Why Hasn’t It Stopped: Workplace Violence in Emergency Care
Workplace violence by patients and visitors against emergency nurses has been ongoing for over 40 years. In 1981, Dubin reported on the conditions most associated with patient violence, including substance use, intoxication, and withdrawal; acute psychosis; paranoia; borderline personality; and organic brain disease. He further warned clinicians to watch for signs of escalation, such as aggressive body posture, speech, and motor activity.
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These patient conditions and “warning signs” have not changed in the last 40 years, although the catalog of conditions and signs has increased. Additional considerations are patients dissatisfied with care, diagnosed with cornoavirus disease-2019, with a chief complaint of injury, and over the age of 60 years, as well as environmental factors such as emergency department crowding and staffing shortages.2
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Given that emergency nurses have had this knowledge for over 40 years, why is workplace violence still a problem? Why hasn’t it stopped?Workplace violence in emergency care persists for a myriad of reasons. As the number of inpatient beds and outpatient treatment centers has decreased over the decades, access to mental health services also has decreased.
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These changes created a health care system where the emergency department has become the safety net for mental health care.5
However, the emergency department continues to be ill-prepared for managing mental health emergencies due to a lack of expert clinicians to provide diagnoses, treatment, and care, as well as limited availability of rooms to provide the care safely. An additional aspect of this problem is the lack of funding to support mental health services in the emergency department for patients reporting both physical and mental health problems.4
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Even if the public health crisis for mental health could be curbed, incidents of workplace violence will persist due to the general public not having the resources to manage a situational crisis. In moments of crisis, emotions, fear, and frustration can reduce individuals’ abilities to control their actions. As an example, consider a scenario where you, as an emergency nurse, get a call that your 6-year-old child was struck by a motor vehicle running from the school playground onto a city street. Your child was transported to the regional trauma center in the adjacent town. Upon your arrival at the trauma center, you don’t recognize anyone. You see a reception desk that has a registration clerk, triage nurse, and security officer. You ask to be taken to your child’s bedside. You are informed, “Take a seat, please. We’ll get with you as soon as we can. The trauma team is still working on your child.” Are you really willing to “take a seat”? Or are you more likely to raise your voice, try to walk around the person telling you to wait, or even push through the door to get into the trauma bay? Are you willing to use profanity or threats to get to your child? If you say “Yes” to any of these questions, then you are admitting that you are willing to use workplace violence during a situational crisis. This demonstrates that even rational and professional emergency nurses who understand that workplace violence is wrong can experience a circumstance where aggressive behaviors could be used.
The aim of emergency nurses and members of the public health system should always be to strive for the complete eradication of workplace violence so that emergency nurses can work in safe, caring environments. Until that perfect world comes, emergency nurses need to recognize that workplace violence will occur. But workplace violence should not be condoned, and emergency nurses should never give up their efforts toward eradication. Emergency nurses should recognize that workplace violence can happen and plan for it. In 2011, a delegation of emergency nurses traveled to Cuba to study the health care system. The delegation learned that “…anger was an expected outcome for poor health or significant changes in health status” (p. 561) and that health care providers began educating patients and families upon arrival on how to prevent and manage their anger.
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If emergency nurses could assume that workplace violence is likely to occur in all patients, then a strategy for universal violence precautions could be routinely used. This perspective could improve the safety of all emergency nurses and persons in emergency care settings.Definition and Typology for Workplace Violence
The National Institute for Occupational Safety and Health, a division of the United States Centers for Disease Control and Prevention, defines workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.”
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A definition that more broadly defines the construct in terms of where work takes place is provided by the International Labor Office, International Council of Nurses, World Health Organization, and Public Services International. They jointly define workplace violence as “incidents where staff is abused, threatened or assaulted in the circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health” (p. 3).National Institute for Occupational Safety and Health
Occupational violence.
Occupational violence.
https://www.cdc.gov/niosh/topics/violence/default.html
Date accessed: January 28, 2023
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In addition to definitions for workplace violence, there are myriad of terms used to depict workplace violence. Workplace aggression and occupational violence are other terms you will see used in this special issue.International Labour Office, International Council of Nurses, World Health Organization, Public Services International, Public Services International
Framework guidelines for addressing workplace violence in the health sector.
Framework guidelines for addressing workplace violence in the health sector.
https://apps.who.int/iris/bitstream/handle/10665/42617/9221134466.pdf?sequence=1&isAllowed=y
Date accessed: January 28, 2023
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Workplace violence is not confined to the actions of patients and visitors. The University of Iowa Injury Prevention Research Center convened a national panel of experts to discuss workplace violence.
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From that panel, a new typology for workplace violence based on the relationship of the aggressor to the employee was developed. Type I of this typology is criminal intent violence. In emergency care, type I workplace violence occurs when a person enters the emergency department to seek and injure someone they previously had an altercation with (eg, gang violence). Other actions include a person entering the emergency department seeking to steal property such as purses or opioid medications from an automated medication dispensing machine or keys to patient vehicles.Injury Prevention Research Center, University of Iowa
Workplace violence: a report to the Nation.
Workplace violence: a report to the Nation.
https://iprc.public-health.uiowa.edu/wp-content/uploads/2015/09/workplace-violence-report-1.pdf
Date accessed: January 28, 2023
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Type II is customer/client violence. Type II workplace violence is the most frequently reported type of violence in the emergency care setting. This type of violence against emergency nurses includes patient and visitor behaviors such as hitting, spitting upon, throwing objects, etc. The majority of the articles published in this special issue will address type II workplace violence. Type III is worker-on-worker violence. Type III workplace violence in the emergency department occurs when a current or previous employee targets another employee. The behaviors can include verbal abuse and assault; however, they also can include bullying or mobbing-type behaviors.- Ninke J.
Man charged with stealing car from College Station emergency room. KLTV.
https://www.kltv.com/2021/07/02/man-charged-with-stealing-car-college-station-emergency-room/
Date accessed: February 7, 2023
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Type IV is personal relationship violence. Type IV workplace violence is rarely addressed in the literature. This type of violence can include a current or previous intimate partner of the emergency nurse coming into the emergency department and demonstrating harassing or assaultive behaviors.Workplace violence is further defined based on the actions taken or behaviors exhibited by an aggressor, not the intention of the aggressor. For example, an older adult who is confused and pinches or hits an emergency nurse during a physical examination or invasive procedure still commits workplace violence. Despite the older adult not meaning to assault the emergency nurse, physical and emotional pain can still be experienced by the emergency nurse, as noted by Somes in this special issue.
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Specific categories of workplace violence include verbal abuse, sexual abuse, physical threats, and assaults. Each category can occur across the 4 types (I, II, III, and IV) of workplace violence.Universal Violence Precautions
The term “Universal Violence Precautions” was first used by Gillespie to describe interventions that emergency nurses could use to prevent or manage workplace violence.
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This construct is similar to universal bloodborne pathogen precautions in which emergency nurses wear gloves during invasive procedures to prevent the risk of acquiring hepatitis and other bloodborne diseases. Rather than being selective on who might have a bloodborne disease, the emergency nurse assumes everyone might be infected and therefore takes universal precautions. The need for universal violence precautions is similar. The emergency nurse should maintain the assumption that anyone can enact violence at any time, and therefore, the emergency nurse would change how they might typically interact with others to promote personal safety.The Occupational Safety and Health Administration (OSHA), a division of the United States Department of Labor, provides a framework for workplace violence prevention guidelines.
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In their framework, there are 5 categories for prevention interventions: (1) management commitment and employee participation, (2) worksite analysis, (3) hazard prevention and control, (4) safety and health training, and (5) recordkeeping and program evaluation. The following Table provides examples of strategies based on the OSHA framework. Additional strategies are detailed by Howard and Robinson in this special issue.Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration.
https://www.osha.gov/sites/default/files/publications/osha3148.pdf
Date accessed: January 28, 2023
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TableExamples of strategies to foster universal violence precautions for the prevention and management of workplace violence in the emergency care setting
| Categories for workplace violence prevention programs | Workplace violence prevention strategies |
|---|---|
| Management commitment and participation 11 ,17 , Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/osha3148.pdf Date accessed: January 28, 2023 18 , 19 , 20 , 21 |
|
| Worksite analysis 17 ,Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/osha3148.pdf Date accessed: January 28, 2023 22 ,23 |
|
| Hazard prevention and control 10 ,15 ,17 , Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/osha3148.pdf Date accessed: January 28, 2023 18 , 19 ,23 , 24 , 25 , 26 , 27 |
|
| Safety and health training 11 ,17 , Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/osha3148.pdf Date accessed: January 28, 2023 18 , 19 ,21 ,23 ,28 |
|
| Recordkeeping and program evaluation 17 ,Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/osha3148.pdf Date accessed: January 28, 2023 19 ,23 ,25 ,29 |
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Consequences of Workplace Violence
In this special issue, Gillespie and Berry
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provide a framework for the consequences incurred by patients and visitors, the worker, the workplace, and patient care when workplace violence occurs. The negative impact on patients and visitors exhibiting workplace violence includes patients being restrained, visitors being evicted or removed from the emergency department, and offenders having charges pressed against them.11
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Worker effects are physical injuries, psychological stress, and supportive care by coworkers.11
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Effects of workplace violence on the workplace or employer are absenteeism and emergency nurses quitting and seeking employment elsewhere.21
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Consequences to patient care resulting from workplace violence can manifest as a decrease in overall work productivity with patients, delayed treatment for non-violent patients, and errors in patient care.11
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Special Issue on Workplace Violence
In this special issue, you will find a series of articles focusing on workplace violence against emergency nurses. We recommend paying particular attention to the clinical articles by Spradlin and Dunseth-Rosenbaum,
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Cabilan et al,10
and Carr and Derouin.24
The authors provide extensive details of their project procedures and implications for emergency nurses. Spradlin and Dunseth-Rosenbaum23
describe the components of their intervention: zero tolerance for workplace violence campaign, daily safety huddles, review of policies and procedures, senior leadership support, behavioral health response team, case reviews, and data dashboard.23
Cabilan et al10
incorporated the Queensland Occupational Violence Risk Assessment Tool for use with the electronic health record of their emergency patients. The tool is being used to identify patients at higher risk for workplace violence so that preventive interventions can be deployed. Carr and Derouin24
implemented a duress alarm system for emergency nurses to use when needing to call for help during workplace violence.24
Although their project did not reduce the prevalence of workplace violence, they provide sound recommendations for future use of duress alarms to yield a desirable outcome.Final Thoughts
After you read this special issue on workplace violence, we recommend you continue your exploration of the prevention and management of workplace violence. The articles in this special issue are not exhaustive regarding the recommendations available to emergency nurses. First, it is important to know your rights as an employee before, during, and after workplace violence. For emergency nurses in the United States, please see Box 1, which displays the rights of workers granted by OSHA.
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For emergency nurses who practice outside of the United States, we encourage you to contact relevant nursing advocacy groups, legislators, and occupational health agencies to determine your rights. Resources, including position statements, white papers, and policy recommendations, are provided in Box 2.Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration.
https://www.osha.gov/sites/default/files/publications/osha3148.pdf
Date accessed: January 28, 2023
Box 1
Worker’s rights outlined by the United States OSHA.
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Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration.
https://www.osha.gov/sites/default/files/publications/osha3148.pdf
Date accessed: January 28, 2023
Tabled
1
| Workers have the right to: |
|
|
|
|
|
Box 2
Position statements, white papers, and policy recommendations for the prevention and management of workplace violence.
Tabled
1
| American College of Emergency Physicians (2022) |
|
| American Hospital Association (2023) |
|
| American Hospital Association and International Association for Healthcare Security & Safety (2021) |
|
| American Nurses Association (2015) |
|
| American Organization for Nursing Leadership and Emergency Nurses Association (2022) |
|
| Emergency Nurses Association (2020) |
|
| International Labor Office, International Council of Nurses, World Health Organization, and Public Services International (2002) |
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| National Quality Forum (2020) |
|
| Registered Nurses Association of Ontario (2019) |
|
| The Joint Commission (2022) |
|
| United States Government Accountability Office (2016) |
|
| United States Occupational Safety and Health Administration 17 Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration. https://www.osha.gov/sites/default/files/publications/osha3148.pdf Date accessed: January 28, 2023 |
|
|
We do dream of a future where the tenured emergency nurse reads this editorial and says, “Workplace violence? Was that ever really a thing?” These questions will indicate that the efforts of the emergency nursing and public health community will have achieved their ultimate aim for the safety and well-being of emergency nurses across the globe.
Author Disclosures
Conflicts of interest: none to report.
This work was partially supported by the National Institute for Occupational Safety and Health through the University of Cincinnati Education and Research Center Grant #T42OH008432.
References
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- Predicting workplace violence in the emergency department based on electronic health record data.J Emerg Nurs. 2023; 49: 415-424https://doi.org/10.1016/j.jen.2023.01.010
- Impact of the COVID-19 pandemic on workplace violence at an academic emergency department.Am J Emerg Med. 2022; 53: e1-e5https://doi.org/10.1016/j.ajem.2021.09.045
- Mental health awareness isn’t enough: more funding is needed.(Published October 15, 2022)
- Emergency departments a frayed safety net for behavioral, mental health.(Published January 7, 2022)
- Addressing the problem of severe underinvestment in mental health and well-being from a human rights perspective.Health Hum Rights J. 2020; 22: 35-49
- Workplace aggression in Cuban health care settings.J Transcult Nurs. 2017; 28: 558-565https://doi.org/10.1177/1043659616666327
- Occupational violence.(Published August 31, 2022)https://www.cdc.gov/niosh/topics/violence/default.htmlDate accessed: January 28, 2023
- Framework guidelines for addressing workplace violence in the health sector.https://apps.who.int/iris/bitstream/handle/10665/42617/9221134466.pdf?sequence=1&isAllowed=yDate accessed: January 28, 2023
- Introducing a digital occupational violence risk assessment tool into an emergency department: a pilot implementation study.J Emerg Nurs. 2023; 49: 360-370
- Qualitative analysis of workplace assault outcomes from the perspectives of emergency nurses.J Emerg Nurs. 2023; 49: 450-460https://doi.org/10.1016/j.jen.2022.09.015
- Workplace violence: a report to the Nation.https://iprc.public-health.uiowa.edu/wp-content/uploads/2015/09/workplace-violence-report-1.pdfDate accessed: January 28, 2023
- Man charged with stealing car from College Station emergency room. KLTV.(Published July 2, 2021)https://www.kltv.com/2021/07/02/man-charged-with-stealing-car-college-station-emergency-room/Date accessed: February 7, 2023
- Mental health and harassment in the workplace.J Emerg Nurs. 2023; 49: 341-344https://doi.org/10.1016/j.jen.2022.09.011
- Agitated geriatric patients and violence in the workplace.J Emerg Nurs. 2023; 49: 320-325
- Violence Against Healthcare Workers in a Pediatric Emergency Department.Dissertation. University of Cincinnati. 2008;
- Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration.(Published 2016)https://www.osha.gov/sites/default/files/publications/osha3148.pdfDate accessed: January 28, 2023
- Addressing a key leadership challenge: workplace violence.J Emerg Nurs. 2023; 49: 326-329
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- Chart it to stop it: failure modes and effect analysis for the reporting of workplace aggression.Nurs Clin North Am. 2019; 54: 21-32https://doi.org/10.1016/j.cnur.2018.10.004
- Workplace violence in the hospital: strategies for meaningful change.J Emerg Nurs. 2023; 49: 345-351
- Staff duress alarms for workplace violence in the emergency department: a mixed-methods evaluation.J Emerg Nurs. 2023; 49: 387-394https://doi.org/10.1016/j.jen.2023.01.008
- Screening for behavioral health patient aggression in emergency departments to reduce workplace violence.J Emerg Nurs. 2023; 49: 403-414https://doi.org/10.1016/j.jen.2022.09.010
- Pharmacologic therapy to mitigate acute agitation in the emergency department: case reports of diverse patient presentations.J Emerg Nurs. 2023; 49: 336-340https://doi.org/10.1016/j.jen.2022.12.005
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Biography
Gordon L. Gillespie, Member, Greater Cincinnati Chapter, is a Professor, University of Cincinnati College of Nursing, Cincinnati, OH. Twitter: @glgillespie2. ORCID identifier: https://orcid.org/0000-0002-0231-1123.
Dr. Gordon Gillespie has been a registered nurse for over 25 years working in emergency department, public health, and academic settings. His research on workplace violence against healthcare workers has been funded by the CDC-National Institute for Occupational Safety and Health (NIOSH), Robert Wood Johnson Foundation, American Nurses Foundation, and Emergency Nurses Association Foundation. He has been invited by the CDC-NIOSH to develop an educational program on workplace bullying and consult on two national online learning modules. His work has been cited by the Occupational Safety and Health Administration, U.S. Government Accountability Office, American Nurses Association, and practitioners and researchers across six continents. He has chaired the national workplace violence conference, guest edited two interprofessional journal issues on workplace violence, co-chaired the Registered Nurses’ Association of Ontario’s second edition of the Best Practice Guideline “Preventing and Managing Bullying and Violence in the Workplace”, and served as an international Director of the Emergency Nurses Association. Currently he is a Professor and Interim Dean at the University of Cincinnati College of Nursing.
Biography
Sara Tamsukhin, Assistant Professor, College of Nursing and Health Professions, Arkansas State University, Cincinnati, OH. Twitter: @thepurpleRD. ORCID identifier: https://orcid.org/0000-0002-3922-1439.
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© 2023 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
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