No fix without the front line: Why healthcare workers must drive change to stop ER violence

In winning a new contract on Oct. 12, Temple University nurses and technicians didn’t just get pay raises. They won more protections from violence.

It’s an extraordinary moment when basic safety becomes a bargaining issue. But that’s the reality for emergency room workers who continue to face rising levels of physical, verbal, and sexual assault. Touted as heroes during the pandemic, these workers now show up in risky environments that are wired to create more violence.

One simple yet little-used strategy is to ask frontline nurses and doctors what works, and what doesn’t, to prevent assaults. We did that, and the answers cited below may surprise you.

Tougher laws by themselves haven’t worked. The airline industry has laws that protect staff from assaults in the workplace: If a passenger attacks an airline crew member, they are removed from the airline and could face a fine or criminal charge.

It is not so straightforward in healthcare. Safety protections vary state by state for workers who face a stigma for reporting an event, and no guarantee their concerns will reach employers or authorities. Most crucially, a violent patient differs from an unruly airplane passenger. Most patients need care and support when they become violent.

As emergency room clinicians, we know patients come to us during their most vulnerable moments. Their medical challenges, coupled with worry, compounded by prolonged waiting room times and care delays, create the perfect recipe for rising ER violence. The larger frustrations patients experience get offloaded onto the clinician before them.

Workplace violence is a top reason why nurses leave healthcare jobs, and it contributes to their burnout and job dissatisfaction. Dangerous conditions can harm their physician colleagues, as well.

In the U.S., it is largely up to hospitals and their leaders to uphold safety measures for workplace violence. No federal policies exist to protect healthcare workers from assaults or regulate how hospitals should prevent violence.

Most states pass laws that fall into two broad categories: 1) establishing penalties (charges, fines) for assaulting healthcare workers, and/or 2) requiring hospitals to establish measures to prevent and address violence. Most state policies fall into the latter.

In May, the Pennsylvania House passed the Healthcare Workplace Violence Prevention Act. If it passes the state Senate, the bill would require that all healthcare facilities in the state establish workplace violence committees to perform annual risk assessments and identify strategies to prevent attacks. It also requires facilities to post signage indicating that assault of a healthcare worker is a felony.

These policies represent an important first step, but again, if you were to ask our ER colleagues if a sign would make them feel safer, you can only imagine their responses. Should hospitals invest in more security? Less security? Train clinicians on self-protection? What should we focus on?

To answer some of these questions, we conducted a study that put nurses and physicians in discussions together to find out what could work. We interviewed 23 emergency room nurses and physicians in a Philadelphia Level I trauma center for their priorities.

What works? Establishing in-the-moment procedures to de-escalate potentially dangerous situations and support clinicians who experience an assault in real time. Like a “Code Blue,” some hospitals have created overhead page calls that summon coworkers when violence occurs.

No federal policies exist to protect healthcare workers from assaults or regulate how hospitals should prevent violence.

Other hospitals have designated violence de-escalation teams with special training who aid staff in proven ways to deter violence.

These hospitals are proactive, and others should follow.

It’s no coincidence that Temple nurses are demanding safer patient-to-nurse staffing ratios in the context of workplace violence. When nurses care for too many patients at a time, they can’t attend to their patients in a timely manner. Extended delays can trigger violence.

As one nurse in our study stated: “Patients go hours where they’re like, ‘What the heck, what am I waiting for?’ There’s no updates because nurses have more patients than we can reasonably be expected to manage. And so patients become frustrated because they’re not being served well, because the nurses are stretched so thin.”

Whether through hospitals’ own action or state bills establishing minimum staffing rules (like the proposed Pennsylvania Patient Safety Act, stalled in the Senate), nurses demand safer patient-to-nurse staffing ratios so they can give high-quality care to patients.

When medical professionals are assaulted, their reports must be monitored by their employers. These people need support, with time away from work after an assault and support time for legal action.

Policy safeguards like the violence prevention bill would hold hospital executives accountable for mandated reporting and strategies to reduce violence. But nurses and doctors need to be a part of the solution to stem the violence epidemic.

Jane Muir and Anish Agarwal are senior fellows at the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Muir, an emergency nurse by training, is a practicing family nurse practitioner and an assistant professor at Penn Nursing in the Center for Health Outcomes and Policy Research and the Penn Medicine department of emergency medicine. Agarwal is an ER physician and assistant professor of emergency medicine.