Survey: Most ED staff victimized by violence never report incident

Almost one-third of respondents in New Jersey say they have been assaulted

Several years ago in an ED in Virginia, a triage nurse was taking a patient's history when the family member of another patient approached her. Angered that his relative had not received care quickly enough, this individual pulled a gun on the nurse and demanded immediate care. The nurse complied, no shooting occurred, and security subdued the violent individual.

"However, that nurse could never work in the ED again," notes Mary Pat McKay, MD, MPH, director of the Center for Injury Prevention and Control at The George Washington University, Washington, DC, and an ED physician at The George Washington University Hospital.

Such long-term effects often are the result of a traumatic experience such as that — especially when the events are not reported and the victims must deal with the memories alone, experts say. As a new survey conducted by the New Jersey Department of Health and Senior Services shows, this happens far too often.

The recently released report, "Workplace Violence and Prevention in New Jersey Hospital Emergency Departments," said workers in New Jersey hospital EDs are routinely subjected to verbal abuse and almost one-third have been assaulted. It also found that 72% of those who were verbally or physically assaulted never report the event. Here are other survey findings:

  • Nurses are at highest risk for being victims of verbal or physical assault.
  • Verbal abuse at least once per year was reported by 90% of the respondents, with 27% reporting verbal abuse more than 96 times per year.
  • Only 6% reported no verbal abuse.
  • Threats were reported by 61% of employees, with most being threatened between one and 12 times per year.
  • Almost one-third of workers who responded to the state survey reported being assaulted, and 12% reported three or more assaults per year.

A critical issue

Beyond the obvious threat to the physical well-being of ED staff members, the psychological repercussions can affect the job performance of the victims — possibly tainting their attitudes toward patients or even making them afraid to return to work, say experts. For all of these reasons, they agree, ED managers must be proactive in their efforts to empower and encourage their staff to come forward when such incidents occur.

Recognize the problem to bring attention to it, advises Donna L. Mason, RN, MS, CEN, president of the Emergency Nurses Association and nurse manager of adult emergency services at Vanderbilt University Medical Center in Nashville, TN. "You have to educate every member of your team — nurses, doctors, registration people, transporters, and volunteers — that violence is never OK, and that for their own safety they must do something about it," she says.

By the very nature of their jobs, ED professionals deal with a lot of angry people, Mason notes. Most individuals do not come to the ED in their normal state of mind. "When they come to the ED they are stressed, and everyone handles stress differently," she says. "Teach your staff that this is normal for some people, but that it's not normal to accept demeaning language."

ED managers "have got to be the absolute best role model to support their staff," she says. For example, she says, if a VIP comes into the ED and starts pushing one of the nurses around, the manager cannot accept such behavior. "You have to follow up with the employee through the system," Mason says. "If charges need to be filed, you go with them, and if they need the EAP [employee assistance program], you help them make contact. If they fear the manager will not help, they will not report."

You have to continually follow through on your commitment, she says. "Bring the issue up at staff meetings, and send information out at least quarterly about violence or safety," she says. "Keep it in the forefront, so the staff will know you think it is important."

Have processes in place

As an ED manager and director, you want to have an environment that is open and honest enough so your staff can report their concerns — whether it is a quality, safety, or environmental issue, says Leon L. Haley Jr., MD, MHSA, chief of emergency medicine and vice chairman of clinical affairs for Grady Health System and associate professor in the Department of Emergency Medicine at Emory University, both in Atlanta.

"You must have a process by which the staff can bring their concerns — whether it is a suggestion box, open office hours, regular staff meetings or forums," he says.

Structure staff meetings around this issue, Haley advises. If you have access to a good mental health or crisis staff, you also can conduct inservices, says Haley. "We use our mental health staff to do regular inservices to make sure the staff know how to report and what to report," he says. "This creates that open comfort zone."

Haley's approach is similar to the one he takes when addressing ED crowding: an "input, throughput, output" model, he says. "In terms of input, you want resources available for protection, like security guards, metal detectors, and a process by which you can monitor things," Haley explains. "Once [a potentially violent person is] in the ED, what are the tools you can use to help reduce patient and family stress, and if they are in need of mental health assistance, how quickly can they get it?" The third phase, he says, are the policies and processes for reporting incidents if something does happen.

In the Virginia ED mentioned above, for example, the "input" phase was strongly addressed after the gun-toting incident. "The whole ED was redesigned, and the first thing they did was enclose the triage area in bulletproof glass," she says.

The manager's role

It's impossible to overemphasize the role of the ED manager in creating an environment that encourages reporting incidents of violence, says Mason.

Be aware of the different types of violence, she says. "Nurse managers are key — not just in the case of violence by a patient or family member, but in lateral incidents where nurses demean other nurses, or doctors belittle someone," she says. "That's just as bad as a patient calling you names." It is the manager's job to let the staff know that this kind of behavior is also unacceptable, she says.

"I have a chair of emergency medicine who will absolutely not tolerate any kind of [demeaning talk from] doctors to nurses," Mason says. Vanderbilt has a professional practice program, she says. "If a doctor is verbally abusive to a nurse, they can report it to the professional practice program, and it will go in their file," she says. "All the physicians know this."

Tech threatens to 'go postal'

In staff-on-staff incidents, adds McKay, the appropriate managers must get involved. "Last week, at another institution, I heard the story of a nurse who called a lab tech to add on a test to a tube of blood, and for whatever reason, the tech threatened to come up to the ED and 'go postal,'" she recalls. "Clearly, the managers of those two people needed to get involved so the incident would not continue."

There's no substitute for having such reporting policies and providing appropriate managerial response, says McKay. "One of the reasons people do not report incidents is they see no benefit," she says. "That's when you need a process, or an EAP, or whatever behavioral supports there are. As a group in the ED, we probably don't avail ourselves of that kind of support as much as we should."


For more information on reporting incidents of violence in the ED, contact:

  • Leon L. Haley Jr., MD, MHSA, Chief of Emergency Medicine, Vice Chairman of Clinical Affairs, Grady Health System, Atlanta, and Associate Professor, Department of Emergency Medicine, Emory University, Atlanta. Phone: (404) 616-6419. E-mail:
  • Donna L. Mason, RN, MS, CEN, Nurse Manager, Vanderbilt University Medical Center, Adult Emergency Services, 1211 Medical Center Way, Room 1314 VUH, Nashville, TN 37232-7240. Phone: (615) 343-7223.
  • Mary Pat McKay, MD, MPH, Director, Center for Injury Prevention and Control, The George Washington University, Washington, DC. Phone: (202) 741-2947.

To obtain a free copy of Workplace Violence and Prevention in New Jersey Hospital Emergency Departments, go to

The New Jersey State Assembly is considering Bill No. 3027, The "Violence Prevention in Health Care facilities Act," aimed at requiring health care facilities to establish violence prevention planning, programs, and training, and state reporting processes. For more information, go to, or contact the sponsor, Assemblyman Herb Conaway, MD, at (856) 461-3997. E-mail: