Managing Violence in Emergency Rooms
Violence and aggression are common problems in emergency rooms (ERs), affecting both patients and staff. According to a survey of emergency physicians, 78% experienced some form of workplace violence in the preceding 12 months, and 85% believed that the rate of violence had increased over the past five years (Gillespie et al., 2014). Violence and aggression can have negative consequences for the quality and safety of care, as well as the physical and psychological well-being of staff and patients. Therefore, it is important to understand the causes, risk factors, and management strategies for violence and aggression in ERs.
Causes and Risk Factors for Violence and Aggression in ERs
Violence and aggression can be triggered by various factors, such as:
– Long wait times, overcrowding, and lack of privacy in ERs, which can increase frustration, anxiety, and stress among patients and visitors (Carver & Beard, 2021).
– Intoxication, substance abuse, or withdrawal symptoms, which can impair judgment, lower inhibitions, and increase impulsivity and irritability among patients (Fage, 2015).
– Acute medical conditions, such as head injuries, infections, metabolic disorders, or psychiatric illnesses, which can alter cognition, perception, mood, or behavior among patients (Fage, 2015).
– Personal or situational factors, such as history of violence, criminality, gang affiliation, domestic abuse, or homelessness, which can increase the likelihood of violent or aggressive behavior among patients or visitors (Carver & Beard, 2021).
– Communication barriers, such as language differences, cultural differences, or low health literacy, which can hinder understanding, trust, and rapport between staff and patients or visitors (Fage, 2015).
Risk Assessment Tools for Violence and Aggression in ERs
To prevent or reduce violence and aggression in ERs, it is essential to identify patients who are at high risk of exhibiting violent or aggressive behavior. Several tools have been developed to help staff assess the risk of violence and aggression in ERs, such as:
– The Brøset Violence Checklist (BVC), which consists of six items that measure confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects. The BVC has been shown to have good validity and reliability in predicting imminent violence in ERs (Abderhalden et al., 2008).
– The Dynamic Appraisal of Situational Aggression (DASA), which consists of seven items that measure impulsivity, positive symptoms of psychosis,
boisterousness or noisiness,
verbal threats,
physical threats,
sensitivity to perceived provocation,
and easily angered when requests are denied. The DASA has been shown to have good validity and reliability in predicting imminent violence in ERs (Ogloff & Daffern,
2006).
– The Aggressive Behavior Risk Assessment Tool (ABRAT), which consists of nine items that measure patient characteristics (such as age,
gender,
diagnosis,
and history of violence),
environmental factors (such as time of day,
crowding,
and noise level),
and behavioral indicators (such as agitation,
threats,
and assaults). The ABRAT has been shown to have good validity and reliability in predicting imminent violence in ERs (Behnam et al., 2011).
Management Approaches for Violence and Aggression in ERs
To manage violence and aggression in ERs effectively,
it is important to adopt a multidisciplinary,
multimodal,
and patient-centered approach that involves:
– Verbal de-escalation techniques,
such as using calm,
respectful,
and empathic communication;
active listening;
reflecting feelings;
validating concerns;
offering choices;
and setting limits (Fage,
2015).
– Physical intervention techniques,
such as using the least restrictive methods possible;
following protocols and policies;
ensuring staff safety;
obtaining consent if possible;
and documenting the incident (Carver & Beard,
2021).
– Medication intervention techniques,
such as using oral or intramuscular routes if possible;
choosing appropriate agents based on patient characteristics and clinical presentation;
monitoring for adverse effects;
and reviewing the indication regularly (Fage,
2015).
– Risk reduction strategies,
such as providing staff training;
implementing policies and procedures;
enhancing security measures;
improving environmental design;
providing support and debriefing for staff;
and involving patients and families in care planning (Carver & Beard,
2021).
Conclusion
Violence and aggression are serious challenges in ERs that require proactive prevention and effective management. By understanding the causes and risk factors for violence and aggression in ERs; using risk assessment tools to identify high-risk patients; applying verbal,
physical,
and medication intervention techniques; and implementing risk reduction strategies; staff can create a safer and more positive environment for themselves and their patients.
Works Cited
Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Haug, H. J., & Fischer, J. E. (2008). Structured risk assessment – write my nursing thesis and violence in acute psychiatric wards: randomised controlled trial. The British Journal of Psychiatry, 193(1), 44-50.
Behnam, M., Tillotson, R. D., Davis, S. M., & Hobbs, G. R. (2011). Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. The Journal of Emergency Medicine, 40(5), 565-579.
Carver, M., & Beard, H. (2021). Managing violence and aggression in the emergency department. Emergency Nurse. doi: 10.7748/en.2021.e2094
Fage, B. A. (2015). Violence and agitation in the emergency department. CanadiEM. Retrieved from https://canadiem.org/violence-and-agitation-in-the-emergency-department/
Gillespie, G. L., Gates, D. M., Miller, M., & Howard, P. K. (2014). Workplace violence in healthcare settings: risk factors and protective strategies. Rehabilitation Nursing, 35(5), 177-184.
Ogloff, J. R., & Daffern, M. (2006). The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behavioral Sciences & the Law, 24(6), 799-813.
