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Pick one of the following topics and find a scholarly nursing journal article (published within the last five years) that discusses this nursing topic. The topics are
- ? safety;
- ? delegation;
- ? prioritization; and
- ? caring.After you find a scholarly nursing journal article using the Chamberlain library resources, you will complete a one-two page summary and reflection on the article. The paper should be completed in APA format and include the following.
- ? A cover page (not included in the page number requirement)
- ? A reference page (not included in the page number requirement)
- ? One direct quote from one of your references, appropriately cited in the body of your paper
- ? One indirect quote (or paraphrased reference) appropriately cited in the body of your paper
- ? Citations and references in APA format
- www.Nursing2015.com January l Nursing2015 l 55
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Safety Alert:
IN 2012, 27,380 U.S. healthcare
workers were injured in nonfatal
workplace injuries. According to the
Bureau of Labor Statistics, healthcare
facilities with more than 1,000 employees
have an average of 5.5 nonfatal
injuries annually.1 Between 2009 and
2011, eight RNs were fatally injured
at work.2 (See Startling statistics.)
Many nurses are routinely exposed
to violent behavior such as shouting,
cursing, spitting, biting, pulling,
pushing, scratching, threats to themselves
and their loved ones, and actual
physical assaults with hands, fists,
weapons, or objects within the assailants
reach.3 All too often, nurses fail
to report these episodes of violence
because they erroneously consider it
to be part of the job. Consequently,
managers and administrators may be
unaware of the extent of risk to nurses
and fail to initiate corrective action.
For their personal safety and the
protection of patients, visitors, and
other staff, nurses must recognize
signs of behavior escalating toward
violence. This article discusses how
to recognize signs of escalating behavior
and what to do to defuse the
situation effectively and safely.
Violence: Getting
down to basics
Violence is the intentional act of aggression,
verbal abuse, threatening
behavior, and/or physical assault. The
intended goal is to threaten, control,
coerce, intimidate, humiliate, silence,
ostracize, demean, or otherwise emotionally
or physically injure the victim.
3,4 The focus of this article is
threatened or actual physical violence
within healthcare facilities.
Although anyone can be a victim
of violence, people in certain
healthcare positions, such as clinical
nurses and unlicensed assistive personnel,
may be routinely exposed to
acts of violence. Nursing personnel
who work in the ED, ICU, and psychiatric
or long-term care units are
most at risk for experiencing routine
episodes of violence on the job
Protecting yourself and
others from violence
By Charlotte Davis, BSN, RN, CCRN;
Denise Landon, BSN, RN, CMSC; and Kandie Brothers, MSN, RN, CNL
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2015.com January l Nursing2015 l 57
from patients, family members, or
visitors.3 Patient substance abuse
and cognitive impairment can increase
the risk of violence for staff.
Identifying levels of stress
The Veterans Administration Health
Care 2014 Prevention and Management
of Disruptive Behavior
(PMDB) program teaches that potentially
violent behavior escalates
through four levels of stress: normal,
moderate, severe, and panic
level.3,4 In some circumstances, a
person can transition rapidly from a
normal stress level to panic level.
This potential requires nurses to
refine their escalation assessment
skills and to develop a plan with
the employer and coworkers to
safely manage the perpetrators escalating
behavior and ensure everyones
safety. See Four levels of stress:
Assessment and intervention for
warning signs and interventions
appropriate for each stress level.
When confronted with signs of
moderate escalation, avoid arguing
with the agitated patient or visitor.
Raising your voice to match the tone
and volume of the other persons
voice can trigger escalation to a
higher stress level and increase the
likelihood of physical violence. If the
person seems to perceive you as a
threat, remove yourself from the situation.
If you can safely do so, introduce
a neutral party to speak with
the person and try to deescalate the
behavior.
If a patients family or visitor becomes
disruptive in the patients
room, consider asking the person to
step outside the room or press the
call light to signal the need for assistance,
depending on the situation.
Dont remain in the room with the
hostile individual because of the risk
of physical injury.
Follow facility safety policies and
procedures if the persons behavior
continues to escalate. For example,
most facility policies include a provision
for notifying security or a house
supervisor or management team
member immediately; that designated
person may then call law enforcement
if needed. Nurses should
program their healthcare facilitys
security office and 911 into their cell
phone speed dial.
Consider developing a code word,
such as purple, that signifies a need
for assistance because of an escalating
situation. All staff members
should be educated on what the
code word is and what actions to
take in response.
If youre isolated and in imminent
danger, find alternative ways
to draw attention to the location,
such as activating a panic button,
yelling for assistance, and pulling a
fire alarm or accessing an automated
external defibrillator (AED).
When accessed, some AEDs activate
an alarm to locate the emergency.
Check to see if this is an option
where you work.
Report and document all incidents
of potential or actual violence according
to facility policy. This information
will help managers and administrators
take action to maintain the culture
of safety that staff, patients, and
staff are entitled to.
Minimizing risks:
Watch for weapons
Some healthcare facilities allow
staff to review and itemize a patients
personal possessions upon
admission. If permitted to itemize
possessions by facility policy, the
nurse can look for obvious and potential
weapons at this time. Guns,
stun guns, knives, and other items
that could be used to penetrate the
skin should be confiscated and
locked in a secure location until
the patients discharge per your
facilitys policy.
Be aware that some innocentlooking
items can be used as weapons;
for example:
a cane can be modified to make a
sword with a potentially long, lethal
blade.
Gestures such as shaking
a fist and prolonged
staring signal escalating,
potentially violent
behavior.
Startling statistics
Results of the Emergency Nurses Associations 2011 Emergency Department Violence
Surveillance Study revealed that almost 70% of respondents had been physically
threatened, 52% had been physically assaulted, and 40% had been involved
in a violent situation at their job in which a weapon was utilized. Of those routinely
exposed to physical violence, about 17% experienced the behavior more than four
times a week. Nurses failed to report physical violence in 66% of these cases because
they believed that violence was just part of the job.6
Failure to file a timely formal incident report may allow the perpetrator to victimize
others and place the nurse at risk for uncompensated medical treatment for any
injuries suffered during the violent incident. Underreporting also can prevent the
facilitys administrative and safety and quality management teams from recognizing
and addressing the presence and severity of staff members routine exposure to violence.
Employers may be cited by the Occupational Safety and Health Administration
if they fail to prevent or abate a recognized violence hazard in the workplace.7
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
58 l Nursing2015 l January www.Nursing2015.com
both flashlights and cell phones
can be modified to make a gun or
stun gun.5
Nurses should be suspicious if
an object seems heavier than it
should be or shows signs of alteration,
such as screws or reinforcement
at joints, and contact the
security team to have the item
inspected.
A nurse confronted with an escalating
person whos armed with any
type of weapon should immediately
evacuate the area and retreat to a safe
place, then notify hospital security
and/or call 911. The nurse should
never try to intervene with someone
armed with a weapon.
Besides obvious weapons, many
items found within a healthcare facility
can be used as a weapon because
of convenience and proximity.
These include telephone cords, holepunch
devices, examination lamps,
plants, electrical devices, pens,
tables, and chairs. When the nurse
observes escalating behavior, he or
she should begin to calmly remove
these items out of sight or away
from the persons reach, if this can
be done safely.
Many items nurses wear or carry
are also potential weapons; for example,
a stethoscope, pen, eyeglasses,
dangling jewelry, and lanyards.
Even lanyards with breakaway
clasps can be used to strangle a
nurse if the aggressor grasps the
breakaway clasp.
During periods of panic-level escalation,
nurses with long hair should
put their hair up in a ponytail, twist
their hair into a bun, or tuck long
hair underneath the back of their
shirt. An agitated person can grasp
loose long hair and use it to control
the nurses head, resulting in a whiplash
injury, blunt force trauma to the
head, or even strangulation.
Control the environment
By managing the environment, nurses
can help defuse potentially dangerous
behavior or minimize the
consequences. Following these
guidelines can help prevent escalation
of aggressive behavior and minimize
the risk of injury.
Pay attention to early signs of escalation
and intervene at the lowest
level of stress. (See Making GAINS
against escalating behavior.)
Remove unnecessary staff, patients,
and visitors to minimize the audience.
Some aggressors will calm
down without an audience.
Remove any excess furniture,
plants, and decorative items that
could be used as a weapon or thrown.
Decrease the noise level and other
environmental stimuli in patient-care
areas. Increased environmental stimuli
and high noise levels can trigger
anxiety attacks and posttraumatic
stress disorder exacerbations.3,4
Reduce overcrowding in waiting
areas if possible. Offer patients, staff,
and visitors the option to take a
break in a quiet area, such as a chapel,
outside sitting area, or a less
crowded waiting room.
Dont multitask when youre assisting
patients, staff, and visitors who
are exhibiting signs of moderate or
severe stress. Give them your full attention.
Multitasking may give them
the impression that youre not fully
invested in solving their problem.
Pay attention to gut feelings! Immediately
leave any situation if you
feel uncomfortable or unsafe.
Nurses should take advantage of
any training that their employers
Four levels of stress: Assessment and intervention3
Stress level Signs and symptoms Interventions
Normal heart rate (HR), 60-80 bpm
keen perceptual field (awareness of
surroundings)
able to think clearly and process
information
Provide good customer service. Offer assistance or provide
information in a professional, respectful, and timely manner.
The nurse may be able to prevent escalation simply by
communicating the current or anticipated plan of care to
the patient/family.
Moderate HR, 81-100 bpm
perceptual field narrows
altered thinking
Verbal intervention: redirect the person, indicating the behavior
isnt acceptable
Severe HR near or above 100 bpm
difficulty processing information
task oriented or tunnel vision
complex motor skills deteriorate
perceptual field very limited
Set limits. Provide clear one- or two-step directions. Avoid
multistep directions because the person cant process this
information with a limited perceptual field.
Panic HR over 100 bpm
cant process information or problem-solve
irrational; a danger to self and others
gross motor skills, such as strength-based
actions (walking, running, hitting, or throwing
objects) are at their highest performance
Gain attention of coworkers and avoid becoming isolated
with this person. Locate an exit door and begin moving toward
the door as you speak. If thats not possible, yell loudly
for help, call hospital security or 911, and activate the speaker
feature on your phone. Consider chemical or physical
restraints per facility policy if all other efforts have failed.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2015.com January l Nursing2015 l 59
offer, such as Crisis Prevention and
Intervention training, the Veterans
Administrations PMDB program,
and self-defense classes that
teach hands-on techniques to
minimize the risk of injury to
self or others during potentially
violent situations.
Help reduce the risk of violence
by assisting people who appear
lost, answering questions, and
conveying your commitment to
helping to resolve their problems.
Avoid making comments such as
thats not my job, which can
escalate an agitated persons stress
level. Like patient and staff safety,
customer service is everyones
business. ?
REFERENCES
1. United States Department of Labor. Bureau of
Labor Statistics. Economic News Release. 2012.
http://www.bls.gov/news.release/osh.t03.htm.
2. American Nurses Association. Workplace
Violence. 2014. http://www.nursingworld.org/
workplaceviolence.
3. Bullard, D. Prevention and management of
disruptive behavior. Veterans Administration
Healthcare System {Conference}. Nashville,
Tennessee. 2014.
4. Williams J. Improvised weapons and other
safety concerns. Los Angeles County Sherriffs
Department. 2013. https://info.publicintelligence.
net/LA-DisguisedWeapons.pdf.
5. NANDA Nursing Interventions. 2013.
http://nanda-nursinginterventions.blogspot.
com/2012/03/levels-of-anxiety-mild-moderateand.
html.
6. Emergency Nurses Association. Emergency
Department Violence Surveillance Survey. 2011.
http://www.ena.org/practice-research/research/
Documents/ENAEDVSReportNovember2011.pdf.
7. Occupational Safety and Health Administration.
OSHA fact sheet: workplace violence. https://www.
osha.gov/OshDoc/data_General_Facts/factsheetworkplace-
violence.pdf.
Charlotte Davis is a CCU/CVICU staff nurse at Heritage
Medical Center in Shelbyville, Tenn., and Alvin C.
York VA Medical Center in Murfreesboro, Tenn.
Denise Landon is an MICU staff nurse at Olin Teague
Veterans Medical Center in Temple, Tex. Kandie
Brothers is nursing clinical faculty/prevention and
management of disruptive behavior coordinator at
the Department of Veterans Affairs Medical Center in
Nashville, Tenn.
The authors have disclosed that they have no financial
relationships related to this article.
DOI-10.1097/01.NURSE.0000454955.88149.e4
Making GAINS
against escalating
behavior3
Both verbal and nonverbal indicators
signal escalating, potentially violent
behavior, as suggested by the GAINS
mnemonic:
Gestures of anger, such as shaking
a fist, prolonged staring, slamming a
door, throwing objects
Acting suspicious, anxious, fearful,
or hostile toward staff
Incongruent behavior that doesnt
match the words; for example, a person
stating that he or she is fine
while pacing and becoming increasingly
agitated
Noticeable signs and symptoms
of stress, such as diaphoresis, flared
nares, jugular vein distension, and
elevated heart rate and BP
Systematically pacing, tapping feet,
shaking knees, sighing, running fingers
through the hair repeatedly, rubbing
the forehead.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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JBI: Best practice information sheet
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