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Violence in the Emergency Room

Pandemic Stresses Make a Tough Job More Difficult

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Above image credit: Hospital operating room. (Adobe)

The nurse became the patient.

The attack happened in a blur of flailing fists, with staff reacting like bouncers to a brawl.

Agitated about waiting hours to be seen by a doctor, the patient had paced and launched verbal threats while at the University of Kansas Health System in mid-November.

Emergency room nurse Jessica Fultz said that she’d tried to reassure the woman, explaining that staff was stretched and wait times were long as doctors were treating people suffering with COVID-19.

The explanation seemed to rile the patient more, Fultz said, because the woman countered with something to the effect of, “So, you’re telling me that I’m not sick?”

Shortly after, the patient charged, slamming a closed fist to the nurse’s lip. Fultz was sent sprawling, her head banging on a bed frame as she fell to the floor.

Two nurses and an emergency room technician were able to pry the woman off of Fultz. They kept her restrained until police arrived.

Fultz remembers curling into a fetal position. She’d later be diagnosed with a concussion.

It’s not an isolated incident, according to those who work in emergency rooms. 

“We need people to understand what we are facing,” said Mike Hastings, the 2020 president of the Emergency Nurses Association. “We need the community to rise up and say, ‘this is not acceptable.’ “

Dangerous Work

Health care workers are about 50% of all victims of workplace assaults, according to data from the Occupational Safety and Health Administration. Emergency departments are especially vulnerable, and nurses in particular, as they spend the most time with patients.

The pervasive fear is that such incidents, verbal and physical attacks on medical staff, will escalate as the pandemic rages on.

Emergency departments are something of a canary in the coalmine, an early indicator for the sweeping and unrelentingly disruptive nature of COVID-19 on society.

“In addition to treating and admitting an increasing number of patients with COVID, ER staff across the Kansas City metro are seeing increasing numbers of patients who are suffering from stress, anxiety, substance abuse and violence,” said Dr. Joseph Reuben, emergency physician at AdventHealth, in a statement. “Some of this was on the rise prior to COVID, but we attribute some to the impact of the pandemic on everyone’s physical and mental health.”

AdventHealth has given its security team advanced training to address the added stressors affecting patients and their families. The goal is for security to be “prepared for the potential that patients or family members will lash out.”

And, like KU and other health care systems in the Kansas City area, AdventHealth is being more intentional about addressing the mental health and stress levels of the medical staff.

Nearly half of all emergency room physicians have been physically assaulted at work and an even higher percentage of emergency nurses have been hit or kicked on the job, according to surveys by the American College of Emergency Physicians and the Emergency Nurses Association.


Tough Duty

Graphic depicting the prevalence of violence in health care emergency rooms.
The Emergency Nurses Association reports that violence is common in health care emergency rooms. (Graphic | Emergency Nurses Association)

Burnout rates for emergency department staff are among the highest in the medical profession.

Hastings, of the Emergency Nurses Association, reached out to Fultz after the incident. He’s employed in a health care system near Seattle now, but worked in the emergency room of the KU health system for about 10 years.

KU, with its own dedicated and specially trained police force, is better equipped than most of the nation’s hospitals to ensure the safety of staff and patients, Hastings said.

“A lot of places don’t have security after hours,” Hastings said. “They have to call 911 and wait for a police officer to arrive. I would love to go back to the resources that I had at KU.”

In addition, the KU health system has a rapid response team trained to de-escalate violence toward health care workers anywhere in the hospital, including the emergency department. And all employees are trained annually to react as patients and families “can get physical in high stress situations or if they are under some kind of influence,” said Jill Chadwick, director of media relations.

Fultz, who no longer works at KU health system, insisted on filing charges against the woman, as she said she’d done several times in 2020 following other alleged attacks. Fultz said she did so in hopes of reducing what she says is an institutional nonchalance about attacks on medical staff.

The day of the attack she was working in what once was an ambulance bay, a space the hospital had converted to help manage patient numbers as the pandemic increased caseloads. Additional safety features have since been added to the area, Fultz said.

“I’m just going to close this book and move on,” Fultz said. “I’m collateral damage.”

Silence on Violence

The Chicago-area based Emergency Nurses Association had grand plans for 2020. A marketing campaign, a documentary film and a legislative roadmap were in place.

The Workplace Violence Prevention for Health Care and Social Service Workers Act of 2019 would have required health care and social service employers, including hospitals, to take specific steps to guard against workplace violence. The organization, in partnership with the American College of Emergency Physicians, saw the legislation pass the House, before it stalled in the Senate.

Plans were in place to try again.

The “No Silence on ED Violence” campaign sought to gain the public’s support, countering an attitude advocates cite as a normalization of threats and attacks, as if medical staff should simply accept it as part of the job.


Being Heard

The American College of Emergency Physicians and the Emergency Nurses Association produced a video to promote the “No Silence on ED Violence” campaign.

But the pandemic put the campaign on hold.

Earlier studies found that workplace violence for emergency departments was on the rise before COVID-19.

One 2018 study, “Nursing Under Pressure: Workplace Violence in the Illinois Healthcare Industry,” concluded: “For frontline healthcare workers such as the Illinois nurses surveyed, the expectation of violence is a fundamental part of the job.“

Attuned to the existing problems, some advocates predicted that such incidents would decrease as hospitals shifted protocol, such as not allowing visitors or extended family into health care centers.

Initially, Hastings and others said, that seemed to be coming true. A grace period of sorts lasted through the spring, with doctors and nurses lauded as heroes.

But as the pandemic wore on into 2021, support seems to be waning.

A former operating room nurse at Truman Medical Centers said that, initially, new rules to keep the virus from spreading had a positive effect. Families could no longer enter the pre-op area, or most places in the hospital.

“Families were often more hostile than patients, so this was heaven,” recalled the nurse, who requested anonymity because medical centers are highly attuned to negative characterizations.

But frictions began to develop among hospital staff as the pandemic wore on.

“The stress of the influx of cases we had, being understaffed and seeing the same (co-workers) each day while being separated from our usual coping mechanisms put many of us on edge,” said the nurse.

Confidentiality issues often intervene when the media ask about specific incidents. Patient medical history must be protected as a matter of law. And medical systems also don’t want to make people fear the hospital, not at any time, but especially not during a pandemic.

But the lack of transparency also limits the ability to fully address problems, advocates said. The Emergency Nurses Association seeks to increase the filing of charges in assault cases and to prevent retaliation against nurses who press for such legal action.

Hastings said that a man recently became very angry, “using all kinds of foul language” at the Washington state hospital where he works. The man couldn’t see his wife, due to rules governing visits during the pandemic.

“He was yelling at the staff that he hoped they will all get COVID and die,” Hastings said. “How is that acceptable? But that is what we see happening across our country.”

Helping Doctors and Nurses

A stoic pride pervades medicine, said Dr. Ravindran Sabapathy, the clinical psychologist in charge of medical staff well-being with AdventHealth. There’s a sense that doctors and other medical staff can handle it all.

“We never question their toughness or their resilience,” he said.

But the additional pressures of serving patients during a pandemic are immense.

“COVID wears on people. It wears mentally, physically and emotionally,” he said. “The amount of fatigue and stress — it’s unprecedented.”

His role involves checking in on medical staff, making contacts by phone, text and in person. The cumulative stress of the pandemic is a major concern, he said.

“Our Emergency Department in particular does experience patient violence on occasion, both physical and verbal. But the greatest impact is not from any individual situation, it’s the burnout that providers experience now that we’re nine months into a pandemic,” Sabapathy said.

In addition to their work, doctors and nurses are dealing with family pressures related to COVID just like everyone else, such as tending to children doing remote learning.

Most believe that they will catch the virus, Sabapathy said. And they are very fearful of bringing it home to their family members.

Bridging the reluctance of medical professionals to seek treatment for their own mental health is a specialty of Dr. Kim Templeton of the University of Kansas Health System.

She is a past president of both the American Medical Women’s Association and the Kansas State Board of Healing Arts. She has worked on changes to licensure questions regarding past and present alcohol or drug use and mental health. The wording alone can influence whether a doctor will seek help, or worry that doing so might later impact their license to practice or hospital privileges.

Yet, advocates say seeking help now is more important than ever.

Templeton also recently worked on a letter to Kansas physicians, raising awareness of the 400 deaths by suicide each year in the profession. She noted that many doctors work in environments where they might feel like they have little control.

“We entered medicine to become physicians and help others; not to become patients ourselves,” the letter reads. “We are the ones that are supposed to have the answers, but stress and anxiety, especially during the pandemic, frequently leave us feeling lost.”

Flatland contributor Mary Sanchez is a Kansas City-based writer and a nationally syndicated columnist with Tribune Content Agency.

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