Emergency departments are experiencing an increase in use by the public. Hospitals are unable to keep up. An analysis of this use points to one unintended consequence of a non universal private health care system. The emergency department of a hospital is the only location in an overburdened health care system where any patient who shows up must be treated regardless of ability to pay. With state facilities and programs for mentally ill citizens, and those suffering drug addiction being eliminated these patients often end up in emergency wards. Visits to emergency departments(ED) for alcohol or drug related incidents are on the rise.
Emergency departments are often overcrowded. Overcrowding is defined as all beds in use and the waiting room full for more than 6 hours a day, patients placed in halls, and seriously ill patients having to wait more than 1 hour to see a doctor. (1)
Long waits are more then rule than the exception. Add sickness, trauma, mental illness and drug use to the lack of privacy, and a less than ideal situation is created for patients to appropriately cope with stress.
Nurses who execute care and spend the most time in triage and treatment suffer the brunt of patient and family frustration. They are subject to verbal and physical abuse at unacceptable rates. Studies have shown that health care workers are the most likely to suffer workplace violence after prison guards and police officers. In a profession where healing and mercy are requirements it is disturbing that nurses are subject to these assaults.
Nurses are abused verbally by been sworn or yelled at, or called names. Physical violence includes being spat upon, scratched, hit, slapped, kicked, or stabbed. Injuries can range from the not visible to months taken off work for severe injuries.
The Emergency Nurses Association believes that violent incidents are underreported according to a recent survey. Nurses often don’t report incidents. They fear it will reflect badly on them as being less than competent. Or they believe that the administration will not take them seriously or be indifferent. They do have some basis to believe that as up to 75% of medical centers do not respond to reported workplace violence. Also many institutions do not have workplace violence policies or prevention programs. Nurses also believe that abuse by patients and families are part of the job. In some cases they can empathize with the scenario that created the violence. Often they believe if they press charges that the perpetrator will escape conviction because they were mentally ill or high on drugs.
Nurses associations are advocating to end violence against nurses. The Pennsylvania Association of Staff Nurses and Allied Professionals had a conference in early November, Massachusetts Nursing Association is one that has done a lot of work in raising awareness. The Occupational Safety and Health Administration office has issued guidelines for medical centers to address this challenge. However, these guidelines should become enforceable standards. The survey shows that hospitals with a zero tolerance workplace violence program have less than half the number of incidents of other medical centers that have no policy.
In Massachusetts, a House representative and a senator have introduced an act requiring Health Care Employers to Develop and Implement Programs to Prevent Workplace Violence. 26 states now have more strict penalties for assaults on nurses. New York very recently made assaulting a nurse a felony same as assaulting a police officer, firefighter, or EMS personnel. In contrast, 2 states that were going to move these assaults from misdemeanor to felony killed the proposal. Another state deferred the decision. Even in hospitals where severe assaults have disabled staff, the administration has only struck committees yet have failed to disclose when the committee would meet or the results of the meeting.
Prevention and being proactive are the keys to meeting this challenge. If administration is committed to training all staff and encourages reporting of incidents there would be progress towards prevention. Administration must also be committed to having adequate staffing levels at all times in the ED. Several bodies such as the American College of Emergency Physicians and the International Association for Healthcare Security and Safety, have made recommendations such as yearly risk assessments especially if the hospital is located in an area where there is high crime or gang activity. If it means having metal detectors and visitor sign-in those should be put in place as one hospital in Detroit did. Why would anyone need to bring a gun or a knife into the ED?
In the Institute of Medicine’s(IOM) report in 2007 on emergency care in the US they commented that that crowding, boarding, and ambulance diversion were the total opposite of high quality medical care. The Joint Commission for Accreditation of Hospitals had tried in 2004 to institute strong measures to counteract these now common practices but pressure from hospitals caused the measures to be watered down. In no uncertain terms the IOM’s report recommends that these measures be reinstated. Decreasing crowding, boarding and ambulance diversion would go a long way to dealing with ED violence and allow high quality emergency care. The violence is only a symptom; the root caused must be addressed.
One interesting fact is that less than half of ED patients require urgent care. To reduce wait times hospitals are considering NPs to treat non urgent patients.
The Ed puts a microscope on societal attitudes to nurses, health care, and especially violence. The examination is not pretty. Why do patients feel they need to act out their frustrations on someone that will ultimately help them get better? Why aren’t hospital executives proactively seeking to prevent violent incidents? The IOM notes that hospitals have no financial incentives to reduce ED crowding. Are numbers and dollars more important than patients and staff safety and well being? Has society become so desensitized to assaults that it is seen as an inevitable part of life? How can anyone tolerate that a nurse can be abused on the job? Acceptance of the unacceptable says a lot about the people that have the power to change it.