Violence In Emergency Department Research Articles

Workplace violence against nurses in the emergency departments of three hospitals in Riyadh, Saudi Arabia: A cross-sectional survey

BackgroundEmergency department nurses are continuously exposed to violence on the job. ObjectivesThis study sought to identify the prevalence and pattern of workplace violence and the consequences of violence on nurses working in emergency departments in Riyadh. DesignCross-sectional survey conducted from April to May 2015. SettingEmergency departments of three hospitals in Riyadh. ParticipantsNurses participated voluntarily and anonymously. MethodsNurses were recruited by advertisement. A self-administered questionnaire with 23 items was given to participants by a head nurse. Violent acts were classified as physical or nonphysical. Descriptive statistics are presented and statistical comparisons were made to evaluate differences by gender, nationality, age, experience and other demographic variables. ResultsOf 150 questionnaires distributed, 121 were returned (80.6%). One hundred were females (82.6%) and 71 (58.7%) had worked in nursing for less than or equal to 5 years. Most participants (n=108, 89.3%) had experienced a violent incident in the past 12 months. Eighty (80/108, 74.1%) of those who had experienced violence had experienced verbal abuse and 20 (20/108, 18.5%) had faced verbal and physical violence during the past year. The type of violence was associated with gender and educational level. Patients (89/108, 82.4%) and their relatives (70/108, 64.8%) were the most common instigators of violence. Most nurses (78/108, 72.3%) expressed dissatisfaction with the manner in which incidents were handled. ConclusionWorkplace violence was pervasive in the emergency departments of these three hospitals in Riyadh. The data are consistent with other reports of workplace violence in emergency departments in Saudi Arabia and in other countries. RecommendationsSuitable strategies to deal with the issue include establishing workplace violence management teams and creating appropriate rules and regulations that can improve workplace safety for nurses, while improving patient care quality. Security systems and formulation of violence prevention policies and procedures are mandatory measures in emergency departments. In addition, training programs are needed to help support, teach and provide nurses with the knowledge and skills needed to manage violent situations in the workplace.

Development of an Emergency Department Violence Intervention Program for Youth: An Integrated Knowledge Translation Approach.

Violent interpersonal injury is a common presentation to emergency departments (EDs) and is increasingly being treated as a preventable condition. Given the complexity of the issue, it is key to ensure interventions are feasible and acceptable within the communities that are affected by violence. Our team consists of ED staff, community members who work with youth affected by violence, people who were affected by violence in their youth, and researchers. We describe how an integrated knowledge translation (KT) process was used to develop an ED violence intervention program (EDVIP) for youth affected by violence. We used the Canadian Institutes of Health Research Guidelines for integrated KT (iKT) to develop an EDVIP. Specifically, we report the Knowledge to Action process which involves both knowledge creation and an action cycle. Our team determined the research question, the research approach, assessed feasibility and determined outcomes for our study. Using the iKT approach facilitated initiation of a funded trial that is now active. This paper highlights the benefit of including community experts at the beginning of and throughout the research process.

At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses

Violence is widespread in Australian emergency departments (ED) and most prevalent at triage. The aim of the present study was to identify the causes and common acts of violence in the ED perceived by three distinct groups of nurses. The Delphi technique is a method for consensus-building. In the present study a three-phase Delphi technique was used to identify and compare what nurse unit managers, triage and non-triage nurses believe is the prevalence and nature of violence and aggression in the ED. Long waiting times, drugs and alcohol all contributed to ED violence. Triage nurses also indicated that ED staff, including security staff and the triage nurses themselves, can contribute to violence. Improved communication at triage and support from management to follow up episodes of violence were suggested as strategies to reduce violence in the ED CONCLUSION :There is no single solution for the management of ED violence. Needs and strategies vary because people in the waiting room have differing needs to those inside the ED. Participants agreed that the introduction and enforcement of a zero tolerance policy, including support from managers to follow up reports of violence, would reduce violence and improve safety for staff. Education of the public regarding ED processes, and the ED staff in relation to patient needs, may contribute to reducing ED violence. What is known about the topic? Violence is prevalent in Australian healthcare, and particularly in emergency departments (ED). Several organisations and government bodies have made recommendations aimed at reducing the prevalence of violence in healthcare but, to date, these have not been implemented consistently, and violence continues. What does this paper add? This study examined ED violence from the perspective of triage nurses, nurse unit managers and non-triage nurses, and revealed that violence is experienced differently by emergency nurses, depending on their area of work. Triage nurses have identified that they themselves contribute to violence in the ED by their style of communication. Nurse unit managers and non-triage nurses perceive that violence is the result of drugs and alcohol, as well as long waiting times. What are the implications for practitioners? Strategies to reduce violence must address the needs of patients and staff both within the ED and in the waiting room. Such strategies should be multifaceted and include education of ED consumers and staff, as well as support from management to respond to reports of violence.

Workplace violence in emergency department and its effects on emergency staff.

Workplace violence (WPV) is a growing problem for healthcare providers, particularly for those in the Emergency department (ED), with its increasing frequency and severity. Characteristics of WPV are similar in different parts of the World with different sociocultural and economic status. As this problem remains unsolved, its unwanted effects on mental and physical health of staff become more problematic. The most common psychological affects are reduced job satisfaction and fear. When the reasons of WPV are investigated; lack of preventive policies, educational inadequacy, unwillingness to report assaults as a result of a consideration of violence as a routine by the staff and unmet expectations of patients and their family may be listed. In the short-term, increasing the number of security personnel, flagging the names of the patients with a potential of aggression in the computer system and reducing length of stay in the ED are measures to implement immediately. In the long-term, governments must focus on this subject and develop necessary policies including educational programmes in order to reduce WP, before it is too late for another ED worker.

Addressing health workers’ exposure to violence at Lebanese emergency departments: What do the stakeholders think?

Healthcare settings are notorious for exposing their employees to high levels of verbal and physical violence. A recent study on occupational violence at Lebanese Emergency Departments (EDs) revealed that 70% of surveyed ED workers were exposed to at least one incidence of violence over the last twelve months. Acting on the findings of this study a multi-stakeholder policy forum was held with key ED stakeholders to discuss possible policy and practice changes to reduce health workers’ exposure to occupational violence. Stakeholder deliberations revealed that the root causes of violence in EDs could be classified under three main categories relating to the administration of EDs including the presence of antiviolence policies, the management of human resources, and balancing patient expectations. Stakeholders built a consensus on a number of remedial actions at the societal, health care facility and policy levels. Engaging with various stakeholders in an open forum was a unique initiative that contributed to building a consensus among key stakeholders on a road map to help protect health workers in EDs and beyond.

The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: A multi-site evaluation

BackgroundPatient aggression is a common source of occupational violence in emergency departments. Staff attitudes regarding the causes for aggression influence the way they manage it. The Management of Clinical Aggression – Rapid Emergency Department Intervention is a 45min educational program that aims to promote the use of de-escalation techniques and effective communication skills to prevent patient aggression. ObjectiveWe sought to evaluate the impact of the program on staff attitudes regarding the prevention and early management of patient aggression. DesignA mixed methods approach was used including a pre-test post-test survey of training participants and individual interviews with key stakeholders. Setting and sampleThe setting was public sector hospital emergency departments located in metropolitan and regional Victoria, Australia. A convenience sample of eighteen emergency departments was recruited via the Victorian Department of Health. ParticipantsSurvey participants were nurses and midwives who were employed at the study sites. Interview participants were a purposive sample of nurse unit managers and trainers. MethodsThe Management of Aggression and Violence Attitude Scale was administered to training participants immediately before and 6–8 weeks after training. Semi-structured telephone interviews with trainers and managers occurred 8–10 weeks after the intervention. ResultsFour hundred and seventy one participants completed the pre-test and post-test. Statistically significant shifts were observed in 5/23 items (Wilcoxon Signed Ranks Test: p≤0.01). Despite training, participants were undecided if it was possible to prevent patient aggression, and continued to be unsure about the use of physical restraint. Twenty-eight (82.3%) of managers’ and trainers’ eligible to be interviewed provided their perceptions of the impact of the program. Overall, these perceptions were consistent with the significant shifts observed in the survey items. ConclusionThere was limited evidence to demonstrate that the program significantly modified staff attitudes towards the prevention of patient aggression using the Management of Aggression and Violence Attitude Scale. Additional survey items that specifically measure staff attitudes about the use of restraint in emergency settings are needed to better understand decision making about restraining practices. Further work is indicated to quantify the impact of training in practice.

Violence and Abuse Faced by Junior Physicians in the Emergency Department from Patients and Their Caretakers: A Nationwide Study from Pakistan

BackgroundAcross the globe, physicians in the emergency department (ED) are subject to violence by patients and visitors. This has been shown to have negative effects on patient care and physician performance. Study ObjectivesThis study was conducted to determine the magnitude of the problem in a developing country, to examine the effects of ED violence on physician satisfaction and performance, and to identify underlying etiologies and potential solutions. Methods and SettingThis nationwide cross-sectional study examined physicians-in-training (n = 675) in the EDs of nine major tertiary care hospitals in Pakistan. ResultsThe study reveals a significant problem, with 76.9% of physicians facing verbal (65.0%) or physical (11.9%) abuse from patients or their caretakers in the previous 2 months. Male physicians were more likely than female physicians to be victims of such episodes (p < 0.05), as were physicians who had spent more than 60 h in the ED in the past 2 months (p < 0.0001). Reduced job satisfaction and a decline in the quality of job performance were reported by 40.7% and 44.3% of physicians, respectively. Junior trainee physicians were more likely to report impairment in job performance when compared to their senior colleagues (p = 0.014). Patients’ lack of education, overcrowding in the ED, and lack of coverage by security staff were identified as the major areas that need attention to address the problem. ConclusionThis study provides further evidence of the global prevalence of the problem, with the first nationwide epidemiological study performed in a developing country.

AMA Recommends Strategies to Reduce Violence in ED

Back to table of contents Previous article Next article Professional NewsFull AccessAMA Recommends Strategies to Reduce Violence in EDMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Dec 2010https://doi.org/10.1176/pn.45.24.psychnews_45_24_011AbstractA resource document outlining essential services necessary to address emergency department violence was approved at last month's meeting of the AMA House of Delegates.The document, in the form of a report by the AMA's Council on Science and Public Health (CSAPH), is designed to assist in the implementation of procedures to protect physicians and other staff in emergency departments (EDs) and to assure optimal care for patients, including those with psychiatric or behavioral conditions. The AMA will make it available to hospitals, emergency medicine departments, physicians, mental health clinicians, patient advocates, and law-enforcement organizations.Child psychiatrist Louis Kraus, M.D., vice chair of the Section Council on Psychiatry and a member of the CSAPH who helped write the report, told Psychiatric News that care and management of patients with psychiatric illness is a critical focus of the document. “The report emphasizes—and a number of people testified in hearings on the document—that psychiatric patients who are appropriately medicated are no more likely to be violent than the general population,” Kraus said.Louis Kraus, M.D., a member of the Section Council on Psychiatry and the AMA Council on Science and Public Health, testifies at last month's meeting of the AMA House of Delegates in San Diego.Credit: Mark MoranThe report notes that hospital EDs are treating an increasing number of patients with mental and substance use disorders because of the decline in availability of federal-, state-, and community-funded services.The report also draws attention to APA's Practice Guideline for the Psychiatric Evaluation of Adults, which describes specific approaches for the emergency evaluation of psychiatric patients. The AMA report also notes that a monograph available on the APA Web site titled Safe MD discusses practical applications and approaches to safe practices including those recommended for managing aggressive patients.“Several patient characteristics that may increase the risk of aggression are noted, as are several tips for working safely with potentially dangerous patients,” according to the CSAPH report. “Use of a predetermined emergency department triage system or scale to ensure timely and appropriate treatment of patients who are very distressed, acutely psychotic, violent, or aggressive can be helpful. Where possible, EDs should have dedicated treatment rooms for psychiatric patients that avoid exacerbation of the patient's illness. Facilities with significant psychiatric presentations should consider hiring dedicated psychiatrically trained staff.”The CSAPH report examines data on the occurrence of violence in the ED, explains current standards that apply to workplace safety and security in hospital settings, and reviews recommendations of various organizations on how to mitigate violence in the ED, with some attention to handling patients with psychiatric conditions.The CSAPH has for several years addressed some of the issues most important to psychiatry. A report on use of antipsychotic medication in children, which Kraus has been instrumental in writing, will be brought to the House of Delegates at the June 2011 meeting in Chicago, for example.A CSAPH report on health programs for impaired physicians was also the subject of considerable debate at the November meeting, but was ultimately referred back to the CSAPH for reconsideration. That report gives an overview of the development and operation of physician health programs and addresses the barriers to use of these programs and the effectiveness of their confidentiality safeguards. It also recommends the following as essential components of a state-sponsored physician health program:•. Contingency management that includes both positive and negative consequences•. Random drug testing•. Linkage with the 12-step programs•. Management of relapses by intensified treatment and monitoring•. Use of a continuing-care approach and a focus on lifelong recoveryBut in reference committee hearings, some delegates expressed concern that the report focused too exclusively on addiction without sufficiently addressing other issues relevant to physician impairment, including other psychiatric illness and the so-called “disruptive physician.”Kraus, in an interview with Psychiatric News, said that disruptive behavior is not an uncommon reason for referring physicians for treatment, but is a problematic designation that can be misused. “It's not in the DSM, and hospital personnel can use this construct to discipline a physician who challenges the administration,” he said.Other items that the CSAPH dealt with that were approved by the AMA include a report on health risks associated with the BP Gulf oil spill and resolutions on possible rescheduling of medical cannabis, return of children and adolescents to play or sports practice following a concussion, and improved residency training on the care of gay and transgender patients.The reports on ED violence and physician health programs as well as other items addressed by the CSAPH are posted at <www.ama-assn.org/ama/pub/meeting/reports-resolutions.shtml>. ISSUES NewArchived

Verbal and physical violence in emergency departments: a survey of nurses in Istanbul, Turkey

The aim of this study was to determine the perceived verbal and physical violence and related factors experienced by nurses in emergency settings. Studies on violence in emergency departments indicate an increasing frequency of these incidents. However, little is known about the violence experienced by the Turkish nurses working in emergency departments. Survey. The study population included 255 nurses. Data were collected using a questionnaire. Verbal violence was reported with a frequency of 91.4%. Of the nurses, 74.9% had been exposed to physical violence in at least several episodes during the previous 12 months. Patients' relatives were the main perpetrators, followed by patients, most of whom were male. After experiencing violence, most of the nurses reported that, they had felt fear and only 3% described that they took sick leave, while 80% did not report the incidences of violence they experienced. The nurses described that, after a violent incident, they sought support mainly from their colleagues in emergency departments rather than from the administration. Over half of the nurses (65%) felt safe 'none of the time' in emergency departments, and 89.8% of them described that patients and patient relatives may potentially exhibit violent behaviours towards the staff when they are first admitted to emergency department, while 73.7% believed that the staffing pattern and physical environment of their emergency departments were not adequate to prevent violence. Most of the nurses (83.5%) stated that they should be provided with the training that will help them prevent and manage violence as part of their in-service education, whereas 82.7% of them had not received any such training. The findings have implications for occupational health and safety from both employer and employee perspective.

Hate violence: emergency department perspective

PurposeThe purpose of this study was to investigate the status and potential of Emergency Department (ED) data for identifying and preventing hate violence.MethodsFace-to-face interviews with patients attending three EDs in...

Preventing Interpersonal Violence in Emergency Departments: Practical Applications of Criminology Theory

Over the past two decades, rates of violence in the workplace have grown significantly. Such growth has been more prevalent in some fields than others, however. Research shows that rates of violence against healthcare workers are continuously among the highest of any career field. Within the healthcare field, the overwhelming majority of victims of workplace violence are hospital employees, with those working in emergency departments (EDs) experiencing the lion's share of violent victimization. Though this fact is well-known by medical researchers and practitioners, it has received relatively little attention from criminal justice researchers or practitioners. Unfortunately, this oversight has severely limited the use of effective crime prevention techniques in hospital EDs. The goal of this analysis is to utilize techniques of situational crime prevention to develop an effective and easily applicable crime prevention strategy for hospital EDs.

Increasing identification of domestic violence in emergency departments: A collaborative contribution to increasing the quality of practice of emergency nurses

This project was initiated to improve the quality of identification and response practices of Emergency Department (ED) nursing staff dealing with possible victims of domestic violence (DV). Nursing staff were trained to identify three key actions in the pathway for domestic violence presentations in the ED. A survey of ED staff was taken pre-training to determine a base-line measure of self-reported knowledge regarding domestic violence policies and practices. The survey was re-administered 1 month and 6 months post-training. A file audit was also undertaken prior to and following the training. Results show the training improved the nurses’ confidence, practice and skills in the identification of, and response to, domestic violence, particularly in relation to children. ED nurses are well placed to identify and respond to domestic violence as the ED provides a gateway into health services for women and their children. This paper reports on a participatory action research project which aimed to improve quality and practice around DV for ED staff. The dissemination of the results in this paper are considered to be essential to health services due to dearth of information and research about best practice initiatives for responding to and recognizing domestic violence in the ED.

Visits Coded as Intimate Partner Violence in Emergency Departments: Characteristics of the Individuals and the System as Reported in a National Survey of Emergency Departments

This study was conducted to explore the characteristics of intimate partner violence (IPV) victims whose visit was coded as IPV and the health care delivery system in emergency departments (ED). This study utilized a secondary data analysis of a national probability sample that comprised the National Hospital Ambulatory Medical Care Survey for 1997 to 2001. There were 111 coded ED visits of IPV victims 16 years or older (equivalent of 482,979 out of 4 million national visits for the 5-year study period). Women (94%), African Americans (35%), those 25 to 44 years of age (64%), and uninsured patients (38%) were significantly more likely to be categorized as an IPV visit (odds ratios 14, 1.9, 2.7, and 2.4, respectively) compared with non-IPV visits. Characteristics of the health care delivery system (region, metropolitan vs. non-metropolitan, type of hospital, and type of health care provider) were not associated with IPV. Caution should be implemented when interpreting the study results because they represent only coded IPV visits in the emergency department. The study findings suggest the critical need to improve identification, documentation, and coding of IPV visits.

Incidence and Related Factors of Violence in Emergency Departments—A Study of Nurses in Southern Taiwan

Nurses in emergency departments are high-risk groups who are most likely to experience the offense of violent behaviors. In a comparison on the occurrence of verbal and physical abuses in emergency departments, this study aimed to analyze the correlation of staff properties and occupational conditions in an attempt to provide a reference on violence prevention. Eleven hospitals in southern Taiwan were selected and a survey of 267 nurses was conducted. The results were analyzed by percentage, Pearsons chi2 test and logistic regression. The 236 valid questionnaires showed that nurses experienced significantly more verbal abuse (92%) than physical abuse (30%). The highest occurrence of verbal abuse was 49% in night shift, and the physical abuse was 44% in overnight shift. Long waiting (89%), difference in cognition (87%), and lack of communication (82%) were the common causes. The occurrences of verbal abuse and physical abuse were significantly correlated to less-informed (odds ratio [OR], 1.67 and 1.22, respectively) and basic-level nurses (OR, 2.30 and 1.34, respectively). In addition, younger age (OR, 2.80; p < 0.01) and single status (OR, 9.09; p <0.05) were correlated with occurrence of verbal abuse, but not of physical abuse. The test on occupational conditions showed a significant correlation (OR, 0.68/0.44; p < 0.005) between the occurrence of verbal/physical abuse and whether supervisors could provide enough training to cope with violence. This study suggested that a well-informed nurse should be arranged to take the night/overnight shifts in order to reduce the occurrence of abuses in emergency departments.

STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments

This paper is the report of a study to explicate the components of observable behaviour that indicate a potential for violence in patients, their family and friends when presenting at an emergency department. Violence towards nurses is a contemporary, multifaceted problem for the healthcare workforce globally. International literature identifies emergency departments as having high levels of violence. A mixed method case study design was adopted, and data were collected by means of 290 hours of participant observation, 16 semi-structured interviews and 13 informal field interviews over a 5-month period in 2005. Thematic analysis of textual data was undertaken using NVivo2. Frequency counts were developed from the numerical data. Five distinctive elements of observable behaviour indicating potential for violence in patients, their families and friends were identified. These elements can be conceptualized as a potential nursing violence assessment framework and described through the acronym STAMP: Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling and Pacing. Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling and Pacing provides a useful, practical nursing violence assessment framework to assist nurses to quickly identify patients, families and friends who have a potential for violence.

Violence in emergency departments: under‐reported, unconstrained, and unconscionable

Violence in emergency departments (EDs) has reached a level that requires concerted action and a shift in attitude - to eradicate a socially and professionally unacceptable peril. In some EDs, violence is a daily occurrence, with nursing staff reporting several episodes each week. Increased societal violence results in an increase in presentations for injury. Anger and pain and the influence of alcohol and drugs contribute to violence spilling over into the ED. The well known "system blockers" to reporting adverse events in hospitals result in under-reporting of violence episodes. Violence in EDs is different from other forms of violence - the aggressor has no overt dominance or power status and, in a setting of care, victims are likely to excuse the behaviour. Strategies to curb violence in EDs include modifying building design, providing security systems and personnel, and training staff in aggression management. The key to successful intervention is a strong preventive orientation that looks for high-risk indicators, and may extend to active physical and behavioural screening.

Self harm and domestic violence.

Women who deliberately self harm are 75 times more likely to report physical or verbal abuse by their partners than those who do not, according to a study of patients in the emergency department of Addenbrooke's Hospital, Cambridge. The authors state that this is the first British prospective study to consider domestic violence in emergency departments specifically, though there are many studies that consider assaults and their aetiology.

Emergency Department Violence: a Local Scene

ObjectivesTo study the nature, frequency and magnitude of violence in a local emergency department.DesignProspective epidemiological study in a three‐month period, during which involved staff filled in a survey form immediately after violence incidents.SettingAccident &amp; Emergency Department of a public general hospital in the northeastern New Territories.PopulationAssailants and victims of violence in the emergency department.Main outcome measuresNature of violence, frequency, cause, morbidity, epidemiological characteristics of assailants and victims.ResultsThere were 25 incidents with 26 assailants in the three‐month period. The great majority was verbal abuse only (64%). No weapon was involved. Long waiting time (36%), deranged mental condition (28%) and dissatisfaction with service (20%) were the leading causes of violence. Assailants showed a predominance of male (69%) and age between 21–50 years. They were either patients (69%) or accompanying persons (31%). Nurses (59%) and to a lesser extent doctors (23%), were the main victims.ConclusionThe incidence of emergency department violence (0.08%) was low and the majority was verbal abuse only. Nurses bore the brunt of the violence. Long waiting time, confused patients and dissatisfied patients were high risk factors.

An Emergency Department Violence Prevention Program

An Emergency Department Violence Prevention Program

The effect of an education program on violence in the emergency department

Study Objective: We examine whether a specific educational effort reduces emergency department violence in the short term and quantify the amount of violence in the ED. Methods: Cross-sectional prospective surveys were conducted at a tertiary referral center at baseline (1998) and at 3 and 6 months (1999) after the Prevention and Management of Aggressive Behavior Program (PMABP). ED staff on all shifts for 7 alternate days in a 2-week period were surveyed. We measured the total and mean number of physical and violent events per survey. A generalized estimating equation Poisson regression model examined the effect of the program on the numbers of physically and verbally violent events per shift per employee, after adjusting for other covariates. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results: Physical violence events per survey at baseline, 3 months posttraining, and 6 months posttraining were 0.27, 0.10, and 0.21, respectively. The number of reported violent interactions at the same intervals were 49, 19, and 46 (adjusted OR 1.0, 0.35 [95% CI 0.15 to 0.84], and 0.79 [95% CI 0.48 to 1.40]), respectively. Verbal violence events per survey at baseline, 3 months posttraining, and 6 months posttraining were 0.85, 0.31, and 0.51, respectively. The number of reported interactions involving verbal violence at the same intervals were 154, 58, and 69 (adjusted OR 1.0, 0.31 [95% CI 0.21 to 0.46], and 0.47 [95% CI 0.33 to 0.66]), respectively. Conclusion: Violent events are frequent in the ED. Education programs may reduce the number of events at least temporarily but do not clearly reduce violence in the long term. [Fernandes CMB, Raboud JM, Christenson JM, Bouthillette F, Bullock L, Ouellet L, Moore CF, for the Violence in the Emergency Department Study (VITES) Group. The effect of an education program on violence in the emergency department. Ann Emerg Med. January 2002;39:47-55.]