Silent No More: Ending Violence Against Nurses in the Emergency Department
The kick came suddenly and without warning. Late one evening in the emergency department (ED) of a large, level I trauma hospital in Dallas, my best friend, and fellow nurse, was alone with a recently arrived psychiatric patient when she felt the blow. Like a wrecking ball to the gut, the force of the patient’s foot sent her flying across the room and into a wall. Luckily, she came away relatively unscathed and only a little shaken up, but I remember the story like it happened yesterday, and still cringe when telling it.
I wish that I could say hers is one of those rare stories that we all have from working in the crazy world of the ED, particularly when dealing with unstable psychiatric patients. But the unfortunate truth is that it is not. Violence against nurses and other frontline staff in United States’ EDs is a widespread and growing problem. In many ways, this is not a surprise. EDs are the first line of entry into health care facilities, and the people arriving are at their most vulnerable and agitated. It is a setting filled with crisis and chaos – people who are hurt, dealing with trauma, often without friends or family to provide support. Oftentimes they are addled by the abuse of drugs and alcohol, which make them more aggressive. Magnifying these forces are the multitude of “big picture” ED issues, such as crowding and understaffing. If ever there were a recipe for human violence, the ED has all the ingredients.
Every one of my colleagues has a story of being kicked, bitten, spit at, cursed out – or even worse – in the normal course of their work day. Despite the fact that we all know about violence against nurses in the ED firsthand, no one really understands just how widespread the problem is because few report it and even fewer institutions formally record those reports.
Recognizing the lack of understanding and awareness of this issue, I recently helped lead an effort with the Emergency Nurses Association (ENA) to undertake the first national study of emergency nurses’ perceptions and experiences of workplace violence. Our study surveyed nearly 3,500 registered members of the national ENA about: (1) their experiences with physical violence and verbal abuse in the ED, (2) the policies and procedures of their hospitals and EDs for addressing workplace violence, and (3) their personal beliefs about the causes of the violence and barriers to reporting it.
The results of the survey were an eye-opening indication of the magnitude of the problem. More than two out of three emergency nurses surveyed (67 percent) rated their perception of safety in the emergency department at five or lower on a 10-point scale. More than half reported experiencing physical violence on the job. Twenty-five percent said that they had been physically assaulted more than 20 times in the past three years, while a staggering 20 percent reported having been verbally abused more than 200 times during the same period. One in three respondents reported having considered leaving their department, or the field of emergency nursing altogether, because of violence.
Perhaps what was saddest and scariest was the acceptance of the violence that had established itself among nurses and observing the cultural barriers that stops us from dealing with it. The majority of respondents reported that violence was “part of the job” in the ED, and that they have become desensitized to it. Many said that it was a hassle to report the violence, and therefore they did not bother.After presenting the findings at the 2008 national ENA meeting, nurses from around the country approached me and poured out their hearts. Person after person recounted horrifying stories of the violence they had encountered in the ED – from extremes of rape and murder of staff, stalking and threatening phone calls late at night, the indifference of administrators, and inadequate hospital security. It is heartbreaking to think that this is taking place in our backyards.
Perhaps what was saddest and scariest was the acceptance of the violence that had established itself among nurses and observing the cultural barriers that stops us from dealing with it. The majority of respondents reported that violence was “part of the job” in the ED, and that they have become desensitized to it. Many said that it was a hassle to report the violence, and therefore they did not bother.After presenting the findings at the 2008 national ENA meeting, nurses from around the country approached me and poured out their hearts. Person after person recounted horrifying stories of the violence they had encountered in the ED – from extremes of rape and murder of staff, stalking and threatening phone calls late at night, the indifference of administrators, and inadequate hospital security. It is heartbreaking to think that this is taking place in our backyards.
The ENA study suggested many strategies and interventions for ED nurses and hospitals intent on tackling the issue. Ultimately though, I think it boils down to three simple, but important steps:
Acknowledge that ED violence against nurses is a problem that must be addressed. It was clear from the results that nurses and institutions do not see this as a major problem. It is time for all of us in the ED – nurses and administrators – to face the reality that violence against frontline staff in the ED is a serious issue and needs to be addressed. Until we change this mindset, things can never improve.
Develop policies and practices to support reporting incidents. Two of the biggest barriers to formally reporting and acting upon violent ED incidents is a perceived lack of support, and fears of retaliation by hospital administration, ED management, or other nursing staff and physicians. This, coupled with ambiguous policies for reporting incidents and a perception that doing so might have a negative effect on customer service reports or scores, contributes to keeping the problem silent. Institutions and administrators serious about change should make it clear that they support and encourage reporting, along with developing a clear procedure for doing so. When incidents occur, they must make sure that the reports are acted upon and not swept under the rug to be ignored.
Improve hospital security. From simple (and cost-effective) architectural improvements – better doors and locks, plexiglas or bulletproof barriers, 24/7 on-site security and panic buttons – improving hospital security helps keep ED staff, patients and visitors safe. Even changes to procedures, such as instituting a visitors’ policy, can have a significant impact with minimal cost. Like many of the problems in our nation’s hospitals, addressing the issue of violence against nurses and other frontline staff in the ED will not be easy. It is a problem that has largely gone untreated, because we choose to “tough it out” and ignore the problem. We need to take the initiative to say “enough is enough” and stand up to violence in the ED. As strong and resilient as we ED nurses are, I am confident that we will succeed.
Lara Boyett, MSN, RN, ACNP-BC, CEN, ER Provider for Little River Healthcare System in Rockdale, Texas
