Articles Dealing with Workplace Issues
by Mary Rau-Foster, RN BS ARM JD
Violence in the Dialysis Unit Revisited
by Mary Rau-Foster, RN BS ARM JD
From "Nephrology News and Issues" magazine
It is impossible to predict with absolute certainty which dialysis patients may become physically violent. There are certain indicators that might be significant in identifying an individual who may become violent, and measures that can be taken to decrease the likelihood that violence will occur. The patient who shot and seriously wounded a nurse at a dialysis unit in Kankakee, Illinois had no previous incidences of disruptive behavior. But it is important to train the dialysis staff in understanding the causes of violence, and what behaviors may escalate or may defuse an explosive situation.
Unresolved anger is a key component in violent situations. The contributing factors for anger among the dialysis patient population may include feelings of inadequacy, lack of control, hopelessness, and feeling de-humanized. These feelings may be unknowingly exacerbated by well-intentioned staff who are ill prepared and unskilled in dealing effectively with patients who are very stressed. The lack of good and effective communication skills by both the dialysis staff and the patients can result in misunderstandings, inadequately met needs, and unresolved frustration. If these feelings go unresolved or are driven underground, the ultimate result may be an explosion of emotions. Under certain circumstances, and to the degree that a patient feels that he or she is being treated in an unfair or unjust manner, this explosion may take the form of physical violence.
There are three categories of patients who may threaten or commit acts of violence against physicians, nurses and other healthcare professionals:
Group 1: Individuals with no history of violence who become overwhelmed with their own illness or that of a family member.
Group 2: Individuals with an active mental illness who have a conflict, real or perceived, with the physician (or healthcare professional) or the institution, or the individual has difficulty with impulse control as a result of their illness.
Group 3: Individuals with or without a diagnosis of certain personality disorders, who engage in antisocial behavior, or have other problems with anger control. (1)
There is no exact method to predict when a person will become violent. One or more of the following warning signs may be displayed before a person becomes violent but does not necessarily indicate that an individual will become violent. A display of these warning signs should trigger concern as they are usually exhibited by people experiencing significant problems, irrational beliefs, and ideas that may lead to an act of violence.
Verbal, nonverbal or written threats or intimidation
Fascination with weaponry and/or acts of violence
Expressions of a plan to hurt him or her self or others
Externalization of blame
Un-reciprocated romantic obsession
Taking up much of supervisor's (employee) or staff members time with behavior or performance problems
Fear reaction among coworkers/other patients
Drastic change in belief systems
Displays of unwarranted anger
New or increased source of stress at home or work
Inability to take criticism
Feelings of being victimized
Intoxication from alcohol or other substances
Expressions of hopelessness or heightened anxiety
Productivity and/or attendance ( work or dialysis) problems
Violence towards inanimate objects
Steals or sabotages projects or equipment
Lack of concern for the safety of others (2)
Training employees in nonviolent responses and conflict resolution may reduce the risk that volatile situations will escalate to physical violence. The staff training should include:
1. Recognition of signs and symptoms of a patient whose frustration and anger level may be significant enough to result in a violent act.
2. Methods to de-escalate potentially violent situations. These methods include maintaining the proper distance (3-6 feet) from the patient, maintaining a relaxed yet attentive posture, projecting calmness and listening to the patient, acknowledging that the patient is upset and asking his or her recommendations for correcting the problem, establishing ground rules if unreasonable behavior persists and calmly describing the consequences of any violent behavior. (3)
3. Recognition of the negative effect of certain actions, gestures, words, and communication styles that may result in a hostile or violent reaction by the patient.
4. Techniques for understanding and properly managing their own frustration and anger.
5. The proper methods of communication and interaction with patients as a tool to reduce the presence of conflict (and it's impact) in the dialysis setting.
Each dialysis facility should recognize the potential for violence and should take steps to address and plan for it. This includes creating and enforcing a zero tolerance for violence policy that is applicable to both patients and staff. In addition, all threats of violence should be taken seriously and immediately addressed with the person making the threats.
(1) Schouten, Ronald, When patients threaten. Forum. 1995, pg.3 Risk Management Forum
(2) Combating workplace violence. Defense Personnel Security Research Center for the Private Sector Liaison Committee of the International Association of Chiefs of Police
Ms. Rau-Foster has a background in nephrology as a corporate attorney, director of risk management and renal nurse. She is president of Foster Seminars and Communications LLC in Brentwood, TN. Phone: 1-615-371-3114 Email:
© 1999 Mary Rau-Foster. Reprinted by permission of "Nephrology News & Issues" magazine.
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