Disruptive Behavior from Patients and Families

Disruptive behavior escalating to violence is on a continuum. Reasons listed for its increase include crowding and long waits, sense of entitlement and a lack of societal controls, impaired patients and families (because of drugs, alcohol, or psychiatric conditions), and the patients’ anxiety-provoking situations. The role of the nurse is to set limits, effectively intervene early, and prevent the escalation to overt violence.

Prevention

According to the saying “an ounce of prevention is worth a pound of cure,” consistent practice of good patient relations can help prevent the patient and family frustration and irritation that can escalate to violent situations. Consider the following practices to establish trust and diffuse patient and family anxiety. This approach starts with triage setting the tone that should follow throughout the emergency department visit.

Violence

The Emergency Nurses Association’s (ENA) Emergency Department Violence Surveillance Study ⁶ and Gacki-Smith et al.⁷ found that 8% to 13% of emergency nurses are victims of physical violence every week and more than half of nurses who work in emergency departments have been physically assaulted on the job. No one indicator of potential violence or intervention is always effective, as patients or family members who become violent are a heterogeneous group.

Preventing Disruptive Behavior ^1,⁸

• Education in self-protective measures and de-escalating techniques

• Environmental controls such as:

• Controlled access doors

• Panic buttons and personal alarms

• Breakaway glass

• Report incidents to increase awareness

• Facilities with zero-tolerance programs have reported fewer violent occurrences.^6,⁷

• Identify high-risk patients and communicate this status (for instance, flagging or labeling the chart) to all involved health care professionals (e.g., “Wear goggles and gown when entering room; patient may spit.”).

A key predictor for current violence is how volatile a patient was in the past.⁸ Numerous scales exist to assess agitation in psychiatric patients. The Behavioral Activity Rating Scale (BARS) is a single-item, seven-point scale on agitated behavior. Schumacher et al.⁹ found BARS to be effective in identifying patients likely to need behavioral management during their emergency department stay. It was also suggested that a retrospective assessment of the behavior during the two hours prior to triage may be useful in identifying the currently calm patient who is at risk for becoming agitated during the emergency department visit.^9,¹⁰ Consider the following interventions to further prevent violence in the emergency department:

• Work practices can also help prevent danger to health care providers.

• Do not allow employees to work alone in a high-risk area.

• Always have an exit always available.

• Promote legislation on violence prevention. At least 10 states have legislation to strengthen or increase penalties for acts of workplace violence affecting nurses. In New York it is a felony to assault nurses who are on duty.⁸