Violent situations are becoming all too common in healthcare settings, regardless of whether the facility is in a large city or rural area. As a result, it's important for nursing staff to recognize the signs of potential violence, and know how to respond to a violent situation to protect themselves, their colleagues and, most importantly, their patients. Risk Factors
According to OSHA, some of the risk factors for workplace violence in healthcare settings include:
- handguns and other weapons among patients and others;
- individuals with acute and chronic mental illness who have been released from hospitals without follow-up care;
- individuals seeking drugs or money from the hospital, clinic or pharmacy (robbery);
- unmonitored movement of the public in common areas;
- long waits for service that cause frustration and anger;
- presence of gang members, distraught family/friends, drug/alcohol abusers;
- low staffing levels at high-volume times;
- staff working alone, in remote locations, with no backup or way to get help;
- lack of proper security systems, alarms or communication devices; and
- lack of staff training in recognizing, managing and de-escalating violent behavior.
Violent situations typically follow a pattern:
1. Baseline calm - The person before becoming agitated.
2. Preassault - Verbal and nonverbal behaviors, threatening violence, abusive remarks and physical agitation. Other signs include pacing and restlessness, clenched fists, louder speech and profanity.
3. Assault/acute excitement - Out-of-control verbal and physical behavior requiring immediate crisis intervention.
A patient's case history may reveal clues to potentially violent behavior. The nurse should check the chart for any clinical diagnoses that may contribute to violent behavior, and maybe even consult law enforcement about history of violence against people, animals or property; court actions related to violent behavior; and noncompliance with psychiatric treatment. Protecting Yourself
If you are in a rapidly escalating violent situation, experts recommend taking the following steps.
Make sure you have an escape route. Do not let the individual get between you and the door. Never turn your back on the individual.
Keep a distance of 5-7 feet between you and the individual to keep out of his reach and keep him from becoming more agitated.
Stay calm and remember to breathe.
Speak in a normal tone of voice, use simple sentences and do not try to talk when the individual is shouting.
Do not argue or become defensive or react to any abusive statements.
Set limits calmly but firmly.
Call for help before the individual's behavior escalates.
After the event, in addition to any physical medical treatment, anyone who has experienced violence in the workplace should receive psychiatric evaluation and counseling, such as crisis intervention debriefing. Prevention
To reduce the likelihood of a violent event, OSHA recommends the following:
- train staff to recognize and diffuse violent situations in patients;
- maintain adequate staffing levels with experienced clinicians on each shift;
- install alarm systems and other security devices (phones, panic buttons);
- install metal detectors to check for concealed weapons;
- have bright lighting inside and outside the facility;
- maintain closed-circuit video of high-risk areas;
- mount curved mirrors at hallway intersections or "hidden" areas;
- enclose nurses' stations and use bullet-proof, shatter-resistant glass in reception areas; and
- arrange furniture to prevent entrapment of staff and remove items with sharp edges or those that can be used as weapons.
DiStasio, C.A. (2002). Protecting yourself from violence in the workplace. Nursing 2002, 32(6) 58-63.
Kuhn, W. (2004). Dealing with violence in the emergency department. Retrieved Feb. 21, 2007 from the World Wide Web: http://www.mcg.edu/som/clerkships/EM/violenceinEDManual.PDF
OSHA. (2004). Guidelines for preventing workplace violence for health care & social service workers. Retrieved Feb. 21, 2007 from the World Wide Web: http://www.osha.gov/Publications/osha3148.pdf
OSHA. (2004). Hospital eTool emergency department (ED): Workplace violence. Retrieved Feb. 21, 2007 from the World Wide Web: http://www.osha.gov/SLTC/etools/hospital/er/er.html#WorkplaceViolence
Compiled by Abigail Scott, senior associate editor at ADVANCE.