June 28, 2016

Implementing Tough Safety Policies in the ED

Keeping nurses and ED staff safe


Caring for patients often means seeing people at their worst, when they feel vulnerable, scared and frustrated – and unfortunately this can lead to violence. According to a 2014 survey conducted by nurses at Inova Loudoun Hospital in Leesburg, Virginia, more than 75 percent of nurses reported having experienced violence by patients and visitors in the previous year. (Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors, Journal of Emergency Nursing, 2014; 40(3):218–228.)


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Violence has increased in hospitals and in EDs in particular, within the last decade. In 2010, the Joint Commission issued a Sentinel Event Alert outlining the problem and listing actions to help healthcare organizations combat this trend.

“Our patients are changing,” says 31-year nurse veteran James Bryant, MSN, RN, CEN, CCRN, NEA-BC, Cleveland Clinic’s Associate Chief Nursing Officer of Emergency Services. He cites the proliferation of drug and alcohol addiction and the possession of weapons as the biggest reasons for violence today.

Christian Burchill, PhD, RN, CEN, a Cleveland Clinic nurse researcher who studies workplace violence, agrees with Bryant’s assertion about drugs and violence as key factors to the increase in violence, but he says the problem is even more complex. Two additional factors are the increase in the number of people with health insurance through the Affordable Care Act and the increased need for mental healthcare services.

“Many healthcare professionals think patient violence is just part of the job, which leads to underreporting of events,” says Dr. Burchill, who himself was assaulted by a patient when he worked as an ED nurse in Philadelphia.

“One of the key findings from my research is that ED nurses feel safest in knowing that their manager and administrators have their back,” he says. “Nurses need to feel supported by their leaders.” That means nurse and hospital leaders must encourage caregivers to report violent incidents and then support the staff in their actions following an event.

Development of an enterprise workplace violence prevention program

“Cleveland Clinic already had many safety protocols in place, but to further support nursing staff a more robust and comprehensive policy of mitigating harm was implemented,” Bryant says. A new policy was created “to establish an evidence-based standard of assessment and intervention to care for ED patients at risk for harming themselves or others.”

Among other components, the policy allows nurses to take a patient’s cell phone and clothing and put them in a gown or scrubs to establish the patient-caregiver roles up front. Nurses also have the option to put patients in a “safe room” where they can’t harm themselves or others.


“We took a hard look at the hospitals in our system that have (psychiatric) behavioral units and added safe rooms that are free of equipment, structures or supplies that could be used as weapons,” Bryant explains.

He added, “We have given staff additional safety training, and we’ve written protocols for excitable patients – not just patients under the influence of drugs, but people who are stressed, have a lot of anxiety or have an undiagnosed mental illness.”

Nurses in several Cleveland Clinic hospitals also wear badges with a tracking device and alert button that allow them to instantly communicate with other staff members. The badge makes it easy to call for help in a violent situation.

For several years, staff members received training from the NAPPI (Non-Abusive Psychological and Physical Intervention) and ALICE (Alert, Lockdown, Inform, Counter, and Evacuate) programs. NAPPI, which is nearly 40 years old, was created to teach healthcare workers, among others, to assess, prevent and even physically manage violence. ALICE training helps teach staff what to do in an active shooter situation.

Cleveland Clinic police force works to make EDs safer

“Emergency Departments are the riskiest locations in any healthcare environment,” says Tom Lynch, Senior Director of Protective Services for Cleveland Clinic. “And they are riskier at night when they become the main entrance to the entire hospital.”

To make the physical environment safer, Cleveland Clinic police officers are assigned to the majority of the hospitals in the health system. They are available to respond to any situation in the ED. In many locations, community police officers also patrol the EDs to be close at hand.

“Police support has become a great abater of problems,” Lynch says. A visitor badging system has helped as well. Anyone wishing to enter the hospital to see a patient must present identification and be verified against the patient census.


Lynch says that metal detectors (magnetometers) virtually eliminate weapons in the ED. Cleveland Clinic’s main campus and Lutheran Hospital already have them in place at the entrances. The plan is to have metal detectors at all health system EDs by mid-2016. “Our caregivers in both hospitals are exposed to less risk,” he says.

Bryant says he feels safer now that so much focus has been put on protecting nurses and securing the ED environment.

Help after a violent incident

Today, the Cleveland Clinic Police Department employs a social worker and victim advocate, Ashley Withrow MSSA, LISW-S, who offers hospital staff support following a violent incident.

Withrow’s position is federally funded by the Victims of Crime Act. She provides immediate emotional support to victims and helps them connect with community resources for ongoing support. “A person who witnesses violence can experience crisis and trauma as well,” she says. “Going back to work after an incident can be challenging.” Withrow also provides support to employees experiencing domestic violence at home or abusive situations with co-workers.

“Historically, hospitals along with schools and places of worship were considered safe havens from violence,” says Lynch. “This paradigm has shifted, with a growing number of active shooter and violent events taking place in these locations. Today, Cleveland Clinic is doing everything it can to prevent a situation before it happens.”

National Support Resources

National healthcare and government agencies have taken measures to help healthcare workers faced with the threat of violence:

  • The Emergency Nurses Association completed several studies on workplace violence and offers an online violence prevention course for emergency nurses and healthcare workers.
  • The Centers for Disease Control and Prevention also created an online training course geared toward helping healthcare workers avoid violence.
  • The Occupational Safety and Health Administration published “Guidelines for Preventing Workplace Violence for Healthcare and Social Workers,” which is available on its website.
  • Many states (including Ohio where Cleveland Clinic is headquartered) have instituted or strengthened laws against assaulting healthcare workers.

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