Employee Safety: Preventing Violence in the Emergency Department


January / February 2009
Employee Safety

Preventing Violence in the Emergency Department

A 260-pound psychiatric patient charges his nurse and strikes her in the face as she prepares to take his blood pressure in the emergency department (ED). A subdued female patient suddenly draws a knife from her purse and stabs an emergency physician 13 times, allegedly because the physician would not prescribe the antibiotic she had requested. A combative patient wrestles a handgun from an armed security guard, shooting and killing a radiology technician and another patient.

Events like these are devastating to caregivers, hospitals, and patients. The effects of such violence can include on-the-job fear for physicians and nurses and setbacks in caregiver recruitment and retention for the hospital. In addition, negative community perception of the hospital can lead to fewer patients and poor financial performance. Unfortunately, violence in EDs is a nationwide trend.

An Industry-wide Issue
According to the Bureau of Labor Statistics (n.d.), healthcare workers experience violent assaults at a rate four times higher than average. Nurses experience violence at 12 times the national average, and it is even worse for emergency nurses.

The Emergency Nurses Association (ENA) initiated a study of workplace violence in 2007. Distributed to nearly 3,500 emergency nurses, the survey results revealed that workplace violence is shockingly prevalent and has caused great fear among the nursing community. Preliminary search results revealed that 86% of emergency nurses had experienced physical violence during the last 3 years, and 27% had experienced violence on more than 20 occasions during that time period. Physical violence ranged from pushing and scratching to assault with deadly weapons and sexual assault.

Naturally, these violent events caused fear and concern among nurses. Seventy-two percent reported they did not feel safe on the job, and 19% indicated they were leaving the emergency nursing profession because of violence. In addition, nurses said that many incidences of violence are unreported due to fear of retaliation, inconvenience of reporting, a lack of physical injury sustained, or concern that doing so may affect customer service scores.

ED physicians have had similar experiences. A 6-year (1993-1999) National Crime Victimization Study conducted by the Department of Justice concluded physicians are injured 28% more often than workers in other industries (Dunhard, n.d.).

According to a study conducted in Michigan, 75% of ED physicians reported having been threatened in the past year and 28% had been physically assaulted (Kowalenko, 2005). As a result, 16% considered leaving their hospital or job and 18% had obtained a gun for protection.

Unfortunately, some violent events result in healthcare providers losing their lives. Between 1996 and 2000, there were 69 homicides reported in health services, and 23% of the homicides took place in the ED (U. S. Dept. of Labor, n.d.).

The emotional, social and financial cost of ED violence is incalculable. Reducing the number of violent incidents that take place and minimizing the long-term effects of the ones that occur is a top priority. However, before efforts can be taken to curb violence against ED caregivers, healthcare leaders must understand the causes.

Cause for Concern
Many factors contribute to violence against ED caregivers, so no single solution will eliminate the problem. EDs are publicly accessible facilities that are open 24 hours a day. They stock narcotics and often have cash on hand, making them vulnerable to potential robbery. Many EDs have aging physical structures with poor design and lighting that can place providers at risk.

EDs care for an often-underserved population, including patients with psychiatric, social, criminal, or substance-abuse problems. Individuals who have been arrested for alcohol- and drug-related violations are often brought to the ED for medical clearance before being taken to jail. Gang activity and the prevalence of concealed firearms also contribute to the problem.

During a 1-month period, a hospital in Los Angeles identified and confiscated 300 weapons from patients, including shotguns, .357-magnum handguns, and automatic military weapons (Lavoie, et al., 1988). Still, relatively few EDs are staffed with qualified, armed security personnel.

Addressing the Problem
Hospital administrators have a responsibility to make their facilities as safe as possible, but many do not know where to start. Various studies have supported hospitals’ ability to reduce assaults through organized approaches such as employee training. However, little evidence exists that a specific set of measures can eliminate violence in the hospital.

Despite the myriad causes and challenges associated with violence against ED caregivers, certain measures can be taken to curb the likelihood of violent events and improve staff responses in order to minimize the harmful results. A multifaceted approach must be considered to craft the optimal solution that mitigates risk of violent incidents. The solutions must be tailored to the hospital risk analysis and trend experiences. This approach includes human, policy, process, equipment, and technology dimensions.

While all cases are unique and no actions are guaranteed to eliminate violence, the following five steps may provide an initial framework for administrators to assess their hospital’s vulnerability for violence and take measures to prevent it.

1. Become familiar with your facility’s unique violence risks.

Review the findings of your most recent Joint Commission hazard vulnerability analysis (2009 standard: EM.01.01.01) as well as incident reports, Occupational Safety and Health Administration (OSHA) logs, and security logs. Your local crime index report can add additional insight to your facility’s unique risks. Involve a multidisciplinary team that includes staff, supervisors, risk management professionals, hospital security and the local police in order to help promote an institutional understanding of the importance of the project. Consider utilizing trained experts when reviewing equipment and technology-based security measures.

2. Assess and update your facility’s workplace violence prevention program.

OSHA offers a comprehensive set of fundamental guidelines that can assist in this assessment. Available at the OSHA web site (www.osha.gov), these guidelines clearly identify five key elements for an effective program:


  • management commitment and employee involvement; worksite analysis;
  • hazard prevention and control;
  • safety and health training; and
  • recordkeeping and program evaluation.


Use the above risk analysis and this program assessment to take specific action to improve onsite security. Evaluate security personnel and select additional security equipment based upon the potential for violence in the specific facility. Taking action on the information from the initial analysis will not only make the facility safer but also help staff members feel more secure.

3. Revise and improve your workplace violence prevention training program.

Staff training and awareness is a critical component of workplace safety, and programs can vary widely from hospital to hospital. Many facilities offer programs that do not include hands-on training or real-life scenarios Make sure your training program involves all hospital staff members and addresses the specific potential events identified in the risk analysis and program assessment. Provide non-violent crisis intervention designed to develop skills such as diffusion of escalating situations. Also, consider including role-playing to teach basic physical defensive maneuvers and correct take-down and restraint application techniques. Remember to include physicians, volunteers, contract employees, and clerical staff in this training.

4. Enact a “zero-tolerance” policy for violence and encourage reporting of violent incidents.

Make sure hospital workers understand that violence against them is never appropriate. Demonstrate that hospital administrators support violence prevention efforts by regularly communicating about these issues. Safety should be a topic at every staff meeting. Encourage reporting of every incident of workplace violence, however small it may seem.

5. Provide opportunity for crisis debriefing and staff support following a violent incident.

If a violent event takes place in the facility, proactively arrange opportunities to debrief. Providing an opportunity for staff members to review and process an incident in a timely manner can be emotionally beneficial, ultimately allowing them to resume patient care duties and reduce time away from work. Depending on the nature of the event, consider utilizing experts trained in post-crisis management to ensure the positive benefits of these efforts are realized. Of course, not every staff member will feel comfortable participating in debriefing. Allow individuals to deal with the event as they choose.

While sometimes complicated and time-consuming, taking steps to prevent violence against ED caregivers is always worthwhile. EDs are the medical safety net of our country, and, in order to recruit and retain qualified caregivers for the long haul, their safety must be a priority.

Theresa Tavernero is a veteran emergency nurse executive with extensive experience as a clinician, educator, and administrator. As associate director for patient safety programs and vice president of client services for TeamHealth, Tavernero is responsible for implementing programs in nearly 350 emergency departments nationwide to keep patients, caregivers, and administrators safe. Tavernero is a former instructor for the U. S. Army combat medic proficiency course and is currently a national consultant for MedTeams, a healthcare team training program based on principles originally developed for aviation settings. Tavernero may be contacted at Theresa_Tavernero@teamhealth.com.


Dunhard, D. T. (n.d.). U.S. national crime victimization survey, 1993‚1999. U.S. Department of Justice. Bureau of Justice Statistics. Available at http://www.ojp.usdoj.gov/bjs/pub/pdf/vw99.pdf. (Accessed February 2008.)

Emergency Nurses Association. (n.d.). Issue brief: Violence in ED. Available at www.ena.org/government/Advocacy/Violence/Issuebrief.pdf. (Accessed June 2008.)

Kowalenko, T., Walters, B., Khare, R., & Compton, S. (2005). Workplace violence: A survey of emergency physicians in the state of Michigan. Annals of Emergency Medicine, 46 (2), 142-147.

Lavoie, F. W., Careter, G. L., Danzi, D. F., et al. (1988). Emergency department violence in United States teaching hospitals. Annals of Emergency Medicine, 17(11), 1227-1233.

U. S. Department of Labor. Bureau of Labor Statistics. (n.d.). Injuries, illnesses, and fatalities. Available at www.bls.gov/iif/. (Accessed February 2008.)