Background
Methods
Study design
Participants and recruitment
Data collection
Section | General subjecta | Specific topic |
---|---|---|
1 | Data on demographics and occupation | - Age, gender, working hours, profession, work experience |
2 | Prevention measures known by participants | - Measures to identify aggressive patients and to deal with them on the environmental, organisational, and individual-focused level - Support in dealing with aggressive patients |
3 | Implementation of measures | - Perceived effectiveness of measures - Perceived barriers regarding implementation |
4 | Further needs | - Demands to prevent or reduce violent incidents on the environmental, organisational, and individual-focused level |
Data analysis
Results
Characteristics of the study population
Characteristics | n | %a |
---|---|---|
Gender | ||
Male | 12 | 44 |
Female | 15 | 56 |
Age (in years) | ||
20–29 | 3 | 11 |
30–39 | 8 | 30 |
40–49 | 6 | 22 |
50–59 | 10 | 37 |
Occupation in the ED | ||
Doctor | 13 | 48 |
Nurse | 14 | 52 |
Medical or nursing leadership position in the ED | ||
Yes | 16 | 59 |
No | 11 | 41 |
Work experience in the current ED (in years) | ||
< 1 | 2 | 7 |
1–5 | 14 | 52 |
6–10 | 6 | 22 |
11–15 | 2 | 7 |
> 15 | 3 | 11 |
Working hours in the ED | ||
Full-time (≥35 h/week) | 24 | 89 |
Part-time (< 35 h/week) | 3 | 11 |
Working in shifts in the ED | ||
Yes (shifts during nights and/or weekends) | 16 | 59 |
No (work only on weekdays during the day) | 11 | 41 |
Emergency care levelb of the current ED | ||
1 (basic care level) | 8c | 29 |
2 (enhanced care level) | 7c | 25 |
3 (comprehensive care level) | 13c | 46 |
Sponsor of institution | ||
Commercial sponsor (profit-oriented) | 4 | 15 |
Public sponsor | 12 | 44 |
Independent sponsor (non-profit, charity, church) | 11 | 41 |
Violence prevention measures
Environmental measures | Organisational measures | Individual-focused measures | ||
---|---|---|---|---|
Technical | Architectural | Employees | Patients and attendants | |
Alarm systems - Permanently installed or carried devices - Loud or silent alarm | General structure of the ED - Patient flow - Open and calming atmosphere - Secured equipment - Means of escape | Staff organisation - Exchanging the responsible colleague - Supporting colleagues during violent incidents - Attending potentially aggressive patients | Training regarding violence prevention - Education on causes of violence, early warning signs, verbal de-escalation, or self-defence | Communication - Patient information (e.g., explaining waiting periods) - Means of information and entertainment (e.g., video screens, posters, or patient information systems) |
Locking systems - Restricted access to (the core area of) EDs | Registration and waiting areas - Registration area: welcoming design while considering staff safety - Waiting area: either outside of the ED or inside to make the workload visible; providing water and snacks | Security service - Intervening verbally and physically - Quick availability | Staff care - Support from supervisors - Promoting stress resistance | Access restrictions - Expelling aggressive patients and attendants from the ED - Restricting access for attendants |
Records of violent incidents - Free-text entries, protocols, or attributes assigned in patient files | Police - Last resort, mostly called in cases of physical violence | |||
Camera surveillance - For crucial areas inside and outside of the ED | Treatment rooms - Single rooms, especially for individuals with substance misuse or psychiatric patients | Guidelines and standard operating procedures (SOPs) - Written instructions regarding violence prevention | Physical restraint - As a last resort to prevent aggressive patients from hurting themselves or others | |
Screening tools - Assigning higher urgency to anxious or aggressive patients | ||||
Structural conditions - Specialised treatment centres for individuals with substance misuse - Outpatient clinics |
Environmental measures – technical
Alarm systems
Furthermore, it was described that carrying these devices provided a sense of security and thus facilitate confidence in demeanour. Several disadvantages of alarm-systems were discussed. Permanently installed emergency buttons or bell systems might be out of reach, while using silent alarms with an intercom device required the person on the other side to be very cautious, since the aggressor might be triggered on noticing that an alarm was initiated. Wireless pagers or telephones with an emergency feature needed to be available in adequate quantity, which was expensive. Demands regarding technical measures mostly pertained to further expansion of alarm systems, e.g., permanently installed alarm buttons to improve reachability. Furthermore, advanced pager and telephone systems were in demand, just as more simple portable alarm devices to equip each employee with them.“Well, we all have telephones with us and there is an, so to speak, emergency button, where you can speak freely, so that you don’t need to have the telephone in your hand. Instead, when I press it (…), I think some kind of security service gets connected, which can follow the conversation via speaker.” [#5, female ED nurse]
Locking systems
Other participants reported that only the core area enclosing the treatment rooms was secured from unauthorised access by locking systems and thus, separated from the registration area and the waiting room.“(…) our entrances are secured, so all entrances are locked at night. So then you can only get in with a key from the building or via a numeric code at the entrance of the emergency department, which only the ambulance service, the police and us internal people have. (…) I was at a different hospital before and there all doors were open at night. (…) There I often felt much more insecure on the ward, I have to say.” [#18, female ED nurse]
Records of violent incidents
Negative statements regarding these records were related to their visibility and thus effectiveness in warning colleagues before contact with the patient. Hence, highlighted warnings equal to those generally indicating crucial medical conditions were described as more helpful compared to entries hidden in the patient file. Some participants reported that entries were more often used in cases of physical compared to verbal violence and others rarely or never documented violent incidents as warnings for their colleagues.“(…) our computer system that we use for the treatment, there is a comments section. It is often filled out directly during the first contact, if there are any incidents that is also saved. Everyone can also access it, who is currently involved in the treatment.”[#18, female ED nurse]
Camera surveillance
“I would like enhanced video surveillance. In principle, we are technically prepared for it, but (…) there are, if you set up cameras, conflicts of interest between staff safety and personal privacy, which the staff council evaluates.” [#6, male ED physician]
Environmental measures – architectural
General structure of the ED
In addition, one participant addressed the need for a separate room for staff so that employees could have a break in a calm atmosphere to reduce their stress level.“Then we took various other measures, we banned water bottles and we looked at the spatial orientation of the desks in the rooms (…), but that is all very difficult and not 100 percent feasible, (…) because simply the structural conditions are sometimes as they are.” [#27, male ED physician]
Registration and waiting areas
A central registration and triage area further had the benefit of having all areas within range of vision in order to notice colleagues needing support. Two different concepts regarding waiting areas were described as beneficial. First, an open design (e.g., glass encased) so that waiting people can see the busy ED routines and understand why they have to wait, or second, keeping waiting rooms outside the core area of the ED to prevent impatient or aggressive patients from entering. A one-way-system with several waiting areas was suggested for implementation, meaning that patients would always move forward and never come back to the same waiting room, preventing them from getting frustrated over feeling stuck in slow ED processes.“(…) our base for example, it is a closed room, but where the patients (…) also step up to the counter. And if they (…) come behind the counter – which is no problem – then you have one sole chance, to jump out of the window (…). There is no second exit at the moment, which is impractical.” [#5, female ED nurse]
Treatment rooms
An important concern were insufficient treatment capacities for the high number of patients. Thus, fast track rooms were planned in one ED to efficiently handle less ill patients so that they do not have to wait. The importance of day light in treatment rooms was emphasised as well, so that patients did not become disorientated while waiting.“We can accommodate the people in a low-stimulus environment, we can put them in a single room. Like this they cannot get close to another patient that fast, start a fight with him. We have the possibility, (…), that we can let him sleep calmly and still supervise him with monitors in every room, we can sober them up properly and these are the main patients I am concerned with. And this sobering up in a stable, medical setting, but also in a calm, shielded atmosphere, that is what often helps (…).” [#3, male ED physician]
Organisational measures
Staff organisation
Likewise, female participants shared that they called their male colleagues for help, e.g., in cases of sexual harassment. Calling the quality or complaint management to get a third perspective from someone who could mediate was reported as well. Preliminary verbal warnings about aggressive patients were also common, either from colleagues, or from paramedics and police officers during admission to the hospital. In case of a violent assault, immediate help was provided by all available ED colleagues and the manpower was further increased by calling staff from other wards, especially psychiatric wards. It was reported that during the daytime there was enough staff around to help, but participants also told that this was different at night, especially in smaller EDs. Regarding staff rostering, the participants described several factors. For instance, the registration desk should be staffed with employees trained in de-escalation to calm down aggressive patients and recognise early warning signs for aggressive behaviour right from the beginning. In addition, it was described as beneficial if experienced and trained colleagues were available in every shift, as well as a mix of male and female colleagues. In general, fast ED-processes were perceived as helpful to prevent aggression caused by long waiting times, e.g., fast registration and triage for patients to be informed about their medical situation. However, the high number of patients exceeding ED capacities was addressed, causing long waiting times, leading to aggression, and also impeding the application of preventive measures. Hence, almost all participants addressed the need for more staff in EDs. While a lack of nursing staff was highlighted, an additional shortage of doctors was recognised to cause long waiting times.“So it is actually like that, especially when it comes to communication, then the nursing colleagues directly go to the doctors’ level or to the nurses’ supervisor level (…). If someone gets abusive, then it is being said: ‘I am leaving and I am coming back with my supervisor’ or ‘I am leaving, I am coming back with the doctor, the doctor will discuss this with you now’.” [#26, male ED physician]
Furthermore, participants had experienced supervision of potentially aggressive patients as an effective measure, especially for individuals with substance misuse having limited impulse control. This could be carried out by students, patient transport service, or security staff, who could attend respective patients through all ED processes and respond to their requests (e.g., food, water, or visiting the washroom). Such one-on-one maintenance for psychiatric or demented patients was experienced to limit the use of physical restraints. Altogether, caring for aggressive patients was described to require personnel who were then not available to provide medical treatment.“Nursing staff as a whole in the emergency department is too little, yes. The idea in Germany that one is supposed to cover the most severe scenarios with a minimal skeleton crew, that is downright bizarre. And then it must be clear to you that an aggressive patient in the emergency department needs at least the same amount of personnel as a polytrauma (…), where without batting an eye, five to ten people are ordered.” [#3, male ED physician]
Security service
Security staff was further perceived as helpful if they were able to de-escalate verbally but could also intervene physically if necessary. However, some participants told there were restrictions that prohibited physical interventions from security staff and thus some patients were not daunted by them anymore. It was also mentioned that the presence of security staff could provoke aggressive patients even more, and uniforms might only suppress aggression that could erupt once security staff was gone. One participant had previously experienced security service in plain clothes as an effective measure and wished for its reintroduction. If security staff was available in the ED itself, they were mostly positioned in the entrance area, but in general on-call security service was more common. In that case, security staff was not perceived as helpful if they needed too long to reach the ED. The biggest constraints regarding security staff were if they had too little personnel to cover all their areas of application, or if their personality and physical appearance was not suitable for the job (e.g., inciting character, not trained for the job, not physically fit, or not willing to intervene). In EDs without security staff, participants wished for its implementation at least at night or on the weekends. Others wished to expand the time where security staff was available and wanted them to be present right by the ED instead of on-call duty. Overall, well organised security services comprising competent staff was perceived as very effective, while poorly organised security service that did not have enough capacities or unskilled personnel was perceived as unhelpful.“Well, what is very nice is that now security service is sitting in front at the entrance area, because its presence alone sometimes helps a bit. You do not have to look yourself all the time because he is also looking (…). Or otherwise, if we have a psychiatric patient, who might be very restless because he absolutely wants to go outside to smoke et cetera, then we can also just resort to the security service, who will then accompany him. And then we are more relaxed because we know: okay he will be accompanied to go outside and they will also bring him back. That disburdens us a lot.” [#1, female ED nurse]
Police
It was perceived as helpful if the police stayed throughout the treatment, but there were also participants stating that sometimes the police was not good in de-escalating and showed aggressive behaviour themselves. There were only few further demands regarding the police, e.g., if they generally took too long to arrive at the ED or did not stay to support aggressive patients’ treatment.“As I said, if I have a 1.90m, muscular, young man who additionally has perhaps taken drugs somehow as a background, then I know: I need a bit more manpower and there I also need people who know exactly how to handle them. And even our psychiatric ward (…), they also call the police. So in my opinion that's the most effective or the most helpful means.” [#4, female ED nurse]
Guidelines and standard operating procedures (SOPs)
Participants also stated that violent incidents were heterogeneous and that it would be difficult to write down a general guideline that would help with the correct behaviour in such diverse situations. Hence, it was also stated that basic principles of violence prevention were rather transferred verbally, along with reminding each other of the correct behaviour, instead of relying on guidelines and SOPs. However, other participants wished for a general guideline instead of having to muddle through the daily work routine without a concept regarding violence prevention.“There is a process instruction in the QM portal [quality management portal] (…). So it is just written there, yeah, to somehow ‘impinge on the situation in a de-escalating way’ – full stop. Whatever that is supposed to mean.” [#25, male ED physician]
These participants wished for clear instructions regarding the right behaviour during violent incidents and demanded to be informed about the guidelines and SOPs relevant for their workplace on a regular basis, e.g., during induction period or training measures.“I think we still do too little. I think, it is a lot that you just accept and manoeuvre yourself through the daily routine. But a proper plan, we actually…, only few have.” [#19, female ED physician]
Screening tools
“(…) there are no good scores or tools so far to identify these [aggressive] patients early on. And thus, there is of course no structured means to stop this escalation, because you do not recognise it at all.” [#24, male ED physician]
Structural conditions
Secondly, there were many patients with minor medical complaints that insisted on treatment in EDs due to longer waiting times in outpatient clinics. Thus, participants described the benefits of integrating an outpatient practice into the hospital setting for referral of those patients.“(…) there I would wish for a reasonable way of dealing with intoxicated people and that this is done in a specialised manner and an institution established for this purpose. And namely with participation of the police, the judiciary, and also a somatic hospital.” [#3, male ED physician]
“For four years now, we have the medical emergency service in our house, from the association of statutory health insurance physicians, in the emergency service practice. And a lot has already been de-escalated there. So since then, we also have considerable improvements because simply the waiting times are not so long.” [#20, male ED physician]
Individual-focused measures – employees
Training regarding violence prevention
Other training measures aimed at understanding the patients’ and their attendants’ perspectives, which was further complemented with knowledge regarding diseases that increase the risk of aggressive behaviour (e.g., dementia, psychiatric diseases, or substance misuse). As a last resort, physical self-defence, the procedure of physical restraint, or recognising the right time to flee and alert others was also a part of training measures.“Well, there are the early warning signs (…) that we train: restlessly walking up and down, hitting objects, fixed gaze, sweating, clenched fists. (…) The best de-escalation is the one that does not have to take place because he [the patient] does not escalate because instead you recognise him, and approach him, and dare to address him directly.”[#8, female ED nurse]
Furthermore, it was described as important that the team was included in the process of developing and deciding about measures to implement, so that respective changes were more successful.“(…) for this as well, we have too little training: how do I deal with it myself, if I was verbally attacked and hurt. It is always based on us not having any emotions at all and always just have to accept it. But it is not always like that, we are also only humans and sometimes just more susceptive for such, let’s say, verbal lapses of others than on different days.” [#17, female ED nurse]
Further details regarding training in violence prevention are provided in Fig. 1.“The team always wants to be integrated and be part of the decision. I always find, performing efforts at persuasion and then introducing a proposal to the team, which the team works on and gets it off the ground that is actually the best to initiate change, volitional change.” [#8, female ED nurse]
Staff care
These aspects were perceived as crucial in order to equip employees to work in the ED until retirement age.“(…) it would not be my first priority to do training in the direction of de-escalation now, because you can do as much de-escalation training as you want, if you yourself are completely stressed, you will forget all of it, yes.” [#15, female ED nurse]
Individual-focused measures – patients and attendants
Communication
In general, the personal behaviour of staff was described to play an important role, meaning that it had a substantial influence on the course of a violent incident. Participants stressed the importance and effectiveness of approaching patients in a calm and friendly way without prejudices, if necessary, in a one-on-one situation and a quiet atmosphere. Even patients showing a more challenging behaviour like those with dementia or intoxication were described as easier to deal with if they were treated with time and patience to build up trust or were left alone for a while to adapt to the ED atmosphere. In general, two things were important when communicating with (aggressive) patients. Firstly, since longer waiting periods were a major reason for aggression, it was reported as helpful to make patients understand the reasons (e.g., patients are treated according to urgency, or employees from different disciplines may have different capacities). Secondly, participants felt it was effective to validate patients’ problems, show understanding, and ask for their individual needs to dissolve the confrontation, since eventually the patients visiting an ED were in an exceptional situation. Thus, to prevent aggressive behaviour, participants emphasised an increased information flow, e.g., transparency regarding ED processes and providing reasons for longer waiting periods. Along with measures for patient entertainment (e.g., free WLAN-access or TV), patient information was demanded in the form of video clips displayed in waiting areas, posters or sheets available in several languages, or patient information systems (e.g., showing the number of severely ill patients currently treated). Patients were also described to get aggressive if smaller requests were denied (e.g., food or going outside to smoke), so it was described as effective to accommodate these needs. However, due to time pressure in ED processes, participants told they were too stressed and had too little personnel resources to deal with patients in the manner described above.“Conversations of course, that is the ultimate, that is what always helps in case of doubt, talking to people.” [#7, female ED nurse]
Participants wished for more awareness in the general population regarding the amount of violent behaviour ED staff had to face on top of their stressful work, especially in terms of verbal violence. They asked to clearly state to patients and their attendants that ED staff had to be treated with more respect and that violent behaviour was not tolerable.“You usually don’t have the time for any long de-escalation talks, while in the background somehow three patients are almost dying. (…) and you are always running behind time.” [#10, male ED nurse]
Furthermore, participants wished for the general population to be educated about the fact that only medical emergencies should be treated at the ED and people with less pressing issues should visit practitioners from out-patient care to unburden EDs.“So, what I think would be more useful from the start, what I still miss a bit, that this is reflected to the outside, that it becomes clearer to the population (…) that verbal violence is also not tolerated here. Because many people do not know that shouting and complaining at the highest level, that this is verbal violence and that we do not tolerate it, yes.” [#16, female ED physician]
Access restrictions
“In my opinion, relatives in the emergency department, excuse my expression, do not belong there (…). Of course, it is nice for the patient, then he is not alone, but for the procedure and for the potential of aggression it is absolutely counterproductive in my view, because at the end of the day there is one more person who is constantly asking questions: (…) ‘why is nothing happening?’ (…). Which on the one hand disturbs the workflow, and on the other hand, of course (…), also promotes aggression. Of course, there are always exceptions: seriously ill patients, mentally retarded patients, very anxious patients. I think you have to make exceptions there, and we do that.” [#22, male ED physician]
Physical restraint
“What we always try to do first is to have a conversation. (…) In the one-on-one situation the psychiatrists try to reach a consensus. In many cases, this can already calm things down and it doesn't have to come to a situation of physical restraint or something. But the decision towards physical restraint (…) is then made by the psychiatrist.” [#24, male ED physician]