3rd essay in a series highlighting the significant issue of violence occurring in the Emergency Room.

1. Running head: EMERGENCY ROOM VIOLENCE: SOLUTIONS 1
Emergency Room Violence: Solutions
Edward Struzinski
Kaplan University

2. EMERGENCY ROOM VIOLENCE: SOLUTIONS 2
Emergency Room Violence: Solutions
This is the third essay in a series surrounding the issue of violence seen in healthcare,
specifically in the emergency department. It is a significant subject for reasons including patient
and staff safety, poor training, under-reporting of events, and injuries incurred that can have
lifetime consequences. Death to healthcare workers has resulted from violent outbursts occurring
in the hospital: deaths that were in all likelihood, senseless acts of aggression that could have
been prevented had potentials solutions been identified and followed. To that end, this essay
shall discuss ideas and actions that have been shown to reduce violence in the emergency
department, including concepts that are evidence-based in literature. A detailed discussion will
follow in regard to the presence of security personnel and other measures, de-escalation training
programs, and finally environmental considerations.
Security: A peaceful presence or fueling the fire?
In considering the topic of violence, the idea of safety and security automatically comes
to mind. How can it be achieved? The Occupational Safety and Health Act (OSHA) was enacted
in 1970 to protect employees from harm occurring to them on the job, and that it is the duty of
employers to maintain all workers are free of workplace hazards that can lead to death or
physical harm, including acts of workplace violence (Gillespie, Gates, Miller, & Howard, 2012;
U.S. Department of Labor, 2014). The presence of security personnel posted in the emergency
department to achieve a safe and secure environment, free from violence and any possible
aggression from patients and/or visitors, seems logical. But a literature review indicates that
security officials also lead into the problem, inciting more violence. Participants in one study
stated that contacting security was comparable to raising the stakes or ante in a poker game and
even pouring gasoline on a fire (Gillespie et al., 2012) because of their interpersonal skills and

3. EMERGENCY ROOM VIOLENCE: SOLUTIONS 3
treatment toward individuals who are already showing aggression. This can have greater
negative effects than positive returns, especially when a strong personality or drill-sergeant type
attitude is injected into an already hostile situation. Not every upset individual will respond
positively to being commanded to calm down, just like not all fires can be extinguished with
water. Some turn dramatically worse when it is applied. However, despite any negative
consequences and undesirable approach security personnel may have on a situation, participants
across the studies unanimously agreed they are a substantial and integral part in maintaining
overall safety in the emergency department and that a uniformed presence of a guard actually
lowered violence from erupting (Gillespie et al., 2012).
Re-modeling of approaches
To that end, appropriate training of personnel and certain environmental considerations
have been proven through evidence-based practice to reducing aggression or escalating it further.
Strong consideration to building design of the hospital and layout of the emergency department,
authorized-access only zones, and surveillance systems can all help control the flow of people,
adding to staff protection (Pinar & Ucmak, 2011). Other points to ponder influencing violence in
the emergency department is long waiting times and over-crowding. Building design can help
alleviate the issue of over-crowding, though the issue of impatience of people will still exist
despite the best architectural layout. The expectancy from patients and visitors for healthcare
workers to expedite processes is often a factor in frustration and escalating tempers, though it is
also variable to culture. Americans, living in a technology-driven era that is focused on
everything from internet and downloading speeds to time spent at a drive-thru or watching for
the stoplight to turn green, are generally far less forgiving with regard to waiting. According to
Pich, Hazelton, Sundin, and Kable (2010), the majority of violence erupting happened within the

4. EMERGENCY ROOM VIOLENCE: SOLUTIONS 4
first hour of presenting to the emergency department with patients assigned a triage level of three
or four and expected to might wait about one hour. Knowles, Mason, and Moriarty (2013) also
found that the duration of waiting are directly related to and contribute to violence erupting in the
emergency department. Incorporating advocacy into the waiting room, staff training, and
considering structural design of the emergency department have all been suggested as avoidable
strategies (Ogundipe et al., 2013) to use against the initiation or escalation of violence.
De-escalation is one such training to consider. It focuses on a psychological approach to
dealing with upset individuals and developing a relationship that effectively makes a connection
showing empathy for the individual. This type of training is important for several reasons,
notwithstanding the skills acquired to recognize a dangerous situation but how to deal with it.
Evidence has demonstrated that de-escalation training that is routinely performed was positively
correlated with a lower incidence of violence occurring. A twenty-three percent drop was
associated with the trainings in a one-year study by researchers. According to Gillam (2014),
monthly records of code purples, the hospital code for a violent situation, were decreased when
greater percentages of staff received non-violent crisis intervention education in the previous
three to five month window of time.
Conclusion
As violence in healthcare increases, and recalling it to be a problem for all emergency
departments worldwide, considering all options that can help prevent these occurrences from
first happening is vital to patient and staff safety. Uniformed security guards, although not
necessarily all trained in formal police tactics, have demonstrated to be a deterrent of violence by
their very uniformed appearance alone. Waiting time reduction methods using diversionary ideas
or placing a volunteer to act as a patient advocate can mitigate incidence of violence occurring

5. EMERGENCY ROOM VIOLENCE: SOLUTIONS 5
while waiting to be seen. Finally, training programs in de-escalation techniques is another
preventable measure to take, though it is costly to invest a training program into individuals who
may not show longevity with the hospital. However, all violence comes with an unpredictable
amount of risk, from bruises to death, and it is impossible to estimate the cost of the
consequences from a violent event. Gillam (2014) raises the unavoidable question if, based on
the amount of participants in the study, spending nearly one percent of an annual payroll worth
the investment to see a twenty-three percent reduction of violence? The answer may not be as
clear to many administrators operating on strict budgets, as it would be to the nurses and other
staff who bear the burden of most violence in the emergency department. Powley (2013) states
that all emergency department staff should be trained to identify and approach violent or
aggressive individuals for their own safety and the safety of others. Recall that the Occupational
Safety and Health Act was enacted over forty years ago to promote safety in the workplace, a
safety that is worth every penny invested.

6. EMERGENCY ROOM VIOLENCE: SOLUTIONS 6
References
Gillam, S. (2014). Nonviolent crisis intervention training and the incidence of violent events in a
large hospital emergency department: An observational quality improvement study.
Advanced Emergency Nursing Journal, 36(2), 177-188.
doi:10.1097/TME.00000000000000
Gillespie, G., Gates, D. M., Miller, M., & Howard, P. (2012). Emergency department workers'
perceptions of security officers' effectiveness during violent events. Work, 42(1), 21.
Ogundipe, K., Etonyeaku, A., Adigun, I., Ojo, E., Aladesanmi, T., Taiwo, J., & Obimakinde, O.
(2013). Violence in the emergency department: A multicentre [sic] survey of nurses'
perceptions in Nigeria. Emergency Medicine Journal: EMJ, 30(9), 758-762.
doi:10.1136/emermed-2012-201541
Pich, J., Hazelton, M., Sundin, D., & Kable, A. (2010). Patient-related violence against
emergency department nurses. Nursing & Health Sciences, 12(2), 268-274.
doi:10.1111/j.1442-2018.2010.00525.x
Pinar, R., & Ucmak, F. (2011). Verbal and physical violence in emergency departments: A
survey of nurses in Istanbul, Turkey. Journal of Clinical Nursing, 20(3/4), 510-517.
doi:10.1111/j.1365-2702.2010.03520.x
Powley, D. (2013). Reducing violence and aggression in the emergency department. Emergency
Nurse, 21(4), 26-29.
U.S. Department of Labor. (2014). OSH Act of 1970, Sec. 5. Duties. Retrieved from
https://www.osha.gov/pls/oshaweb/
owadisp.show_document?p_table=OSHACT&p_id=3359

7. EMERGENCY ROOM VIOLENCE: SOLUTIONS 7