hospitals can reinforce the safety culture in the ED by having a formal policy and reiterating the organization's zero tolerance for assaults on staff, says Robert Siciliano, CEO of NurseSecurity.com and a personal security expert in Boston.
"That policy should be posted, included in paycheck envelopes, handed out at safety and security meetings any way you can get it in front of people repeatedly," he urges. "If they are continually reminded, there is a better chance that they will remember in the heat of moment, when they are faced with a potentially dangerous situation."
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