Analysis of antecedents, critical attributes and consequences of violent incidents perpetrated against AMU and ED staff in large acute NHS trust: A retrospective case review (2019-2022).

Introduction
Violence perpetrated by patients and relatives against staff working in Acute Medicine Units (AMUs) and Emergency Departments (EDs) is escalating.1 Violent incidents impact staff physically and psychologically, cause disruption to patient care, and have significant cost implications.2 Despite the national data on violence incidence in EDs, very little has been published on the issue in AMU. We asked, what are the antecedents, critical attributes, and consequences of reported violent incidents in AMU and ED? Our objective was to analyse reported incidents using a systematic approach.
Methods
A retrospective case review of 1,500 incident reports (2019-2022) in ED and AMU at a large UK teaching trust. A four-stage process was employed: - (1) purposive data extraction and categorisation of antecedents, critical attributes, and consequences (2) first reiteration using literature review of same topic, (3) second reiteration using the research questions (4) integration of Transitions theory to facilitate development of abstracted concepts and generalisation. Research governance permission: Ref: GF0048.
Results
Eleven interrelated themes were developed from the incident review.
Discussion
Patient transition into AMU/ED often occurs at speed. ‘Being separated’ from relatives/carers was a trigger for anxiety, anger, verbal abuse and escalated to violence against attending staff. The waiting room is a ‘stage for performance’ where relatives are fundamental to involvement staff verbal abuse. Staff frequently call security teams to aid the management of patients with delirium and associated aggression. The pattern of responses from security ‘using physical blocking, restraint and containment’ reduces patient control but often escalates aggression. Staff attitude through purely transactional behaviours reportedly minimise staff distress yet increase defensive behaviour by patients.
Greater understanding of patient & relatives’ anxiety and, actively measures to reduce separation could reduce violent incidents in AMU and ED. Staff training regarding the management of patients with delirium could reduce need for a security response.
1. Ashton RA, Morris L, Smith I. A qualitative meta-synthesis of emergency department staff experiences of violence and aggression. International Emergency Nursing. 2018;39:13-19.
2. Senz A, Ilarda E, Klim S, Kelly A-M. Development, implementation and evaluation of a process to recognise and reduce aggression and violence in an Australian emergency department. Emergency Medicine Australasia. 2021;33(4):665-671.
3. Gale N, Heath G. et al. Using the Framework Method for the Analysis of Qualitative Data in Multidisciplinary Health Research. BMC Medical Research Methodology. 2013; 117.