In Depth Series: Violence in the Emergency Department

In Depth Series: Violence in the Emergency Department

Violence in the emergency department (ED) is a significant problem world wide. Psychiatric and emergency settings are widely considered as high-risk areas, with the incidence of nurses’ exposure to violence ranging from 60% to 90%. Besides the impact on the health professionals, violence also directly and indirectly affects the quality of patient care and satisfaction of patients. Inevitably, it also contributes to an escalation of health care costs.

Understanding the nature of violence in the ED, its risk factors (patient, staff, situational and interaction factors) and the perceptions of health professionals is an important step towards minimising this problem. Knowledge about the theories of violence and the culture that contributes to violence is also critical to the development of effective long-term violence management strategies for the ED.

Health care workers are about 50% of all victims of workplace assaults, according to data from the Occupational Safety and Health Administration. Emergency departments are especially vulnerable, and nurses in particular, as they spend the most time with patients.
The pervasive fear is that such incidents, verbal and physical attacks on medical staff, will escalate as the pandemic rages on.

Emergency departments are something of a canary in the coalmine, an early indicator for the sweeping and unrelentingly disruptive nature of COVID-19 on society.

“In addition to treating and admitting an increasing number of patients with COVID, ER staff across the Kansas City metro are seeing increasing numbers of patients who are suffering from stress, anxiety, substance abuse and violence,” said Dr. Joseph Reuben, emergency physician at AdventHealth, in a statement. “Some of this was on the rise prior to COVID, but we attribute some to the impact of the pandemic on everyone’s physical and mental health.”


(Graphic | Emergency Nurses Association)


According to surveys by the American College of Emergency Physicians and the Emergency Nurses Association, almost half of emergency physicians report being physically assaulted at work, while about 70 percent of emergency nurses report being hit and kicked while on the job. Furthermore, the vast majority – 80 percent – of emergency physicians say violence in the emergency department harms patient care. Similarly, emergency nurses report that the harmful consequences of experiencing a violent event at work interfere with the delivery of high-quality patient care.

The frequency of violent attacks on nurses, physicians and patients in our nation’s emergency departments is unconscionable and unacceptable. For medical professionals, being assaulted in the emergency department must no longer be tolerated as “part of the job.”

In an effort to meaningfully minimize these attacks and protect emergency department professionals, ENA and ACEP launched a new campaign called “No Silence on ED Violence.” This joint effort aims to support, empower and provide the resources our respective members need to effect safety improvements at their workplace, while engaging state and federal policymakers, stakeholder organizations and the public at large to generate action to address this crisis.

No Silence on ED Violence Campaign (

The American College of Emergency Physicians (ACEP) believes that workplace violence is a preventable and significant public health problem and that optimal patient care can be achieved only when patients, health care workers, and all other persons in the emergency department (ED) are protected against violent acts occurring within the department. As such,
ACEP advocates for increased awareness of violence against health care workers in the ED and for increased safety measures in all EDs. Further, ACEP encourages all states to enact legislation that provides a maximum category of offense and criminal penalty against individuals who commit violence against health care workers in the ED.

To ensure the safety and security of the ED environment, the hospital and its administrators have the following responsibilities:

  • Provide an ED security system based upon institution-specific risk assessment that includes adequate security personnel, sufficient training of personnel, physical barriers, surveillance equipment, and other security components.
  • Conduct ongoing assessments of the ED security system performance.
  • Coordinate the hospital security system with local law enforcement agencies.
  • Develop written ED protocols with input from employees for violent situations occurring in the ED to ensure the safety of patients, visitors, and health care workers alike.
  • Educate staff through formal, regular training on early recognition of individuals with potential to become violent, techniques for de-escalation, non-violent crisis intervention, and importance of seeking assistance.
  • Develop and enforce a mandatory reporting policy that requires employees to promptly report any verbal or physical assault. Such policies should clearly state that reporting will not result in any adverse action by the hospital such as termination, threatening to terminate, demoting, suspending, or in any manner discriminating against an employee who reports an assault.
  • Adopt a zero tolerance policy for employees, patients, and visitors that states that any violence in the ED is not acceptable. Educate employees that any assault is not considered “part of the job.”
  • Provide appropriate post-incident support for employees involved in violent events including prompt medical treatment, debriefing, counseling, and employee assistance.
  • Pursue maximum criminal prosecution, when deemed appropriate, against those individuals who commit violent acts against health care workers.

Additionally, ACEP recognizes that the EMS system is an integral component of emergency care and supports and encourages efforts to protect EMS personnel against physical violence in the prehospital environment.

ACEP Supports Workplace Violence Prevention Act (March 2019)

ACEP knows violence in the ED is a serious and growing concern (see survey statistics below for details.) To that end, ACEP sent a letter of support for H.R. 1309: The Workplace Violence Prevention for Health Care and Social Service Workers Act, asking Congress to consider how EDs are staffed to ensure the important provisions of this legislation are implemented appropriately. ACEP’s letter requested additional clarity of the legislation’s wording to ensure any new federal requirements do not create any unintentional burdens for entities that do not control the healthcare workplace.

What steps can hospitals take to reduce workplace violence? Experts recommend the following:

Establish clear policies. Hospitals need policies and procedures for dealing with workplace violence and investigating incidents. The policies should be shared with staff and communicated to patients. (That could even include posting signs that state: “This is a zero-tolerance environment for violence and verbal threats.”) Johns Hopkins University, for example, has established clear policies as part of its “Safe at Hopkins” program, which covers everything from bullying to violence to disrespectful behavior.

Enforce policies consistently. Consistency is important even for something as simple as visiting room policies, says Kowalenko. If the policy states that a patient can only have two visitors, and one nurse follows the rules, and another doesn’t, the result can be anger and frustration. “We need to have guidelines, policies, procedures, and consistent behavior by the caregivers themselves,” Kowalenko says.

Offer training (particularly de-escalation training). Training should be mandatory and ongoing — not an easy-to-forget, one-time session. “These things need to be practiced,” says Pat Finan, MD, a third-year resident at MedStar Georgetown University Hospital. “It can help us work on de-escalating and noticing things we say that might be inflammatory and exacerbating the problem rather than solving it.” Kowalenko believes that de-escalation training should not just be for nurses and techs, but for anyone who interacts with a patient. “I’d want even housekeeping and volunteers to get training,” he says. At the Staten Island University Hospital, all staff members receive two days of training that covers everything from self-protection to the conditions and patterns that can lead to aggressive behavior.

Increase security. In the 2018 ACEP/ENA survey, nearly half of respondents said that hospitals could do more to protect workers by adding security, cameras, and metal detectors, as well as increasing visitor screening, especially in the emergency department. The Cleveland Clinic uses metal detectors, but it takes others steps as well. Security guards inspect visitors’ bags. Staff ID badges include wireless panic buttons. Plainclothes officers patrol in the ED. “I think we need more security and more of a culture change, where things that wouldn’t be acceptable in the outside world shouldn’t be acceptable in the emergency department,” says Mitra.

Study your space. Improvements can include better lighting, clear evacuation plans, badge detectors, mirrors (so that no area is hidden), removing potential weapons (such as IV poles, which are now frequently built into beds), and reducing the number of exits and entrances. Choi also recommends being more aware of your surroundings. At the Bay Area ED where he works, paramedics once transferred a drunk patient from a gurney onto a bed. When the patient became violent, a nurse was trapped in the corner because the gurney blocked her access to the door. “Simple things like preplanning can prevent those types of situations,” he says. ACEP offers a free guide on the subject titled Design Considerations for a Safer Emergency Department.

Protect against cyber stalking. “I believe threatening behavior on the Internet and social media is going to be the next area of concern,” says Kowalenko. Many nurses now cover their last names on their badges with tape, he says, to prevent patients from discovering where they live.


“We are tolerating it”

In healthcare, the widespread practice of abstaining from pressing charges in cases of workplace violence is making the problem worse, Costigan said.

“Workplace violence is persisting and increasing because we are tolerating it. It’s never OK to assault another person, not when you’re drunk, not when you’re sick, not when you’re having a bad day—it’s just never OK. To my knowledge, violence is not tolerated in any other profession.”

The emotionally challenging environment in healthcare settings does not excuse assaultive behavior or justify exposing healthcare workers to violence, she said.

“We work in emotionally charged and high-stress situations, but our protection in the hospital shouldn’t be any different than what is afforded to everybody else. We don’t tolerate assault in a courtroom, or a library, or a restaurant. The same rules should be applied and enforced everywhere because everybody has a right to feel safe, supported, and protected in their workplace.”

There must be some accountability when workplace violence incidents occur, Costigan said. “Healthcare workers need support from the administration, the police, the district attorney, and judges. The only way to stop this violence is to send a clear message that it is not acceptable.”

Paul Hudson, FACHE
Chief Operating Officer