Assaults against ED nurses are largely unreported: Act now to prevent violence
While you’re starting an intravenous line, an intoxicated patient suddenly begins shouting vulgar language. Would you report this incident? What if the patient threatened or shoved you?
Verbal and physical assaults on ED nurses are alarmingly frequent, but they often go unreported, according to sources interviewed by ED Nursing. "If someone is injured they can fill out an incident report — but we know this is underreported, especially when it is verbal abuse," says Denise Proto, RN, MS, CEN, nurse educator for emergency services at Gwinnett Medical Center in Lawrenceville, GA.
Too often, emergency nurses have the attitude "it’s part of the job," says Karen Clements, RN, BSN, MSB, department manager and administrator for the ED at Eastern Maine Medical Center in Bangor. "For too long, we have had to endure verbal and physical abuse," she says. "Our profession teaches us to nurse’ everyone, even those that call us names and take a swing at us."
A new study finds verbal threats, physical assault, and even stalking are common occurrences in EDs. Of 171 ED physicians surveyed, 76% reported experiencing at least one violent act over the previous 12 months, and nearly one-third were victims of physical assaults, with intoxicated patients inflicting 45% of assaults. Despite frequent violence, less than a third of EDs surveyed had 24-hour security, according to the study.1
"I think that nurses are probably even more on the front line than physicians when it comes to confronting potentially violent patients and may be at even higher risk," says Terry Kowalenko, MD, program director of the emergency medicine residency program at University of Michigan in Ann Arbor and the study’s lead author.
In many cases, verbal and physical abuse are never reported by ED nurses, says Kowalenko. "In a busy ED, people don’t have time to report these incidents," he says. "There is a perception that this is part of the territory, and people become desensitized to it."
To encourage nurses to report verbal and physical abuse, do the following:
- Support nurses who press charges.
At Eastern Maine’s ED, a "no-tolerance" policy for verbal and physical aggression applies to any patient, visitor, or employee. "In our ED, we have changed our entire culture concerning this issue," says Clements. The policy states, "Violence, intimidation, harassment or threats thereof, toward an employee, patient, medical staff member, visitor, or toward the facility or its equipment must be reported immediately to the first available manager and to the security department. Every employee is obligated to make such reports."
Managers and administrators enforce this policy to the point that they go to court to testify against chronic offenders, she adds. "We have even barred some patients from our hospital [for all but emergency care]. We have had several visitors and a few patients escorted from the ED." One example was a girlfriend who became quite disruptive by calling nurses vulgar names and threatening staff. She was arrested for disorderly conduct, Clements recalls.
You’ll need to determine whether the violent behavior has medical causes or not, and provide appropriate medical treatment based on the circumstances, says Len Giambalvo, Eastern Maine’s vice president of legal services. "However, if patients are violent, they lose their right to confidentiality as far as is necessary to get law enforcement assistance and to prosecute any crime," he says. "We will not take care of them if it is dangerous to us, to other patients, or to visitors to do so."
The ED’s case manager, vice president for patient care services, and Clements have testified against patients who have abused or assaulted staff. "Most have received jail time and also restrictions if they return to the ED," she says. "They can only come to the ED for emergent medical needs. A few have been singled out to have a police escort with them when they arrive."
Nurses won’t take action unless they feel they have the backing of higher-ups, says Clements. "Once we did the first prosecution, staff got in line to report these incidents," she says. "Staff now cut articles out of the local paper when any patient or visitor has had charges pressed. This boosts other nurses to do the same."
The decision to report is left up to the nurse, says Clements. "We do not pressure staff in reporting to the police," she says. "However, we do expect them to fill out an incident report for tracking and to follow up with employee health if needed."
The power of data
- Track the number of incidents.
By documenting all incidents that occur in your ED, you will have more ammunition to lobby for needed resources, says Kathy Hendershot, RN, director of clinical operations for the ED at Clarian Health Partners in Indianapolis. Hendershot asked for additional security for the ED over a two-year period, but her requests were denied.
"I then looked at all reports of incidents for the past year and found that the ED had more officer calls than any other department," she says. "We were able to show that an officer needed to be in the ED full-time around the clock. This is a situation where extra documentation helped."
Security officers fill out a formal report after any incident involving theft, arrests, or escort from the property, says Hendershot. "Before, these reports were kept in security and not formally shared with us," she says. "I now get a copy of those reports. This helps me to keep informed in a more timely manner."
The reports revealed that a large number of incidents involved psychiatric and intoxicated patients, which supported the need for additional education for these areas, adds Hendershot. She recommends asking pharmacists, psychiatrists, and behavioral health staff to give inservices to ED nurses. "We did our own in-house training on physical restraints and de-escalation, taught by our behavioral care staff," she says. "Pharmacy and psychiatry gave excellent information on drugs that can be therapeutic for agitated patients."
Security now works very closely with ED staff in tracking incidents, says Hendershot. "They come to our clinical practice meetings, participate on our behavioral care task force, and are involved with any redesign issues," she says. "They are a very valuable resource."
- Ask for resources right after incidents occur.
In four months, there were three assaults on ED nurses at Beth Israel Deaconess Medical Center in Boston, resulting in neck injuries and facial bruising. "Our nurses were very upset, and it was a constant topic of discussion," says Michelle McCool Heatley, RN, BSN, CEN, director of ambulatory operations and emergency services. "I asked staff what they would like to see us do. I solicited feedback at staff meetings and documented e-mails and phone calls."
After the second assault occurred, Heatley brought her nurses’ concerns to administrators, along with data from incident reports. She asked for 24-hour security coverage in the ED, with additional coverage in the psychiatric, substance abuse, and triage areas.
"After the third assault occurred, the administrative process for approval of additional resources sped up. I think that the incidents and the documentation from the staff drove the process more than dollars," says Heatley. As a result, a 24-hour security guard was placed in the psychiatric assessment area, in addition to a security guard out front.
In addition, eight hours of annual mandatory crisis prevention training is now given on site by the Brookfield, WI-based Crisis Prevention Institute, and about 60% of ED staff is currently trained. (For more information, see sources/resource below.) The ED has not had an assault in the seven months since these measures were implemented, she reports.
Nurses are encouraged to report incidents and asked to include as many specifics as possible. "Violence is only going to get worse in the ED, as psychiatric and substance abuse services become less available and length of stay increases," Heatley says. "The need is getting greater and won’t go away anytime soon."
Reference
- Kowalenko T, Walters BL, Khare RK, et al. Workplace violence: A survey of emergency physicians in the State of Michigan. Ann Emerg Med 2005. Abstract. Published on-line 2/14/05. Accessed at www2.us.elsevierhealth.com.
Sources/Resource
For more information on reporting assaults in the ED, contact:
- Karen Clements, RN, BSN, MSB, Administrator, Emergency Department, Eastern Maine Medical Center, 489 State St., Bangor, ME 04401. Telephone: (207) 973-8010. Fax: (207) 973-7985. E-mail: [email protected].
- Michelle McCool Heatley, RN, BSN, CEN, Director, Ambulatory Operations and Emergency Services, Beth Israel Deaconess Medical Center, Ambulatory Administration, 330 Brookline Ave., Shapiro 245, Boston, MA 02215. Telephone: (617) 667-8803. E-mail: [email protected].
- Kathy Hendershot, RN, MSN, CS, Director of Clinical Operations, Emergency Medicine and Trauma Center, Methodist Hospital, I-65 at 21st St., P.O. Box 1367, Indianapolis, IN 46206-1367. Telephone: (317) 962-8939. Fax: (317) 962-2306. E-mail: [email protected].
- Terry Kowalenko, MD, Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0305. Telephone: (734) 936-3007. Fax: (734) 763-9298. E-mail: [email protected].
The Crisis Prevention Institute offers one-day, two-day, and four-day training programs in nonviolent crisis intervention training to manage disruptive and assaultive behavior. For more information, contact:
- Crisis Prevention Institute, 3315-K N. 124th St., Brookfield, WI 53005. Telephone: (800) 558-8976 or (262) 783-5787. Fax: (262) 783-5906. E-mail: [email protected].
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