Do You Have a Plan to Curb ED Violence?

Violence is escalating in hospital emergency departments. While the Occupational Safety and Health Administration (OSHA) has created guidelines to help prevent violence and aggression in the workplace, implementation of these recommendations is not mandatory. A recently released study by the Emergency Nurses Association (ENA) indicates some hospitals may not even have prevention programs and those that do often fail to adequately protect staff members.

The numbers are staggering. More than 50% of nurses surveyed indicated they had been “hit, pushed/shoved, scratched or kicked” by patients or visitors. Yelling, cursing, and sexually aggressive language was heaped on more than 70%. The malicious incidents were not isolated. In the past three years, nearly one-quarter of ED nurses responding to the survey were assaulted more than 20 times, and almost one in five nurses reported being verbally abused on over 200 occasions. “I was stunned at the frequency of incidents and the number of nurses (33%) who were considering leaving the profession,” comments Kim McAllister, RN, who has worked in San Francisco-area EDs for 18 years.

The ED is a high-stress environment. Patients are ill or injured. Family members are upset. Tough patients and visitors, prone to violence, introduce another kind of fear factor. Emotions run high and rage against staff members often follows. But the scenario doesn’t have to play out that way.

“Knowledge is power,” confirms Alan Butler, director of operations and consulting for HSS, one of the nation’s largest healthcare security firms. “I hear it almost every day: ‘It happened so fast; I didn’t see it coming.’” According to Butler, when staff are properly trained to assess a situation and prepare, violent incidents are largely preventable. Even if an event does occur, a well-defined security response plan will minimize risks and maximize safe outcomes. Butler describes three components of an effective ED security response plan—environmental assessment; policies, procedures, and training; and feedback.

Environmental Assessment

Take a critical look at your ED layout. Many facilities have failed to keep pace with reconfiguring the ED space for safe, efficient, higher-capacity patient throughput. Small, common-sense physical improvements can often make a big difference.

• Check-in/triage desk(s) need to be protected with multiple escape pathways.
• All ED entrances should be visible from the check-in desk(s).
• Waiting areas require adequate seating with chairs arranged so that individual space is not severely compromised.
• The unit should be clean and décor calming to help ease tension.
• Easy visual and auditory contact between ED staff and a clear view of what’s going on in the unit promote safety.

Policies/Procedures/Training

Delayed care frustrates patients and those accompanying them.

• Strict tracking of patient wait times is crucial.
• Personnel must be instructed how to candidly but calmly interact with agitated visitors.
• Effective response plans deal with behavior that escalates from normal to heightened to dangerous levels.
• Input from security and local police improves planning and training.

Feedback/Debriefing

Abuse reporting must be encouraged and valued.

• Staff-friendly protocols for reporting are essential.
• A constructive ED team discussion follows any violent event.
• The response plan should be promptly adjusted to improve safety for all.

“When EMTs, security, environmental services, social services, food service workers, clergy, and medical staff train as a team, everyone has a better understanding of their role and how individual actions contribute to a successful response,” says Butler. “Experience shows that awareness, planning, communication, and teamwork promote safety in today’s demanding ED setting.”

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