STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments

Risk factors for violence in an emergency department: Nurses' perspectives

OBJECTIVE

Work-related violence remains a significant problem in healthcare settings, including EDs. Violence risk assessment tools have been developed to improve risk mitigation in this setting; however, incorporation of these tools into standard hospital processes remains scarce. This research aimed to explore nurses' perspectives on the Bröset Violence Checklist used in routine violence risk assessment and their recommendations for additional items.

METHODS

Thirty nursing staff who used the Bröset Violence Checklist (BVC) as standard practice for 5 years participated in two focus groups where 23 violence risk factors were presented. Using multiple methods, participants were asked to select and elaborate from a pre-determined list what they considered most useful in violence risk assessment in respect to descriptors and terminology.

RESULTS

Quantitative data showed most risk factors presented to the group were considered to be predictive of violence. Ten were regarded as associated with risk, and overt behaviours received the highest votes. The terms 'shouting and demanding' was preferred over 'boisterous', and 'cognitive impairment' over 'confusion'. Patient clinical characteristics and staff perceptions of harm, inability to observe subtle behaviour, imposed restrictions and interventions and environmental conditions and impact were also important considerations.

CONCLUSIONS

We recommend that violence risk assessment include: history of violence, cognitive impairment, psychotic symptoms, drug and alcohol influence, shouting and demanding, verbal abuse/hostility, impulsivity, agitation, irritability and imposed restrictions and interventions. These violence risk factors fit within the four categories of historical, clinical, behavioural and situational.

Maintaining a safe environment in emergency department waiting rooms

Increasing demand, overcrowding and insufficient resources have led to situations where patient care is delivered in emergency department (ED) waiting rooms. For nurses undertaking triage in the ED waiting room, overcrowding is challenging, particularly in terms of assessing patients in a timely fashion, monitoring patients for clinical deterioration and ordering investigations. Additionally, long waiting times and a lack of information can lead to communication breakdowns with patients and, at times, patient confrontations with ED staff. This article explores the effects of the busy environment in ED waiting rooms on patients and staff such as triage nurses and waiting room nurses.

Predicting Workplace Violence in the Emergency Department Based on Electronic Health Record Data

INTRODUCTION

Emergency departments are extremely vulnerable to workplace violence, and emergency nurses are frequently exposed to workplace violence. We developed workplace violence prediction models using machine learning methods based on data from electronic health records.

METHODS

This study was conducted using electronic health record data collected between January 1, 2016 and December 31, 2021. Workplace violence cases were identified based on violence-related mentions in nursing records. Workplace violence was predicted using various factors related to emergency department visit and stay.

RESULTS

The dataset included 1215 workplace violence cases and 6044 nonviolence cases. Random Forest showed the best performance among the algorithms adopted in this study. Workplace violence was predicted with higher accuracy when both ED visit and ED stay factors were used as predictors (0.90, 95% confidence interval 0.898-0.912) than when only ED visit factors were used. When both ED visit and ED stay factors were included for prediction, the strongest predictor of risk of WPV was patient dissatisfaction, followed by high average daily length of stay, high daily number of patients, and symptoms of psychiatric disorders.

DISCUSSION

This study showed that workplace violence could be predicted with previous data regarding ED visits and stays documented in electronic health records. Timely prediction and mitigation of workplace violence could improve the safety of emergency nurses and the quality of nursing care. To prevent workplace violence, emergency nurses must recognize and continuously observe the risk factors for workplace violence from admission to discharge.

Implementation of a Violence Risk Assessment and Interventions Aimed at the Prevention of Patient-Perpetrated Violent Events Across Care Settings

Healthcare worker violence at the hands of patients is the leading cause of workplace injury with reports demonstrating yearly increases. Literature suggests organizational strategies to reduce workplace injury are necessary to create safe environments for patients to receive care and for healthcare workers to practice, but tactics lack a care continuum focus and largely focus on deescalation and management of violent events. One healthcare system identified that the use of an assessment widely used in Canada, identifying patients at risk for violent behaviors, would supplement already existing efforts at protecting patients. The implementation of this tool across care settings is presented in this article.

A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings

INTRODUCTION

Violence risk assessment is commonplace in mental health settings and is gradually being used in emergency care. The aim of this review was to explore the efficacy of undertaking violence risk assessment in reducing patient violence and to identify which tool(s), if any, are best placed to do so.

METHODS

CINAHL, Embase, Medline, and Web of Science database searches were supplemented with a search of Google Scholar. Risk of bias assessments were made for intervention studies, and the quality of tool development/testing studies was assessed against scale development criteria. Narrative synthesis was undertaken.

RESULTS

Eight studies were included. Three existing violence risk assessment tools featured across the studies, all of which were developed for use with mental health patients. Three newly developed tools were developed for emergency care, and 1 additional tool was an adaptation of an extant tool. Where tested, the tools demonstrated that they were able to predict patient violence, but did not reduce restraint use. The quality issues of the studies are a significant limitation and highlight the need for additional research in this area.

DISCUSSION

There is a paucity of high-quality evidence evaluating the psychometric properties of violence risk assessment tools currently used along the emergency care pathway. Multiple tools exist, and they could have a role in reducing violence in emergency care. However, the limited testing of their psychometric properties, acceptability, feasibility, and usability in emergency care means that it is not possible to favor one tool over another until further research is conducted.

Selecting an Instrument for Assessing the Risk of Patient Violence Across a Healthcare System

ABSTRACT

Physical violence is one of the leading causes of nurse injury in the workplace. Studies indicate patients most often incite the violence and both patient and organization factors contribute to violent events. It has been suggested that an assessment be done upon admission to identify those patients at risk for violent behavior. To implement this intervention, organizations must objectively select a screening instrument that is accurate, easy to use, and appropriate for multiple patient populations.

Multisite study of Aggressive Behavior Risk Assessment Tool in emergency departments

Objective

Violence is a major preventable problem in emergency departments (EDs), and validated screening tools are needed to identify potentially violent patients. We aimed to test the utility of the Aggressive Behavior Risk Assessment Tool (ABRAT) for screening patients in the ED.

Methods

A prospective cohort study was conducted among adult and pediatric patients aged ≥10 years visiting 3 emergency departments in Michigan between May 1, 2021, and June 30, 2021. Triage nurses completed the 16‐item checklist using electronic health records (EHRs), and the occurrence of violent incidents were collected before ED disposition. A multivariate logistic regression model was applied to select a parsimonious set of items.

Results

Among 10,554 patients, 127 had ≥1 violent incidents (1.2%). The regression model resulted in a 7‐item ABRAT for EDs, including history of aggression and mental illness and reason for visit, as well as 4 violent behavior indicators. Receiver operating characteristics analysis showed that the area under the curve was 0.91 (95% confidence interval [CI], 0.87–0.95), with a sensitivity of 84.3% (95% CI, 76.5%–89.9%) and specificity of 95.3% (95% CI, 94.8%–95.7%) at the optimal cutoff score of 1. An alternative cutoff score of 4 for identifying patients at high risk for violence had a sensitivity and specificity of 70.1% and 98.9%, respectively.

Conclusion

The ABRAT for EDs appears to be a simple yet comprehensive checklist with a high sensitivity and specificity for identifying potentially violent patients in EDs. The availability of such a screening checklist in the EHR may allow rapid identification of high‐risk patients and implementation of focused mitigation measures to protect emergency staff and patients.

Validity and reliability of the novel three‐item occupational violence patient risk assessment tool

Aim

To develop and psychometrically test an occupational violence (OV) risk assessment tool in the emergency department (ED).

Design

Three studies were conducted in phases: content validity, predictive validity and inter‐rater reliability from June 2019 to March 2021.

Methods

For content validity, ED end users (mainly nurses) were recruited to rate items that would appropriately assess for OV risk. Subsequently, a risk assessment tool was developed and tested for its predictive validity and inter‐rater reliability. For predictive validity, triage notes of ED presentations in a month with the highest OV were assessed for presence of OV risk. Each presentation was then matched with events recorded in the OV incident register. Sensitivity and specificity values were calculated. For inter‐rater reliability, two assessors—trained and untrained—independently assessed the triage notes for presence of OV risk. Cohen's kappa was calculated.

Results

Two rounds of content validity with a total of N = 81 end users led to the development of a three‐domain tool that assesses for OV risk using aggression history, behavioural concerns (i.e., angry, clenched fist, demanding, threatening language or resisting care) and clinical presentation concerns (i.e., alcohol/drug intoxication and erratic cognition). Recommended risk ratings are low (score = 0 risk domain present), moderate (score = 1 risk domain present) and high (score = 2–3 risk domains present), with an area under the curve of 0.77 (95% confidence interval 0.7–0.81, p < .01). Moderate risk rating had a 61% sensitivity and 91% specificity, whereas high risk rating had 37% sensitivity and 97% specificity. Inter‐rater reliability ranged from 0.67 to 0.75 (p < .01), suggesting moderate agreement.

Conclusions

The novel three‐domain OV risk assessment tool was shown to be appropriate and relevant for application in EDs. The tool, developed through a rigorous content validity process, demonstrates acceptable predictive validity and inter‐rater reliability.

Impact

The developed tool is currently piloted in a single hospital ED, with a view to extend to inpatient settings and other hospitals.

Factors affecting stress levels in attendants accompanying patients to emergency department

Introduction:

Staff in emergency departments work in an environment where they are continuously exposed to situations with aggressive patients and their caretakers. With increasing incidents of reported violence, the present study was conducted to identify factors associated with stress levels among patients’ attendants.

Methods:

A prospective, cross-sectional, observational study was conducted among 256 attendants of patients presenting to Emergency Department (ED). Signs of stress and imminent violence were recorded using STAMP method at initial encounter. Stress levels were assessed using Perceived Stress Scale 10 and Visual Analog Scale at the end of 2 h during patient's stay in emergency department. Factors associated with stress were studied using linear regression analysis. There was a follow-up to estimate the level of stress, to identify risk factors and types of violence in the sample population.

Results:

98.9% of attendants exhibited some form of stress. Age of <40 years, female gender, single marital status, lower educational background, lack of previous experience with ED, perceived long waiting time, and first-degree relatives were the significant risk factors associated with high stress. Verbal aggression was the most common and frequent form of aggression. Noncritically ill patient attendants, no previous experience with EDs, graduates, middle age group, perceived long waiting time, and poor patient response to treatment were found to be risk factors for impending violence.

Conclusion:

Stress was exhibited in majority of caregivers. Further programs are needed to strengthen training for ED staff to identify early and impending violence and to develop coping mechanisms for well-being of both attendants and health-care professionals.

Development and Implementation of an Emergent Documentation Aggression Rating Tool: Quality Improvement

INTRODUCTION

Workplace violence is prevalent in the emergency department, putting patients and staff at risk for harm. An ED-specific standardized tool is needed to promote a consistent assessment process to strengthen documentation of escalating patient behaviors, give justification for de-escalating interventions, and reduce restraints. The purpose of this project was to design, implement, and evaluate feasibility of an ED-specific tool to help nurses proactively identify and intervene with patients' escalating behaviors, capture better documentation of aggressive/violent patient events, and reduce restraint usage.

METHODS

A quality improvement design was used. The Emergent Documentation Aggression Rating Tool was constructed by combining evidence-based behavioral cues for potential aggression/violence with observed behaviors and successfully implemented interventions in patients. Nurses were trained on how to use the tool to rate patients' behaviors and take necessary action. Chart data were collected from August 2018 to December 2019 at a Midwestern Suburban Hospital Emergency Department. Chart audits and just-in-time education were conducted after implementation. Survey data were collected to evaluate nurses' perception of the tool's usefulness.

RESULTS

Use of the novel Emergent Documentation Aggression Rating Tool increased over time (67.36% in Quarter 3 2018 to 97.55% in Quarter 4 2019). After Emergent Documentation Aggression Rating Tool implementation, visual inspection of the time series indicated a decrease in percent restraints, and there was an overall increase in documented escalations de-escalations over time. The patients that escalated most frequently had diagnoses of alcohol use, suicidal ideations, pain-related complaints, or mental health issues.

CONCLUSION

The Emergent Documentation Aggression Rating Tool was feasible for emergency nurses to proactively identify and intervene with patients at risk for aggression/violence.

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation)

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

Engaging with nurses to develop an occupational violence risk assessment tool for use in emergency departments: A participatory action research inquiry

BACKGROUND

Early detection of occupational violence (OV) risk factors could facilitate timely and appropriate management of patients in the emergency department. For this purpose, an OV risk assessment could be useful and best initiated at triage.

AIMS

To understand the need for and determine potential utility and desirable components of an OV risk assessment tool; and to determine specific challenges to its implementation if appropriate.

METHODS

A participatory action research was conducted. Data were collected through focus groups and semi-structured interviews. Thematic analysis was done inductively and collaboratively using Braun and Clarke's technique.

FINDINGS

Six themes were identified from triage nurses (N = 15) pertaining to: i) OV risk assessment; ii) communication of OV risk; iii) clinical implications of risk assessment; iv) tool attributes; v) future implementation challenges; vi) unintended consequences.

CONCLUSION

The development of an OV risk assessment tool is supported, but with very specific attributes. Findings herein also have implications on the implementation and evaluation of this tool in emergency settings.

[Experiences of aggression and violence against ophthalmologists]

BACKGROUND

The media have reported an increased willingness of patients and relatives to use violence against medical personnel. So far a few studies have been carried out on this topic and the data situation is correspondingly weak. Ophthalmologists in particular have close contact with patients at the slit lamp and are often alone with patients.

METHODS

A questionnaire was developed based on the perception of prevalence of aggression scale (POPAS) questionnaire and the survey on aggression and violence among general practitioners. In autumn 2018, all members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists (BVA) received an invitation by e‑mail to complete the questionnaire online.

RESULTS

Of the 9411 ophthalmologists contacted a total of 1508 (age 49 ± 12 years) took part in the survey (16%). Of the respondents 806 (53.7%) were female and 1139 (75.5%) participants worked in practices. A total of 1264 (83.3%) ophthalmologists had experienced aggression/violence in their work, 986 (65%) respondents had already experienced verbal assaults without threats, 363 (24.1%) doctors reported experiences with threats of physical violence and 30 (2%) participants had received medical treatment for severe physical violence. Sexual intimidation/harassment was affirmed by 322 (21.4%) of respondents, of whom 243 (75.5%) were female and 533 (47.9%) doctors felt that aggressive/violent behavior had increased in the last 5 years.

CONCLUSION

The high number of participants indicates the high relevance of the topic. The survey produced astonishing results, which should lead to further discussion and action to improve the safety of employees.

The validity and utility of violence risk assessment tools to predict patient violence in acute care settings: An integrative literature review

To examine risk assessment tools to predict patient violence in acute care settings. An integrative review of the literature. Five electronic databases - CINAHL Plus, MEDLINE, OVID, PsycINFO, and Web of Science were searched between 2000 and 2018. The reference list of articles was also inspected manually. The PICOS framework was used to refine the inclusion and exclusion of the literature, and the PRISMA statement guided the search strategy to systematically present findings. Forty-one studies were retained for review. Three studies developed or tested tools to measure patient violence in general acute care settings, and two described the primary and secondary development of tools in emergency departments. The remaining studies reported on risk assessment tools that were developed or tested in psychiatric inpatient settings. In total, 16 violence risk assessment tools were identified. Thirteen of them were developed to assess the risk of violence in psychiatric patients. Two of them were found to be accurate and reliable to predict violence in acute psychiatric facilities and have practical utility for general acute care settings. Two assessment tools were developed and administered in general acute care, and one was developed to predict patient violence in emergency departments. There is no single, user-friendly, standardized evidence-based tool available for predicting violence in general acute care hospitals. Some were found to be accurate in assessing violence in psychiatric inpatients and have potential for use in general acute care, require further testing to assess their validity and reliability.

Brief interventions to de-escalate disturbances in emergency departments

This study aimed to systematically review evidence to assess the efficacy of non-pharmacological brief interventions in the emergency department to reduce the incidence, severity and impact of acute behavioural disturbances. The literature search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 18 articles were identified as meeting the inclusion criteria and read in full. Following a full read and a consensus discussion, it was subsequently considered the studies chosen had not met the inclusion criteria. Research into the use of non-pharmacological brief interventions in the management of acute behavioural disturbance in the emergency department is warranted given the absence of evidence found by this systematic review.

Identification of processes that mediate the impact of workplace violence on emergency department healthcare workers in the USA: results from a qualitative study

OBJECTIVES

Violence towards emergency department healthcare workers is pervasive and directly linked to provider wellness, productivity and job satisfaction. This qualitative study aimed to identify the cognitive and behavioural processes impacted by workplace violence to further understand why workplace violence has a variable impact on individual healthcare workers.

DESIGN

Qualitative interview study using a phenomenological approach to initial content analysis and secondary thematic analysis.

SETTING

Three different emergency departments.

PARTICIPANTS

We recruited 23 emergency department healthcare workers who experienced a workplace violence event to participate in an interview conducted within 24 hours of the event. Participants included nurses (n=9; 39%), medical assistants (n=5; 22%), security guards (n=5; 22%), attending physicians (n=2; 9%), advanced practitioners (n=1; 4%) and social workers (n=1; 4%).

RESULTS

Five themes emerged from the data. The first two supported existing reports that workplace violence in healthcare is pervasive and contributes to burn-out in healthcare. Three novel themes emerged from the data related to the objectives of this study: (1) variability in primary cognitive appraisals of workplace violence, (2) variability in secondary cognitive appraisals of workplace violence and (3) reported use of both avoidant and approach coping mechanisms.

CONCLUSION

Healthcare workers identified workplace violence as pervasive. Variability in reported cognitive appraisal and coping strategies may partially explain why workplace violence negatively impacts some healthcare workers more than others. These cognitive and behavioural processes could serve as targets for decreasing the negative effect of workplace violence, thereby improving healthcare worker well-being. Further research is needed to develop interventions that mitigate the negative impact of workplace violence.

Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles

Context:

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods.

Evidence acquisition:

This review was conducted by searching “Violence,” “Aggression,” and “workplace violence” keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review.

Results:

Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint.

Conclusion:

In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Aggressive behaviour risk assessment tool for long-term care (ABRAT-L): Validation study

This prospective cohort study was conducted to validate the usefulness of the Aggressive Behaviour Risk Assessment Tool for Long-Term Care (ABRAT-L) in predicting aggressive events. A total of 615 newly admitted residents at 22 long-term care homes in Canada were included. The risk of aggression was assessed using the six-item ABRAT-L within 24 hours of admission, and incident reports of aggressive events occurring within 30 days of admission were collected. Forty-seven residents out of 615 had one or more aggressive events (7.6%). The receiver operating characteristics analysis of ABRAT-L showed a good discriminant ability at the previously recommended cut-off score of 4, with satisfactory sensitivity and specificity. The usefulness of ABRAT-L in identifying potentially aggressive residents at the time of admission was confirmed. This validation study supports the adoption of a proactive risk assessment tool, ABRAT-L, as a part of routine admission assessments at long-term care homes.

Staying safe: Responding to violence against healthcare staff

This article takes a look at the incidence of verbal or physical violence nurses face on a daily basis and examines the importance of preparedness in handling potentially violent situations in the workplace.

Characterization of the vaginal microbiome during cytolytic vaginosis using high-throughput sequencing

Background

Cytolytic vaginosis (CV) is a common disease that results in pruritus, dyspareunia, and vulvar dysuria. However, the pathological mechanisms of the disease are still unclear. Compared to traditional methods, high‐throughput sequencing can obtain more accurate qualitative and quantitative information on the microbiome.

Methods

We collected 75 samples from 32 healthy women (average age 44 ± 8) and 43 patients with CV (average age 38 ± 8). We used high‐throughput sequencing of the 16S rRNA V3‐V4 region to characterize and compare the vaginal microbiota of patients with CV and healthy women and to identify potential biomarkers for CV.

Results

The vaginal pH of patients with CV was ≤3.8, and the vaginal concentration of H₂O₂ was ≥2 μmol/L. Colony densities of Lactobacillus spp. in patients with CV ranged from +++ (5‐30) to ++++ (>30) and were significantly higher than those in healthy women. High‐throughput sequencing showed that Lactobacillus was the most prominent genus both in patients with CV and in healthy women, with abundances of 83.8% and 97.2%, respectively (P < 0.001). Lactobacillus crispatus was more abundant in patients with CV, whereas Lactobacillus sp. L‐YJ was more abundant in healthy women, with area under the curve (AUC) values of 0.9375 and 0.8379, respectively.

Conclusion

The abundance of Lactobacillus spp. in CV patients was significantly different from that of healthy patients. Two suitable biomarkers, L. crispatus and Lactobacillus sp. L‐YJ, were identified. These results will be useful for the identification of women at risk of serious illness before they develop obvious symptoms.

[Usefulness of Korean Version of Behavioral Cue Checklist for Predicting of Patient Violence in Emergency Departments]

PURPOSE

This study aimed to evaluate the usefulness of a behavioral cue checklist (BCC) containing 17 items developed by Wilkes et al. (2010) for identifying potentially violent patients in emergency departments.

METHODS

This was a prospective observational study to evaluate the usefulness of the Korean version of a BCC (K-BCC) as an assessment tool for predicting patient violence in emergency departments, and was conducted over 4 weeks in a regional emergency medical center located in B City. A total of 1,324 patients were finally analyzed.

RESULTS

Logistic regression analysis was performed to investigate whether each item of the K-BCC predicts violence, and a parsimonious set of 8 statistically significant items was selected for the tool. Receiver operating characteristic analysis of the BCC showed that the area under the curve was .97 (95% confidence interval: .94~1.0). The sensitivity, specificity, positive predictive value, and negative predictive value at the cut-off score of 2 were 75.6%, 98.9%, 68.2%, and 99.2%, respectively.

CONCLUSION

The K-BCC was found to be useful in predicting patient violence toward emergency department staff. This tool is simple, and fast to use and can play a significantly role identifying potentially violent patients. Owing to this advance identification, this tool can be helpful in preventing the potential for violence from manifesting as violent behaviors.

Preventing and managing workplace violence against healthcare workers in Emergency Departments

Background and aim: Healthcare workers (HCWs) employed in Emergency Departments (EDs) frequently face with patients becoming violent because of long wait or diseases or under the influence of alcohol or drugs. Globally, workplace violence (WPV) in EDs is a major challenge to safety for HCWs, involving significant consequences to the victims, patients, and healthcare organizations. We reviewed the current literature with the aim to explore the topics focused on and to detect new evidences about approaching the issue of WPV toward HCWs in EDs. Methods: A search for articles regarding WPV toward HCWs employed in EDs and published from January 2007 through December 2017 was performed; using predetermined criteria for inclusion, selected articles were reviewed and qualitatively assessed for the aims of the review. Results: We found 60 papers which matched our inclusion criteria; the topics, discussed in order of frequency from highest to lowest, were: “Risk Assessment”, “Occurrence Rates”, “Risk Management”, and “Physical/non Physical Consequences”. Dementia, schizophrenia, anxiety, acute stress reaction, suicidal ideation, and alcohol and drug intoxication were found as predictors of physical violence perpetrated by patients against HCWs. Conclusion: A strategic way to the effective management of WPV should prioritize training courses focused on: constructing HCW-patient relationship, improving the workers’ communication skills, accurate reporting of each violent incident, and improving the labor context through management commitment and employee involvement in WPV prevention programs. A special effort is required in implementing workplace design effective in minimizing stressful conditions in waiting rooms which turned out to be the most frequent site of assaults.

Safety, risk, and aggression: Health professionals' experiences of caring for people affected by methamphetamine when presenting for emergency care

The crystalline form of methamphetamine, commonly known as crystal meth (crystal methamphetamine) or ICE, is a highly-addictive and powerful stimulant. Users of crystal meth often require emergency care, and are associated with a substantial burden of care by emergency care providers. The aim of the present qualitative study was to explore health professionals' experiences of providing care for patients affected by ICE who presented to the emergency department (ED). Nine semistructured interviews were conducted. The major theme, 'staying safe', was revealed, in which participants described their experiences of being exposed to potentially unsafe situations, and their responses to challenging behaviours, including aggression. The findings highlight the need for ED staff to understand the nature of ICE use and its adverse impact on the mental and physical health of users. Furthermore, it is clear that establishing and maintaining safety in the emergency care setting is of utmost importance, and should be a priority for health-care managers.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace

Introduction

Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting.

Methods

We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center.

Results

We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different.

Conclusion

Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.

Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage)

INTRODUCTION

Workplace violence is one of the most significant and hazardous issues faced by nurses globally. It is a potentially life-threatening and life-affecting workplace hazard often downplayed as just "part of the job" for nurses.

METHODS

A cross-sectional design was used and data were collected using a purpose developed survey tool. Surveys were distributed to all members of the College of Emergency Nurses' Australasia (CENA) in 2010 and 537 eligible responses were received (RR=51%).

RESULTS

Patient-related violence was reported by 87% of nurses in the last six months. Precipitants and antecedents for episodes of violence were reported in three categories: nurse-related; patient-related and emergency-department specific factors. Triaging was identified as the highest risk nursing activity, and the triage area identified as the highest risk location in the department. Patients who presented with alcohol intoxication, substance misuse or mental health issues were identified as the groups at greatest risk for potential violence.

DISCUSSION

Patient-related violence was reported by the majority of emergency nurses surveyed. A number of precipitants and antecedents perceived to be risk factors by participants were found to be significant and are unavoidable in the working lives of emergency department nurses.

Aggressive Behaviour Risk Assessment Tool for newly admitted residents of long-term care homes

AIM

The aim of this study was to revise the 10-item Aggressive Behaviour Risk Assessment Tool for predicting aggressive events among residents newly admitted to long-term care homes.

BACKGROUND

The original tool had acceptable sensitivity and specificity for identifying potentially aggressive patients in acute care medical-surgical units, but its usefulness in long-term care homes is unknown.

DESIGN

A retrospective cohort study design was used.

METHODS

All residents admitted to 25 long-term care homes in western Canada were assessed for the risk of aggression using the original tool within 24 hours of admission from January 2014 - December 2014 (n = 724). Incident reports of aggressive events occurring within 30 days of admission were collected. Multiple logistic regression and receiver operating characteristics analyses were performed.

RESULTS

Fifty-three residents of 724 exhibited aggressive behaviours. The demographic variable of age less than 85 years was found to be a positive predictor of aggressive events in multivariate logistic regression model and was added to the tool. The revised six-item Aggressive Behaviour Risk Assessment Tool for Long-Term Care consists of one new item, age less than 85 years and five items from the original tool: History of physical aggression, physically aggressive/threatening, anxiety, confusion/cognitive impairment and threatening to leave. The receiver operating characteristics of the revised tool with weighted scoring showed a good discriminant ability with satisfactory sensitivity and specificity at the recommended cut-off score of 4.

CONCLUSION

The revised six-item tool may be useful in identifying potentially aggressive residents newly admitted to long-term care homes.

Security Implications of Physical Design Attributes in the Emergency Department

BACKGROUND

Security, a subset of safety, is equally important in the efficient delivery of patient care. The emergency department (ED) is susceptible to violence creating concerns for the safety and security of patients, staff, and visitors and for the safe and efficient delivery of care. Although there is an implicit and growing recognition of the role of the physical environment, interventions typically have been at the microlevel.

OBJECTIVE

The objective of this study was to identify physical design attributes that potentially influence safety and efficiency of ED operations.

METHOD

An exploratory, qualitative research design was adopted to examine the efficiency and safety correlates of ED physical design attributes. The study comprised a multimeasure approach involving multidisciplinary gaming, semistructured interviews, and touring interviews of frontline staff in four EDs at three hospital systems across three states.

RESULTS

Five macro physical design attributes (issues that need to be addressed at the design stage and expensive to rectify once built) emerged from the data as factors substantially associated with security issues. They are design issues pertaining to (a) the entry zone, (b) traffic management, (c) patient room clustering, (d) centralization versus decentralization, and (e) provisions for special populations.

CONCLUSION

Data from this study suggest that ED security concerns are generally associated with three sources: (a) gang-related violence, (b) dissatisfied patients, and (c) behavioral health patients. Study data show that physical design has an important role in addressing the above-mentioned concerns. Implications for ED design are outlined in the article.

Feasibility and need for violence risk screening at triage: an exploration of clinical processes and public perceptions in one Australian emergency department

BACKGROUND

Research on patient aggression in hospital emergency departments supports the development of a systematic process for identifying individuals at risk of becoming violent. The feasibility and community acceptance of this approach is unknown. In this study, we determine the feasibility and explore the need for a violence risk screening process in one Australian emergency department.

METHOD

We used a descriptive exploratory design that involved semistructured interviews and observations of practice. The setting was an adult tertiary referral hospital and major trauma centre located in Melbourne, Australia. A convenience sample of nine triage nurses were observed assessing patients to explore how risk screening was undertaken in practice. Semistructured interviews were conducted with emergency department (ED) service users (N=19) to explore community perspectives on the process of violence risk screening.

RESULTS

Observations of practice revealed that nurses used observed and reported information to screen for potential risk of violence rather than employing a direct questioning approach. Interviews with community members in the emergency department waiting room highlighted a public expectation that nurses screen and accurately identify patients at risk of violence on arrival to the ED.

CONCLUSIONS

Consistent with local prevalence data, public expectations of emergency care supported the need to adopt a uniform approach to identifying people at risk of becoming violent on arrival to hospital. Observations of triage nurses interactions with patients revealed that the existing violence risk screening approach was not being consistently used by triage nurses. An integrated approach to determining violence risk during triage assessment is recommended.

Determining the frequency, kinds and cues of violence displayed by patients in an acute older person ward environment: findings from an observational study

BACKGROUND

Workplace violence is one of the most complex and significant occupational hazards experienced by nurses in healthcare settings. Verbal abuse and physical violence are particularly prevalent in older person assessment wards, owing to the prevalence of illnesses involving cognitive dysfunction; the high frequency and nature of contact with staff; and the frustration caused by high levels of disability.

AIM

To determine the frequency, kinds and cues of violence displayed by patients towards nurses in an acute older person assessment ward environment using a structured observational tool - the Violence Assessment Tool (VAT).

DESIGN

Observational study.

METHOD

Non-participant structured observations of behavioural cues for violence towards nurses in an acute older person hospital ward were gathered and analysed.

RESULTS

One hundred and twelve hours of observations were undertaken, resulting in 95 behavioural cues for violence in 19 patients. Four of these patients subsequently escalated to physical violence. Pacing around the bed was the only commonality in the behavioural cues of patients who became violent. All patients who became violent had previously demonstrated showing.

CONCLUSIONS

To date, the assessment of potentially violent older patients has not been adequately addressed. The VAT may be one way of addressing this challenge through early identification of the more subtle behavioural cues that could indicate potential for violence. Further research on the VAT using a larger data set could determine its predictability for physically violent acts displayed by older people.

Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (Type II) on hospital workers: a review of the literature and existing occupational injury data

PROBLEM

Non-fatal type II violence experienced by hospital workers (patient/visitor-on-worker violence) is not well described.

METHODS

Hospital administration data (2004-2009) were examined for purposes of calculating rates of type II violent events experienced by workers. We also conducted a review of the hospital-based literature (2000-2010) and summarized findings associated with type II violence.

RESULTS

484 physical assaults were identified in the data, with a rate of 1.75 events/100 full-time equivalents. Only few details about events were captured, while non-physical events were not captured. The literature yielded 17 studies, with a range proportion of verbal abuse (22%-90%), physical threats (12%-64%) and assaults (2%-32%) reported. The literature lacked rigorous methods for examining incidence and circumstances surrounding events or rates of events over time.

DISCUSSION

For purposes of examining the impact of type II violence on worker safety, satisfaction and retention, rigorous surveillance efforts by hospital employers and researchers are warranted.

Mosaic of verbal abuse experienced by nurses in their everyday work

AIMS

To report observational data collected as part of a multi-phased study examining violence in the health sector. The findings presented detail the nature of verbal abuse experienced by nurses during their everyday interactions with patient, their families, or companions.

BACKGROUND

Nurses have unacceptably high levels of exposure to violence, which commonly includes verbal abuse. However, relatively little is known about the nature of verbal abuse against nurses.

DESIGN

Observational design.

METHODS

During 2010, 1150 hours of observation resulted in data on 220 patients displaying cues for physical violence and 210 qualitative observational notes. These observational notes constitute the data for this paper and reveal the nature of verbal abuse experienced by nurses in their everyday work.

RESULTS

A mosaic of abuse was revealed through three major categories: a discourse of gendered verbal abuse that was largely sexual; insults, ridicule, and unreasonable demands; and hostility, threats, and menacing language.

CONCLUSIONS

For the nurses observed in this study, everyday nursing practice occurred in a backdrop of verbal abuse and hostility, which had a strong theme of gendered and sexualized overtones. We recommend that interventions that target verbal abuse should address the gendered and sexualized nature of the abuse experienced by nurses.

When patients are impatient: the communication strategies utilized by emergency department employees to manage patients frustrated by wait times

Studies have documented the frustrations patients experience during long wait times in emergency departments (EDs), but considerably less research has sought to understand ED staff responses to these frustrations. In-depth interviews were conducted with 18 ED social workers, patient navigators, and medical staff members at a large urban hospital regarding their experiences and interpersonal strategies for dealing with frustrated patients. Staff indicated that patients often attribute delays to neglect and do not understand why their health problem is not prioritized. They voiced several strategies for addressing wait time frustrations, including expressing empathy for patients, making patients feel occupied and wait times seem more productive, and educating patients about when health issues should be treated through primary care. All staff members recognized the need for engaging in empathic communication with frustrated patients, but social workers and patient navigators were able to dedicate more time to these types of interactions.

Violence in the emergency department: an ethnographic study (part II)

Violence in the emergency department (ED) is a significant and complex problem worldwide. This is a part II of a 2-part series on an ethnographic study. The study which aimed at exploring the cultural aspects of violence was carried out at a major metropolitan ED for 3 months. This paper presents the findings and discussions of the study. One hundred and three violent incident questionnaires were completed. A total of 242.5h of observation and 34 (33%) interviews with nurses were conducted. From the data analysis, three critical cultural themes (i.e. 'problems and solutions', 'requests and demands' and 'them and us') were identified. The study indicated that the cultural meanings of violence were complex and highly subjective. Factors such as environment, conflicting messages regarding waiting time, and the nurse-patient/relative behaviours and the resulting reciprocal relationships were critical. Nurses' efforts to establish rapport with patients was crucial and needed to occur early. There was usually a 'turning point' that provided an opportunity for the nurse to avoid violence. While violence is a complex issue with many paradoxes, the study indicates that effective interpersonal empathetic communication has a significant role in reducing violence in the ED.

Expectations of Care, Perceived Safety, and Anxiety following Acute Behavioural Disturbance in the Emergency Department

Objective. We explored perspectives of emergency department users (patients and visitors) regarding the management of acute behavioural disturbances in the emergency department and whether these disturbances influenced their levels of anxiety. Methods. Emergency department patients and visitors were surveyed using the State-Trait Anxiety Inventory, and a purpose-designed questionnaire and semistructured interview. The main outcome measures were themes that emerged from the questionnaires, the interviews, and scores from the state component of the State-Trait Anxiety Inventory. Results. 70 participants were recruited. Users of the emergency department preferred behaviourally disturbed people be managed in a separate area from the general emergency department population so that the disturbance was inaudible (n = 32) and out of view (n = 40). The state anxiety levels of those that witnessed an acute behavioural disturbance were within the normal range and did not differ to that of ED patients that were not present during such a disturbance (median, control = 37, Code Grey = 33). Conclusions. Behavioural disturbances in the emergency department do not provoke anxiety in other users. However, there is a preference that such disturbances be managed out of visual and audible range. Innovative design features may be required to achieve this.