You’re in the middle of a typical shift when a patient starts yelling at one of the nurses. You rush to help your colleague when the patient then starts yelling at you. There is no other doctor to treat this patient. What do you do? Is your action any different if the patient physically assaults you or your staff?

Violence in the health care setting is a disturbing reality and a growing problem.⁷ The unique environment of the emergency department, where all comers are cared for and acuity and emotions run high, lends itself to a higher incidence of patient aggression than most other hospital departments.⁵ A 2006 survey of emergency department employees found that in a six-month period, the 242 employees surveyed experienced 319 assaults perpetrated by patients, and that most workers had been verbally harassed by patients or visitors.³ Other studies found similar trends.^5,8,10

Often, when verbally or physically assaulted, what you want to do and what you must do are not the same. Ethically, you are bound by the medical oath to help those who seek your care. But how do you separate your feelings from your actions and deliver good care to someone who has attacked you or your staff? What is your responsibility as a provider to care for this patient?

Caregivers may find it difficult to deliver excellent care in such circumstances. Indeed, ACEP policy states, “optimal patient care can be achieved only when patients, health care workers, and all other persons in the emergency department are protected against violent acts occurring within the department.”¹

Many times, the violent patient is intoxicated or has psychiatric issues. Sometimes the patient or family is reacting to the stress of being in the emergency department. The emotional trauma, feelings of danger and insecurity this type of violence causes can compromise the well-being of other patients and visitors. Violence in the emergency department makes other patients feel unsafe and reduces the quality of their care due to the disproportionate allocation of resources and personnel to attend to the violent patient.

The exposure to violence in the workplace can also contribute to burnout. It may result in emergency department personnel suffering fear, anxiety, self-doubt, and even post-traumatic stress disorder.^3,5,9

Often, emergency department staff might think that verbal and physical violence is just part of the job. But if you change the setting to a doctor’s office or retail store, no one would accept violence toward them as part of their job. Why is it OK in the emergency department? There exists a mind-set that to be abused by patients or their visitors is something to which emergency physicians should be resigned. In contrast, ACEP policy states that emergency physicians have a duty to oppose violence and to “protect themselves, staff, and patients from violence.”¹ Most emergency care workers have either been assaulted or been threatened with violence at some point, and have developed their own de facto idea of best management, which likely falls somewhere in between these two opposing paradigms.

What, then, is the emergency physician’s responsibility?

Physicians are charged with the duty of advancing the health-related interests of their patients, known as the physician’s fiduciary obligation. The prevention of violence and the establishment of a safe environment are in the best health interest of both patients and staff in the emergency department. However, the provision of high quality health care is also a fiduciary obligation. Health care providers must not allow the strongly negative personal feelings that an aggressive patient may evoke to undermine their provision of the best care possible.

It is in the tension between being a victim and being an unbiased caregiver and noncombatant that the emergency physician’s professional virtues come into play.

Professional virtues are cultivated character traits that empower physicians to “discern and discharge moral obligations to patients.”

The virtue of impartiality is exhibited when these patients are treated with an objectivity that transcends the natural hostility and anger that personal aggression ignites. The virtues of courage and self-sacrifice allow emergency physicians to assume the leadership role and even take personal risks to provide “steadfast care” for violent patients.¹

When considering the consequences of violence, emergency physicians must think about physical, emotional and legal consequences of violence and what outcomes may transpire if it is not prevented through the use of trained personnel, appropriate policies, and timely interventions. How can emergency physicians prepare themselves both morally and technically for the prevention and management of violence? To begin, emergency physicians can set the standard for other emergency department staff to be aware of this problem, to identify it as unacceptable, to know hospital policy, and to promote and participate in education programs.¹

In addition, there is a great deal of research to be done and knowledge to be gained about how best to reduce violence in emergency departments. Incidents of violence often go unreported.^2,3,4

This makes them difficult to study, so it is not surprising that few interventions have been prospectively investigated.⁴ Likewise, the reasons health care workers fail to report incidents of violence are inadequately studied, but may include institutional factors and/or worker stigma associated with filing complaints or calling police to the emergency department. Failure to report may also be related to the serious consequences anticipated for the violent patient charged with assault.

Many intoxicated patients believe that violence against health care workers will go unpunished. They are confused about what constitutes criminal behavior during an emergency department visit. Early on, patients demonstrating escalation of bad behavior (swearing, spitting, self-injurious) need to hear a clear message from their providers. Physically assaulting emergency care providers may be a felony under locally applicable law. A felony count may be punishable by a fine, imprisonment, or both.

As a first step, all emergency department staff, especially physicians, should be trained in techniques that can keep both patients and staff safe. The most important technique is using an open body posture and listening to the patient’s concern. Additionally, the staff should be aware of a person’s body language and learn to diffuse a situation before it gets violent. If the person has a reasonable request, you or the staff member should try to resolve the issue in a non-confrontational way. In extreme situations, the patient may be briefly restrained and then allowed to emotionally recover while de-escalation techniques are continued.

Some emergency departments rely on professional outsourcing to provide violence prevention training for all staff. These programs focus on teaching interactive skills to staff providers that allow the patients to vent, reassess themselves and have a mutually acceptable non-violent, non-physical resolution. Workshop formats included in these programs also discuss techniques for safely restraining a patient when verbal intervention and de-escalation techniques do not work. At other institutions, the training segments are completed by house staff learners for maximum uptake. ACEP members can access relevant articles and other online resources including www.crisisprevention.com/Specialties/Nonviolent-Crisis-Intervention/Onsite-Training that further address and organize constructive responses to violence in the emergency department. Emergency physicians must resist the idea that violence is expected and to be tolerated. Unfortunately, violence will never be eliminated from the emergency department, but being aware of the problem, learning violence de-escalation techniques and having an expectation to work in a violence-free environment are a start to treating all patients in an ethical manner.

Dr. Delpier is an emergency physician at Union Hospital in Elkton, Md., and Bayhealth Kent General in Dover, Del. Dr. Benson is a resident in Otolarynology, Head and Neck Surgery, at Johns Hopkins in Baltimore.

References

1. American College of Emergency Physicians: 2011 Policy Compendium. Revised December 31, 2010. Available online at: http://www.acep.org/Content.aspx?id=32334 (Accessed April 7, 2011).
2. Emergency Nurses Association Institute for Emergency Nursing Research: Emergency Department Violence Surveillance Study. August 2010. Available online at: http://www.ena.org/ IENR/Documents/ENAEVSSReportAugust2010.pdf (Accessed April 7, 2011).
3. Gates DM, Ross CS, McQueen L. Violence: Recognition, Management and Prevention. J. Emerg Med 2006:31(3):331-337.
4. Gates DM, Gillespie G, Smith C, Rode J, Kowalenko T, Smith B. Using Action Research to Plan a Violence Prevention Program for Emergency Departments. J. Emerg Nurs 2011;37(1):32-39.
5. Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, Ryan AD, Mongin SJ, Watt GD. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med 2004;61:495-503.
6. Ho J, Ralston DC, McCullough LB, Coverdale JH. When Should Psychiatrists Seek Criminal Prosecution of Assaultive Psychiatric Inpatients? Psychiatr Serv 2009;60:1113-1117.
7. Joint Commission: Sentinel Event Alert. Preventing violence in the health care setting. June 2010; Issue 45. Available online at: http://www.jointcommission.org/sentinel_event_alert_issue_45_preventing_violence_in_the_health_care_setting_/ (Accessed April 7, 2011).
8. Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid DJ, Kaushal R, Camargo CA, Blumenthal D. A Survey of Workplace Violence Across 65 U.S. Emergency Departments. Academic Emergency Medicine 2008;15(12):1268-1274.
9. Laposa JM, Alden LE, Fullerton LM. Work stress and posttraumatic stress disorder in ED nurses/personnel. J. Emerg Nurs. 2003;26(3):210-215.
10. Workplace Violence and Prevention in New Jersey Hospital Emergency Departments. 2007. Available online at: http://www.nj.gov/health/surv/documents/njhospsec_rpt.pdf (Accessed April 7, 2011).