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Recognising the warning signs

Violence is a significant problem in many Australian health care settings, particularly emergency departments writes Linda Belardi.

Incidents of violence in triage have increased dramatically in the past 10 years, putting the safety of nursing staff and other patients at risk.

In response, an evidence-based clinical guideline has been established which outlines the risk factors that contribute to patient-initiated violence.

This guideline emphasises early identification and prevention rather than the management of violence, says Dr Natisha Sands, School of Nursing and Social Work senior lecturer and co-author of the guideline.

“Incidents of violence are very common particularly in acute care,” says Sands.

In a 2005 study conducted in Victoria, 2264 episodes of patient aggression occurred in four hospitals over a six--month period.

Elsewhere, a 2003 Tasmanian workplace study of over 2400 respondents identified that 64 per cent of nurses had experienced violence in the preceding four weeks.

“Violence in Australian healthcare settings is a significant problem requiring urgent attention,” says Sands.

Access to staff injury rates is also needed to ensure that occupational violence is dealt with in an appropriate and comprehensive way.

The release of this information needs to be coordinated by hospitals and the state governments to better identify the significance of the problem, says Sands.

Adding to the difficulty of data collection, is the common practice of not reporting violence incidents to the authorities.

Triage is the point of initial assessment, and enables nursing staff to make timely and more astute observations regarding patient behaviour, temperament and mood.

Using the guideline, nurses for the first time will be able to make highly informed decisions based on the recognition of warning signs detailed in the research.

This will give triage nurses, despite differing levels of expertise and experience, the confidence to act intelligently and in a decisive manner to prevent the escalation of violence, says Debra Cerasa, CEO of Royal College of Nursing, Australia.

Warning signs include verbal abuse, property damage, intrusion into personal space and a lack of cooperation.

Cerasa believes the guideline can also have a wider application for use by ambulance officers and police as they come into contact with individuals en route to hospital.

Risk factors for violence identified in the clinical guidelines include drug use, intoxication, history of violence, involuntary admission and delusional or paranoid thinking.

Although symptoms of mental illness may be risk factors for violence it is imperative nurses assess every patient and situation independently, says Sands.

Mental illness is a risk factor but it does not categorically predict an escalation to violence.

Assessment should be conducted on an individual basis and with sensitivity to avoid discriminating or marginalising vulnerable populations.

Emergency departments should have designated areas for conducting mental health assessments, the guidelines say. These areas should be co-located in the department.

Analysis of the risk factors also shows violent episodes are more likely to occur in crowded emergency rooms with long waiting times and where access to food or fluids is not available.

Patients identified as at higher risk for violence should be expedited for care or further assessment to prevent a violent incident, the guidelines recommend. It also suggest waiting room should be designed to be comfortable, including being quipped with a television, water, reading material, pay phones and written service information.

Younger Australians were also more likely to commit assaultive acts towards nursing staff compared to older patients, says the report released in conjunction with the Nurses Board of Victoria.

Contrary to popular assumption, females in healthcare settings are equally likely to be as violent as males particularly in acute and mental settings, says Sands.

Emergency departments require a system to alert staff about patients who pose a risk of violence.

Previous episodes of violence must be clearly documented as an alert in the medical records.

Recognition of patient risk factors, however needs to be complemented with an understanding of how staff behaviour and attitude can escalate or deescalate violence.

A clear finding of the systematic review was that patient violence rarely occurs in isolation from environmental or situational factors.

“Staff need to be mindful of how their own communication and behaviour impacts on violence,” says Sands.

Training in interview technique and an awareness of verbal and non-verbal communication is critical to effective prevention and is currently lacking in professional education, says Sands.

This new research needs to be incorporated as a training resource into undergraduate and post graduate nursing study as well as in professional development courses to better equip current and future nurses.

“All employees involved in direct service-user care including: doctors, nurses, dentists, allied health clinicians, service staff, security staff, supervisors and managers, should be included in staff training programs on managing violence and aggression,” says Sands.

Suggested screening questions to assist in assessing risk of violence at triage
1. Are you feeling ok? You seem a bit upset / angry at the moment.
2. Has something happened to you to make you feel this way?
3. Are you angry with anyone in particular?
4. Are you feeling like hurting this person?
5. Have you had thoughts about harming somebody?
6. Are you hearing voices telling you to harm somebody?
7. Have you ever hurt anyone before? What did you do?
8. Have you thought about how you would harm this person/these people?
9. When do you think you will act on these thoughts? (now/soon/future)
10. Do you have access to a weapon? Are you currently carrying a weapon?

Triage quick reference guide to risk factors for violence
• Appearance
• Uncooperative
• Angry
• Restless/agitated
• Currently intoxicated
• Behaviour
• Irritability
• Suspiciousness
• Property damage
• Conversation
• Thinking disturbances (thought disorder)
• Cognitive impairment (confusion, memory impairment)
• Delusions and hallucinations
• Homicidal thoughts
• Historical factors
• History of poly-substance use (illicit drugs)
• History of mental illness
• Previous diagnosis of anti-social personality disorder
• History of previous violence
• History of non-compliance with psychiatric medications
• History of alcohol abuse
• Environmental factors
• Population density (overcrowding)
• Staffing levels (low)
• Agitation levels on ward
• Waiting times (long)

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