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ED violence: Occupational hazard?

Greenlund, Lisa CHSP, ARM

doi: 10.1097/01.NUMA.0000398673.76876.a5
Feature: CE Connection

Psychiatric patients seeking help in the ED can put nursesin danger. Are you prepared for these situations?

Lisa Greenlund is a director of Risk Management and Safety in East Greenwich, Rhode Island.



Workplace violence is an occupational hazard for hospital staff providing psychiatric care in hospital EDs. Nursing students specialize in emergency medicine to treat diverse medical issues in an exciting, fast-paced environment, but are unprepared to encounter verbal threats and physical assaults. Seasoned ED employees are at risk for life-changing injuries affecting their careers and families. The ED environment is constantly evolving due to various external influences, including the economy and availability of inpatient and outpatient treatment options. The same external influences have increased the number of psychiatric patients seeking emergency care, presenting an unusual challenge for EDs.

Workplace violence can be a financial burden for hospitals with excessive staff injuries. Payments of workers' compensation claims and overtime costs to replace injured workers have a negative impact on the bottom line. Department productivity after an event needs to be considered, in addition to the administrative costs of investigating violent incidents. Injured staff may suffer from a posttraumatic stress disorder, impacting their professional and personal life and requiring long-term counseling services. Recognizing the risk of workplace violence and implementing preventive strategies to reduce the risk will have a positive impact on a hospital's bottom line and productivity, and improve the satisfaction of staff working in EDs.

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Why's the ED dangerous?

Hospital EDs provide emergency medical care to the public. Many hospital EDs provide emergency medical services 24 hours a day, 7 days per week. Medical care consists of psychiatric care, first aid, diagnostics, and treatment of illnesses that can't be easily managed by a family practitioner due to the time of day, severity of the illness, or an illness that requires immediate attention of a specialist such as a surgeon, cardiologist, or psychiatrist.

Over the years, healthcare insurers have scrutinized hospital admissions. In addition, both the government and health insurers have made budgetary decisions resulting in the decreased availability of mental health services. Both changes have resulted in a changing patient population using hospital ED services. In addition, the ED climate is further compromised by physical accessibility issues. Control of unwanted visitors and abusive family members presents an environmental challenge for hospitals that provide emergency care.

A landmark 2001 survey showed that "a primary safety issue was the ease with which others could access entry into the emergency department."1 The study further concludes "the nurses reported that they frequently experienced verbal assault from distraught family members and identified patients, particularly those with psychiatric problems, as being the most common source of aggression and violence.... Prime risks for violence include alcohol intoxication, substance abuse, and psychiatric problems."1 Patients with emotional or mental problems present an increased risk of violence when compared with patients with physical conditions, and psychiatric care is increasing in hospital EDs. Patients with psychiatric problems are voluntarily and involuntarily brought to EDs in a confused or mentally unstable state due to medication- or substance abuse-related issues. Managing these patients is difficult for most EDs due to the lack of resources, treatment policies, and physical environment needed for treatment.

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Hospitals must implement preventive measures to minimize workplace violence in EDs. Adequately trained staff is the first of three strategies that must be implemented to minimize violent episodes. Specialized staff training is one measure hospitals can use to improve interactions between mental health patients and staff. Hiring a psychiatric care specialist or nurse to oversee the care of these patients may provide the ED staff with the resources they need to manage these patients. Nursing staff would be able to utilize the specialist for guidance before and during care of the mental health patient. The specialist may also assist in training nursing staff and others on the care and treatment of psychiatric patients.

Hospitals can provide ED staff with crisis management training. Employees providing psychiatric care should receive the training; however, all employees can benefit from these skills regardless of their location in the organization. Violence prevention verbal skills and body language should be included in employee orientation and ongoing education programs. Additional training programs should target awareness of the stages of a crisis and using verbal techniques to prevent a violent incident from occurring. There are nationally recognized programs available that incorporate verbal de-escalation and physical restraint techniques. Due to the increased risk of staff and patient injuries, physical restraint techniques are considered a last resort only after other efforts have been exhausted. Training on the use of chemical and physical restraint should be required of all ED staff and security, regardless of their assignment.

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In addition to adequately trained staff, the physical environment plays an important role in the treatment program. Environmental improvements and specialized treatment protocols are necessary to prevent violent episodes. In a 2008 study completed by Northern Kentucky University, it was learned that "ED nurses reported that their physical work environment, hospital staffing patterns and policy for receiving patients when unable to safely care for them play important roles in the risk for violence."2 The environment for psychiatric patients should be free from furniture and bedside medical supplies that can be used as weapons. Following the same guidelines used to construct psychiatric and suicidal inpatient treatment areas, hospitals can reduce the risk of staff injuries simply by removing objects from the ED psychiatric treatment area. The plan should also incorporate at least one seclusion or holding room for patient observation. Sometimes, simply rearranging furniture can prevent staff from getting trapped if confronted by a violent patient or visitor.

Another environmental strategy is to ensure privacy for these patients. Open treatment areas provide an audience for psychiatric patients in need of attention to act out. The public display may cause the medical patients to feel uncomfortable and place staff in a vulnerable position in the middle of the two patient populations. Treating psychiatric patients in private rooms in a secure location to discourage elopements can minimize external stimulus and distractions, creating a peaceful, nurturing environment for these patients. The secure location should be adequately staffed and include panic buttons and personal alarms for staff in need of assistance.

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Specialized treatment protocols specific to psychiatric patients provide staff with a consistent plan of care. Using a multidisciplinary approach, hospitals can physically map the psychiatric treatment plan, reviewing every aspect of patient treatment from triage to discharge. Facilities need to involve staff from security, administration, risk management, human resources, and high-risk clinical areas. Mapping out the area will provide an opportunity to review uses of technology such as access control, video surveillance, and metal detectors. The multidisciplinary team may also identify opportunities to improve the patient experience by permitting patients to wear their own clothing or watch TV.

Don't overlook clinical treatment protocols. A thorough risk assessment must be completed to ensure that key treatment protocols, including but not limited to close observation, suicide precautions, and use of restraints, are clearly defined and consistently implemented in accordance with regulatory agencies. Also don't overlook external resources from both inside and outside of the hospital. Rapid restraint or Code Gray teams comprising hospital-wide staff can quickly respond to an ED. Off-duty police officers can be paid to work during high-risk shifts in uniform and can be a deterrent for violent behavior while protecting staff and other patients from injury.

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Posttraumatic stress

The effects of workplace violence on staff range from embarrassment and intimidation to leaving their place of employment in fear. Long-term effects, including disabling injuries, are difficult and costly for hospital workers' compensation programs to manage. In 2007, Mountain State University completed a study and reported that "the 2005 Emergency Nurses Association's Annual Meeting revealed data regarding the occurrence of violence against ED staff. Results indicated 94% of participants had suffered verbal harassment, 66% reported verbal threats, 48% reported physical assault, and 39% reported sexual harassment."3 The results demonstrate that nearly two thirds experienced verbal threats and approximately half of the participants experienced physical assault. Hospitals can expect that approximately half of their ED staff will be physically assaulted during their career, resulting in workers' compensation costs. It can also be assumed that many of the ED staff will suffer from emotional effects, in addition to the physical effects of these assaults.

Implementing strategies to prevent violence in the ED is the first step to decrease injuries and fear; however, workplace violence may still occur. Hospitals need to establish programs to treat victims of violent attacks. Posttraumatic stress disorders are common for staff following an injury from a violent attack. Providing counseling services through state-funded employee-assistance programs or hospital-based critical incident stress debriefing teams (often used after an unexpected, adverse patient outcome) may be affordable options for hospitals. The follow-up actions should also include coworkers of the injured because they too experience posttraumatic stress through witnessed events or when asked to care for the violent patient after an event has occurred. These programs should be initiated automatically after a violent event because a staff member may be too embarrassed to ask for assistance.

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Preparation, your best defense

Workplace violence in hospital EDs is a frequently occurring occupational hazard. Although it occurs often, there's a relatively small amount of literature available regarding this topic. Caring for psychiatric patients has become a leading workplace violence hazard for EDs that can be minimized through training, specialized treatment protocols, and environmental considerations. A multidisciplinary approach should be taken to tailor programs specific to treating psychiatric patients in the ED.

Hospitals must also recognize that workplace violence can't be completely eliminated. Posttraumatic stress disorders caused by violent attacks must be addressed to decrease the long-term impact on both hospitals and staff members. Counseling services for the injured staff member and coworkers, provided by the employer immediately following an occurrence, have proven to be an effective healing method. Expeditiously restoring an employee's confidence and ability to perform is critical in preventing medical mistakes and supports a culture of safety. Well-constructed plans completed by the major stakeholders will minimize risks to staff and ensure appropriate care in compliance with regulatory requirements.

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1. Catlette MP. Workplace violence experienced by registered nurses in hospital emergency care settings. 2011 DSN dissertation, The University of Alabama at Birmingham. Retrieved May 7, 2009, from Dissertations & Theses: Full Text Database.
2. Stanley AE. Emergency department nurses' experiences and perceptions of workplace violence. 2008 MSN dissertation, Northern Kentucky University. Retrieved May 8, 2009, from Dissertations & Theses: Full Text Database.
3. Tyler F. Emergency department violence toward registered nurses in West Virginia. 2007 MSN dissertation, Mountain State University. Retrieved May 8, 2009, from Dissertations & Theses: Full Text Database.
© 2011 by Lippincott Williams & Wilkins, Inc.