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Curbing ED dangers requires strong leadership


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Alexandra Wilson Pecci, for HealthLeaders Media, April 24, 2012

Last week, I wrote about the importance of making sure student nurses stay safe at work, and a reader wrote the following comment:

"[The] Culture of safety in my hospital certainly does not apply to nurses when they are sometimes attacked by intoxicated patients who come to our ER. Apparently, intoxication is an excusable "medical condition" that is somehow acceptable without consequences for this behavior. I wonder how acceptable it would be if the same intoxicated person attacked or punched an innocent bystander in a public place outside of the hospital setting. Certainly more needs to be done to protect medical staff."

Most people in most professions don't feel threatened when they go to work every day. But for nurses, especially those in the ED, the threat of danger at work is real and acute. Nurses get kicked, slapped, pushed, spit on, and yelled at every day at EDs across the country.

EDs are unpredictable places where anyone, in any condition, can enter. But nurses have the right to a safe working environment, which means hospitals and nurse leaders have the obligation to educate their staff about crisis prevention and intervention and offer resources to deal with crises when they occur.

According to Teri Johnson-Kelley, MSN, RN, CEN, the director of nursing for the ED at Banner Estrella Medical Center in Phoenix, her hospital started requiring crisis prevention intervention courses for staff working in areas identified as high risk for potential combative patients in January 2011. Johnson-Kelley (who is speaking on a HealthLeaders webcast on April 30) says the training helps nurses learn when to call a "Code Gray" for a combative patient.

But perhaps most importantly, nurses are learning to recognize which patients may become disruptive and how to de-escalate situations so they don't turn violent in the first place.

For example, patients or family members often get angry when they've been waiting for a long time; if they don't like the information that they're getting—or not getting—from staff; or if they aren't receiving the medical treatments that they want or expect. Often these patients are highly stressed, frustrated, and scared.

"Sometimes you see those [types of patients] in your lobby because they're tired of waiting, or they don't feel like they're being updated or kept apprised of whatever situation is going on," Johnson-Kelley says. "It's the anxiety of not knowing."

The crisis prevention training teaches nurses how recognize when patients might feel this way. The nurses are encouraged to share information with patients and family about what's happening and why.

"A lot of times that can help deescalate the situation," Johnson-Kelley says.

In fact, she says, a lot of the training involves "how to talk to patients, almost scripting on how to de-escalate," as well as how to read patients' body language early—before they get angry.For example, "if you have a patient that stands in the door of their room a lot, those are the patients that you want to go and address early before they come out yelling and screaming," she says.

Nurses also learn about using non-confrontational body language. For instance, standing with an "open" body—arms uncrossed, knees apart, etc—is less threatening than standing with a closed body.

Of course, there are times when violent or disruptive behavior can't be prevented—patients under the influence of drugs or alcohol are especially unpredictable. In these cases, learning when to call for backup is critical.

According to Johnson-Kelley, since implementing the training, they've seen an increase in the use of "Code Gray," which she says can be attributed to the staff learning how to use it. The incidents of staff assault have remained the same.

"So, if you note that the number of calls is up and the number of injuries has not increased you can draw the conclusion that the training is helping as the assaults reported has not increased with the number of Code Gray calls," she says.

Nurses at the center of violent situations also need to feel cared for themselves. Johnson-Kelley says if nurses are hurt, they should not only be given medical care in the ED; the hospital should also provide support if the nurse decides to press charges against the assailant.

After all, "a physical assault against a healthcare worker is a federal offense," Johnson-Kelley says. Just because they're in a hospital setting, doesn't mean the patient is exempt from prosecution, and nurses leaders should be remind their staff of that.

If the nurses endure a particularly violent or disturbing event, Johnson-Kelley says the staff will do a "huddle" afterwards to "talk with everybody about what happened and get everyone's feelings out." Nurse leaders should also follow-up with abused nurses to see how they're coping.

Here are a few other tips from Johnson-Kelley:

  • Anticipate the situation. Teach your staff to round with patients and their families.
  • Put systems in place to provide safety for the staff, such as emergency panic buttons and security officers that are on-site and visible
  • Debrief. "We try to do it right after the incident so we can involve everyone involved. Make use of your organizations Employee Assistance Program (counseling) to ensure your staff receive the support they need," she says. "Make sure your staff feel supported when they report an assault."

Although violent patient behavior may never go away, perhaps especially in the ED, the commenter on last week's column is correct: "Certainly more needs to be done to protect medical staff." Mandatory crisis prevention courses might not be the whole answer, but they are a start. So, too, are leaders who provide support and education to nurses.

"I don't tolerate it," Johnson-Kelley says. "It's not acceptable at any level for anybody to either verbally or physically abuse the staff here."

Source: HealthLeaders Media