Take steps to curb violence, improve safety for ED personnel

Hospitals use staff training, metal detectors, and visible security personnel to address violence

The potential for violence in the ED is well-recognized and often discussed. Several organizations such as The National Institute for Occupational Safety and Health at the Centers for Disease Control in Atlanta, GA, for example, cite the ED as being one of the most dangerous places in health care to work, and a study completed last year by the Des Plaines, IL-based Emergency Nurses Association noted that every week, between 8% and 13% of ED nurses experience some type of physical violence in the course of doing their jobs.1

Despite the subject's high profile, however, there is not a lot of hard data on what strategies are most effective at de-escalating tense situations or dealing with violent eruptions when they do occur, explains Stephen Davis, MPA, MSW, the director of clinical research and an adjunct associate professor at West Virginia University Department of Emergency Medicine in Morgantown, WV. The harsh reality of the situation was brought painfully close to home for Davis when a family member who was working as a triage nurse was assaulted while on the job. The incident prompted Davis to join colleagues in taking a closer look at violence in the ED to see what solutions were being leveraged to manage the problem.

Carefully consider location of security

The researchers, led by Marcelina Behnam, MD, an emergency medicine physician at Santa Clara Medical Center in Santa Clara, CA, surveyed a cross-section of ED physicians about the issue, and what they learned was sobering: Out of 263 surveys that were returned and analyzed, more than three-quarters (78%) reported at least one incident of workplace violence in the previous 12 months. Further, while the most common type of violence reported involved verbal threats, 21% reported physical assaults, 5% reported confrontations outside of the workplace, and 2% reported incidents involving stalking.2

Most of the survey participants noted that their EDs offered full-time security, although less common was a security presence where patients were receiving care, says Davis. Further, 40% reported that their EDs employed some type of weapons screening, and 38% utilized metal detectors. Just 16% reported that their EDs offered some type of violence workshop, and fewer than 10% offered self-defense training.

Davis concedes that the research is just a first step toward finding out what strategies work well, and where new approaches need to be tried. However, the research highlights several areas that ED managers should consider when reviewing their own security procedures.

For example, while many survey participants reported that their EDs offer security at the point of access, violent incidents tended to occur back in patient care areas. "We received some feedback about EDs trying to put security in the ambulance bay or the trauma bay to get more of a presence in the patient care areas," says Davis. "That's something we need to look at to see if it is more effective."

Some EDs reported that they were posting security personnel out in the parking lots, while others were providing security escorts to ED personnel as they returned to their cars, he says.

Tightly control access

While incidents of violence are more common in high-volume EDs, smaller operations in less-populated areas are not immune to the problem. The ED at Scotland Memorial Hospital in Laurinburg, NC, was the scene of a shooting incident in February of 2010. The reception area was already outfitted with bullet-proof glass, and there was a log-in system for after-hours visitors, but hospital administrators took additional steps to control access to the ED after the incident occurred.

The shooting was not a random act; the gunman was looking for a person with whom he had had an earlier altercation, explains Karen Carlisle, RN, BSN, the director of Scotland Memorial Hospital's emergency center. Consequently, the ED now goes on lockdown whenever an assault victim is being treated. "No visitors are allowed in the back, and patients have to be wanded [with metal detectors] when they come in the door," she says.

In addition, the hospital hired an additional security officer for each shift, and these officers make more frequent rounds through the facility than they used to. "I think just their presence deters violent behavior," adds Carlisle.

Since the shooting, nurses, techs, and other ED personnel have undergone training on non-violent crisis intervention as well as violent patient management, says Carlisle. If patients or family members become irate or anxious, ED personnel will try to speak with them and calm them down. However, if a person becomes aggressive or starts to make threats, the policy is to call in law enforcement, says Carlisle.

Master verbal techniques

McKee Medical Center in Loveland, CO, began looking at ways to improve security in 2007 as part of an initiative of Phoenix, AZ-based Banner Health. "We were seeing an upswing in behavioral health patients, patients who were agitated, and patients who were violent system-wide," explains Shelley Simkins, MSN, the ED nursing director at McKee. "We realized we needed to prepare a toolkit so that frontline staff would be able to successfully handle these patients with the best outcome." (Also, see Management Tip on consulting frontline staff on how to deal with aggressive behavior, below.)

Simkins adds that McKee's policy is to make every effort to avoid using restraints or medicines to calm patients down. "We don't want [these measures] to be the first line of defense," she says. "We want to create an environment where we can verbally start talking to patients and get them de-escalated so that we don't have to utilize further interventions."

Staff training, which is led by Simkins and the hospital's security team, is key to the approach, says Simkins, explaining that all new hires go through the training, and there are refresher classes offered to existing staff every year. Frontline staff learn to keep an eye out for verbal and non-verbal cues that patients or family members are becoming agitated, and they get schooled in various techniques for effectively communicating with these individuals.

For example, if someone is pacing back and forth or becoming verbally aggressive, it can be helpful to invite the person to sit down so that you can discuss his or her concerns, explains Simkins. "Sometimes just allowing people a period of time to vent their frustrations can help to settle them down," she says. "You don't necessarily have to say a whole lot. They often just want someone to understand what their issue is, and what they are concerned about."

There are times, however, when it is important to calmly establish boundaries or expectations related to a patient's or family member's aggressive behavior, adds Simkins, noting that this can be done tactfully by first indicating that you understand their frustration, but that you need them to help you with the situation.

"Sometimes people lash out because they feel like they don't have control over a situation where a friend or family member is sick. The agitation is a coping mechanism," says Simkins. "What you may hear between the lines is that they have been dealing with the situation for a long time and they are just burned out, so giving them the space to [discuss their difficulties] can bring down the tension level."

When aggressive or agitated outbursts are handled skillfully, there can be rewards beyond the successful de-escalation of the situation. Simkins points out that people have returned to the ED on occasion just to apologize for their behavior and to thank the staff for the way they handled the incident.

Devise an escape route

Verbal de-escalation strategies are helpful, but staff also receive safety guidance. "We include components such as how to remain safe if you are in a patient room. Make sure, for example, that you are always close to a door and that you have an escape route if things start to escalate and you need to get out," explains Simkins. Personnel are also encouraged to call security or the police if they feel they are in danger.

A crowded waiting room or long waits to see a provider will heighten anxiety levels, and elevate the risk for aggressive behavior, says Simkins. Consequently, she advises ED managers to consider calling in extra help during such periods. For example, during any high-census period at McKee, a person from guest relations is brought in to make rounds in the waiting room and make sure that all non-medical needs are being met, she says.


  1. Emergency Department Violence Surveillance Study, Emergency Nurses Association Institute for Emergency Nursing Research, August 2010. Web: www.ena.org/IENR/Documents/ENAEDVSReportAugust2010.pdf.
  2. Behnam M, Tillotson R, Davis S, et al. Violence in the emergency department: A national survey of emergency medicine residents and attending physicians. J Emerg Med. 2011;40:565-579.


  • The Emergency Nurses Association offers a web-based workplace violence toolkit that can help ED managers assess their needs, establish goals, and monitor progress. The toolkit can be accessed here: http://www.ena.org/IENR/ViolenceToolKit/Documents/toolkitpg1.htm
  • Karen Carlisle, RN, BSN, Director, Emergency Center, Scotland Memorial Hospital, Laurinburg, NC. E-mail: karen.carlisle@scotlandhealth.org.
  • Stephen Davis, MPA, MSW, Director of Clinical Research and Adjunct Associate Professor, West Virginia University Department of Emergency Medicine, Morgantown, WV. E-mail: smdavis@hsc.wvu.edu.
  • Shelley Simkins, MSN, ED Nursing Director, McKee Medical Center, Loveland, CO. Phone: 970-669-4640.

Management Tip

Consult frontline staff on how to deal with aggressive behavior

To develop a consistent standard of care for dealing with aggressive behavior, be sure to consult with your frontline personnel, advises Shelley Simkins, MSN, the ED nursing director at McKee Medical Center in Loveland, CO. "They're out there every day and they have phenomenal ideas on what can work well in these patient situations and what resources would be helpful," she says.

Also, to access training resources, consider partnering with local law enforcement agencies. "SWAT teams or individuals who handle hostage negotiations are experts at verbal de-escalation strategies," says Simkins. "It really doesn't matter if you are dealing with a hostage situation or an angry patient or family member in the ED. The techniques are basically the same."