So often today, you turn on the news to see that another shooting has happened in the nation. They happen at schools, movies, concerts, nightclubs, grocery stores, shopping malls, and even in health care facilities.
Do you know what you would do if you were around when an active shooter event took place? David W. McRoberts, CPP, a retired Law Enforcement Captain with 30 years of experience, is a security consultant for The Sullivan Group, is the Owner of Assured Assessments, Inc., and is the co-author of the course “Active Shooter Event in a Healthcare Environment.” McRoberts says that instead of becoming a victim who says after such an event, “I couldn’t believe what was happening, and there was nothing I could do,” nurses need to know that “There is always something each of us can do—but we must have thought it through in advance.”
Develop These 3 Habits
McRoberts says that nurses should subscribe to the following personal protection skills as their personal safety habits:
Situational Awareness: Knowing exactly where they are, where they are moving to or from, and what exists around them in terms of their realistic ability to react to occurrences in their presence.
It Can Happen Anywhere: Nurses must acknowledge that bad things happen—and often without warning. McRoberts says that this doesn’t mean nurses need to become paranoid, but rather, understand that shootings can happen anywhere.
See the Threat: He also states that nurses must develop the ability to look for and see threats—and suspend disbelief. “They must take the first two habits and merge them into an ironclad ability to not become paralyzed with shock and fear and fall victim simply because they never once even considered the fact that they would need to function in a moment of the gravest extreme,” says McRoberts.
Shots Fired: What Do You Do?
When asked about the first thing that nurses should do, McRoberts says, “Because nurses are professional caretakers with ethical, moral, and personal value-based responsibilities in the care of others, this is not an easy circumstance to navigate. Active Shooter Events on average last about two minutes. Shooter victims can be random or specific individuals that the shooter targets.
“With that as a baseline, I believe that creating or increasing what law enforcement refers to as the ‘reactionary gap’ is essential. Simply put, this is creating more distance and/or cover between themselves and the threat. That may mean temporarily leaving the immediate area of patient care. Nurses may feel they are abandoning their patients, but they need to remember that these events are over in about two minutes. The brutal truth is that when faced with a person bent on shooting and killing people, nurses who are determined to remain stalwart and immovable will, in all probability, become victims themselves and incapable of delivering patient care. It’s better to have moved away from the threat and then return to patients when the event is over.”
Do You Interact?
What happens next? Do nurses provide aid? Should they talk with the shooter? “There are as many different scenarios to Active Shooter Events as there are events themselves; they are very dynamic events. A nurse’s first reaction to an injury resulting from an Active Shooter Event would be to render aid. Perhaps this is the right thing to do—maybe this action will decentralize the shooter’s thought process enough to stop the carnage. But like so many reported Active Shooter Events, it may be that nothing stops the shooting and killing until and unless the shooter stops or is stopped,” explains McRoberts. “A nurse may believe he/she can reason with an active shooter, but attempting this may be a tactical mistake; interacting/talking with a person who has already decided to shoot, injure, and kill others is too risky. Begging for compassion from a shooter—including begging for their own life or the life of another—needs to be supplanted with fighting for their own life and the lives of others.”
Keeping a Clear Head
Unless you prepare before an Active Shooter Event occurs, it can be nearly impossible to keep a clear head. “Each of the previous skill developments build one upon the other to create a foundation of action items that give nurses the best chance to survive. With that as underlying support, the next step is practicing ‘stress inoculation’—not the clinical variety, but the very practical application of understanding our limitations as humans and what happens to us physiologically when we are under extreme stress,” says McRoberts.
“Tachypsychia, auditory exclusion, and fine motor skill erosion occur in everyone and diminish our abilities to function under stress. However, we can mitigate these negative effects and develop the ability to function through the high stress of an Active Shooter Event. In its most basic form, stress inoculation is the practice of very specific actions, movements, and functions. Consider what we would need to do in a high-stress event: see clearly what is happening; speak clearly to communicate; walk or run; dial a phone; etc. To complete tasks under stress, nurses need to practice them while under manufactured stress,” says McRoberts. “For example, a common situation in an Active Shooter Event might be finding and climbing stairs, and then dialing your cell phone and telling someone out loud your exact location. Nurses can practice speaking into a phone clearly and in a controlled manner while breathing at an accelerated rate from a brisk walk, run, or stair climb; they can test and challenge each other with random quizzing by unexpectedly asking a colleague exactly where they are located; and they can follow that up with asking them where they would move to for the greatest level of safety. These seem like extremely simple things, but it is practicing them in advance that is the secret to making them ‘simple.’ Once you know you can do these things, it creates a positive cascading effect of believing in yourself and your ability to complete these tasks under stress. Like anything else, the more we practice something, the better we get at it.”
McRoberts give these final tips to give nurses guidance as to what they should and shouldn’t do in an Active Shooter Event:
Look for the threat and then react to it; don’t panic and freeze.
Remember that this event will happen quickly and will only take about two minutes, but you will perceive it to be very long and protracted.
Rely upon your new mindset, knowing that you can function through this event.
Know exactly where you are (your surroundings) and where you must move to for safety.
Know what to say to communicate to others, including what may be required by pre-established agency/facility protocols.
Know that you may have to move more than once.
Don’t try to negotiate or plead with an active shooter; you are better fighting for your life, not begging for your life.
Know in advance that you may have to move away from patients temporarily to survive so you can be there to help them later.
Know that when law enforcement gets to the scene, they will move quickly past everyone and everything to get to the shooter and stop them; this may mean moving past injured people, patients, colleagues, and you.
Workplace safety is a topic of major concern and discussion for workers and employers in a variety of occupations and workplace settings. In nursing, patient safety is an essential and vital component of quality nursing care. However, the recent Ebola outbreak and the growing risks of antibiotic-resistant microorganisms have created a heightened awareness around the fact that nursing is still one of the most dangerous occupations in the United States. This raises the following question: Just how safe are nurses in the work setting? In this 21st century, one may easily assume that nurse safety has been addressed. However, the answer is not clear.
Data from the Bureau of Labor Statistics (BLS) show that the health care sector continues to be the most dangerous place to work in America. According to the Occupational Safety and Health Administration (OSHA), health care workers are confronted with the following job hazards: bloodborne pathogens and biological hazards; potential chemical and drug exposures; waste anesthetic gas exposures; respiratory hazards; ergonomic hazards from lifting and repetitive tasks; laser hazards; workplace violence; hazards associated with laboratories; and radioactive material and X-ray hazards. In 2010, there were 653,900 workplace injuries and illnesses in the health care sector, which is more than 152,000 more injuries than the manufacturing sector, according to a 2013 Public Citizen report.
The paradigm for promoting nurse safety is changing, but slowly, and has not kept up with the technology to prevent injury, says Amber Hogan Mitchell, DrPH, MPH, CPH, president and executive director of the International Safety Center. “There have been a lot of advances over the last few decades to significantly improve nurses’ safety, but more can be done to collect and analyze data that would help speed adoption of innovative technology and spur swifter action to revise and implement stronger safety-related best practices and policies.”
The issue of nurse safety is pervasive. Unfortunately, musculoskeletal injuries are common from lifting patients without enough assistance. Nurses lift the equivalent of 1.8 tons every eight hours. Unanticipated exposures to blood and body fluids (BBFs) pose infection and illness risks to nurses on a daily basis. In the process of caregiving, patients or family members occasionally strike out at the nursing staff. Assaults from patients and patient visitors are far from being listed as isolated incidents.
“Health care has reached a critical tipping point,” says Alexandra Robbins, author of the New York Times bestseller The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. “With looming physician shortages and an increasing demand for services, workplaces will have no choice but to make changes to accommodate nurses, our largest health care provider.”
Clinically Proven Textile Technology About one in two nurses experience blood exposure, other than from a needle stick, on their skin or in their eyes, nose, or mouth at least once a month, according to a 2012 study by the International Healthcare Worker Safety Center at the University of Virginia. In fact, nurses experience these exposures most often while providing direct care, when they are least expecting it and not wearing protective clothing, according to data from the International Safety Center’s Exposure Prevention Information Network (EPINet).
In order to better protect nurses from unexpected exposures to harmful pathogens, we need to first address the role their daily attire can play in protecting them, says Barbara DeBaun, RN, MSN, CIC, consulting vice president of clinical affairs at Vestagen Technical Textiles, Inc. When exposure is unexpected and nurses are not donning personal protective equipment (PPE), traditional scrubs leave nurses vulnerable to direct contact with harmful contaminants that stay with them all shift long.
“Traditional scrubs allow micro-organisms, blood, and other body fluids to leach through the fabric, resulting in nurses carrying contaminants from patient to patient and home to their families,” DeBaun says. “New ‘active-barrier’ textile technologies, made with fabric such as Vestex, contain fluid-repellent, antimicrobial, and breathability properties.”
Debaun explains that this innovative fabric technology combination is key in helping reduce the acquisition, retention, and transmission of harmful pathogens on health care worker attire. Working together, the fluid-repellent barrier causes harmful contaminants to bead up and roll off the fabric, and the antimicrobial agent limits growth of bacteria on the fabric. Vestex’s active-barrier apparel is currently the only textile technology that has shown clinical effectiveness at reducing MRSA infections by 99.9%, in comparison to traditional attire.
Active-barrier apparel is already available in scrubs and white coats for health care workers and health care facilities to purchase. Hospitals such as Baptist Health in Jacksonville, Florida, have already established a systemwide uniform policy that requires staff to wear active-barrier protective uniforms. The organization made a commitment in 2014 to transition more than 6,000 workers, and all patient attire, to Vestex garments to enhance their culture of safety.
“As more data shows the risk that attire can play in transferring harmful contaminants, we believe that advancements in textile technologies will soon become the new industry standard for nurses in all health care settings,” DeBaun says.
Better Security Nursing is the third most dangerous profession in the country because the vast majority of nurses are attacked by the people they are trying to help. According to data from the BLS, U.S. health care workers experience the most nonfatal workplace violence compared to other professions by a wide margin, with attacks on them accounting for almost 70% of all nonfatal workplace assaults and causing days away from work.
In 2014, 68-year-old Charles Emmett Logan, a patient at a Minnesota hospital, attacked a group of nurses with a pipe pulled from his hospital bed. The incident, which was caught on video, showed Logan running through the nurse’s station wielding a metal pole, hoisting it over his head, and hitting nearby nurses who attempted to flee the scene. One nurse suffered a collapsed lung, another fractured her wrist, and others had cuts and bruises. Medical staff told police that Logan, who died in police custody, suffered from paranoia.
“Hospitals do not protect their nurses, and it’s time they do,” says Robbins. “There is so much more that can be done, both tangible changes and major shifts in attitudes.”
Some hospitals believe that posting security personnel near triage looks negative, so they don’t put enough security staff at the entry points to the hospital and near triage. This puts the triage staff at risk when patients who are high, drunk, or psychotic come in the door, explains Robbins.
After the episode in Minnesota, the hospital initiated a training program to teach workers how to recognize and de-escalate potentially violent situations. However, many hospitals lack this basic safety measure — an oversight that leaves caregivers vulnerable.
“Understandably, nurses are focused on providing the highest quality and safest care to their patients, and often at the unintended risk of not protecting themselves,” Mitchell says. “A shift towards promoting a culture of safety that encompasses both patient and worker safety and security can create an overall better, more effective health care environment.”
To help promote a culture of safety, Robbins recommends that hospitals take the following steps:
• Install metal detectors to reduce the chances of patients or visitors injuring nurses and other staff members with weapons.
• Keep a computer database that flags patients known to be belligerent or aggressive.
• Install bulletproof glass and beef up security.
• Practice safe staffing and hire enough nurses so that the nurse–patient ratios are safe.
“The secret to improving American health care is to hire more nurses and insist that workplaces do a better job of protecting our frontline responders,” Robbins adds.
New Policies and Procedures Exposures to BBFs pose a very large safety risk to nurses. According to data from EPINet, 47.7% of nurses were exposed to BBFs while on the job in 2012. Perhaps even more alarming, from 2003 to 2012, 83.9% had BBFs touch unprotected skin. These rates are high because nurses aren’t protected from unanticipated exposures, and compliance with PPE is surprisingly low. There is mounting evidence as well that nurses’ attire is contaminated with pathogens and can thus become a vector of transmission to other nurses as well as the patients they treat.
Mitchell believes that hospitals need to have programs in place that not only promote the use of PPE, but also measure compliance. This type of surveillance can allow the facility to identify where risks are high and compliance is low, and target programs in those areas, thus reducing exposures and reducing risk.
“EPINet is free to use and is an example of a surveillance system that can help hospitals to reduce risks,” Mitchell says. “The National Institute for Occupational Safety and Health [NIOSH] is launching a national system called the Occupational Health Safety Network [OHSN], and it is compatible with EPINet. Using systems like these allow facilities to compare themselves to others like them and to constantly improve.”
It is important to remember that safety is guided by a hierarchy of controls, which means that it is important first to eliminate hazards and risks to the lowest possible extent. Mitchell says this is done using engineering controls such as safety-engineered devices that eliminate or protect needles (e.g., needleless IV systems, retracting or shielded needles used on syringes, and blunt suture needles). For exposures to BBFs that splash and splatter, engineering controls might include closed systems for suction canisters or spill-resistant specimen containers. It may even include the use of new innovations in textiles, including those that are fluid-repellent and antimicrobial so that BBFs run right off of them, and fluids don’t soak in to the skin.
There will always be more that can be done to address nursing safety risks, Mitchell believes. Organizations like OSHA, NIOSH, and the Association of PeriOperative Registered Nurses, are always open to feedback, and it is only in providing them with your experiences and opinions that they can provide better guidance.
Mitchell adds that addressing nursing safety risks means creating the safest possible working environments and identifying and measuring hazards, so that programs and interventions can be designed to target and prevent them.
“This involves frontline nurses contributing to the review, evaluation, and selection of engineering controls, medical devices, and even textiles used in their hospitals,” Mitchell says. “Finally, it means working together across specialties, across units, across facilities, and across disciplines to share ideas, foster collaboration, and learn from each other.”
Terah Shelton Harris is a freelance writer based in Alabama.
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