key: cord-0757909-dmbptjrh
authors: McGuire, Sarayna S.; Gazley, Bou; Majerus, Angela C.; Mullan, Aidan F.; Clements, Casey M.
title: Impact of the COVID-19 pandemic on workplace violence at an academic emergency department
date: 2021-09-23
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2021.09.045
sha: c5c191f9a85136c81e3dadc1aed5acc5e87f869f
doc_id: 757909
cord_uid: dmbptjrh

STUDY OBJECTIVES: COVID-19 brought unique challenges; however, it remains unclear what effect the pandemic had on violence in healthcare. The objective of this study was to identify the impact of the pandemic on workplace violence at an academic emergency department (ED). METHODS: This mixed-methods study involved a prospective descriptive survey study and electronic medical record review. Within our hospital referral region (HRR), the first COVID-19 case was documented on 3/11/2020 and cases peaked in mid-November 2020. We compared the monthly HRR COVID-19 case rate per 100,000 people to the rate of violent incidents per 1000 ED visits. Multidisciplinary ED staff were surveyed both pre/early-pandemic (April 2020) and mid/late-pandemic (December 2020) regarding workplace violence experienced over the prior 6-months. The study was deemed exempt by the Mayo Clinic Institutional Review Board. RESULTS: There was a positive association between the monthly HRR COVID-19 case rate and rate of violent ED incidents (r = 0.24). Violent incidents increased overall during the pandemic (2.53 incidents per 1000 visits) compared to the 3 months prior (1.13 incidents per 1000 visits, p < .001), as well as compared to the previous year (1.24 incidents per 1000 patient visits, p < .001). Survey respondents indicated a higher incidence of assault during the pandemic, compared to before (p = .019). DISCUSSION: Incidents of workplace violence at our ED increased during the pandemic and there was a positive association of these incidents with the COVID-19 case rate. Our findings indicate health systems should prioritize employee safety during future pandemics.

Violence in the emergency department (ED) is a common and longstanding threat to staff [1] [2] .

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic with coronavirus disease 2019 (COVID-19) resulted in unprecedented isolation and stress to individuals and brought unique challenges to healthcare institutions and employees. The impact of the pandemic on mental health and home life has been previously documented [3] [4] [5] [6] ; however, it remains unclear what effect the pandemic had on violence in healthcare. The objective of this study was to identify the impact of the pandemic on workplace violence at our academic emergency department in the Midwestern United States.

J o u r n a l P r e -p r o o f Journal Pre-proof Pandemic and Workplace Violence

This mixed-methods study involved a prospective descriptive survey study and electronic medical record (EMR) review. The study took place within the ED of a large, academic, Level 1 trauma center in a small urban city in the Midwest. The ED has 24/7 security presence available and had an average patient volume of 78,000 annually prior to COVID-19, with 65,500 patients seen in 2020. The hospital referral region (HRR) refers to the catchment area of patients referred to our institution. Within our HRR, the first COVID-19 case was documented on 3/11/2020 (n = 1) and the peak of documented cases occurred in mid-November 2020 with an average of 109.9 new positive COVID-19 cases per day (range: 0 -498). The average monthly HRR COVID-19 case rate per 100,000 people was obtained from 3/11/2020 through 12/31/2020. Monthly incidents of ED violence were obtained from the institution"s Office of Security from January 2019 to December 2020 and included both physical assault and verbal threats where security officers were notified to respond. These incidents were combined with monthly reports of violent events from the electronic medical record during the same time period. Overlapping data from both sources were counted only once. Monthly ED patient volume was obtained to calculate a rate of violent incidents per 1,000 ED visits.

We compared anonymous responses from a prior survey that was sent to all multidisciplinary ED staff pre/early-pandemic (April 2020) as previously described in McGuire et al. [7] to responses J o u r n a l P r e -p r o o f Journal Pre-proof Pandemic and Workplace Violence received from a similar second survey mid/late-pandemic (December 2020). Both questionnaires surveyed respondents regarding the incidence of verbal abuse and physical assault experienced over the prior 6-months (November 2019-April 2020 and July 2020-December 2020) and perception of safety in the workplace.

The survey study target population consisted of all multidisciplinary staff that work within the ED, including non-ED staff assigned to other departments that perform services for ED patients. 

The initial pre/early-pandemic survey was developed in REDCap and the mid/late-pandemic survey was developed in Qualtrics. Both surveys were anonymous and included single-choice, multiple-choice and Likert-scale response questions. Participants were asked to indicate whether they had experienced any of the following forms of verbal abuse in the prior 6 months while working in the ED: threatening tone of voice; abusive language/statement; harassment (eg, racial, gender, sexual); or personal verbal threats (eg, threat of physical or sexual violence, threat of physical assault to occur outside the workplace). Participants were asked to indicate whether they had experienced any of the following forms of physical assault in the prior six months while working in the ED: physical assault with weapons (including hospital equipment); physical assault with bodily fluids (eg, saliva, urine, feces, wound exudate, blood, or spit); or physical assault in the form of punching, biting, rough handling, scratching, kicking, shoving/pushing, or hitting. Likert scales were used to measure participants" perception of safety and estimated frequency of verbal abuse. Standard demographic measures were collected.

The primary outcome was the correlation between the monthly HRR COVID-19 case rate per COVID-19 Pandemic and Workplace Violence Our survey respondents indicated an increase in incidents of physical assault; specifically, assault with bodily fluids. This may be explained by generalized perception during the pandemic that spitting and coughing directly on others served to cause them significant harm [13] . Violent patients may have used this method of assault to their advantage and ED staff may have perceived this behavior to be more threatening during COVID-19. We found no significant difference in survey respondents" workplace violence reporting behaviors during the pandemic; however, due to protection of employee anonymity, this was not corroborated with actual employee incident reports.

This study has several important limitations. To preserve anonymity of employees, the surveys were sent to email distribution lists (DL) and included some DLs with employees working in other departments other than the ED (eg, phlebotomy, and ECG and radiology technicians), or who also worked at additional sites elsewhere in our health system (eg, clinicians). Thus, it is not possible to know the actual number of employees from different disciplines who work in the ED to obtain an exact response rate for our survey. Our estimated response rate of 23-27% may represent an unintended selection bias with individuals who have experienced workplace violence being more likely to respond regarding their experience. Additionally, to further preserve anonymity, we did not ask in-depth demographic questions. Without knowing full-time vs part-time status of respondents, it is possible that some responses came from employees working part time and this may have skewed our incidence of violence. The definition of "verbal abuse" is highly subjective to individual respondents and survey inclusion of "threatening tone of voice"" may have contributed to over-reporting of verbal abuse in general by respondents. The study was also subject to recall and reporting bias in terms of violence experienced over a six-J o u r n a l P r e -p r o o f Journal Pre-proof Pandemic and Workplace Violence month time period, as well as the reporting of incidents. Recall bias may have been even more significant during the pandemic. Likewise, reporting bias is possible if staff were more likely to report during the pandemic or during periods of increased COVID-19 patient volume than they were prior to the pandemic. We acknowledge that because this was a single-center study some aspects may not be generalizable to all institutions or geographic regions. However, the finding of an increased incidence of workplace violence during the COVID-19 pandemic is important and not likely related to local factors.

Our findings indicate that health systems should additionally prioritize employee safety during future pandemics.

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