Stressful Incidents of Physical Violence Against Emergency Nurses
Stressful Incidents of Physical Violence Against Emergency Nurses
The Ecological Occupational Health Model of Workplace Assault (Levin et al., 2003) provided an adequate framework for studying workplace violence in emergency nurses. The following discussion of the findings is presented in relation to personal worker, workplace, and aggressor factors, and the assault situation.
Several participants in our study reported being physically assaulted during the commission of their nursing practice (e.g., starting an intravenous line, inserting an indwelling urinary catheter, triage assessment). An essential protective strategy to prevent being assaulted is maintaining a safe distance from a potential aggressor (Zuzelo, Curran, & Zeserman, 2012). However, nursing practice as depicted by our participants requires close contact with patients. This close contact increases the likelihood an emergency nurse will become the victim of physical violence, especially if the signs of violence are absent or missed (Fujita et al., 2012). Gillespie et al. (2010) reported that participants in their sample of workers in a pediatric ED were most surprised when physical violence ensued during routine patient care. The surprise of physical violence during nursing practice may explain why some acts of violence in our study were depicted as the most distressful recent event of violence.
One of the participants in our study commented that the design of the patient room (e.g., no windows) coupled with a lack of security devices (e.g., closed caption cameras in the patient room) caused her to feel at risk when entering a patient's room. The design of the workplace and use of security devices have been shown to impact the risk for workplace violence (Peek-Asa et al., 2009). When physical violence occurs, it may be warranted for the emergency nurse to leave the immediate area for personal safety. An effective workplace design is required for the safe egress by staff away from the violent patient or visitor until help can respond (Peek-Asa & Jenkins, 2003).
Several participants in our study related the importance of a physically secure work environment (e.g., "locked down" ED, security officers limiting access). AbuAlRub and Al-Asmar (2011); Peek-Asa and Jenkins (2003); and Gillespie et al. (2010) discussed the importance of having a secured work environment where access to the patient treatment area is managed. However, as was related in our study, access is not always controlled. Violent patients and visitors were able to gain entry to the treatment area, leaving emergency nurses feeling insecure and fearful that a physical assault would occur. Gillespie et al. (2010) described a similar finding in their study; patients' and visitors' ability to access the patient treatment area was a threat to the safety of ED workers.
Policies and procedures are vital for workplace safety from physical violence. One specific policy mentioned in this study was a visitor restriction policy; however, the participant believed that enforcement of this policy led to physical violence. It is possible that the physical violence was partially accounted for by the lack of consistently enforcing the visitor policy at all times. Gillespie, Gates, Miller, and Howard (2012) described that security officers inconsistently enforced the visitor policy in the pediatric ED where their study was conducted. This led to too many visitors in the ED treatment area. It is important that policies are developed with a focus on violence prevention (AbuAlRub & Al-Asmar, 2011; Gacki-Smith et al., 2009); however, policies need to be uniformly enforced at all times by all employees (AbuAlRub & Al-Asmar, 2011; Gates, Ross, & McQueen, 2006).
Security officers can play a pivotal role in the security of the ED and safety of ED personnel. While some researchers have depicted a degree of dissatisfaction by ED workers for the effectiveness of security officers (Gates et al., 2006; Gillespie et al., 2012), the participants in our study overwhelmingly wrote about the positive presence, support, and actions taken by security officers to keep them safe. Peek-Asa and Jenkins (2003) posited that workplace safety requires an effective relationship with security officers which generally reflected the narrative accounts in our study. Gillespie et al. (2012) discussed that while not all ED workers appreciated the effectiveness of security officers, the ED workers "… overall valued and respected the security officers with whom they worked" (p. 24). Reasons for this dichotomy may be the limitations placed on security officers as noted in our study by hospital policies and procedures (e.g., not being allowed to carry a firearm, not being permitted to assist with the application of physical restraints, over reliance on police officers).
Several commonly held beliefs were supported by our findings. Consistent with workplace violence literature (Chapman, Perry, Styles, & Combs, 2009; Gacki-Smith et al., 2009; Gates et al., 2006; Gunasekara et al., 2011), emergency nurses in our study perceived that patients most likely to commit physical violence had a mental health disease or disorder or were under the influence of drugs or alcohol. Several reasons account for why these two groups of patients may be more violent than general ED patients. First, patients may have been brought to the ED against their will for a psychiatric examination. Second, some patients may be informed that they will be involuntarily admitted to a behavioral health unit and then become violent as an expression of dissatisfaction or in an attempt to leave the ED (Gillespie et al., 2010). Third, multiple patients that became violent were in police custody, including one patient that disarmed the police officer in an effort to escape and potentially shoot the police officer and ED workers during his escape attempt. Fourth, nurses are less tolerant of patients that become violent when they are under the influence of alcohol (Luck, Jackson, & Usher, 2008). This intolerance may start as soon as intoxicated patients arrive to the ED. If the patient perceives this intolerance, the perception may actually lead to the ultimate escalation to physical violence. Fifth, patients under the influence of drugs or alcohol may have lower inhibitions and a greater desire to satisfy their personal needs at the expense of others becoming physically injured or intimidated.
Nurses in our study indicated that they wished they had known that a patient had a history of being physically violent. This knowledge would have led them to interact differently with the patient prior to being physically assaulted. Peek-Asa et al. (2007) and Zuzelo et al. (2012) wrote that the ED needs to have procedures for communicating to colleagues that a patient is at risk for being physically violent. Gates, Gillespie, Smith, et al. (2011) concluded that there needs to be a mechanism to flag previously violent patients as an alert for when the patient returns to the ED in the future. Another important strategy is to assess every ED patient and visitor upon arrival for the risk of becoming violent. Chapman et al. (2009) created the STAMPEDAR assessment tool to determine patients and visitors at risk for violent behaviors. The acronym STAMPEDAR stands for staring, tone and volume of voice, assertiveness, mumbling, pacing, emotions, disease process, anxiety, and resources. While the tool cannot predict who will or will not become physically violent, STAMPEDAR does serve as an essential tool to focus emergency nurses on behavioral precursors to violence (e.g., staring, tone and volume of voice, assertiveness, emotions, disease process).
The assault situations in our study were characterized as physical assaults, physical threats, and intimidation. These types of physical violence were similar to those found by other researchers studying workplace violence. Zuzelo et al. (2012) provided a list of types of physical assaults experienced by their sample of nurses working on behavioral health units that mimicked our list including throwing objects and body fluids, kicking, biting, and punching. As previously stated, a large portion of the distressful patients enacting violence in our study was committed by patients with mental health diseases or disorders or under the influence of drugs or alcohol. One reason for why the violence received by these two groups of patients was identified as the most distressful may be the uncertainty involved in the outcome of the assault situation. Participants may have been more likely to question themselves, asking "What if—?" in terms of what would have happened if the aggressor had not been stopped. As noted in Table 2, the outcome for one victim was death. The participants in our study may not have believed that physical violence from patients would result in an inability to work or death.
Eleven nurses in our study identified the use of a weapon by a patient or visitor during the commission of physical violence. AbuAlRub and Al-Asmar (2011) reported that 15.8% (n=15) of the acts of physical violence in their study included the use of a weapon. The number of weapons identified in our study (n=11, 6.2%) was fewer, but still enough to note. As the concern for weapons increases in the ED, some nurses posit that a metal detector would increase their safety from being assaulted by a firearm or knife. Rankins and Hendey (1999) reported in their classic study that even after the implementation of a weapons screening process, 17 weapons were still found on patients in the patient treatment area. While a weapons screening program is an essential strategy to reducing potential harm from weapons, the program may also lead to a false sense of security. Nurses could become more confrontational believing that the patient or visitor could not have a weapon, when in fact he or she may. Even with a weapons screening program, attention needs to be paid on preventing escalation to physical violence.
Discussion
The Ecological Occupational Health Model of Workplace Assault (Levin et al., 2003) provided an adequate framework for studying workplace violence in emergency nurses. The following discussion of the findings is presented in relation to personal worker, workplace, and aggressor factors, and the assault situation.
Personal Worker Factors
Several participants in our study reported being physically assaulted during the commission of their nursing practice (e.g., starting an intravenous line, inserting an indwelling urinary catheter, triage assessment). An essential protective strategy to prevent being assaulted is maintaining a safe distance from a potential aggressor (Zuzelo, Curran, & Zeserman, 2012). However, nursing practice as depicted by our participants requires close contact with patients. This close contact increases the likelihood an emergency nurse will become the victim of physical violence, especially if the signs of violence are absent or missed (Fujita et al., 2012). Gillespie et al. (2010) reported that participants in their sample of workers in a pediatric ED were most surprised when physical violence ensued during routine patient care. The surprise of physical violence during nursing practice may explain why some acts of violence in our study were depicted as the most distressful recent event of violence.
Workplace Factors
One of the participants in our study commented that the design of the patient room (e.g., no windows) coupled with a lack of security devices (e.g., closed caption cameras in the patient room) caused her to feel at risk when entering a patient's room. The design of the workplace and use of security devices have been shown to impact the risk for workplace violence (Peek-Asa et al., 2009). When physical violence occurs, it may be warranted for the emergency nurse to leave the immediate area for personal safety. An effective workplace design is required for the safe egress by staff away from the violent patient or visitor until help can respond (Peek-Asa & Jenkins, 2003).
Several participants in our study related the importance of a physically secure work environment (e.g., "locked down" ED, security officers limiting access). AbuAlRub and Al-Asmar (2011); Peek-Asa and Jenkins (2003); and Gillespie et al. (2010) discussed the importance of having a secured work environment where access to the patient treatment area is managed. However, as was related in our study, access is not always controlled. Violent patients and visitors were able to gain entry to the treatment area, leaving emergency nurses feeling insecure and fearful that a physical assault would occur. Gillespie et al. (2010) described a similar finding in their study; patients' and visitors' ability to access the patient treatment area was a threat to the safety of ED workers.
Policies and procedures are vital for workplace safety from physical violence. One specific policy mentioned in this study was a visitor restriction policy; however, the participant believed that enforcement of this policy led to physical violence. It is possible that the physical violence was partially accounted for by the lack of consistently enforcing the visitor policy at all times. Gillespie, Gates, Miller, and Howard (2012) described that security officers inconsistently enforced the visitor policy in the pediatric ED where their study was conducted. This led to too many visitors in the ED treatment area. It is important that policies are developed with a focus on violence prevention (AbuAlRub & Al-Asmar, 2011; Gacki-Smith et al., 2009); however, policies need to be uniformly enforced at all times by all employees (AbuAlRub & Al-Asmar, 2011; Gates, Ross, & McQueen, 2006).
Security officers can play a pivotal role in the security of the ED and safety of ED personnel. While some researchers have depicted a degree of dissatisfaction by ED workers for the effectiveness of security officers (Gates et al., 2006; Gillespie et al., 2012), the participants in our study overwhelmingly wrote about the positive presence, support, and actions taken by security officers to keep them safe. Peek-Asa and Jenkins (2003) posited that workplace safety requires an effective relationship with security officers which generally reflected the narrative accounts in our study. Gillespie et al. (2012) discussed that while not all ED workers appreciated the effectiveness of security officers, the ED workers "… overall valued and respected the security officers with whom they worked" (p. 24). Reasons for this dichotomy may be the limitations placed on security officers as noted in our study by hospital policies and procedures (e.g., not being allowed to carry a firearm, not being permitted to assist with the application of physical restraints, over reliance on police officers).
Aggressor Factors
Several commonly held beliefs were supported by our findings. Consistent with workplace violence literature (Chapman, Perry, Styles, & Combs, 2009; Gacki-Smith et al., 2009; Gates et al., 2006; Gunasekara et al., 2011), emergency nurses in our study perceived that patients most likely to commit physical violence had a mental health disease or disorder or were under the influence of drugs or alcohol. Several reasons account for why these two groups of patients may be more violent than general ED patients. First, patients may have been brought to the ED against their will for a psychiatric examination. Second, some patients may be informed that they will be involuntarily admitted to a behavioral health unit and then become violent as an expression of dissatisfaction or in an attempt to leave the ED (Gillespie et al., 2010). Third, multiple patients that became violent were in police custody, including one patient that disarmed the police officer in an effort to escape and potentially shoot the police officer and ED workers during his escape attempt. Fourth, nurses are less tolerant of patients that become violent when they are under the influence of alcohol (Luck, Jackson, & Usher, 2008). This intolerance may start as soon as intoxicated patients arrive to the ED. If the patient perceives this intolerance, the perception may actually lead to the ultimate escalation to physical violence. Fifth, patients under the influence of drugs or alcohol may have lower inhibitions and a greater desire to satisfy their personal needs at the expense of others becoming physically injured or intimidated.
Nurses in our study indicated that they wished they had known that a patient had a history of being physically violent. This knowledge would have led them to interact differently with the patient prior to being physically assaulted. Peek-Asa et al. (2007) and Zuzelo et al. (2012) wrote that the ED needs to have procedures for communicating to colleagues that a patient is at risk for being physically violent. Gates, Gillespie, Smith, et al. (2011) concluded that there needs to be a mechanism to flag previously violent patients as an alert for when the patient returns to the ED in the future. Another important strategy is to assess every ED patient and visitor upon arrival for the risk of becoming violent. Chapman et al. (2009) created the STAMPEDAR assessment tool to determine patients and visitors at risk for violent behaviors. The acronym STAMPEDAR stands for staring, tone and volume of voice, assertiveness, mumbling, pacing, emotions, disease process, anxiety, and resources. While the tool cannot predict who will or will not become physically violent, STAMPEDAR does serve as an essential tool to focus emergency nurses on behavioral precursors to violence (e.g., staring, tone and volume of voice, assertiveness, emotions, disease process).
Assault Situation
The assault situations in our study were characterized as physical assaults, physical threats, and intimidation. These types of physical violence were similar to those found by other researchers studying workplace violence. Zuzelo et al. (2012) provided a list of types of physical assaults experienced by their sample of nurses working on behavioral health units that mimicked our list including throwing objects and body fluids, kicking, biting, and punching. As previously stated, a large portion of the distressful patients enacting violence in our study was committed by patients with mental health diseases or disorders or under the influence of drugs or alcohol. One reason for why the violence received by these two groups of patients was identified as the most distressful may be the uncertainty involved in the outcome of the assault situation. Participants may have been more likely to question themselves, asking "What if—?" in terms of what would have happened if the aggressor had not been stopped. As noted in Table 2, the outcome for one victim was death. The participants in our study may not have believed that physical violence from patients would result in an inability to work or death.
Eleven nurses in our study identified the use of a weapon by a patient or visitor during the commission of physical violence. AbuAlRub and Al-Asmar (2011) reported that 15.8% (n=15) of the acts of physical violence in their study included the use of a weapon. The number of weapons identified in our study (n=11, 6.2%) was fewer, but still enough to note. As the concern for weapons increases in the ED, some nurses posit that a metal detector would increase their safety from being assaulted by a firearm or knife. Rankins and Hendey (1999) reported in their classic study that even after the implementation of a weapons screening process, 17 weapons were still found on patients in the patient treatment area. While a weapons screening program is an essential strategy to reducing potential harm from weapons, the program may also lead to a false sense of security. Nurses could become more confrontational believing that the patient or visitor could not have a weapon, when in fact he or she may. Even with a weapons screening program, attention needs to be paid on preventing escalation to physical violence.
