WASHINGTON ― Speaker after speaker, veteran emergency department (ED) physicians and nurses approached the podium for a press conference last Wednesday morning on the US Capitol lawn across from the East Senate steps to describe violent incidents — being bitten, punched, slapped, kicked, choked, spat on, threatened — that they have both observed and have been subject to while working in EDs.
The press conference was co-sponsored by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), which have partnered since 2019 on the No Silence on ED Violence campaign.
The numbers confirm their experience. A 2018 poll of 3500 ED physicians nationwide, which was conducted by Marketing General Incorporated and was reported at ACEP's annual meeting that year, found that nearly half of respondents had been assaulted at work; 27% of them were injured from the assault. Nurses, who spend more time with patients, may face even higher rates.
Incidence was reported to be increasing in 2018, and that was before the social and psychological upheavals imposed by the COVID pandemic caused assaults on staff in the hospital to go up an estimated 200% to 300%.
But what really grated was that more than 95% of such cases, mostly perpetrated by patients, were never prosecuted, said Jennifer Casaletto, MD, FACEP, a North Carolina emergency physician and president of the state's ACEP chapter. "Hospital and law enforcement see violence as just part of the job in our EDs."
It's no secret that workplace violence is increasing, Casaletto said. Four weeks ago, she stitched up the face of a charge nurse who had been assaulted. The nurse didn't report the incident because she didn't believe anything would change.
"Listening to my colleagues, I know the terror they have felt in the moment — for themselves, their colleagues, their patients. I know that raw fear of being attacked, and the complex emotions that follow. I've been hit, bit, and punched and watched colleagues getting choked."
Casaletto was present in the ED when an out-of-control patient clubbed a nurse with an IV pole as she tried to close the doors to other patients' rooms. "Instinctively, I pulled my stethoscope from around my neck, hoping I wouldn't be strangled with it."
Tennessee emergency nurse Todd Haines, MSN, RN, AEMT, CEN, said he has stepped in to help pull patients off co-workers. "I've seen some staff so severely injured they could not return to the bedside. I've been verbally threatened. My family has been threatened by patients and their families," he reported. "We've all seen it. And COVID has made some people even meaner. They just lose their minds, and ED staff take the brunt of their aggression. But then to report these incidents and hear, 'It's just part of your job...,' well, it's not part of my job."
Haines spent 10 years in law enforcement with a sheriff's department in middle Tennessee and was on its special tactical response team before becoming an ED nurse. He said he saw many more verbal and physical assaults in 11 years in the ED than during his police career.
"I love emergency nursing at the bedside, but it got to the point where I took the first chance to leave the bedside. And I'm not alone. Other nurses are leaving in droves." Haines now has a job directing a trauma program, and he volunteers on policy issues for the Tennessee ENA. But he worries about the toll of this violence on the ED workforce, with so many professionals already mulling over leaving the field because of job stress and burnout.
"We have to do something to keep experienced hospital emergency staff at the bedside."
What's the Answer?
Also speaking at the press conference was Senator Tammy Baldwin (D-WI), who pledged to introduce the Workplace Violence Prevention for Health Care and Social Services Workers Act, which passed the House in April. This bill would direct the Occupational Health and Safety Administration (OSHA) to issue a standard requiring employers in healthcare and social services to develop and implement workplace violence prevention plans. It would cover a variety of health facilities but not doctor's offices or home-based services.
An interim final standard would be due within a year of enactment, with a final version to follow. Covered employers would have 6 months to develop and implement their own comprehensive workplace violence prevention plans, with the meaningful participation of direct care employees, tailored for and specific to the conditions and hazards of their facility, informed by past violent incidents, and subject to the size and complexity of the setting.
The plan would also name an individual responsible for its implementation, would include staff training and education, and would require facilities to track incidents and prohibit retaliation against employees who reported incidents of workplace violence.
On Wednesday, Senator Baldwin called for unanimous consent on the Senate floor to fast-track this bill, but that was opposed by Senator Mike Braun (R-IN). She will soon introduce legislation similar to HR 1195, which the House passed.
"This bill will provide long overdue protections and safety standards," she said. It will ensure that workplaces adopt proven protection techniques, such as those in OSHA's 2015 guideline for preventing healthcare workplace violence. The American Hospital Association opposed the House bill on the grounds that hospitals have already implemented policies and programs specifically tailored to address workplace violence, so the OSHA standards required by the bill are not warranted.
Another speaker at the press conference, Aisha Terry, MD, MPH, FACEP, an emergency physician for George Washington University and the Veterans Administration in Washington, DC, and current vice president of ACEP, described an incident that occurred when she was at work. A patient punched the nurse caring for him in the face, knocking her unconscious to the floor. "I'll never forget that sound," Terry said. "To this day, it has impacted her career. She hasn't known what to do."
Many people don't realize how bad workplace violence really is, Terry added. "You assume you can serve as the safety net of this country, taking care of patients in the context of the pandemic, and feel safe — and not have to worry about your own safety," she said. "It's past due that we put an end to this."
Haines called the workplace violence bill a game changer for ED professionals, now and into the future. "We're not going to totally eliminate violence in the emergency department. That is part of our business. But this legislation will support us and give a safer environment for us to do the work we love," he said.
"The biggest win for this legislation is that it will create a supportive, nonretaliatory environment. It will give us as nurses a structured way to report things." And, when these incidents do get reported, staff will get the help they need, Haines said. "The legislation will help show the importance of implementing systems and processes in emergency settings to address the risks and hazards that makes us all vulnerable to violence."
No relevant financial relationships have been disclosed.
Larry Beresford is an Oakland, California–based freelance medical journalist with a breadth of experience writing about the policy, financial, clinical, management, and human aspects of hospice, palliative care, end-of-life care, death, and dying.
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Image 2: Dr Jennifer Casaletto
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Cite this: Larry Beresford. ED Staff Speak Out About Workplace Violence, Ask for Mitigation - Medscape - May 11, 2022.