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According to published data, about one in four emergency physicians (EPs) and nurses report that they were victims of physical assault in the past year. A recent study found that as many as 78% of EPs reported at least one act of physical or verbal aggression in the previous year, and 21% reported more than one episode. Another analysis revealed that before completion of training, more than 50% of emergency medicine residents had been physically hit or pushed by patients. Fear of assault or being shot was their second-leading concern, trailing only needlestick injuries from patients with HIV.

EDs have been identified as high-risk settings for workplace violence (WPV), says Terry Kowalenko, MD. “In addition to the immediate concern of personal safety, WPV can decrease productivity and job satisfaction and contribute to the problem of early burnout. The toll of WPV may be even higher for non-physician staff. What’s clear is that data from recent reports on WPV are concerning, as the threat of violence in EDs is escalating throughout the United States.”

A Call to Action: Preventing Violence in Healthcare

Several organizations, most notably the Occupational Safety and Health Administration (OSHA), have recently issued a call to action to improve initiatives aimed at preventing violence in healthcare settings. In the Journal of Emergency Medicine, Dr. Kowalenko and colleagues had an analysis published that reviewed ED workplace violence in the context of risk factors for WPV. The study also reviewed current concepts for interventions designed to prevent WPV in the ED.

“The reasons behind WPV in the ED are multifactorial,” explains Dr. Kowalenko. “Factors such as mental health issues, stress, substance abuse, pain, overcrowding, long wait times, and the general stressful environment of the ED can all contribute to WPV. Further complicating matters is that many EDs lack adequate security to appropriately prevent and/or manage WPV.”

Interventions for Workplace Violence

OSHA has issued guidelines for preventing WPV for healthcare and social service workers, and other interventions have also been issued specifically for ED staff to help decrease aggression. “These interventions look at the problem of WPV in terms of training medical staff, modifying ED facilities and security, and instituting policy changes,” Dr. Kowalenko says (Table 1). “Each entity is important to ensuring the safety of ED staff and patients.”

OSHA recommends that a WPV prevention program has committed support from management and conducts worksite analyses specific to the environment. The worksite analyses should then be used to develop site-specific interventions. “These components are not specific to the ED, but they can serve as a starting place for ED leaders to address this critical problem at their site,” adds Dr. Kowalenko.

Taking a Step-Wise Approach

When establishing a WPV prevention program, the first step is for EDs to get leaders, managers, and hospital staff committed to reducing the incidence of WPV (Table 2). “Having buy-in from the administration, management, and staff to reduce WPV is paramount,” Dr. Kowalenko says. “This requires promoting a philosophy that violence and aggression are unacceptable. The organization must value their employees’ well-being and safety in the workplace.”

The second step is to complete a work-site-specific analysis of the ED. This involves conducting an assessment of risk factors for violence in the ED, including the number of psychiatric and substance use patients who are treated each year in the ED and the number of patients who are victims of violence with potential for in-unit retaliation (eg, gang violence). Assessing staffing ratios and the prevalence of handguns and weapons in the community is also important. Risk factors that are part of the environmental design of the hospital, such as poorly lit corridors, rooms, and parking lots, should also be considered.

The final step to developing an effective WPV prevention program is to implement site-specific interventions based on work-site analysis data. “WPV is a complex issue, but there are clear actions that can improve safety of ED staff. The key is to collect and analyze the data specific to the ED site being evaluated,” Dr. Kowalenko says. “Leadership can use this information to develop interventions that can help reduce violence in the ED. It’s time for emergency medicine to move beyond acceptance of WPV as ‘part of the job’ and make efforts to prevent these issues from arising in the first place.”


Kowalenko T, Cunningham R, Sachs CJ, et al. Workplace violence in emergency medicine: current knowledge and future directions. J Emerg Med. 2012;43:523-531. Available at: http://linkinghub.elsevier.com/retrieve/pii/S0736-4679(12)00350-2.

Gates D, Gillespie G, Smith C, et al. Using action research to plan a violence prevention program for emergency departments. J Emerg Nurs. 2011;37:32-39.

Anderson L, Fitzgerald M, Luck L. An integrative literature review of interventions to reduce violence against ED nurses. J Clin Nurs. 2010;19:2520-2530.

Kowalenko T, Walters BL, Khare RK, Compton S. Workplace violence: a survey of emergency physicians in the state of Michigan. Ann Emerg Med. 2005;46:142-147.

Gacki-Smith J, Juarez AM, Boyett L, et al. Violence against nurses working in US emergency departments. J Nurs Adm. 2009;39:340-349.

American College of Emergency Physicians (ACEP) Board of Directors. Protection from physical violence in the Emergency Department environment. ACEP Website. Available at: http://www.acep.org/practres.aspx?id=29654.

Emergency Nurses Association. Position statement: violence in the emergency care setting. Emergency Nurses Association Website. Available at: http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Violence_in_the_Emergency_Care_Setting_-_ENA_PS.pdf.

Kansagra SM, Rao SR, Sullivan AF, et al. A survey of workplace violence across 65 US emergency departments. Acad Emerg Med. 2008;15:1268-1274.