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Interventions to reduce the risk of violence toward emergency department staff: current approaches

Authors Ramacciati N, Ceccagnoli A, Addey B, Lumini E, Rasero L

Received 11 December 2015

Accepted for publication 8 February 2016

Published 21 April 2016 Volume 2016:8 Pages 17—27


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Hans-Christoph Pape

Nicola Ramacciati,1,2 Andrea Ceccagnoli,2 Beniamino Addey,3 Enrico Lumini,4 Laura Rasero1,5

1Department of Experimental and Clinical Medicine, University of Florence, 2Emergency Department, S. Maria della Misericordia Hospital, 3Emergency Medical System, S. Maria della Misericordia Hospital, Perugia, 4Department of Health Sciences, University of Florence, 5Research and Development Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy

Introduction: The phenomenon of workplace violence in health care settings, and especially in the emergency department (ED), has assumed the dimensions of a real epidemic. Many studies highlight the need for methods to ensure the safety of staff and propose interventions to address the problem.
Aim: The aim of this review was to propose a narrative of the current approaches to reduce workplace violence in the ED, with a particular focus on evaluating the effectiveness of emergency response programs.
Methods: A search was conducted between December 1, 2015 and December 7, 2015, in PubMed and CINAHL. Ten intervention studies were selected and analyzed.
Results: Seven of these interventions were based on sectoral interventions and three on comprehensive actions.
Conclusion: The studies that have attempted to evaluate the effectiveness of interventions have shown weak evidence to date. Further research is needed to identify effective actions to promote a safe work environment in the ED.

Keywords: workplace violence, violence prevention and control, emergency department, aggression, security, review


Every emergency nurse and physician is aware that there exists a dark side to their job: the violence against emergency department (ED) staff.1 The “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty” are considered by the National Institute of Occupational Safety and Health as workplace violence (WPV),2 and this phenomenon in health care settings, and especially in the ED, is so widespread throughout the world that it has assumed the dimensions of a real epidemic.3,4 This trend of WPV is continually growing,5,6 so that several international organizations, such as the International Labour Office, the International Council of Nurses, the World Health Organization, and Public Services International, have been issuing specific guidelines on this topic for a long time.7 A very recent study highlights that more than two-thirds of physicians experienced work-related assaults and >50% of physicians suffered WPV in the previous year,8 and nurses are even less safe than other ED workers.9 WPV affected 90% of emergency nurses in the previous year.10 Table 1 lists the incidence of WPV against emergency personnel reported in some international studies.1121

Table 1 Incidence of WPV in the ED by year, country, profession, type of violence, and period
Abbreviations: ED, emergency department; WPV, workplace violence.

Due to this high prevalence, violence is regarded worldwide by emergency nurses and physicians as “inevitable”,22 or “part of job”.23 Whelan5 stated that the first documentation of aggressive encounters from patients and the public toward nurses dates back to 1824. Violence against emergency staff has also been reported as a problem in countries such as the UK,24 Ireland,19 Spain,25 Italy,26 Australia,12 Canada,27 and the US.28 Only in the past year were studies conducted on the issue of assault against emergency staff in Taiwan,8 Pakistan,29 Jordan,30,31 Italy,32 US,3338 Norway,39 Australia,40 Palestine,41 Ethiopia,42 Iran,43 Singapore,44 Cyprus,45 and France.46 These studies, as well as most of those published until now, concern a review of WPV incidence and prevalence in ED, a description of precipitants and risk factors, types of violent acts (verbal or physical), or, in the qualitative studies, an analysis of the experiences and feelings of the staff suffering aggression. Of course, many studies have highlighted the need for methods to ensure the safety of staff and proposed interventions to address the problem. However, in the international literature, documentation of specific actions to address or reduce violence is lacking,47 and when these studies do recommend possible solutions, the analysis of intervention effectiveness is often only a secondary consideration48 or limited in scope and evaluation.49


The aim of our review is to propose a narrative of the current approaches to reduce WPV in the ED, with a particular focus on evaluating the effectiveness of the proposed emergency response programs.


In September 2015, a preliminary search of the international literature on the subject of this study was conducted in the PubMed database using the following search terms: “emergency department”, “aggression”, “workplace violence”, “approach”, and “intervention”. The terms were combined using the Boolean operators OR and AND. This preliminary study allowed us to obtain useful elements for carrying out the “facet analysis” necessary to identify the key terms to be used in the search strategy. The PICO framework was used to develop literature search strategies. Table 2 shows the research question in analytical format. The MeSH terms and the search terms were combined to maximize the sensitivity of the research. In the CINAHL database, the near operators N1 and N2 were used in order to retrieve records with two terms in the same sentence or multiple words to increase the specificity of the search. Similarly, “search terms” in inverted commas were used in the PubMed database.

Table 2 From PICO framework to facet analysis: search terms
Abbreviations: ED, emergency department; WPV, workplace violence.

The final search was conducted between December 1, 2015 and December 7, 2015, in the PubMed database (the free Medline version) and the CINAHL database (CINAHL Plus with full text, using EBSCO host). Literature were included in this review if the following inclusion criteria were met: 1) the article is written in English, French, or Italian; 2) abstracts or full text is available; 3) publication date is from January 1, 2011 to December 7, 2015; and 4) workplace intervention is evaluated to prevent occupational violence in the ED.


The search carried out in PubMed and CINAHL produced 26 studies in the first database and 25 in the second database. The flowchart of Figure 1 shows the selection process. Applying the inclusion and exclusion criteria, we selected ten studies examining the phenomenon of violence against ED staff by evaluating approaches or strategies for the management of aggression.

Figure 1 Flowchart of selection process.


Through the analysis of the selected publications (Table 3), some approaches to the problem of WPV in the ED emerged. Seven of these approaches are based on sectoral interventions and three on comprehensive actions.

Table 3 Selected studies
Abbreviations: AONE, American Organization of Nurse Executives; ED, emergency department; ENA, Emergency Nurses Association; MOCA-REDI, Management of Clinical Aggression – Rapid Emergency Department Intervention; WPV, workplace violence.

Guiding principles for mitigating WPV

In presenting the current approaches to the problem of WPV in the ED, we believe that it is important to start with the guiding principles and priority focus areas recently developed jointly by the American Organization of Nurse Executives and the Emergency Nurses Association and published in the July editions of both the Journal of Emergency Nursing33 and the Journal of Nursing Administration.34 Many studies have in fact shown that health professionals often feel unsupported by their institutions and leaders.32,44,50,51 For the first time, 13 participants (members of the American Organization of Nurse Executives and Emergency Nurses Association) at the Day of Dialogue on Mitigating Violence in the Workplace proposed eight guiding principles for mitigating WPV (Table 4) and five focus areas for health care organizations: encouraging respectful communication and behavior, establishing a zero-tolerance policy, ensuring ownership and accountability, offering training and education on WPV, and creating outcome metrics of the program’s success. This toolkit and the guiding principles can assist health care professionals (ED managers, nurses, or physicians) in implementing and applying useful approaches for systematically reducing patient and family/caregiver violence in hospitals.

Table 4 Guiding principles on mitigating violence in the workplace and five priority focus areas
Notes: Reprinted from the Journal of Emergency Nursing; 41(4); American Organization of Nurse Executives; Emergency Nurses Association; AONE and ENA develop guiding principles on mitigating violence in the workplace; 278–280; Copyright © 2015 Elsevier; with permission from Elsevier.34
Abbreviations: WPV, workplace violence; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.

Scenario-based training methods

Kotora et al,52 in-line with the fifth point of the fourth priority focus area (Table 4), recently proposed a simulation training approach using health-care-specific case studies with simulations to enhance behavioral awareness in situations of violence which they see as an essential element of training and education on WPV. The authors constructed a comprehensive training experience to better prepare health care workers for an active shooter (an extreme situation that may occur in the ED) using didactic and scenario-based training methods. After completing a ten-item pretest developed by the Department of Homeland Security’s IS:907 Active Shooter course, 32 resident nursing and medical students participated in a single shooting scenario simulation followed by a lecture on hostage recovery and crisis negotiation. They were then exposed to simulated multiple shooting. A post-test and debrief concluded the stage. Didactic lectures combined with case-based scenarios have proven effective in teaching health care workers how to best manage an active shooting incident. In fact, the paired Student’s t-tests confirmed a statistically significant difference between the pre- and post-test scores for all the participants (P<0.002 [−0.177, −0.041]).

Rapid training program

Educational interventions that aim to promote effective communication skills and use of de-escalation techniques to prevent patient aggression are certainly a useful strategy (the fifth point of fourth priority area in Table 4). The approach proposed by Gerdtz et al53 aims to provide this type of expertise quickly and widely. Their study published in 2013 was conducted to evaluate the effectiveness of their proposed intervention, based on the theoretical model of Duxbury,54 that divides the causal factors for patient aggression into three categories: internal (patient/biomedical causes), external (environmental causes), and interactional (situational causes). The Management of Clinical Aggression – Rapid Emergency Department Intervention is a rapid training course, which is delivered over a 45-minute staff in-service session. The Australian authors have tested this program with a mixed approach: both with a pre- and post-test administered to trainee participants immediately before and 6–8 weeks after training, and with individual interviews of managers and trainees 8–10 weeks after the intervention. This involved three key learning activities: 1) viewing of a 3.5-minute DVD simulation of an episode of patient aggression in the ED; 2) discussion on research evidence regarding the prevention of aggression in health care settings, risk factors for WPV, and early warning signs for aggression; and 3) review of the current approaches used to manage episodes of aggression in the workplace and discussion on the ways in which practice may be improved. A total of 471 participants from 18 EDs located in Victoria completed the pre- and post-test after training. Twenty-eight managers and trainers provided their perceptions of the impact of the program. Despite undergoing training, the participants reported feeling unsure about whether or not it would be possible to prevent episodes of patient aggression (statistically significant shifts were only observed in five of 23 items). However, qualitative changes were reported by managers in the way some members of staff worked to prevent episodes of patient aggression during practice.

Hybrid educational intervention

Prevention-focused education is considered by many authors to be a major strategy in reducing the risk of violence in the ED. The likelihood of achieving significant learning outcomes and retention by the use of a hybrid (online and classroom) educational program was recently demonstrated by Gillespie et al.55 In this study, the authors tested an educational approach that covered the topics usually proposed in programs of this kind with three online modules: the prevention of WPV (environmental safety, risk assessment, and communicating effectively with patients and visitors), the safe management of WPV through a coordinated team approach, and the post-incident response (incident reporting and caring for victimized workers). After a 2-hour interactive classroom session, the participants held a discussion with their colleagues on how to best manage the WPV events. Thanks to a quasi-experimental study, which enrolled 143 nurses (120 of whom formed the study sample) from the two US EDs, the effectiveness of the educational program was evaluated by three tests (at baseline, post-test, and 6-month post-test). A significant time effect was observed in the results obtained from a repeated-measures analysis of variance carried out to determine whether individual test scores increased significantly over time. The authors concluded that this type of educational prevention program on WPV tailored to the needs of ED employees can be a useful strategy for the achievement of satisfactory learning outcomes.

Rapid response teams

The presence of security guards in the ED is widely considered effective in reducing violent episodes, but few studies have evaluated the role and the impact of security officers to contrast WPV. Gillespie et al56 in their qualitative study published in 2012 tried to fill this gap. An alternative approach is proposed by Kelley57 in her study, where the security officers are placed in a rapid response team consisting of physicians, nurses, social workers, technicians, human resources personnel, members of administration, and risk management personnel. According to the study by Gillespie et al, the support offered by the security officers (not only limited to the rapid actions required when a patient or visitor becomes violent but also including assisting in the restraint and observation of violent patients, managing visitors on arrival in the ED, following-up on violent event reports, participating in interdisciplinary WPV prevention, and management training) is perceived by the emergency staff as valid and useful, although their effectiveness in maintaining a safe work environment is not perceived.56 Similarly, Kelley’s research highlights the usefulness of introducing a multidisciplinary de-escalation team to provide the best response to violent behavior of patients and visitors.57

Comprehensive approach

Gillespie et al,58 who have carried out a lot of pertinent research, suggest that an effective approach to reduce physical assaults and threats in the ED must be based on comprehensive intervention. Implementing any necessary environmental changes, laying down policies and procedures, and offering education and training are the three fundamental interventions benefitting all staff members, no matter what their role is (physicians, nurses, social workers, security officers, registrars, psychologists, and risk managers). Continuous feedback from employees, managers, and administrators, and the advice of experts in WPV prevention and management are crucial for the success of this type of preventive action. Although, in their study, the hypothesis that the intervention sites would have a significantly greater decrease in WPV episodes compared to control sites was not supported, the authors note that two out of three intervention sites recorded a significant decrease in violent events.

Similarly, in the overview of interventions for WPV in the ED recently proposed by Kowalenko et al,59 multiple approaches are suggested: training individual medical staff members; modification of the physical structure and security of the ED, and changes to local (institutional/regional) and national policies or action plans aimed at reducing violence in the ED. Unfortunately, this review of the literature shows that there is still no evidence of effectiveness for any of the proposed actions.

Action research approach

The complexity of the phenomenon of WPV can be addressed with an actions research approach. This is the strategy proposed by Gates et al.60 The researchers have used the Haddon matrix,61 which combines the epidemiologic concepts of host, vehicle, agent/vector, and environment with the concepts of primary, secondary, and tertiary prevention, to identify and categorize their intervention strategies for reducing episodes of aggression in the ED (Table 5).

Table 5 The Haddon matrix applied to ED violence prevention
Note: Reprinted from The Journal of Emergency Nursing; 37(1); Gates D, Gillespie G, Smith C, Rode J, Kowalenko T, Smith B. Using action research to plan a violence prevention program for emergency departments; 32–39; Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved; with permission from Elsevier.60
Abbreviation: ED, emergency department.

The results of the qualitative study conducted by the authors with 97 members of staff who participated in 12 focus groups showed that the planned intervention strategies were relevant, acceptable, feasible, and comprehensive for both employees and managers.


The phenomenon of WPV in the health sector, and in the ED in particular, is the subject of numerous international studies. Interesting theoretical models54,62 and explanatory frameworks63 have been developed. Understanding the types of violent acts (verbal or physical) and the perpetrators (patients, their relatives, or their friends), highlighting the precipitants and risk factors, and quantifying the phenomenon are among the main objectives of many papers. These studies are generally analytical and descriptive, usually with a mixed qualitative/quantitative methodology.64 Some of these have focused on intervention strategies to address the violence against health care workers. Moreover, the few studies that have attempted to evaluate the effectiveness of interventions have shown weak evidence to date. Further research is needed to identify effective training content, best practices, and security measures designed to promote a safe work environment in the ED. We think that the complexity of the phenomenon and the strong interrelation between various factors suggest that the problem of violence in the ED could be effectively faced only with multiple strategies based on “multidimensional” analysis of the operating ambiences and interventions.65 Global10 and interdisciplinary66 approaches for managing aggression in the ED will allow us to find effective solutions. The biggest challenge is to ensure that violence against health professionals does not “come with the job”67 and ceases to be considered “part of our job”.68


The authors report no conflicts of interest in this work.



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