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ED nurses work to curb violence


Nurses caring for patients in EDs never know who will walk or roll through the door next. ED nurses also don’t know whether a patient or visitor has a propensity for violent behavior, is carrying a weapon or presents some other safety threat.

In some local EDs, nurses have taken steps to reduce those risks.

“With collaboration, teamwork and education, it makes a difference and creates a safer environment for patients and staff,” said Sharon Kelly, RN, MSN, NEA-BC, manager of emergency services at Overlook Medical Center in Summit, N.J. Overlook’s ED won the 2013 Team Award from the New Jersey Emergency Nurses Association.

Since implementing the Nurse Safe program about five years ago, Overlook’s two EDs — at its main and satellite campuses — experienced a 36% decrease in employee injuries from violent patients, a 35% decrease in codes called for a violent patient incident and a 59% decrease in work days lost from injuries, resulting in significant cost savings, according to Kelly.

Overlook began reassessing its safety program after the 2007 mass shooting at Virginia Tech. Nurses at Overlook were reminded that an active shooter could show up anywhere since its ED clientele changed after the closure of two neighboring hospitals.

The change resulted in an increase of nurses calling for security to help with violent patients. In collaboration with hospital security, Overlook’s nurses decided to make the environment safer and ensure everyone knew how to handle violent situations.

“Violence remains a significant problem, but some progress has been made in some areas,” said Marylou Killian, RN, DNP, FNP-BC, CEN, a nurse practitioner in the ED at Saint Francis Hospital in Poughkeepsie, N.Y., and an Emergency Nurses Association national board member.

Some nurses and administrators view violence as part of the job, but it’s not, Killian said.

Killian called violence a multifaceted problem, one in which crowding plays a role. “A high volume of psychiatric patients may trigger things more, or patients coming in in high-stress situations,” she said.

Trauma care also presents opportunities for violence. For instance, a perpetrator or gang member could come looking for a gunshot or stabbing victim to finish the job.

Knowing that, the Robert Wood Johnson University Hospital, New Brunswick, N.J., has instituted a lockdown process when a victim of violence arrives at its Level 1 trauma center, said Timothy J. Murphy, RN, MSN, ACNP-BC, CEN, trauma education coordinator at RWJUH and president of the New Jersey ENA. The lockdown stays in place until law enforcement authorities determine little or no risk to staff or other patients exists.

A previous history of violent behavior increases risk, but ED staff rarely will know that about a patient or visitor, said Patricia “Nikki” Allen, RN, BS, MBA, author of the book “Violence in the Emergency Department: Tools and Strategies to Create a Violence-Free ED.” She reported the “highest perpetrator of violence is a young, urban male from low socioeconomic strata with a history of alcohol and/or substance abuse, poor work/school history, potential access to weapons and limited family support.”

Overlook’s electronic health record system flags anyone with a history of violence at the facility, so if that person returns, staff know about the past episode.
Creating a safer environment begins with a risk assessment. The ENA’s Workplace Violence Toolkit assists leaders in evaluating an ED’s status, such as whether it has secure entrances and exits, a back door or panic buttons. Nurses can give that information to administration to develop plans to protect staff and evaluate those actions.

Overlook’s security staff and local law enforcement evaluated the hospital’s EDs and determined a need for changes to better secure the department and improve staff training.

John T. Mather Memorial Hospital in Port Jefferson, N.Y., also has taken the violence issue seriously. The hospital has adopted a zero-tolerance policy, added security upgrades, improved communication with local law enforcement, created shooter and weapons policies, and requires managers and supervisors receive a one-day training in assessing for violence potential. Phillip S. Messina, RN, director of nursing for emergency services at Mather, indicated those efforts have reduced violence and improved safety in his ED.

Upgrades to the physical environment of a facility can help. Overlook obtained a federal grant to fund upgrades of its ED doors, which now limit access to staff, patients and visitors vetted by the ED team. It conducts “Red Cell” tests in which outsiders attempt to gain access. All staff members are expected to talk to the person and call security. Successful attempts have decreased from about 50% to less than 10%. Staff interceptors receive recognition.

Mather upgraded all of its ED doors, allowing swipe card access only for staff and emergency medical services personnel. It also installed additional closed-circuit TV cameras.

A security guard maintains a presence around the clock, with two during its busiest times. This month, Mather plans to begin using a metal detector wand on high-risk patients to check for weapons. Knowing that crowding can precipitate violence, Mather’s emergency services team developed a comprehensive policy and limits visitors to one per patient.

Staff training about signs of impending violence and how to defuse it is valuable in mitigating situations, said JoAnn Lazarus, RN, MSN, CEN, 2013 president of the Emergency Nurses Association.

Overlook conducted Code Lockdown, a two-hour training about violence prevention, and a Nurse Safe training program to educate staff about de-escalation and moving to a safe zone. Mather’s training teaches nurses to watch for someone reaching a tipping point, perhaps pacing, tapping fingers on a desk or wall, a far-away look or a raised voice. The training called for nurses and healthcare professionals to talk to that person directly and respectfully and to call for help immediately if they feel threatened. Nurses’ observational skills are great tools for preventing violence, Messina said.

“If a staff member sees a person has a low threshold for tolerating any more stress, they will bring them into a quieter area of the [ED], talk about their issues and try to calm them down,” Messina said.

Mather nurses aim to keep patients updated every 15 to 30 minutes to let them know the status of laboratory or imaging studies or any other interventions.
“Open communication, going to them versus them coming out, helps quite a bit,” Messina said.

Debra Anscombe Wood, RN, is a freelance writer.


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