The Emergency Department Hires Security Before It Hires Nurses

Healthcare workers are assaulted at work more often than employees in almost any other civilian occupation, and the number reported is understood by everyone in the field to be a fraction of the number occurring. Nurses describe being hit, grabbed and threatened as a feature of the job rather than an event, which is why so little of it reaches an incident form.

What has changed is not the phenomenon but the accounting. Security is now a standing line in hospital operating budgets rather than a facilities afterthought — badge readers, controlled entry, cameras, weapons screening at emergency entrances, and officers stationed where staff can reach them.

The spending competes with the thing that would reduce the risk

Here is the uncomfortable structure. Most escalation happens during waits, and waits are a function of staffing. A patient in pain for six hours in a corridor is the condition under which incidents occur, and the intervention that most reduces incidents is enough clinical staff to shorten the wait.

Security spending and staffing spending come from the same operating budget. So a department under pressure buys the thing that manages the consequence rather than the thing that reduces the cause, because the consequence is immediate and the cause is expensive — and every dollar spent on containment is unavailable for the staffing that would have prevented it.

The workforce effect compounds it. Assault is a substantial reason experienced nurses leave bedside practice, and each departure lengthens waits for whoever remains — which is how travel nursing stopped being temporary, with contract staff filling posts that permanent staff left partly because of conditions the contract model does nothing to improve.

Emergency departments absorb the largest share for a reason that has nothing to do with emergency medicine. They are the only part of the health system that cannot turn anyone away, so they receive the psychiatric crises, the intoxications and the untreated conditions the rest of the system has no capacity for. A department functioning as the default point of contact for several failing systems is going to see the behaviour those systems produce.

Legislative responses have mostly taken the form of enhanced penalties for assaulting healthcare workers, which are straightforward to pass and difficult to connect to any change in incidence. What appears to work is duller: visible staffing, shorter waits, de-escalation training that is actually resourced, and reporting that does not punish the person filing it.

Topics healthhospitalsworkforce