A Survey of Workplace Violence Across 65 U.S. Emergency Departments

Objectives: Workplace violence is a concerning issue. Healthcare workers represent a significant portion of the victims, especially those who work in the emergency department (ED). The objective of this study was to examine ED workplace violence and staff perceptions of physical safety. Methods: Data were obtained from the National Emergency Department Safety Study (NEDSS), which surveyed staff across 69 U.S. EDs including physicians, residents, nurses, nurse practitioners, and physician assistants. The authors also conducted surveys of key informants (one from each site) including ED chairs, medical directors, nurse managers, and administrators. The main outcome measures included physical attacks against staff, frequency of guns or knives in the ED, and staff perceptions of physical safety. Results: A total of 5,695 staff surveys were distributed, and 3,518 surveys from 65 sites were included in the final analysis. One‐fourth of surveyed ED staff reported feeling safe sometimes, rarely, or never. Key informants at the sampled EDs reported a total of 3,461 physical attacks (median of 11 attacks per ED) over the 5‐year period. Key informants at 20% of EDs reported that guns or knives were brought to the ED on a daily or weekly basis. In multivariate analysis, nurses were less likely to feel safe “most of the time” or “always” when compared to other surveyed staff. Conclusions: This study showed that violence and weapons in the ED are common, and nurses were less likely to feel safe than other ED staff.     

Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presentations: findings from a national qualitative study

Background

Mental health related presentations are common in Australian Emergency Departments (EDs). We sought to better understand ED staff knowledge and levels of confidence in treating people with mental health related problems using qualitative methods.

Methods

This was a qualitative learning needs analysis of Australian emergency doctors and nurses regarding the assessment and management of mental health presentations. Participants were selected for semi-structured telephone interview using criterion-based sampling. Recruitment was via the Australasian College for Emergency Medicine and College of Emergency Nursing Australasia membership databases. Interviews were audio-recorded and transcribed verbatim. Thematic framework analysis was used to identify perceived knowledge gaps and levels of confidence among participants in assessing and managing patients attending EDs with mental health presentations.

Results

Thirty-six staff comprising 20 doctors and 16 nurses consented to participate. Data saturation was achieved for four major areas where knowledge gaps were reported. These were: assessment (risk assessment and assessment of mental status), management (psychotherapeutic skills, ongoing management, medication management and behaviour management), training (curriculum and rotations), and application of mental health legislation. Participants’ confidence in assessing mental health patients was affected by environmental, staff, and patient related factors. Clinicians were keen to learn more about evidence based practice to provide better care for this patient group. Areas where clinicians felt the least confident were in the effective assessment and management of high risk behaviours, providing continuity of care, managing people with dual diagnosis, prescribing and effectively managing medications, assessing and managing child and adolescent mental health, and balancing the caseload in ED.

Conclusion

Participants were most concerned about knowledge gaps in risk assessment, particularly for self-harming patients, violent and aggressive patients and their management, and distinguishing psychiatric from physical illness. Staff confidence was enhanced by better availability of skilled psychiatric support staff to assist in clinical decision-making for complex cases and via the provision of a safe ED environment. Strategies to enhance the care of patients with mental health presentations in Australian emergency departments should address these gaps in knowledge and confidence.     

Correction to: Quick and effective improvement of leucine enriched dietary supplement on malnutrition in acute stroke patients receiving enteral tube feeding

Emergency Department (ED) crowding occurs when demand for care exceeds the available resources. Crowding has been associated with decreased quality of care and increased mortality, but the prevalence on a national level is unknown in most countries. We performed a national, cross-sectional study on staffing levels, staff workload, occupancy rate and patients waiting for an in-hospital bed (boarding) at five time points during 24 h in Swedish EDs. Complete data were collected from 37 (51% of all) EDs in Sweden. High occupancy rate indicated crowding at 12 hospitals (37.5%) at 31 out of 170 (18.2%) time points. Mean workload (measured on a scale from 1, no workload to 6, very high workload) was moderate at 2.65 (±1.25). Boarding was more prevalent in academic EDs than rural EDs (median 3 vs 0). There were an average of 2.6, 4.6 and 3.2 patients per registered nurse, enrolled nurse and physician, respectively. ED crowding based on occupancy rate was prevalent on a national level in Sweden and comparable with international data. Staff workload, boarding and patient to staff ratios were generally lower than previously described.     

Pandemic (H1N1) Influenza 2009 and Australian emergency departments: Implications for policy,practice and pandemic preparedness

Objective: To describe the reported impact of Pandemic (H₁N₁) 2009 on EDs, so as to inform future pandemic policy, planning and response management. Methods: This study comprised an issue and theme analysis of publicly accessible literature, data from jurisdictional health departments, and data obtained from two electronic surveys of ED directors and ED staff. The issues identified formed the basis of policy analysis and evaluation. Results: Pandemic (H₁N₁) 2009 had a significant impact on EDs with presentation for patients with ‘influenza‐like illness’ up to three times that of the same time in previous years. Staff reported a range of issues, including poor awareness of pandemic plans, patient and family aggression, chaotic information flow to themselves and the public, heightened stress related to increased workloads and lower levels of staffing due to illness, family care duties and redeployment of staff to flu clinics. Staff identified considerable discomfort associated with prolonged times wearing personal protective equipment. Staff believed that the care of non‐flu patients was compromised during the pandemic as a result of overwork, distraction from core business and the difficulties associated with accommodating infectious patients in an environment that was not conducive. Conclusions: This paper describes the breadth of the impact of pandemics on ED operations. It identifies a need to address a range of industrial, management and procedural issues. In particular, there is a need for a single authoritative source of information, the re‐engineering of EDs to accommodate infectious patients and organizational changes to enable rapid deployment of alternative sources of care.     

Perceptions of nurse practitioners by emergency department doctors in Australia

Background

The Australian Medical Association is strongly opposed to the nurse practitioner (NP) role with concerns that NPs may become doctor substitutes without the requisite training and education that the medical role demands. Despite this, NPs have been heralded by some as a potential solution to the access block, workforce shortage and increased demand affecting emergency departments (EDs).

Aims

The purpose of this study was to determine the perception of NPs by medical staff working in Australian EDs.

Methods

Semi-structured telephone interviews were conducted with closed and open-ended questions. Participants were drawn from a representative stratified sample of two city, two metropolitan and two provincial hospitals of each State/Territory.

Results

A total of 95 doctors from 35 EDs participated in this study including 36 Departmental Directors; 36% of participating Directors indicated having an NP on staff. Doctors were strongly opposed to the statement that NPs could replace either nurses or other prevocational doctors; 71 interviewees commented on the role of NPs in the ED. Thematic analyses revealed polarised views held by doctors. Eight major themes were identified, the most common being that there is a lack of clarity of the NP role definition, their scope of practice and differentiation from the medical role.

Conclusion

Although ED NPs represent a highly skilled professional group their role is poorly understood by ED doctors. Opposition to the NP role is a significant barrier to the introduction of great numbers of ED NPs as a strategy to overcome the medical workforce shortage.     

Paediatric emergency department staff perceptions of infection control measures against severe acute respiratory syndrome

Objectives

To determine paediatric emergency department (ED) staff perceptions of the effectiveness and practice of infection control measures against a novel virulent pathogen.

Methods

All medical staff of the paediatric ED in a tertiary medical centre completed a written questionnaire near the onset of the severe acute respiratory syndrome (SARS) outbreak. Level of concern regarding SARS, and perceptions of effectiveness and use of infection control measures were assessed on a 5 point scale. Statistical analysis was performed using χ² test and one way analysis of variance with significance at p<0.05.

Results

Response rate was 97% (116/120). All scores were given out of 5 possible points. Using isolation rooms (mean score 4.6), wearing a mask when examining patients (4.5), and handwashing (4.5) were considered most effective. Staff physicians reported handwashing more than nurses and trainees (4.9 v 4.5 and 4.5, respectively; p<0.05) while other measures were reported equally. Respondents considering SARS a high public health threat reported higher compliance with handwashing (4.8 v 4.4), always wearing a mask (3.9 vs 3.2) and gloves (3.6 v 2.9) in the ED (p<0.05), but not eye protection (3.4 v 3.0), gown use (4.9 v 4.7), or wearing a mask when examining patients (5.0 v 4.8). Staff who considered combined infection control measures effective in protecting patients and healthcare workers did not report increased compliance.

Conclusions

Eye protection was perceived as only moderately effective in protecting against the spread of SARS, and reported compliance was relatively poor among ED staff. Concern of SARS as a public health threat rather than perceived effectiveness of infection control measures appears to have a greater impact on compliance.     

Personality,stress and coping in intensive care nurses: a descriptive exploratory study

Aim: The aim of the study was to investigate the relationship between personality traits, perception of workplace stress and coping among intensive care unit (ICU) nurses. Background: Research has indicated that ICUs are stressful environments. There is a tendency for research studies to investigate causes of stress and ways of coping, but few studies, particularly in recent years, have considered the personality traits of the staff who thrive in this challenging environment, the work stress they perceive and the coping strategies they use. Method: A convenience sample of critical care nurses (n = 46) completed three standardised questionnaires during September 2007: the revised NEO personality inventory (NEO‐PI‐R); the nurses stress scale (NSI) and the Brief Coping Orientations to Problems Experienced (COPE) scale. Findings: ICU nurses did not perceive their workplaces to be stressful. Certain personality traits, openness, agreeableness and conscientiousness, were associated with problem‐solving coping strategies such as active planning and reframing. Openness and extraversion were associated with less perceived stress from the ‘patients and relatives' dimension of the NSI; there were also negative correlations between conscientiousness and the ‘workload stress' and stress from lack of ‘confidence and competence’ dimensions of the NSI. Conclusion: Certain personality traits may have a buffering effect on workplace stress. Pre‐employment screening to identify staff that exhibit personality and coping traits associated with low perceived stress may be considered as part of the recruitment strategy to address problems relating to stress, sickness and retention. Relevance to clinical practice: The retention and recruitment of staff who have lower perceived workplace stress and who utilise problem‐focused coping may result in less reported absences and fewer critical incidents and errors.     

STRESSORS,COPING STRATEGIES AND STRESS-RELATED OUTCOMES AMONG DIRECT CARE STAFF IN STAFFED HOUSES FOR PEOPLE WITH LEARNING DISABILITIES

Self-reported stressors, coping strategies and stress-related outcomes were explored among 68 direct-care staff working in two networks of small staffed houses for people with learning disabilities. The two networks tended to have lower rates of staff turnover, and staff tended to be older, more qualified and more likely to have dependants, than staff in UK community services reported in previous studies. Staff in Network 2 rated several stressors as more stressful and reported themselves as experiencing greater general distress and work-related stress, than staff in Network 1. Multiple regressions revealed that: (1) stressors relating to the emotional impact of the work, violent service user behaviour and the use of a wishful thinking coping strategy were associated with perceived work stress; (2) stressors relating to the conflict of work with personal or family demands, and the use of a wishful thinking coping strategy, were associated with symptoms of general distress; (3) perceived work stress, together with uncertainty concerning job tasks and limited opportunities for personal advancement, were perceived to have a high impact on work     

Nurses’ perceptions of dealing with death in the emergency department

BackgroundProviding end-of-life care to patients and their families in the emergency department (ED) is challenging, with high workloads, the busy environment, and a focus on providing lifesaving treatments to patients at odds with providing end-of-life and palliative care.AimThe purpose of this study was to investigate nurses’ experiences of providing end-of-life care in EDs, including their perceptions of the most vital elements of care, ability to provide aspects of care, as well as perceptions of their role, communication processes, family presence/involvement, and the ED environment.MethodsNurses (n = 211) working in Australian EDs for at least 12 months completed an anonymous online survey.FindingsNurses identified vital elements of care for dying patients including adequate pain control and a move away from burdensome treatments, sensitive care of families and family access to loved ones, and a quiet environment. However, nurses were not always able to provide such care to their patients. Often, the ED was seen as an unsuitable place for end-of-life care or care of families once the patient had died, and communication between staff and between staff and families was challenging.DiscussionThe ED physical environment, lack of staff training and debriefing, and lack of time to communicate with family, particularly after death, may compromise nurses’ ability to provide end-of-life care that is satisfying to them, their patients, and families.ConclusionThere is a need for focus on the ED physical environment, staff training, and consideration of the emotional experiences of frontline nurses caring for patients at the end of life.     

Workplace stressors, coping, demographics and job satisfaction in Chinese intensive care nurses

Background: Prior research has suggested that certain workplace stressors, coping strategies and demographic characteristics are related to job satisfaction in nurses. Most of the research in this area has been conducted within western culture countries, with little research being carried out in Asian culture countries, especially China. It remains unclear if the findings of the research conducted in western culture countries are applicable to Chinese nurses, especially intensive care nurses. Aims and objectives: Therefore, the aims of this study were to examine, in Chinese intensive care nurses, the most often occurring workplace stressor; the most frequently used coping strategy; and the relationships among workplace stressors, coping strategies, demographic characteristics and job satisfaction. Design: The study design was a survey using four self‐report questionnaires. Methods: One hundred and two intensive care nurses, from four hospitals located in two major cities in central China, were administered four self‐report questionnaires. Results: Findings suggested that the most frequently cited workplace stressor was workload, while the most commonly used coping strategy was planning. Two hundred and twelve significant positive and negative correlations were found among the various workplace stressors, coping strategies, demographic characteristics and the different factors comprising job satisfaction. Conclusions: These findings identify factors that need to be considered when addressing workplace stress, coping strategies and demographic characteristics as they relate to job satisfaction in Chinese intensive care nurses. Relevance to clinical practice: It is important for both hospital and nursing administrators to address factors contributing to job satisfaction, so that retention of qualified ICU nurses, within the workforce, will be facilitated.     

Personal protective equipment for COVID-19 among healthcare workers in an emergency department: An exploratory survey of workload,thermal discomfort and symptoms of heat strain

Objectives

To examine workload, thermal discomfort and heat-related symptoms among healthcare workers (HCWs) in an Australian ED during the COVID-19 pandemic.

Methods

A cross-sectional study design was employed among HCWs in an ED at a metropolitan hospital in Brisbane, Australia. Respondents provided demographic information including their self-reported age, sex, height, weight, role (e.g. doctor, nurse), and whether they wore personal protective equipment (PPE) during their shift, rated as either Full PPE, Partial PPE, or usual uniform or scrubs. The workload of HCWs was assessed with the National Aeronautics and Space Administration's task load index (NASA-TLX). Thermal discomfort was evaluated using scales from the International Organisation for Standardisation. Responders rated their subjective heat illness using the Environmental Symptoms Questionnaire.

Results

Fifty-nine HCWs completed the survey (27 male, 31 female, one prefer not to answer). Overall workload from the NASA-TLX was 64.6 (interquartile range [IQR] 56.5–73.3) for doctors, 72.5 (IQR 63.3–83.3) for nurses and 66.7 (IQR 58.3–74.17) for other staff, representing moderate to high ratings. Eighty-one percent reported thermal sensation to be slightly warm, warm, or hot, and 88% reported being uncomfortable, ranging from slightly to extremely. Ninety-seven percent reported at least one heat-strain symptom. More than 50% reported light-headedness or headache and approximately 30% reported feeling dizzy, faint, or weak.

Conclusions

ED HCWs experience thermal discomfort when wearing PPE. Combined with their workloads, HCWs experienced symptoms related to heat strain. Therefore, careful consideration should be given to managing heat strain among HCWs when wearing PPE in an ED.     

“What Do People Do If They Don't Have Insurance?”: ED‐to‐ED Referrals

Objective

Up to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore 1) whether patients making a repeat ED visit are self‐referred or indirectly referred from the other ED and 2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits.

Methods

This mixed‐methods study conducted over a 10‐week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint. Selected patients presenting with fractures were then enrolled for semistructured qualitative interviews, which were audiotaped, transcribed, and independently coded by two team members until thematic saturation was reached.

Results

A total of 143 patients were identified as being recently seen at another local ED for the same chief complaint prior to presenting to the public hospital; 94% were uninsured and 61% presented with fractures. A total of 27% required admission at the public ED and 95% of those discharged required further outpatient follow‐up. Fifty‐one percent of patients completed a survey and qualitative interviews were conducted with 23 fracture patients. Fifty‐three percent of patients reported that staff at the first hospital told them to go the public hospital ED, and 23% reported referral from a follow‐up physician associated with the first hospital. Seventy‐three percent reported receiving the same tests at both EDs. Interview themes identified multiple health care visits for the same injury, concern about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow‐up care without insurance, loss of work, and financial strain.

Conclusions

The majority of patients presenting to a public hospital ED after treatment for the same complaint in another local ED were indirectly referred to the public ED without transferring paperwork or records, incurring duplicate testing and patient anxiety.

     

Factors Influencing Perceived Effectiveness in Dealing with Self-harming Patients in a Sample of Emergency Department Staff

Background

Past self-harming behavior is one of the most significant predictors of future suicide. Each year in Ireland there are approximately 11,000 presentations of self-harm to emergency departments (EDs) across the country.

Study Objectives

This study examines predictors of perceived personal effectiveness in dealing with self-harming patients as reported by ED staff. The predictors are derived from past research and are influenced by Bandura's Social Cognitive Theory.

Method

One hundred twenty-five ED medical staff (28 doctors and 97 nurses) from five EDs in the West and South of Ireland completed a questionnaire. Predictor variables included in the design, and informed by past research, included knowledge of self-harm and suicidal behavior and confidence in dealing with incidents of self-harm.

Results

Standard multiple regression suggested a statistically significant model fit between the two predictors and the criterion variable, accounting for 24% of total variance. Knowledge and Confidence were significant contributors to perceived personal effectiveness in dealing with self-harming patients.

Conclusions

Little is known regarding specific factors that influence perceived effectiveness in dealing with self-harming patients in the ED setting. These findings have implications for psycho-education and training content for staff. The findings suggest that increasing knowledge of self-harm and confidence in dealing with self-harming patients can lead to more positive perceived personal effectiveness in responding to clients' needs.     

Screening for Behavioral Health Patient Aggression in Emergency Departments to Reduce Workplace Violence

IntroductionPatient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings.MethodsThis quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation.ResultsViolent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation.DiscussionUsing an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.     

The relationships among workplace stressors, coping methods, demographic characteristics, and health in Australian nurses.

Nursing is known to be stressful. Stress detrimentally can influence job satisfaction, psychological well-being, and physical health. There is a need for increased understanding of the stress that nurses experience and how best to manage it. Three hundred twenty Australian acute care public hospital nurses participated in a study by completing four questionnaires that examined (a) how various workplace stressors relate to ways of coping, demographic characteristics, and physical and mental health and (b) which workplace stressors, coping mechanisms, and demographic characteristics were the best predictors of physical and mental health. Significant correlations were found between stressors and physical and mental health. Multiple regression showed age to be the only significant predictor of physical health. The best coping predictors of mental health were escape-avoidance, distancing, and self-control. Other significant predictors of mental health were support in the workplace, the number of years worked in the unit, and workload. Mental health scores were higher for nurses working more years in the unit and for those who used distancing as a way of coping. Mental health scores were lower for nurses who used escape-avoidance, lacked workplace support, had high workload, and used self-control coping. The findings have implications for organizational management, particularly in terms of recommendations for stress management, social support, and workload reduction.     

Immigrants and the utilization of hospital emergency departments

BACKGROUND:

Immigrants with language barriers are at high risk of having poor access to health care services. However, several studies have indicated that immigrants tend to use emergency departments (EDs) as their primary source of care at the expense of primary care. This may place an additional burden on already overcrowded EDs and lead to a low level of patient satisfaction with ED care. The study was to review if immigrants utilize ED care differently from host populations and to assess immigrants’ satisfaction with ED care.

DATA SOURCES:

Studies about immigrants’ utilization of EDs in Australia and worldwide were reviewed.

RESULTS:

There are conflicting results in the literature about the pattern of ED care use among immigrants. Some studies have shown higher utilization by immigrants compared to host populations and others have shown lower utilization. Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a longer length of stay in EDs, and are less satisfied with ED care as compared to host populations.

CONCLUSIONS:

Immigrants might use ED care differently from host populations due to language and cultural barriers. There is sparse Australian literature regarding immigrants’ access to health care including ED care. To ensure equity, further research is needed to inform policy when planning health care provision to immigrants.KEY WORDS: Emergency department, Health service, Immigrants, Language, Utilization     

What factors help and hinder efforts to address incivility in Australasian emergency departments? A modified Delphi study of FACEM perspectives

Objective

Workplace incivility is a global challenge for healthcare and a major leadership challenge facing emergency physicians. However, little is known about emergency physicians' understanding of the factors that help and hinder attempts to address incivility, or what emergency physicians believe are the priority factors to address. The present study makes a novel contribution to research in this area by examining the perceived enablers of, and barriers to, efforts to address incivility in Australian and Aotearoa New Zealand EDs.

Methods

An online modified Delphi study was conducted with 22 FACEMs. To structure the process, participants were sorted into four panels. Using a three-phase Delphi process, participants were guided through the process of brainstorming, narrowing down and ranking the factors that help and hinder attempts to address incivility in EDs.

Results

There was general agreement that FACEMs' cross-department relationships and networks were key helping factors, and that poor workplace culture and time pressure were major hindering factors. However, despite agreement about these three factors, a wide range of intrapersonal, interpersonal, intergroup, and organisational factors were identified as pertinent to attempts to address incivility in EDs.

Conclusion

The causes of incivility in Australian and Aotearoa New Zealand EDs are complex and highlight incivility in EDs as a key adaptive leadership challenge of emergency physicians. Fundamentally, the results underscore the need to foster a workplace culture of respect, inclusion and civility in Australasian hospitals.