Addressing ED Workplace Violence

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Dealing with an often unrepresented issue starts with prevention and care collaboration.

Sexual assault, physical assault and other forms of violence in the emergency department (ED) no longer shock clinicians — especially those who work in understaffed, high-volume hospitals. Alarmingly, many healthcare workers come to expect workplace violence, so much so that it is underreported. [1]


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But in 2020, it should be getting our attention.

A 2018 report [2] published by the American College of Emergency Physicians (ACEP) — based on a survey of more than 3,500 respondents — indicates nearly 75 percent of emergency physicians personally witnessed other staff members being assaulted at work. Nearly 7 in 10 physicians believe violence has increased over the past five years, while about half of the ED physicians polled said they’ve been physically assaulted on the job, with a shocking 60 percent of assaults occurring over the previous year.

Unfortunately, the problem is in no way limited to physicians. In an Emergency Nurses Association (ENA) survey of 147 staff members in a Level 1 Shock Trauma center, 88 percent reported [3] that they experienced some kind of exposure to workplace violence over the previous six months. The problem is also not just limited to physical abuse.


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According ACEP’s 2018 report, 96 percent of female ED staff reported receiving inappropriate comments or unwanted advances, while 80 percent of male physicians experienced similar treatment. With statistics like these, it’s no surprise that most ED staff feel that verbal abuse is just a part of the job.

The good news is we’re making some progress. Groups such as ACEP and ENA have developed guidelines and begun sharing best practices with healthcare leaders to prevent and mitigate violence, as well as reduce the stress and sources of workplace violence. Yet we still need to do more.

Invoking Change

Many healthcare leaders will point out that we’ve made tremendous progress in our response to workplace violence. We’re starting to see increases in security measures in hospitals, including metal detectors, better lighting, security cameras and more limited entry points.


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While this is a great start, here are some other steps that could be taken:

  1. Make a Plan

Healthcare professionals are four times [4] more likely to miss work due to workplace violence or injury than workers in any other profession, and these incidents are on the rise. Between 2012 and 2014, workplace violence doubled [5] for nurses and nurse assistants — and these statistics are likely severely underreported.

The National Institute for Occupational Safety and Health [6] recommends that EDs develop a protocol [7] for addressing workplace safety and security events. ED staff — including clinicians and non-medical personnel — should be regularly trained so they know the best practices for preventing and responding to any workplace violence they encounter, such as language to use to de-escalate an agitated patient.  Many risks of violence can be minimized or in some cases completely prevented through this approach.

  1. Implement an alert and tracking system

Employees should also be taught how to track and monitor patients with a history of violence. According to a study [8] conducted by Julie Stene, MHA MSN, RN, a former staff nurse in the Department of Nursing at Mayo Clinic Hospital-Saint Mary’s campus, the act of implementing a simple notification tool to monitor patients with a history of violence encouraged and increased reporting. Prior to a 2012 implementation in the ED of a large academic Level-1 trauma center, no incidents were officially reported. After implementation and system training, over 50 incidents were reported.

Similarly, CHI St. Anthony, a critical access, 25-bed hospital in Pendleton, Ore., has increased reporting with a similar tool, which alerts hospital staff when a patient with a history of violence is on premises. With this tool, the hospital increased workplace violence reporting rates by 20 percent, and in turn, received additional funding to establish an on-site security facility. Having a proximate security team increases workplace safety by significantly reducing response times and in many cases actually prevents incidents. These teams also ensure a clear protocol in case incidents occur.

Ideally, physicians or staff members will be able to respond quickly and appropriately to red flags, preventing a security encounter through an established action plan, including an implemented alert system.

  1. Communicate with Your Network

Beyond tracking and contacting law enforcement, ED staff must regularly communicate with other health facilities in their network. With a notification system in place that enables providers to share and exchange information, patients with violent histories are identified immediately upon check-in within any network facility. When ED staff and security are notified, they are prompted to implement violence-prevention plans to minimize or eliminate risk, which may include practices such as clinicians to pair up and avoid isolating themselves from a potentially violent patient.

Solutions in Action

When properly implemented, these strategies can work and pay dividends beyond risk reduction. Researchers predict [9] reduced incidents of workplace violence will lead to fewer time-off requests, prevent significant legal issues and costs, improve employee morale and elevate the quality of care.

EDs around the country are already seeing the benefit. Earlier this year, a patient sexually assaulted a nurse in an Oregon ED. That ED tracked the event and reported it into a care-collaboration platform. In the record details, the ED staff noted the patient name, medical record number, date of the incident and a physical description. Physicians detailed future patient care recommendations, including assigning a male staff member to the individual as well as alerting security personnel upon patient check-in. While they did not want to undermine the patient’s clinical care, they wanted to ensure safety for both the staff and patient while that care was administered.

A few days later, the same patient checked into an ED in California. Because the Sacramento facility used the same collaboration software as the Oregon ED, staff instantly received a security alert when the patient arrived. This alert allowed providers to follow their established violence prevention plan and the Oregon care team’s security notification care recommendations. The patient’s visit was incident free.

Fixing a Global Issue Starts Here

With consequences like job burnout and dissatisfaction for providers, it’s so important for the healthcare community to acknowledge and examine the best way to address workplace violence. Studies have shown that prevention is undeniably the best way to mitigate the issue. Through continued efforts to spread awareness, train emergency department staff, and maintain accurate security events, significant reductions in workplace violence will soon become a nationwide norm.

Efforts don’t have to end in the workplace. Healthcare leaders can reach out to their respective medical and nursing societies and associations to let them know that ED violence is a big problem. These organizations frequently work with lawmakers to draft legislation that benefits healthcare workers. They also pay attention to proposed rules to ensure workers are protected and preventive measures are detailed before new rules are enacted.

With the availability of technology-enabled collaborative solutions, care teams across the country can help keep one another safe. If we can continue to challenge traditional mindsets that ignore or downplay workplace violence, we learn to prevent these events through stronger communication — network by network. Improvement will ripple across the nation, creating a safer medical neighborhood for patients and providers alike.

References:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4403590/
  2. https://www.emergencyphysicians.org/globalassets/files/pdfs/2018acep-emergency-department-violence-pollresults-2.pdf
  3. https://pubmed.ncbi.nlm.nih.gov/28272178/
  4. http://asbbs.org/files/2019/JBBS_30.2_Fall_2018.pdf
  5. https://cas.byu.edu/cas/login?service=https%3A%2F%2Flib.byu.edu%2Fremoteauth%2F%3Furl%3Dhttps%253A%252F%252Fsearch.proquest.com%252Fdocview%252F2151195014%253Faccountid%253D4488
  6. https://www.cdc.gov/niosh/index.htm
  7. https://www.cdc.gov/niosh/docs/2002-101/default.html
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4403590/
  9. https://cas.byu.edu/cas/login?service=https%3A%2F%2Flib.byu.edu%2Fremoteauth%2F%3Furl%3Dhttps%253A%252F%252Fsearch.proquest.com%252Fdocview%252F2151195014%253Faccountid%253D4488

ABOUT THE AUTHORS

Ben Zaniello, MD, MPH, is the Chief Medical Officer at Collective Medical, the nation’s most effective network for care collaboration. Dr. Zaniello has worked in care transformation for over a decade, most recently at Providence St. Joseph Health as Chief Medical Information Officer in Population Health.

Mallory Keith is an employee at Collective Medical with a personal and academic interest in Workplace Violence, focusing on the subject as she completes an advanced degree.

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