The first essay in a series of three written projects aimed to discuss the topic of violence occurring in the Emergency Department

1. Running head: VIOLENCE IN EMERGENCY DEPARTMENTS 1
Violence in Emergency Departments
Edward Struzinski, RN
Kaplan University

2. VIOLENCE IN EMERGENCY DEPARTMENTS 2
Violence in Emergency Departments
There is an important issue in healthcare that is significantly trending, especially within
the emergency department. Violent situations and eruptions have steadily increased, an issue that
is not isolated to within the borders of the United States but is reported and being studied on an
international scale. Violence and aggression is everywhere: hospitals are no exception. They are
organizations that actively seek and need the human factor to generate income and maintain their
status as a business. Emergency departments are essentially open for business twenty-four hours
a day. They are an obvious area of high emotions during medical crises, a source of various
pharmaceuticals with strong potential for abuse, and even an undetermined amount of money
held by registration clerks. Several hospitals are located within poor or dangerous sections of
inner cities and the emergency departments cannot choose their clientele visiting them. This
leaves the door wide open to unpredictable people that may also lead to unpredictable situations,
including physical injury or death. Nurses and staff in the emergency department, among other
areas, are at a much greater risk of experiencing violence and aggression from patients or their
visitors than other departments in the hospital (Gillam, 2014). This is the second essay in a series
of three articles that aims to discuss a compilation of current literature on the subject of violence
found in the emergency department, identifying common themes, factors, pitfalls, and report on
statistical analysis of this very important issue that has numerous consequences.
A review of literature
A review of several sources was carefully evaluated for validity in reporting. All articles
on the subject were peer-reviewed. They included research projects utilizing questionnaires,
taped interviews, incident reports, surveys, and several review articles. After careful review of
various literature and other sources on the subject of emergency room violence, several themes

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were identified that trended together. They include: incidence or prevalence of violent events
specifically in the emergency department, under-reporting by staff, desensitization of staff in the
face of violence, lack of appropriate training in dealing with aggressive behavior or violent
individuals of whom many are under the influence of alcohol/ drugs or whom have a mental
health history, and lack of support from administrative leadership. The last common link
detailing administrative response is actually quite interesting to learn in light of the events that
occur and the very likelihood of subsequent injuries, property damage, and financial
reimbursements associated with it – to say nothing about the negative effects on department
morale that itself has an affect on the business.
Overall, the incidence of aggressive events and violent outbursts occurring in emergency
departments is staggering. Although it is slightly outdated information, in 1992, the nursing
profession logged the highest number of physical attacks in the workplace (Pich, Hazelton,
Sundin, & Kable, 2010). However, with recent reports showing violence to have only trended
upward in the healthcare industry since and much of it going unreported, this data from
essentially only twenty years ago could still be on target. Most aggressive actions are aimed at
nursing staff and registered nurses generally take the impact of all these aggressive or violent
outbursts. Although there is no solid definition for nursing violence in the emergency rooms,
much of the literature defines the actions as verbal or physical in nature. Physically violent
incidents have a wide range of actions that include being hit, kicked, pushed, spit on, bitten, or
any aggressive action made with the general aim to harm the target. Verbally abusive incidents
can be defined as those with non-contact. These can include threats, gestures, yelling or any non-
physical attempts to frighten or intimidate the subject. They almost entirely will always include
abusive language, swearing, or racial and ethnic epithets.

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Through their nine-month study involving six hospitals, researchers Kowalenko, Gates,
Gillespie, Succop, and Mentzel (2013) found the emergency departments to have the highest risk
of violence and nursing staff to have an assault-injury rate that was ten times higher when
compared to other areas. Also reported by Kowalenko et al. (2013), statistical analysis from the
Bureau of Labor Statistics revealed nearly sixteen percent of all physical altercations across all
industries occurred to those in the nursing staff and assistants. Another study conducted by
researchers over a one-year period affirmed physical violence on seventy-two percent of subjects
over the course of their career, over forty percent in the year preceding the study, and almost
sixty percent assaulted in yet another study that also spanned a one-year period (Taylor & Rew,
2011). A smaller study of emergency room nurses from six institutions in Nigeria showed not
only a ninety percent response rate to the surveys but that almost ninety percent of the
respondents bore witness to violent or aggressive acts in their emergency departments (Ogundipe
et al., 2013).
Finally, ninety-eight percent of another study – almost the entire body of research
subjects – reported verbal aggression or abuse in the emergency department (Pinar & Ucmak,
2011). From these accounts, one can easily see that violence in the emergency department is a
significant problem that is felt globally. It has the highest incidence of violence in healthcare and
is increasing. And although that sounds alarming, one must not forget that these figures are only
generated by the information that is actually reported. To that end, there are likely three or four
times the number of cases that go unreported.
Under-reporting of incidents and desensitization
Another common link to the literature review is the discussion by researchers on the
under-reporting of violent encounters or other aggressive events in the emergency department

5. VIOLENCE IN EMERGENCY DEPARTMENTS 5
that should have been brought to the attention of managers, etc., but were not for a variety of
reasons. One reason commonly shared across the literature is the idea that violence and other
volatile situations is an expected part of the job in dealing with the public or treating patients in
the emergency department. That perception alone by healthcare workers minimizes the
significance for reporting events, and because of it, there is desensitization to the issue.
Pich et al. (2010) reports on many nurses rationalizing violent behavior as an unavoidable hazard
that is expected to come with the occupation. Additionally, Powley (2013) reports many nurses
rationalize not reporting incidents based on the idea that it was not the true intention of many
patients to lash out at them. Considering these factor, the true incidence of emergency
department violence to date remains unknown; estimations could range anywhere from as little
as twenty percent to as shocking as ninety percent (Pich et al., 2010). Kowalenko et al. (2013)
determined under-reporting in their cases and other studies to be a common theme. In fact, only
half of the incidents were brought to the attention of hospital administration and an astounding
five percent of physical assaults were reported to law enforcement (Kowalenko et al., 2013).
That translates to mean that ninety-five percent of assaults on healthcare workers from patients
and visitors were not reported to the police to be brought up on charges of battery in that
particular study by researchers.
In their investigation on the subject, Taylor and Rew (2011) state how under-reporting of
events was a consistent parameter across the studies and literature they collected. This is
habitually true with all forms of aggression, be it verbal or physical. Both of which can
negatively impact the individuals it is aimed at, the morale of the department, and ultimately
patient care. The victims often dismissed incidents of violence in the emergency department of
another study that still had negative impacts on department morale (Belayachi, Berrechid,

6. VIOLENCE IN EMERGENCY DEPARTMENTS 6
Amlaiky, Zekraoui, & Abouqal, 2010). Many nurses will often feel a moral dilemma between
reporting violent occurrences with those they are caring for, feeling that is something that comes
along with the job (Powley, 2013). However, moral dilemma or not, the incidence of not
reporting these particular events is as high as the incidents themselves and just as significant.
Importance of proper training
By far, several literature studies and sources uncovered a significant issue on the safety of
employees in the emergency department regarding how to approach a tense situation or
otherwise unruly patient with the intent for de-escalation versus physically restraining the
subject. In the study by Ogundipe et al. (2013), all six hospitals within the research project had
poor prevention plans and lacked in basic safety strategies. These included a range of topics from
on-site security or other surveillance to proper training of staff in crisis management. Three-
quarters of the research subjects in the project reported they had no form of skilled training in
managing or even identifying an erupting or violent situation (Ogundipe et al., 2013).
De-escalation training is a helpful solution to preventing impending violence. It requires
training using an empathetic and psychological approach to reducing a tense or evolving
situation. By first recognizing and identifying impending crises early along with using
negotiation skills for conflict resolution, the idea of de-escalation techniques is to prevent a
situation from worsening (Touzet et al., 2014). This is the idea behind the STAMP method of
identification shared in the various literature sources. STAMP is an acronym professionals can
use to recognize aggression that is brewing before it reaches the boiling point. Angry or upset
people in emergency rooms will often display signs of staring, tone of voice, anxiety, mumbling,
and pacing (Pich et al., 2010; Taylor & Rew, 2011). This acronym allows nurses and other staff
to recognize signs early and take appropriate, corrective action, including calling for hospital

7. VIOLENCE IN EMERGENCY DEPARTMENTS 7
security or even the police. Although despite all the literature showing nursing staff generally
receives little or no training in dealing with violence matters, some nursing staff choose not to
call for help, feeling they can still resolve the flaming situation on their own (Gillespie, Gates,
Miller, & Howard, 2012). This appears to be a show of poor judgment in the face of danger.
Generally speaking, unless a hospital formally provides training in nursing orientation for
dealing with behavioral subjects, it seems to be a skill that is learned on the job and through trial
and error of experiences. Errors can have grave consequences. One study reported sixty-nine
deaths to nursing staff that occurred in a matter of four years time (Pich et al., 2010). That is an
average of between one and two deaths to healthcare workers that happened every month! Proper
training cannot be over-emphasized. Pinar and Ucmak (2011) reiterates that the Occupational
Health and Safety Act mandates employers adequately train their employees so as to work safely
and minimizes risks to their well-being. In spite of this, upwards of eighty-five percent of nurses
reported receiving no such training during their orientation, yet they thought or felt they should
have (Pinar & Ucmak, 2011) in order to be better prepared to manage angry or upset individuals
that one is likely to encounter often in an unpredictable environment like emergency rooms.
Emergency departments offer very little for environmental factors that heighten the risk
of violence to occur, especially with psychiatric patients that should have a quieter atmosphere. It
has been suggested there is a connection with severe mental illness and violent behavior, tripling
the odds of a potential outburst for those who suffer from such diseases like schizophrenia or
bipolar disorder (Pich et al., 2010). In fact, mental illness and alcohol intoxication were shared
across much of the literature as factors influencing violence and aggression. Intoxicated
individuals generally have a lower threshold for having patience and they are significantly
correlated to violence in some fashion with risk statistics for violence ranging from twenty-five

8. VIOLENCE IN EMERGENCY DEPARTMENTS 8
percent to ninety-eight percent (Pich et al., 2010); there was also a demonstrated increase in
violent episodes in the emergency department that coincided with the number of patients with
mental illness (Gillam, 2014) in the department.
Administrative response influences
Sources also included how respondents felt that administrative leadership was a negative
influence on their decision to either report or not report incidents of violence. There was
generally a lack of support reported surrounding those from whom the employees would look to
for support and direction. Nurses reported feeling a lack of support from managers, fear of
retaliation, or were just not happy with feedback received (Pich et al., 2010). According to
Ogundipe et al. (2013) the health industry as a whole does not have now or even applied a zero-
tolerance policy toward violence occurring in the workplace, sharply contrasting other
businesses. It has been suggested zero-tolerance policies have been viewed by some
administrators as being unreasonable in healthcare because it interferes with establishing a
satisfying relationship with patients (Pich et al., 2010) – customers of a business.
Conclusion
Healthcare violence is not a new subject. Some of the surveys performed in the literature
review could be called into question for their validity, mostly due to respondent bias on the
subject of being the target of a violent or aggressive act. Kowalenko et al. (2013) suggest several
workers may also have opted out of research projects due to not wanting to relive an experience.
The literature reviewed, however, showed interesting trends in data and information, particularly
the frequency of violent and aggressive occurrences to nursing staff in the emergency
departments on an international scale. In particular, those working in the specialty consider the
violent actions inflicted by mostly patients or visitors as a normal part of the working day.

9. VIOLENCE IN EMERGENCY DEPARTMENTS 9
Because of the predominance of these acts, there is desensitization to the issue of verbal and
physical assaults on healthcare workers. This has led to an occupational acceptance of unsafe
behaviors that are certainly also disrespecting to educated professionals whom have pledged to
care for others. Multiple events go undocumented and unreported to administrators and other
authorities because of this generalized acceptance, of which the true results would likely be too
alarming to believe as possible. Lack of appropriate training and feelings of an unsupportive
management only complicate matters that require formal and responsible actions. This can be
identified as a problem rather than a solution. Solutions to the violence happening to healthcare
workers in the emergency department, if there are any, is largely preventative and requires
unanimous cooperation and support in finding a resolute answer. This must come from all who
are involved, including the perpetrators, as responsibility includes accountability.

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References
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