Reducing the opportunity for violence in healthcare

By Sam Asselstine

Two things are required in order for a crime to be committed. First you need a perpetrator. There are many theories on why people perpetuate criminal activity. Some will argue the strain theory defined as “society putting pressure on individuals to achieve socially accepted goals though they lack the means, this leads to strain which may lead the individuals to commit crimes.” Other theories speak towards genetics, early childhood trauma and varying psychological explanations as to why crime occurs. An individual does not become a perpetrator until they have taken advantage of an opportunity to follow through and commit the crime.

Whatever our views are on why people commit crime the fact remains that crime occurs everywhere and hospitals are not immune to criminal activity. In fact, criminal activity in healthcare has been reported at alarming rates across North America for years. So, in keeping with the idea that criminal activity requires an equation, being (Perpetrator)+(Opportunity) = Crime the question is not how can we stop it, but rather how can we reduce the likely hood of it occurring in the first place.

Hospitals are designed to accommodate sick people as well as the well-meaning folks charged with the responsibility to care for them. People use hospitals, and we can’t control that. However we can reduce the opportunity of crime thereby limiting the perpetrators ability to commit it. Since violence in healthcare seems to be the predominant discussion taking place today, lets focus our attention in that direction. Here are some tips for my favourite people in the world – our nurses, on how to put their safety first while working in close proximity to the patients.

Scene survey

As a former first aid and CPR Instructor, I will never preach to the choir about the importance of first aid. There is one guiding principle learned in first aid and CPR that people routinely forget and it’s called the Scene survey. Nurses, take your time. Before engaging in a non-urgent situation, look around, look at the patient, consider by-standers. As you’re donning your non-latex gloves engage with the patient to briefly evaluate their level of crisis. If something gives you that feeling that something isn’t right – disengage, call another nurse or security for back-up and then enter again with support.

Alternative scheduling

Shake things up. My colleagues in other high-risk public service areas tell me that certain people will examine patterns of behavior if given enough time. Rotating nursing staff through a variety of different patients over an eight- hour period will disrupt this from happening. This is why security posts often rotate every couple of hours, a new set of eyes, a different perspective creates less complacent behaviour. Operationally, this could present challenges, but it’s a security principle that can be employed by anyone.


Lower the bed

Patient beds are often placed at a convenient height for clinicians to work, assess and care for the patient. This being said it’s also convenient for a patient to strike and kick from that location. In placing the bed at a lower height, the patient may not be able to strike your throat or face. This does not mean you won’t be assaulted, but you are substituting your head, face and neck, for other regions of the body that may be able to sustain less serious injury.


Non -verbal indicators of crisis

All too often people give themselves away with their non-verbal indicators of crisis. Due to the busy nature of nursing, sometimes sight is lost on the obvious cues. Pacing, clenched fists, staring, target glance, gross extremity movement – not an inclusive list but a good start. If a patient’s hands are not visible, ask to see them. If the patient refuses, disengage immediately and assemble your back up plan to safely engage the patient.


Room design

The number of weapons available within arms-reach within a typical emergency department set-up is  incredible. Perhaps it’s not realistic, but reconsidering the traditional design of a patient room may contribute to fewer incidents involving weapons. In placing medical devices and items out of arms-length fewer opportunities will exist. Ask your security director/manager about principles of CPTED – they would be happy to talk to you about it!

Nurses will always be required to work in very close proximity to patients, and most of these patients will accept and appreciate the care they receive while in hospital. However as violence continues to rear its head in our hospitals, it’s time to start thinking differently about our approach to violence, and through root cause analysis it starts with reducing the opportunity.

Sam Asselstine is the Manager of Security, Safety and Parking at The Royal Ottawa Mental Health Centre, and is Chapter Chair of IAHSS Ottawa/Carleton.