Improving the sad state of physical and verbal abuse toward emergency nurses and other healthcare employees will require the combined efforts of legislators, hospital administrators, government agencies, nursing organizations, and emergency physician organizations.   We all find it easier to point out what is wrong than to develop a consensus for change.  Powerful lobbies will oppose anything that costs money.  Therefore, we must have some data and rationale to justify the recommendations we make.

The first step in understanding physical and verbal abuse in emergency departments has already been taken.  In 2011 the Emergency Nurses Association published a landmark study that clearly defined the scope of the problem.  We know approximately how many emergency department nurses suffer which kind of abuse.  We know what environmental measures are used by hospitals to control physical and verbal abuse.

The ENA study listed these preventive environmental measures with the utilization in their sample of departments—-bullet-proof glass 10.0%, chemical restraints 74.3%, enclosed nurses’ station 11.4%, handcuffs 20.0%, limits on number of visitor 62.0%, lock box/safe for cash 61.6%, locked treatment room 24.7%, locked /coded ED entries 80.6%, Mace 9.5%, mirrors to show hidden spaces 29.9%, panic button/silent alarm 73.6%, personal belongings search 53.3%, physical/leather restraints 88.0%, pseudonym to call a code 77.5%, security batons 14.6%, security cameras 85.3%, security signage 42.4%, visitor tag/badge 44.4%, and well-lit areas in the ED 91%. Metal detectors were not mentioned.

An attempt was made in this study to associate various environmental measures with the occurrence of physical and verbal violence. I would like to underscore that an association of an environmental measure with physical or verbal abuse does not imply a causal relationship, only a co-existent relationship.  If only 10 per cent of hospitals have bullet-proof glass, 11 per cent have enclosed nurses stations, and 10 per cent use MACE, this utilization may be too small to draw conclusions.  A true test of efficacy of any environmental measure must include physical and verbal abuse statistics before and after a measure is implemented. This ENA study was not designed to test the efficacy of environmental measures.  It was a surveillance study.

Panic buttons/silent alarms were associated with lower physical violence rates while the presence of an enclosed nurses’ station, locked/coded ED entry, security signage and well-lit areas were associated with significantly lower verbal abuse rates.

Perhaps the most important relationship noted in this study was the relationship between physical violence, population density, and the size of emergency departments.

Physical violence rates tended to increase as population density increased, rising from rural (9.1%) to large urban (14.8%) settings with middling rates in suburban and small urban settings. The rate was significantly above average in large urban settings (OR=1.45, pThe larger the department, the greater need for preventive environmental measures.  Larger departments are in areas of higher population density.

Thus, it makes sense that Level I Trauma centers need almost every type of environmental control measure, while lesser measures are required in smaller emergency departments associated with a lower population density.  This is a very important observation to those of us working for change.  Our goal isn’t to force expensive measures onto small hospitals that are unlikely to benefit from those environmental measures.  Every emergency department does not need bullet proof glass and a metal detector.  I would argue that every department does need on-site uniformed, armed security.  Physical violence can occur in any size department and muscle may be required to contain it.

In the study, hospital-employed, police/sheriff, campus police, and private security were all associated with a higher odds of physical violence.   This is not a causal relationship.  It is a co-existent relationship.  More baby carriages are found where there are more babies, but baby carriages do not cause babies.  Hospitals with the most violence are likely to have the most security.

I am sure that some people will read the association of human security personnel and violence and conclude that having armed security results in more violence.  The idea that not having an armed security person in an emergency department will lessen the chance of violence is foolish and not supported by this ENA study or any other study.  Most mass shootings occur in gun-free zones.  The first principle of crowd control is a credible show of force.  Vladimir Putin has just shown us an example of this principle in the Winter Olympics.  The only way to test the validity of uniformed, armed security as a violence prevention measure is to compare statistics before and after such security is implemented.

An important step in the arduous task of addressing ED violence is to establish some rational framework for recommending environmental security measures.   Each measure should be proposed in light of what we know about the relationship of size of a department to the threat of physical and verbal violence.  All environmental measures could be divided into:

1. Measures every hospital must comply with.

2. Measures that apply to departments with less than 20,000 visits/year.

3. Measures that apply to departments with 20,000-40,000 visits/year.

4. Measures that apply to departments with greater than 40,000 visits and/or have trauma center

designation.

5. Measures for pediatric emergency only departments reflecting their diminished risk of violence.

These are just examples.  We must start somewhere. Let’s glean some other insight from the ENA Study.

Since panic button/silent alarms are clearly associated with lower physical violence rates, then every emergency department should be using them, not 74%.  Since the presence of an enclosed nurses’ stations, locked/coded ED entry, security signage and well-lit areas are associated with significantly lower verbal abuse rates, every emergency department should be using them, not 11.4%, 27%, 42%, and 91%, respectively.

In the ENA study, higher commitment to violence mitigation from hospital administration and ED management and the presence of reporting policies (especially zero-tolerance policies) were associated with a lower odds of physical violence and verbal abuse. Specifically, hospitals with no reporting policy had an 18.3% physical violence rate, hospitals with a non-zero tolerance reporting policy had a 13.7% physical violence rate, and the lowest rate was in settings with a zero-tolerance reporting policy (9.1%). Nurses whose hospital administration (OR = 0.81) and ED management (OR = 0.77) were committed to workplace violence control were less likely to experience workplace violence. This level of commitment and policy must be made mandatory for all hospital administrations and ED managers. 

The majority of the participants who were victims of workplace violence did not file a formal event report for the physical violence (65.6%) or the verbal abuse (86.1%). Of the emergency nurses who indicated experiencing physical violence, almost half (46.7%) reported that no action was taken against the perpetrator as a result of the violence, and less (20.4%) reported that the perpetrator was given a warning. When asked about the hospital’s response/recommendation to the nurse, nearly three-quarters of nurses (71.8%) stated that the hospital gave them no response concerning the physical violence they experienced. Similarly, half (49.7%) of the nurses who indicated being victims of verbal abuse responded that no action was taken against the perpetrator(s), and just over a quarter (28.5%) reported that the perpetrator was given a warning. In regard to the hospitals’ responses to the nurses who experienced verbal abuse, more than three-quarters (80.6%) indicated that the hospital gave them no response.

This is outrageous. Hospitals must be held accountable for protecting their employees—physically, emotionally, and legally.  They must be forced, even if kicking and screaming, to support injured employees and prosecute physical and verbal abusers.  Every verbal abuser should receive a minimum of a letter from the hospital outlining the zero tolerance policy. Hospital administration must be judged by standards of compliance.

DUI offenders are not excused for their behavior or the injuries they cause because they are intoxicated. Calling a violent intoxicated person a “customer” while not providing basic human rights and legal rights to your own employees is disgusting.

I feel that it is long past time for healthcare to give up the ridiculous “customer” model.  We take care of patients, not customers.  Patients are frightened, sick, injured, vulnerable, and sometimes under the influence of drugs and alcohol. Some are seeking drugs. They are not coming to us to buy hamburgers. The customer model is an affront to both patients and caregivers.  Our goal as caregivers is to provide the most compassionate and appropriate care possible—-not to boost Press Ganey scores for an administrator.

My parents taught me to do the right thing, not the thing that pleases. We should never expect that doing the right thing will always please, or that pleasing somebody represents quality care.  So many of our necessary procedures cause pain.  Buying a hamburger does not cause pain.  Customers are always right.  Patients know what hurts.

Press Ganey scores need to be trashed.  This crude club was based on the false analogy of patients to customers and the false concept that pleasing a patient represented quality care.  Don’t you think that the failure of administrators to support their own abused employees is related to their view that patients are customers?  I do.

I welcome your comments.  My next post will address how environmental measures and changes in the management of the mentally ill can be paid for.

Charles C. Anderson M.D., FACP, FACEP