ED nurses share methods for deterring workplace violence
Recognizing warning signs can help avoid catastrophe
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By Karen Schmidt, RN
EDITOR'S NOTE: Karen Schmidt, RN, is a freelance writer.
"We found [via a survey of 13,000 nurses] that one-third of nurses report considering leaving the ED or nursing altogether due to violence,” said Lisa Wolf, PhD, RN, FAEN, CEN, director of the Institute for Emergency Room Nursing Research at the Emergency Nurses Association.

Nurses experience both physical and verbal assaults in the ED. These incidents occur with patients and family members — and also other healthcare professionals.
Lateral violence, or bullying, is important to address, said Kristine Powell, MSN, RN, FAEN, NEA-BC, director of Emergency Services at Baylor Scott & White Health in north Texas. “A culture that permits lateral violence amongst internal staff is going to be at higher risk for other kinds of violence.”
Wolf said it is clear that reporting of incidents has increased. She explained that getting nurses to report violent encounters has been very difficult: It takes time to fill out forms, and often, “people feel like nothing will happen.”
Reporting is becoming more frequent as nurses recognize physical and verbal mistreatment is not part of their job description. Facilities also are offering training, which endorses nurses reporting incidents. Training can decrease violence, according to Jenessa Williams, BSN, RN, CEN, Adeptus Health regional nurse manager for Colorado. “We focus on training nurses in de-escalation techniques. This means looking for signs, then respecting the person’s space.”
Common signs, or alerts, signaling a potential violent outbreak, require nurses to develop situational awareness. “Be aware of little things, like the person avoiding eye contact, skirting answers to questions, avoiding any type of treatment for their healthcare needs. These are early signs,” Williams said.
“Remember, it’s not part of your job to have a patient be verbally or violent toward you,” Williams said. “Be empathetic toward patients, but hold them accountable.” Also being aware of one’s own nonverbal actions is important, said Williams. For example, a nurse should consciously choose not to react when an individual is starting to challenge or question them. They also can alert their team and others to the potentially violent person.
Most recent studies show the majority of workplace violence is related to patients who have some sort of alcohol or drug-related reason for their visit, according to Williams. “Everyone is at a high-level of anxiety in an ED, so anyone could have a trigger that could lead to a situation,” Williams said.
“Don’t become complacent with ‘typical’ patients; be consistently aware.”
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A culture that permits lateral violence amongst internal staff is going to be at higher risk for other kinds of violence.”
— Kristine Powell, RN
Increase in reporting violence
At Baylor Scott & White, Powell said nurses are taught to recognize potential violence using the acronym STAMP: staring, tone of voice, anxiety, mumbling or pacing.
“We teach nurses to recognize some of those obvious indicators; the more that are present, the higher the risk,” Powell said.
As indicators develop toward violent behavior, nurses will deploy de-escalation and intervention tactics, Powell said. At Baylor, staff receive mandatory classroom training in addition to completing the ENA’s free workplace violence online training module.
She advocates that ED nurses pursue their own training. Nurses also can share the joint American Organization of Nurse Executives/ENA toolkit on mitigating violence with their nursing leadership.
“With the support of nursing administration, we can make better headway in reporting violence and improving safety,” Powell said. She also stressed every ED should have a no-tolerance for violence culture. According to Powell this means reporting must happen for any violent incident, including those with a co-worker or physician.
Whether at a small, free-standing ED or one in a frenetic, high-volume hospital, many ED nurses regularly confront violence at work.
Use the STAMP acronym
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