3 ways to promote mental health and physical safety in the ER

An emergency room staff is accustomed to a certain level of unpredictability. As patients with mental and behavioral issues make more frequent visits to the ER, their unique needs can challenge the assumption of how much unpredictability is too much.

Without control of their mental faculties, anyone can inflict physical violence on those nearby, potentially creating the most dangerous situation an ER worker will face. 

Unfortunately, a rising behavioral health patient population isn’t the only reason more staff members are being threatened and assaulted. Many people are presenting to the ER scared, hurting and sometimes grieving. These factors can make a person more stressed and behave out of character, which leads to a general increase in hostile, aggressive, threatening and assaultive behaviors.

At the onset of the pandemic, healthcare workers were lauded as heroes. After two to three years of COVID-19 restrictions and mandatory vaccinations, people are coming into the hospital on edge and ready to snap at the simplest frustrations.

Different hospitals have different resources available to them when an ER altercation escalates. In that moment, the exact protocol from one facility to the next will differ based on who and what is available. In between ER shifts, staff can take a few basic measures to keep patients with behavioral issues safe, reduce the likelihood of physical conflict and promote their own mental health.

  1. Prepare the team

Train the ER staff to de-escalate patient and visitor behaviors that have the potential to become violent. Multiple training models are available to help anyone de-escalate emotionally volatile behaviors in the moment. Studies have demonstrated the effectiveness of de-escalation training in improving the confidence of clinicians coping with patient aggression.

Keep in mind that not all ER patients and visitors with extreme frustration and anger are suffering from a mental health condition. The American Journal of Nursing noted that 25 percent of nurses reported being assaulted by patients or the patient’s family members. Focused attention from any human, not merely an expert, might be all that is needed to de-escalate their feelings.

At the same time, prepare your ER team to set reasonable limits for not tolerating any aggressive, threatening, or assaultive behaviors. When answering the phone, for example, it’s appropriate to tell an aggressive caller “you are not going to yell at me. Call back when you’re calm. I’m going to hang up now.”

  1. Leverage available resources from inside and outside your facility

Adequately preparing for situations that might arise in the ER might mean asking for outside help. Some hospitals have K-9 units available to deploy whenever any patient becomes physically aggressive or defiant. Local law enforcement or independent security might also be needed to intervene at a moment’s notice. 

Also, consider asking any available personnel with backgrounds in intervention situations to be ready to help in advance. The staff chaplain, case manager, social worker, or clinical educator might represent a familiar face, and the ER staff will be more responsive to their suggestions in crisis situations.

  1. Be sensitive to the ER staff’s needs

Apart from any physical danger a patient or guest presents, the emotional wear and tear of threatening situations can take a toll on an ER staff’s mental health. Basic safety needs are universal. If your staff doesn’t feel safe coming to work, eventually they will not come back.

Be intentional about finding ways to help your team heal. CISM (critical incident stress management) is a heuristic for responding to extreme circumstances in a healthcare setting. A trained facilitator ― the staff chaplain, for example ― can lead a group discussion/listening session following an incident, giving the ER team space to discuss their emotions. These can be moving opportunities that allow people to come together, talk through their stress, and ultimately reduce burnout and promote cohesiveness within the group.

Take each altercation between staff and aggressive guests and patients as a learning opportunity. How your staff responds to each incident will be limited by your resources at hand, so take time to prevent the next incident from escalating any further.

Steve Polega, RN, MHA, has served University of Michigan Health-West since 2012 as its Executive Vice President and Chief Nursing Officer. Previously, he was UMH-W’s Director, Emergency and Urgent Care Services. Steve obtained his Masters in Health Administration from Ohio University. He is also a veteran of the U.S. Navy and has more than 23 years of experience managing and improving the delivery of healthcare in acute care, ambulatory, and inpatient settings.

Kate J. Veenstra, DNP, RN, CNL, CMSRN, ACM, NEA-BC is University of Michigan Health-West’s Associate Chief Nursing Officer and Vice President of Nursing. She previously served as the hospital’s Director of Case Management, Social Work and Spiritual Care, as well as a clinical nurse leader, clinical coordinator, nursing administration shift supervisor and registered nurse. She received her Doctor of Nursing Practice from the University of Michigan-Flint and is a longtime mentor to new nurses and nursing leaders.

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