What ED Nurses Can Do To Identify and Manage Situations that May Lead to Violence Maria F. Giganti RN,MSN,FNP,CEN
Objectives Describe aggressive behavior and what are the current attitudes on aggressive behavior Identify factors that may lead to aggressive behavior and triggers in the ED that may also cause it Identify appropriate responses to aggressive behavior
Definition of aggressiveness ready and willing to fight, argue, etc. : feeling or showing aggression using forceful methods to succeed or to do something medical : very severe Source: Merriam Webster s Dictionary
What is aggressive behavior? Behavior that causes emotional or physical distress to a person. This can be done verbally, psychologically or physically. It is intentional Left unchecked, it may lead to violence
Current Attitudes Our society applauds the assertive person & many people confuse aggression with assertiveness. People are less inhibited when it comes to expressing displeasure or frustration. Culture of immediate gratification
Current Attitudes The patient is sick so he s not really responsible. What did the nurse or hospital do to provoke the patient? Reporting violent incidents makes the hospital look bad or unsafe.
In the Media Movies and Television shows that depict aggressiveness and violence. ( even in the good guys )
Video Games Video games that promote aggression and violence. ( Ones that are labeled M for mature or R )
Music Music that glorifies violence and abuse (i.e. Gangsta Rap) Violent music videos
Contributing factors that may lead to aggressive behavior Psychiatric conditions, behavioral disorders Health conditions, i.e demetia Disruption within family, &/neglect, Societal factors, i.e. inability to secure steady or adequate employment, stable housing etc.
Factors that may lead to aggressive behavior Difficult or failed relationships with others, personality traits Substance abuse Fear & / frustration Just Having a Bad day
Potential Triggers
Potential Triggers Long waits for Triage Long waits to be seen after being triaged. Long waits for treatment, discharge or for a bed on admission
Potential Triggers
Potential Triggers Being too busy to answer questions, Ignoring the patient.
Potential Triggers Appearing annoyed when patients ask questions. Having an attitude when speaking to the patient
Other Factors Cultural Misunderstandings regarding emergency care Fear of the unknown for the patient himself or for a loved one who is sick
And Last but Not Least Inadequate Staffing!
Early Signs Restlessness or anxiety Inability to stay still, drumming fingers etc. Asking questions repeatedly Evidence of substance abuse, AOB,
STAMP out violence Staring Tone or volume of voice Anxiety Mumbling Pacing http://www.ena.org/practiceresearch/practice/violencetoolkit/documents/toolkitpg 10.htm
Raising of the voice Next Refusing to do what is asked. Threatening
Loss of control Screaming Spitting Throwing objects Attacking And then
What s a Nurse to Do? First and foremost, Make sure that your surroundings are safe! and There is a way for you to exit, should this be necessary.
What is a nurse to do? Ask How can I help? and introduce yourself to the patient ( significant other/ relative, etc.)
What s a nurse to do? Put yourself on the same level as the person you are having a conversation with: If the person is seated, sit down or bend down to their level Do not stand over the person and speak down to them
Listening Listen to the patient ( significant other/ relative etc). What are they really saying? Look at the speaker! Repeat back what is said,to make sure that you understand what the person wants.
Next Ask the person s name and use it when addressing them. Try to remove the audience or speak to the person in an area away from where others can hear.
Listening & Giving Answers Can I answer the question or solve the problem, or do I need assistance from someone else? Is it a question that can be answered? i.e. HIPPA Do I have any control over this situation, and if so, what can I do?
What can I do to help?
It s More than Just What We Say Facial Expression Tone of voice/ inflection Body Language
It s More That Just What We Say Body Position Personal Space
Facial Expression Is it neutral, totally devoid of expression? (dead-pan) Is it scowling? Or one of annoyance? Is the expression one of concern?
Voice When people raise their voices, lower your voice when speaking to them. Keep your voice calm and even.
Voice Avoid inflections of sarcasm or anger in what you say. Do not to use jargon.
Body Language Arms crossed against the chest or hands on hips do not convey open-ness or acceptance
Body Language Try a slightly outstretched hand, with the palm up, to suggest willingness to help
Body Position Turn your body sideways, with your feet slightly spread apart. This makes you look less threatening. With the hand outstretched, more approachable. (Also, easier to retain your balance if pushed and easier to turn and walk or run away if necessary!)
Personal Space Personal Space is about as far as we can extend our arms, about 3 ½ feet. Respect the person s personal space
Now Let s Role Play! A patient is waiting for an admission bed. He has been crying aloud in pain for about 10 minutes. His next dose of pain medication is due in 45 minutes.
Role Play A patient strides briskly into the waiting room with her friend. When she sees how crowded the waiting room is, she begins to cry out I can t breathe, I can t breathe in a loud voice. Her friend shouts to you, the Triage Nurse, Are you going to let her sit here and suffocate?
Role play An 80 year old woman was admitted to the hospital with a stroke. She has been in the ED for about 5 hours. Her daughter keeps repeatedly asking you When will she get a bed? The daughter is now raising her voice and saying What sort of hospital is this? Who would make a sick woman wait so long for a bed?
Documentation Document exactly what has happened and what you hear. Avoid using terms that are judgmental i.e. Patient refused to get back into bed when asked. rather than patient was being uncooperative
Documentation Document the names of any Supervisors, Doctors, Patient Representatives that interact with the patient ( relative etc.) Use full names and document the time they interacted with the patient Do not use Supervisor aware or MD aware
Documentation If Hospital Police are involved, write down the officers names and badge numbers ( if they have them) or other identifying items. i.e. Security Personnel from area 3.
Documentation Make sure that each entry is dated, with the time and is signed!
Thank you! Bibliography: Cantlette, M, A Descriptive Study of the Perceptions of Workplace Violence and Safety Strategies of Nurses Working in Level 1 Trauma Centers; JEN Dec. 2005,Vol 31, issue 6, pp 519-525 Joint Commission Preventing violence in the health care setting Oakbrooke Terrace, Il 2010 June 30. http://www.jointcommission.org/assets/1/18/sea 45.pdf Kelly,E, Violence in the Emergency Department: A Rapid Response Team Approach; JEN, January 2014, Vol. 40 issue 1,pp 60-64 Martindale, D. Safety Monitor: Violence Prevention Training for ED Staff; AJN, September 2012 Vol.112 No. 9 pp.65-68 Wheaton, T. The Escalating Trend of Violence Toward Nurses; JEN April 2008, Vol. 34, issue 2,pp130-133 Wilson-Pecci, A, Violence Racks Up Huge Costs, Health Leaders Media, February 11, 2014