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Reducing violence in emergency departments requires a paradigm shift away from identifying and managing perpetrators, and towards remediating the structural and systemic drivers of violence in this context.
Working as an emergency nurse for the past decade, I have witnessed and experienced violence in the emergency department many times. Occupational violence has been an endemic issue for Australian emergency departments, and contributes to staff injury, turnover and burnout, in addition to the negative impact it has on individual episodes of care. Strategies to address this problem in Australia’s public health system often focus on the individual level, by equipping health care workers with skills and strategies to identify risk, de-escalate situations, and engage in self-defence, as well as applying increasingly significant legal penalties for assault of health care staff. Systems are also in place to label particular patients with alerts for aggression and assist with identifying potential offenders (here and here). Each of these strategies have their place and can help to reduce the burden of violence in emergency departments. Focusing on the actions of individual perpetrators and staff members, however, while lamenting that increasing occupational violence is simply “a trend that is reflected broadly in the community”, misses some of the deeper yet modifiable aspects of the emergency department that contribute to this violence.
What causes violence in the emergency department?
Violence is multifactorial, and it requires a multifaceted response. While much attention is given to identifying, controlling and punishing perpetrators of violence, we often spend less time discussing the structural and systemic reasons that violence occurs in health care contexts. What is it about the environment and processes of an emergency department that contribute to violence, and how could these be changed? To go even further, in what ways do we as the health care system perpetrate violence, or other more subtle forms of harm, coercion, discrimination or dehumanisation in how we design and deliver this system? This is not about shifting blame, but recognising every part of the dynamic environment in which violence occurs and thinking critically about those aspects we can change.
Emergency department violence has been well studied. Its workings are complex but not mysterious. Factors associated with violence include patients lacking information, insufficient personnel and equipment, communication breakdowns, staff shortages and lack of resources, and, importantly, long waiting times. One study of Australian emergency departments found that longer waiting times were associated with five times the risk of violence. Issues of mental health, drugs, and alcohol are also key correlates of violence and aggression, but these are in play before the patients arrive to emergency. The question is what can be done after that point to improve everyone’s safety?
The answer to this question may be simply to see, treat, and admit or discharge patients in a professional, collaborative, and timely manner. Developing this kind of functional, adequately resourced system would remove many of the correlates of violence listed above. This option is difficult and expensive, but not radical or impossible. It is not about upskilling an already skilled workforce or taking a law-and-order approach to crack down on the behaviour of patients. We simply require a physical space that is equipped to receive, manage, and restrain potentially volatile and unpredictable patients, and a workforce that is adequately staffed to treat the entire patient cohort in a way that minimises triggers for violence. The evidence seems to show, however, that that is what we lack.
Build it, because they are coming
The potential impact of this basic approach has been recently demonstrated by the Psychiatry and Drug And Alcohol (PANDA) unit, initiated in 2020 at St Vincent’s Hospital in Sydney, which provides tailored care for people presenting with acute mental health concerns plus complex comorbidity. The PANDA unit has become one of the best performing units in the hospital for time-to-be-seen, and the number of behavioural disturbance episodes in the emergency department dropped from 20 in the six months prior to the unit opening to 12 in the subsequent six months. This is the result of a space dedicated to these higher risk patients, which can provide the resources needed to manage their behaviours and minimise escalation. The development of further such PANDA units or safe spaces to facilitate the management of higher risk patients was a key recommendation from the recent review of health care-related violence by NSW Health. These answers are not rocket science; we are just often unwilling to spend the money on what is required. A practically and politically easier option is dehumanising the perpetrators of aggression and treating the pervasive violence of emergency as a crime issue arising from the violent characteristics that some members of the community inherently possess.
Whose side are we on?
In addition to providing physical and human resources that allow staff to minimise violence, the style of clinical encounters can also help prevent escalation and aggression. At a systemic level, we know that perpetrating violence is associated with things like adverse childhood experiences, traumas related to harmful drug use, poor mental health and having less access to services and support. This does not justify or excuse violence; but it does support the use of trauma-informed care in the emergency department to help minimise it. Trauma-informed approaches are based on four key aspects:
- Understanding how widespread the impacts of trauma can be and how people recover.
- Identifying signs of trauma when they present.
- Integrating awareness and understanding of trauma into organisational policies, procedures and clinical practise.
- Actively avoiding instances of re-traumatisation.
These principles can assist with responding effectively, compassionately and consistently to aggression and violence, without excusing it or downplaying its significance.
Additionally the concept of structural competency has been developed to describe how emergency department staff defuse potentially violent situations by acknowledging the wider context of disadvantage that some patients experience. Similar to how trauma-informed care is practised with acute awareness of the effects of trauma, there can also be “structure-informed care”, with an even broader awareness of social determinants of health, and an ability to articulate this in clinical encounters. As one nurse explained, she de-escalated a patient by acknowledging and validating their experiences, something that “made it clear whose side I was on”. This core value of solidarity with patients, even those that may present a risk of aggression, can be difficult to hold and to practise; however, it can short-circuit or defuse many of the interpersonal processes that develop into violence, within the time- and resource-constrained contexts of a modern emergency department.
Beyond zero tolerance
Violence may be ineradicable to some degree in emergency departments. Its incidence can be minimised; however, by designing and funding clinical spaces that have the physical infrastructure and human resources necessary to avoid the kinds of prolonged and dehumanising interactions with the health care system that can precipitate it. At the clinical level, a multidimensional approach to violence that avoids an adversarial, law-and-order approach, that recognises the kinds of trauma and structural factors that can lead to aggression, while also avoiding passive tolerance of aggression towards staff, will help to minimise it further.
Significantly reducing violence in emergency departments is not out of reach, it is just financially and politically expensive for those with the power to achieve it. We need to look beyond zero tolerance policies and ways to better control or punish violent patients, and instead take a rational, compassionate, health care-oriented approach that identifies the core issues, and demands the far-reaching paradigm shift that is required to minimise occupational violence in emergency departments.
Samuel Brookfield is a clinical nurse at the RBWH Emergency & Trauma Centre, and a senior principal social scientist at the University of Queensland School of Public Health. He is also an emergency nurse specialist with the International Committee of the Red Cross, recently working in South Sudan and Gaza.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Over the last 30 years in ED Nursing the 3 key drivers of violence in the metal health cohort have been:
1. Application of a Section or Inpatient Treatment Order.
2. Length of Stay- contributing factors, delay to initial mental health specialist assessment / Long waiting times for inpatient bed.
3. the forces cessation of smoking privileges. It is not patient centred to decide that a psychologically unwell person would have the headspace to agree now is the time to give up smoking.
Samuel Brookfield’s article gives me some hope. I have long had doubts about zero tolerance. Fighting antagonism with antagonism is fine if we want to kill the antagonists, but if we hope to treat them, I agree that Empathy is the better way. For most clients in ED, it is not their scene, they would rather be elsewhere.
Hi, Chris. I have also observed the health care system over decades (mainly from inside the ED, though now from emergency telemedicine). Throughout this time, there have always been patients coming to ED because they could not access any other service that served their needs at the time that they needed it. Those needs could be an acute symptom, or a source of anxiety, or often a referral from another health care provider.
During my career, three additional things have changed:
– Starting in the 1980s, and increasing since, excess patients needing inpatient admission, and those considered “too sick for the ward but not sick enough for ICU” are held in ED – for hours to days.
– Mental healthy units stopped doing their own intake of acute patients and re-directed then to ED; and
– Increasing societal risk-aversion means more referrals from community providers to ED, and more anxiety among patients and families if there is uncertainty.
Emergency telemedicine has been able to tackle some of this pre-hospital by assessing and reassuring and (where possible) treating some patients without them having to leave their homes (or nursing homes).
Mental health units could take back their traditional intake roles for patients with an exacerbation of a known mental health condition, or who are physiologically stable.
Inpatient units must be helped to find a way to accommodate all incoming admissions from ED, so that flow through ED continues.
As a community, we must teach and encourage all our patients to anticipate and self-manage when they have predictable exacerbations of known conditions, or winter viruses etc.
As somebody who has observed the system over decades, we have made some major errors, especially the failure to sustain the critical role that properly resourced, respected and empowered GP’s fulfilled as skilled frontline providers and gatekeepers. Unfortunately that has collapsed at the same time as our society has become disrespectful of the institutions that underpin good behaviour, for example the way teachers and law enforcers are abused and even assaulted. Not unsurprisingly the worst of a dysfunctional system and sick society sadly coalesce in the provider of last or even only resort, being our public EDs.
Thank you for the valuable messages. The elephant in the room is that our health system is designed to concentrate the “too hard problems” in ED, while simultaneously holding ED staff to account for the waiting times and outcomes for patients with severe acute life-threatening conditions. EDs provide the backstop for gaps in every other healthcare and social service – from mental health to housing, cancer care to domestic violence, corrections health, end-of-life care – and so much more. This situation is not only untenable, but makes the workplace very unhealthy for staff.
One of the situations that makes people angry after a long wait is when they find that the site they have attended cannot provide the service they had expected, or that their attendance cannot solve their problem (especially when expectations have been created by referring clinicians in the community).
The effect then snowballs – worried people who have been waiting for a long time get anxious, taken out on staff. Staff are too harried to be consistently calm and sympathetic on every occasion, and get burned out and leave. Staff shortages lead to longer waits. Post-hoc criticism from colleagues using a powerful “retrospectoscope” leads to further frustration and demoralisation. Patients arrive being already anxious, but with the mindset of needing to fight for their “rights”. And so it goes.
Add violent patients affected by a potent combination of stimulant drugs and mental illness, and you have a chaotic, dangerous ED.
I applaud models such as PANDA, so long as they have open admission policies, are not risk-averse and have access to senior decision-makers.
We CAN avoid long-waits for non-productive ED attendances through a combination of (senior, non-risk-averse) pre-hospital triage/advice (including telemedicine) as well as re-triage to more suitable services. This should not be seen as “denying” access to ED, but providing a more suitable alternative for the patient’s issue.
The entire health care community needs to share the excess risk and workload. Continuing to concentrate it in ED will eventually lead to the collapse of a system that we all assume will be there when we need it.