Opinion | ‘Violence Has Become a Daily Occurrence In Our Hospitals’
Crushing chest pain, an itch that festers into torment, an inconsolable baby, no place to sleep at 3 a.m., an ankle twisted on a jog, a fentanyl overdose, a car crash, the need to tell someone, “I feel sad and lonely.” The only place that tends to this kaleidoscope of needs is the emergency room, its doors perpetually open to all.
It’s what I love — fiercely, unwaveringly — about emergency medicine. It’s why I and other doctors pursued it as a specialty: to provide a safety net. For many people, we may be the first health care workers they meet at their most dismal hour. But it’s also what makes our workplace so dangerous, more than ever, and jeopardizes the emergency care that everyone receives.
Last year one of my patients was on the phone, lamenting about how long he had been in the emergency room. He had already waited several hours to get a CT scan. Medications he was supposed to be given were repeatedly delayed. I heard his voice rise and fall, with each swell more expansive than the one before. When I turned to look at him, he yelled a racial epithet before hurling a desktop computer into the area where doctors and nurses sit. A seasoned nurse ducked. As I pushed an intern and medical student out of the way, he charged at us with a steel tray. Thankfully, no one was injured.
In a 2022 American College of Emergency Physicians survey of E.R. doctors, 55 percent said they had been physically assaulted, almost all by patients, with a third of those resulting in injuries. Eighty-five percent had been seriously threatened by patients. The risks can be even higher for E.R. nurses, with over 70 percent reporting they had sustained physical assaults at work. I don’t know anyone who works in the E.R. who hasn’t suffered some form of violence there. The health workers at the University of Vermont Health Network in the video above share examples of this.
“People, appropriately so, feel that the safety net should always be there, no matter what, and should serve its purpose of not letting people fall through the cracks,” Dr. Aisha Terry, the president of the American College of Emergency Physicians, told me. But it’s this tenet at the heart of emergency medicine that also allows it to be exploited. “Whether intentionally or unintentionally, those factors have resulted in us becoming more vulnerable to violence.”
In the E.R., there’s a certain level of resignation that violence is just part of the job, like getting bloodstains on our shoes. We have come to endure racist, sexist and homophobic slurs, choosing silence over confrontation, to fulfill our duty to care for human life. After all, we pledge to hold our patients’ well-being above all else.
In some sense, violence in the E.R. is stark evidence of society’s broader neglect: a medical system in which mental health beds are scarce, primary care remains elusive and prescription costs soar; a shelter network that’s buckling; a country where parents may not make enough to feed their children. All of this can lead to intolerable overcrowding and interminable waiting in the E.R., which can rupture into frustration, anger and incivility.
Even before the Covid pandemic, the trajectory was troubling. The U.S. Bureau of Labor Statistics reports that the rate of injuries from workplace violence against health care workers grew by nearly two-thirds from 2011 to 2018. The pandemic worsened the situation, cracking society wide open and exposing its systemic failures. During the pandemic, more than 40 percent of American adults reported high psychological distress, which may contribute to outbursts. It has also sown profound mistrust between patients and medical professionals.
The repercussions of this are being felt. Only 15 percent of surveyed hospital nurses said they would continue in the same job in one year; a third of nurses said they had considered exiting the profession because of the pandemic. The burnout rate among E.R. doctors climbed to 65 percent, the highest rate among all specialties. When employees leave, those who remain face terribly short-staffed workplaces. Or employees meet a revolving door of new colleagues, making it impossible to understand one another’s strengths or compensate for one another’s shortcomings — to become a team. This can worsen outcomes for patients.
Organizations and lawmakers are starting to address violence against health care workers. The Joint Commission, a group that accredits hospitals, added workplace violence regulations last year. This year Virginia became the first state to pass a law requiring that all emergency departments keep a security officer on site around the clock. Federal legislation is also in progress: If passed, the Workplace Violence Prevention for Health Care and Social Service Workers Act would mandate health employers to adopt plans to prevent workplace violence. Another bill, the Safety From Violence for Health Care Employees Act, modeled on protections in the airline industry, would create federal criminal penalties for people who assault health care workers.
Health care, though, is not the same as air transportation. Because of the Emergency Medical Treatment and Labor Act, in place since 1986, every person who goes to an E.R. for treatment must be medically examined and assessed. Hospitals don’t create no-fly lists, akin to airlines, nor should they. A patient can be aggressive and also be seriously ill. Patients struggling with mental illness, addiction or delirium may have violent episodes but also need compassionate care.
Federal and state laws are necessary as backstops, permitting warning signs to be posted, so that everyone knows a boundary exists that will be enforced. But hospital administrators also need to prioritize their staff members’ safety. Hospital systems have added electronic flags to the charts of patients who threatened or assaulted staff members in the past. Currently, these flags are put in by providers to warn one another and don’t go beyond individual charts. This is a starting point, but more must be done.
Simple confidential reporting systems that encourage employees to formally record these incidents in detail for further review, as they would with any medication error, should be instituted. Hospital administrators need to then perform thorough dissections of the events to diagnose what went wrong, applying the same rigor as they would to clinical mistakes, and intervene with specific remedies — whether it’s bolstering security in certain areas or equipping staff members with personal panic buttons. Some health care workers have already taken matters into their own hands by undergoing self-defense training, even looking into wearing body armor.
What has stayed with me most is not the near miss of a thrown computer or a slur a patient used but a medical student saying to me after he witnessed a violent episode, “I learned today that I don’t want to go into emergency medicine.” The field is seeing a steep decline in applicants. Who will tend to waiting patients? What will happen when society’s safety net withers away?
Standing up to end violence against health care workers does not mean taking care away from anyone. Instead, it promises to make care better for everyone.
Roland Kielman is a communications specialist with the University of Vermont Health Network, where he focuses on storytelling and corporate communications. Ryan Mercer is a communications specialist with the University of Vermont Health Network, where he focuses on multimedia storytelling. Helen Ouyang (@drhelenouyang) is a physician, an associate professor at Columbia University and a contributing writer for The New York Times Magazine.
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