Violence in the Emergency Department Mini Literature Review
Purpose statement: The purpose of this paper is to examine the causes and effects of violence towards nurses in the Emergency Department (ED).
Angland, S., Dowling, M., & Casey, D. (2014). Nurses’ perceptions of the factors which cause violence and aggression in the emergency department: A qualitative study.
International Emergency Nursing, 22(3), 134-139. doi:10.1016/j.ienj.2013.09.005
This article examines an Emergency Department (ED) in an Irish urban ED. This qualitative study determined that barriers to communication and environmental factors led
to violence toward ED nurses. In addition, long wait times, substance abuse and the stress of an overcrowded ED contribute to violence and aggression from patients.
Environmental factors include wait times, overcrowding, security issues and triage related issues. Communication factors included interpersonal relationships, attitude
of staff, fear, and vulnerability. However, participants in this study believed that long wait times contributed the most to acts of aggression from patients.
Crilly, J., Chaboyer, W., & Creedy, D. (2004). Violence towards emergency department nurses by patients. Accident & Emergency Nursing, 12(2), 67-73.
This article examines two different emergency departments in which the nurses were asked to fill out a survey. The majority of nurses concluded that most violent acts
occurred during the night shift and were perpetrated by patients who were under the influence of drugs and/or alcohol. In addition, patients with a mental illness were
more likely to commit a violent act.
This article also investigated the types of abuse that nurses endured which included being sworn at, pushed, hit and kicked. Most violent acts occurred at the triage
desk and within 1 hour of presentation to the emergency department. Certain patient characteristics such as demanding behavior or requesting attention were precursors
to aggression, however, ED nurses did not suspect that these behaviors would lead to violence.
SIMILARITIES AND DIFFERENCES BETWEEN ARTICLE 1 & 2
• Long wait times
• Substance abuse
• Most acts of violence occurred at Triage
• Crilly, Chaboyer, and Creedy included mental illness as a contributing factor to violence
• Crilly, Chaboyer, and Creedy investigated the different types of abuse
• Crilly, Chaboyer, and Creedy noted behaviors that would lead to violence
• Angland, Dowling, and Casey were able to differentiate causes of violence into two categories including communication barriers and environmental factors
SYNTHESIZATION OF ARTICLE 1 & 2
Violence in the Emergency Department (ED) has been contributed to various causes including long wait times and substance abuse. Additionally, most violent acts occur
within one hour after presentation to the ED and commonly involve the Triage nurse. However, research has found additional contributing factors and behaviors that
predispose patients to committing aggression and violence in the ED.
Patients suffering from a mental illness are more likely to commit violent acts toward nurses. One study found that 40% of patients who committed acts of violence were
mentally ill (Crilly, Chaboyer, & Creedy, 2004). This study also found that patients who exhibited a demanding behavior or who were requesting attention led to
aggression and that these behaviors were precursors to violence. Additionally, this study concluded that there are various types of abuse including being sworn at,
pushed, hit and kicked.
Another study sought to understand the reasons behind the abuse and summarized the causes into two distinct categories including communication barriers and
environmental factors. Environmental factors include wait times, overcrowding, security issues and triage related issues. Communication factors included interpersonal
relationships, attitude of staff, fear, and vulnerability (Angland, Dowling, & Casey, 2014). Most importantly, both studies found that long wait times contributed
significantly to acts of violence towards nurses in the emergency department.
Kelley, E. C. (2014). Reducing Violence in the Emergency Department: A Rapid Response Team Approach. JEN: Journal Of Emergency Nursing, 40(1), 60-64.
In an effort to reduce violence in the Emergency Department (ED), we must create a response team that has specialized training and the skills necessary to address the
growing harm that nurses face in the workplace. Kelley (2014) recommends that a team approach is essential to combat violence in the ED. In addition, Kelley (2014)
found that “since the introduction of the Code S protocol, take-downs, locked observation, and patient and staff injuries have been reduced dramatically” (p. 62).
Kelley (2014) concludes that various methods including restraint, medications and seclusion can be used to deter violence. However, these methods are only to be used
if strategies such as verbal deescalation do not produce favorable results. A reduction in violence in the ED was achieved after implementation of the Code S protocol
Taylor, J. L., & Rew, L. (2011). A systematic review of the literature: workplace violence in the emergency department. Journal Of Clinical Nursing, 20(7/8), 1072-
A systematic review of the literature regarding workplace violence in the Emergency Department (ED) was conducted in 2011. It was determined that the majority
of the research being done regarding violence in the ED was based on incidence rates and negative outcomes experienced by staff instead of focusing on intervention
based research (Taylor & Rew, 2011). Taylor and Rew (2011) concluded that not much has changed in the way we treat workplace violence in the ED.
Additionally, there were many barriers to determining incidence of violence in the ED. It was determined by Taylor and Rew (2011) that workplace violence is
underreported which poses “a significant barrier to determining the actual depth of the problem” (p. 1083). Inefficient reporting systems and fear of reprisal by
hospital administration attribute to the lack of data available for research purposes.
Powley, D. (2013). Reducing violence and aggression in the emergency department. Emergency Nurse, 21(4), 26-29.
Powley (2013) states that nurses can address workplace violence in the Emergency Department (ED) by reflecting on violent incidents which will enable them to prepare
for similar incidents in the future. The reflective cycle allows nurses to analyze and evaluate the incident as well as prepare an action plan for future incidents.
The five stages of the reflective cycle include: description, feelings and thoughts, evaluation, analysis, conclusion and action plan (Powley, 2013).
Powley (2013) recommends incorporating a three-point action plan when dealing with workplace violence in the ED. The action plan involves attending a training program
that focuses on violence and aggression, recording incidents in a journal and enhancing listening and observational skills (Powley, 2013). In order to reduce workplace
violence it is essential that nurses are aware of their surroundings and use remediation techniques if violent incidences occur.
Ray, M. (2007). The dark side of the job: violence in the emergency department. JEN: Journal Of Emergency Nursing, 33(3), 257-261.
This article focuses on the Emergency Nurses Association (ENA) and the International Council of Nurses (ICN) role in Emergency Department (ED) violence. The ENA and
the ICN are strong advocates for nurses who may experience violence in the workplace. The ENA offers their protection to nurses who may face repercussions for
reporting violence in the ED (Ray, 2007). Additionally, the ICN condemns all forms of abuse towards nurses and works diligently to educate healthcare professionals
about workplace violence.
Support from the ANA and the ICN may promote awareness about violence in the ED, however, it is important that nurses are able to identify triggers and risk factors.
Ray (2007) states that there are multiple risk factors associated with violence in the ED including long wait times, patient pain and discomfort, and lack of
sufficient training for security personnel. In addition, workplace violence can affect morale and employee turnover (Ray, 2007).
SIMILARITIES AND DIFFERENCES BETWEEN ARTICLES 3, 4, 5, 6
• Rew and Taylor (2011) and Ray (2007) state that workplace violence in the Emergency Department (ED) is underreported.
• Kelley (2014) and Powley (2013) state that verbal deescalation techniques should be used to deter violence in the ED.
• Kelley (2014) supports a team approach to combat violence in the ED.
• Taylor and Rew (2011) state that most of the research available regarding violence in the ED is lacking intervention based solutions.
• Powley (2013) focused her research on reflective techniques to prevent future violent incidents in the ED.
SYNTHESIZATION OF ARTICLES 3, 4, 5, 6
Ray (2007) discusses the American Nurses Association (ANA) and the International Council of Nurses’ (ICN) involvement in advocating for nurses that experience violence
in the workplace.
Workplace violence in the Emergency Department (ED) has become of increasing interest to the American Nurses Association (ANA) and the International Council of Nurses
(ICN) due to the increased incidence of altercations (Ray, 2007). Kelley (2014) reported that 50.7% of nurses experience physical and verbal abuse from patients and
visitors. However, these estimates are not entirely accurate because many incidents of violence in the ED is underreported due to a fear of reprisal and an attitude
that it is simply part of the job (Rew & Taylor, 2011).
There are many techniques to deter violence in the ED including de-escalation, reflecting on events, and the implementation of an emergency response team. In addition,
restraints, seclusion and medications could be used but verbal de-escalation should be attempted first (Kelley, 2014). Powley (2013) suggested that reflecting on a
violent incident by journaling could prevent future incidents. However, the most effective measure of minimizing violence in the ED is to implement an emergency
response team that responds to acts of aggression and abuse (Kelley, 2014).
The majority of the research being done regarding violence in the Emergency Department (ED) has been based on incidence rates and negative outcomes experienced by
staff instead of focusing on intervention based research (Taylor & Rew, 2011). According Kelley (2014), it is essential that hospital administrators adopt a team
approach to combat violence in the ED. The intervention of adopting an emergency response team has seen dramatic results and led to reduced violence in the ED (Kelley,