60% of residents reported sexual abuse and workplace violence
We are vulnerable.
The emergency department is among the most frequent locations for violent events in the health care setting as patient flow is ever changing and patients often present with undifferentiated complaints and social issues.
If the mention of “workplace violence” made you recall experiences you have had in the emergency department, when a patient or a visitor may have harassed or even assaulted you or one of your colleagues, you are not alone. Let me share some statistics with you:
Prior studies have demonstrated that over half of physicians working in an emergency department have been physically assaulted by a patient or visitor at least once during their career. Multiple studies have demonstrated that more than three quarters of emergency resident physicians have been the victim of one act of workplace violence. And we know that the emergency department is the most frequent site for hospital shootings.
This is a problem that we need to urgently address. This is the mission that my residency co-chiefs and I sought to accomplish in our research project entitled, Workplace Violence and Harassment Against Emergency Medicine Residents, set to be published in the Western Journal of Emergency Medicine later this year. Prior to this study, our literature search demonstrated only one prior study that examined the emergency medicine resident experience of physician harassment, which was conducted by McNamara and colleagues in 1995.
Of course, being residents ourselves during this research study, we directly identified with the subjects of our work. About one year later, we all graduated from residency. As I began my first year as an attending physician, and my responsibilities and perspective shifted, I also noted that this study was also important as residents are a vulnerable population. Residents are physicians in training, and often lack a complete set of skills to both prevent and manage incidents of workplace violence. There are also often poorly defined institutional reporting systems and support systems for those who are victimized.
The purpose of the study we conducted was to quantify and describe the incidence of violence and harassment against emergency medicine residents by patients and visitors, as well as to identify perceived barriers to safety in the emergency department. The study involved three NYC-based emergency medicine residency training programs.
The primary outcome we sought to examine was the incidence of workplace violence as reported by emergency residents. Secondary outcomes included subtypes of violence experienced by these residents as well as perceived barriers to safety while on shift.
Approximately 84% of residents at the institutions studied completed the survey. These residents were queried regarding non-physical and physical experiences of violence at the hands of either patients or visitors. Non-physical violence was defined as verbal harassment, verbal threats, and sexual harassment. Physical violence was defined as being physically attacked by either a patient or a visitor.
Almost all residents (96.6%) of residents reported prior verbal harassment from a patient in the emergency department. Approximately 78% of residents reported experiencing verbal threats from patient, and 55.5% reported receiving verbal threats from a visitor. A concerning 65.5% of emergency medicine residents surveyed reported having at least one experience of physical violence committed by a patient.
Over half (41.9% males, 68.9% of females), of resident respondents reported experiencing sexual harassment from a patient. Being female increased the odds of experiencing an incidence of sexual harassment threefold. This finding is in line with other studies, particular those by Gates and colleagues who found that female emergency department staff reported a statistically significant higher frequency of sexual harassment from patients when compared to male staff. Few emergency department-based studies have looked further into the relationship between gender and vulnerability to and experience with workplace violence. As such, this area of focus is ripe for future study.
A statistically significant correlation was noted between post-graduate (PGY) level and frequency of violent incidents from patients (p = 0.002), with more incidents reported as PGY year increased (excluding PGY IV year). This emphasizes that there is a steady pattern of exposure over time of violence. It also demonstrates that years of experience do not appear to have a protective effect with regard to resident victimization.
When asked regarding patient factors that contribute to incidents of ED-based workplace violence, alcohol and illicit drug use, along with psychiatric and organic causes (i.e. dementia) were most frequently cited. Over two-thirds of residents surveyed reports that environmental factors, particularly lack of security or police presence and/or security or police not responding in a timely manner were the most common contributors to physical violence.
Alarmingly, almost half of the residents surveyed reported that they were either very or somewhat dissatisfied with the current security system in their emergency department.
Residents in the study were also queried regarding their prior training with violence prevention or de-escalation techniques that occurred within the past year. Only less than one fifth (16.8%) of residents had reported participating in such sessions. A study by Fernandes and colleagues looked at the use of an educational program, the Prevention and Management of Aggressive Behavior Program, would lead to a decreased in incidents of ED-based workplace violence. While some positive short term effects were noted, this intervention did not appear to decrease the incidence of violence in the long-term. Other studies have looked at staff confidence and attitudes related to ability to handle episodes of workplace violence should they arise, and similarly found short-term gains in provider confidence in managing these situations, without long-term changes in staff attitudes. While currently there is lack of evidence that de-escalation and violence prevention techniques may work in the emergency department, this should not be taken to say that resident physicians (and all ED-staff) should not be empowered by these techniques. Perhaps a more sustained, longitudinal curriculum that focuses on violence prevention, factors related to patient proclivity towards violence, and safe, effective methods to deal with violence when it occurs, can lead to decreased incidence of violence and increased feelings of staff safety.
This data not only confirms that violence against emergency medicine residents is a significant concern, but also, is truly disconcerting. The majority of residents reporting being the victim of at least one incident of physical violence (hitting, slapping, punching, kicking, spitting, shooting, stabbing, biting, hitting with an object, throwing an object) or sexual harassment (unwelcome sexual advances, insulting gestures, requests for sexual favors, offensive contact) in the emergency department.
I plan on expanding this research interest as have started my career as a junior faculty member. There is more data to be collected regarding incidence of violence against resident physicians, as well as expanding this data set to include other emergency department staff. Future directions of this work would entail evaluating strategies to prevent workplace violence and steps to manage violence if it occurs.
What can be done now?
You can conduct your own research – this work needs others to validated its data with their own prospective observational data.
You can bring your concerns to your respective institution and hospital leadership can commit to a comprehensive violence reduction plan. Workplace violence has huge costs related to the need to bolster security teams that is already in place, as well as in terms of absenteeism, medical and psychological care of victims, and increased career dissatisfaction.
You can lobby on a state or national level for policy changes that clearly outline a no-tolerance policy for emergency department based violence.
Collectively, the above will effect change that will improve the quality of the residency experience and enhance resident wellness.
Let’s continue the dialogue.
Given the patients we treat and the formidable level of violence in the world generally, we should expect violence in EDs. A policy of not tolerating violence against medical care professionals is laudable, but I think not realistic. Hospital management seem much more interested in patient satisfaction surveys than they do in protecting the lives and well-being of the medical and nursing professionals who provide care to ED patients.
Unfortunately everything has to cash flow.
Patient Satisfaction surveys translates into $ for hospital management.
Increased security costs money.
Hospital management is under pressure.
That leaves us in the ER to protect ourselves, but not to upset patients when we do.