Experts: To crack down on violence in the ED, establish a robust system of reporting, educating staff
ED is a magnet for people who are upset, out of control
Financial Disclosure:Author Dorothy Brooks, Managing Editor Leslie Hamlin, Executive Editor Shelly Morrow Mark, and Nurse Planner Diana S. Contino report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Executive Editor James J. Augustine discloses he is a stockholder in EMP Holdings. Caral Edelberg, guest columnist, discloses that she is a stockholder in Edelberg Compliance Associates.
How big of an issue is violence in the ED? Gordon Gillespie, PhD, PHCNS-BC, FAEN, an assistant professor at the University of Cincinnati College of Nursing in Cincinnati, OH, and a Robert Wood Johnson Foundation nurse faculty scholar, says that according to research he has done on the issue, about half of all ED workers will be physically assaulted at some point in their careers, and 97% to 100% of them will experience some form of verbal abuse.1
By verbal abuse, Gillespie is not referring to incidents in which providers are merely cursed at. He’s referring to language that is more sinister, such as threats to a person’s safety or comments designed to cause emotional distress. "At some point, [all ED workers] are either going to be the target of this kind of behavior or they are going to be around watching somebody else being verbally abused or physically assaulted," explains Gillespie.
The reasons why EDs are often on the receiving end of such aggression is not that hard to understand, explains William Wilkerson Jr., MD, an associate professor in the Department of Emergency Medicine at the University of Michigan Health System in Ann Arbor, MI, who teaches both medical students and residents about how to deal with violence in the emergency setting. "The ED is inherently a magnet, unfortunately, for people who are either upset, out of control, or violent," he says. "
For instance, people who are shot or injured in a fight are brought to the ED, just as people who are intoxicated, suicidal, or psychotic are brought in, observes Wilkerson. "We obviously have that facing us in the ED. We are just a little bit different than other parts of the hospital," he says. "Because of what we do, we are more subjected to violence."
However, that doesn’t mean that ED personnel are defenseless when faced with this type of aggression. To the contrary, there are strategies that providers, techs, registration staff, and other personnel can use to de-escalate pressure-cooker situations, but it is up to administrators to make sure that such strategies are disseminated on a regular basis.
The first step in developing an effective approach to violence in the ED is to educate staff on what workplace violence is because health care workers routinely consider certain types of aggression as not being examples of violence, even if they have been harmed, says Gillespie, who will soon begin testing interventions to reduce violence against ED workers.
"In their minds, if a 4-year-old bites you while you are doing an IV start, or an 87-year-old dementia patient slaps you, these are not instances of workplace violence," he says. However, Gillespie emphasizes that these definitely are cases of workplace violence. "It doesn’t matter what the intent of the person is, it only matters what actually transpired, so any kind of hitting, biting, or slapping are all examples of violence," he says.
The reason why it is important to appropriately identify and report these instances of violence is so that the patients involved can be flagged in the hospital’s computer system. With the proper notations in place, providers will know to take extra precautions when these patients come into the ED in the future, explains Gillespie.
"Some organizations may just flag the patients with a notation to call security or the social work department for more information, while others will specifically say that there has been a previous violent event," says Gillespie. "Either way, when the 4-year-old who bit a provider during an IV start comes in again and needs an IV, you will realize that you need an extra person there, or that you need to do different things with the family so that another violent event doesn’t happen."
Gillespie acknowledges that the best way to respond to instances of violence is going to vary. For instance, you wouldn’t call security or the police in the case of the 4-year-old or even the 87-year-old patient with dementia who is lashing out, but with forewarning, providers can be better prepared to deal with these patients.
"We all understand that patients with dementia react to stimuli, so you will know to go into the exam room with someone else to help divert the older adult so that he doesn’t slap you," says Gillespie. "But if these types of incidents are not reported, then we can’t do anything to prevent those same events with the same patients from happening in future, similar situations."
It can be a challenge for administrators to get ED personnel accustomed to regularly reporting instances of violence, says Gillespie. However, once employees see the value of reporting, the task becomes easier, he says. For example, he recalls the case of one ED that he worked with to improve this type of reporting. "Their reporting went from something like three or four incidents per quarter to about 40 events in a quarter," says Gillespie. And that got the attention of higher ups. ". In many hospitals, the documentation results in the upgrading of hospital security prescence, or the hiring of off-duty police officers to reduce violence.
Identifying episodes of violence
"As a result of that reporting, the hospital hired an expert to come in and validate that the ED needed additional resources," says Gillespie. This led to significant investments to improve environmental safety, which is what the staff really wanted. "Those employees really saw the value of reporting."
Be aware of clues
There are telltale clues that a patient or family member may become agitated or violent, and these should not be ignored, explains Wilkerson. For instance, he notes that ED personnel need to be on the alert for people who start pacing, raising their voices, tensing their postures, or making unrealistic demands. "Go in and find out what is going on before the situation escalates," he says.
In such instances, empathy and good customer service skills can usually go a long way, but a lot depends on the manner in which you approach the patient, notes Wilkerson. "For most people who are angry, 95% of their understanding is just from your presentation. They are not even listening to what you are saying. They are looking at the way you are standing, listening to your tone of voice, and observing whether you look disgusted," he says. "We teach people to have a neutral rather than a defensive stance, avoid staring people down, and utilize a calm voice. Just explain things and ask what you can do to help the situation."
ED personnel should not hesitate to get help if someone they are dealing with becomes particularly agitated, and they feel uncomfortable or threatened. "Sometimes you have to do what we call a show of force," says Wilkerson. This is when you approach the patient, along with three or four other people, and let him or her know that if the situation continues, you are going to have to restrain them, he says. "Restraining is not a good option," says Wilkerson. "People can have heart attacks, or they can get twisted up in the restraints, so it is not something we like to do. If we can do something lesser, like a show of force, that is always better."
Gather input and collect data
For ED administrators who are just in the beginning stages of developing a strategy for dealing with violence, Gillespie recommends that they put together a team with representatives from every environment, including housekeeping, registration, and even medical records, in addition to the clinical areas. "Everybody who comes in contact with a patient or a visitor needs to be part of this planning group because they may have recommendations that, unless you ask for them, you are never going to hear," he says.
For example, Gillespie recalls an experience with one such planning group in which a man from registration noted that he could call ahead and give the nurse in the ED a heads up when a patient comes in who is acting edgy or agitated. This kind of input can help administrators develop an approach that is more likely to fit the workplace involved. Adds Gillespie, "Only people on the front lines are going to understand why something is or isn’t going to work."
1. Kowalenko T, Gates D, Gillespie G, et al. Prospective study of violence against ED workers. Am J Emerg Med. 2013,31:197-205.
- Gordon Gillespie, PhD, PHCNS-BC, FAEN, Assistant Professor, University of Cincinnati College of Nursing, Cincinnati, OH, and Robert Wood Johnson Foundation Nurse Faculty Scholar. E-mail: email@example.com.
- William Wilkerson, Jr., MD, Associate Professor, Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI. E-mail: firstname.lastname@example.org.