Violence in healthcare settings, particularly against nurses and nursing assistants, occurs at much higher rates than in other workplaces — and it’s on the rise.
Registered nurses experience intentional injuries at a rate of 8.8 per 10,000 employees compared to 1.9 across all occupations. In addition, 1 in 4 nurses will be assaulted over the course of their careers, and 1 in 4,000 healthcare workers are hit once a month. The highest rates of violence occur in the emergency department, geriatric and psychiatric settings.
What’s more, many healthcare employees have little to no education about workplace violence, from strategies to avoid it to how to report if it does happen.
“Many people think it’s okay to spit at a nurse or be hollered at or have a bed pan flung across a room,” explains Margaret Morales, APRN, ACNS, NEA-BC, VP at Mount Sinai Hospital in New York City. “Especially in our emergency room, we found [the attitude was,] ‘That’s just the way our patients are,'”
That’s why Morales along with two colleagues — Lydia Lopez, RN, NEA-BC, and Taina Rivera, RN, MS — spoke at American Nurses Credentialing Center’s Magnet Conference about how they successfully reduced violence in several units, including psychiatry.
These are some of the strategies they used, supplemented with information from a Quick Safety note released by the Joint Commission in January 2019.
What is de-escalation?
Similar to conflict resolution, conflict management, crisis resolution, talk down and defusing, de-escalation is a combination of strategies, techniques and methods intended to reduce a patient’s agitation and aggression.
Examples of such strategies include communication, self-regulation, assessment, actions and safety maintenance. Restraints and seclusion fall into these categories but should be a last resort performed only to protect the patient and others nearby from physical injury.
“Using a restraint is a failure to us, and we’ve taken that seriously,” Rivera notes.
How to recognize when a patient may act violently
The Mount Sinai team relies heavily on the Brøset Violence Checklist (BVC) to assess this risk.
As Lopez explains it: “It can’t be just a gut sense. Back in the day, as nurses, we used to say, ‘Watch that guy in room 10. Something’s not right about him.’ But now we have true, evidence-based tools to talk to each other shift to shit to know what’s going on with a patient.”
The BVC is not a long-term assessment; rather, it’s most effective for “in the moment” interventions, Lopez says.
It assesses patients based on six variables: confused, irritable, boisterous, physical threats, verbal threats (explicit and implicit), and attacking objects. The presence of any earns a score of 1; if it’s not present, mark 0. If a patient earns a 1-2, assess him or her regularly throughout your shift. A rating of 3 or higher merits taking preventative measures.
Consider using the BVC in the same way you would a pain rating. Perform it at the beginning of your shift and endeavor to hand off the patient at 0.
The Joint Commission also recommends STAMP for use in the ED, OAS in inpatient settings for children and adults, and the BRACHA in the ED to determine the need for placement on an inpatient psychiatric unit.
How to prevent a patient from acting violently
In addition to using the BVC, the Mount Sinai team recommends collaborating with the patient on an individual crisis prevention plan (ICPP) when he or she enters the hospital. The goal of the ICPP is to understand the patient’s triggers, early warning signs of aggression, and interventions that will effectively calm the individual.
To gather this information, ask simple questions, such as, “What makes you feel upset? What frightens you? What helps you feel calm?” Doing so promotes interventions that reduce the risk of trauma to the patient, Lopez explains.
When a patient starts to exhibit warning signs of violence per the BVC or their ICPP, address what’s causing it as soon as possible. For example, updating the white board might help a confused patient.
“When somebody’s having difficulty breathing or chest pain, we know the steps we must follow,” Lopez says. “The same applies when someone’s having a behavioral crisis … You can’t just leave and deal with the guy down the hall instead. You have to look at both, and figure out what your priorities are.”
What to do when a patient is acting aggressively
While individualized interventions based on a pre-determined ICPP are some of the most effective, the Joint Commission offers general, communication tips to defuse aggression:
- Be clear, calm and non-confrontational. Avoid using abbreviations or healthcare terms.
- Use non-threatening body language.
- Be respectful and understanding of the patient’s concerns.
- Address the patient’s concerns as best you can. This creates a sense of trust.
- Set clear limits for the patient to follow.
- Consider implementing environmental controls, such as minimizing lighting, noise and loud conversations.
The Crisis Prevention Institute also offers top 10 de-escalation tips that are applicable in healthcare settings. In addition, the Joint Commission recognizes the efficacy of the following de-escalation models:
- Dix and Page, which revolves around assessment, communication and tactics (ACT).
- Turnbull, et al., which emphasizes trying different de-escalation tactics and constantly monitoring the aggressor’s response to each.
- Safewards, which begins by moving the patient to a safe area and maintaining a safe distance; asking what’s prompting the anger; and resolving the problem by finding a mutually agreeable solution.
What to do if a patient acts violently towards you
Despite best efforts, violence in healthcare settings can still occur. The Mount Sinai team encourages clinicians to “tap out,” or leave the situation, if a patient’s behavior makes them uncomfortable or impedes their ability to provide quality care. The same goes if you see a fellow provider struggling — ask the individual if he or she would like to “tap out.”
Reporting violence can also improve the safety of your unit. The Joint Commission says every episode or threat warrants a notification to leadership, internal security and, if appropriate, law enforcement. You should also take the time to fill out an incident report.
Even though healthcare workers risk violent encounters every day, the good news is people are finally starting to pay attention.