The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department

Objectives: The emergency department (ED) has been recognized as a high-risk environment for workplace violence. Acutely agitated patients who perpetrate violence against healthcare workers represent a complex care challenge in the ED. Recommendations to improve safety are often based on expert opinion rather than empirical data. In this study we aim to describe the lived experience of staff members caring for this population to provide a broad perspective of ED patient violence. The findings of this study will contribute to the development of a comprehensive framework for ED agitated patient care that will guide safety interventions. Methods: We conducted uniprofessional focus groups and individual interviews using a phenomenologic approach with emergency medicine resident physicians, ED staff nurses, patient care technicians, and hospital police officers at an urban hospital in New York City. Audio recordings were transcribed and coded for thematic analysis using the constant comparison method. Results: We reached theoretical saturation with 31 interprofessional participants. Three broad themes emerged from our analysis: 1) ED healthcare workers provide high-quality care to a marginalized patient population that concurrently poses safety threats, creating a patient care paradox; 2) teamwork is critical to safely managing this population, but hierarchy and professional silos hinder coordinated care between healthcare professionals; and 3) environmental challenges and systems issues both in and outside the ED exacerbate threats to safety. Conclusion: The experience of ED staff members while caring for agitated patients is complex and multidimensional. We identified issues that coalesced into four tiers of healthcare delivery at the individual, team, environment, and system levels. Future research is needed to determine applicability of our findings across institutions to build a comprehensive framework for ED agitated patient care.