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    Rising violence in the emergency department

    Nearly 50% of emergency physicians say they’ve been assaulted. 70% of emergency nurses report being hit or kicked on the job. So what’s the solution?

    Police line tape across an emergency department room

    Since 2018, Amy Prescott, MD, has worked as a resident at MedStar Georgetown University Hospital in Washington, D.C. About six months ago, one of her colleagues, an experienced emergency department (ED) nurse, was punched in the face by a patient. “It was super scary,” Prescott says of the assault, which sidelined her colleague for months. Prescott still plans to work as an emergency medicine physician — she loves the teamwork and intellectual challenges — but she knows the dangers are inescapable. As a resident, she’s endured verbal — but not physical — abuse, and she says she’s developed a “Spidey sense” for when patients are becoming aggressive. But sometimes she wonders: Have I just been lucky?

    It’s a question many providers are asking. Roughly 70% of emergency nurses say they’ve been hit and kicked on the job and 47% of emergency physicians say they’ve been assaulted, a 2018 survey by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) found. Health care workers are four times more likely on average to suffer from serious workplace violence (incidents where an injured worker needs time off to recuperate) than those in private industry, Occupational Safety and Health Administration (OSHA) data shows. And nearly 70% of physicians in the ACEP/ENA survey said that emergency department violence is increasing. Cleveland Clinic CEO Tom Mihaljevic, MD, called the problem “a national epidemic” in his 2019 “State of the Clinic” speech: “Daily, literally daily, we’re exposed to violent outbursts, in particular in our emergency rooms,” he said.

    Every physician and nurse interviewed for this story has experienced or witnessed violent acts, including biting, scratching, spitting, kicking, and punching. Some patients have thrown objects, they say, including chairs. Others have yanked out IVs and threatened to fling blood at providers. “I’ve had to change my clothes because a patient threw feces at me and it hit me on my shirt,” says Avir Mitra, MD, assistant professor of emergency medicine at the Icahn School of Medicine at Mount Sinai. “We’ve had patients intentionally urinate on nurses. One of our nurses who's been working in the ER for 30 years came out of a room, bleeding from scratches. And there are so many instances of verbal and emotional abuse.”

    “He said, ‘I know your shift ends at 11 o'clock. I know where the doctor’s lot is. I’ll be waiting for you.’ I was truly afraid for my safety.”

    Terry Kowalenko, MD

    Medical University of South Carolina College of Medicine

    Physical violence and verbal assaults — e.g., insults, threats, sexual and racial harassment — all fit the Department of Labor’s definition of workplace violence. And workers are increasingly pushing for change. In 2018, ACEP and ENA launched a joint campaign called “No Silence on ED Violence.” Twenty-nine states have passed laws that increase the penalties for harming health care workers, says Terry Kowalenko, MD, chair of the Department of Emergency Medicine at the Medical University of South Carolina College of Medicine, who studies workplace violence. In November 2019, the U.S. House of Representatives passed the Workplace Violence Prevention for Health Care and Social Service Workers Act, which would require employers to investigate incidents and provide training to employees, among other requirements. The bill is currently awaiting action in the Senate.

    As Kowalenko says, “I think many healthcare professionals have said, ‘Enough is enough.’”     

    Too Many Patients, Too Little Reporting

    The reasons for rising violence are numerous — mental health issues, drug abuse, understaffed emergency departments — but multiple experts emphasize the increase in ED patients. ED visits rose from 94.7 million in 1995 to 142.6 million in 2016, the American Hospital Association reports, and nearly half of U.S. hospital-associated medical care is delivered by emergency departments.

    “So many people are shut out of healthcare and they’re coming to the emergency department for everything,” says Mitra. “They’re coming for primary care, for social services, for food. We're like the safety net.”

    Frustration with the health care system is also a factor. “When you cram an underresourced ER with people who need help, and who can’t get help, patients will become agitated,” says Jimmy Choi, MD, a martial arts instructor, emergency department physician, and co-founder of My Occupational Defense, a San Francisco-based company that teaches self-defense to companies and employees (about half of his business is from health care facilities). Choi mentions a frustrated patient who started throwing clipboards at staff. “There’s volume, volume, volume, and a lack of resources to address that volume,” says Choi.

    Increasing levels of hostility in America could also be a factor, many physicians say. Ninety-three percent of Americans believe that the nation has a civility problem, a 2019 survey found. But many doctors and nurses shrug off physical and verbal abuse as simply part of the job. In the 2007 Minnesota Nurses Study, which asked 6,300 randomly selected nurses to describe their experience with work-related violence, nurses were more likely to say that assault was an expected part of their work than a control group.

    That culture contributes to a lack of reporting on violence. Only 69% of physical assaults and 71% of non-physical assaults were reported to a manager in the Minnesota Nurses Study. Bullying and verbal abuse are particularly prone to underreporting, according to OSHA, even though they can be as frightening as physical violence. Kowalenko says his scariest ED moment came when he refused to give a patient narcotics. “He said, ‘I know your shift ends at 11 o'clock. I know where the doctor’s lot is. I’ll be waiting for you.’” Kowalenko did paperwork and other jobs until 1 a.m. and then asked a security guard to walk him to his car. “I was truly afraid for my safety,” he says.

    “I think we need more security and more of a culture change, where things that wouldn’t be acceptable in the outside world shouldn't be acceptable in the emergency department.”

    Avir Mitra, MD

    Icahn School of Medicine at Mount Sinai

    The “part of the job” attitude isn’t the only reason for what Kowalenko calls “gross underreporting” of workplace violence. Staff can feel discouraged if a hospital responds tepidly — or not at all — to a serious incident. Other reasons can include lack of a reporting policy, fear of retaliation, and cumbersome procedures. “If you’re a nurse who just worked 12 hours, and you were shoved by a patient but didn’t sustain any injuries, are you going to take 20 minutes before you go home to fill out some form?” Kowalenko asks.

    And yet, reporting is essential for good decision-making. “Administrators don't know you have a problem until they have data that shows it,” says Kowalenko. “And whether it’s metal detectors, whether it’s increased security — all of this stuff costs money. And no administrator will give you the money to train your staff, which costs tens if not hundreds of thousands of dollars, to solve a problem that they perceive is not there.”

    Finding Solutions

    What steps can hospitals take to reduce workplace violence? Experts recommend the following:

    Establish clear policies. Hospitals need policies and procedures for dealing with workplace violence and investigating incidents. The policies should be shared with staff and communicated to patients. (That could even include posting signs that state: “This is a zero-tolerance environment for violence and verbal threats.”) Johns Hopkins University, for example, has established clear policies as part of its “Safe at Hopkins” program, which covers everything from bullying to violence to disrespectful behavior.

    Enforce policies consistently. Consistency is important even for something as simple as visiting room policies, says Kowalenko. If the policy states that a patient can only have two visitors, and one nurse follows the rules, and another doesn’t, the result can be anger and frustration. “We need to have guidelines, policies, procedures, and consistent behavior by the caregivers themselves,” Kowalenko says.

    Offer training (particularly de-escalation training). Training should be mandatory and ongoing — not an easy-to-forget, one-time session. “These things need to be practiced,” says Pat Finan, MD, a third-year resident at MedStar Georgetown University Hospital. “It can help us work on de-escalating and noticing things we say that might be inflammatory and exacerbating the problem rather than solving it.” Kowalenko believes that de-escalation training should not just be for nurses and techs, but for anyone who interacts with a patient. “I’d want even housekeeping and volunteers to get training,” he says. At the Staten Island University Hospital, all staff members receive two days of training that covers everything from self-protection to the conditions and patterns that can lead to aggressive behavior.

    Increase security. In the 2018 ACEP/ENA survey, nearly half of respondents said that hospitals could do more to protect workers by adding security, cameras, and metal detectors, as well as increasing visitor screening, especially in the emergency department. The Cleveland Clinic uses metal detectors, but it takes others steps as well. Security guards inspect visitors’ bags. Staff ID badges include wireless panic buttons. Plainclothes officers patrol in the ED. “I think we need more security and more of a culture change, where things that wouldn’t be acceptable in the outside world shouldn't be acceptable in the emergency department,” says Mitra.

    Study your space. Improvements can include better lighting, clear evacuation plans, badge detectors, mirrors (so that no area is hidden), removing potential weapons (such as IV poles, which are now frequently built into beds), and reducing the number of exits and entrances. Choi also recommends being more aware of your surroundings. At the Bay Area ED where he works, paramedics once transferred a drunk patient from a gurney onto a bed. When the patient became violent, a nurse was trapped in the corner because the gurney blocked her access to the door. “Simple things like preplanning can prevent those types of situations,” he says. ACEP offers a free guide on the subject titled Design Considerations for a Safer Emergency Department.

    Protect against cyber stalking. “I believe threatening behavior on the Internet and social media is going to be the next area of concern,” says Kowalenko. Many nurses now cover their last names on their badges with tape, he says, to prevent patients from discovering where they live.

    Many emergency department professionals worry not only that violent incidents diminish the quality of care for patients, but also that it’s causing physicians and nurses to rethink their careers. Mitra, an emergency department physician for five years, recently experienced an epiphany when a young man with a minor injury grew angry in the ED. “He started yelling, ‘If you don't see me now, I'm going to kill every single one of you,’” Mitra recalls. “We hear these types of threats a lot, but in that moment, something struck me: You shouldn't be able to say that to another person. I mean, if you were at a grocery store and threatened to kill a clerk, you might get arrested.”

    Knowing that your workday may include threats or hate speech or violence leads to persistent, low-level anxiety, he says. “I definitely see nurses and physicians saying, ‘You know, I’m going to go work in the urgent care because this is so crazy,’” Mitra says. “I hope to keep working in the ER, but maybe in 20 years, I'll be one of those people that says, ‘Enough is enough.’ I hope by then we’ve made some progress.”