Emergency department nurse and researcher shares knowledge about how employers can retain nurses and keep them safe
By Jiun Zullo
June 28, 2023
You’ve researched how verbal abuse can affect emergency department nurses. What would you say were the most surprising findings? What advice would you give nurses who have experienced verbal abuse?
In 2020, I interviewed six nurses who had experienced verbal abuse while employed in the emergency department (read the study). As a result of verbal abuse from patients and/or visitors, these nurses identified that they experienced occupational disappointment. Occupational disappointment is the feeling of disheartenment in career choice. I also found something even more concerning when I did the study: not only did nurses experience occupational disappointment because of verbal abuse, they also did so in spite of it. What I mean by this is that, using a qualitative descriptive methodology to develop an understanding of this phenomenon, nurses identified that their occupational disappointment similarly resulted from lack of support from leadership to address verbal abuse, along with lapses in policies and procedures designed to mitigate violence and aggression.
Nurses weren’t burnt out, though many of the nurses interviewed were nearing their capacity for this. Nurses who experienced occupational disappointment were, however, genuinely considering alternate options for employment or leaving the profession altogether at the time of the study.
Nurses continue to experience verbal abuse daily, and often this is a precursor to physical violence — an unacceptable side effect to increasing wait times, inappropriate care settings or heightened emotions due to illness and pain in self or loved ones. Those in acute care hospital environments must be knowledgeable about institutional policies that direct their practice in response to verbal/physical abuse. If none exist, then they must ask leaders for guidance to manage these situations (see section 2.0, p. 10, in the Registered Nurses’ Association of Ontario’s Managing and Mitigating Conflict in Health-care Teams). Any opportunity for learning how to navigate these precarious situations should be taken.
When nurses experience any type of violence, reporting is fundamentally required. There can be no remedy to this without appropriate documentation of its occurrence. The documentation of the event collects data for establishing trends. Too often, front-line nurses normalize this type of behaviour in the workplace and fail to identify it as an outlier. Reporting is vital to addressing abuse of any sort in health-care settings.
The importance of identifying discussion on occupational disappointment is acutely reflected in the current state of nursing. The pandemic highlighted for many the importance of prioritizing personal health and satisfaction. In this context, and considering the nurses’ experience of occupational disappointment, it appears that nurses are choosing to leave settings that contribute to this sort of disheartenment. The disappointment in career choice is remedied by finding work elsewhere, in environments where they may be well supported in policy or remuneration or where they practise safely with adequate resources. These issues are clearly not well addressed currently in some acute care hospital settings, where nursing attrition is high.
How would you describe the emergency department nursing culture before the pandemic? How would you describe it now? Please provide examples to illustrate.
Nursing culture within the emergency department has always been challenging. To work in an emergency department is to commit to always anticipating the unknown. It is a chaotic and loud environment, where people from all walks of life enter in what can be their most vulnerable and greatest time of need. The sense of family and bonds between nursing shift partners caring for the sickest people, however, are strong. As an emergency nurse, being able to trust in your fellow nurse, your team, forges relationships that few experience professionally.
Pre-pandemic, the challenges that prevailed included staffing of skilled nurses, upskilling junior nurses to meet advanced requirements of caring for high-acuity patients, and meeting the care demands of patients in hectic environments. Violence, both verbal and physical, was often experienced; reducing the incidence of violence was a quality improvement target for nursing leadership. The emergency department pre-pandemic was already fraught with issues, making it an imperfect system. Nurses continued forward serving the community, trying each day to improve this department through membership in committees and implementation of process improvement plans.
As I examined the situation in the latter part of 2022, the health system is approaching its third year of the COVID-19 pandemic. The pandemic years have worsened a system already in distress. Post-pandemic, there are critical nursing shortages now being highlighted daily by media. There is acute unavailability of skilled nurses able to work. Numerous Ontario emergency department closures have occurred due to unprecedented low nursing numbers over the summer of 2022. Difficulty in maintaining adequate levels of safe staffing, recruitment and retention of skilled nurses who can safely manage patients of higher acuity is increasingly daunting. Anecdotally, many emergency nurses are at or are reaching a point of occupational disappointment and/or burnout as they are forced to simultaneously work multiple roles or provide care in unbearable patient assignments.
Colleagues in the emergency department who I have worked with have left for many reasons, including the allure of working in less stressful environments for comparable wages. They want to work in departments where patient safety is not jeopardized because of disproportionate nurse-patient ratios or where patient care is not aggravated by nurse attrition. This last point is important when considering the risk to staff when violence or aggression occurs. With inability to secure safe staffing numbers each shift, the effectiveness of the response of team members to violence and the efficiency of de-escalation is compromised, while the risk of negative outcomes for nurses is heightened.
These issues have contributed to the decimation of a previously robust nursing culture. Lack of staff, lack of being able to work as a team, increased volatility, increasing frequency of working alone — coupled with the loss of seasoned nurses and what seems to be a revolving door of nurses entering and quickly leaving the emergency department — has critically affected those who remain. Emergency nursing culture is influenced by nursing satisfaction in the workplace, and, unfortunately for many, there are more incentives to leave than to stay.
If you had a wish list of three things you could change in the profession to improve the culture, what would they be?
A first recommendation would be recognition of nurses as a vital part of health care, acknowledging their value in delivery of all health services and, in doing so, increasing their remunerations to be consistent with other public sector professions and consistent with cost-of-living increases. It has become evident that the nursing profession has become undervalued by those who hold the seat of power, in both health-care institutions and in government. Institutionally, nurses are the driving force in delivery of care, yet their skilled contribution is not reflected in wages. Despite the current climate of understaffing and increasing nurse-patient ratios, wages remain stagnant.
In Ontario, for example, legislated wage suppression (Bill 124) has limited salary increases to one per cent. The increased working demands and the volatility of environments nurses must work in are simply not reflected in their wages. Legislated wage increases are also well below current inflation and well below the salary increases afforded to other traditionally male-dominated professions, such as police or firefighters. It cannot be understated that right now, in this context of nursing shortages, a financial incentive must be added to entice nurses to work, specifically in critical areas, like emergency departments, where the doors simply do not close.
A second recommendation for improving nursing culture is to revert to a hands-on approach, where mock codes are performed and educators come out of their offices to deliver vital in-person teaching. Many emergency department nurses desire education that extends beyond now commonplace “email education,” whereby educators compile vast amounts of necessary education and deliver it in weekly updates. This transition from hands-on training to a decidedly less interactive, more figure-it-out-yourself model seems to contribute to a disconnected nursing culture where maintaining current education is not prioritized. Rather, organizations only seem to require the mere presence of a physical body willing to work. The skilled nurse is replaced by any nurse who is available.
In the current climate of understaffing coupled with the exodus of skilled nurses, the importance of in-person education is tremendous. Traditional education formats, such as in-services provided by product vendors, were limited prior to the pandemic and have now completely ceased, with no plans of restarting. Skills days also no longer exist as clinical educators become bound to increasing corporate portfolio demands, limiting their departmental availability to plan and execute this type of collaborative education. The skills of emergency nurses lie in gaining experience through demonstration and repetition. This simply cannot be achieved via email.
Finally, the acknowledgment of prevalent verbal and physical violence directed toward emergency department nurses must be prioritized. Leaders often thank nurses for their care via mass-delivered emails, yet their actions don’t match the messages they deliver. Verbal and physical violence is so prevalent, yet these critical incidents are rarely addressed. The impacts of these sorts of events are as powerful to nurses as the resuscitation of critically ill people; however, one event will likely be debriefed, while the other will not. Since nurses know that patients can present with alterations in mood or behaviour because of organic illness, the influence of drugs or alcohol or simply due to a situational crisis, it is reasonable to expect a more open and frank discussion about this sort of violence. More consistent dialogue inevitably creates solutions to mitigate these incidents or prevent them from occurring. A purposeful shift away from the normalizing of violence could demonstrate to remaining nursing resources in emergency departments that they are valued and that their safety is non-negotiable.
Registered Nurses’ Association of Ontario. (2012, September). Managing and mitigating conflict in health-care teams. Retrieved from https://rnao.ca/sites/rnao-ca/files/Managing-conflict-healthcare-teams_hwe_bpg.pdf
Zullo, J., Corcoran, L., & Cook, K. (2022). Occupational disappointment and emergency nurses: A qualitative descriptive study. Canadian Journal of Emergency Nursing, 45(2), 83–89. doi:10.29173/cjen166
Jiun Zullo, RN, is a career emergency department nurse at Lakeridge Health and a sessional instructor at the Trent/Fleming School of Nursing in Ontario.