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Nursing leadership’s impact on reducing violence in the emergency department

Authored by:

JoAnn Lazarus, MSN, RN, CEN, FAEN, Managing Partner, Emergency Department Services, Peregrine Health Services, LLC

Jeanne Venella, DNP, MS, CEN, CPEN, Strategic Advisor, Commure Strongline

The Emergency Department (ED) is a dynamic and challenging environment where healthcare professionals provide care to patients in crisis. Unfortunately, it is also a setting where violence and aggression towards healthcare staff have become increasingly common. Nursing leadership plays a crucial role in mitigating and addressing this issue. This article explores the significant impact of nursing leadership on reducing violence in the ED.

Workplace violence in the U.S. is an epidemic, and 80% of all reported incidents target healthcare workers. A 2022 study found that an average of 57 nurses are assaulted every day. Among healthcare professionals, doctors and nurses working in EDs are most at risk, with over 50% of emergency doctors reporting some form of assault during their careers. A startling 70% of emergency nurses say they have been hit or kicked. Unfortunately, these statistics and recent events are just the tip of the iceberg, as workplace violence incidents are grossly underreported. Other high-risk medical environments include pediatric hospitals, psychiatric units, and critical care settings. A Press Ganey survey found in April 2022 92% of all healthcare staff witnessed or experienced WPV during 2011-2018: 60% increase in workplace violence in healthcare.

“By creating a culture of safety, providing education, and training, and advocating for staff support, nurse leaders significantly impact the well-being of both healthcare workers and the patients they serve.”

The effects of this rising crisis are catastrophic: Those exposed to workplace violence are 2-4x more likely to experience anxiety, depression, burnout, and PTSD. Suicide among female nurses is double that of the public. And this increasingly negative workplace experience is having a significant contributor to the tremendous staffing churn and the Great Resignation across healthcare. One in three nurses plans to leave their current role in direct patient care. Among those surveyed, a safe work environment was the number one factor impacting their decision to stay or leave. 

The result is a workforce that is changing and becoming less tenured. In the last year alone, we saw a 55.5% increase in shifts being filled by nurses with less than one year of tenure — and much of the indirect cost of turnover is due to workplace violence. Not only is that unsustainable, but it’s also simply unacceptable.

Leadership plays a pivotal role in creating a safe and efficient work environment within the ED.  Effective leaders establish clear expectations, promote a culture of safety, and implement strategies to de-escalate tense situations. In times of crisis, leaders are essential in coordinating staff responses, ensuring the safety of both patients and staff, and liaising with law enforcement if necessary. These leaders include nurse managers, charge nurses, and clinical educators who must work together to create a culture of safety and respect. 

When leadership positions are vacant or are inadequately staffed, it can lead to a sense of uncertainty and instability among the staff.  This may contribute to decrease morale and job satisfaction, potentially making healthcare workers more vulnerable to workplace violence.  Vacancies in leadership positions may also lead to gaps in security measures, policies, and the ability to hold staff accountable for their actions, both among staff and patients.  All of this increases the risk for violence with the department.

An interim leader may be needed while searching for the permanent leader. Interim leaders play a pivotal role in maintaining a safe and productive work environment.  They can have a profound impact on addressing and preventing violence by implementing crisis management strategies, enhancing policies and procedures, fostering team cohesion, and prioritizing training and education.  Measuring success through incident reports, staff and patient satisfaction, and staff turnover rates can help assess the effectiveness of interim leadership in creating a safer emergency department environment.

Today, preventing workplace violence requires a proven and strategic combination of early intervention and conflict de-escalation approaches, simple-to-use and widely effective safety programs and technologies, and cross-functional collaboration and leadership buy-in from the top down.

When health organizations can check off all these boxes, they are poised to not just improve the physical and psychological wellbeing of employees, but directly and positively impact their key business imperatives — including financial efficiency, patient outcomes, and employee retention:

In organizations where staff feel the safest, we see a 52% lower rate of RN-perceived missed care and 22% higher overall CMS Hospital Quality star rating (Press Ganey). And not only does physical and psychological safety have clear and critical impacts to the health and wellbeing of the healthcare workforce and their patients, it’s also a critical piece of the ever-growing employee attrition puzzle. More than ever before, workplace safety is the most critical priority to engaging and retaining a thriving nursing workforce. A safe work environment is the number one factor affecting nurses’ decisions to continue working for or to leave their current organization. (McKinsey)

There is no single solution to end workplace violence for good but, through actions both big and small, healthcare organizations can still enact meaningful change. By establishing comprehensive safety strategies, hospitals and health systems can operate as a united front to combat workplace violence and restore “care” into the healthcare environment for all caregivers.

Most facilities have one or more safety measures in place, such as visible security presence, fixed hospital panic buttons, hand-held communications devices. video surveillance, and de-escalation training. These are necessary but not sufficient. Implementation of robust safety measures can include enhanced surveillance systems, access control mechanisms, weapons detection systems, wearable duress alarms, and proper lighting in all areas, including parking lots and entrances.

Providing your staff with wearable duress alarms allows them to call for help early in conflict escalation. Local alerting at the first sign of conflict helps promote early intervention and de-escalation. An optimal solution engages nearby staff, in addition to security, to step in and help with de-escalation. Healthcare organizations should consider all attributes of workplace safety solutions before implementation.

Nursing leadership, whether it is permanent or interim, plays a pivotal role in addressing and reducing violence in the emergency department. By creating a culture of safety, providing education, and training, and advocating for staff support, nurse leaders significantly impact the well-being of both healthcare workers and the patients they serve. The collaborative efforts of nursing leadership, healthcare institutions, and policymakers are essential in making the ED a safer environment for all.

When staff feel safe, they are more likely to stay at their job and provide high-quality, focused patient care without fear or distraction. Healthcare organizations can foster a culture of safety through regular feedback mechanisms, open channels of communication, and initiatives that prioritize staff safety and well-being.


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