It has been well documented that violence in our emergency departments is on the rise. Violence may be an actual assault, or it may manifest as aggressive, threatening or intimidating behavior.
It may come from the young man high on amphetamines or from the elderly female office worker.
A recent doctoral study completed in an Australian emergency department has developed a tool to help nurses predict potential for imminent violence directed toward staff by patients, family members or friends.
The study lead by Lauretta Luck has developed the acronym STAMP to help nurses categorize behavior sets that may point to a raised potential for violent behavior. I have added my own tool to help you defuse such a situation:
predicting violence with STAMP:
Stamp stands for staring, anxiety, mumbling, pacing.
Staring.
Staring was flagged as an important indicator of violence potential. That prolonged, intent, eye contact we have all experienced drilling into our backs as we go about our work, is a good predictor of increasing anger.
Anxiety.
The large number of emotional and physical stressors poking into the patient, can easily push them into a space where their behaviour is not in character or control.
Pain, loss of control, fear, alcohol or drugs can all induce an internal environment fueled by acute anxiety.
Indicators such as rapid speech, flushed face and hyperventilation were identified as predicting trouble ahead.
Mumbling.
When combined with other negative cues, mumbling or slurred and incoherent speech, especially when composed of aggressive, negative statements about the waiting times or service was a another good predictor.
Pacing.
Patients pacing around the waiting room or visitors pacing around patients beds was found to be indicative of mounting agitation.
Averting violence with AID:
So you have a pretty sure feeling that you and your patient are headed for conflict. What can you do? Well here is a tool I have come up with to minimize a situation of escalating violence.
AID stands for attend, inform, defence.
Attend.
One of the big generators of anxiety amongst patients and relatives is the feelings of *abandonment* they experience in the ED. Never mind if its the waiting room or a treatment area, patients often perceive that they are not receiving the level of attention they need.
By making an effort give attention to these patients we can often diminish these feelings. Even if we cannot meet all their perceived needs the very act of exercising authentic concern may be enough.
Though it may not be an easy task, try not to avoid a patient that is beginning to show signs of STAMP.
This simple act of attentiveness is often enough to de-escalate any anger and will often prove a far easier interaction than trying to manage a later situation of overt hostile aggression.
Inform.
Communication breakdown is another major cause of increasing aggression and contributes to feelings of abandonment and loss of control.
When patients are waiting to be seen, or waiting for test results, or waiting for a ward bed to become available, keep them informed of the expected delays and any changes to their position in the queue. Listen to any questions they may have.
Tell them what has happened what is happening and what will happen.
Many emergency departments now have hand-outs or notices explaining both the Triage process as well as preparing them to spend an extended time as they are treated in the ED. Make sure all your patients have an opportunity to access this information.
Patients should also be informed with signage and handouts that aggressive behavior will not be tolerated.
defence.
Stay safe.
Never forget that even though we may be able to predict an escalation of emotions that may lead to violence, it is much harder to predict how that violence might be expressed.
With a sustained exposure many ED nurses have desensitized themselves to low-level violence and have a much higher threshold of acceptance than most people. This is a bad thing.
The fact is we should be promoting a zero tolerance for aggressive or violent behavior, period.
Agitated or aggressive patients are enveloped in a no-go bubble that extends the distance of their outstretched arms. Never enter their bubble unless absolutely necessary.
Never let an aggressive person come between you and your exit strategy. Talk in a calm, even, clear voice. Make any instructions short and unambiguous. Avoid prolonged eye contact if patient is agitated or paranoid.
As I have advised before: When interacting with a potentially volatile patient it may be helpful to try and see your self as an observer of the scene. Imagine yourself stepping *outside* the situation looking on dispassionately. Watch how the relationship between the other you and the patient is evolving. Remember all this anger is not yours unless you choose to react to it.
Its not easy, but using this technique may help you from getting caught in the emotional wash from an abusive patient and feeding the escalation with your own reactions.
It should be part of your ongoing professional development to establish a set of skills and strategies for dealing with these sort of scenarios. Many hospitals offer courses on dealing with cases of professional assault which offer a combination of de-escalation strategies as well as simple self defence techniques.
Of course if all else fails….you can slap them.
Reference:
STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments.
Lauretta Luck, Debra Jackson, Kim Usher
Journal of Advanced Nursing
Vol. 59 Issue 1 Page 11 July 2007
If you need to enter the “bubble”, get in CLOSE if you can. They can grab you, but can’t accelerate a punch to do damage. Not enough room.
[...] that has been left unattended and uninformed for even a relatively short period of time. Use STAMP AID to manage the [...]
One good trick I learned working in homeless shelters is to look at the point between someone’s eyebrows– the other person feels as though you’re addressing them but not staring at them in challenge. Also turning your body slightly diagonally, like a partly opened door, so that you’re meeting them but also not challenging.
Oh, and if someone really is going to pop you– don’t back up! it escalates them like crazy!