In total, 5,695 staff surveys were distributed, and the overall response rate at the 69 participating EDs was 66%. To minimize nonresponse bias, we excluded staff responses from four EDs with response rates of 45% or less and surveys missing 80% or more items. There were no statistically significant differences in main characteristics between the 65 EDs that were included and the 4 that were excluded from the analysis (data not shown). Of the 3,641 staff surveys, 3,518 were included in the final analysis. At the ED level, key informants at all 65 sites completed the initial key informant survey, and of those, 62 (95%) completed the follow-up e-mail survey.
displays the demographic and occupational characteristics of the staff included in the final analysis. Most of the respondents were women. Nurses comprised 55% of the survey respondents; attending physicians were the second most represented group, followed by residents. One-third of respondents had worked in the ED for less than 3 years, and 26% of respondents had worked greater than 10 years.
Staff Characteristics Reported in Staff Survey
Seventy-three percent of staff reported they felt safe most of the time or always. Another 19% said they sometimes felt physically safe; the remaining 8% of ED staff reported that they never or rarely felt physically safe while working in the ED.
The distribution of attacks and weapons reported by key informants is displayed in . The majority of EDs were combined adult and pediatric EDs. Forty-five percent of EDs were from the Northeast, and 62% were the primary site for an emergency medicine residency program. The overwhelming majority (94%) of key informants reported their site had in-hospital security personnel available 24 hours per day. Slightly less than half of key informants reported training nurses and physicians in techniques for managing violent patients. Only 14% of key informants reported using metal detectors to screen nonstretcher patients or visitors.
Attacks and Weapons by Emergency Department (ED) Characteristics
Overall, key informants reported more than 3,461 physical attacks for the 5-year period. The reported number of attacks ranged from zero to “over 1,000” (analyzed as 999, which was the highest response allowed in the 3-digit answer space), with a median of 11 physical attacks per site for the 5-year period. Twenty percent of key informants reported that guns or knives were brought to the ED daily or weekly.
Results from the multivariate analysis indicated that after controlling for staff and ED characteristics, nurses were five times less likely to feel safe “most of the time” or “always” compared to attendings, residents, nurse practitioners, and physician assistants (odds ratio [OR] = 0.21; 95% confidence interval [CI] = 0.16 to 0.28; p < 0.0001; ). White individuals felt safest among the self-identified races. Staff who had worked more than 5 years felt less safe than staff who had worked shorter periods of time. Staff in the Northeast felt the least safe. Frequency of weapons, number of attacks, presence of metal detectors, and violence training were not statistically significant predictors of staff feeling safe most of the time or always.
Multivariate Logistic Regression Model Evaluating Characteristics Associated with a Perception of Safety “Most of the Time” or “Always”
In multivariate analysis, EDs with metal detectors reported a higher number of physical attacks () and were much more likely to have weapons brought to the ED on a daily or weekly basis (data not shown; OR = 26.3; 95% CI = 2.0 to 339; p = 0.01). Frequency of weapons was not associated with the actual number of attacks. Also, adult-only EDs were associated with a higher number of attacks than combined adult/pediatric EDs.
Parameter Estimates for Linear Regression Model Assessing ED Characteristics Associated with Attacks