R E V I E W S & A N A LY S E S Violence Prevention Training for Emergency Department Staff Denise Martindell, RN, JD INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Events of violence in the emergency department (ED) are a safety risk for patients and staff. In June 2011, the Pennsylvania Patient Safety Authority surveyed Pennsylvania acute care hospitals about violence protection practices in the ED. The survey was based on current best practices, including the guidelines of the International Associa- ABSTRACT tion for Healthcare Security and Safety (IAHSS) and Occupational Safety and Health In June 2011, the Pennsylvania Patient Administration (OSHA). Survey results were presented in the December 2011 Pennsyl- Safety Authority surveyed violence pro- vania Patient Safety Advisory.1 Gaps in violence protection practices identified through tection practices in Pennsylvania acute the survey suggest opportunities for improving violence protection practices to increase care hospitals. The survey was based the safety of both ED staff and patients. Training in violence prevention practices for on current best practices, including the ED staff was one potential gap and is the focus of this article. Sixty-eight percent of guidelines of the International Associa- survey respondents reported that their hospitals offered violence prevention training tion for Healthcare Security and Safety to staff; however, only 36% of all respondents reported mandatory violence prevention and Occupational Safety and Health training for ED staff. Administration. Survey results were A comprehensive violence prevention program, which includes violence preven- presented in the December 2011 tion training for staff, has been recognized as essential to the prevention of violent Pennsylvania Patient Safety Advisory. incidents in the healthcare setting.2,3 However, violence prevention programs are Gaps identified through the survey sug- not mandated under federal law, and currently only nine states have enacted laws gest opportunities for improving violence requiring violence protection programs in healthcare facilities, better reporting, or protection practices in the emergency additional study of the problem.4 In Pennsylvania, a new bill has been introduced department (ED). ED staff and patients that would require Pennsylvania hospitals and other healthcare facilities to take steps are being exposed to violence, and to protect nurses and other healthcare workers from workplace violence.5 House Bill studies support that violence prevention 1992, if enacted into law, would require hospitals to establish a violence prevention training is an important component in a committee, develop a written violence protection plan, and assess security risks annu- comprehensive violence prevention pro- ally to create a safer workplace. gram. Available research supports the Organizations such as IAHSS and OSHA promote comprehensive violence prevention need for violence prevention training for programs. The Joint Commission’s June 2010 issue of Sentinel Event Alert emphasized staff in the ED as part of a comprehen- the existence of violence in healthcare; the risk to patients, visitors, and staff; and the sive violence prevention program. Risk need to provide more effective workplace violence education.6 The Emergency Nurses reduction strategies and best practices Association and the American College of Emergency Physicians have issued policy promoted by professional organizations statements recommending that hospitals educate staff on handling violence.7,8 and accrediting bodies promote patient safety, as well as the safety of visitors Despite recommendations from professional organizations, accrediting bodies, and leg- and ED staff. (Pa Patient Saf Advis 2012 islators, ED violence rates continue to rise, exposing patients, staff, and visitors to the Mar;9[1]:1-4.) risk of harm.9 There is not a large body of research to quantitatively address which tech- niques are effective in violence prevention in the ED and none identified as of January 13, 2012, showing whether this training should be mandatory. However, several recent studies support staff training as an important component in any violence prevention program. In addition, events reported to the Authority exemplify instances in which violence prevention training may have resulted in a different outcome. Available stud- ies supporting the need for violence prevention training as part of a comprehensive violence prevention program and related risk reduction strategies will also be discussed. AUTHORITY EVENT REPORTS Events of violence in the ED reported to the Authority (384 events of violent acts or verbal abuse reported from 2006 through 2010) are described in a December 2011 Advisory article.1 The need for violence prevention training, particularly violence de- escalation techniques, may have been a contributing factor in the following examples of Authority reports. Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 1 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Patient was being combative and VIOLENCE PREVENTION size of the hospital and by the hospitals’ swinging his fists while staff and a TRAINING IN THE LITERATURE background community crime rate.13 Dur- family member were trying to keep him Although only 18% of states currently ing the 10-year study period, the rate of from climbing out of bed. The patient mandate violence prevention training assaults against ED staff was highest in sustained bruises on both hands. for ED staff,4 the need for a comprehensive small hospitals in areas with high rates of A patient was in a waiting area violence prevention training program has violent crime. Small hospitals located in when another person approached the been demonstrated in several studies. In communities with low violent crime rates patient and punched the patient’s 2007, Peek-Asa et al. compared workplace had the second-highest rate of serious face several times. Prior to being violence prevention programs in a ran- assaults against ED staff among all hospi- assaulted, the victim had gone to domly selected and representative sample tal categories. These results were thought the registration window to alert staff of EDs in California and New Jersey.10 to be related to the variance in hospital that a person was verbally assaulting California was the first state to enact security programs due in part to the per- others in the waiting area. Security legislation requiring that acute care and ception of risk for violence. Staff in all was called to the ED but had not yet psychiatric hospitals implement compre- hospitals reported incidents of violence arrived when the assault occurred. hensive workplace violence prevention among all types of patients and visitors programs.11 California was also the first due to the high stress and emotionally The patient came to the ED com- challenging experience of an ED visit. The state to release specific guidelines for the plaining of back pain and was also authors cite that the variability in hospital establishment of such a program.12 In diagnosed with a behavioral prob- security programs found in this study comparison, New Jersey follows only fed- lem. The patient became extremely argues for the need to ensure consistency eral OSHA guidelines. combative and uncooperative in the and implementation of security programs ED. The patient was physically and The goal of the study was to determine with features such as those in the OSHA verbally abusive to staff. The patient the most commonly implemented vio- guidelines and that a comprehensive secu- scratched two employees. The police lence prevention program elements and rity program is needed in all hospital EDs. were called by hospital security. identify gaps in existing programs.10 With regard to workplace violence training, over Benham et al. addressed the issue of vio- The physician was informing the lence protection programs and the rate of 91% of California hospital EDs provided patient of the need for intravenous violent acts experienced by ED residents workplace violence prevention training antibiotics for cellulitis of the foot. and attending physicians. In a prospective, as required by California law. New Jersey The patient became agitated and cross-sectional online survey of emergency has no training requirements, and 72% of punched the physician in the eye. medicine residents and attending physi- New Jersey hospitals provided workplace When asked why he hit the physician, cians in 65 emergency medicine residency violence protection training. Mandatory the patient would not answer. Police programs, Benham et al. demonstrated training for staff regularly assigned to the and hospital security were notified. that at least one workplace violence act in ED was reported by 7.5% of California The patient attempted to run out of hospitals and 5.6% of New Jersey hospitals. the previous 12 months was reported by the ED. The nurse confronted the The study showed that while the majority 78% of respondents, with 21% reporting patient and asked where the patient of hospitals offered violence protection more than one type of violent act.14 The was going. The patient raised both training, few ED staff are actually trained. most common type of workplace violence hands and attempted to hit the nurse. The study identified that it was common was verbal threats (75%), followed by The nurse defensively took hold of for hospitals to offer existing packaged physical assaults (21%), confrontations both of the patient’s hands. Other programs that did not include hospital- outside the workplace (5%), and stalking staff members moved in to assist specific policies and procedures and poten- (2%). Security was available full-time in the patient in walking back to the tial risk factors. Peek-Asa et al. note that most settings (98%) but was least likely to room. The patient continued to yell states interested in enacting security legisla- be physically present in patient care areas. at staff and attempt to get free. Staff tion should take into account the variance The majority of respondent EDs did not attempted to assist the patient to in hospital environments and require that screen for weapons (60%) or have metal lie down on the litter. The patient’s hospitals design programs that are specific detectors (62%). Notably, only 16% of hand became free and grabbed a hold to their needs. programs provided violence workshops of a nurse’s throat . . . Staff and and less than 10% offered self-defense Blando et al. also studied hospital work- security took control of the patient. training. Self-defense training was not place violence protection programs and associated with a reduction in violence, examined how security features varied by Page 2 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority but respondents who reported attending attending physician, and the nursing for all employees regularly assigned to the a violence prevention workshop were coordinator is required before the deci- ED, the authors highlighted the following less likely to report experiencing verbal sion is made to change the color status. training topics to be covered in ED vio- abuse, suggesting that communication Access control/security presence. The lence prevention programs: techniques can be used to de-escalate a number of visitors and amount of secu- — Hospital safety policies and situation before it erupts into physical rity presence is determined by the stage procedures violence. The authors also suggest that the ED is experiencing. Difficult parties — Aggression and violence predicting more research is needed to determine the are separated as necessary to de-escalate factors impact of violence prevention training on potentially dangerous situations. Difficult violence in the ED. — Characteristics of aggressive and parties may be moved from one side of violent patients the waiting room to the other or com- ED VIOLENCE PREVENTION — Verbal methods to diffuse or avoid pletely outside the ED waiting room. PROGRAMS aggressive behavior Staff training. Engagement and training — Obtaining a history from a patient More research is needed to study the of all staff is a critical component of the with violent behavior impact of violence protection programs program. Staff are trained to recognize on violence in the ED. However, gaps in — Techniques for restraining violent environmental changes that can escalate violence protection programs were noted patients into violent disruptions if not handled in the above studies and in the Author- quickly and effectively. Training is manda- — Self-defense if preventive action does ity’s ED violence protection practices tory and conducted when members of all not work survey, suggesting the need for a com- disciplines are present. Training includes — Appropriate use of medications to prehensive violence protection program presentations, videos, and interactive subdue aggressive patients that includes training ED staff. A recent team exercises. — Resources available for victims of project has identified implementation workplace violence In the two years before implementation strategies most likely to be successful in of the UWHC program, staff reported a — How to report a violent event violence prevention efforts. In 2006, a number of injuries from being punched, Training specific to the hospital’s poli- multidisciplinary team at the University hit, and bitten. After implementation, cies, procedures, and potential risk factors of Wisconsin Hospitals and Clinics there has been one reported injury and has been recommended.10 Before train- (UWHC) developed a comprehensive ED no injury-related absences. Staff reported ing interventions are implemented, a security program in response to concerns the belief that the program has not thorough needs assessment will help about violence voiced by ED nursing decreased day-to-day risk, but has helped identify weaknesses from material, staff.15 The program components include them identify the stages of escalation and systematic, environmental, or cultural the following: take appropriate, prompt action. The sources.16 OSHA provides a workplace Stages of escalation grid. A staged esca- authors report that the UWHC ED secu- violence protection checklist that can lation grid (i.e., green, yellow, and red rity program outlines strategies to meet assist in the development of a needs levels) addresses security status changes the needs of the patient and their support assessment at http://www.osha.gov/ and creates awareness of changing condi- network, and that the process has allowed Publications/OSHA3148/osha3148. tions in the ED. the nursing staff to focus on the primary html.3 The National Institute for Occu- Staff cues. Green, yellow, and red lights nursing care needs of their patients. pational Safety and Health (NIOSH) has are placed strategically around the ED to In addition to considering the program also published strategies for workplace represent the security status of the ED. A components above, facilities may consider violence prevention training applicable to change in status is cued by a three-second incorporating the training components the ED setting.17 The strategies emphasize audible alarm. Green represents business of an ED violence prevention program management and worker commitment as usual, yellow heightened tension levels, identified by Peek-Asa et al.9 As previously to workplace violence prevention and and red a threat to safety and security (e.g., discussed, the authors compared elements a multidisciplinary approach. NIOSH behavioral problems, surge capacity issues, of the California state guidelines and the recommends the presence of manage- gang-related activities, police involvement). New Jersey approach based on federal ment at training sessions to demonstrate OSHA guidelines. Recommending that the organization’s top-down support of Huddle. A huddle between the ED workplace violence training be required the program. Training (initially and on a team leader, a security supervisor, the ED recurring basis) can be provided on the Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 3 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S hazards specific to the organization, CONCLUSION gap in violence protection practices identi- with emphasis on reporting requirements. Those who work in and visit the ED are fied by the Authority’s survey of violence A train-the-trainer approach may be increasingly being exposed to violence. protection practices. Staff training in used, with supervisors responsible for A comprehensive violence prevention violence prevention strategies as part of a training and evaluating training for their program is necessary to promote a safe comprehensive violence prevention pro- own staff. environment for patient care in the ED. gram can promote the safety of patients, Mandatory training for ED staff is one staff, and visitors. NOTES 1. Martindell, D. Survey of emergency 6. Joint Commission. Preventing violence in pub/93-94/bill/asm/ab_0501-0550/ department practices in Pennsylvania the health care setting [online]. Sentinel ab_508_bill_931008_chaptered. hospitals to protect patients and staff. Event Alert. Issue 45. 2010 Jun 3 [cited 12. California State Department of Industrial Pa Patient Saf Advis [online] 2011 Dec 2011 Nov 10]. Available from Internet: Relations, Cal/OSHA. Guidelines for [cited 2012 Jan 10]. Available from Inter- http://www.jointcommission.org/ security and safety of health care and net: http://patientsafetyauthority.org/ assets/1/18/SEA_45.PDF. community service workers [online]. 1998 ADVISORIES/AdvisoryLibrary/2011/ 7. American College of Emergency Physi- Mar [cited 2011 Nov 14]. Available from dec8(4)/Pages/126.aspx. cians. Protection from physical violence in Internet: http://www.dir.ca.gov/dosh/ 2. Healthcare Security: Basic Industry the emergency department environment dosh_publications/hcworker.html. Guidelines [website]. 2010 Oct [cited 2011 [online]. 2011 Jun [cited 2011 Nov 14]. 13. Blando JD, McGreevy K, O’Hagan E, Nov 10]. Glendale Heights (IL): Interna- Available from Internet: http://www. et al. Emergency department security pro- tional Association for Healthcare Security acep.org/content.aspx?id=29654. grams, community crime, and employee and Safety. Available from Internet: 8. Emergency Nurses Association. Violence assaults. J Emerg Med 2009 Jan 2. http://www.iahss.org/About/ in the emergency care setting [online]. 14. Behnam M, Tillotson RD, Davis SM, Guidelines-Preview.asp. 2010 Dec [cited 2011 Nov 14]. Available et al. Violence in the emergency depart- 3. Occupational Safety and Health Admin- from Internet: http://www.ena.org/ ment: a national survey of emergency istration. Guidelines for preventing SiteCollectionDocuments/Position%20 medicine residents and attending physi- workplace violence for health care & Statements/Violence_in_the_ cians. J Emerg Med 2011 May;40(5):565-79. social service workers [online]. [cited 2011 Emergency_Care_Setting_-_ENA_PS.pdf. 15. Rees S, Evans D, Bower D, et al. A pro- Nov 10]. Available from Internet: http:// 9. Meyer H, Hoppszallern S. 2011 Hospital gram to minimize ED violence and keep www.osha.gov/Publications/OSHA3148/ security survey. Maximum protection: employees safe. J Emerg Nurs 2010 Sep; osha3148.html. spending remains a priority amid hospital 36(5):460-5. 4. Stokowski LA. Violence: not in my job safety challenges. 2011 Oct [cited 2012 Jan 16. Anderson L, FitzGerald M, Luck L. An description [online]. Medscape. 2010 13]. Available from Internet: http:// integrative literature review of inter- Aug 23 [cited 2011 Nov 9] Available from www.hfmmagazine.com/hfmmagazine/ ventions to reduce violence against Internet (membership required): http:// images/pdf/2011PDFs/HFM1011_ emergency department nurses. J Clin Nurs www.medscape.com/viewarticle/727144. SecurityWebX.pdf. 2010 Sep; 19(17-18):2520-30. 5. H.B. 1992, 2011 Gen. Assemb., Reg. Sess. 10. Peek-Asa C, Casteel C, Allareddy V, et al. 17. National Institute for Occupational (Pa. 2011). Also available: http://www. Workplace violence prevention programs Safety and Health. Workplace violence legis.state.pa.us/CFDOCS/Legis/PN/ in hospital emergency departments. J prevention strategies and research needs Public/btCheck.cfm?txtType=PDF&sessY Occup Environ Med 2007 Jul;49(7):756-63. [online]. 2004 Nov [cited 2011 Nov 15]. r=2011&sessInd=0&billBody=H&billTyp 11. Assemb. B. 508, 1993 Leg., Reg. Sess. (Cal. Available from Internet: http://www.cdc. =B&billNbr=1992&pn=2761. 1993). Also available: www.leginfo.ca.gov/ gov/niosh/docs/2006-144. Page 4 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 1—March 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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