Violence in the Emergency Department
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This document discusses violence against healthcare workers in emergency departments. It notes that nursing staff in emergency departments face a greater risk of harm from violence than those in other clinical areas. Violent incidents can have rippling psychological and professional effects, including post-traumatic stress disorder, burnout, and nurses leaving the profession. While there is no absolute definition, violence generally presents as physical or non-physical acts. Contributing factors include long wait times, mental illness, and alcohol. The document recommends training programs in de-escalation, communication, and security measures to help address this issue.
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Violence in the Emergency Department
- 1. Violence in the Emergency Department Edward D. Struzinski, RN, CEN, CCRN
- 2. Introduction Violent & aggressive incidents on the rise. Nursing staff in EDs are at much greater risk of harm than those in other areas (Gillam, 2014). “Major portal of entry into healthcare” (Ogundipe, 2013). Unknown, unscreened, unpredictable. Sixty-nine deaths to healthcare workers in four years (Pich, Hazelton, Sundin, & Kable, 2010).
- 3. Rippling effects … Psychological Post-Traumatic Stress Disorder Anxiety / Depression Job stress Burnout Job performance and satisfaction Leaving Healthcare
- 4. Definitions No absolute definition exists due to broad issue. Violence and aggression presents in two forms. Physical Non-physical
- 5. Factors Waiting times. Anxiety / Frustration. Expectations of care. Alcohol. Mental illness.
- 6. Process of conflict De-humanization – the process of viewing each other as less than human, and therefore undeserving of civilized or otherwise normal treatment or what are generally accepted as fundamentally right (Conflict Research Consortium, 2005). Projecting fault onto opposing individuals. Escalatory spirals (Wilmot & Hocker, 2007).
- 7. Fuel for the fire Attitudes. Untrained individuals. Un-met needs. Poor communication. Power struggle. Suddenly .................. Struzinski, E. (2005). Arson watch. [Photograph].
- 8. “He needs 10 and 2” Struzinski, E. (1999). Charles’s Law. [Photograph].
- 9. De-sensitization Overwhelming perception from healthcare workers that violence is an inevitable part of emergency rooms (Pich et al., 2010). Downplaying of event, minimizing significance. Under-reporting.
- 10. Under-reporting Lack of time (Touzet et al., 2014). Considered waste of time due to unsupportive or administrative response (Pinar & Ucmak, 2011). Apologies from abuser (Taylor & Rew, 2011). Fear of retaliation (Kowalenko, 2013).
- 11. Room for improvement? Training. Security measures. Communication. Leadership and support.
- 12. Solutions Environmental considerations. Security/ Police presence – KCMH vs SCH vs YNHH. Video surveillance & personal alarms – BMC vs YNHH. Administrative support. De-escalation training – CHA.
- 13. De-escalation Training Early identification. Recognizing an evolving incident is crucial to helping to prevent it from worsening (Touzet et al., 2014). STAMP acronym for early identification. Upset individuals often Stare, change their Tone of voice, show Anxiety, Mumble, and Pace back & forth (Pich et al., 2010; Taylor & Rew, 2011).
- 14. De-escalation Training De-escalation begins with a connection. SOLER approach to listening. Sit squarely. Open posture. Lean forward. Eye contact. Relax framework (Powley, 2014). Relationship. Understand why individual is acting out. Offer solutions.
- 15. Conclusion Emergency Rooms are at greater risk for violent episodes than most other areas. Nurses generally take the hit. Rippling effects. Under-reporting. Training, training, training.
- 16. References Conflict Research Consortium, University of Colorado. (2005). Dehumanization. Retrieved from http://www.colorado.edu/conflict/peace/problem/dehuman1.htm 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., Miller, M., & Howard, P. (2012). Emergency department workers’ perceptions of security officers’ effectiveness during violent events. Work, 42(1), 21.-27. Kowalenko, T., Gates, D., Gillespie, G., Succop, P., & Mentzel, T. (2013). Prospective study of violence against ED workers. The American Journal of Emergency Medicine, 31(1), 197-205. doi:10.1016/j.ajem.2012.07.010
- 17. References Ogundipe, K., Etonyeaku, A., Adigun, I., Ojo, E., Aladesanmi, T., Taiwo, J., & Obimakinde, O. (2013). Violence in the emergency department: a multicentre 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.
- 18. References Struzinski, E. (2005). Arson watch. [Photograph]. Struzinski, E. (1999). Charles’s Law. [Photograph]. Taylor, J., & Rew, L. (2011). A systematic review of the literature: workplace violence in the emergency department. Journal of Clinical Nursing, 20(7/8), 1072-1085. doi:10.1111/j.1365-2702.2010.03342.x Touzet, S., Cornut, P., Fassier, J., Le Pogam, M., Burillon, C., & Duclos, A. (2014). Impact of a program to prevent incivility towards and assault of healthcare staff in an ophtalmological emergency unit: study protocol for the PREVURGO On/Off trial. BMC Health Services Research, 14(1), 40-56. doi:10.1186/1472-6963-14-221 Wilmot, W., & Hocker, J. (2007). Interpersonal conflict (7th ed.). New York, NY: McGraw-Hill.
Editor's Notes
- Violence in the emergency department is an important issue to discuss in nursing and in healthcare in general because it has steadily been on the rise for an unknown amount of time. It has likely been around for as long as nursing first came to practice. There is generally not much discussion about the issue because of perceptions that violence and upset individuals simply comes along with the job of caring for one another. It then becomes a tolerated issue. Nursing care in the emergency department Is highly volatile for several reasons, including the unpredictability of medical and trauma incidents that arrive daily. Individuals are generally unknown to the caregivers, unscreened prior to entering, and with unknown intentions. Perpetrators of violence are usually males (patients and visitors alike) and most violence occurs on off-shift hours toward the weekends.
- Violence in all forms and in all settings can have dramatic and lasting effects. At the center is psychological trauma to the victim. This can have profound effects on the nurse’s ability to care for patients and in one’s general performance on the job. According to Taylor and Rew (2011), the effects of violence are profoundly substantial and costly, with millions spent on medical/ legal expenses, injuries and rehabilitation, missed time from work, etc.
- There is no set definition of violence happening in the emergency department because the category is so broad and diverse, along with the variability from individual to individual on what constitutes a violent act. Acts are categorized into two main categories: physical and non-physical. Physical is everything with contact, including punching, kicking, being pushed, held, spit upon, etc. Non-physical forms are stated as verbal violence and can actually be far more terrorizing and psychologically lasting than being physically assaulted. Theses include swearing, yelling, threats, and gestures made by the assailant that are intended to induce fear. Fear is the weapon of choice because it is quite effective.
- Factors that are identified as the spark for violence initiating are related to time. Waiting can be very frustrating and fearful to an individual who is worried about a loved one and feels removed from the situation and not in control. Anxiety builds. There is also a high level of expectancy in the healthcare industry, especially within the emergency department, where all situations are considered emergent issues. Additionally, across the literature, alcohol and mental illness have been identified as common denominators of the perpetrators of violence and aggression.
- De-humanization and escalatory spirals are part of the process of a situation growing out of control. De-humanization serves as a “removal” of the individual initiating conflict. As one removes themselves further from the targeted subject, it is easier to demonstrate violence and aggression toward them because they are considered to be not the same as the provoking person. “Escalatory conflict spirals have only one direction – upward and onward. They are characterized by a heavy reliance on over power manipulation, threats, coercion, and deception” (Wilmot & Hocker, 2007, p.21).
- Attitudes cannot be over-emphasized as one of the strongest fuels that adds to a fire. The old saying about attracting more flies with honey than vinegar is a good comparison to approaching angry individuals. It can become even worse when individuals not trained in psychology believe they can make the difference or do not call for help. One study expressed that some emergency department staff members chose not to call for help from security, believing they could handle the situation non-violently (Gillespie, Gates, Miller, & Howard, 2012).
- Violence in the emergency department occurs so often that we inevitably become de-sensitized to the subject. This is a causative factor in how we respond to the event and how we move on to handle it in the future. Under-reporting of violence is immeasurable.
- Literature that investigates the under-reporting of violent outbursts in the emergency department shows several similar reasons. Nurses are already overburdened in work and normal charting and feel they simply cannot make the time to fill out yet another form. It is also considered a waste of time given the negative response perceived or received from management, who sometimes frown upon it. There is forgiveness of the event, especially when apologies are offered. And, lastly, fear of retaliation from all angles.
- By far and large, across the literature, there is a lack of formal training that occurs for the prevention of violence erupting. Improvement in security measures could include not allowing subjects into the emergency department who are known to be under the influence of alcohol, a major factor in violent situations. Communication could and should be enhanced into the waiting areas, combined with more effective distraction methods.
- Kent County Memorial Hospital (KCMH) offers training of their security personnel by a former police officer. They are a hands-on security force, trained in safely interacting with patients, especially physically. Contrast this to South County Hospital (SCH) that has a single individual whose sole purpose is to round the hospital and parking lots, no patient interaction is expected or allowed. Meanwhile, at Yale-New Haven Hospital, protective services are duly-sworn officers having arrest powers and are fully armed. Baystate Medical Center (BMC) is similar, but without firearms. The three hospitals making up Cambridge Health Alliance (CHA) provide mandatory de-escalation training as part of everyone’s general orientation, performed every month.
- A major part of de-escalation training is early identification of anger and frustrated individuals. One of the methods taught is the STAMP acronym for early identification, an easy reminder outlining the most common clues that are seen in angered individuals as they escalate. Early identification and early intervention can suppress the a growing situation from turning violent.
- SOLER is another acronym taught in de-escalation training. It is an easy reminder to the nurse or other staff member about how to approach an angry individual and show your willingness to actively listen to them. The “leaning forward” portion is a controversial aspect because one must still be cognizant of their own safety and getting closer to a situation that is already a dangerous one. An alternate, more safe body stance to take is one in which the hips and shoulders are forward to the aggressive individual and both feet slightly set apart. This provides not only stability to remain standing if pushed, but also reducing the opportunity to be struck in vital areas of the body because of how it is turned away/ positioned from the aggressor.