Of the hundreds of pages in her emergency medicine textbook, only two discussed violence in the emergency department, recalled Marcy Behnam, MD, after a wearying night in which she once again juggled patients against time pressures till dawn's early light.
Despite her need for sleep and fighting a frog in her throat and periodic interruptions from impossible-to-stifle yawns, she wanted to talk about that lapse in medical education, the low priority given to managing and preventing aggression in the ED. “I knew a psychiatry resident who had two days of training,” she said pointedly.
It's a big reason she and her colleagues wanted to survey others in emergency medicine about threats and incidents of physical assault from patients and their families.
More than a fifth of 263 residents and attending physicians from 65 emergency medicine residencies reported workplace violence in the previous year in the researchers' online poll. (J Emerg Med 2011;40:565.) And those encounters weren't always confined to the hospital. There were 13 reports of violence outside the workplace among these emergency physicians, which generally involved some kind of confrontation. And in a finding likely to send shivers down every EP's spine, they found that four of those were stalking incidents.
Similar findings emerged from a study of 7,000 emergency nurses this past year. The overall frequency of physical violence and verbal abuse during a week-long study period for ED nurses was found to be nearly 55 percent, according to the Emergency Department Violence Surveillance. Twelve percent of the participants reported experiencing physical violence, and 42.5 percent endured verbal abuse.
A majority of nurses who experience this kind of violence don't report it to employers or law enforcement, according to the Emergency Nurses Association, which conducted the survey. Workplace violence for the nurses was described as it was in the physician study, ranging from offensive or threatening language to homicide, including physical assault, verbal abuse or threats, and harassing or coercive behavior at work.
Has it gotten worse in the past year or two? Not according to the study, but it hasn't gotten any better either. And the use of harsh words and threatening language seems to have gotten a lot more common, said AnnMarie Papa, DNP, the president of ENA. Anecdotal reports also note that domestic violence is not only sending more patients to EDs, but erupting there as well, particularly during waiting periods. A dispute between a woman and her fiancé awaiting health care in one Pennsylvania ED culminated in her retrieving pepper spray and unleashing it on him, affecting others in the ED area, including health care providers. (See FastLinks.)
Dr. Behnam, who works in the San Francisco Bay area, said workplace violence may not have escalated, but it does feel that way in the ED. The National Crime Victimization Survey conducted by the U.S. Department of Justice is looking into that very possibility, and for good reason. Risk factors for family violence — a common reason for explosive situations in the ED — have increased in the past few years. Joblessness and economic stress are significant and contributing influences in provoking intimate partner violence, according to the Centers for Disease Control and Prevention.
News accounts tell a similar story. This past year, the media covered screaming patients wielding weapons at doctors and nurses in EDs and outbursts that involved furniture being pushed or tossed across waiting areas. In one case, a crime suspect who needed ED treatment tried to grab the arresting officer's gun, and the ED staff subdued him. (See FastLinks.)
Alcohol or drug abuse accompanies such outbursts 70-85 percent of the time. Crowding that leads to long waits, which are pretty typical, is thought to be a predisposing factor as well. An increasingly recognized period of vulnerability occurs after a death, when the outcome is being imparted to the family. “I had a situation early one morning, about 3 a.m., when I had to give bad news, and the family there [in the waiting area] had gone from two to what seemed about 15 or 20,” Dr. Behnam said. “They started blaming each other. A brawl broke out.”
Ms. Papa had an even more threatening situation unfold when she had to give the same kind of message several years ago. “I was threatened with losing my life. The guy just flew off the handle at me. If you deliver this kind of bad news, don't do it alone,” she advised.
A chaplain, social worker, or counselor is seen by the family as part of their team, and should always be on hand to help deal with the shock and grief, she said.
For the most part, it is the nurses who get the brunt of the spitting and cursing, but the incidents affect emergency physicians, even if it is not as direct, Dr. Behnam observed. “This is about the sense of physician wellness, something that gets chuckled and laughed about,” she said, adding that a veneer of toughness is seen as a part of the job, even a mark of professionalism.
In the study she and her colleagues conducted, the majority of the EDs did not screen for weapons or have metal detectors. Fewer than 20 percent of them had workshops for violence, and only 10 percent offered any kind of self-defense training.
At her workplace at the University of Pennsylvania, Ms. Papa noted, a program called “Management of Aggressive Behavior” shows how to verbally de-escalate and teaches tips for maintaining safety, such as staying within easy reach of the examining room door. “I think one important part of it, though, is that physicians, tech, security guards, and nurses take the training together so then we all speak the same language,” she said.
Training programs do work, studies show. In California, training for such encounters is now mandated, and one requirement is learning how to apply verbal de-escalation to agitated patients, as defined in the California's Health and Safety Code.
Such training needs to be tailored to the specific facility, said William Nesbitt, the president of a security consulting firm in Newbury Park, CA. What is socioeconomic environment? Does the hospital maintain a Level I trauma center? What is crime like in the hospital's service area? What are the perceptions of the emergency department's staff about their overall safety?
Online questionnaires at facilities for which his company, Security Management International, Inc., consults help him understand staff perceptions. “Before we step foot on the campus, we want to know what's going on there, and that includes how people feel about safety and security,” he said. Ironically, staff members sometimes feel safer in higher-crime urban hospitals because they have grown accustomed to aberrant and aggressive behavior, and are experienced in handling patients' odd or threatening behavior.
Perhaps the most important step is empowering staff to recognize and report suspicious behavior. In one East Coast hospital, for example, a man who had brutalized his wife showed up in disguise after she was hospitalized and murdered her.
Nurses and others had noticed his peculiar appearance — he was obviously wearing a woman's wig — but they did not alert security. Why not? Pressure on health care providers to be tolerant of patients and families who don't meet traditional stereotypes. At times, the staff has to be reconditioned through training to react appropriately rather than dismissing their perceptions as possible bias, he said. Another effective deterrent, aside from training, has been shown to be the use of canine patrols, he added. (See sidebar.)
Dr. Behnam said she is hopeful defensive training will become more commonplace. And she wants it to be preventive. “But it seems like we are always being retrospective. It seems to take an incident to make a change,” she said.
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A One-Dog Security Force
Here comes the judge. That's what the emergency staff at Long Beach Memorial Medical Center in California can say now that a Rottweiler named Judge is on the job. He's a newbie on the medical center's canine security detail, but he has the laser focus of a London barrister and the disposition of your sweetest school teacher, according to Joe Cruz, the medical center's director of security.
But don't let those liquid-puppy eyes fool you. Judge is a force to be reckoned with if violence breaks out, Mr. Cruz noted. Like his predecessors dating back 15 years, Judge is trained to keep order in a place where that can mean the difference between life and death. “Sometimes, all we need to do is walk by,” and any arguing in the waiting area dwindles into a whisper, Mr. Cruz said. Anyone using loud, harsh words “just stops when they see the dog. It just stops right there, and then there's an apology.”
Canine security is effective if “done right,” said William Nesbitt, the president of Security Management International, Inc., in Newbury Park, CA. Dogs are visible, they command respect, and “you can't con a dog,” he said.
He recalled one of his first encounters with guard dogs in a hospital. The concept seemed risky to him, and he admitted that he went in with a negative bias. “Well, I changed my mind,” he said. “It works. It certainly is a deterrent.”
Statistics on such canine security “tools,” as they are called, aren't available so it isn't known how many hospitals and medical centers use dogs as an antiviolence measure. A large cluster of hospitals in the Southern California area does, however, in part because word spread once a few of them, like Long Beach Memorial, reported success with canine patrols.
Four-legged security guards warrant some special considerations, however. The dogs cost $8,000 to $10,000, they require a designated and specially trained handler from the security staff (who also agrees to house them), and they occasionally develop complications that make them incapable of continuing for the typical decade of service. Judge, for example, replaced a dog that contracted cancer after only a few years.
Judge has shown great control — the ability to take commands and the capacity to do so without excessive reaction — since his arrival this winter, and he has an unusually smooth temperament, Mr. Cruz said. A hospital dog like Judge has to be able to overwhelm an aggressive individual on cue, but he also needs to be able to be hugged by children. Judge is a master at both, he added.
Unlike some past dogs at Long Beach Memorial, Judge has become known for “prancing” in the corridors. “He is so light on his feet … and he hasn't bulked up yet,” Mr. Cruz said, explaining that the paces Judge is being put through to learn his guard duties literally make him a lightweight, slimmed down from “a lot of training, a lot of exercise.”
More than 20 years ago, on the other side of Los Angeles County, Pomona Valley Hospital Medical Center instituted security dogs. The neighborhood around the medical center had a gang presence, and some of that activity was spilling over into the hospital, explained Kathy Roche, a spokesperson for the facility. A proposal for arming security guards was discussed at the time, but then the idea of a canine program surfaced. As soon as it was implemented, “the whole tenor of what was happening changed — it was quelled,” she said.
As for the dogs, they are now considered an integral part of the security staff. “They make great employees,” Ms. Roche said. “They love working. They never complain, and when they retire, they don't have to worry about benefits.”
— Anne Scheck
▪ Read about the pepper spray incident in a Pittsburgh ED at http://bit.ly/EDpepperspray.
▪ An article about the staff in a Texas ED subduing a crime suspect who grabbed the arresting officer's gun is available at http://bit.ly/vebkb0.
▪ Comments about this article? Write to EMN at email@example.com.