Preventing health care violence in the ER requires moving from safety to security

A slight man falls off his barstool. Now he’s an ER patient, slurring insults and flailing at staff trying to examine him for injuries. When a nurse begs him not to because we don’t know yet whether he has a neck injury, this respectable-looking man in a collared shirt tries to punch her.

What’s responsible for such behavior? Too much alcohol? Other substances? A brain bleed? Low blood sugar or a mental health disorder? A bad day?

Those of us working in the ER don’t know. We’re busy defending ourselves and protecting the patient from himself, absorbing his insults and guarding against judging him. At this moment, threats to our safety might signal an urgent medical condition that requires our care.

The growing crisis of health care worker violence is marked by high-profile tragedies and silently endured assaults. The spine surgeon and three others at a medical office in Tulsa gunned down by a patient in continued back pain after his recent operation. Or the nurse violently assaulted by a patient in an inpatient psychiatric ward. The events that rise to public awareness draw cries for necessary safety measures. However, in my home of emergency medicine, policy and process measures to improve safety must also seek to preserve health care worker security.

Safety and security both refer to protection from threats and harm and are often used interchangeably. But they provide different lenses for understanding and designing violence prevention efforts in the ER’s complex medical and moral environment.

Folded into security is the belief that a thing or a place is fixed, reliable, and trustworthy. It acknowledges the mission of emergency medicine and the purpose of providing health care access for all. The Emergency Medical Treatment and Labor Act (EMTALA) codified this ethos into statute. Every patient presenting to the ER can expect a screening exam for a medical emergency. For the patient who fell off the barstool, the screening exam entails labs, a brain CT scan, sedation so he’ll lie still for the scan, and tough love.

Early in my career, I learned a counterintuitive understanding of aggressive and threatening patients — their behavior can be motivated by feelings of powerlessness and a loss of control. A sensitive and firm response should try to restore a measure of control to them. Those efforts include a quiet room, nonjudgment, and an offer for medication if necessary.

A respectful restoration of control is core to security, and control can feel elusive to ER patients as well as staff.

Coaxing him through various tests demands patience, time, and compassion. He’s more than a safety threat, he’s a danger to our emotional security. Compassion runs low with patients such as this one, especially when he’s not the only one acting this way during a busy ER shift.

I remember an ER colleague who was called from the bedside of a sick patient to try to reason with a spitting, screaming woman in our ambulance triage area. She suffered from mental illness and substance use, but the crowded space itself was provoking her behavior. With boarding and staff shortages, there wasn’t anywhere quiet and less stimulating for her. Even so, my colleague’s usual empathy was spiked with frustration. He told her, “Your behavior is killing other patients.” But the real enemy here was the system, not the woman who was suffering.

His cutting metaphor is a literal truth and hints at the threat of violent behavior to our cognitive security. Difficult patients drain our mental resources and make it harder to reason analytically and process information, making medical errors more likely. ER physicians must cater to the kaleidoscope of needs for 20 or more patients. What patients act out, they require immediate attention. These added interruptions and breaks in task compromise health care quality and safety. The crisis of ER boarding of hospital patients and crowding require constant workarounds that add to these cognitive demands. Through the lens of security, high occupancy rates double as environmental pressures that contribute to violence against ER staff.

Pinched between system challenges and patient expectations, I feel increasingly powerless and yet accountable for problems beyond my control. Do patients find the ER a source of comfort or distress, a helping hand or a dismissive maze?  When thinking about my feelings of moral distress and burn out, I must remember that patients suffer from burn out, too.

Most patients wouldn’t come to the ER if given other choices such as a timely appointment with their doctor or ready access to needed health services. When they discover the ER’s open door doesn’t translate into empty beds, it can push tired, frustrated, and otherwise reasonable people to their edge.

Once, a patient and I knocked heads over a shared feeling of powerlessness. I examined him in the triage area and entered orders for pain medications and labs. But he wasn’t going to a room anytime soon. We tried to explain the wait and what we can do. He stood and started pacing. “This is what you can do,” he yelled. “Do your job.”

His scolding hit a nerve, in part because he was right. But ER boarding prevented us from doing our job. Ashamed, I snapped back, well aware that we were failing our patients and our values. My behavior was rooted in insecurity and judgment instead of the acceptance and curiosity he needed. My reaction added to his displeasure and deepened my sense of failure.

Ambrose Hon-Wai Wong and colleagues describe the “patient care paradox” of ER work — the struggle to care for harmful patients who are often marginalized and suffering from psychosocial stressors in a high-risk environment. The stress from these experiences follows patients and staff home.

The ER is one of the most common hospital areas for violence to occur. A 2018 survey by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) reported that nearly 70% of emergency nurses say they’ve been hit and kicked on the job. An updated 2022 survey reported that two-thirds of emergency physicians were assaulted in the previous year alone.

And it’s not just nurses and physicians, but other vital team members such as ER techs, social workers, registration staff, and housekeepers. Community problems bleed into the ER, and incivility and violence are growing problems for other service industries, including restaurants, retail, schools, airlines, and even riverboats.

Health care workers experience five times more violence on the job compared with the general population, and these statistics suffer from under-reporting and omit those situations when the staff’s experience prevented the tension from igniting into a crisis.  Health care workers may shrug it off as part of the job, but that doesn’t mean our capacity for adaptability, compassion, and clinical acumen is limitless.

I applaud initiatives that call for zero tolerance of violence against health care workers. I agree with emergency physician colleagues in their desire for critical safety protections, including more security guards, cameras, security for parking lots, metal detectors, and increasing visitor screening inside hospitals. I share their concerns about the lack of punitive consequences and institutional support when ER workers are assaulted. I’m hopeful for meaningful legislative action on bills currently in Congress, including the Workplace Violence Prevention Act for Health Care and Social Service Workers Act and the Safety from Violence for Healthcare Employees (SAVE) Act.

But will safety restore my security, my dwindling sense of control?

ER staff talk about their line in the sand — when they finally had enough. Health care violence is associated with decreased productivity, moral distress, workforce attrition, and lower quality of care. A loss of control contributes to violence and health care worker burnout and turnover, taxing institutions with shocking costs to morale and their bottom line.

In my experience, medical schools and graduate medical training tend to address methods for defusing an escalating situation, interdisciplinary team communication, self-defense, proper procedures for restraints, and how bias can influence those decisions.

These critical safety measures give a false sense of control by ignoring the uncertainty surrounding these situations. There’s often no bright line that distinguishes a medical cause from a mental crisis from an insulting and bullying personality in an aggressive ER patient. Often, threatening and violent patients need our help. Even before the pandemic, one in eight ER patients presented with mental health and substance use disorders. Since the pandemic, the ER visit rates for mental health disorders, suicide attempts, and overdoses have increased in a health care system suffering from insufficient mental health services.

Security, in addition to safety, honors the duty of the ER as the hospital’s open door and the high-stakes pressures and uncertainty that can overwhelm this high-risk environment. We can’t control what human problems will walk through the door, but system problems are plain to see and within our grasp. Organizational commitment to healthcare worker security must seek operational solutions that ensure their physical safety, preserve their cognitive and emotional well-being, and promote the well-being of all patients.

Jay Baruch is an emergency physician, professor of emergency medicine, and director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University; and author of “Tornado of Life: Constraints and Creativity in the ER” (MIT Press, August 2022).