Workplace Violence in Emergency Department and its Effects on Emergency Staff

Workplace violence (WPV) is a growing problem for healthcare providers, particularly for those in the Emergency department (ED), with its increasing frequency and severity. Characteristics of WPV are similar in different parts of the World with different sociocultural and economic status. As this problem remains unsolved, its unwanted effects on mental and physical health of staff become more problematic. The most common psychological affectsare reduced job satisfaction and fear. When the reasons of WPV are investigated; lack of preventive policies, educational inadequacy, unwillingness to report assaults as a result of a consideration of violence as a routine by the staff and unmet expectations of patients and their family may be listed. In the short term, increasing the number of security personnel, flagging the names of the patients with a potential of aggression in the computer system and reducing length of stay in the ED are measures to implement immediately. In the long term, governments must focus on this subject and develop necessary policies including educational programmes in order to reduce WPV, before it is too late for another ED worker.


INTRODUCTION
Emergency departments (EDs) are known to have the highest rate of violence in the hospitals (Stultz, 1996-97). Workplace violence (WPV) affects nurses, physicians and workers almost equally (Kowalenko, Hauff, Morden et al., 2012). The definition of WPV is "Incidents in which an employee is abused, sexually harassed or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health" (Norwegian Labour Inspection Authority, 2009).
Unfortunately the frequency and severity of violence tend to increase over time (Fernandes, Bouthillette, Raboud et al., 1999). Aggressions may be divided into verbal and physical. Verbal aggression is defined as a non-physical type of aggression as any annoying and unpleasent act that creates a vicious work environment. Physical aggression is forceful, hostile or aggressive behavior which may or may not cause harm (Magnavita & Heponiemi, 2012). It was reported that fewer than half of the ED workers reported posttraumatic stress symptomatology. Workplace aggression affects mental health of the workers (Gillespie, Bresler, Gates et al., 2013).
In this review, our aim was to investigate reasons, characteristics and prevention methods of WPV in the light of current literature data involving different places in the World. We also aimed to make our suggestions to reduce WPV and contribute to the literature.

MATERIALS AND METHODS
We reviewed the medical literature to quantify the international widespread of aggressions towards staff working in EDs and identify the consequences on healthcare providers. The search included articles related to violence in the ED and was limited to studies in the English language.
Original papers were searched using Medline, Pubmed, and Medscape data. The search was formulated by entering the words "workplace violence" and "emergency department" into the databases as keywords. Particularly, studies within the last 10 years were included into the study.

Literature Data
Workplace violence is a challenging issue particularly in EDs with its multiple affects. Psychological affects of this unwanted situation may arise as bothersome memories, super-alertness and feelings of avoidance and futility (Zafar, Siddiqui, Ejaz et al., 2013). It is also known that WPV causes serious personal and professional sequalae (Bigham, Jensen, Tavares et al., 2014). After a survey study in England, it was determined that most of the respondents experienced impaired job performance up-to 1 week after the incident. Of the respondents, 73% expressed that they were afraid of the patients as a result of violence, 49% hid their identities from the patients and 74% had reduced job satisfaction. In the same study, it was reported that after violent events, victims preferred to get support from their colleagues rather than officials (Fernandes, Bouthillette, Raboud et al., 1999). In a study in the United States (US) including 69 EDs, it was reported that up-to one-fourth of staff felt unsafe in the ED. It was reported that violence and weapons were common in the EDs and attacks towards staff occured frequently. Among the staff, nurses were less likely to feel safe in the workplace when compared to other ED workers (Kansagra, Rao, Sullivan et al., 2008). Another study revealed that statistically significanct differences were not present between nurses, physicians and workers with regard to severity scores of sexual or physical violence (Kowalenko, Hauff, Morden et al., 2012). In the US, in a six year period, 1.7 million episodes of workplace-related violence were reported and healthcare providers constituted 12% of the total (Duhart, 1993-99). In Canada, most paramedics experience violence in the form of verbal abuse (Bigham, Jensen, Tavares et al., 2014). In Australia, it has been reported that violent and aggressive behavior towards healthcare providers widely occured (Stanley & Goddard, 2002). Similar to the results in Canada, a study revealed that paramedics who are an important part of emergency settings in Australia, commonly experienced WPV, predominantly in the form of verbal abuse.In this study, it was also reported that, besides WPV, significant number of paramedics complained about sexual harassement by work colleagues (Boyle, Koritsas, Coles et al., 2007).  (Gillespie, Gates & Berry, 2013). Besides, a better triage system and maintaining a shorter turnaround time at EDs could be useful to reduce the frequency of aggression (Alameddine, Kazzi, El-Jardali et al., 2011). As Canbaz et al. Proposed, promoting awareness of the risks and destructive impact of WPV, providing adequate reporting systems, encouraging healthcare providers to report minor violenceand providing psychological support to workers exposed to violence, are the necessary steps to take (Canbaz, Dündar, Dabak et al., 2008). Educational programmes should be encouraged to reduce WPV (Gillespie, Gates & Mentzel, 2012). We, as authors of this article, propose making strict laws for assailants in the ED. Regardless of cultural differences, universal guidelines to prevent WPV are needed. International organizations must focus on this subject that has personal and social bad outcomes.

CONCLUSION
Problems related to WPV in the ED are similar in different parts of the World. So, universal measures must be taken in order to prevent staff from assaults and assailants. When literature is investigated, it is observed that verbal attacks are the most common type of assaults. Emergency department staff must be encouraged to report every incident regardless of its magnitude. Assaults in the ED should not be considered a part of their job by ED staff. It has undesired psychological affects such as post-traumatic stress disorder, reduced satisfaction, bothersome memories, super-alertness and feelings of avoiding and futility.
In another study investigating WPV in Australia, EDs and military settings were found to be the leading places where psychological support was needed (McFarlane & Bryant, 2007). In Italy, it was reported that WPV was a hidden fact and there was a lack of policies for prevention. It was also found that employees who experienced verbal violence had lower levels of perceived organizational justice and social support. They also had higher levels of stress related to work and psychological problem scores. Even though the reasons of aggression seem to occur as a result of patient interactions and issues arising from the patient care, unfortunately, significant proportion of violence was found to be perperated by other healh care workers (Magnavita & Heponiemi, 2012). A study from Pakistan revealed that the most common type attack in the EDs in this country was also verbal abuse. A different result of this study was that 26.9% of these incidents involved a weapon (Zafar, Siddiqui, Ejaz et al., 2013 ).
In a survey study in Norway, it was reported that some EDs have applied many preventive measures regarding workplace safety. However, it was also reported that the difference these measures make to the number of violent incidents was not exactly known (Morken & Johansen, 2013). In Brazil, it was reported that 100% of nurses, 88.9% of nurse assistants and 85.7% of doctors have been victims of violence. However, the workers stated that these assaults were not documented (Cezar & Marziale, 2006). In Thailand, a study among nurses including a survey and an interview was conducted. It was found that nurses reported lack of institutional support and feeling of insecurity in the workplace. Also, low job satisfaction was reported (Kamchuchat, Chongsuvivatwong, Oncheunjit et al., 2008). In the literature, nurses are more frequently exposed to violence. A study in Turkey reported different results. According to this study with a total of 109 staff, it was determined that the group most commonly exposed to aggression were emergency physicians. According to the authors, the emergency physician is always held responsible for every issue by the assailants and therefore becomes the first target of violence (Gülalp, Karcioğlu, Köseoğlu et al., 2009). In another study in by Canbaz et al., prevalence of violence towards workers in the EDs and its psychological outcomes in Turkey wereinvestigated via State-trait anxiety inventory (STAI). It was determined that the verbal abuse was highly frequent and workers perceived the violence as a part of their job. After STAI, it was found that violence had a negative influence on participants' conditions (Canbaz, Dündar, Dabak et al., 2008). In a study in Lebanon, reasons for violence were reported to be unmet expectations by patients or their family members and friends (Alameddine, Kazzi, El-Jardali et al., 2011). Finally in Jordan, of a total of 227 participants, 75.8% was exposed to at least one type of violence, predominantly verbal assault (ALBashtawy, 2013).

Prevention
In a study involving surgical residents, of 334 attacks, the highest number events (173) were reported to occur in the Emergency room. Emergency departments are most problematic settings in where assault is experienced (Barlow & Rizzo, 1997). Workplace violence is also occuring pediatric in EDs. In a study, increased security staff and local police have been determined to make healthcare providers feel more safe (Shaw, 2014). Early interventions to agitated patients and their family members may be useful for preventing violence. Besides, education of staff and flagging the patients with a history of assault in a hospital's computer system are recommended (Gillespie, Gordon, Wilkerson et al., 2013). In a study, it was proposed that efforts to prevent violence and promote workplace safety should focus on work designs allowing for the quick egress of employees away from violent patients and visitors. It was also reported that policies aimed to prevent WPV and maintain positive working relationships with security officers had to be enforced