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Gangstas-not in my hospital!

Gang violence is a real and prominent threat in any health care environment. Can you recognize and manage the risks?

A young man was brought to the emergency department (ED) with gunshot wounds to the chest. The ED lobby soon swarmed with his family and friends, many of them wearing red clothing and accessories. As a nurse updated the patient's family on his condition, others in the crowd began swearing and yelling and someone shoved the nurse.

Gangstas-not in my hospital! The father of an infant in the neonatal intensive care unit came in sporting tattoos, a colored bandanna on his head, and a football jersey worn backward-all symbols of gang membership. On the day of the infant's discharge, both parents paid attention and behaved appropriately in the required infant CPR class.

These events took place in an urban trauma center. If someone were to ask how gang violence affects your facility, you might protest, "Not in my hospital!" But gang violence, traditionally considered an inner-city problem or a risk only in the ED, is a growing threat to health care facilities throughout the country. As the second scenario above illustrates, gang members aren't always violent. However, the potential is there.

Your hospital's first line of defense against gang-related problems is to be aware of the gang culture in your community and develop a safety plan. Our hospital's work with the local police to develop a plan to deal with gang violence motivated us to write this article. In it, we'll detail what we learned about recognizing gang members and minimizing the risk of gang-related problems.

Recognizing the signs and symbols

Police define a gang as three or more people who wear like colors and clothing and commit crimes. Their involvement in criminal activity, especially the drug trade, is what sets gangs apart from clubs established for other purposes. According to the Department of Justice, 24,500 known gangs exist in the United States, with approximately 770,000 members.

Gangs cross cultural, socioeconomic, and sex boundaries, from ghettos to gated communities. Many members, however, live in extremely violent worlds where crime is the norm.

Gangs use unique identification methods, such as bandannas of a specific color and symbols worn on their clothing or tattooed on their skin. They may mark the neighborhood with graffiti to warn others that they "own" it. If a gang member feels that a fellow "gangsta" (or his own reputation) has been threatened or offended, he may react with violence. He might also turn on a fellow gang member if he perceives a threat or a breach of loyalty.

Insidious threat to hospitals

The threat of gang-related violence is insidious in todays health care settings. If an injured gang member seeks medical treatment, several of his "posse" may come along. If his injury occurred in a gang war, his rivals may attempt to finish the job. When members of two gangs are transported to a single hospital for treatment, the facility is at risk for continued violence and retaliatory acts. Unfortunately, the health care team may suffer the brunt of violence, especially if the patient dies.

Your hospital can take steps to protect patients, staff, and hospital property from gang violence. (For tips on how you can help, see Hospital Safeguards.) These people and agencies play key roles in maintaining safety:

Local law enforcement. Hospital administration should stay in touch with the local police to learn about gangs in the area and disseminate the information to the staff. You're better prepared to deal with gangs when you can recognize characteristic clothing, tattoos, and colors and relate them to gang names, activities, and crime patterns. The police can alert hospital security and recommend additional safeguards when they expect gang activity in your area.

Hospital security. Integral to violence prevention, security staff must be thoroughly educated on gang activity, including how to recognize and deal with escalating violence. Their presence should be routine in situations where several gang members might descend on the hospital. For example, your hospital should have a policy to call security staff whenever any patient comes in with penetrating trauma, such as gunshot or stab wounds. They should also be notified if gang violence might be the mechanism of a patient's injury, such as initiation beatings of potential members.

Your hospital should have a "violence in the workplace" policy and protocols for security staff to follow to defuse potentially violent situations and to respond to violent acts. They must know how to explain to gang members that the hospital is a neutral area and that threatening hand signals and language-"stackin'"-aren't allowed. (See Gang Slang for examples.)

Security also must establish cues for calling police and protocols to "lock down" the hospital if violence erupts. For example, many hospitals have a code like those used for medical emergencies to call for assistance in violent situations.

Security rounds in the hospital should include looking for graffiti. Suspected gang graffiti should be photographed and documented as soon as possible. Never cross it out because this act can be seen as "dissing" or disrespectful. Once documented, graffiti should be professionally covered or the object replaced if necessary. All graffiti should be reported to the police, and the facility may choose to keep its own records of gang graffiti.

Human resources. Through references and government agencies, the human resources departments in health care facilities should get background checks on all employees and take special note of violent crimes. Gang members may be drawn to pharmacy jobs for access to drugs or security jobs to get weapons. The hospital dress code should prohibit gang-related clothing and visible gang-related tattoos while an employee is on the premises.

The nursing staff and other employees. Learn how to interact with suspected gang members because they might retaliate if they feel disrespected. For example, a gangster's clothing may represent his affiliation, so handle it with care. If a known or suspected gang member is a patient, be straightforward and honest when talking with him about his injuries. Don't preach; treat him as respectfully as you would any other patient. When possible, speak with family members privately away from other gang members to reduce the chance of escalating violence.

Education and teamwork

No matter where you work, you can't consider your hospital immune from gang-related problems. With education and understanding, the hospital administrators, you, and your colleagues can team up to recognize gang activity and de-escalate a potentially violent incident.

SELECTED WEB SITE

Florida Department of Corrections: Gang and Security Threat Group Awareness

http://www.dc.state.fl.us/pub/gangs

When researching gang information on the Internet, avoid official gang Web sites. Search only sites sponsored by law enforcement, education, or gang-prevention groups.

Last accessed on August 2, 2004.

SELECTED REFERENCES

Hall-McGee, P: "Gang Awareness for Healthcare Professionals," Journal of Healthcare Protection Management. 15(2):108-114, Summer 1999.

Presley, A.: "The End of Innocence: Opening the Midlands' Eyes to Gangs," Free Times. 24-26, June 18-24, 2003.

"Protecting Your Hospital from Gang Activity," Hospital Security and Safety Management. 21(10):9-11, February 2001.

"Violence in the Hospital: A Response Plan," RN. 63(2):24hf4-24hf5, February 2000.

By Kelly McAdams, RN, CCRN, MSN; Helen Russell, RN,C, MSN; and Christine Walukewicz, RN, CEN, MN

The authors are clinical nurse specialists at Palmetto Health/Richland in Columbia, S.C., Kelly McAdams in critical care, Helen Russell in neonatal intensive care, and Christine Walukewicz in the emergency department.