HCWs face violence, abuse from patients

Study: Need for better reporting, training

After the shock of the 9/11 terrorist attacks, hospitals beefed up their security. But a study of New Jersey hospitals shows that hospitals need to take further measures to protect health care workers from the more common violent events — verbal and physical assaults from patients in the emergency department.

Hospitals need a uniform method of reporting events, improved training, and better coordination between security personnel and employee health and other clinicians, according to a report issued by the Occupational Health Surveillance Program of the New Jersey Department of Health and Senior Services.

"There is definitely attention being paid to this issue, but [there's] not a clear-cut trend in how to respond to it," says Corinne Peek-Asa, MPH, PhD, professor of occupational and environmental health at the University of Iowa School of Public Health and an expert on workplace violence.

Peek-Asa conducted the study, which was sponsored by the National Institute for Occupational Safety and Health, as part of a broader review of California's violence prevention activities

California was the first state to pass a law addressing workplace violence in health care; it requires hospitals to conduct security assessments, respond to identified risks, and provide regular training to employees on safety and security measures. Peek-Asa used New Jersey as a comparison to represent the status quo at hospitals that do not have specific legislative or regulatory imperatives to address workplace violence.

"I would hope this kind of study would encourage states to examine what their own practice is," says Eddy Bresnitz, MD, MS, deputy commissioner for public health services with the New Jersey health department and the New Jersey state epidemiologist.

The problem of violence in emergency departments is widespread, he says. "There's no part of this country that doesn't have significant populations [with] drug or mental health problems or other problems that could contribute to violence in an emergency department," he says.

In the study, the 50 hospitals varied greatly in the extent of the measures they had taken. Some were strong in one area, but weak in another. "Having a strong training program was largely unrelated to having strong components in other areas," Peek-Asa says.

For example, in one hospital, a vocal advocate in nursing may have influenced the creation of strong training programs, while in another hospital a security director may have implemented better procedures and equipment for that area.

"Every hospital had done something. We did not find a hospital that had not at least thought about this issue," she says.

Nurses suffer most assaults

Violent events are often underreported. But the analysis of data from 1992 to 2001 provides a picture of the violence that occurs in emergency departments.

Patients were the "perpetrator" in 85% of incidents, and nurses were the employees most likely to be assaulted (43%). Incidents were most likely to occur when employees were trying to restrain or subdue a patient or with combative patients, but 30% of the incidents occurred during medical care or nursing functions.

In three-quarters of the cases, an emergency department employee suffered a strain, sprain or spasm, and about two-thirds involved a bruise or contusion. In one-third (32.9%) of the cases, an employee missed at least one day of work due to injury from the incident.

Verbal abuse is endemic in emergency departments, interviews with nurses revealed. Some 27% of the nurses reported that verbal abuse occurred more than 96 times per year. About a third reported being physically assaulted. But whether the incident was physical, verbal, or a threat, 72% of the nurses said they did not report it.

Much of the violence relates to the stressful conditions of American emergency departments. "We have overcrowded conditions in virtually all our emergency rooms," reports Aline Holmes, RN, APNC, senior vice president for clinical affairs at the New Jersey Hospital Association in Princeton. The hospital association is now working with the Emergency Nurses Association to create a workplace violence prevention program.

Most of the New Jersey hospitals (82%) provided training on workplace violence prevention. But the study identified weaknesses in security and prevention programs and offered recommendations for improvement. Here are some of the key points:

The reporting and surveillance of violent events is uncoordinated. Some events were reported to security, while those involving injury were reported to employee health. Hospitals need to assess their reporting gaps, develop a uniform reporting system, and improve dialogue between security and clinicians in the emergency department. "We found that even very large events weren't on the OSHA [U.S. Occupational Safety and Health Administration] logs at all," says Peek-Asa.

Most hospitals did not have a formalized way for nurses, physicians, or other employees to communicate information about violent patients. Most often, nurses told each other information informally, but physicians, security personnel, and others may be left out. Hospitals could use code words on an exam room door or color coding on charts to provide that information.

Not everyone in the emergency department received training. Physicians were often left out, as were clerical staff, volunteers and contract employees. "You have to have ongoing training throughout the course of the year and everybody needs to be trained," says Peek-Asa.

Training programs did not address the specifics of the hospital's own emergency department. Training should be tailored for the facility, and it should include interactive sessions and role-playing.

(Editor's note: A copy of the report, Workplace Violence and Prevention in New Jersey Hospital Emergency Departments, is available at http://www.state.nj.us/health/eoh/survweb/documents/njhospsec_rpt.pdf.)