Workplace Violence and Harassment Against Emergency Medicine Residents

Benjamin H. Schnapp, MD; Benjamin H. Slovis, MD; Anar D. Shah, MD, MBA; Abra L. Fant, MD, MS; Michael A. Gisondi, MD; Kaushal H. Shah, MD; Christie A. Lech, MD


Western J Emerg Med. 2016;17(5):567-573. 

In This Article


In the past two decades, only one other study has focused exclusively on the resident physician experience with violence in an American urban ED, with our results demonstrating similar measurements of violence against emergency physicians in training. Our response rate was overall high, with 84% of potential respondents participating in the study. Respondent demographics were comparable to the overall population of the participating residencies (62.6% male, 37.3% female) and also appear to be representative of the demographics of emergency medicine across the country, with the latest documentation from the Association of American Medical Colleges demonstrating EM residents as being 63% male and 37% female.[12]

Our results demonstrate that 78% of respondents experienced at least one act of workplace violence, which is consistent with a previous study reporting a rate of 76%,[13] but higher than another report that 37% of resident physicians had experienced physical violence committed by patients and visitors.[9] Touzet et al reported an even higher rate of violence committed against ED staff, with 96% experiencing a violent incident (although this study population also included nurses and medical technicians).[3] Only 16% of residents in our study reported prior training in violence prevention or de-escalation techniques. This percentage is similar to prior studies in which 14% of ED physicians overall had previously participated in violence training/workshops.[14]

The patient-based factors reported in this study to correlate most highly with propensity to violence (alcohol, drug use, and history of psychiatric disease, 95%, 94.1%, and 91.6%, respectively), are similar to what has been reported in prior literature.[3,8] Previous studies of ED-based workplace violence have found that 84% of all physician respondents believed that patients making verbal threats were intoxicated "frequently or most of the time." Similarly, 68% of physicians believed that those patients who had physically assaulted them in the ED were intoxicated "frequently or most of the time."[8]

The majority of residents in this study reported at least one incidence of verbal harassment (96.6%) or verbal threats (78.2%). This is higher than previously reported levels of verbal harassment of residents by patients and visitors of 86.1% and verbal threats of 60.9%.[9] Over half (52.2%) of residents in the current study reported being sexually harassed by a patient, and the majority also reported sexual harassment (68.9% of female participants, 41.9% of male participants). These findings suggest a higher prevalence of sexual harassment, especially of male residents, than previously reported.[3]

While it is important to note that 77.3% of the residents in our study reported feeling safe at work "Often" or "Always," nearly a quarter of residents felt safe "Occasionally," "Seldom" or "Never" while working in the ED. These results are nearly identical to prior studies in which 25% of all eemergency physician respondents reported feeling safe at work "Sometimes," "Rarely," or "Never."[4,8] A study of all ED staff found that only 7.2% "always" felt safe in the ED, similar to the 10.9% of residents who "always" felt safe in our study. An unsafe work environment has been shown to correlate with negative mental health effects,[15] increased costs to the hospital,[16] decreased productivity at work,[17] and decreased job satisfaction for ED staff, along with having harmful effects on patient care.[18] A work environment that is perceived as unsafe also detracts from resident wellness: residents questioned their decision to become emergency physicians, and experienced emotional and family disruption as a result of workplace violence.[9] Although our study found similar rates of violence against residents as previous studies that included a broader range of workers in the ED, it is interesting to note that residents, attending physicians, nurses and other ED staff each have very different levels and rates of contact with potentially violent patients.

Self-reported violence against EM resident staff committed by patients and visitors is a significant concern within the ED environment, and the majority of residents in this study reported being the victim of at least one incident of physical violence or sexual harassment in the ED. If these results are validated with prospective, observational data, ED security policies and staffing should be examined to ensure that they are maximizing the safety of ED staff. On an institutional level, hospital leadership can commit to a comprehensive violence reduction plan.[7] On a state or national level, policy changes that clearly define a no-tolerance policy for ED violence would likely help reduce the incidence of violence against all ED staff. As our study found a higher rate of sexual harassment for physicians than has been previously reported, future research could aim to confirm these findings and examine specific interventions to target this behavior. Additionally, nonviolence and de-escalation techniques should be further investigated as a possible method to reduce violent incidents in the ED.[19] If successful, these training programs could be explored as a possible addition to the ABEM Model of Clinical Practice for Emergency Medicine.