The health care industry has been identified as one of the most violent workplace sectors, with emergency departments (EDs) ranked as one of the highest risk areas. Over the last decade, violence in EDs in NSW has reached a concerning level, with 90% of ED nurses reporting exposure to violence, both verbal and physical, at some point in their careers.
In Brisbane, two men were recently charged by police for a brawl in the Royal Brisbane Hospital ED that involved up to 14 staff and resulted in four nurses and one security guard suffering injuries as well as hospital property being damaged. In the same week, a security guard at Gympie Hospital died of a suspected heart attack after a violent confrontation with a mental health patient in the hospital's ED. These incidents have occurred shortly after the Queensland Government began an advertising campaign to educate the public about the number of assaults on emergency services employees and the penalties for committing those assaults.
Episodes of violence are so frequent around the country that nurses and other staff members have begun to see violence as "part of the job". The term violence encompasses a wide range of behaviours from physical assault or direct violence to non-physical forms of violence, such as verbal abuse or sexual harassment. While patients are usually the most common source of violence against nurses, other sources include friends and relatives accompanying patients. Earlier this year, a security guard at the Royal Prince Alfred Hospital attended a violent brawl between two women over who should be with their dying grandmother. The security guard and another staff member were badly assaulted and a female nurse had her hair pulled.
Why has there been an increase in violence?
With the increased use of drugs, particularly the ice epidemic, instances of violence in the ED have also been increasing. In 2004, statistics were published that up to 50% of violent episodes in Australian EDs were associated with alcohol or drugs. It was also noted that the timing of such violence is related to social patterns of substance use, with violence occurring more commonly during the evening shift and on weekends. Coupled with the fact that, at these times, the ED is generally functioning with minimal staffing resources, the ability of staff to deal with a violent incident is questionable.
The number of ice-related presentations to 59 public hospital emergency departments in NSW increased more than seven-fold between 2009 and 2014, according to a NSW Health background paper released in September 2015. In the first six months of 2015, there were 1,942 ice-related presentations—a 50% increase on the same period in 2014.
Nurses in EDs significantly under-report violent incidents. This is thought to be because of the high levels of violence in EDs sustained over a long period that has resulted in desensitisation on the part of many nurses, to the point where violence has become an accepted part of their job.
State Government approach
In January 2015, NSW Health published a Policy Directive called "Preventing and Managing Violence in the NSW Health Workplace – A Zero Tolerance Approach".
Compliance with the directive is mandatory for NSW Health and is a condition of subsidy for public health organisations.
NSW Health organisations must:
- Maintain a zero tolerance approach to violence as well as establish work systems and environments that enable, facilitate and support the zero tolerance approach.
- Have in place a violence prevention program that focuses on the elimination of violence related risks. Where the risks cannot be eliminated, they must be reduced to the lowest possible level using control strategies developed in consultation with staff.
- Ensure that managers and staff have the skills to respond promptly, consistently and appropriately to effectively manage incidents of violence if they do occur and, as far as possible, to prevent these incidents reoccurring.
- Report all incidents of violence locally using reporting mechanisms. All physical assaults and serious threats of assault against individuals must be reported to the police.
Implications for insurers
It is clear that a failure to address this disturbing trend will have far-reaching consequences for all parties involved in the broader health industry, including insurers of health care facilities and medical professionals.
While the legal precedent that a defendant should not be held liable for the violent, illegal activities of another party remains good law, the unique environment in which large health facilities operate means that the duty of care is capable of being broadened to require that appropriate measures be taken to mitigate the foreseeable risks of workplace violence.
We would like to acknowledge the contribution of Charlotte Alexander to this article.
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