Workplace Violence in the Emergency Department
Workplace violence is an issue in EDs because of the crowded and emotional situations that can occur with emergencies. In addition, ED patients could be involved with crimes, weapons, or violence
from other people that could put the ED employee at an increased risk of workplace violence.
The Bureau of Labor Statistics shows the majority (nearly 60 percent) of all assaults (nonfatal) and violent acts in the workplace occurred in the health care and social assistance industries in 2007.
And, according to the Emergency Nurses Association, nearly half (46 percent) of all assaults (non-fatal) and violence that result in days away from work are committed against registered nurses.
Good work practice recommends a security management program that addresses workplace violence in the ED and could include:
- Train staff to recognize and diffuse violent situations and patients.
- Be alert for potential violence and suspicious behavior and report it.
- Provide intervention measures including verbal, social, physical, and pharmacological interventions.
- Adequate staffing levels, with experienced clinicians on each shift.
- Counseling and treatment for employees who have experienced workplace violence.
- The use of appropriate engineering controls to provide security such as:
- Install concealed panic buttons in the ED, on staff, and at the check-in area, that can be pushed for emergency help. These buttons could notify hospital security as well as directly reach the local Police Department.
- Improve lighting and video surveillance.
- Use an escort or buddy system.
Possible Solutions (Continued)
- Limit access to ED area and personnel, by implementing:
- A waiting room area with controlled access to ED area. Patients must be buzzed in by receptionist from a secure door.
- ED exits that exit out only, so people off the streets can't access the ED unless they enter through the waiting room area.
- The use of metal detectors.
- Provide a "secure" room for patients identified to be violent. This room could include controls such as:
- video camera surveillance
- visual surveillance with a window
- door locks on patient rooms
- bed with tie down straps
- locked cabinets
- furniture and equipment attached to the floor so patients can't throw them at employees
Warning Signs of Violence
The warning signs of increasing anger/violence include:
- pacing and/or restlessness
- clenched fist
- increasingly loud speech
- excessive insistence
- posture: tense, clenched
- speech: loud, threatening, insistent
- motor: restless, pacing, easily started
Historical and Epidemiologic Clues
- history of violence (especially if frequent, serious or unprovoked)
- threats or plans of violence
- symbolic acts of violence
- young and male
Kind of Diagnosis
Certain diagnoses are associated with violent behavior:
- substance abuse, either acute intoxication or withdrawal
- acute psychoses (especially acute mania or acute schizophrenia)
- acute organic brain syndrome
- personality disorders
- partial complex seizures
- temporal lobe epilepsy
Time of Day
Incidents are more likely to occur on a night shift. During a recent study performed at the University of California at Irvine, almost 32% of violent incidents occurred between 11 p.m. and 7 a.m.
Primary Reason for Hospital Violence
According to the American College of Emergency Physicians, there has been quite an increase in ED hospital violence.
The organization says the primary reason is an overall increase in societal violence today. This includes:
- increased presence of gangs, particularly in urban, inner-city settings
- prolonged waits for patients seeking medical care, sometimes compounded by unpleasant waiting room environments
- increased prevalence of drug and alcohol use in society
- increased numbers of private citizens arming themselves related to perceived threats of violence in their neighborhoods
- use of emergency departments for “medical clearance” of drug- and alcohol-related arrests
- unavailability of acute psychiatric treatment, so emergency department provides “psychiatric clearance”
Emergency Staff Response
Emergency staff should trust their senses if they feel uncomfortable around a patient. They should be vigilant and not isolated. They should call security when they first become aware of a threat.
In addition, emergency staff should maintain a safe distance, if possible, and keep an open path for exiting. They should present a calm, caring attitude and not match threats or give orders.
It’s important to acknowledge the person’s feelings and avoid behaviors that may be interpreted as aggressive. Eye contact should be limited.
Measures to Manage Violence
Emergency departments should have a plan for managing potentially violent situations. This plan should include who responds, a team leader, each person's responsibility (including the team leader),
and the steps that should be taken to respond. In addition, each hospital and emergency department must base its responses to violence on physical location, types of patient populations and histories
of prior violent incidents.
Some measures that can be taken are:
- Train personnel: Increase training of doctors, nurses and security personnel about de-escalation techniques (and “take down” techniques), how to recognize potentially violent patients early and getting help before incidents occur.
- Provide secure environments:
- Use 24-hour presence of trained security officers and closed circuit television cameras with 24-hour trained observers (especially useful in low-traffic areas).
- Place "panic buttons" unobtrusively in several locations of an emergency department.
- Use direct phone lines to security in the hospital or local police departments.
- Control access and egress between the emergency department and other areas of the hospital.
- Use coded badges for patients and visitors.
- Install metal detectors (Henry Ford Hospital in Detroit used this with success without diminishing access or level of care. In the first 6 months of screening, 33 handguns, 1,324 knives, 97 mace sprays and many other hazardous items were confiscated).
- Install physical barriers or bullet proof glass at hospital emergency department entrances.
Emergency room nurse Erin Riley suffered bruises, scratches and a chipped tooth last year (2009) from trying to pull the clamped jaws of a psychotic patient off the hand of a doctor at
a suburban Cleveland hospital.
A second assault just months later was just as upsetting: She had just finished cutting the shirt off a drunken patient and was helping him into his hospital gown when he groped her.
"The patients always come first — and I don't think anybody has a question about that — but I don't think it has to be an either-or situation," said Riley, a registered nurse for
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For more information, including how to create a violence prevention program at your facility, please see OSHAcademy course 776: Preventing Workplace Violence in Healthcare.
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