Four steps to reduce violence in the ED

[Editor's note: This is the second in what is now scheduled to be a three-part series on reducing violence in the ED, due to breaking news. In last month's article, our experts discussed the importance of a "zero tolerance" policy. In this article, we outline key steps recommended for reducing violence and discuss the importance of having clear procedures when it comes to dealing with patients and their families. Next month we will examine the Sentinel Event Alert just published by The Joint Commission that discusses why the ED is particularly susceptible to episodes of violence, outlines leading causal factors, and provides additional guidance for violence prevention.]

One of the keys to preventing violence in the ED is having clear procedures about processing patients, says Jean Henry, PhD, an assistant professor of health science at the University of Arkansas, Fayetteville, and co-author of a chapter titled "Prevention of Workplace Violence," in the book Leadership and Nursing Care Management (W.B. Saunders, 2010). This approach helps you avoid treating patients as a number or as insignificant, Henry says.

"Make sure during the intake process there is an attitude of caring," she says.

That doesn't mean, however, that you assume all patients are harmless, warns Phillip Knotts, RN, administrative supervisor of nursing at Patient's Hospital in Pasadena, TX. Knotts learned a painful lesson several years ago when treating a psych patient. "He had a psychotic break," he recalls. "He was telling us that we had kidnapped him and were holding him on a ship."

Knotts, who was the charge nurse, talked the patient down and thought everything was fine. Then he made a critical error. "I turned my back on him, and he picked up a telephone and hit me in the head and knocked me out cold," Knotts recalls. "My lesson was not to turn your back on a disturbed patient, and it's something I teach all my nurses now."

Agencies give guidance

When trying to reduce violence in the ED, consider these recommendations from the Occupational Safety and Health Administration (OSHA, www.osha.gov/Publications/OSHA3148/osha3148.html), cited by Jean Henry, PhD, an assistant professor of health science at the University of Arkansas, Fayetteville, and co-author of a chapter titled "Prevention of Workplace Violence," in the book Leadership and Nursing Care Management (W.B. Saunders, 2010).

OSHA says that the team or coordinator should periodically inspect the workplace and evaluate employee tasks to identify situations that could lead to violence. The team or coordinator should:

  • Analyze incidents, including the characteristics of assailants and victims, an account of what happened before and during the incident, and the relevant details of the situation and its outcome. When possible, obtain police reports and recommendations.
  • Identify jobs or locations with the greatest risk of violence as well as processes and procedures that put employees at risk of assault, including how often and when.
  • Note high-risk factors such as types of clients or patients (for example, those with psychiatric conditions or who are disoriented by drugs, alcohol, or stress); physical risk factors related to building layout or design; isolated locations and job activities; lighting problems; lack of phones and other communication devices; areas of easy, unsecured access; and areas with previous security problems.
  • Evaluate the effectiveness of existing security measures, including engineering controls. Determine if risk factors have been reduced or eliminated and take appropriate action.

The National Institute for Occupational Safety and Health (NIOSH) also has guidelines for risk management that can be downloaded for free on its web site.

Sources & Resources

For more information on preventing violence in the ED, contact:

  • Jean Henry, PhD, Assistant Professor of Health Science, University of Arkansas, Fayetteville. Phone: (479) 575-2899. E-mail: ljhenry@uark.edu.
  • Phillip Knotts, RN, Administrative Supervisor of Nursing, Patient's Hospital, Pasadena, TX. Phone: (281) 785-2239.
  • For guidelines on workplace violence from The National Institute for Occupational Safety and Health, go to www.cdc.gov/niosh. Select "Industries and Occupations," Then select "Health Care." Scroll down to "Violence" and select "Violence: Occupational Hazards in Hospitals."
  • For guidelines on workplace violence from the Occupational Safety and Health Administration, go to www.osha.gov. Search for "workplace violence." Select
  • "Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers – OSHA Publication 3148 (2004)."