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If a confused Alzheimer’s patient shoved you during a procedure, would you report the incident? What if an irate, intoxicated patient threatened you with a knife? Research suggests many ED nurses consider such assaults to be just "part of the job," reports Lisa Erickson, MSN, CEN, CCRN, FNP, assistant professor of nursing at Southwest Tennessee Community College in Memphis.
A recent study showed patients had assaulted 56% of ED nurses surveyed during the previous year, yet 29% of those were unreported.1 "This is not counting the ones that the nurses had forgotten about,’" says Erickson, the study’s principal investigator.
As an ED nurse, your risk for patient assaults is six times higher than other health care and social service workers.2 Studies have shown that assaults occur in all areas within the nursing community, including general floors and home health, Erickson acknowledges.3,4 "However, due to the nature of patients seen in EDs, which includes injuries related to drugs, alcohol, and violence, plus the emotional stress of a sudden accident or illness on the patient and their families, ED nurses are at a higher risk than most nurses," Erickson explains.
Most EDs are easily accessible to the public at all hours of the day, Erickson adds. "This makes the staff easier targets than if an assailant had to take an elevator up five floors."
Another factor contributing to more assaults by patients in EDs is waiting times, Erickson asserts. "Patients who are sick and/or injured come to EDs expecting to be seen immediately. They become easily agitated by long waits."
The body of research showing risk to ED personnel is growing rapidly, reports Betty Wendt Mayer, RN, MSN, ARNP, an ED nurse practitioner at Florida Emergency Physicians in Maitland. "More research is available on violence against psychiatric workers, but we are quickly catching up," she notes. Mayer notes one important difference between the two nursing specialties: "The difference is that even though bad things happen in the psychiatric areas, the nurses there have extended training in management of violent patients."
Here are some of the reasons that ED nurses do not report assaults, according to Erickson and Mayer’s research:
• ED nurses take assaults for granted. According to Erickson’s study, the biggest factor in nonreporting was habituation. "Nurses were so used to minor’ assaults that they actually forgot about them by the time the shift was over," she says.
• There is a perception that reporting might be "whining" or troublemaking. Nurses want to be seen as patient advocates, says Mayer. "This is particularly true if the patient has some physiological reason for bizarre behavior, such as retardation, hypoxia, or Alzheimer’s, as opposed to illegal drug abuse," she says. "Until it is acknowledged that no violence is acceptable, this will remain a problem."
• There is a lack of time to fill out incident reports. With overwhelming patient loads and the amount of paperwork necessary for routine patient care, reports generally are not filed unless a nurse is seriously injured, says Erickson. "In addition, if a report is filed, many hospitals require extensive follow-up with employee health during the employee’s own time," she adds.
• There is a lack of support for nurses who are assaulted. This blasé attitude may come from peers, supervisors, administration, the police, and the judicial system, Erickson stresses. "Nurse assaults are not a high priority," she says.
You must report all patient assaults, urges Erickson. Here are the reasons:
• Occupational Safety and Health Administration (OSHA) requirements. According to OSHA regulations, you’re required to enter the following injuries on the OSHA Log of Injury and Illness:
You also must enter on the log any injury caused by an assault that is otherwise recordable. The regulations require a fatality or catastrophe resulting in the hospitalization of three or more employees must be reported to OSHA within eight hours, including those related to workplace violence. (See excerpt from Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers in this issue.)
• Ability to track assault patterns. You need to apply the same stringent standards to documenting assaults as you would to complying with risk management requirements, says Erickson. "Nursing 101 is if it wasn’t charted, it wasn’t done,’’’ she notes. Erickson is working to develop legislation to make the assault of a health care provider a felony in her home state of Tennessee. "However, I have little data to show that it is a problem," she notes. "Why should administration or legislators care about something that supposedly happens so infrequently?"
• Validation. Documenting occurrences is the first step to correcting the problem, says Erickson. "It makes the statement that we are not going to tolerate it any more."
• Allocation of hospital resources. File reports so that administrators can understand the true severity of the problem, Mayer advises. "Your word is never enough. It must be documented," she adds. "Hospitals are not willing to spend money on protective devices and security if there is no record of such incidents occurring." There are measures that hospitals can take to decrease patient assaults; however, they all cost money, says Erickson. "As nurses increase reporting of their assaults, hospitals can track turnover rates and missed work days related to assaults."
Take the following steps to encourage nurses to report assaults:
• Debrief the staff after an assault occurs. Erickson recommends a debriefing of the entire staff as soon after the event as possible. "Unit debriefings reinforce the notion of This could happen to any nurse; it was not the nurse’s fault that an assault occurred,’" she says. Debriefing also provides peer support and validation of the assault, says Erickson. "Group meetings also make it possible for brainstorming of solutions to the department’s assault problems," she notes.
• Pay for counseling for nurses who are assaulted. Depending on the nature of assault and/or injuries, personal counseling should be offered and paid for by the institution, says Erickson. "After an assault, many nurses find themselves being more defensive at work and to their patients," she explains. "Through verbal or nonverbal language, they may actually make themselves prone to a repeat assault." The ED will save money on decreased nurse sick days and higher retention rates by providing counseling to nurses after an assault, says Erickson.
Only one-third of nurses surveyed in Erickson’s study said they would actually press charges against an assaultive patient. "The majority of nurses I spoke with believe the deciding factor to call the police is patient intent," she notes. "There is a difference between a drunk, belligerent patient who kicks you and a confused, elderly lady who takes a swing at you." Even for the latter example, Erickson recommends conferring with the patient and/or family. "The goal is to convey that this is unacceptable behavior and to reach a decision on how to prevent this from occurring in the future," she explains.
If you do decide to file a police report, be sure to show up at court, Erickson urges. "If you don’t, it again reiterates the idea that the assault of a nurse is no big deal,’" she says. (See next month’s issue for tips on how to prevent an assault.)
1. Erickson L, Williams-Evans SA. Attitudes of emergency nurses regarding patient assaults. J Emerg Nurs 2000; 26:210-215.
2. Mahoney B. The extent, nature, and response to victimization of emergency nurses in Philadelphia. J Emerg Nurs 1991; 17:282-284.
3. Poster E. A multinational study of psychiatric nursing staffs; beliefs and concerns about work safety and patient assault. Arc Psychiatr Nurs 1996; 10:365-373.
4. Carmel H, Hunter M. Staff injuries from inpatient violence. Hosp Community Psychiatry 1989; 40:41-46.
For more information about reporting patient assaults, contact:
• Lisa Erickson, MSN, CEN, CCRN, FNP, 1720 Bucksnort Road, Covington, TN 38019. Telephone: (901) 475-6483. Fax: (901) 476-8294. E-mail: firstname.lastname@example.org.
• Betty Wendt Mayer, MSN, CEN, ARNP-CS, 1084 Torchwood Drive, Deland, FL 32724. Telephone: (904) 738-3336. Fax: (904) 738-5733. E-mail: email@example.com.
Below is a partial listing of resources pertaining to management of violent patients:
• Crisis Prevention Institute (CPI) offers three levels of intervention training. For more information, contact CPI, 3315-K N. 124th St., Brookfield, WI 53005. Telephone: (800) 558-8976 or (262) 783-5787. Fax: (262) 783-5906. E-mail: firstname.lastname@example.org. Web: www.crisisprevention.com.
• REB Training International offers Management of Aggressive Behavior (MOAB) courses, which provide skills training for management of violent behavior. For more information, contact REB Training International, P.O. Box 845, Stoddard, NH 03464. Telephone: (603) 446-9393. Fax: (603) 446-9394. E-mail: email@example.com. Web: www.rebtraining.com.