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Essay Paper on Violence in the Emergency Department

by Benjamin Hanson

What are the factors that lead to patient violence against nurses in the Emergency Department and how can this violence be minimized or prevented?


Violence at work is a growing global concern, especially in the healthcare industry. Since 1976, aggressive tendencies toward nursing staff have been observed finally prompting the 1991 International Counsel of Nurses organization to speak out on it (Crilly 2000, p 68, para 2). Recognized as second to only security personnel for workman’s compensation relating to violence (Gilcrest, 2011, para 1, p.10). Ineffective strategies include zero tolerance policies that are not enforced, and an increasing reliance on security staff in ED.

Several studies have focused on different areas of concern about the violence and nursing, particularly in the ED. From basic definitions, legislation, zero tolerance policies, effects on staff, workplace violence is a complex issue. These 10 studies cover the issue for last decade , but makes reference to over 30 years of literature.

The Australian healthcare system is one that provides services to all. This publically funded system varies according to the area served. It includes public and private hospitals. Medicare is the system used for healthcare cost, but many providers also charge a fee to patients to cover the gap between what the government pays for and actual cost. The Australian Federal Government and state and territory governments fund the healthcare system. It is administered by state and territory health departments. The Medicare system aims to provide access to cheap or free, medical care for all Australians. Private doctors charge a fee in addition to the Medicare payment and is covered by patients. (Pich 2011, p. 13)

The parts of this puzzle:

Most findings can be broken down into key areas of concern; these include patient, staff, management and educational/profession factors. Several findings cropped up in the different studies across Australia. Those relating to patient factors are drug and alcohol abuse, and mental illness. Drug and alcohol abuse are social/familial issues that also contribute to the incidence of violence in the emergency departments.  Most staff felt like alcohol and drug abuse were factors in the majority of cases (Crilly 2004, Table 5, pg 71 and “Discussion”) (Gilcrest 2010, “Who are the aggressors?” para 1, pg 13). They also felt it was increasing.

Mental illness has become another increasing concern. There has been a steep increase in the cases presenting to the ED.In 2004, one–tenth of all patients in Austrailan ED suffered from mental illness (Kerrison, 2007 para 1, page 49). Non-mental health nurses have expressed concern over their lack of ability to deal with these cases.

Nursing and other staff in the ED also contribute to the levels of violence seen today. This is not a case of blaming the victim, but instead recognizing a pattern to the data collected in the last decade. Apathy has seeped in to the nursing profession; staff feel that management does prosecute offenders and that this aggression is just an ugly part of the job. There is also the fear of disapproval by employer to be label a complainer (Cecil, . However, other reasons exist for this as well including underreporting.

The underreporting by staff of violent episodes.  Substantiated by Lyneham 2000 and Crilly 2004 (“Discussion” para 1, pg  ) Luck et al, 2005, para 4, pg 1072-states that some estimates are as high as 75%

2007 Kerrison (“Workplace Agression and Violence” para 4, pg 52) found that the length of the reporting form was also cause for underreporting, as well as continued lack of staff awareness about the importance of reporting all incidences of violence. (Lyneham 2000, pg 9, para 3).

(2005 Luck, last para, pg1072) listed previous lit including Cecil that indentified nurses as feeling unsafe about reporting violence to management.

Other findings for underreporting were linked to the nurses’ experience of a violent situation. Luck identified three areas, personalization of the violence, contributing factors, and reasons for visit that influence staff’s decision to report (Luck et all, “Findings” para 1, pg 1074).

Management is lax in several areas concerning aggression. Policies and training are not well established concerning violence. Even when they exist, strategies are not clearly promoted by leadership. Support systems are also not communicated to staff.

Ineffective zero tolerance policies and the idea of reacting versus preventing violence at work. Besides, zero tolerance policies won’t work when they aren’t enforced (Pich 2011, p. 16, para 1).

Interraction that escalates violence typically due to lack of training that is mandatory by law. However, management violates this mandate (Pich 2011, p. 17, column I, last para)

Not communicating wait times to patients because of concern that the patient will leave (Pich 2011, The Study Site, p.13, para 3)

Other areas of  hospital/management concerns include:

Wait time observed in excess of ACEM guidelines, (Crilly 2004, “Results” para 5, pg. 70)

Unpleasant waiting environment without toys, magazines, etc.

Lack of education initiative to help patients understand triage system coupled with an ungrateful attitude, viewing health care as a right, not a priveledge (Pich 2011,  p.15, para 6)

Lack of proper support for victims of workplace abuse. (Pich 2011, p.17, column II, para 3)

Education programs are also lacking and need to incorporate violence training into nursing programs. These courses need to be included in the core curriculum for nursing. This also includes educating the next generation of nurses on breaking the culture of silence that underreporting continues (Lyneham 2000, pich 2011, p. 17, column II, para 4).

Other issues from these 10 articles  that should be reviewed to see if it’s in the literature:

Uncalculated costs-worker claims, time off from work, annual rate for nurses leaving the field.

Child abuse rates, anger issues, divorce rate among nursing staff.

Other areas of interest moving forward include alcohol and substance abuse among nurses. The 2000 O’Connel study (Nurses’ Reactions…pg. 607, para 2 ) found that 20% of nurses reported drinking alcohol or taking drugs in response to the stress of violent behavior at work. A new subgroup of violent offenders was identified as  young mothers of injured children (Pich 2011, Antecedents, p. 15,  para 5).

Study into the structure and practices of management and human resources currently in place in hospitals in private and public hospitals and in urban and rural areas. In the study of restraint practices, there were a large number of hospitals that did not respond. The vast majority did not have a director for emergency services. This would be a promising future study. What are the efficiency rates, patient satisfaction, staff satisfaction, violence rates, wait times among hospitals with a director versus hospitals without one? Or private hospitals and public hospitals in search of the best techniques for customer satisfaction.

Study on management/human resources staff. Because management was an issue raised in workplace violence, a study on the staff size, resources, structure, between hospitals would be a good source of information about the most efficient way to run a HR staff.

Follow up. With staff identified in the one-day training, empirical data would help to see if the staff actually reduced rates of violence or if the gains were seen in only their perception of violence. Also, see if these gains were temporary or permanent.

Patients: Data collection should center on patients. Focus group on patients identified as unsatisfied to brainstorm solutions from this end of the equation.

Many questions have been raised by these studies that need to occur in the public sphere. The general population needs to dialogue with lawmakers, asking these questions.

Why isn’t management pushing initiatives of training, support, and reporting for staff?

Why don’t degree programs incorporate violence training for nurses?

Why is funding an issue for this important problem? Why not scrap ineffective policies like zero tolerance in favor of training and education?

Why aren’t patients informed and educated about triage system and wait times? Even simple posters about different levels would help.

In a government regulated system, why aren’t policies concerning reporting, restraint use, and training uniform?

What is the significance of the way doctors are treated versus nurses?

In a field dominated by women, why is violence such a pressing issue? What does that say about society’s view of women?

Issues about the studies:

Best and worst studies for rigor-

Both Luck studies -Luck et all 2007- THE best ran study because of long-term – 5 months, mixed methods approach to collect data, 290 hours observed, 16 incidences of violence witnessed by researcher, in person researcher. These studies show the highest standards applied to the data and provide a example of a properly conducted study.

Second best -the number 2 Crilly article on Violence in the ED against nurses and staff. Why?

4 collection forms used that were piloted; validated, verified and literature review, demographic info collected, long-term- 5 months, verified by second source; hospital database, data collected weekly in person by researchers and based on responses, a detailed report was filled out, consent forms signed, extensive literature review that identified key issues and what was lacking, locations of violence as well as time and types.Only lacked a journal.

Poorest research study: Why?

Gilcrest 2010. Should be a more representative sample, and a mixed methods strategy incorporating interviews with key informants would have provided richer data for a more comprehensive understanding of this phenomenon.

Unintentionally points to a key weakness in this and Lyneham 2000 study on pg 14, para 1 under section, “Alcohol related violence and aggression in the ED.” Both have weaknesses of recall bias in their studies, asking participants to look back over the previous year for instances of violence. The similarities in the two could likely be a function of human memory recall than an actual statistics being corroborated.

The others fall somewhere between these two based on their sample size, questions used (open, closed-ended), if they were first piloted, how they were collected, response rate.

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Reference List:
2001-Cannon, M.E. – Restraint practices in Australasian emergency departments, Australian and New Zealand Journal of Psychiatry 35(1), pp. 464-467.
2004-Crilly, J. – Violence towards emergency department nurses by patients, Accident and Emergency Nursing 12(3), pp. 67-73.
2004-Deans, C. – The effectiveness of a training program for emergency department nurses in managing violent situations, Australian Journal of Advanced Nursing 21(4), pp. 17-22.
2010-Gilchrist, H. – Experiences of emergency department staff: alcohol-related and other violence and aggression, Australasian Emergency Nursing Journal 14(1), pp. 9-16.
2007-Kerrison, S.A. – What general emergency nurses want to know about mental health patients presenting to their emergency department, Accident and Emergency Nursing 15(1), pp. 48-55.
2008-Luck, L –  Australia Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence, Journal of Clinical Nursing 17(1), pp. 1071-1078.
2007-Luck, L – STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments, Journal of Advanced Nursing 59(1), pp. 11-19.
2000-Lyneham, – Violence in New South Wales emergency departments, Australian Journal of Advanced Nursing 18(2), pp. 8-17.
2000-O’Connell, B., et al. – Nurses’ perceptions of the nature and frequency of aggression in general ward settings and high dependency areas, Journal of Clinical Nursing 9(1), pp. 602-610.
2011-Pich, J.- Patient-related violence at triage: A qualitative descriptive study, International Emergency Nursing 19(1), pp. 12-19.

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