Expert Analysis

The pre-home visit safety assessment of this client revealed a potential risk due to the prior history of violence on the part of the boyfriend and the loss of child custody. The neighborhood, while somewhat depressed, was not a high crime area during the day. Although clients have become violent when faced with the loss of their child to protective services, Sylvia's role had to do with mother-baby support. High-risk home visits would trigger additional protections and monitoring. In some cases, home care nurses go out in pairs or take an escort. But because the boyfriend was not living in the home, this visit did not appear to be a high-risk home visit for violence.

Safety evidence suggests that nurses working alone are at risk of physical injury when a client escalates. It is strongly advised that nurses get out of the house quickly in those situations. Not only is the risk of physical attack high, the severity of the injuries can be worse because there is no assistance. If there is a second person with the nurse, de-escalation and therapeutic conversation may be appropriate. Providers with mental health training may feel comfortable staying and attempting to de-escalate the client, but without an escort or second person, the experienced mental health provider is at just as high risk. There have been several fatalities of specially trained mental health personnel who were killed because of confidence in their ability to de-escalate a deteriorating patient. Furthermore, most home care RNs are not specialists in de-escalation techniques and may not be as skilled.