Pick one of the following topics and find a scholarly nursing journal article (published within the last five years) that discusses this nursing topic. The topics are

•  safety;
•  delegation;
•  prioritization; and
•  caring.After you find a scholarly nursing journal article using the Chamberlain library resources, you will complete a one-two page summary and reflection on the article. The paper should be completed in APA format and include the following.

•  A cover page (not included in the page number requirement)
•  A reference page (not included in the page number requirement)
•  One direct quote from one of your references, appropriately cited in the body of your paper
•  One indirect quote (or paraphrased reference) appropriately cited in the body of your paper
•  Citations and references in APA format
• www.Nursing2015.com January l Nursing2015 l 55
  THIS IS THE PAPER I CHOSE.MAMMAMAART/iSTOCK

  Safety Alert:IN 2012, 27,380 U.S. healthcareworkers were injured in nonfatalworkplace injuries. According to theBureau of Labor Statistics, healthcarefacilities with more than 1,000 employeeshave an average of 5.5 nonfatalinjuries annually.1 Between 2009 and2011, eight RNs were fatally injuredat work.2 (See Startling statistics.)Many nurses are routinely exposedto violent behavior such as shouting,cursing, spitting, biting, pulling,pushing, scratching, threats to themselvesand their loved ones, and actualphysical assaults with hands, fists,weapons, or objects within the assailant’sreach.3 All too often, nurses failto report these episodes of violencebecause they erroneously consider itto be “part of the job.” Consequently,managers and administrators may beunaware of the extent of risk to nursesand fail to initiate corrective action.For their personal safety and theprotection of patients, visitors, andother staff, nurses must recognizesigns of behavior escalating towardviolence. This article discusses howto recognize signs of escalating behaviorand what to do to defuse thesituation effectively and safely.Violence: Gettingdown to basicsViolence is the intentional act of aggression,verbal abuse, threateningbehavior, and/or physical assault. Theintended goal is to threaten, control,coerce, intimidate, humiliate, silence,ostracize, demean, or otherwise emotionallyor physically injure the victim.3,4 The focus of this article isthreatened or actual physical violencewithin healthcare facilities.Although anyone can be a victimof violence, people in certainhealthcare positions, such as clinicalnurses and unlicensed assistive personnel,may be routinely exposed toacts of violence. Nursing personnelwho work in the ED, ICU, and psychiatricor long-term care units aremost at risk for experiencing routineepisodes of violence on the jobProtecting yourself andothers from violenceBy Charlotte Davis, BSN, RN, CCRN;Denise Landon, BSN, RN, CMSC; and Kandie Brothers, MSN, RN, CNLCopyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.www.Nursing2015.com January l Nursing2015 l 57from patients, family members, orvisitors.3 Patient substance abuseand cognitive impairment can increasethe risk of violence for staff.Identifying levels of stressThe Veterans Administration HealthCare 2014 Prevention and Managementof Disruptive Behavior(PMDB) program teaches that potentiallyviolent behavior escalatesthrough four levels of stress: normal,moderate, severe, and paniclevel.3,4 In some circumstances, aperson can transition rapidly from anormal stress level to panic level.This potential requires nurses torefine their escalation assessmentskills and to develop a plan withthe employer and coworkers tosafely manage the perpetrator’s escalatingbehavior and ensure everyone’ssafety. See Four levels of stress:Assessment and intervention forwarning signs and interventionsappropriate for each stress level.When confronted with signs ofmoderate escalation, avoid arguingwith the agitated patient or visitor.Raising your voice to match the toneand volume of the other person’svoice can trigger escalation to ahigher stress level and increase thelikelihood of physical violence. If theperson seems to perceive you as athreat, remove yourself from the situation.If you can safely do so, introducea neutral party to speak withthe person and try to deescalate thebehavior.If a patient’s family or visitor becomesdisruptive in the patient’sroom, consider asking the person tostep outside the room or press thecall light to signal the need for assistance,depending on the situation.Don’t remain in the room with thehostile individual because of the riskof physical injury.Follow facility safety policies andprocedures if the person’s behaviorcontinues to escalate. For example,most facility policies include a provisionfor notifying security or a housesupervisor or management teammember immediately; that designatedperson may then call law enforcementif needed. Nurses shouldprogram their healthcare facility’ssecurity office and 911 into their cellphone speed dial.Consider developing a code word,such as “purple,” that signifies a needfor assistance because of an escalatingsituation. All staff membersshould be educated on what thecode word is and what actions totake in response.If you’re isolated and in imminentdanger, find alternative waysto draw attention to the location,such as activating a panic button,yelling for assistance, and pulling afire alarm or accessing an automatedexternal defibrillator (AED).When accessed, some AEDs activatean alarm to locate the emergency.Check to see if this is an optionwhere you work.Report and document all incidentsof potential or actual violence accordingto facility policy. This informationwill help managers and administratorstake action to maintain the cultureof safety that staff, patients, andstaff are entitled to.Minimizing risks:Watch for weaponsSome healthcare facilities allowstaff to review and itemize a patient’spersonal possessions uponadmission. If permitted to itemizepossessions by facility policy, thenurse can look for obvious and potentialweapons at this time. Guns,stun guns, knives, and other itemsthat could be used to penetrate theskin should be confiscated andlocked in a secure location untilthe patient’s discharge per yourfacility’s policy.Be aware that some innocentlookingitems can be used as weapons;for example:• a cane can be modified to make asword with a potentially long, lethalblade.Gestures such as shakinga fist and prolongedstaring signal escalating,potentially violentbehavior.Startling statisticsResults of the Emergency Nurses Association’s 2011 Emergency Department ViolenceSurveillance Study revealed that almost 70% of respondents had been physicallythreatened, 52% had been physically assaulted, and 40% had been involvedin a violent situation at their job in which a weapon was utilized. Of those routinelyexposed to physical violence, about 17% experienced the behavior more than fourtimes a week. Nurses failed to report physical violence in 66% of these cases becausethey believed that violence was just “part of the job.”6Failure to file a timely formal incident report may allow the perpetrator to victimizeothers and place the nurse at risk for uncompensated medical treatment for anyinjuries suffered during the violent incident. Underreporting also can prevent thefacility’s administrative and safety and quality management teams from recognizingand addressing the presence and severity of staff members’ routine exposure to violence.Employers may be cited by the Occupational Safety and Health Administrationif they fail to ”prevent or abate a recognized violence hazard in the workplace.”7Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.58 l Nursing2015 l January www.Nursing2015.com• both flashlights and cell phonescan be modified to make a gun orstun gun.5Nurses should be suspicious ifan object seems heavier than itshould be or shows signs of alteration,such as screws or reinforcementat joints, and contact thesecurity team to have the iteminspected.A nurse confronted with an escalatingperson who’s armed with anytype of weapon should immediatelyevacuate the area and retreat to a safeplace, then notify hospital securityand/or call 911. The nurse shouldnever try to intervene with someonearmed with a weapon.Besides obvious weapons, manyitems found within a healthcare facilitycan be used as a weapon becauseof convenience and proximity.These include telephone cords, holepunchdevices, examination lamps,plants, electrical devices, pens,tables, and chairs. When the nurseobserves escalating behavior, he orshe should begin to calmly removethese items out of sight or awayfrom the person’s reach, if this canbe done safely.Many items nurses wear or carryare also potential weapons; for example,a stethoscope, pen, eyeglasses,dangling jewelry, and lanyards.Even lanyards with breakawayclasps can be used to strangle anurse if the aggressor grasps thebreakaway clasp.During periods of panic-level escalation,nurses with long hair shouldput their hair up in a ponytail, twisttheir hair into a bun, or tuck longhair underneath the back of theirshirt. An agitated person can grasploose long hair and use it to controlthe nurse’s head, resulting in a whiplashinjury, blunt force trauma to thehead, or even strangulation.Control the environmentBy managing the environment, nursescan help defuse potentially dangerousbehavior or minimize theconsequences. Following theseguidelines can help prevent escalationof aggressive behavior and minimizethe risk of injury.• Pay attention to early signs of escalationand intervene at the lowestlevel of stress. (See Making “GAINS”against escalating behavior.)• Remove unnecessary staff, patients,and visitors to minimize the “audience.”Some aggressors will calmdown without an audience.• Remove any excess furniture,plants, and decorative items thatcould be used as a weapon or thrown.• Decrease the noise level and otherenvironmental stimuli in patient-careareas. Increased environmental stimuliand high noise levels can triggeranxiety attacks and posttraumaticstress disorder exacerbations.3,4• Reduce overcrowding in waitingareas if possible. Offer patients, staff,and visitors the option to take abreak in a quiet area, such as a chapel,outside sitting area, or a lesscrowded waiting room.• Don’t multitask when you’re assistingpatients, staff, and visitors whoare exhibiting signs of moderate orsevere stress. Give them your full attention.Multitasking may give themthe impression that you’re not fullyinvested in solving their problem.• Pay attention to gut feelings! Immediatelyleave any situation if youfeel uncomfortable or unsafe.Nurses should take advantage ofany training that their employersFour levels of stress: Assessment and intervention3Stress level Signs and symptoms InterventionsNormal • heart rate (HR), 60-80 bpm• keen perceptual field (awareness ofsurroundings)• able to think clearly and processinformationProvide good customer service. Offer assistance or provideinformation in a professional, respectful, and timely manner.The nurse may be able to prevent escalation simply bycommunicating the current or anticipated plan of care tothe patient/family.Moderate • HR, 81-100 bpm• perceptual field narrows• altered thinkingVerbal intervention: redirect the person, indicating the behaviorisn’t acceptableSevere • HR near or above 100 bpm• difficulty processing information• task oriented or tunnel vision• complex motor skills deteriorate• perceptual field very limitedSet limits. Provide clear one- or two-step directions. Avoidmultistep directions because the person can’t process thisinformation with a limited perceptual field.Panic • HR over 100 bpm• can’t process information or problem-solve• irrational; a danger to self and others• gross motor skills, such as strength-basedactions (walking, running, hitting, or throwingobjects) are at their highest performanceGain attention of coworkers and avoid becoming isolatedwith this person. Locate an exit door and begin moving towardthe door as you speak. If that’s not possible, yell loudlyfor help, call hospital security or 911, and activate the speakerfeature on your phone. Consider chemical or physicalrestraints per facility policy if all other efforts have failed.Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.www.Nursing2015.com January l Nursing2015 l 59offer, such as Crisis Prevention andIntervention training, the VeteransAdministration’s PMDB program,and self-defense classes thatteach hands-on techniques tominimize the risk of injury toself or others during potentiallyviolent situations.Help reduce the risk of violenceby assisting people who appearlost, answering questions, andconveying your commitment tohelping to resolve their problems.Avoid making comments such as“that’s not my job,” which canescalate an agitated person’s stresslevel. Like patient and staff safety,customer service is everyone’sbusiness. ■REFERENCES1. United States Department of Labor. Bureau ofLabor Statistics. Economic News Release. 2012.http://www.bls.gov/news.release/osh.t03.htm.2. American Nurses Association. WorkplaceViolence. 2014. http://www.nursingworld.org/workplaceviolence.3. Bullard, D. Prevention and management ofdisruptive behavior. Veterans AdministrationHealthcare System {Conference}. Nashville,Tennessee. 2014.4. Williams J. Improvised weapons and othersafety concerns. Los Angeles County Sherriff’sDepartment. 2013. https://info.publicintelligence.net/LA-DisguisedWeapons.pdf.5. NANDA Nursing Interventions. 2013.http://nanda-nursinginterventions.blogspot.com/2012/03/levels-of-anxiety-mild-moderateand.html.6. Emergency Nurses Association. EmergencyDepartment Violence Surveillance Survey. 2011.http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf.7. Occupational Safety and Health Administration.OSHA fact sheet: workplace violence. https://www.osha.gov/OshDoc/data_General_Facts/factsheetworkplace-violence.pdf.Charlotte Davis is a CCU/CVICU staff nurse at HeritageMedical Center in Shelbyville, Tenn., and Alvin C.York VA Medical Center in Murfreesboro, Tenn.Denise Landon is an MICU staff nurse at Olin TeagueVeterans Medical Center in Temple, Tex. KandieBrothers is nursing clinical faculty/prevention andmanagement of disruptive behavior coordinator atthe Department of Veterans Affairs Medical Center inNashville, Tenn.The authors have disclosed that they have no financialrelationships related to this article.DOI-10.1097/01.NURSE.0000454955.88149.e4Making “GAINS”against escalatingbehavior3Both verbal and nonverbal indicatorssignal escalating, potentially violentbehavior, as suggested by the GAINSmnemonic:Gestures of anger, such as shakinga fist, prolonged staring, slamming adoor, throwing objectsActing suspicious, anxious, fearful,or hostile toward staffIncongruent behavior that doesn’tmatch the words; for example, a personstating that he or she is “fine”while pacing and becoming increasinglyagitatedNoticeable signs and symptomsof stress, such as diaphoresis, flarednares, jugular vein distension, andelevated heart rate and BPSystematically pacing, tapping feet,shaking knees, sighing, running fingersthrough the hair repeatedly, rubbingthe forehead.Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.