Assaults on nurses in the emergency department have long been viewed as part of the job. But this "culture of acceptance" comes with a high price tag, not least of which is the cost to replace nurses when they quit.
More than half of ED nurses have been hit, kicked, spit on, or scratched at work, and more than 70% have been yelled at, cursed at, intimidated, or threatened with sexual violence. Many don't feel safe at work, and one-third have considered leaving their jobs or emergency nursing altogether, according to a 2009 study.
Some people argue that violence in the ED is just part of the job for nurses. Maybe it is. It's certainly part of the job for other professionals, such as police officers, who often deal with unpredictable people in tense situations. In the ED, people are hurt, sick, scared, and sometimes intoxicated, making it a powder keg of potential violence.
But just because violence can sometimes be expected doesn't mean it should be tolerated, says Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, president of the Emergency Nurses Association. She points out that when a police officer is attacked in the line of duty, you better believe that the assailant is prosecuted and punished.
No one ever expects a cop not to press charges because violence "is just part of the job." Brecher adds that, "In some cases it's a felony to hit a stripper, but not a nurse."
"An assault on a nurse is considered part of the job by the nurses themselves, the nurse leaders, and also by law enforcement," Brecher says. "From a nursing leadership perspective, understanding that that's the culture we are living in right now is key to making a difference.
A new ENA-sponsored study of assaults on emergency nurses [PDF] found a need to radically change this "culture of acceptance." The study, published in the Journal of Emergency Nursing, also showed a need to better train nurses about recognizing situations that might turn violent.
"When we look at violence in general, we don't like to talk about it as a society. Culturally, even outside the ED, we've turned to violence as an acceptable way of expressing your frustration," Brecher says.
In hospitals, a culture of safety needs to start from at the top, which means the entire organization should be supportive of nurses.
"We know from our studies that the one thing that seems to have the biggest impact on decreasing violence in the workplace is a zero-tolerance policy," Brecher says. If violence does occur, the entire organization—including the administration—should support nurses in whatever action they choose to take, such as calling 911 or pressing charges.
"There is a barrier when hospital administration and hospital leadership don't support nurse reporting," Brecher says, adding that although nurses' direct managers might support them, that support might disappear higher up the chain of command.
The new study illustrates these kinds of barriers. Some leaders, for instance, might be afraid of bad publicity for the hospital. One nurse who experienced violence said, "[The Chief Nursing Officer] seemed to be more concerned that I was filing a police report than over the fact that I was assaulted." Another nurse said that the hospital wanted to appear "friendly" so it didn't secure the doors or install weapon detectors: "Administration will only take action when some lethal event happens."
Brecher says despite barriers like these, she believes that hospitals can change the culture of complacency and acceptance around violence in the ED. In fact, she's seen it happen.
"The ones that were successful had a multidisciplinary team who were not afraid to look back…and assess the culture of their organization," she says. They define violence clearly (for instance, is spitting violence?) and educate staff about what it is.
They don't assume that violence doesn't happen at their hospital because it's small or in a nice neighborhood. They use resources, like ones from the ENA, to combat and refuse to tolerate violence. They also teach their nurses to recognize signs of potential trouble; Brecher says high-risk people tend to be "intoxicated, frustrated, and may have waited a long time to be seen."
If nothing else, the fact that nurses consider leaving—and in some cases do leave—a job because of violence should be impetus enough for hospital leadership to take the problem seriously. Brecher says it costs about $65,000 to replace a nurse.
"From the nurse leader's perspective, this is a huge loss," she says. "It's an incredible amount of money going out the door."
Alexandra Wilson Pecci is an editor for HealthLeaders.
