Workplace Violence and Harassment Against Emergency Medicine Residents

Using body-worn cameras in emergency departments: a pilot project

Nurses and other emergency department (ED) staff often experience verbal and physical abuse as part of their everyday work. Body-worn cameras are one tool that ED staff can use to try to reduce workplace violence and abuse and have been shown to be effective in other healthcare environments, such as mental health units. This article describes a pilot service evaluation which used a survey to assess the effectiveness of using body-worn cameras for staff in the author's ED. Findings suggest that nurses believed the cameras provided support when they were confronted by abusive or aggressive patients or relatives and in some instances diffused potentially violent situations.

Occupational violence in a tertiary emergency department: A retrospective descriptive study

OBJECTIVE

Occupational violence in emergency departments (EDs) impacts staff and patients. Most hospitals have a response mechanism called a 'Code Black' or similar. We aimed to determine the incidence of Code Black activations in a tertiary ED and describe contributory factors, management strategies and adverse events.

METHODS

Descriptive study in a tertiary ED in South-East Queensland in 2021. Adult patients for who a Code Black had been activated were eligible. Data were obtained from a prospectively collected Code Black database, supplemented with retrospective electronic medical records.

RESULTS

There were 386 Code Black events. The incidence of Code Black activation was 11.0 per 1000 adult ED presentations. Individuals requiring Code Black activation were 59.6 % male with a mean age of 40.9 years. The primary diagnosis was mental illness related in 55.1 %. Alcohol was a suspected factor in 30.9 %. When Code Black activation occurred, median length of stay increased. Restraint including physical, chemical or both were used in 54.1 % of Code Blacks.

CONCLUSION

Occupational violence occurs at a three-fold greater incidence within this ED than reported elsewhere. This study reinforces other literature suggesting an increase in occupational violence, demonstrating the need for dedicated preventative strategies for patients at risk of agitation.

Workplace Violence Faced by Medical Doctors in Kerala, India

INTRODUCTION

The escalation of violence against doctors, a global concern, is also evident in India. In recent years, there has been a noticeable increase in the instances of violence against doctors in Kerala, a state situated in the southern part of India. This study examines the prevalence and types of violence against doctors in Kerala, considering factors, such as gender, workplace, designation, timing, and those involved.

METHODOLOGY

This cross-sectional study involved modern medicine doctors holding a minimum degree in Bachelor of Medicine and Bachelor of Surgery (MBBS), practicing in Kerala. Data collection used validated questionnaires distributed as Google Forms through WhatsApp and email after obtaining contact details from the Indian Medical Association, Kerala wing. A total of 2,400 doctors across all 14 districts participated, and data analysis was done using the IBM SPSS Statistics for Windows, version 21 (released 2012; IBM Corp., Armonk, New York, United States).

RESULTS

Among 1,948 respondents, 65.6% (n=1279) of doctors experienced violence, predominantly verbal abuse (89.9%, n=1150), and intimidation by gestures (32.7%, n=418). Most incidents happened during the day (84.7%, n=1083), with 32% (n=409) occurring after duty hours. Casualty triage had the highest incidence (57.5%, n=736), followed by outpatient departments (33.6%, n=430). Relatives or bystanders were the foremost perpetrators in 81.5% (n=1043) of cases. Although 48.6% (n=621) of incidents were reported to authorities, only 13.5% (n=173) had any sort of preventive measures taken. A significant 76.7% (n=981) of doctors contemplated relocating abroad.

CONCLUSION

This research underscores the alarming prevalence of workplace violence against doctors in Kerala, echoing global trends. The inadequate implementation of preventive measures highlights the gap between awareness and action, necessitating an examination of barriers in healthcare settings.

Prevalence and predictors of workplace violence against emergency physicians in China: a cross-sectional study

BACKGROUND

Workplace violence (WPV) is considered a global problem, particularly in the health sector; however, no studies have assessed the national prevalence of WPV against emergency physicians and the associated factors in China.

METHODS

A national cross-sectional survey was conducted in 31 provinces/autonomous regions/municipalities across China between July 2019 and September 2019. A total of 15 455 emergency physicians were selected using a multistage stratified random sampling method. A structured self-administered questionnaire was used to collect information on WPV and potential associated factors among emergency physicians. Descriptive and multivariable logistic regression analyses were used to identify the predictors of WPV.

RESULTS

A total of 14 848 emergency physicians responded effectively (effective response rate: 96.07%). Of the respondents, 90.40%, 51.45%, and 90.00% reported exposure to any type of WPV, physical or nonphysical violence in the preceding year, respectively. Verbal aggression (87.25%) was the most common form of violence, followed by threat (71.09%), physical assault (48.24%), verbal sexual harassment (38.13%), and sexual assault (19.37%). Patients' families were the main perpetrators of these incidents. Unmet patient needs, taking drugs or drinking, and long waiting times were the main contributors to WPV. Physicians who were from low-developed regions, female, and without shift work were less likely to have experienced any type of WPV. Chinese emergency physicians who were from medium-developed regions, had a bachelor's degree, worked in a higher level hospital, had a higher professional title, with lower incomes, had a history of hypertension or coronary heart disease, were smokers or drinkers, and worked in hospitals without preventive measures or training for WPV and not encouraging to report WPV were more likely to have experienced any type of WPV. The predictors of WPV varied in different types of WPV.

CONCLUSIONS

This study shows that the prevalence of WPV against emergency physicians is high in China. Measures should be taken at the physicians, patients, hospital, and national levels to protect GPs from WPV; for example, improving physicians' level of service and hospital' reporting procedures. Creating a prevention strategy and providing a safer workplace environment for emergency physicians should be prioritized.

Sublingual dexmedetomidine: repurposing an anesthetic as an anti-agitation agent

INTRODUCTION

Especially when acutely ill, individuals with schizophrenia and bipolar disorder can present with agitated behavior. The initial approach to agitation management are non-pharmacologic strategies such as verbal de-escalation techniques; however, pharmacologic interventions may be needed. Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist, and a sublingual formulation has been approved in the US for the treatment of agitation associated with schizophrenia and bipolar disorder in adults.

AREAS COVERED

The authors review the published literature on sublingual dexmedetomidine using the US National Library of Medicine's PubMed.gov resource. Pharmacodynamics, pharmacokinetics, and efficacy and tolerability findings are summarized. The authors also provide a discussion to its potential place in the treatment armamentarium.

EXPERT OPINION

Sublingual dexmedetomidine is an effective and well-tolerated pharmacologic option for the treatment of agitation associated with schizophrenia and bipolar disorder. The sublingual method of administration allows for a rapid onset of action with treatment effects beginning as early as 20 minutes after administration. Adverse effects include somnolence, hypotension, oral paresthesia, hypoesthesia, and dry mouth. Further study will be needed to evaluate sublingual dexmedetomidine in real-world patients receiving concomitant psychotropic medications.

Safe and Sound: An Improvisational Theater-Based Curriculum and Behavioral Intervention to Address Violence in the Emergency Department

BACKGROUND

Emergency department (ED) workplace violence has become increasingly prevalent in the United States, warranting the development of legislation, policy, and advocacy to protect health care workers. Solutions to address ED violence remain limited, and staff-oriented trainings often exist as short, one-time didactic sessions, which are not practical nor often applicable to the ED setting. There is a paucity of evidence-based interventions that incorporate behavioral-based training to adequately prepare staff for the complicated, multifactorial presentation of violence in the ED.

OBJECTIVE

This pilot study sought to assess the feasibility of an improvisational theater-based, simulation intervention for health care professionals to address ED violence.

METHODS

A longitudinal curriculum for ED violence was developed in collaboration with a committee of emergency medicine (EM) faculty, EM simulation experts, hospital security and police personnel, professional theater and improvisational performers, resident physicians, and medical students. This pilot intervention was tailored to new EM residents (n = 25) at a large, urban, academic medical center. Sessions were led by facilitators trained in group facilitation, simulation, and improvisation.

RESULTS

Participants felt the curriculum was helpful (82.6%), engaging (91.3%), applicable (73.9%), and enjoyable (82.6%). Participation primarily by residents identifying as female and people of color suggested the efficacy of creative expression and nontraditional modalities in engaging diverse learners. Ninety-five percent of participants expressed interest in future sessions.

CONCLUSIONS

A multidisciplinary workplace violence intervention leveraging principles of improvisational theater, health equity, organizational psychology, and EM simulation may prove useful in preparing health care professionals for violence in the ED.

Incivility in medical education: a scoping review

Incivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. In this scoping review, we use the term incivility to encompass a spectrum of behaviors that occur across the continuum of medical education, and which include verbal abuse including rude or dismissive conduct, sexual and racial harassment and discrimination, and sexual and physical assault. We identified research on incivility involving medical students, residents and fellows, and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. Our results reinforce that incivility is likely under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients, not emphasized in previous reviews. The authors suggest a zero-tolerance national policy if this problem is to be resolved.

Sexual harassment from patient to medical student: a cross-sectional survey

BACKGROUND

There is little existing research investigating SH/SA specifically from patients to students. This study aims to assess the prevalence and impact of SH and SA from patient to medical student.

METHODS

A cross-sectional survey study was administered via electronic email list to all current medical students at the University of Washington School of Medicine (n = 1183) over a two-week period in 2019. The survey questions addressed respondents' experiences with SH/SA from patients, frequency of reporting, and impact on feelings of burnout.

RESULTS

Three hundred eleven responses were received for a response rate of 26%; 268 complete responses were included in the final analysis. Overall, 56% of respondents reported ever experiencing SH from a patient. SH from a patient was reported by significantly more of those who identify as female compared to male (66% vs 31%; p < .001). Similar frequency of experiencing SH within the last year were reported by females and males (90% vs 88%; p = .96). Clinical students were more likely to have ever experienced SH compared to preclinical students (61% vs 39%; p < .001). The majority (86%) of respondents who experienced SH/SA did not report it in an official capacity. Those who identify as female were more likely to report that SH from a patient contributed to feelings of burnout (21% vs 5% for male; p = .02). Behaviors consistent with SA were experienced by 16% of respondents, with similar frequency between females and males.

CONCLUSIONS

This study demonstrates that patient to medical student SH/SA is a common occurrence, particularly among students identifying as female. It also highlights the significant impact of SH/SA incidents on feelings of burnout.

Identifying Predictors of Workplace Violence Against Healthcare Professionals: A Systematic Review

Understanding the predictors of workplace violence amongst healthcare professionals is important to develop and implement prevention and mitigation strategies. We conducted a systematic review to synthesize the recent evidence on predictors of workplace violence across healthcare settings. The review has been done as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two electronic databases (PubMed and Google Scholar) were used to search peer-reviewed studies published for the year 2009-2020 to identify studies reporting predictors of workplace violence. The significant predictors were analyzed using descriptive statistics such as proportions in most of the studies and some studies used inferential statistics such as logistic regression analysis, Chi-square test, ANOVA and Student's t-test. A total of 46 studies were identified and overall evidence was graded using an adapted GRADE approach. Some of the moderate quality predictors associated with workplace violence were the patient with a history of mental health disease, psychiatric setting, professional's gender and work experience and evening shift workers. Being a nurse was the only high-quality predictor. Healthcare professionals and administration can identify the predictors relevant to their setting to mitigate episodes of violence against healthcare personnel.

A combined behavioural economics- and simulation-based medical education to promote effectiveness among medical residents in coping with workplace violence in Northern China: a quasi-experimental study

Background

Workplace violence is internationally recognised as a major concern for the workforce, which entails serious consequences, and research shows that medical residents are more likely than other doctors to experience violence in the workplace. This study first examines the effectiveness of simulation-based medical education, and then simulation-based medical education combined with behavioural economics as interventions in medical residents' perception of, attitude toward, and self-efficacy in coping with violence in the workplace.

Methods

A quasi-experimental design was used, 190 participants were randomised into three study groups to respectively test the effect of simulation-based medical education only and simulation-based medical education plus behavioural economics interventions, compared with a control group. Data were obtained from structured questionnaires, including (1) a perception of aggression scale, a management of aggression and violence attitude scale, a general self-efficacy scale, and (2) socio-demographic characteristics.

Results

The results show that the scores attained by simulation-based medical education (SBME) and simulation-based medical education combined with behavioural economics (SBME + BE) interventions for perception, attitude, and self-efficacy were significantly higher than those in the control group (p < .01). The SBME + BE group recorded a greater improvement in perception, which could be ascribed to the behavioural economics effect. Furthermore, the higher perception of workplace violence is correlated with single residents and those with more work experience, prior experiences of violence in the workplace, and training related to workplace violence. A higher positive correlation of workplace violence was recorded by female and widowed residents,and a higher level of self-efficacy related to violence in the workplace correlated with male, widowed,and senior (third-year) residents.

Conclusions

This study contributes important evidence regarding changes in the perception, attitude, and self-efficacy of subjects following both the SBME + BE and SBME interventions among medical residents in coping with workplace violence, the biggest perception change having been recorded after the SBME + BE intervention, which can be explained by the inclusion of behavioural economics.

Prevention Strategies for Sexual Harassment in Academic Medicine: A Qualitative Study

Sexual harassment and gendered discrimination in the workplace are global issues that can affect anyone regardless of their age, gender, job title, or field of employment. The medical field is also relevantly concerned, yet effective prevention measures are scarce. The purpose of this study was to explore preventive options for sexual harassment in an academic medical context from the employees' perspective and to develop transferable strategies. We conducted semi-structured interviews with 15 female physicians and 15 female nurses working at a tertiary referral center in Berlin, Germany, in the months of April to November 2015. The one-on-one interviews addressed the perception of sexual harassment and available and desirable preventive measures. Data were analyzed by qualitative content analysis. The participants outlined preventive measures at two levels: individual and institutional. Individual options included personal safety measures and individual protection strategies against patients, peers, and superiors. Institutional strategies included guidelines and workplace policies, structured complaint and reporting procedures, formal training options, and organizational development and leadership strategies. The current study highlights how the prevention of sexual harassment hinges on a combination of individualized and system-wide measures to capture the personal as well as the organizational dimension of sexual harassment. Only a concerted effort addressing both aspects will sensitize the workforce, support the victims, and prevent sexual harassment in medical institutions.

Addressing Mistreatment of Providers by Patients and Family Members as a Patient Safety Event

OBJECTIVE

Mistreatment of health care providers (HCPs) is associated with burnout and lower-quality patient care, but mistreatment by patients and family members is underreported. We hypothesized that an organizational strategy that includes training, safety incident reporting, and a response protocol would increase HCP knowledge, self-efficacy, and reporting of mistreatment.

METHODS

In this single-center, serial, cross-sectional study, we sent an anonymous survey to HCPs before and after the intervention at a 213-bed tertiary care university children's hospital between 2018 and 2019. We used multivariable logistic regression to examine the effect of training on the outcomes of interest and whether this association was moderated by staff role.

RESULTS

We received 309 baseline surveys from 72 faculty, 191 nurses, and 46 residents, representing 39.1%, 27.1%, and 59.7%, respectively, of eligible HCPs. Verbal threats from patients or family members were reported by 214 (69.5%) HCPs. Offensive behavior was most commonly based on provider age (85, 28.5%), gender (85, 28.5%), ethnicity or race (55, 18.5%), and appearance (43, 14.6%) but varied by role. HCPs who received training had a higher odds of reporting knowledge, self-efficacy, and experiencing offensive behavior. Incident reporting of mistreatment increased threefold after the intervention.

CONCLUSIONS

We report an effective organizational approach to address mistreatment of HCPs by patients and family members. Our approach capitalizes on existing patient safety culture and systems that can be adopted by other institutions to address all forms of mistreatment, including those committed by other HCPs.

Is sexual harassment and psychological abuse among medical students a fatality? A 2-year study in the Paris Descartes School of Medicine

INTRODUCTION

An observatory of sexual harassment and psychological abuse was set up at one of France's largest schools of medicine to both quantify and reduce sexual harassment or psychological abuse of medical students.

METHODS

Over a 2-year period, we described the evolution of sexual harassment and psychological abuse and explored for associated factors. Moreover, a qualitative analysis using an inductive approach was performed from students' verbatim.

RESULTS

2795 responses were collected. Sexual harassment was reported in 7% and psychological abuse in 15%, at baseline, and decreased after the observatory was set up. Women had higher odds of being a victim of sexual harassment. Older students reported less often psychological abuse and being a witness of sexual harassment. Surgery departments were associated with up to 5.7-fold increased odds of sexual harassment. Surgery and pediatrics departments were associated with a 2-fold increased odds of psychological abuse. Qualitative analysis revealed four categories: humiliation, the feeling of inferiority, sexual harassment, and manifestations of violence.

CONCLUSION

During clerkships, factors associated with higher odds of sexual harassment and psychological abuse were female gender, younger age, and departments of surgery. Setting up such an observatory may contribute to reduce this burden and provide a useful tool to raise awareness.

Prevalence of Discrimination, Abuse, and Harassment in Emergency Medicine Residency Training in the US

IMPORTANCE

The prevalence of workplace mistreatment and its association with the well-being of emergency medicine (EM) residents is unclear. More information about the sources of mistreatment might encourage residency leadership to develop and implement more effective strategies to improve professional well-being not only during residency but also throughout the physician's career.

OBJECTIVE

To examine the prevalence, types, and sources of perceived workplace mistreatment during training among EM residents in the US and the association between mistreatment and suicidal ideation.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study conducted from February 25 to 29, 2020, all residents enrolled in EM residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) who participated in the 2020 American Board of Emergency Medicine computer-based In-training Examination were invited to participate. A multiple-choice, 35-item survey was administered after the examination asking residents to self-report the frequency, sources, and types of mistreatment experienced during residency training and whether they had suicidal thoughts.

MAIN OUTCOMES AND MEASURES

The types and frequency of workplace mistreatment and the sources of the mistreatment were identified, and rates of self-reported suicidality were obtained. Multivariable logistic regression models were used to examine resident and program characteristics associated with suicidal thoughts.

RESULTS

Of 8162 eligible EM residents, 7680 (94.1%) responded to at least 1 question on the survey; 6503 (79.7%) completed the survey in its entirety. A total of 243 ACGME-accredited residency programs participated, and 1 did not. The study cohort included 4768 male residents (62.1%), 2698 female residents (35.1%), 4919 non-Hispanic White residents (64.0%), 2620 residents from other racial/ethnic groups (Alaska Native, American Indian, Asian or Pacific Islander, African American, Mexican American, Native Hawaiian, Puerto Rican, other Hispanic, or mixed or other race) (34.1%), 483 residents who identified as lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) (6.3%), and 5951 residents who were married or in a relationship (77.5%). Of the total participants, 3463 (45.1%) reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) during the most recent academic year. A frequent source of mistreatment was identified as patients and/or patients' families; 1234 respondents (58.7%) reported gender discrimination, 867 (67.5%) racial discrimination, 282 (85.2%) physical abuse, and 723 (69.1%) sexual harassment from patients and/or family members. Suicidal thoughts occurring during the past year were reported by 178 residents (2.5%), with similar prevalence by gender (108 men [2.4%]; 59 women [2.4%]) and race/ethnicity (113 non-Hispanic White residents [2.4%]; 65 residents from other racial/ethnic groups [2.7%]).

CONCLUSIONS AND RELEVANCE

In this survey study, EM residents reported that workplace mistreatment occurred frequently. The findings suggest common sources of mistreatment for which educational interventions may be developed to help ensure resident wellness and career satisfaction.

The pandemic of workplace violence: the gendered experience of emergency medicine trainees

OBJECTIVES

Many health care providers experience physical and verbal abuse from patients and their visitors. This abuse is a form of workplace violence and likely has negative implications for the providers well-being. The objective of our study was to determine the rates of nonphysical workplace violence against emergency medicine (EM) trainees with a focus on prevalence by provider gender.

METHODS

This was a single-center prospective cohort study using tally counters to track occurrences of nonphysical workplace violence perpetrated by patients and their visitors against EM trainees in the adult emergency department.

RESULTS

There were a total of 39 completed responses submitted by 22 respondents. Of the 22 respondents, 14 identified as women and eight identified as men. On average, both men and women experienced near daily occurrences of nonphysical workplace violence. However, women experienced higher rates compared to their colleagues who are men with a mean of three occurrences per day versus 0.9, respectively.

CONCLUSION

We found that women trainees were more likely to experience nonphysical workplace violence from patients and their visitors.

Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium

Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.

Risk assessment of workplace violence towards health workers in a Chinese hospital: a cross-sectional study

OBJECTIVE

This study aimed to assess the risk factors associated with workplace violence towards health workers (HWs) in a Chinese hospital.

METHODS

We conducted a cross-sectional survey in a Chinese secondary hospital in 2019 using an international survey questionnaire, and collected valid data from 1028 HW respondents via mobile phone. Alongside analysing the potential association between exposure to violence and respondents' characteristics, we compared the workplace violence between this survey and a baseline survey in the same hospital using the same questionnaire in 2018, and investigated the existing measures.

RESULTS

A total of 5.45% of respondents had encountered physical violence while 41.63% had experienced psychological violence. Women (OR=3.45, 95% CI 1.87 to 6.38), those working in outpatient and emergency departments (OR=7.96, 95% CI 2.27 to 27.95), and those with extremely high concern about workplace violence (OR=7.94, 95% CI 1.04 to 60.85) were significantly more likely to suffer physical violence. Working in the outpatient and emergency department (OR=2.03, 95% CI 1.23 to 3.34), having direct physical contact/interaction with patients (OR=2.98, 95% CI 1.62 to 5.49), and extremely high worry about workplace violence (OR=6.47 95% CI 3.38 to 12.40) significantly increased the risk of psychological violence. When the results of the baseline survey were compared with those in this survey, it was shown that physical violence declined significantly from 8.79% in 2018 to 5.45% in 2019, while psychological violence declined significantly from 47.14% in 2018 to 41.63% in 2019. The most recognised measures were security measures (81.03%) while the least recognised measures were check-in procedures for staff (11.19%).

CONCLUSION

Workplace violence towards HWs is a global problem with country-specific features. In our study, workplace violence in the hospital is of great concern. While demonstrating the effectiveness of measures in some degree, there is significant room for improvement. To achieve the vision of 'zero violence' in the health sector, aligned comprehensive measures should be systematically adopted.

Factors influencing violence at emergency departments: Patients' relatives' perspectives

INTRODUCTION

In hospitals, the places where the highest rate of violence is perpetrated are emergency departments (EDs). Evaluating patient relatives' perceptions of violence and obtaining their views about how to prevent violence incidents are important in terms of uncovering the factors that increase violent behaviors. This study was aimed at determining the factors increasing violence in the emergency department (ED) from the perspectives of patient relatives.

METHODS

The sample of this study consisted of 520 individuals who brought a relative to the Adult ED of Akdeniz University Hospital in Turkey between April 2017 and June 2017. Data was collected using a two-part questionnaire prepared by the researcher. The first part consists of 15 items questioning the demographic characteristics of the participants. The second part consists of 20 statements asked the participants to rate the reasons urged patients or their relatives to perpetrate violence in the emergency department. Numbers and percentage calculations were used to evaluate the data.

RESULTS

Of the participants, 55.6% were men and 54.7% were married. According to the participants' statements, of the relatives of the 520 patients, 141 (27.1%) witnessed verbal violence against emergency department staff, 76 (14.6%) witnessed physical violence against emergency department staff, 9 (1.7%) witnessed verbal threat against emergency department staff, especially against nurses. According to the participants, the primary factor causing people to perpetrate violence at EDs was that patients or their relatives were not adequately informed about the patient's condition. More than 40% of patients' relatives said that anxiety and nervousness arising from being a patient's relative, and stress and sadness they suffered were among the leading factors causing people to perpetrate violent incidents.

CONCLUSION

In order to prevent and decrease incidents of violence in the emergency departments, healthcare systems should be reviewed and revised. Our study revealed that informing patients and their relatives about the patient's condition and empathic approaches displayed by healthcare employees towards patients reduced the number of incidents of violence. Unlike other studies, this study addresses the negative experiences of patients' relatives in the emergency department and the factors influencing these experiences. Obtaining the opinions of the patients' relatives about possible solutions to the violent events in the ED makes this study unique.

Workplace violence against doctors: Characteristics, risk factors, and mitigation strategies

Workplace violence is a major occupational issue concerning doctors that has a significant impact on their physical and psychological well-being. This ultimately affects the health care services of the country. Patient-led episodes of verbal violence are more prevalent in Asian countries, especially in the emergency department, psychiatric wards, and intensive care units, mostly faced by junior doctors and residents. Some common precursors of violence against doctors are patients and their attendants' dissatisfaction and low impulse control, poor administration, miscommunication, infrastructural issues especially differences in services between private and public hospitals, and negative media portrayal of doctors. The assessment of risk factors, development and implementation of workplace violence programs, and addressing underreporting of violent episodes have been suggested as some successful organizational mitigation strategies. Recommendations on the management of workplace violence include the development of participative, gender-based, culture-based, nondiscriminatory, and systematic strategies to deal with issues related to violence. This article aims to present a comprehensive review of workplace violence against doctors, discussing the prevalence, degree of violence, predictors, impact on physical and psychological health and intervention strategies to devise practical actions against workplace violence.

Extent and risk factors of psychological violence towards physicians and Standardised Residency Training physicians: a Northern China experience

Purpose

Physicians and Standardised Residency Training physicians (SRTPs) have relatively high exposure to psychological violence. Its adverse effects are far greater than those of physical violence. However, no previous research has paid attention to the problem of psychological violence among them. This study aims to evaluate the extent, characteristics, and risk factors of psychological violence among SRTPs in comparison to physicians, and also to highlight the psychological violence experienced by SRTPs and suggest preventive measures.

Methods

A cross-sectional survey was conducted in northern China. 884 physicians and 537 SRTPs completed a questionnaire which compiled by the ILO, ICN, WHO and PSI in 2003 to measure violence in the workplace. Descriptive statistics and logistic regression analysis were used to analyse results.

Results

The effective response rates of physicians and SRTPs were 63.1%(884/1400) and 86.3%(537/622) respectively. 73.0%(645/884) of physicians and 24.8%(133/537) of SRTPs suffered psychological violence in the past year. Compared to physicians (29/645, 4.5%), SRTPs (42/133, 31.6%) experience more internal violence. Further, after experiencing psychological violence, physicians are willing to talk to family and friends, but SRTPs generally take no action. Shift work was a risk factor for both physicians (OR 1.440, 95% CI 1.014–2.203) and SRTPs (OR 1.851, 95% CI 1.217–2.815) suffering from psychological violence. In contrast, no anxiety symptoms protected physicians (OR 0.406, 95% CI 0.209–0.789) and SRTPs (OR 0.404, 95% CI 0.170–0.959) against psychological violence.

Conclusions

SRTPs and physicians in northern China have a high risk of experiencing psychological violence, and physicians experience more. Meanwhile, there are obvious differences in responses to psychological violence and risk factors between them. Therefore, medical institutions should pay more attention to psychological violence, especially among SRTPs, such as supporting the reporting of psychological violence, strengthening team relationships, and providing psychological comfort and counselling.

Trial registration number (Project Identification Code: HMUIRB20160014), Registered May 10, 2016.

Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation)

Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.

Addressing Workplace Safety in the Emergency Department: A Multi-Institutional Qualitative Investigation of Health Worker Assault Experiences

OBJECTIVE

This study aims to identify interventions to address workplace violence in the emergency department based on direct evidence from experiences of patient assault.

METHODS

We performed de novo coding and thematic analysis of datasets from two geographically distinct institutions and five different sites that contained interviews with 80 health workers.

RESULTS

We identified concepts that corresponded to the micro (workers and patients), meso (organizations and clinical units), and macro (society at large, worldviews, and values) levels of the healthcare system. Within each level, potential interventions fell into the prevention, response, and recovery phases of emergency preparedness.

CONCLUSION

Efforts to address workplace violence should consider interconnected influences from individual workers, organizations, and society at large. Comprehensive approaches at multiple phases of preparedness are needed to have sustained impact on safety.

The Experience of Male Physicians with Sexual and Gender-Based Harassment: a Qualitative Study

BACKGROUND

Sexual harassment and gender-based harassment are common in medicine; however, there is little in the literature regarding men's experience with gender-based and sexual harassment.

OBJECTIVE

The objective of this study was to better understand the experience men have with sexual and gender-based harassment in medicine.

DESIGN

We developed and piloted an interview guide based on a review of the literature and conducted semi-structured interviews of male physicians, from trainees to attendings, at a tertiary care facility. Participants were recruited via email between April and August of 2019. These interviews were transcribed verbatim and, using an iterative coding approach based in grounded theory, were coded and analyzed for themes.

MAIN RESULTS

We conducted a total of 16 interviews. Five major themes were identified: (1) personal experiences of harassment, (2) witnessed harassment, (3) characterization of harassment, (4) impact of harassment, and (5) strategies for responding to harassment. The men reported experiences with sexual and gender-based harassment but were hesitant to define these encounters as such. They had minimal emotional distress from these encounters but worried about their professional reputation and lacked training for how to respond to these encounters. Many had also witnessed their female colleagues being harassed by both male patients and colleagues but did not respond to or stop the harassment when it originated from a colleague.

CONCLUSION

We found that men experience sexual harassment differently from women. Most notably, men report less emotional distress from these encounters and often do not define these events as harassment. However, similar to women, men feel unprepared to respond to episodes of harassment against themselves or others. Whether to deter sexual harassment against themselves, or, more commonly, against a female colleague, men can gain the tools to speak up and be part of the solution to sexual harassment in medicine.

Strategies for Provider Well-Being in the Emergency Department

A variety of operational and administrative factors have the potential to decrease wellness and negatively impact emergency physicians, in terms of both their on-the-job performance and their long-term career satisfaction. Among these are the issues of workload balance, physiologic and circadian stresses, and larger issues of malpractice risk and institutional support. This overview covers both emerging research on how these problems affect emergency physicians and strategies to help mitigate these challenges.

Prevalence of intimidation, harassment, and discrimination among resident physicians: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to establish the prevalence of intimidation, harassment, and discrimination (IHD) reported by resident physicians during their training, to identify factors associated with reported IHD, and to identify adverse sequalae associated with IHD.

METHODS

This review followed the PRISMA guidelines. Eight electronic databases were searched for cross-sectional studies reporting the prevalence of IHD among resident physicians. Prevalence estimates were pooledacross studies using random-effects meta-analysis, with variance stabilization using Tukey double arcsine transformation. Heterogeneity was assessed with forest plots, the I ² statistic, subgroup analyses, and multivariate meta-regression.

RESULTS

52 cross-sectional studies were included in the meta-analysis. The overall pooled prevalence of IHD was 64.1% (95% confidence interval [CI], 51.0-77.1). Verbal, physical, and sexual IHD were the most common forms of IHD reported by residents. Training status (55.5%), gender (41.7%), and ethnicity (20.6%) were the most commonly cited risk factors for IHD. The most common sources of IHD were relatives/friends of patients, nurses, and patients (cited by 50.7%, 47.8, and 41.7%, respectively).

CONCLUSIONS

The prevalence of IHD among resident physicians is high and associated with multiple negative outcomes, including burnout. Despite the availability of multiple anti-IHD interventions, reports of IHD appear to be rising in many residency programs.

Gender-based Harassment of Emergency Medicine Trainees: What Faculty Educators Need to Know

There is increased interest in workplace harassment as reports of improper workplace conduct have surfaced among multiple industries and governments. Accounts of sexual misconduct in academic medical centers also highlight the need for further education and training for faculty educators. The purpose of this paper is to provide faculty educators with the tools to recognize and respond to gender-based harassment of medical trainees. More specifically, we will review existing literature, the definition of gender-based harassment, federal laws, institutional reporting protocols, and retaliation toward reporters of harassing behavior.

Manifestations of verbal and physical violence towards doctors: a comparison between hospital and community doctors

Background

Healthcare workers, in the hospital and in community clinics, are frequently exposed to verbal and physical abuse that can lead to frustration and despair. This study’s objectives were to evaluate trends in violence towards hospital and community doctors in the Negev region of Israel and to compare them to the results of a previous 2005 study.

Methods

A convenience sample of doctors in the hospital and in the community completed anonymous questionnaires on previous exposure to work place violence and their attitudes to it. The data were collected in 2017.

Results

One hundred forty-five doctors participated in the study, of who 63 were hospital doctors and 82 were community doctors. Fifty nine percent of the doctors reported that they experienced at least one incident of verbal abuse over the previous year and 9% were exposed to physical abuse, compared to 56 and 9%, respectively, in the previous study. More hospital doctors (58.7%) were exposed to verbal abuse on the part of family members than community doctors (35.8%) (P = 0.007). The most common reason for a violent outbreak was long waiting times, followed by dissatisfaction with treatment, both consistent with the findings in the previous study. Seventy one percent said that violence was a major problem for doctors. The majority (73.9%) had not participated in a workshop or other training for preventing workplace violence or coping with it, an improvement over the 83% who reported not receiving any training in the previous study.

Conclusions

Workplace violence is a major issue, which affects hospital and community physicians alike. There is a rise in the number of doctors who have undergone training in this area, although the majority have yet to receive formal training.

Workplace violence among prehospital care providers in India: a cross-sectional study

OBJECTIVES

The purpose of this study was twofold: (1) establish the prevalence of safety threats and workplace violence (WPV) experienced by emergency medical technicians (EMTs) in a low/middle-income country with a new prehospital care system, India and (2) understand which EMTs are at particularly high risk for these experiences.

SETTING

EMTs from four Indian states (Gujarat, Karnataka, Tamil Nadu and Telangana) were eligible to participate during the study period from July through November 2017.

METHODS

Cross-sectional survey study.

PARTICIPANTS

386 practicing EMTs from four Indian states.

RESULTS

The overall prevalence of any WPV was 67.9% (95% CI 63.0% to 72.5%). The prevalence of physical assault was 58% (95% CI 52.5% to 63.4%) and verbal assault was 59.8% (95% CI 54.5% to 65%). Of physical assault victims, 21.7% were injured and 30.2% sought medical attention after the incident. Further, 57.3% (n=216) of respondents reported they were 'somewhat worried' and 28.4% (n=107) reported they were 'very worried' about their safety at work.

CONCLUSION

WPV and safety fears were found to be common among EMTs in India. Focused initiatives to counter WPV in countries developing prehospital care systems are necessary to build a healthy and sustainable prehospital healthcare workforce.

Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base

INTRODUCTION

Aggression in the Emergency Department (ED) remains an ongoing issue, described as reaching epidemic proportions, with an impact on staff recruitment, retention, and ability to provide quality care. Most literature has focused on the definition (or lack of) core concepts, efforts to quantify the phenomenon or provide an epidemiological profile. Relatively little offers evidence-based interventions or evaluations of the same.

AIM

To identify the range of suggested practices and the evidence base for currently recommended actions relating to the management of the aggressive Emergency Department patient.

METHODS

A meta-synthesis of existing reviews of violence and aggression in the acute health-care setting, including management of the aggressive patient, was undertaken. This provided the context for critical consideration of the management of this patient group in the ED and implications for clinical practice.

RESULTS

An initial outline of issues was followed by a systematic search and 15 reviews were further assessed. Commonly identified interventions are grouped around educational, interpersonal, environmental, and physical responses. These actions can be focused in terms of overall responses to the wider issues of violence and aggression, targeted at the pre-event, event, or post-event phase in terms of strategies; however, there is a very limited evidence base to show the effectiveness of strategies suggested.

CLINICAL IMPLICATIONS

The lack of evidence-based intervention strategies leaves clinicians in a difficult situation, often enacting practices based on anecdote rather than evidence. Local solutions to local problems are occurring in a pragmatic manner, but there needs to be clarification and integration of workable processes for evaluating and disseminating best practice.

CONCLUSION

There is limited evidence reporting on interventional studies, in addition to identification of the need for high quality longitudinal and evaluation studies to determine the efficacy of those responses that have been identified.

Emergency Medicine in the #MeToo Era

Sexual harassment is a serious threat to a safe and productive workplace. The emergency department (ED) environment poses unique threats, including stress, time constraints, working in close physical proximity, and frequent personal contacts with staff, colleagues, consultants, and difficult patients. Sexual harassment must be recognized and addressed in individual cases, in policy and in law, to protect staff members and patients. This article addresses the scope of the problem of sexual harassment known to date. It describes the ED environment and culture and why they may be conducive to harassment or abusive behavior. The authors examine relationships among staff, legal and regulatory issues, and strategies for prevention and remediation of inappropriate behavior. The article ends with a call for future research.

Perception of Workplace Violence in the Emergency Department

Background:

Workplace violence (WPV) is a serious issue worldwide. Violence against emergency department (ED) staffs causes significant physical and mental distress which affects work productivity and patient care.

Objective:

We seek amount and type of WPV perceived by the emergency physicians and nurses, their reporting agencies, and impact of violence on them.

Methods:

It was a cross-sectional study conducted at a tertiary health care center. Data were collected based on 24-item questionnaire between January and December 2017. Descriptive statistics was used to describe characteristics of participants and exposure to violence. Chi-square and Fisher's exact tests were used for bivariate analysis while logistic regression analysis was to analyze the impact of violence with participant characteristics. P < 0.05 was used to judge the clinical significance.

Results:

Two hundred and thirty-five participants (123 doctors and 112 nurses) completed the survey. About 67% of the participants (158/235) reported verbal abuse (VA), physical assault (PA) was reported by 17% (40/235), while confrontation was reported by 11% (27/235). Family members were the main perpetrator for VA (75%) and PA (35%). Regarding reporting, the violent incidences were mostly reported to ED security and ED faculty. Individuals with comparatively less age group, less experience, and male gender were more exposed to abuse both VA and PA at P < 0.05. Nurses and junior residents reported more abuse than senior residents (P < 0.05). Majority of the participants had reported lack of job satisfaction due to Verbal abuse (P = 0.01).

Conclusion:

WPV is common in ED of the current setting. It results in significant physiological and psychological effects on health-care providers.

Workplace violence by specialty among Peruvian medical residents

OBJECTIVE

To determine the prevalence of workplace violence among Peruvian medical residents and to evaluate the association between medical specialty and workplace violence per type of aggressor.

METHODS

This was a cross-sectional secondary analysis that used data from the Peruvian Medical Residents National Survey 2016 (ENMERE-2016). The outcome of interest was workplace violence, including physical and verbal violence, which were categorized according to the perpetrator of violence (patients/relatives and worker-to-worker). Primary exposure was the medical specialty, categorized as clinical, surgical, and other specialties. To evaluate the associations of interest, we estimated adjusted prevalence ratios (PR) with their respective 95% confidence intervals (95% CI) using Poisson regression models with robust variances.

RESULTS

A total of 1054 Peruvian medical residents were evaluated. The mean age was 32.6 years and 42.3% were female. Overall 73.4% reported having suffered of workplace violence sometime during the residency, 34.4% reported violence from patients/relatives, and 61.1% reported worker-to-worker violence. Compared with clinical residents, surgical residents had a lower prevalence of violence from patients/relatives (PR: 0.71; 95% CI: 0.59-0.87), but a higher prevalence of worker-to-worker violence (PR: 1.11, 95% CI: 1.01-1.23).

CONCLUSION

Nearly three quarters of medical residents reported having suffered workplace violence sometime during their residency. Compared with clinical residents, surgical residents had lower rates of violence from patients/relatives, but higher rates of worker-to-worker violence; while residents from non-clinical and non-surgical specialties had a lower prevalence of both types of violence.