Violence towards junior doctors in accident and emergency departments

Protecting Frontline Workers: Strategies for Preventing and Mitigating Violence in the Emergency Department

Violence in the emergency department (ED) has been escalating for decades worldwide. High-stress situations are commonplace in the ED and can lead to intentional and unintentional aggression from patients. Staff must be educated on the signs of violence and escalation to recognize potentially dangerous situations early. Staff must also identify underlying medical conditions as the source of unintentional violence. Both situations would require different approaches to management. ED violence negatively affects patient care and leads to long-term harmful outcomes for staff. Multiple strategies for mitigation and prevention have been explored in the literature. Among those, weapon detection systems, de-escalation training, and violence prevention programs have demonstrated improved staff outcomes and decreased violence. Formalized procedures and policies should clearly assign roles for each staff member in the event of a violent patient. Training programs should be instituted and may include self-defense classes or crisis intervention courses. Emergency medicine residency programs and EDs around the country must address the rising incidence of violence within EDs through interdisciplinary policy, procedure development, and prevention and mitigation programs.

Aggression towards clinicians within Opiate Substitution Treatment (OST) services: A survey of service providers

Background

High levels of aggression towards staff in healthcare settings have been reported. It seems likely that workers in Opioid Substitution Therapy (OST) would be at increased risk of adverse events and their consequences.

Objectives

This study aimed to establish if practitioners who provide OST are experiencing negative outcomes, specifically aggression, distress, and burnout, and to identify if workload and professional affiliation were associated with these risks.

Methods

A survey was conducted of OST practitioners in a single geographical region of New Zealand (population approx. 344,000). The survey asked for demographics (including caseloads), Perception of Patient Aggression Scale New Zealand Revision (POPAS-NZ), Kessler 10 (K10), Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), and Abbreviated Maslach Burnout Inventory (aMBI) and two qualitative questions asking about the best and worst aspects of working in OST.

Results

All recorded OST workers in the region (n = 181) were invited to participate, 95 practitioners responded to the survey (52.4%). This group included pharmacists, doctors, nurses, social workers and addiction workers. Results indicated aggression, distress, and burnout were being experienced by practitioners. Number of patients seen by a practitioner significantly increased risk of aggression (F(1,90) = 14.14, p < 0.001). Psychiatrists were the most at risk profession (p = 0.016). Burnout responses were high for around 20% of practitioners, with low numbers meeting criteria for distress and PTSD. Positive things about working in OST were relationships with patients, appreciating patient outcomes and positive team environments. Negative aspects were patient behaviours, maintaining empathy, and, administration tasks.

Conclusions

Aggression was a workplace hazard for OST clinicians. Low rates of distress and PTSD symptoms were reported and some evidence of practitioner burnout. Practitioners reported positive relationships, making a difference and teamwork may have been improving this area of mental health work.

Effectiveness of audit in improving interview room safety

Aims and Methods

Safety features of rooms used for clinical interviews were assessed throughout our mental health unit. Following this pilot survey, 12 safety standards were agreed and adopted by a multi-disciplinary audit meeting. Recommendations were disseminated throughout the trust. Adherence to the accepted standards for interview room safety was assessed at 6 months and 1 year after baseline. Following each assessment, results were presented so that the audit cycle was completed twice.

Results

At 6 months 46 interview rooms were assessed against the 12 accepted standards and many were found to be unsatisfactory. After presentation of these results, the 1 year assessment discovered few changes in safety features of the 50 rooms now being used.

Clinical Implications

Unsafe rooms compromise the safety of staff and patients and this is clearly unacceptable. The audit process in itself failed as amethod of improving standards.

Interventions to reduce the risk of violence toward emergency department staff: current approaches

INTRODUCTION

The phenomenon of workplace violence in health care settings, and especially in the emergency department (ED), has assumed the dimensions of a real epidemic. Many studies highlight the need for methods to ensure the safety of staff and propose interventions to address the problem.

AIM

The aim of this review was to propose a narrative of the current approaches to reduce workplace violence in the ED, with a particular focus on evaluating the effectiveness of emergency response programs.

METHODS

A search was conducted between December 1, 2015 and December 7, 2015, in PubMed and CINAHL. Ten intervention studies were selected and analyzed.

RESULTS

Seven of these interventions were based on sectoral interventions and three on comprehensive actions.

CONCLUSION

The studies that have attempted to evaluate the effectiveness of interventions have shown weak evidence to date. Further research is needed to identify effective actions to promote a safe work environment in the ED.

An audit of violent incidents in a drug treatment centre

Objectives: The aim of this study was to examine the prevalence of, and factors associated with violence in a drug treatment centre.

Method: This study is a retrospective audit of all incident forms completed at an urban drug treatment centre between December 1991 and July 1996 with reference to case notes for additional clinical information on individuals involved in violent incidents.

Participants included all patients attending the centre in the aforementioned time period who were involved in violent incidents. Information was obtained about the prevalence and severity of violent incidents and patient details including main drug of abuse, route of use, reason for attendance, comorbid axis 1 diagnosis, history of previous incidents and HIV status at the time of the incident.

Results: One per cent of all patients were involved in violent incidents. Less than one quarter of incidents involved serious injury or assault. Most perpetrators were male intravenous heroin users on a methadone maintenance programme. Nurses and doctors were most frequently the victims of incidents. Ten per cent of patients had a history of previous incidents and almost half the perpetrators were HIV positive. A comorbid axis 1 diagnosis was found in 9% of perpetrators (n = 6), mainly alcohol dependence syndrome.

Violence toward physicians in emergency departments of Morocco: prevalence, predictive factors, and psychological impact

Introduction

Anyone working in the hospital may become a victim of violence. The effects of violence can range in intensity and include the following: minor physical injuries, serious physical injuries, temporary or permanent physical disability, psychological trauma, and death. The aim of this study was to determine the frequency of exposure, characteristics, and psychological impact of violence toward hospital-based emergency physicians in Morocco.

Methods

This was a survey including emergency physicians who ensured emergency service during the last fortnight. The variables studied were those related to the victim (age and gender), and those related to aggression: assaulter gender, number, time, reason (delay of consultation and/or care, acute drunkenness, neuropsychiatric disease), and type (verbal abuse, verbal threat and/or physical assault). After the questionnaire was completed, State-Trait Anxiety Inventory (STAI) of Spielberg was applied to all participants.

Results

A total of 60 physicians have achieved permanence in emergency department during the 15 days preceding the questionnaire response. The mean age was 24 ± 1 year and 57% were male. A total of 42 (70%) had been exposed to violence. The violence occurred at night n = 16 (27%), afternoon n = 13 (22%), evening n = 7 (12%) and morning n = 6 (10%). Reasons for violence were: the delay of consultation or care in n = 31 (52%) cases, acute drunkenness in n = 10 (17%) cases and neuropsychiatric disease in n = 3 (5%) cases. Twenty eight (47%) participants stated that they experienced verbal abuse, n = 18 (30%) verbal threat and n = 5 (8.3%) physical assault. Exposure to some form of violence was related to a higher median [interquartile range, IQR] state anxiety point (SAP); (51 [46-59] vs 39 [34-46]; P < 0,001), and trait anxiety point (TAP) (48 [41-55] vs 40,5 [38-53]; P = 0,01).

Conclusions

This study revealed a high prevalence (70%) of violence toward doctors in Morocco emergency departments. The exposure of physicians to some form of violence is greater among doctors with anxiety trait and was related to significant degree of anxiety state.

Aggression and violence towards health care providers--a problem in Turkey?

Health care providers are increasingly concerned about the escalating incidence of verbal and physical abuse to healthcare staff. Factors, such as long wait in hospital areas, which lead to client frustration over an inability to obtain needed services promptly, are influencing these situations. Nonetheless, incidents of this nature can cause immense psychological harm as well as physical damage among medical employees. The current study aimed to ascertain from staff members aggressive experiences in the workplace, and the effects on the individual. The results of this study mirrored those of similar surveys in Turkey. Non-reporting was revealed as a major problem. Respondents believed they were treated less seriously than similar incidents involving private citizens. Accordingly, staff criticized hospital managers, the police, and the courts for their attitude about assaults towards hospital employees. They reported feeling vulnerable to abuse and there was a general desire for training in preventing and protection. These include teaching staff breakaway techniques, increasing the number of trained security officers on duty, issuing personal alarms, and encouraging staff to officially report all incidents.

Violence and aggression in the emergency department

OBJECTIVE

To investigate the characteristics of incidents of aggression and violence directed towards staff in an urban UK emergency department.

METHODS

A retrospective review of incident report forms submitted over a 1 year period that collected data pertaining to the characteristics of assailants, the outcome of incidents, and the presence of possible contributory factors.

RESULTS

A total of 218 incident reports were reviewed. It was found that the majority of assailants were patients, most were male, and the median age was 32 years. Assailants were more likely to live in deprived areas than other patients and repeat offenders committed 45 of the incidents reported during the study period. The incident report indicated that staff thought the assailant was under the influence of alcohol on 114 occasions. Incidents in which the assailant was documented to have expressed suicidal ideation or had been referred to the psychiatric services were significantly more likely to describe physical violence, as were those incidents in which the assailant was female.

CONCLUSION

Departments should seek to monitor individuals responsible for episodes of violence and aggression in order to detect repeat offenders. A prospective study comprising post-incident reviews may provide a valuable insight into the causes of violence and aggression.

Aggression and violence - a problem in Irish Accident and Emergency departments?

Health care employees are more likely than other workers to be victims of violence or aggression. Results from one Australian study suggest that 30% of respondents experienced aggression on a daily or near daily basis. In an Irish context, a total of 22% of all reported injuries in the health and social sector related to injuries inflicted by another person. However, both in Ireland and internationally, there has been an inadequate categorization of the types of incident to which staff are exposed. This contributes to definitional difficulties as well as problems in comparing research findings and using such findings to make work environments safe. The current study aimed to identify the types of violent or aggressive incidents that staff in Irish Accident and Emergency departments were exposed to within a month long period. A cross-sectional study was undertaken with all nurses (N = 80) working in Accident and Emergency departments in two sites nationally as part of a larger study of aggression and violence in health services looking at both Mental Health Services and Accident and Emergency departments. Data were collected using the Scale of Aggressive and Violent Experiences - questionnaire adapted from the Perception of Prevalence of Aggression Scale. The questionnaire captured data on personal and professional demographics as well as experiences of aggressive or violent incidents respondents may have encountered 'in their work situation'. There was a response rate of 46% (n = 37). Data were analysed utilizing spss-11. The relevant data were subjected to a series of one-way anovas and chi-square analysis. The findings suggest that nursing staff in Accident and Emergency departments experienced high levels of verbal aggression. Additionally, they encountered violence or aggression that is vicariously experienced more than forms that were overtly directed towards staff. It is a matter of concern that less than one-third of staff in this study reported that they had training in the management of aggression and violence. The implications will be discussed in relation to both policy and practice.

Epidemiology of unarmed threats in the emergency department

OBJECTIVE

To evaluate the precipitants, subject characteristics, nature and outcomes of unarmed threats in the ED.

METHODS

A 12 month prospective survey of security codes precipitated by an unarmed threat (Code Grey).

RESULTS

Data were collected on 151 subjects. The Code Grey rate was 3.2/1000 ED presentations. They were most frequent on Saturday and in the late evening/early morning. There were verbal or physical threats of violence made to staff on 104 occasions (69%, 95% confidence interval [CI] 61-76) and a perceived threat of patient self-harm on 114 occasions (76%, 95% CI 68-82). Median time to be seen by a doctor was 8 min (interquartile range [IQR]: 2-21 min) and median time from presentation to Code was 59 min (IQR: 5-222 min). Sixteen subjects (11%, 95% CI 6-17) had a history of violence, 45 (30%, 95% CI 23-38) were affected by alcohol, 25 (17%, 95% CI 11-24) had used illicit drugs and 79 (52%, 95% CI 44-60) had a significant mental illness contributing to the Code Grey. Seventy-one patients (47%, 95% CI 39-55) required psychiatric admission, 49 (79%, 95% CI 66-88) involuntarily.

CONCLUSION

Acutely agitated subjects pose a threat to themselves and the staff caring for them. The reason for the agitation is multifactorial and the majority arrive in a behaviourally disturbed state requiring early intervention. The times most likely to result in a Code Grey coincide with least available resources: ED and hospital risk management policies must account for this. A coherent approach by ED to this population is required to optimize patient and staff outcomes.

Perception of risk: a study of A&E nurses and NHS managers

This exploratory study investigates perceptions of two groups of NHS staff, of a range of risks, topical and relevant to accident and emergency (A&E). Literature suggests that the effectiveness of a risk management strategy is lessened if staff exposed to risk, and managers, have different perceptions of the nature and severity of the risk. A self-administered questionnaire was distributed to registered A&E nurses and to Trust managers at directorate level and above, working in five large inner-city NHS Trusts. Managers and nurses were asked to quantify their perceptions of nine defined adverse events. They were also asked to identify the jobholder with day-to-day responsibility for managing four specific risks. Completed forms were obtained from 38 per cent of managers and nurses. Results showed broadly that managers tended to quantify risks of violence and stress to A&E nurses less highly than did nurses. By contrast, they tended to quantify risks to patients more highly than did nurses. Overall, a coherent pattern of difference in risk perception between the two groups was identified. It is argued that identification of differences of perception is an essential part of the risk management process. Illustrations are given of ways in which these differences can undermine the effectiveness of a risk management strategy.

How secure are Australian emergency departments?

OBJECTIVE

To ascertain the level of security arrangements in Australian EDs.

METHODS

A postal survey to the directors of all Australasian College for Emergency Medicine (ACEM) accredited EDs in Australia. A score based on the ACEM design guidelines for EDs was given. A maximum score of 12 correlated with compliance with the 12 specific ACEM recommendations. Questions regarding satisfaction with security and occurrence of a major incident within the prior five years were included.

RESULTS

There was an 88% response rate to the questionnaire. Of the respondents, 63% were unhappy with the level of security in their ED and 81% reported the occurrence of a major incident within five years. The average score out of 12 was 8.39 (SD 2.4). A total of 7% scored 12/12 and 21% scored 6 or less. There was no difference in scores when the ED were grouped by age, locality or annual attendances.

CONCLUSIONS

The vast majority of Australian EDs do not comply with all ACEM recommendations on security and most department directors are unhappy with the existing level of security in their departments. This is of concern in light of the negative impact of violence on the well-being of ED staff.

How prevalent is violence towards nurses working in general hospitals in the UK?

BACKGROUND

Violence in nursing is not a new phenomenon but in recent years much greater emphasis has been placed on the problem in the United Kingdom (UK). A number of official reports, media stories and national initiatives have focused attention on the problem in this country. However, it is not clear whether violence and abuse have in fact become more prevalent. At present little is known about the scale of the problem for general nurses working in general hospitals in the UK.

AIM OF THE STUDY

A realistic assessment of the scale of this problem should facilitate a meaningful debate about the interventions needed to counter it and support the requests for funding that will be required. This study aimed to establish the utility of existing research findings, to include relevant but previously unused sources and to synthesize the results.

METHOD

A systematic search of the literature pertinent to the aim of the study was followed by a critical review. The focus was on research originating in the UK, including some general research on occupational violence which included data on nurses.

FINDINGS

Overall, the research findings are limited. The best available evidence suggests nurses as a whole do face a high level of risk compared with all workers and this excess risk holds for general nurses. The data support a figure of more than 9.5% of general nurses working in general hospitals assaulted (with or without injury) in any 1 year. Trends over time are impossible to identify at present.

CONCLUSIONS

Efforts to combat the problem should include greater emphasis on the problem outside accident and emergency departments, prioritizing preregistration training in the management of aggression, and further research. Better reporting should also be a priority.

Violence against emergency medical services personnel

BACKGROUND

Emergency medical services (EMS) providers may be exposed to violent behavior while performing their routine duties.

OBJECTIVES

To determine the prevalence of violence against EMS providers in the prehospital setting and to determine factors associated with such violence.

METHODS

Consecutive medical calls for EMS agencies in a southern California metropolitan area were prospectively analyzed for one month. Following each call, prehospital personnel recorded information about any episodes of violence (verbal or physical) during the run as well as variables felt to be associated with these behaviors.

RESULTS

There were 4,102 cases available for analysis. Overall, some sort of violence occurred in 8.5% (349/4,102) of patient encounters. Of this reported violence, 52.7% (184/349) was directed against prehospital care providers, while 47.3% (165/349) was directed against others. The prevalence of violence directed against prehospital care personnel was therefore 4.5% (184/4,102). Patients accounted for most (89.7%; 165/184) of this violent behavior. The type of violence varied, with 20.7% (38/184) being verbal only, 48.9% (90/184) being physical, and 30.4% (56/184) constituting both verbal and physical attacks. Male sex, patient age, and hour of the day were significantly associated with episodes of violence. Logistic regression analysis provided odds ratios (ORs) with confidence intervals (CIs) for factors that were predictive of violent behavior. These included police presence (OR 2.8; 95% CI 1.8-4.4), apparent presence of gang members (OR 2.9; 95% CI 1.6-5.3), perceived psychiatric disorder (OR 5.9; 95% CI 3.5-9.9), and perceived presence of alcohol or drug use (OR 7.0; 95% CI 4.4-11.2).

CONCLUSION

Emergency medical services providers in some areas are at substantial risk for encountering violence in the prehospital setting. Certain situational factors may be used to predict the risk of encountering violence. Training, protocols, and protective gear for dealing with violent situations should be encouraged for all prehospital personnel.

A survey of threats and violent acts by patients against training physicians

OBJECTIVES

The primary purpose was to determine the prevalence of various types of threats or assaults by patients against training physicians and to determine the psychological impact of the most distressing incidents. Differences between specialty of training and gender were examined.

DESIGN

An anonymous mailed questionnaire.

SETTING

The Medical School of the University of Auckland, New Zealand.

SUBJECTS

All 160 postgraduate trainees in psychiatry, general medicine, surgery, and obstetrics and gynaecology. A response rate of 84% (n=135) was obtained.

RESULTS

The majority of trainees had been verbally threatened (n=91, 67%) or physically intimidated (n=73, 54%) at some time during specialty training, while another 41% (n=55) had witnessed Health Board property being damaged in their presence and 39% (n=53) had been physically assaulted. Psychiatry trainees were significantly more likely to experience the various types of threat or violence. Females (n=20, 38%) were significantly more likely than men (n=8, 10%) to report having been sexually harassed (chi2=14, d.f.=1, P < 0.001). The overall mean on the Impact of Event Scale for those who described the most distressing incident was 8. On only one occasion was a training director directly informed about a trainee's most distressing incident and most trainees (n=95, 70%) had not had training on protecting against assault or on managing violence.

CONCLUSION

These findings underscore a priority for developing programmes which effectively reduce threats and violence against trainees and which lessen the psychological sequelae of these incidents.

Emergency medical services providers and weapons in the prehospital setting

OBJECTIVES

To investigate emergency medical services (EMS) providers' experience with weapons encountered while working, and evaluate the training they have received regarding searching for and confiscating weapons in the field.

METHODS

This was a descriptive, cross-sectional survey anonymously completed by a convenience sample of EMS providers in the metropolitan Boston and Los Angeles (LA) areas.

RESULTS

Of 2,672 surveys distributed, 2,224 (83%) were returned. Forty-two percent of the respondents (39% of Boston and 46% of LA) reported searching patients for weapons, and 62% (51% of Boston and 76% of LA) reported finding weapons. The LA respondents were more likely than the Boston respondents to have found a firearm. Twenty-seven percent of the respondents reported they had found more than five weapons in their careers. One thousand seven hundred seventy-two (80%) providers replied that they would report discovered weapons, most frequently to law enforcement personnel. Providers with higher EMS education and ones who received weapons-related training were more likely to search for, find, and report weapons. Four hundred fifty-one (20%) respondents reported receiving formal weapons-related training, 291 (13%) considered their initial EMS training on weapons-related topics to be adequate, and 292 (13%) considered their continuing education in these areas adequate.

CONCLUSIONS

These data suggest that weapons encountered in the field are a widespread problem for EMS providers. Although many EMS providers search for and find weapons on their patients, most of them feel they have been inadequately trained in this area. Prospective studies are needed to document the actual incidence of weapon encounters in the prehospital setting. Multidisciplinary discussions are needed to address the above issues.

Violence and verbal abuse against staff in accident and emergency departments: a survey of consultants in the UK and the Republic of Ireland

OBJECTIVES

To determine the incidence of verbal abuse and physical violence in accident and emergency (A&E) departments and to discover the extent of provision of security measures and instructions for staff on how to deal with these problems.

DESIGN

A postal questionnaire.

SETTING

A&E departments in the UK and the Republic of Ireland.

SUBJECTS

Two hundred and seventy three consultants named in charge of 310 departments.

MAIN OUTCOME MEASURES

Frequency of physical violence and verbal abuse, injuries sustained, perceived precipitating factors, security measures instituted, and legal action taken.

RESULTS

Two hundred and thirty three replies were received. Alcohol, waiting times, recreational drug usage, and patients' expectations were perceived as the chief causes. Patients were the chief perpetrators with nurses being the commonest victims. Staff sustained 10 fractures, 42 lacerations, and 505 soft tissue injuries. There were 298 arrests and 101 court appearances that resulted in 76 convictions. Panic buttons and video cameras were the most common security measures.

CONCLUSIONS

Staff within A&E departments are regularly abused, both verbally and physically. Inner city departments appear to be most affected. Documentation is poor. Perpetrators are seldom convicted. There do appear to be actions which hospitals could undertake that might help to ameliorate these problems.

Emergency department senior house officers' consultation difficulties: implications for training

STUDY OBJECTIVE

We investigated the types of patient presentations that cause senior house officers (SHOs) most difficulty during their tenure in emergency departments and report the extent to which such difficulties are related to SHOs' communication problems, stress, or perceived lack of skills or knowledge.

METHODS

We conducted a questionnaire survey of 171 newly appointed SHOs employed in 27 EDs in the South Thames region of England. Subjects were asked to describe the presentation that gave them greatest difficulty during three subsequent shifts at the end of the first and fourth months of their ED appointment.

RESULTS

A total of 132 (77%) and 110 (64%) respondents returned questionnaires at the end of the first and fourth months, respectively; 61% (105) responded to both questionnaires. The respondents described 537 of a possible total of 726 cases (74%). Communication problems caused difficulty in 406 (76%) cases, SHOs' experience of stress in 352 (66%) cases, and a perceived lack of knowledge or skills in 281 (52%) cases. Communication problems and the experience of stress occurred in 141 (26%) cases. Patients presenting with mental or behavioral disorders and symptoms most frequently gave rise to communication problems, perceived lack of skills, and the experience of stress. The difficulties described at the two time periods were very similar indicating that experience alone had little effect on these problems.

CONCLUSION

ED SHOs may benefit from communication skills training, the opportunity to review difficult case presentations, and the alleviation of organizational stress factors.