In a national survey by the Emergency Nurses Association, more than half of emergency-department nurses reported that they’ve been physically assaulted on the job. For many nurses, being assaulted is a recurring problem: Approximately one-fourth of the 3,465 respondents reported experiencing physical violence more than 20 times in the past three years. While all hospital staff are at risk of both physical assault and verbal abuse, the problem is particularly severe in EDs, and against ED nurses in particular. 

In their article in the July/August Journal of Nursing Administration, the authors (Jessica Grack-Smith et al) explain who’s assaulting ED nurses and what the contributing factors are [references omitted]:

The 24-hour accessibility of EDs; the lack of adequately trained, armed, or visible security guards; and a highly stressful environment are some of the reasons why EDs are especially vulnerable to violence. The overwhelming majority of perpetrators of ED violence are patients and their family members and visitors. Patient pain and discomfort, as well as the tension, stress, and anger of patients, family members, and visitors, are often escalated by cramped space, lack of privacy, and long waiting times. The resulting frustration and vulnerability may incite physical and verbal abuse against ED staff. In addition, verbal abuse and physical assault in the ED can come from disruptive, intoxicated patients who are sometimes accompanied by other intoxicated or disruptive individuals.

Some of these factors are unavoidable – we need emergency departments to be available 24 hours a day, and emergency situations are inherently stressful. Psychiatric patients and patients under the influence of drugs or alcohol are more likely to lash out against those trying to help them. Beyond these factors, though, there’s a lot that both hospitals and our healthcare system as a whole could do to reduce the risk of violence against ED nurses.

The survey found that barriers to reporting ED violent incidents are associated with an increased risk of experiencing those incidents frequently. Barriers to reporting include ambiguous policies about reporting violent incidents, fear of retaliation, and a lack of support from administration or management. The authors have several recommendations for hospital administrators:

As indicated by the nurses in this study, a strong administrative commitment is imperative to reducing ED violence and eliminating barriers to reporting incidents of violence. Staff and ED managers need to know that senior administrators are aware of the violence issue and support efforts to prevent and mitigate violence. Nurse executives must be proactive in taking steps to make the workplace safe. Establishing a culture of acceptance for reporting violent incidents is a positive step toward creating a safer work environment. Procedures for reporting violent incidents should be clear and consistent, and ED staff should have access to medical care and follow-up counseling if needed. Another essential strategy to addressing ED violence is convening an interdisciplinary task force to identify vulnerabilities in the ED and develop a plan for preventing, mitigating, responding to, and reporting violence. This task force should include the chief operating officer, chief nurse executive, ED medical director, ED manager/director, security personnel, risk management personnel, local police, and most importantly, ED nurses.

While the authors focus mainly on what hospitals can do to reduce violence against ED nurses, it’s also worth noting that high rates of ED violence are another symptom of our country’s dysfunctional healthcare system. Crowding, long wait times, patient boarding, and a shortage of ED nurses – which the nurses identified as factors in ED violence – are all results of the economic pressures that emergency departments face. High rates of uninsurance and underinsurance mean that EDs routinely go uncompensated for the care they provide, and reductions in beds and staff are logical outcomes. (See this post for more on ED issues.)

This USA Today article about the survey notes that laws designed to protect nurses from violence vary from state to state (with some states having no laws at all), and that the Emergency Nurses Association is working to strengthen and expand protections for nurses in all states. If healthcare reform efforts succeed in slashing rates of uninsurance and underinsurance, that will also relieve some of the pressures on emergency departments and make it easier for nurses to do their jobs without fear.