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What Will Stop the Violence Toward Emergency Nurses?

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By Megan Murdock Krischke, contributor

February 18, 2013 - When asked if they had experienced physical or verbal abuse in the previous seven days, 54 percent of emergency department nurses responded affirmatively according to a study on violence in the ED recently released by the Emergency Nurses Association (ENA).

Deena Brechner: Hospitals can create spaces for ED nurses to be safe.
Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, 2014 ENA president, encourages hospitals to create spaces within their EDs where nurses can go to be safe.

“This statistic was consistent through 16 rounds of data collection over four years,” stated ENA’s president, Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN. “That tells us there is absolutely a huge issue with violence in the ED and it is pervasive. Knowing that it is an issue is one thing but knowing what to do about it is a lot harder.”

Additionally, 30 percent of the nurses surveyed in 2009 were considering leaving their jobs because of workplace violence. Such an exodus is a costly threat to hospitals that, on average, spend $65,000 orienting a new nurse.

There are a number of reasons that ED nurses are particularly susceptible to experiencing violence.

“One reason is that in the ED we take care of undifferentiated patients--we often have little information about the patient and it is up to us to figure out what is going on for that person in a small window of time. It puts us in a position where we are more likely to encounter someone who might have a weapon or might be under the influence of medications or drugs. If we had we known the issue before we started, we might have taken different precautions,” explained Brecher.

James Bryant: The Cleveland Clinic uses metal detectors in emergency departments
James Bryant, MSN, RN, CEN, CCRN, NEA-BC, associate chief nursing officer of emergency services at The Cleveland Clinic, says they have not received complaints about using metal detectors and conducting bag searches at the entrance to one of their EDs.

James Bryant, MSN, RN, CEN, CCRN, NEA-BC, associate chief nursing officer of emergency services at The Cleveland Clinic, also notes the lack of access to behavioral and mental heath care and the lack of family support as reasons why many ED patients are prone to violence.

The ENA study also found a culture of acceptance of this reality prevalent among nurses, hospital administrators, law enforcement, lawyers and judges.

“As nurses, we haven't been able to fix or stop the problem of violence in the ED and so we start to believe it must be ok, or it is simply a hazard of the job,” stated Brecher. “But it isn’t part of anybody’s job to be assaulted.”

“Because it is so commonly believed that violence is part of the job of an ED nurse,” she continued, “nurses are often hard pressed to find an officer who will take a report or a DA who will press charges, or a judge who will hear the case.  Often hospital leadership won’t support a nurse to give him or her the time off required to pursue legal action.”

“It is time to say, ‘Enough is enough,’ and to start educating people about the unacceptability of assaults against health care workers and to take steps to prevent these assaults from happening,” Brecher asserted.

The Cleveland Clinic has taken a number of practical steps to reduce the occurrences of violence in their EDs, including having a police force on their main campus and police officers in all their EDs, using metal detectors, doing stadium style searches of those entering the ED, providing identification badges to all ED visitors, and posting the laws about and repercussions of assaulting health care workers.

“Many of the officers working in our EDs are off duty, but serve regularly in the surrounding community,” said Bryant. “This creates an extra level of safety because they are familiar with those in the community who have a history of violence and can alert us if those individuals enter our ED.”

As another approach to reducing violent incidents, The Clinic requires all its emergency department staff to go through the Non-Abusive Psychological and Physical Intervention (NAPPI) training.

“The NAPPI training has been very effective in training our staff to recognize heightened levels of anxiety or other indicators of a potentially violent situation,” Bryant remarked. “Our colleagues at Fairview Hospital have documented a decrease in violent episodes following NAPPI training.”

How to protect yourself 

Brecher and Bryant offered eight tips that nurses can use to protect themselves:

•  Don’t wear a stethoscope around your neck--it can easily be used to choke the wearer.
•  Don’t allow a patient or family member to come between you and the door to the room.
•  Be aware of getting caught in a verbal escalation and take action to dissipate tensions.
•  Take extra precautions with patients who seem anxious or withdrawn.
•  Be as clear as possible about the treatments being offered and the amount of time it will take to provide care.
•  Though patients need to be examined, try to give agitated patients as much personal space as possible.
•  Follow your gut.
•  Step in if you see a co-worker getting into a potentially violent situation.

Brecher strongly encourages nurses to keep bringing up the issue of violence in the ED and to keep working on ways to report incidents that happen.

“Look at the dates, the times, and other circumstances to identify trends and continually evaluate whether the safety measures being taken are working,” she said. We severely underreport violence. But when we don’t report, we can’t find trends and identify our weak spots and the work to improve them.”

“A colleague of mine suggests that there is a two-fold solution to the problem: to recognize high-risk individuals and environments on both an individual and organizational level, and to have organizations offer the commitment and resources to actually mitigate the violence.  Change will take a multidisciplinary approach and can sometimes feel nebulous, but if we don't start talking and acting, and changing the culture of acceptance it is only going to get worse,” Brecher concluded.

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