Tension in the waiting room — 86% of ED nurses report recent violence
Crowded waiting rooms 'bring out the worst' in patients
What makes tension erupt into violence in an ED? Sometimes it can be as simple as long waits and frightened people: Patients or family members may not understand why others keep getting seen while they sit waiting.
"We do see increased tension when there is overcrowding," says Linda Fisher, RN, director of emergency nursing at Boston Medical Center. It usually manifests itself in the waiting room, she says. "Patients may not accept the explanation of the triage nurse. They may escalate and start yelling out."
A recent survey of 1,000 ED nurses conducted by the Emergency Nurses Association (ENA) reported that 86% had been the victim of workplace violence in the past three years, and 20% said that they experience workplace violence frequently. More than 40% of nurses indicated their workplace was somewhat safe or not safe at all.
Overcrowded EDs are one factor causing nurses to feel unsafe, reports Donna L. Mason, RN, MS, CEN, current ENA president and ED nurse manager at Vanderbilt University Hospital in Nashville, TN. "Crowding and boarding always tend to bring out the worst in people," she says. When people have waited for hours to be seen or to get an inpatient bed, they grow impatient, Mason says. "Their anger is often directed to the nurse who spends the most time with the patients and their families."
Nurses interviewed by ED Nursing recommended educating staff on de-escalation techniques and appropriate use of chemical or physical restraints.
"Failure to act at the appropriate time can be unsafe," says Fisher. "We certainly do not overuse restraints but appreciate that there is a time when this is an appropriate intervention."
At St. Thomas Hospital in Akron, OH, ED nurses use a "proactive violence" protocol for any patient presenting to the ED with a complaint of suicidal/homicidal thoughts or a history of violent behavior, says Nance Donel, RN, BSN, ED manager. Using one of the ED's observation rooms, staff request that the patients remove all clothing, put on hospital gowns, and place all of their belongings in a bag. Next, security searches their belongings and removes any dangerous objects found.
Past searches have unearthed knives and guns, says Donel. For psychiatric patients being admitted from the ED for medical reasons, a screening process is used to assess the potential for violence. The screening consists of a few questions that tell nurses if a further evaluation is needed by psychiatry to ensure the patient will not become violent, says Donel.
"We began this protocol after we had several patients admitted from the ED to our psychiatric unit, and they found knives on them," Donel says. Nurses were alone with those patients, she says. "Although no one was harmed, we decided to do something before it happened," Donel says.
Security personnel are located at the ED entrance 24 hours a day, which is a powerful deterrent, she says. "The noticeable presence of security helps reduces tension and creates an environment not conducive to violent behavior," Donel says.
Give periodic updates
To reduce tension in your ED's waiting room, do the following:
• Give a reason for the wait.
When wait times are long, ED nurses at Boston Medical Center give periodic updates to the entire waiting room, says Fisher. For example, nurses may say, "We have had several patients arrive that are severely hurt, and they are requiring a great deal of help. This has resulted in a delay for all of you. We anticipate that we can again start taking patients to rooms within 20 minutes."
• Document previous problems with patients.
If a patient is abusive to ED staff at Boston Medical Center, this fact is documented by nurses and the patient is flagged in the ED's electronic documentation system, says Fisher. If a flagged patient comes to the ED at any time, the administrator is called. "This way, someone not involved in their direct care is dealing with their behavioral issues." They talk with the individual and remind them of what the consequences are if the behavior is not appropriate, says Fisher. "This is appreciated by the staff and does help to prevent acting out," she says.
For example, a patient was flagged after he verbally abused a nurse and spat in her face. "When this patient now arrives in the ED, he is reminded of what his behavior was and told that if there is any repeat of this behavior or any other unacceptable behavior, that we will have to ask him to leave," says Fisher, adding that a patient would only be asked to leave if it were medically safe.
• Have a designated person communicate with patients in waiting rooms.
At Stony Brook, a patient representative was hired to act as a liaison between ED nurses and patients, to find solutions to problems, and handle special requests. "This helps us a great deal with communication, because we are so busy running around doing tasks," says Anna Rosenthal, RN, ED nurse manager. "Patients are much happier being told up front that they are going to be waiting four hours, than sitting there having no idea what is going on."
The patient representative conducts "comfort rounds" that involve visiting patients and families routinely; updating them on their care, wait times, and results; assisting patients with making telephone calls; and offering reading materials, warm blankets, and meals.
• Give patients choices.
At Stony Brook's ED, nurses were given training in ways to give patients choices so they feel in control of their care. For example, nurses might allow patients to choose where they will receive an injection, which type of pain medication works best for them, or whether they want to switch to a less noisy room. "It's important to incorporate the patient in their care," says Rosenthal. "They know themselves best."
• Use scripts.
Nurses at Stony Brook attended a class on scripting as a guideline for what to say to patients at key points during their ED visit, given by the ED educator. "Nurses don't memorize the wording or necessarily say it verbatim; it's more to keep that flow of communication going," says Rosenthal. (See the ED's scripts.)
• Comply with simple requests of patients.
Whenever possible, address whatever is upsetting the patient or family member, advises Inge Morton, RN, CPN, education manager of the ED at Childrens Hospital in Los Angeles. "If a mom is worried that her child has a fever, rechecking that temperature is going to be more effective in reassuring her than platitudes," she says. Or if a parent is stressed because he has to pick up another child from school, offer to troubleshoot on how to get the child picked up, instead of just restating the expected wait time, says Morton.
At St. Thomas's ED, a 52-year-old psychiatric patient with traumatic brain damage began yelling and banging on a bedside table. "There was talk of leather restraints. He kept saying, 'I never get cheeseburgers and fries' over and over," recalls Donel. When an ED nurse ordered the patient these items from the hospital cafeteria, the man immediately calmed down.
They kept the patient in the ED for several hours afterward to watch his behavior, Donel says. "He never became violent again," she says. "This is a good example of how small things can make a huge difference."
Sources
For more information on decreasing tension in the ED, contact:
- Nance Donel, RN, Emergency Department, St. Thomas Hospital, 444 N. Main St., Akron, OH 44310. Fax: (330) 379-5747. E-mail: [email protected].
- Linda Fisher, RN, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118. Telephone: (617) 414-5351. Fax: (617) 414-7759. E-mail: [email protected].
- Donna L. Mason, RN, MS, CEN, Nurse Manager, Emergency Department, Vanderbilt University Hospital, 1211 Medical Center Drive, Nashville, TN 37232-7240. Telephone: (615) 343-7223. Fax: (615) 322-1494. E-mail: [email protected].
- Inge Morton, RN, CPN, Manager, Education, Emergency Department MS 74, Childrens Hospital, 4650 Sunset Blvd., Los Angeles, CA 90027. Telephone: (323) 660-2450, ext. 4455. E-mail: [email protected].
- Anna Rosenthal, RN, Nurse Manager, Emergency Department, Stony Brook University Medical Center, Nichols Road, Stony Brook, NY 11794. Telephone: (631) 444-8028. E-mail: [email protected].
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