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Health workers report worsening violence in increasingly overwhelmed and understaffed emergency departments.

“We are desensitized”: Violence escalating in struggling emergency departments

Content warning: Descriptions of violence. 

Samantha Marchand says she and her colleagues in the emergency department at St. Michael’s Hospital in Toronto have experienced so much violence at work they have become numb to it.

Marchand, a registered nurse who has worked at St. Michael’s for five years, says that incidents of physical and verbal abuse occur every single shift. “It’s something that’s been normalized, and we are desensitized,” she says.

Often, the attacks involve patients throwing “vomit, stool, urine, semen,” Marchand says.

“I had someone pull a maggot off them and throw it at me,” she recounts. Another patient “pulled off a necrotic digit, a toe, and threw it at staff.”

And in one incident that Marchand found particularly disturbing, a patient who was upset about being discharged trashed a room and left a used needle poking up under some sheets, seemingly to cause a needlestick injury.

“There are some very extreme things that have happened,” Marchand says. And the violence seems to be escalating as emergency departments are increasingly understaffed and overwhelmed.

More intense, less predictable threats

“It’s becoming more problematic in that it’s less predictable,” says David Kodama, an emergency physician at St. Michael’s. “We’re starting to see patients who we normally wouldn’t think would be overly aggressive becoming both verbally and physically abusive.”

High-risk situations requiring police intervention are also “much more common than in the past when we could handle these things more internally,” Kodama says. One recent incident involving a patient wielding a small axe led to an arrest.

Before the pandemic, healthcare providers were already four times more likely than other workers to experience violence on the job, with half of these attacks occurring in emergency departments.

Nurses are among those most at risk, with more than half of those working in emergency departments experiencing verbal or physical abuse in any given week.

COVID turned up tensions

“This is a field that’s struggled with violence and aggression as it’s the point of entry for the healthcare system,” says Kuldeep Sidhu, chief of emergency medicine at Hamilton Health Sciences.

Chronic understaffing, poor access to other health and social services, and the dual crises of COVID-19 and mental illness and addictions have added to the congestion, noise, and confusion in emergency departments. “That increases the level of anxiety and stress for all staff, patients, and family,” Sidhu says.

The pandemic turned up the heat in what was already a powder keg, according to Alan Drummond, a former president of the Canadian Association of Emergency Physicians (CAEP).

“Volumes are at a higher level than they were pre-COVID and the acuity is higher because a lot of people have put off care or have been unable to access care,” Drummond says. Meanwhile, “we have fewer workers to provide the care that they’re seeking, so what used to be a two-hour wait is now an eight-hour wait.”

“When you’re uncomfortable or you’re with a loved one who is suffering, it’s pretty easy to lash out because of pure frustration,” he says.

Are health leaders failing workers? 

Yet, many hospitals and health systems don’t seem to take the abuse seriously. Violence in emergency departments isn’t tracked in any centralized or standardized way. Many incidents are never reported.

According to CAEP, “the prevailing culture in the hospital system has implied that ED violence is part of the job, an inherent risk that it is futile to try to address.”

Last year, the group called for explicit, written policies and procedures to prevent workplace violence in emergency departments, along with safe physical spaces and the provision of counselling and support for victims.

Drummond says St. Michael’s is “probably the very best example of the way it can be done” – despite the ongoing incidents there.

After a series of events that left staff injured two years ago, the hospital’s safety committee developed a flagging system and screening tool for identifying people at risk of becoming violent.

The tool accounts for things like threatening body language, confusion, and paranoia, as well as a patient’s known triggers. It also suggests action to take depending on the risk level, including calling 911.

It’s too early to tell the impact of the intervention, but Marchand hopes it will make a difference over time.

Limited evidence for interventions

In the early 2010s, a similar system of flagging aggressive patients helped Michael Garron Hospital reduce the percentage of incidents in which “use of force” was necessary to contain a threat.

However, a 2020 Cochrane review found limited evidence supporting any strategies for reducing violence towards healthcare workers, although regular risk assessment has shown promise in psychiatric settings.

And many anti-violence interventions put the onus on health workers to defuse or prevent aggression, while systemic drivers of the problem remain unaddressed.

A recent Canadian study called for a “move away from focusing on the individual worker, who is the victim, to a systems-based approach at the organizational level to help reduce and minimize violence.”

Staffing key to safety

Safety and staffing, for example, are “integrally connected,” according to Orla Smith, senior clinical program director of ED and medicine at Unity Health Toronto.

“If we were fully staffed with nurses, physicians, and other support workers, and security, everybody would feel better and patients would get better care,” Smith says. “We’d still have safety issues, but we’d be able to better manage… we could provide more attention and connect with other services.”

Solutions to reduce violence in emergency departments must go “beyond healthcare,” Smith adds. “We’re not just in a staffing crisis, we’re also in an opioid crisis.”

Without adequate or available social services, many people come to the hospital because they have nowhere else to go, she says. “It’s not just about healthcare access, it’s about access for many, many things.”

Photo credit: BernardaSv/iStock via Getty Images

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