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Responding to an active shooter and other threats of violence

Weeks, Sandra Kenney MSN, RN, CRRN, NEA-BC; Barron, Bridget Tillman BSN, RN-BC; Horne, Marilyn Ray CEH, MESH; Sams, Gayle Perdue MSN, RN, CCRN, CEN, CNML; Monnich, April Bennett RN-BC, CMSRN; Alverson, L. Denise RN

doi: 10.1097/01.NURSE.0000435201.57905.38

Do you know how to keep yourself and your colleagues safe in the face of a shooting or other violent act? Learn from one hospital's plans to respond to a dangerous situation.

Sandra Kenney Weeks is director, Medical and Oncology Nursing, Respiratory Therapy, Sleep Center; Bridget Tillman Barron is director, Psychiatric and Addictions Therapeutic Healing Services (PATHS); Marilyn Ray Horne is director, Environmental Services, Safety and Emergency Management; Gayle Perdue Sams is director, ED, Intensive Care and Cardiology Services; April Bennett Monnich is a charge nurse, PATHS; and L. Denise Alverson is a direct care nurse, PATHS, all at Pardee Hospital in Hendersonville, N.C.

The authors have disclosed that they have no financial relationships related to this article.



NURSES IN HOSPITALS across the nation are increasingly faced with the potential for workplace violence from patients, visitors, or people walking in off the street. This is most likely due to an increased number of patients with mental health disorders using hospitals for follow-up care, a rise in police use of hospitals to hold aggressive and intoxicated individuals, and 24-hour public access to hospitals.1

How do you determine if a patient is becoming increasingly agitated and potentially dangerous? What do you do when critical psychiatric care is needed for a patient outside the psychiatric unit? How do you keep yourself and your colleagues safe while caring for a violent patient? What would you do if a patient (or someone else) produced a gun and started shooting? How do you prepare nurses and other healthcare workers for such an event? This article discusses real-world solutions to these scenarios.

Knowing that violence can erupt unexpectedly, staff at our hospital developed interventions for potential and actual violence. Like most hospitals, ours had security officers, no-weapons signs at entrances, nonviolent crisis intervention training for employees, and a Code 300 call for assistance with combative patients or visitors. To those, we added a Psychiatric Crisis Response Team, the STAMP violence screening process, and a Code Zero: Active Shooter education program and drills.2,3

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Psychiatric crisis response team

When a medical patient presents with a psychiatric emergency, nurses need help in a hurry. This became top priority when, in 1 week, two nurses in our hospital were attacked and seriously injured by patients. Nurses concerned about their patients' acute psychiatric needs and staff/patient/visitor safety raised their concerns in staff meetings and at the Nursing Practice Council, Nurse Retention Council, and Nursing Leadership Council. The request for immediate assistance in addressing psychiatric emergencies in the hospital led to a suggestion for a psychiatric response team patterned after our medical Rapid Response Team. The Director of Psychiatric Services took the challenge back to her nurses and they came up with a plan for action: a Psychiatric Crisis Response Team (PCRT), a policy, a crisis phone number, and PCRT orders approved by a psychiatrist and the Pharmacy and Therapeutics Committee.

The PCRT and Medical Rapid Response phone numbers are now printed side-by-side on a poster in all departments. The PCRT can be activated by any nurse or healthcare provider concerned about a patient exhibiting abnormal behavior, uncontrolled psychosis, agitation, hallucinations, suicidal or homicidal ideation, or violent behavior. Like the medical Rapid Response Team, the PCRT responds immediately anywhere in the hospital.

The team consists of highly qualified psychiatric and substance abuse nurses from our Psychiatric & Addictions Therapeutic Healing Services unit. The team's objective is to assess the patient and collaborate with the acute care nurse and healthcare provider to de-escalate the situation, provide treatment for the patient, and assist in establishing a safe, therapeutic environment for all patients, visitors, and staff.

The acute care nurse provides a concise report telling the responding nurse the patient's diagnoses, psychiatric symptoms, treatment attempted and provided, medications and allergies, and other essential information. The PCRT physician order form allows the psychiatric nurse to administer certain medications, evaluate the need for restraints or seclusion, initiate the involuntary commitment process, or begin transfer proceedings to the state psychiatric hospital. The PCRT nurse calls the psychiatrist for additional orders, if needed.

Nurses throughout the hospital have welcomed the concept and actions of the PCRT. While highly qualified in their patient-care specialties, our acute care nurses aren't psychiatric and substance abuse nurses. They appreciate that psychiatric and addiction nurse experts will respond immediately to help them meet the psychiatric needs of their patients and help keep nurses safe.

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STAMP out violence

Because we want to prevent violence, we've also added the evidence-based STAMP screening practice introduced by ED nurses in Australia. Nurses on our telemetry and psychiatric units took the lead in testing the STAMP process to identify potentially violent patients and prevent harm to patients, visitors, and staff. The STAMP acronym is now part of our assessment screen for easy access and documentation as nurses take action to protect patients and themselves. (See STAMP out violence.)

STAMP serves as an early warning system for nurses who feel threatened by a patient, family member, or visitor and need immediate help. Nurses observing for STAMP behaviors alert each other and call Security and the PCRT so help can arrive, assist, and de-escalate the threatening behavior before the situation becomes a Code 300. STAMP helps them take action early to protect the agitated patient, themselves, their colleagues, and other patients and keep the unit quiet and calm for healing and personal safety.4

Our Security Department further supports us by providing a security officer as a patient observer for 1 hour after a psychiatric emergency or Code 300. This gives the officer time to assess the volatility of the situation and determine if additional security is needed. It also gives the acute care nurse time to arrange for a constant observation sitter if the plan calls for the patient to remain in the ED or on the acute care unit in behavioral restraints or by court order.5

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Code Zero: Active Shooter

We added another step to the violence intervention program with a new code call, Code Zero: Active Shooter. The instructions come from the U.S. Department of Homeland Security, which defines an active shooter as “an individual actively engaged in killing or attempting to kill people in a confined and populated area.”3

The response to an active shooter is different from anything we do in healthcare. This time, nurses are taught to first protect themselves: to run and hide until the shooter can be stopped by the police. Only then can they help injured patients, visitors, and each other.

Our Emergency Management Committee developed an in-service program to teach all associates how to recognize and respond to a Code Zero: Active Shooter. The Code Zero in-service was highlighted on the hospital intranet for easy access by all nurses, other staff members, and healthcare providers 24/7 for 6 weeks before around-the-clock drills were implemented. Meanwhile, the Security Department assessed all departments to ensure the presence and knowledge of locked rooms where nurses and others could hide.

The in-service taught all of us to identify gunshot sounds, call the switchboard to report a Code Zero: Active Shooter, recognize a specific Code Zero overhead emergency sound and Code Zero announcement, and run and hide if we heard gunshots or the Code Zero sound or announcement. We also learned how to respond to law enforcement officers entering the building during an active shooter situation.

Posters in all departments and e-mails sent to all staff announced the dates, times, and instructions for the Code Zero drills. The County Emergency Management Office notified all area emergency response agencies of the Code Zero drill plans to prevent confusion during the drills.

After the 6-week intranet/poster/e-mail/staff meeting education blitz, we practiced the Code Zero response in announced drills on all shifts over 2 days. The hospital operator activated the Code Zero sound, overhead announced the Code Zero Drill, called the police, and sent a Code Zero Drill message to all hospital e-mail and cell phone users. The Administrator on Call notified an Incident Commander and the Incident Command Center was opened.

Accompanied by observers and a camera to record the action, a designated employee wearing a large sign bearing the words “ACTIVE SHOOTER” ran through the hospital pointing at and “counting” employees who didn't hide and were numbered as would-be “victims” of the mock shooter. Each drill lasted less than 15 minutes before an “all clear” was announced.

An after-action report noted that many lives would have been saved because most employees ran and hid when the overhead Code Zero tone sounded. The detailed training empowered nurses and their colleagues with knowledge and actions they could use to alert others and avoid injury and death at the hands of an active shooter.

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Keeping everyone safe

Nurses enter the healing profession to bring compassion and care to people. We hope we never have to face a violent patient or family member or hear a Code Zero called, but we've recognized the possibility and practiced a response. To keep patients safe, we must keep ourselves safe–that is a caring imperative for us all.

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STAMP out violence

The five STAMP components are taring, one of voice, nxiety, umbling, and acing, each with a 20% weight.2 Based on the total score, each component builds upon previous ones:

  • 20%—notify fellow staff members of potential violence
  • 40%—notify Security Department of potential violence
  • 60%—increase visibility of security officers on the unit, and call the PCRT
  • 80%—a security officer stays 1:1 with patient
  • 100%—assess need to call police for law enforcement presence.
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2. Luck L, Jackson D, Usher K. STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. J Adv Nurs. 2007;59(1):11–19.
3. U.S. Department of Homeland Security. Active Shooter: How to Respond. Washington, DC: U.S. Department of Homeland Security; 2008.
4. Strickler J. It hurts to care: workplace violence in healthcare. Nursing. 2013;43(4):58–62.
5. Weeks SK. Reducing sitter use: Outcomes of the decision. Nurs Management. 2011;42(12):37–38.
© 2013 by Wolters Kluwer Health | Lippincott Williams & Wilkins.