What if you woke up every morning scared to go to work? That thought is a stark reality in some parts of the world, like Turkey, where 70 percent of all physicians say they have been targets of a physical attack. (Global Post August 26, 2014; http://bit.ly/ZC8PnL.)
Some 88.6 percent of physicians and staff working in one of three emergency departments in Denizli, Turkey, in fact, said they had been subjected to or witnessed verbal violence, and 49.4 percent had experienced or witnessed physical violence. (Adv Ther 2006;23:364.) Nearly 85 percent of ED staff at five emergency departments in Tabriz, Iran, reported at least one episode of violence in the three months preceding the study, and nearly all reported stress, anxiety, depressive moods, or job dissatisfaction. (Int J Hosp Res 2013;2:11.)
What's even more unsettling is that these events aren't just across an ocean; violence in U.S. emergency departments has been an ongoing problem that hasn't slowed for decades. A significant part of the problem, however, is the paucity of research, not just in the United States but in Europe, the Middle East, and beyond.
“If you talk to anyone who's worked in an emergency department for any length of time, it's hard to find somebody who hasn't been a victim of verbal, sexual, or physical violence,” said Terry Kowalenko, MD, the health system chair for the Beaumont Health System and a professor of emergency medicine at the University of Michigan.
Sixty-seven percent of ED staff experienced at least one episode of sexual harassment from patients or visitors during the previous six months, and 50 percent experienced at least one physical assault from patients or visitors, according to a 2011 study. (Adv Emerg Nurs J 2011;33:303.)
The patient population and accompanying visitors within the ED are two roots of violence against EPs. “Somebody may come in and not appear violent initially but may become violent because of longer wait times, no satisfaction with the service, or not getting what they wanted. There's a subset of patients that if they don't get whatever it is they came in for, whether it's pain medication or whatever, they become violent,” Dr. Kowalenko said.
Verbal threats were the most common form of ED-related violence (74.9%), but 28.1 percent of the 177 emergency physicians who responded to the survey said they were victims of physical assault. Female EPs were more likely to have experienced physical violence than men, and 42 percent of EPs admitted to carrying a gun, knife, or other weapon for protection. (Ann Emerg Med 2005;46:142.)
Dr. Kowalenko said the first step toward reducing workplace violence is better training. “In some of our studies, nearly half of the workers didn't get any training to begin with,” he said. “I think that number has improved recently. So, that's changing. It's become more and more of a requirement.
“Right now, there's no training tool that's used across the country. So, a lot of people keep doing whatever they think is right. A lot of the training frankly is what you do once the patient becomes violent. I think more emphasis needs to be put on the front end and that security has to play a big role. There needs to be a security presence that is meaningful,” Dr. Kowalenko said.
Judy Arnetz, PhD, a professor of family medicine and public health sciences at Wayne State University School of Medicine in Detroit, said ED staff with whom she has spoken said uniformed security officers would certainly be a deterrent to violent behavior. Dr. Arnetz, the lead author of a federally-funded study that researched the hazard risk matrix approach to reduce workplace violence, found that a matrix could predict which hospital units were at high risk for violence. Risk assessment matrices have traditionally been used by the U.S. military and in industries with higher risks for occupational hazards, like mining, but she found it was applicable in hospitals as well, where a patient was the perpetrator in 75.3 percent of the incidents at the five emergency departments studied. (Am J Ind Med 2014;57:1276.)
The Joint Commission has weighed in as well. The June 2010 issue of Sentinel Event Alert identified causal factors to violence in the workplace, according to their event database that includes 256 reports since 1995. The factors included poor leadership in policy and procedure development and implementation, noted in 62 percent of the events; communication failures among staff, patients, and visitors, found in 53 percent of events; and the physical environment, noted in 36 percent of the events, which had flaws in general safety and security procedures and practices. The commission emphasized the need to provide more effective education, including training for violence management, conducting a violence audit and risk assessment walk-through, and learning techniques for identifying potentially violent patients, among others. (Sentinel Event Alert June 3, 2010; http://bit.ly/1xWcp7K.)
It also outlined suggested actions that health care organizations can take to prevent violence and injury, one of which is specific to EDs. “Take extra security in the Emergency Department, especially if the facility is in an area with a high-crime rate or gang activity. These precautions can include posting uniformed security officers, and limiting or screening visitors (for example, wanding for weapons or conducting bag checks),” the document said.
The Iranian study that found widespread violence in Tabriz EDs also revealed that certain strategies reduced these aggressive incidents. Primary among them was having fixed chairs in the waiting room (84.5%), followed by employing enough experienced staff (60%) and staffing the ED with an adequate number of security officers (20.9%). (Int J Hosp Res 2013;2:11.)
OSHA's Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers also noted that the prevalence of handguns and other weapons among patients, their families, and their friends contribute to the problem, which could be solved by installing metal detectors. OSHA also pointed to low staffing levels during times of increased activity such as meal times, visiting times, and when staff is transporting patients as when violence is more likely to occur. Poorly lit parking areas also contribute to violence just outside the ED. (http://1.usa.gov/1ub2tDz.)
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Making the ED Safe
EDs can use the following guidelines and strategies to help maintain a safer work environment.
- Emergency Nurses Association Workplace Violence Toolkit: http://bit.ly/1zdRqlb.
- OSHA Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers: http://1.usa.gov/1ub2tDz.
- CDC Workplace Violence Prevention Strategies & Research Needs: http://1.usa.gov/1qDMrRN.
- FBI Workplace Violence Prevention: http://1.usa.gov/1F5Szfa.