Emergency Department (ED) workers are exposed to such frequent and high levels of violence, that being on the receiving end of death threats, offensive sexual abuse and hitting, go unreported and are simply accepted as part of the job, a new study has found.

But the failure to acknowledge these comparatively “low-level” incidents could “contribute significantly” to stress and sickness, compassion fatigue and general attrition of ED staff, says the report’s author, Dr Sandra Richardson.

As nurses prepare to strike next month for better pay and working conditions, the findings, published in the New Zealand Medical Journal this week, show that ED nursing staff are in the front line when it comes to experiencing workplace violence.

During a one-month campaign, ‘May – it’s not okay’, in 2014, Richardson and her team encouraged ED workers at Christchurch Hospital to fill out a simple form if they were subject to any form of violence, verbal or physical, at work.

The study found there were at least 107 incidents of violence and aggression that month. However not a single one was officially reported, despite all of them meeting hospital criteria for formal reporting.

Those who filled out Richardson’s forms were predominantly female (86 per cent) and 90 per cent were nurses.

Much of the verbal abuse and threats involved highly threatening and offensive language and inappropriate sexual content.

One ED worker was called things like “a f*cking ho and ugly bitch” for almost two hours, until police arrived. Another patient threatened to “kill us all”, one worker wrote. These are not even the worst examples, Richardson says: those were left out of the report.

There were also physical assault and threats, such as punching, hitting and kicking. At least one worker reported having pills spat in their face; another was pinched in the breast.

Richardson said she was not surprised by the findings, but what she was initially surprised about was that “there was a perception [among hospital management] that the violence level had declined”.

Officially, hospital boards and DHBs generally advocate a ‘zero tolerance’ approach to violence. But when reporting is not provided, there is the potential for management to misinterpret the level of violence in the workplace, and be unaware of the need to respond appropriately.

Unfortunately, verbal abuse and aggression has become seen as a normal part of the ED environment and is a key reason for the reluctance to report, says Richardson.

A certain type of toughness is encouraged, that can lead to indifference and emotional burnout.

This normalisation is “particularly disturbing” because it makes it easier to accept it, rather than report it, she says.

Other reasons ED staff may be unwilling to report these incidents include concerns that it would reflect poorly on their abilities, and time constraints, due to the high-pressured nature of the work.

Many nurses are also reluctant to report a patient when they can see why someone is behaving the way they are, such as dementia.

But it’s not about blame, says Richardson, “it is about recognising that this level of violence is occurring within a workplace.”

The issue is not unique to Christchurch Hospital, says Richardson, who is the ED’s nurse researcher.

“What we were trying to do is to highlight that violence and aggression is an ongoing, prevalent condition, not just within our ED but within all EDs and within all of healthcare.”

“It’s about recognising that this is an ongoing issue and that it’s not going to go away, it’s not something that we can continue to accept, it has particular consequences.”

The hospital has repeated the audit every May with the exception of 2017. Yet despite the formation of a group, WAVE or Working Against Violence in ED, the ongoing ‘it’s not okay’ campaign and a “very supportive” ED management, the same issues persist.

The solution is “multi-faceted”, says Richardson. If staff are becoming less tolerant due to being subject to constant abuse, then there are times, she says, that communication would help, to de-escalate a situation.

But there also needs to be education of the general public, particularly around what is acceptable and appropriate behaviour in an ED. Patients are not the only perpetrators; often those people accompanying them can be just as violent. Drugs and alcohol frequently plays as part; as does an ‘all about me’ culture.

“Why is it seen as okay to behave in that way, when you wouldn’t behave in that way at a supermarket, at a bank, or anywhere else?”

“There are just so many factors, it’s not a quick fix.”

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