June 21, 2007 A researcher who spent nearly 300 hours observing patients in an accident and emergency department has developed a method for identifying possible flashpoints, according to the latest Journal of Advanced Nursing.
Lauretta Luck, who carried out her research at the University of Western Sydney, Australia, points out that the STAMP violence assessment framework could have much wider applications than just hospitals.
STAMP - which stands for Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling and Pacing -- could be used by any professionals in potentially violent situations, such as law enforcement and social services.
The five-month research project was carried out in a 33-bedded emergency department in a public hospital serving a large rural, remote and metropolitan community in Australia.
It serves a multi-cultural community, which includes a high number of tourists and seasonal workers as well as a large metropolitan population.
Luck carried out 290 hours of observation and interviewed 20 Registered Nurses who agreed to take part in the study.
"During my time in the department there were 16 violent episodes aimed at staff taking part in the study" says Luck. "Because I was on the spot I was able to obtain feedback from them while the event was still fresh in their minds. They were able to tell me how they perceived the event and how they tried to handle it.
"Many more episodes were observed during the study period and I was keen to note how staff managed to defuse potentially violent episodes".
Key findings of the study, co-authored by Professor Debra Jackson (University of Western Sydney) and Professor Kim Usher (James Cook University), included:
- Staring was an important early indicator of potential violence. It was frequently noted in observational data and featured in nine of the 16 observed violent episodes. Nurses felt that staring was used to intimidate them into prompter action -- when they responded to this cue violence tended to be avoided.
- Lack of eye contact was also an issue and was associated with anger and passive resistance. However, it was noted that there can be cultural reasons for avoiding eye contact and it was important to differentiate these from other cases.
- Tone and volume of voice was associated with 13 of the 16 violent episodes. Most of the cases involved raised voices and yelling but two involved sarcastic and caustic replies.
- Many of the people who attended the emergency department were anxious and nurses were acutely aware of how stressful a visit to casualty could be. They normally intervened before anxiety reached dangerous levels, but one patient's anxiety did escalate into violence.
- However when anxiety levels were raised by the disorientation associated with conditions such as mental illness, substance misuse, dementia, epilepsy, diabetes and head injuries, this became a real issue. Nine violent episodes involved disorientated people with raised anxiety levels.
- Eleven of the 16 patients who became violent were observed mumbling, using slurred or incoherent speech or repeatedly asking the same question or making the same statements. Mumbling was perceived to be a sign of mounting frustration and a cue for violence.
- Pacing was seen as an indication of mounting agitation and was observed in nine of the 16 episodes analysed in detail. Other physical indicators included staggering, waving arms around or pulling away from healthcare staff trying to treat them.
"Violence towards healthcare staff and other professionals such as police officers and social security staff are an increasing part of daily life" says Luck.
"We feel that the STAMP system provides an easy to remember checklist that can be used in a wide range of potentially stressful situations to provide an initial indication of possible violence.
"Recognising the early signs that can lead to a violent episode can give staff the time they need to defuse the situation before it escalates.
"STAMP also provides a basic framework that can be developed by healthcare organisations and other agencies -- using research, observation and experience - to meet their own specific needs."
Reference: STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. Luck L, Jackson D and Usher K. Journal of Advanced Nursing. 59.1 pp 11-19.
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