Don't let violence happen to you, your staff

Over half of ED nurses have been attacked

More than half of ED nurses have experienced physical violence at work in the past three years, says a new study from the Emergency Nurses Association (ENA) that surveyed 3,465 nurses.1 One in four was assaulted 20 times in that time frame, and one in five had experienced verbal abuse more than 200 times.

These findings were not at all surprising, however, to Karen Wiley, RN, MSN, CEN, chairwoman of the ENA's ED Violence Work Team. "We expected that with appropriate reporting, we would find higher incidences than what is represented in the study," she says.

Wiley stresses that "it is not only the psychiatric patients who may have no insight into their behavior who become violent and cause injury. Anyone who walks through or is brought through our doors is capable of becoming violent."

Because EDs with policies for reporting violence had fewer violent incidents, the researchers recommend developing clear and consistent procedures for this. "To prevent verbal and physical assaults, reporting is imperative," says Wiley. "To know the full extent of the problem and prevent it, we need to report it. If it is not reported, then it did not happen."

Wiley says in her 20-bed ED, nurses are to report all incidences of injury, whether verbal or physical. "Our process, if injured, is to notify our manager immediately to report the facts," says Wiley. However, while a nurse will take the time to complete an incident report if injured, many do not when verbally abused. "ENA's Violence Work Team is planning to develop a short incident reporting tool to make it easier for nurses to complete," reports Wiley. "There is no magic tool. It is still up to the nurse to report. Encourage co-workers to report all verbal and physical abuse."

Trust your instincts when dealing with potentially violent patients, says Pam Turner, RN, BSN, assistant nurse manager of the ED at Harborview Medical Center in Seattle. "Our 'nurse sense' is there for a reason. Have a plan before approaching a potentially violent patient," she says. "Never approach such a patient without other staff members nearby who are aware of the situation and ready to intervene."

Wiley says, "Do not be alone or trapped in a room. If you have an impression that a patient may become violent or abusive, have security present in the ED." However, the ENA's study reported that 5% of hospitals had no security, and 13% relied on local police or the sheriff to respond. One rural ED nurse informed Wiley that the hospital's maintenance department doubled as security, and if state police are called, it might be 20 minutes before they respond. This underscores the fact that "ED nurses must be equipped with the necessary training and tools to recognize and de-escalate triggers and precursors to violence," says Turner.

Wait times are a factor

ED nurses reported one or more of these precipitating factors when they experienced abuse: Patients or visitors under the influence of alcohol or illicit drugs, psychiatric patients being treated in the ED, crowding, and prolonged wait times.

"Be aware of the anxiety and reduced coping mechanisms already present in ED patients," says Turner. "Actively assess patients for possible violence, especially in the presence of risk factors such as alcohol or illicit drug intoxication, mental illness, dementia, and other causes of altered mental status."

You also need specific techniques to protect yourself and your patient in the event of a violent incident, Turner says. "Intervention to prevent and/or deal with a violent outburst should be thought of as therapeutic and goal-directed, much as any other nursing process you perform," she says. Turner says these ED nursing interventions might include decreasing surrounding stimuli, communicating with the patient to lessen fear of the unknown, and intervening pharmacologically as soon as it is warranted.

"Be careful how you approach a patient, even if they seem aloof," says Barb Morgan, MSN, RN, nursing director of emergency services at Cleveland Clinic. "Explain exactly what you are doing so the patient is not surprised by your actions, such as drawing blood."


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


For more information on preventing violence in the ED, contact:

  • Pam Turner, RN, BSN, Assistant Nurse Manager, Emergency Department, Harborview Medical Center, Seattle. Phone: (206) 744-6306. E-mail:

Debrief and train to prevent violence

A plan to prevent assaults by patients, and a plan for what to do if despite your best efforts, violence occurs. Your ED needs both of these in place to protect ED nurses, says Pam Turner, RN, BSN, assistant nurse manager of the ED at Harborview Medical Center in Seattle.

"Your ED should have specific policies and training procedures in place that outline techniques for staff to deal with patients at risk for becoming violent," says Turner. You also need a plan in place for debriefing staff after violent incidents when they do occur.

Turner says debriefing should achieve these three goals:

  • ensuring that the patient and staff members are OK;
  • helping staff focus on what they can learn from the incident;
  • allowing staff to improve the way their team addresses violent incidents.

At Harborview's ED, nurses receive specific training and physical competencies that focus on de-escalation techniques. "We also equip our nurses and other ED staff with personal protective actions and nonviolent physical intervention plans," says Turner.

The Cleveland Clinic ED has a work force violence strategy in place, says Barb Morgan, MSN, RN, nursing director of emergency services. "We also send our emergency department employees across the health system to different courses depending on the location," she reports. These include internal courses through the hospital's psychology department, as well as outside programs such as courses offered by Fort Myers, FL-based Non Abusive Psychological & Physical Intervention (NAPPI) International and the Brookfield, WI-based Crisis Prevention Institute.

"These courses help hospital employees identify the people who are potentially violent and learn techniques of dealing with violent patients," says Morgan.


Non Abusive Psychological & Physical Intervention (NAPPI) International offers a safety training program that covers assessing and preventing escalating behavior, manual and mechanical restraint, safely de-escalating and defusing, and self-protection skills. A one-day course is $299. For more information, contact:

Nonviolent Crisis Intervention training demonstrates how you can use empathic listening skills, verbal intervention strategies, and limit-setting techniques to calm hostile and agitated individuals. A one-day seminar costs $459. For more information, contact: