Research suggests peer support programs that may have been developed to support clinicians following an adverse event or medical error also be leveraged to help those suffering from stress, anxiety, or other emotional difficulties following incidents of workplace violence. Administrators of the forYOU program at the University of Missouri Health Care have found the intervention is generalizable to many types of circumstances.

  • Between 2009 and 2019, investigators reported 9% of forYOU program interventions were related to workplace violence. However, between 2018 and 2019, 20% of the interventions were related to workplace violence.
  • Experts note the key to the success of this initiative is choosing the right people to serve as peer supporters — those who can provide an empathic presence.
  • The forYOU program relies on local leaders to identify peer supporters; then, candidates undergo training to learn about what people experience when they go through a clinically challenging event, and how to engage in conversations with individuals in crisis.
  • Leaders across the healthcare organization must learn about the program and regularly engage with the peer support team.

The Occupational Safety and Health Administration reports roughly three-quarters of all workplace violence incidents occur in healthcare settings.1 Further, EDs are consistently found to be among the most common sites of workplace violence in healthcare.2-4

Beefed-up security and other safety measures are critical to keeping healthcare workers and patients safe from this violence. But research suggests there are other important steps organizations can take to help those who have been exposed to on-the-job violence.

Investigators reported well-organized systems of peer support can be marshaled to help those who may be experiencing stress and anxiety following a workplace violence episode.5

Administrators of the forYOU program at the University of Missouri Health Care report they began seeing an increase in referrals for peer support related to workplace violence about five years ago, and the trend has been accelerating of late. Between 2009 and 2019, investigators reported 9% of the peer support interventions were related to workplace violence. However, looking at just the 2018-2019 period, 20% of the interventions were related to workplace violence.

The health system has learned several lessons along the way regarding the importance of providing peer support to healthcare workers affected by workplace violence. Leaders also learned how to respond most effectively to individuals who are suffering emotionally from their exposure to such incidents.

Susan Scott, PhD, RN, CPPS, FAAN, a nurse scientist and associate professor at the University of Missouri Health Care, says the forYOU program’s expansion into cases involving workplace violence was organic, as calls for peer support assistance relating to such incidents began to increase. Fortunately, administrators discovered the intervention is generalizable to many different types of incidents.

“When the [forYOU] team first started, we were kind of looking at adverse events related to medical errors. Quickly, even before the team was deployed, we expanded that scope to include unanticipated clinical events without any type of medical error,” Scott relates. “Then, we expanded again to tragic clinician losses — the loss of a co-worker or death of a co-worker, and workplace violence. Now, we are also offering COVID-related support.”

While such interventions can be helpful, the efficacy often depends heavily on who is providing the peer support. “The main key is to pick the right supporters to serve their co-workers,” Scott stresses.

She advises colleagues to look for individuals with a natural, empathic presence, people who are nurturers. “[We] ask local leadership to identify individuals who have very high emotional intelligence,” Scott says.

To be more precise, Scott will ask leaders to think about those who offer a supportive presence when the department is very swamped with patients. “These individuals tend to be natural confidants for their peers; they hold their confidence and people trust them. These are the kind of people we try to recruit for the [forYOU] team,” Scott says.

Initially, forYOU administrators looked for physicians and nurses to serve as voluntary peer supporters, but they quickly realized the need for a multidisciplinary team.

“There are a lot of individuals within the healthcare environment who can also experience exposures to emotionally challenging ... events that need support,” Scott notes.

For example, she says about 20% of the support offered through the forYOU program goes to non-allied health-trained individuals (e.g., environmental services workers, interpreters, security guards, and many others).

“It is important that you have mechanisms in place so that you can address any of those types of individuals [as well as clinicians],” Scott adds.

Determining the right number of peer supporters to put on a unit depends, in part, on how many second victim incidents have been reported in the area in the last year and whether the individuals reporting such experiences received emotional support from someone within the organization following the experience. This information is derived from culture surveys the healthcare organization collects on a regular basis.

Once peer supporter candidates are nominated and selected, they go through a training course through which they learn about what people experience when they go through a clinically challenging event. Candidates also learn about typical healing patterns so they can intervene at different stages.

“They also learn about partnering and having conversations with individuals in crisis, how to offer a supportive presence,” Scott explains.

Developers of the forYOU approach realized quickly they would need to provide multiple ways to identify people who could benefit from peer support.

“Only about 15% of healthcare workers will ask for help on their own behalf. As healthcare workers, we are very good at helping people, but we are very poor at [requesting assistance],” Scott observes.

Consequently, while the program provides multiple modes of contact people can use to contact the forYOU team, it also relies heavily on local leaders to let them know when intervention might be helpful. “They are the ones who can identify when something goes wrong and to holistically think about who could be involved,” Scott says.

For example, when there is a mass casualty event, a local leader might identify not just the clinicians involved in caring for the patients, but also an environmental services worker who he discovered crying in the locker room after cleaning up after the event. “He would reach out to the forYOU team on behalf of the care team members,” Scott explains.

Another way the program monitors for opportunities to intervene is through the active surveillance efforts of the trained peer supporters. For instance, during shift report, a peer supporter might hear about a mass casualty event that happened the night before.

“That is when the antenna of the peer supporter would be peaked,” Scott says. “The peer supporter would want to know who was involved ... and then to proactively reach out to those folks to make sure they are doing OK.”

Healthcare workers who have benefitted from the intervention are telling forYOU program managers about other colleagues who are hurting. In some cases, these workers will suggest it might help for these hurting workers to talk to someone on the forYOU team.

“The whole culture is evolving into more of a nurturing, caring-for-our-workers mentality,” Scott says. “I think that has been heightened with COVID.”

Prioritize Connections

Finding the time in a busy work environment is challenging, but Scott stresses peer supporters have become creative in finding opportunities to connect with those in need.

“Our average peer support conversation is only 22 minutes, so it is just a little bit longer than the average break might be for people,” she explains. “I know average breaks are few and far between, but people make it work.”

Sometimes, supervisors will cover a little bit extra, or they might enable a staff member to take lunch at the same time as the peer supporter.

“Prior to COVID, we did almost everything face to face. There were very few virtual, over-the-phone or text messages,” Scott recalls. “Now that COVID is here, we are doing a few more [interactions] virtually than face to face. Those seem to be working OK ... peer supporters just make them happen.”

Healthcare personnel who experience physical injuries as a result of workplace violence will be treated for those injuries first. Then, their care will be complemented with emotional support. However, Scott notes about half of employees exposed to workplace violence will suffer from emotional injuries that are, in some ways, harder to treat because there are no obvious bites or scratches.

“The emotional harm you can’t really see, and that is why peer support is so helpful in these particular cases,” Scott says.

In about 13% of cases, workers will require help beyond what the peer supporter can provide. In these cases, there is an escalated process that makes additional mental health resources available.

Spread the Word

Staci Walters, MSN, RN, CNL, CPPS, spent many years as an ED nurse, where she witnessed the effects of workplace violence. “I can think of one specific time when a very experienced nurse was taking care of a teenaged psychiatric patient, and the nurse suffered a significant injury. She really thought she was trying to help the person, and [the assault] came out of the blue,” recalls Walters, who now works as a risk management and claims consultant for Healthcare Services Group in Jefferson City, MO.

The nurse said she would deal with it on her own, but as the nurse’s manager, Walters now believes she should have advocated for more involvement with the forYOU team.

“It wasn’t until I really stepped into a patient safety position and had official training with the forYOU team that I realized how much I should have pushed for it as a department leader,” she says.

Today, Walters considers it fundamental to educate all healthcare supervisors about the program and encourage their involvement with peer support teams.

“Frontline supervisors need to know what it is, and managers and directors need to not only be supportive, but also encouraging [personnel] to reach out to [peer supporters].”

Such advocacy should extend to making sure a manager’s own department is adequately represented by peer supporters.

“Education to the entire staff [is important],” she says. “They have to know that [peer support] is available, and that it is not just for the extraordinary cases. It is for the everyday cases that can build on each other.”

Echoing Scott’s sentiments, Walters emphasizes that for an initiative to work, leaders must recruit the right peer supporters. This goes beyond only offering an opportunity for career advancement in exchange for participation, which might not attract those best suited for the role.

“Some people have the innate ability to be good peer supporters. I think for a peer support system to work in the ED, the people almost have to be hand-selected. Managers and supervisors know who those natural nurturers are,” Walters says.

Walters says some of the best peer supporters are those who have been on the receiving end of such encouragement in the past.

“They recognize that it helped them through an event, and maybe several events in a row,” she says. “They are able to take some of those tools [that they learned] and pass them on to the people who they support.”

In an ED, it is especially important to include EMS professionals as part of the peer support group. “Recognize that there is a lot of shared experience,” Walters adds.

Administrators interested in establishing a peer support program should delve into the second victim experience to ensure they have a thorough understanding of what the impact can be. “Awareness is the first intervention,” Scott says. “As humans, we have some very predictable responses to stress. If [leaders] can understand that, they can understand there are some key clinical events that could evoke a second victim response.”

Next, start proactively gauging the interest in developing a peer support program. Leaders might be surprised at the response. “What I have found is that when one person is interested in helping to develop a program like this, there is almost a groundswell of people who want to help you, and a lot of them are newer graduates,” Scott says.

Finally, engage a key executive champion who appreciates the value of an established peer support system. “Let’s normalize this so that we have something in place, and we don’t have to piecemeal it with each crisis that happens to come up,” Scott says. 


  1. Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 2016.
  2. Baydin A, Erenler AK. Workplace violence in emergency department and its effects on emergency staff. Int J Emerg Ment Health 2014;16:288-290.
  3. Kowalenko T, Gates D, Gillespie GL, et al. Prospective study of violence against ED workers. Am J Emerg Med 2013;31:197-205.
  4. Stene J, Larson E, Levy M, Dohlman M. Workplace violence in the emergency department: Giving staff the tools and support to report. Perm J 2015;19:e113-e117.
  5. Busch IM, Scott SD, Connors C, et al. The role of institution-based peer support for health care workers emotionally affected by workplace violence. Jt Comm J Qual Patient Saf 2021;47:146-156.