It didn’t take long for Gordon Gillespie, RN, PhD, CEN, to discover incidents of workplace violence were an unwritten part of the job description when he started working as an emergency nurse at a small, urban hospital in Ohio.
The hospital was in a tough neighborhood and less than a mile from the county correctional facility. As one of the few male nurses on staff, Gillespie often was asked to treat patients who seemed at risk for exhibiting violent behavior. He was on the receiving end of a kick, hit or punch from a patient about once a week — abuse he thought he needed to accept.
Then one day there was an incident he could not dismiss. A patient from the correctional facility had been involved in a brawl and was carried in on a stretcher. The agitated man was held down by a half-dozen police officers when Gillespie was asked to take his vitals. The patient punched Gillespie in the back of his right hand and started twisting Gillespie’s hand around the stretcher in an attempt to snap it. Gillespie freed his hand in time, but his wrist was swollen and ached for days. Although he was distraught by the act of physical aggression, he was even more disturbed his co-workers had been too overwhelmed with their own patient loads to treat his injuries.
Gillespie’s experiences at this facility left such a strong impression that he has pursued a career in research dedicated to studying the incidence of workplace violence and developing solutions to a problem that seems to be pervasive in healthcare settings.
Of 20 occupations tracked between 2005 and 2009, nurses had the third-highest proportion of workplace violence inflicted upon them — behind law enforcement officers and security guards, according to a report from the Bureau of Labor Statistics published in March. The ED is a high-risk area, and every week between 8% and 13% of emergency nurses in the U.S. are victims of physical violence, according to data from a recent surveillance study by the Emergency Nurses Association. The ENA collected data from more than 3,000 emergency nurses nationwide during a 12-month period and released the findings in September 2010.
In the same study, about 60% of nurses said the level of violence in their EDs had increased in the past year. The study’s researchers suspect violence may be increasing because of understaffing, crowding and longer wait times.
Although the data may only confirm what nurses already know, what is changing is that researchers and healthcare organizations increasingly are concentrating on ways to solve the problem. According to Gillespie, hospitals are more eager than ever to find solutions. At a recent American Organization of Nurse Executives conference, Gillespie was flooded with queries from nurse leaders who wanted to learn more about the solutions he presented.
“Everyone came up saying that workplace violence is a problem and that it is getting worse and worse at their hospitals,” he said. “My goal is to help nurses provide safe, compassionate care rather than worrying throughout the day about getting assaulted. There is always going to be some degree of violence, but by making environmental and policy changes, I think we could prevent the majority of the incidents.”
Reporting is key
To determine which strategies have the best odds of reducing workplace violence, Gillespie was a co-investigator on a study in which researchers worked with six hospitals to design and implement solutions. For the study, which was published in the January 2011 Journal of Emergency Nursing, Gillespie convened ED focus groups including patients, nurses, physicians and security managers to allow employees to share their ideas about how to address the problem. During these discussions, it became clear one of the first steps was to provide training for employees on how to prevent violence and what to do if it occurs.
In a web-based training tool from University of Cincinnati College of Nursing, employees learned, for example, if patients or visitors are showing signs of escalating frustration — such as pacing, coming into the hall or using a loud voice — it is important to intervene.
“If you can acknowledge them and say something like, ‘You seem anxious. What can I do to help?’ this can de-escalate a situation,” Gillespie said. “The training also explains that if a patient continues escalating, it is important to leave the room and ask for help rather than trying to handle it yourself.”
The hospitals in the study also implemented policy changes, such as asking patients and visitors whether they have weapons during triage, and mandating administrators contact employees who were threatened to ask how they could help them. The hospitals created reporting procedures to track when and where violence occurred most frequently — a critical step in creating solutions.
“The interventions are definitely making a difference and we are seeing a lot fewer incidents,” said Carol Brinker, RN, CEN, nurse educator for the ED at Mercy Hospital Western Hills in Cincinnati. “The researchers stressed that we really needed to report what was happening rather than just dealing with it on our own and moving on. If these incidents are not documented, then the administration would have no history of what was going on.”
Nurses initiating change
To encourage nurses to address the issue of workplace violence in their facilities, organizations such as the ENA have created resources that can be tailored to each hospital’s needs. The free online “ENA Workplace Violence Toolkit” (see sidebar), which was released in February, includes assessment tools to evaluate the safety level at a facility, sample policies and procedures, and worksheets to help managers and team leaders create action plans.
The National Institute for Occupational Safety and Health also is working with nurses to develop a free online workplace violence training resource to help nurses recognize and react to violence. The training, scheduled for release next year, is expected to include vignettes of different scenarios and suggestions for how to handle the situation, such as verbal de-escalation, calling for assistance or implementing patient behavioral contracts.
These contracts can work for nurses treating patients who are in facilities for an extended period, such as behavioral-health, developmentally disabled or youth-correctional patients. A contract will include stipulations such as added privileges for good behavior (for example, more time in a recreational area) and consequences for poor behavior (for example, postponing a privilege).
Facility administrators may seek out tools like these, but in many cases it is the bedside nurses who take the lead in changing policies. That was the case for Chris Burchill, RN, PhD, CEN, an emergency nurse at Hospital of the University of Pennsylvania, Philadelphia, who experienced a harrowing assault at work.
About a year ago, Burchill noticed a discharged patient had been sitting in the waiting room, so he asked the man if he needed assistance. Burchill told the man he would help him find a ride home, then the patient stood up, announced he was not going home, and started punching Burchill in the face. Burchill’s calls for help could not be heard through the glass triage window.
The incident was so upsetting to Burchill that he met with administrators and asked for support in creating a hospitalwide violence prevention committee. He gathered a group of 18 nurses, physicians, administrators and security personnel. In the past nine months, the group’s efforts have jump-started numerous changes, including de-escalation training and the installation of additional security cameras in the ED. The group also is investigating personal safety devices attached to nurses’ badges that can activate an alarm.
“Among administrators, there is little awareness of the significance of experiencing violence personally,” said Victoria Rich, RN, PhD, FAAN, chief nurse executive for the hospital. “Chris took that seriously, and he increased awareness among the hospital leadership. We took an incident that wasn’t good, and now we are turning it into something good by making changes that will create a safer environment for everyone.” •