Workplace Violence and Patient Management Time in the Emergency Department: An Observational Study

Chiara Di Giorgio; Isabella Cucchi; Marco Mendola; Maria Cristina Costa; Fabio Tonelli; Elisa Turchet; Matteo Marrazzo; Paolo Carrer

doi:10.23749/mdl.v116i5.17113

Authors

Chiara Di Giorgio Occupational Health Unit, Fatebenefratelli Sacco University Hospital, Milan, Italy
Isabella Cucchi Occupational Health Unit, Fatebenefratelli Sacco University Hospital, Milan, Italy
Marco Mendola Occupational Health Unit, Fatebenefratelli Sacco University Hospital, Milan, Italy
Maria Cristina Costa Occupational Health Unit, Fatebenefratelli Sacco University Hospital, Milan, Italy
Fabio Tonelli Occupational Health Unit, Fatebenefratelli Sacco University Hospital, Milan, Italy
Elisa Turchet Quality, Risk Management and Accreditation Unit – Fatebenefratelli Sacco University Hospital, Milan, Italy
Matteo Marrazzo Quality, Risk Management and Accreditation Unit – Fatebenefratelli Sacco University Hospital, Milan, Italy
Paolo Carrer Occupational Health Unit, Fatebenefratelli Sacco University Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy

Keywords:

Healthcare Workers, physical violence, verbal violence, workplace aggression, emergency care unit

Abstract

Background: Workplace violence is steadily rising, and the healthcare sector is one of the most impacted areas. Several studies have shown that patients’ long management times are a key factor in workplace violence in this setting. Objective: This study aims to analyze the prevalence and characteristics of aggressions against healthcare workers (HCWs) that occurred in 2023 in the Emergency Rooms (ER) of a large university hospital and to evaluate the potential relationship between the management time of a patient in the ER and the risk of violence incidents.Methods: To evaluate the prevalence and characteristics of aggressive events against HCWs that occurred in 2023, data from the “incident reporting” form were analyzed. Then, using the 2023 report on daily ER accesses, the management time of a patient at the ER was calculated. Finally, the average management times of patients on days when there were no aggressions were compared with those on days when there was one or more assaults against HCWs to evaluate the potential relationship between the average length of stay of a patient at the ER and the risk of aggression. Results: In 2023, 271 violent incidents were reported. Verbal aggressiveness was the most common (82.7%), and working the night shift was riskier (42.8%). In 36.2% of cases, patient management time was identified as a potential predictor of aggression. Other identified potential predictors included the patient and/or caregiver relationship with HCW (30.6%), the refusal to accept diagnostic-therapeutic protocols (27.3%), and the cultural background and temperamental traits of the patient or caregiver (18.8% and 11.8%, respectively). According to the logistic regression analysis, the likelihood of a violent incident during a 150-minute stay was less than 10%; it increased to 53% after 650 minutes. Conclusion: Workplace violence in healthcare settings results from a complex interaction of internal and external factors. Understanding how these elements interact and contribute to the development of incidents is essential for identifying key actions to reduce and mitigate violence.

References

1. Pascucci, P. (2022). Le aggressioni al personale sanitario come rischio lavorativo. Diritto della sicurezza sul lavoro, (1), 49-65.

2. Mamo C, Penasso M, & Quarta D. (2020). Infortuni lavorativi da aggressioni nel personale sanitario: dimensioni e trend del problema. Bollettino epidemiologico nazionale.

3. United States. Occupational Safety, & Health Administration. (1996). Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. US Department of Labor, Occupational Safety and Health Administration.

4. Piquero NL, Piquero AR, Craig JM, Clipper SJ. Assessing research on workplace violence, 2000-2012. Aggression and violent behavior 2013;18(3):383-394.

5. Spelten E, van Vuuren J, O'Meara P, et al. Workplace violence against emergency health care workers: What Strategies do Workers use? BMC Emerg. Med. 2022:22(1):78.

6. Nowrouzi-Kia B, Chai E, Usuba K, et al. Prevalence of type II and type III workplace violence Int J Occup Med Environ Health. 2019;10(3):99.

7. Vento S, Cainelli F, Vallone A. Violence against healthcare workers: a worldwide phenomenon with serious consequences. Front Public Health. 2020;8:570459.

8. Phillips J P. Workplace violence against health care workers in the United States. N Eng J Med. 2016;374(17):1661-1669.

9. McGuire SS, Finley JL, Gazley BF, Mullan AF, Clements CM. The Team Is Not Okay: Violence in Emergency Departments Across Disciplines in a Health System. West J Emerg Med. 2023;24(2):169-177. Published 2023 Feb 1. doi:10.5811/westjem.2022.9.57497

10. Spelten E, Thomas B, O’Meara, P F., et al. Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates. Cochrane Database of Systematic Reviews. 2020;4.

11. Civilotti C, Berlanda S, Iozzino L. Hospital-based healthcare workers victims of workplace violence in Italy: a scoping review. Int J Environ Res Public Health. 2021;18(11):5860.

12. Lim MC, Feffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: The risck factors, implications and collaborative preventive measures. Ann Med Surg. 2022;78:103727.

13. Aljohani B, Burkholder J, Tran QK, Chen C, Beisenova K, Pourmand A. Workplace violence in the emergency department: a systematic review and meta-analysis. Public Health. 2021:196;186-197.

14. Brioschi M, Cassioli S, Alberti A, et al. Aggressioni e atti violenti nei confronti degli infermieri di pronto soccorso: studio osservazionale. IJN. 2021;36.

15. Italian Ministry of Health. (2007). Department of Quality. General Directorate of Healthcare Planning, Levels of Care, and System Ethical Principles. Office III. “Patient Safety and Clinical Risk Management: A Manual for Training Healthcare Professionals”. Roma. Available at: https://www.omceo.me.it/news/files/585 /manuale_sicure.pdf (Last accessed: Jul 2025)

16. Agenas (2023) Terza indagine Nazionale sullo stato di salute attuale delle Reti Tempo Dipendenti. Available at: https://www.agenas.gov.it/images/2024/primo-piano/25marzo/3_indagine_nazionale_reti_TD_25-03-24.pdf (Last accessed: April 2025)

17. Rossi MF, Beccia F, Cittadini F, et al. Workplace violence against healthcare workers: an umbrella review of systematic reviews and meta-analyses. Public health. 2023;221:50-59.

18. International Labour Organization (ILO) Violence and Harassment Convention, 2019 (No. 190). Available at: https://www.ilo.org/sites/default/files/wcmsp5/groups/public/@europe/@ro-geneva/@ilo-rome/documents/normativeinstrument/wcms_713379.pdf (Last accessed:April 2025)

19. Gillespie Gl, Gates DM, Miller M, Howard PK. Workplace violence in healthcare settings: risk factors and protective strategies. Rehabil Nurs. 2010;35(5):177-184.

20. d’Ettorre G, Pellicani V, Vullo A. Workplace violence against healthcare workers in Emergency Departments. A case-control study. Acta Biomed. 2019;90(4):621.

21. Guglielmetti C, Gilardi S, Licata M, De Luca G. The healthcare operators’ experience with aggressive patients and their visitors: a cross-sectional study in four clinical departments. Med Lav. 2016;107(3):223-234.

22. Ajumea MEPE, Veyrier CA, Cabrolier LC, et al. Workplace violence against female healthcare workers: a systematic review and meta-analysis. BMJ.2024;14(8):e079396.

23. Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Workplace violence in different settings and among various health professionals in an Italian general hospital: a cross-sectional study. Psychol Res Behav Manag. 2016;Sep23(9);263-275.

24. O’Brien CG, van Zundert AA, Barach PR. The growing burden of workplace violence against healthcare workers: trends in prevalence, risk factors, consequences, and prevention – a narrative review. EClinicalMedicine. 2024May27(72):102641.

25. Italian Government, (2008). Legislative Decree 81/2008: Consolidated law on health and safety at work.

Available at: https://www.ispettorato.gov.it/files/2025/01/TU-81-08-Ed.-Gennaio-2025-1.pdf (Last Access: jul 2025)