Not to get beat up

August 4, 2009 -- Today USA Today ran a very good report by Erin Thompson about a new study detailing the high level of abuse emergency nurses suffer. The article, "More than half of ER nurses have been assaulted on job," describes the results of an online survey of more than 3,000 ED nurses by the Emergency Nurses Association (ENA). The study was published in the Journal of Nursing Administration. The USA Today piece relies heavily on comments from ENA president Bill Briggs about the causes of and potential solutions to the problem. The report might have included comment from hospital representatives as to how they are addressing the abuse. And it might have been more explicit about whether the problem has been exacerbated by the widespread belief that abuse is just part of an ED nurse's job. But on the whole, the article is a helpful look at the dangerous conditions many nurses confront and a commendable example of mainstream coverage of nursing research. We thank Ms. Thompson and USA Today.

The reported results of the 69-question survey might surprise members of the public, though they will be no surprise to ED nurses. In addition to the finding that more than half of the nurses surveyed had been physically assaulted, one in four nurses said they had been assaulted more than 20 times in the past three years. One in five said they had been verbally abused more than 200 times during that period. The USA Today report did not say what proportion of that verbal abuse came from patients and families, as opposed to co-workers. The report did say that nurses reported being "spit on, hit, pushed, shoved, scratched or kicked by patients while on duty." As a result of the abuse, one of three nurses has considered leaving the ED. The report says that the results were published in the current issue of the Journal of Nursing Administration. It's important that USA Today included that fact, because it tells the public that nurses have professional journals in which research is published, which is not something everyone necessarily knows.

Most of the article consists of information from Briggs, who has been a nurse for 30 years. He says that he himself has suffered "bumps and bruises" at work, and it has had an "emotional impact."

I've wondered, do I want to stay? How often do I want this to happen? Most people enter the profession to help people, not to get beat up and not to see your co-workers get beat up.

Briggs explains that the abuse stems in part from the ED's role in U.S. society as a place of last resort:

It's the safety net when you can't get help anywhere else. Every type of patient comes to the emergency department. We accept patients under the influence of drugs and alcohol, psychiatric patients. ... It's very unpredictable.

The report notes that other causes include "a shortage of ER nurses, patient crowding and prolonged wait times," all of which describe essentially the same thing--not enough nurses and other staff to meet patient demand. Of course, if the U.S. health system focused more closely on prevention and expanded coverage for primary care, as some recent health reform proposals do, EDs would not be so overwhelmed with patients.

Commendably, the report devotes significant space, including a sidebar, to potential solutions to the problem of abuse of ED nurses. Briggs suggests that ENA wants the ED to be safe for patients and visitors as well as the staff. The report says that state laws to protect ED nurses vary widely, and that ENA will be urging the Occupational Safety and Health Administration to establish national safety standards. Briggs says every hospital should have "its own plan," including more security staff, alarm buttons, and a "security committee" to create a safer ER, all of which sound like good ideas.

The sidebar, "Making ERs Safer," includes some telling recommendations from the published study. One of these is developing better procedures for reporting violent incidents, but consider the others: ensuring that ED staff know that senior administration is aware of the problem and supports efforts to solve it; encouraging nurse executives to "take steps" to solve the problem; establishing a "culture of acceptance" for reporting violent incidents; and providing access to health care and counseling for victims.

Why do advocates have to work this hard to get a basic level of support for staff who are so often the victims of violence? Can you imagine corporate employees having to plead for a "culture of acceptance for reporting incidents of violence"? Although the article might have said so directly, most of the sidebar recommendations point to a key factor that has slowed action on this problem--the sense that prevails in many clinical settings that abuse is part of the job for nurses, so they should stop complaining and just get over it. After all, they're selfless angels pursuing a vocation, so they don't need safe working conditions any more than they need adequate resources, right? And that brings us to the glaring omission in the proposed solutions reported here: simply hiring more health care staff to address the resource shortages that the report itself says are an important factor in the abuse. (People are less likely to become abusive if there are enough staff to deliver quality health care in the first place.) Of course, that might require decision-makers to devote more up-front resources at a time when health care budgets are very tight. But the savings in reduced turnover, sick days, and other results of the abuse, not to mention better health care, might be worth it in the long run.

A longer report might have been able to probe these issues more deeply, as the Massachusetts Nurses Association has in years of advocacy on the issue (see below). This is not the first study to examine the unusually high levels of abuse nurses face, and the lack of support many of them receive in trying to prevent or recover from it. But this prominent article does a fine job in a limited space to bring attention to some of the basic elements of the problem of abuse in EDs. We thank those responsible.

See the article "More than half of ER nurses have been assaulted on job" by Erin Thompson in the August 4, 2009 edition of USA TODAY.

See an abstract of the original study "Violence Against Nurses Working in US Emergency Departments" by Jessica Gacki-Smith, MPH; Altair M. Juarez, MPH; Lara Boyett, RN, MSN; Cathy Homeyer, RN, MSN; Linda Robinson, RN, BSN & Susan L. MacLean, RN, PhD, in The Journal of Nursing Administration: July/August 2009 - Volume 39 - Issue 7/8 - pp 340-349.

See the Massachusetts Nurses' Association action page on workplace violence "Workplace Violence Prevention at the MNA," its handbook "Workplace Violence," (2008) and a 2004 Survey on Workplace Violence.