Learning Objectives
By the end of this section, you will be able to:
- Discuss the risk assessment tools and recognize potential violence in an emergency department patient
- Identify the common health risks and risks of exposure encountered in the emergency department
- Identify strategies for stress management for nurses working in the emergency department
While violence can occur at any workplace, health-care workers and nurses are particularly at risk for acts of violence (Stafford et.al., 2022). A recent study of emergency department nurses concluded that 89.9 percent had experienced at least one form of workplace violence in the previous year (Li et al., 2019). According to the Emergency Nurses Association, 56 percent of emergency nurses indicated that they had been verbally assaulted, threatened with violence, or physically assaulted within the last three years (Emergency Nurses Association, 2024). To help with violence prevention, nurses must receive training to recognize potentially violent behaviors, use proper screening tools, and employ de-escalation strategies.
Risk Assessment Tools and Strategies to Mitigate Violence
There are many available risk assessment tools that nurses can use to determine the likelihood of a patient becoming violent or dangerous (Kim et al., 2022). One commonly used evidence-based tool is the Triage Tool. The Triage Tool assesses a patient’s potential for becoming violent to others or harming themselves. This is a five-question survey where the patient answers questions about any history of violence and thoughts of hurting themselves or others. Another commonly utilized evidence-based tool is the Danger Assessment Tool, a reliable tool providing a baseline score to assess an emergent situation. The Danger Assessment Tool is a scale from one to five and helps nurses assess the risk of a potentially violent patient or a patient who is in a violent situation (National Institute for Occupational Safety and Health, 2020). The Danger Assessment Tool is easy to use and provides immediate results to help nurses determine the next course of action.
Link to Learning
The Centers for Disease Control and Prevention has several tools, such as the Danger Assessment Tool, that can be used to screen for violent behaviors.
It is imperative that nurses recognize potentially violent behaviors to prevent harm or violent acts. Potential behavioral cues include making inappropriate statements, verbal or written threats, and asking about hospital security. Some behaviors a nurse may witness include pacing, restlessness, and jaw clenching, all of which can indicate future potentially violent behavior (Cybersecurity & Infrastructure Security Agency, 2021). The Centers for Disease Control and Prevention (CDC) recommends utilizing the STAMP method, a quick, focused assessment for identifying signs of immediate potential violence (CDC, 2024a). STAMP stands for:
- (ST) staring/eye contact
- (T) tone and volume of voice
- (A) anxiety
- (M) mumbling
- (P) pacing.
Link to Learning
The Centers for Disease Control and Prevention has created an indicator for violent behavior tool called the STAMP method.
An important strategy for mitigating violence begins with understanding the factors that contribute to it. Workplace violence can come from patients, staff members, or visitors. Nurses should create a culture of respect and honesty and work to implement a zero-tolerance policy that prohibits any act of workplace violence. To report acts of violence, organizations should set up a framework for easy reporting to ensure accountability. Metrics need to be tracked and a complete risk analysis report created to evaluate strengths and opportunities for improvement. Nursing leadership should focus on providing violence prevention training, including recognition techniques, screening tools, and de-escalation strategies to all staff (American Organization for Nursing Leadership, 2022).
Link to Learning
The Joint Commission outlines steps to use when there is an active shooter present in its Quick Safety Guide.
If a violent situation does occur, there are many strategies nurses can utilize to de-escalate the scenario. One effective strategy, according to The Joint Commission (2019). is verbal de-escalation, a method that involves the following:
- Use clear, calm, and nonconfrontational communication.
- Ensure you are not using medical jargon.
- When a patient expresses concerns, be supportive.
- Respond in an appropriate tone and offer explanations.
- Use nonthreatening body language, such as avoiding crossing arms.
- Set clear expectations and limits with patients upfront.
Nurses can implement other safety interventions to protect themselves and others against violence. They should always be aware of their surroundings, have a clear exit path from the room, and keep their back towards the door and not the patient. If a violent situation arises, nurses should know how to call for help and where a safe room is located. To promote a calming environment in the patient’s room, minimize lighting and noise as much as possible. Nurses need to dress for safety by always wearing their name badges and by not carrying items that can become weapons like keys, lanyards, or jewelry (Occupational Safety and Health Administration, 2016).
Common Health Risk Exposure
According to the Centers for Disease Control and Prevention (2024), there are over 22 million health-care workers in the United States. The health-care industry poses its own health risks, where nurses can be exposed to a variety of potential hazards, including diseases and workplace injuries. As a nurse, it’s important to understand these hazards and learn ways to avoid them. Due to the fast-paced environment of the ED and because ED nurses are oftentimes the first line of patient care, they are particularly at risk for exposure.
Exposure risks can occur anytime during patient care, but there is an increased risk in the emergency department because ED nurses often encounter a patient before a diagnosis has been made. It is uncommon for a patient’s contagious illness to not be identified for 24 to 48 hours after they arrive at the emergency department (Liang et al., 2018). In this period, ED nurses could potentially be exposed to illnesses such as viral meningitis, tuberculosis, COVID-19, and hepatitis. Thus, it is important for nurses to use infection control prevention techniques with every patient encounter. For instance, they must wear personal protective equipment (PPE), which includes gloves, masks, gowns, and face shields, during all encounters with patients with a suspected illness (CDC, 2024b).
Clinical Safety and Procedures (QSEN)
Nursing Interventions: Safety
When caring for any patient, nurses must wear the proper personal protective equipment (PPE) to prevent disease and bloodborne pathogen transmission. Never enter a patient’s room without wearing the PPE that is appropriate for the patient’s confirmed diagnosis, even in an emergency. If a patient is placed on precautions, ensure that there is a sign outside of their room and document this in their chart. Patients can be on multiple precautions, such as contact and airborne, so pay attention before entering a patient’s room. If unsure, follow the Centers for Disease Control and Prevention PPE guidelines.
Wearing the correct personal protective equipment is the best way to prevent exposure to chemicals, drugs, and communicable diseases. When utilizing liquid chemicals or handling medications that can splash, it is important to wear safety goggles, a mask, and a face shield to prevent the liquid from getting on the face, mouth, or eyes. However, there are still cases when exposure occurs, and nurses must understand the appropriate next steps. If any liquid enters the eyes, the nurse should not rub their eyes and should use the eye wash station immediately to flush the eyes. They should remove any contact lenses and seek additional medical attention.
Nursing Stress Management
Stress can be harmful to nurses and take a toll on their physical and mental well-being. Exposure to high-paced emergency situations over and over in particular can be stressful. It is important for nurses to be able to recognize and manage their own stress. Symptoms of stress can vary with each individual but can sometimes present as fatigue, exhaustion, or anxiety. Many health-care systems promote self-care activities like exercising, walking outside during breaks, meditation, and wellness routines within the workplace. Most health-care facilities have a culture of safety and offer employee assistance or workplace assistance programs. It is crucial for nurses to be able to self-reflect and assess themselves for signs of burnout. Talking about stress with fellow nurses or health-care professionals is another coping mechanism.
Link to Learning
Studies have found that mindfulness exercises can help reduce workplace stress or nurse burnout (Mayo Clinic, 2023). Explore mindfulness exercises to learn new techniques for how to incorporate mindfulness into your daily habits.