Violence in the ER: Part of the Job?

When I was a new bright-eyed and idealistic nurse, I imagined a future full of connecting with people at their moments of greatest need. To be sure, there have been many brights spots in my career where this has been the case. Nursing can be beautiful and rewarding. What I didn’t know was that it can also be ugly, violent, and abusive.

In the ER, where I have spent the last decade and a half of my career, studies have shown that between 25-88% of health care workers have been a victim of violence from a patient in the last year (D’Ettorre et al., 2018). Anecdotally, I have experienced that to be much closer to 88% than 25%. Just this week, while helping an elderly man from his car, one co-worker was physically assaulted while the other three of us were verbally assaulted and threatened. “I’m going to kill every one of you,” to be specific, sprinkled with a few choice insults and word pictures of our general baseness.

Workplace violence in the ER is an occupational hazard. 94% of nurses experience PTSD symptoms after a violent event and 17% have likely PTSD (Baydin & Erenler, 2014). Considering the high percentage of staff who experience a violent event in one year, that means that most healthcare workers you may interact with in an ER visit are carrying unseen trauma from the job. The fall out from this is far reaching. Staff who have experienced a violent (verbal or physical) event are more likely to experience burnout, to decrease interactions with patients, and to experience decreased empathy and concern for patients (Baydin & Erenler, 2014). That means that violence in the ER does not just effect the staff, but every patient they care for.

Recent studies have focused in on this problem and how to minimize it. 63% of violent events take place in the waiting room. Verbal violence and threats are most common from lucid patients and their family, while physical assaults are more common in patients experiencing a mental health crisis, under the influence of a mind altering substance, or who have Alzheimer’s or other types of dementia . Interventions have focused on staff training in communication and de escalation and in recognizing the potential for violence before it occurs (D’Ettorre et al., 2018). While these are important pieces of the puzzle, for the staff it can also feel like victim blaming. “What could you have done differently to keep that man from hitting you?”

Studies have found that there are several organizational factors that increase the likelihood of workplace violence. There is a relationship between high job demand, work load and stress, and an unbalanced ratio of patients to staff that lead to decreased quality of care, increased staff anxiety, and higher patient frustration, leading to an increased risk for violence (Wu et al., 2014). Hospitals need to do their part to staff adequately and with foresight. They need to see the ER waiting room as part of the hospital, not a no man’s land where they don’t have to worry about staff to patient ratios. One waiting room nurse to 30+ patients (including those who are mentally unstable) is unsafe for the patients and is a pressure cooker for violence. Hospitals need a team based approach to preventing violence, where there is shared responsibility between the organization and the staff, not finger pointing at increasingly demoralized staff (Wong et al, 2015). For hospitals to say they care about the safety of their staff while avoiding responsibility for it is shameful.

References and further reading

Baydin, A., & Erenler, A. K. (2014). Workplace violence in emergency department and its effects on emergency staff. International journal of emergency mental health, 16(2), 288–290. https://doi.org/10.4172/1522-4821.1000112

D’Ettorre, G., Pellicani, V., Mazzotta, M., & Vullo, A. (2018). Preventing and managing workplace violence against healthcare workers in Emergency Departments. Acta bio-medica : Atenei Parmensis, 89(4-S), 28–36. https://doi.org/10.23750/abm.v89i4-S.7113

Ferri, P., Silvestri, M., Artoni, C., & Di Lorenzo, R. (2016). Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study. Psychology research and behavior management, 9, 263–275. https://doi.org/10.2147/PRBM.S114870

Kansagra, S. M., Rao, S. R., Sullivan, A. F., Gordon, J. A., Magid, D. J., Kaushal, R., Camargo, C. A., Jr, & Blumenthal, D. (2008). A survey of workplace violence across 65 U.S. emergency departments. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 15(12), 1268–1274. https://doi.org/10.1111/j.1553-2712.2008.00282.x

Wong, A. H., Wing, L., Weiss, B., & Gang, M. (2015). Coordinating a Team Response to Behavioral Emergencies in the Emergency Department: A Simulation-Enhanced Interprofessional Curriculum. The western journal of emergency medicine, 16(6), 859–865. https://doi.org/10.5811/westjem.2015.8.26220

Wu, J. C., Tung, T. H., Chen, P. Y., Chen, Y. L., Lin, Y. W., & Chen, F. L. (2015). Determinants of workplace violence against clinical physicians in hospitals. Journal of occupational health, 57(6), 540–547. https://doi.org/10.1539/joh.15-0111-OA