Emergency Departments Are a Dangerous Workplace

— Recollections "poignant and often chilling"

MedpageToday
Police tape across a room in a hospital ICU.

At one university medical center located in a mid-sized American city, nearly all emergency department (ED) workers responding to a survey said they'd been verbally abused, and about one-third reported physical assaults.

And most of the time, the victims shrugged off physical attacks without filing formal reports with administrators or the police, and sometimes not even mentioning it to colleagues, according to Christina Shenvi, MD, PhD, and colleagues at the University of North Carolina (UNC) in Chapel Hill.

"Multiple respondents .... voiced a sense of resignation that violence is an unavoidable or expected part of the job and that reporting it would not lead to meaningful change," the group wrote in Annals of Emergency Medicine. Still, the investigators said research is needed to clarify ED workers' reluctance to file formal reports of workplace violence, and suggested that a "multidisciplinary, multipronged approach including individual, institutional, and systems-based strategies is needed."

The study is far from the first to report high rates of verbal abuse and violence targeting ED personnel. Nor is it unique in indicating that workers typically don't report incidents to the authorities. What sets the UNC study apart is that Shenvi and colleagues let respondents describe the attacks and their reactions in their own words, analyzing the responses qualitatively rather than strictly through numerical data. (One such account, however, did appear several years ago in the same journal -- from a Massachusetts physician who told of being punched in the face by a patient's mother.)

Shenvi's group contacted all ED workers at their center in late 2019 -- about 270 in all. Responses were received from 123, including 47 nurses, 27 residents, 22 attendings, and 27 in other roles. Response rates were highest for the physicians (79% for residents and 63% for attendings).

Only 4% of respondents said they'd never been verbally abused; 70% said it happened more than once. Just under 10% indicated that they'd been physically assaulted multiple times, and 25% said it had occurred once. Among trainee physicians, those at the PGY1 level said they had not experienced physical attacks, but 36% of PGY3s said they had.

The narrative stories were, according to Shenvi and colleagues, "poignant and often chilling." Several respondents described being punched; others reported death threats from patients. "Was told by a patient that I was discharging that he would come find me and shoot me in the knee caps," in the word of one resident.

Many staff members said they didn't feel safe at work. Another resident said a patient who threatened to kill staff "was escorted out but only to the hospital front door." When the resident got off work, the man was waiting outside, forcing the resident to rush back in and call police.

Perhaps most disturbing were respondents' "sense of hopelessness, resignation, and futility," as Shenvi and co-authors put it. Nurses and residents expressed beliefs that, even if they did file formal reports, nothing would or could be done.

Several noted that they are required to care for patients come what may. "It's concerning that charges can be filed against a healthcare professional for too much force but nothing can be done when a patient punches, kicks, bites, scratches, pulls hair, or generally assaults you," a nurse told the researchers.

Another reported that police refused to help when a patient with a history of ED violence came in. "The patient proceeded to verbally abuse me," the nurse said.

As a single-center study with only a few dozen participants, it's far from conclusive, Shenvi and co-authors acknowledged. On the one hand, they argued that their institution "is fairly representative of many resident training programs" in the U.S. But because residents handle more than three-quarters of cases there, the findings might not reflect the experience of non-academic centers, the researchers conceded.

They also acknowledged there are no easy answers to the problem.

Some concrete steps include raising the criminal penalties for assaulting hospital staff (already taken in some places, including North Carolina) and developing systems for reporting incidents and -- most importantly -- following up on them. The American College of Emergency Physicians has developed a set of recommendations that include these and others.

But often the violent behavior stems from patients' illnesses. "To what degree should uncontrollable patient factors (e.g., acute psychosis, delirium, dementia, intoxication) have an influence on whether a patient should be held responsible for assault directed toward residents or health care workers? Do any of these complicating factors change the way health care workers experience such assault?" the team wrote. "These questions are multifaceted and require substantial ethical consideration."

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    John Gever was Managing Editor from 2014 to 2021; he is now a regular contributor.

Disclosures

The study authors declared they had no relevant financial interests.

Primary Source

Annals of Emergency Medicine

Source Reference: Querin L, et al "A qualitative study of resident physician and health care worker experiences of verbal and physical abuse in the emergency department" Ann Emerg Med 2021; DOI: 10.1016/j.annemergmed.2021.04.019.