Societal Violence in the Emergency Department

Emergency Departments (EDs) have the highest levels of violence of any hospital units, and according to a 1994 survey, 97% or nurses in these reported verbal violence and 87% physical violence. All EDs have large numbers of uninsured patients, many of them with drug, alcohol of psychiatric problems, which increase the normal stress and anxiety of this environment and make violence far more likely. This problem is compounded by the fact that only 3% of EDs had full-time security on-site, which means that "prevention is the best method to deal with violence in the ED" (Hoag-Apel, 1998, p. 60). All EDs should do a risk assessment that includes the location, design, history and security measures in the facility; the type of in-house security staff, training and weapons, communications with local police and hospital security; nighttime lighting, parking areas, numbers of chemically dependent patients. It should note whether access is monitored and guarded, where panic buttons are installed, and if patients and visitors can be observed and monitored at all times. Written protocols on how to control violent patients and visitors and report verbal and physical threats should be in place. Obviously EDs located in poor and inner-city areas will see large numbers of victims of gun violence, drug overdoses, and the uninsured, so violence there might very well be an everyday occurrence, although almost all emergency rooms will experience it at some point during the tear.

Fear and anxiety are the most common causes of violence in EDs, and staff members should be trained to defuse these in a calm and professional manner while reassuring patients that their problems will be addressed. Studies show that in the hospital, the most normal type of fear is of the "unknown or loss of control of a situation involving oneself or a loved one" (Hong-Apel, p. 60). Long waiting times, chemical and alcohol intoxication, particularly use of amphetamines or delirium caused by alcohol and drug withdrawal are more likely to lead to violent incidents. Among psychiatric patients, those suffering from paranoid delusions are also more likely to act out in a violent manner, such as imagining that the ED staff is plotting to kill or injure them. All staff members should be alert to warning signs of potential violence such as "pacing, staring, [or] any noncompliant behavior" (Hoag-Apel, p. 60). Voice, tone and body language are all important cues that a violent situation might potentially erupt, and the best method for dealing with this situation is to listen to the concerns patiently and rationally, to not "take the anger personally and calmly reinforce your desire to help" (Hoag-Apel, p. 63). Hospital chaplains and patient advocates are also very valuable in helping to defuse anxiety, fear and anger among patients and visitors. EDs should also have procedures for reporting all veiled and direct threats against the staff and for stress debriefings after violent incidents to deal with physical and psychological trauma. In all cases, though, having proper prevention and security measures in place in advance should greatly reduce the potential for violent incidents overall, if not eliminate them completely. By their very nature, EDs have an open door policy and are required by law to treat all patients who appear, so this will always mean that they have a greater likelihood of encountering those with drug, alcohol and psychiatric issues who are more likely to act out in a violent manner.