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Why are incidences of violence three times more likely in healthcare work settings than in the general work sector? 

The Detroit News and the Free Press reported that an emergency physician was stabbed in the neck by a patient at Lansing, MI, Sparrow Hospital near midnight May 4, 2012. Assaults on healthcare workers are becoming all too common. According to the Bureau of Labor and Statistics (2007) education and healthcare sectors accounted for 17% of all non-fatal workplace violence. Sixty percent of all assaults occurred in the healthcare setting. The assault injury rate was 20.4/10,000 in healthcare support workers, with physicians and nurses accounting for 6.1/10,000, which is significantly higher than the 2.1/10,000 reported by the general sector.1 The majority of assaults are committed by patients. We know that the actual assault rate is much higher due to gross under reporting. This is especially true of physical threats. The National Institute for Occupational Safety and Health (NIOSH) defines violent acts as “physical assaults and threats of assault directed toward persons at work or on duty.” Gates, et al. expanded the definition to include verbal threats, verbal harassment and sexual harassment. Kowalenko, et al. added “stalking” to the definition. Not surprisingly, expanding the definition revealed the even greater scope of the problem.

Multiple authors have identified the emergency department as the highest risk area within the hospital. More than three quarters of attending emergency physicians have experienced at least one workplace related violence incident in the previous year, with more than a quarter reporting more than one act of violence. Over a quarter of Michigan attending emergency physicians reported being physically assaulted in the previous year, with 11.7% occurring outside the ED and 3.5% were stalked. Of those who were assaulted 42% sought personal protection by either carrying a gun or knife, or obtaining a security escort. Sixteen percent of these physicians considered leaving their hospital primarily due to fear of assault.2 Fifty percent of emergency medicine residents had reported being hit or punched in the previous year. The rates of threats and assaults are even higher in emergency nurses. Twenty five percent of nurses reported being assaulted more than 20 times over 3 years and were verbally abused more than 200 times over the same time period.3

Workplace violence has significant consequences to the employees in the form of physical injury, emotional distress, and decreased feelings of safety and job satisfaction. This is true of all emergency department occupations, however studies show nurses feel least safe. There are also significant consequences to the employer in the form of costs for medical/psychological care, lost work days, decreased productivity, job turnover, worker’s compensation, and litigation.

There are multiple potential reasons for why the ED is at particularly high risk for violence against healthcare workers. These risk factors include, but are not limited to the following: intoxicated patients and visitors, psychiatric and cognitive disorders, open access, high stress environment (for patients and workers), overcrowding, lack of privacy, long wait times, and insufficient security. However an important factor that may be overlooked is employee training on how to recognize and deal with the potentially violent patient/family. One recent study, revealed less than 50% of employees underwent any training.4

Many organizations are concerned about this growing problem, including the American College of Emergency Physicians, American Association of Critical Care Nurses, Emergency Nurses Association, American Nurses Association, and the Joint Commission on Healthcare Accreditation Organization.  The Occupational Safety and Health Association (OSHA) have published guidelines. These stress management and hospital commitment to reduce ED workplace violence.5 This involves work-site specific analysis of the environment with an emphasis on hazard prevention and control.

Unfortunately, we still do not know much about violence in the emergency department. We do not know much about the characteristics of the victims or the perpetrators.  There is not much data on why or when it occurs. Most importantly there not much evidence on what are the best ways to prevent or deal with violence in the emergency department. To help answer some of these questions the Centers for Disease Control and Prevention (CDC) and NIOSH have funded investigators at the University of Cincinnati and the University of Michigan to investigate this problem using a two-state, multiple hospital study. Some of their initial results have reiterated previous studies showing that all occupations are victims of threats and assaults from both patients and visitors. These acts of workplace violence negatively impact feelings of safety and confidence. In addition these acts result in acute stress which has a negative impact on productivity and their ability to effectively conduct their jobs. (Presented at the 2012 Society for Academic Emergency Medicine Annual Meeting, May, 2012, Chicago, IL).

While no single educational or interventional tool has been shown to significantly reduce, and more importantly sustain reduced ED workplace violence, several suggestions have been published and met with variable success.

The University of Cincinnati Division of Criminal Justice published a 5 step approach.6 The first step is to increase the effort of criminal activity by securing entrances, installing metal detectors, mounting furniture/fixtures, and equipping rooms with restraining devices. It must be noted that although metal detectors can help in confiscating many weapons, they can lead to a false sense of security and mast ambulance patients do not go through them. Second is to increase the risk of getting caught by installing surveillance systems, panic buttons, and having visitors sign-in and show ID. Third is to reduce the rewards by keeping potentially violent visitors away from targets (restricted visitor lists, and false name registration), installing partitions around work areas, increase reporting of all incidents to authorities. Fourth is to reduce provocations by keeping patients and visitors comfortable and informed of where they are in the process (patient advocates). The fifth intervention is to remove excuses by displaying rules of conduct and consequences, and not allowing obviously intoxicated visitors entry to the ED. In addition to these measures, it is important to educate employees on how to recognize potentially violent patients/visitors, how to de-escalate these individuals, and lastly how to protect themselves while safely restraining the violent individual.

In addition to all these measures we need to advocate for more strict laws to punish perpetrators. Violence should not be tolerated in our EDs. We need to continue to work with Hospital Administrators, security, and law makers to make EDs safe for our patients and employees.


References

  1. U.S. Bureau of Labor and Statistics – Janoch JA, Smith TS. Workplace Safety and health in the Health Care and Social Assistance Industry, 2003-2007. U.S. Bureau of Labor and Statistics Web site: http://www.bls.gov/opub/cwc/sh20100825ar01p1.htm.
  2. Kowalenko, T., Walters, B.L., Khare, R.K., & Compton, S. (2005). Workplace violence: a survey of emergency physicians in the state of Michigan. Annals of Emergency Medicine, 46(2): 142-147.
  3. Gacki-Smith, J., Juarez, A.M., Boyett, L., Hoymeyer, C., Robinson, L., & MacLean, S.L. (2009). Violence against nurses working in US emergency departments. Journal of Nursing Administration. 39 (7-8), 340-349.
  4. Gates D, Gillespie G, Kowalenko T, et al. Occupational and demographic factors associated with violence in the emergency department. Adv Emerg Nursing J 2011; 33(4): 303-313.
  5. U.S. Department of Labor. Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration U.S. Department of Labor Web site. Available at: http://www.osha.gov/Publications/OSHA3148/osha3148.html.
  6. Preventing Interpersonal Violence in Emergency Departments: Practical Applications of Criminology Theory. Violence and Victims, 2010; 25(4): 553-65.
 

Comments   

# ER DOC/50K hoursJ A McErlean, MD 2012-06-25 05:46
The sad fact is that hospital administrators, legislators and law enforcement personnel don't give a flying F about violence directed against ER staff. An example: spit in the face, or take a swing at a sitting judge or on-duty cop and see what fate may await you...Now perform the same activity directed to an ER doc and see the difference.
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