When a 93-year-old woman was attacked by a psychiatric patient at San Francisco General Hospital, the facility’s policies, staffing, and security were called into question. Two hospital staff members had been wheeling a psychiatric patient from the emergency department (ED) to a psychiatric unit. After his restraints were removed, the patient jumped off the stretcher. He hid in the elderly patient’s room where he beat and choked the woman. Could the incident have been avoided?
For a number of reasons, acts of violence within health care facilities are becoming more frequent. The majority of them are perpetrated by patients, and much of the violence occurs in the emergency department (ED) where psychiatric patients make up one of every eight cases. According to the Agency for Healthcare Research and Quality, psychiatric disorders and substance abuse cases add up to almost 12 million ED visits a year.
In reality, psychiatric illness may increase the likelihood that some psychiatric patients will commit violent acts, but only a small portion of the violence in society can be ascribed to these patients. Still, personal biases and misperceptions about psychiatric disorders can cause some ED clinicians to have a low comfort level when it comes to caring for psychiatric patients. When you add in the unpredictability of this patient population coupled with a lack of training in dealing with psychiatric emergencies, inadequate staffing, and deficient facility guidelines, the result can be a disaster waiting to happen.
A Trained and Adequate Staff
To help protect both patients and staff from violent acts, adequate staffing is key. Staffing levels at San Francisco General were quickly called into question after the incident that occurred there. But it’s not only a matter of how many clinicians are on staff; what matters most is how well trained they are in recognizing and dealing with psychiatric emergencies. In one study, only about 40 percent of health care facilities surveyed provided emergency nurses with formal training in recognizing and managing aggression and violence. In a white paper published by the Emergency Nurses Association (ENA), ED nurses stated that they lacked the knowledge and nursing skills to care for these patients competently. Adequate education establishes a culture of safe practice and helps nurses properly manage psychiatric emergencies by instilling confidence to face these situations. To close the education gap, the ENA recommends increasing education related to caring for psychiatric patients in all nursing classes, including postgraduate courses, orientation, and continuing education programs. The ENA also recommends establishing a psychiatric nursing position—preferably an advanced practice nurse—within the ED.
Guidelines from The Joint Commission
Concern about the increasing incidence of violent acts within health care facilities prompted The Joint Commission to issue a sentinel alert a few years ago. The Joint Commission listed these factors as major contributors to increased violence:
• a leadership deficit in policy and procedure development and implementation
• insufficient staff education and competency assessment processes
• flawed assessment protocols
• communication failure among staff, patients, and family members
• lack of safety and security measures.
Among the recommendations listed in the sentinel alert is a warning to ensure sufficient security within the ED, which may include posting uniformed security officers and limiting or screening visitors, if needed. The Joint Commission also recommends:
• providing sufficient training to enable staff to respond appropriately to agitated and potentially violent patients and family members.
• working with members of the Security Department to assess the facility’s risk for violence, including a review of crime rates in the surrounding area and a survey of employee perceptions of risk.
• assessing the facility’s violence prevention policies and initiating improvements where needed.
• encouraging staff to report all violent incidents as well as perceived threats.
To access critical information that nurses need to safely care for patients experiencing psychiatric emergencies, look into Handling Psychiatric Emergencies, an e-learning course created by the Emergency Nurses Association in collaboration with members of the American Psychiatric Nurses Association and offered exclusively by Elsevier.