Step One: Understanding the Issue


In this step, we will define your role as the project leader and help you to become an expert resource on the issue of emergency department workplace violence by providing you with information and references for you to study regarding the medical, legal, regulatory and ethical issues surrounding violence in the emergency department. Critical statistical information has been compiled by ENA for you so that you emphasize the importance of making this a priority project to your administrative decision makers.

As the project leader, you are accepting responsibility for change in your department, your hospital and in the greater community. Perhaps you are also considering participating in the initiative for more legislation governing protection of emergency department workers and prosecuting assailants. In this section, ENA will provide you with resources to introduce you to this issue and help you feel comfortable being a thought leader and engaging in the educated discussion necessary to bring a team together to work on this important project.

Begin using this toolkit by reading through this first section and downloading the resources provided to become familiar with the issues, the research initiatives, available guidelines and community and legislative support surrounding emergency department workplace violence.

Comprehensive Approach Defining the Problem Promoting a Culture of Safety Resources Summary and Next Steps


Comprehensive Approach

ENA recognizes that the issue of workplace violence unfolds in three major areas. Unlike some situations or hazards that can be prevented completely, emergency department workplace violence initiatives need to be structured to have a multifocal impact because regardless of how secure you make your emergency department, an occurrence is likely over time. Our job is to help you improve the safety of your emergency department by addressing this issue from these directions:

  • Acknowledge intolerance of all workplace violence and necessity to put measures in place to prevent it from happening in the first place
  • Raise awareness of the culture of acceptance and promote the importance of recognizing escalating situations and intervening early
  • Understand the barriers to an effective prevention program


  • Identify the barriers to swift, effective and safe response to an occurrence
  • Educate the following groups on appropriate response policies, procedures and skills to minimize the likelihood of harm to a patient or staff member
    • Emergency department staff
    • Emergency department management
    • Patients/families
    • Hospital administration


  • Acknowledge that occurrence reports hold valuable information for future improvements and should never generate a punitive response
  • Staff culture and attitudes have an impact on the generation of reports when a violent incident occurs
  • Lack of reporting can impede an initiative to improving the safety of your emergency department for patients and staff


Prevent, respond, report--your new guideline for approaching the problem of emergency department workplace violence on all fronts, in all areas requiring potential improvement.


Background: Workplace Violence Defined

Ideally, the workplace should be free of violent threats or actions and staff should feel safe while at work. Workplace violence has been defined as an act of aggression directed towards persons at work or on duty and ranges from offensive or threatening language to homicide. (1) Workplace violence is commonly understood as any physical assault, emotional or verbal abuse or threatening, harassing or coercive behavior in the work setting that causes physical or emotional harm. (1-6) Workplace violence has gained recognition as a distinct category of violent crime that requires specific responses from employers, law enforcement and the community. (4)

We know that the workers in the health care industry are particularly vulnerable to nonfatal workplace injuries resulting from assaults and violent acts against them. (1,3,6-7) In fact, health care leads all other sectors in the incidence of nonfatal workplace assaults. (4-5,7-9)


Studies have shown that between 35% and 80% of hospital staff have been physically assaulted at least once during their careers. (9) According to 2009 data from the Bureau of Labor Statistics, among health care practitioners, 46% of all nonfatal assaults and violent acts requiring days away from work were committed against registered nurses. (10)

Some of the reasons nurses are at increased risk for workplace violence in the hospital environment include (5,7,11):

  • Lack of violence prevention programs
  • Low staffing levels
  • Lack of effective staff training in recognizing and coping with potentially dangerous patients
  • Inadequate security in some hospitals
  • The tendency for some to view hospitals as sources of drugs and money which makes them robbery targets
  • The presence of guns and other weapons among hospital patients and visitors

In the health care industry, it is difficult to get accurate incidence statistics because violence is often underreported. (7,12-14) Why would an employee fail to report a threatening or injurious action, directly affecting his or her personal safety and well being? In the health care environment as we know it, it may be because (6-9):

  • There is a lack of institutional reporting policies; that is, the employee doesn't know HOW to report it
  • Some employees have a perception that assaults are part of the job
  • Some employees don't believe that reporting will benefit them or correct the situation
  • There are concerns that assaults by patients and visitors may be viewed as a result of poor performance or negligence of the employee


The emergency department setting is particularly vulnerable to violence because of the 24-hour accessibility of the department to the public, the lack of adequately trained, armed or visible security guards and an overall stressful environment. (15-17) Factors such as patient pain and discomfort, family member stress due to a patient’s condition and fear of the unknown, family member anger related to hospital policies and the health care system in general, and the combination of cramped space and long wait times may increase emotional tension among patients and visitors in the emergency department.(4-5,14,17) And, because emergency care services are perceived to be a public entitlement, nurses are often empathetic to the frustration and vulnerability of the patients and visitors, and violence is frequently considered to be just part of the job.(5,15,18)

A National Culture of Safety for Employees, Patients and Visitors

In leading the initiative at your institution to provide a safer environment for staff, patients and visitors, you are joining a growing faction of your colleagues and regulatory agencies that are calling for closer inspection of current practice and recommedations for action, with focus on the role of emergency department leaders and hospital administration in recognizing that the safety of our emergency department staff, patients and visitors deserves priority attention.

Emergency Nurses Association

ENA has completed a comprehensive review of the issue of violence in the emergency care setting studying the causes, effects and needs of current emergency departments in relation to this critical problem. As part of this toolkit, we recommend that you download the resources linked below and use this information to become well versed in the history and extent of the problem of workplace violence and the consequences and needs outlined by ENA.

In ENA's position statement, Violence in the Emergency Care Setting, it was asserted that health care organizations "must take preventive measures to circumvent workplace violence and ensure the safety of all health care workers, their patients and visitors".(19) The position statement outlines the role and responsibilities of emergency nurses in preventing, responding to and reporting workplace violence. ENA's position statement will help identify to your own administration, the national initiative in place to address violence in the emergency department. Review this position statement by clicking on the first link below.

In 2009, ENA published a study entitled, Violence Against Nurses Working in US Emergency Departments. In an effort to better understand the strategies necessary to effectively address this problem and facilitate a safer workplace for emergency nurses, the study focused on investigating nurses' experiences and perceptions of violence from patients and visitors in emergency departments in the United States. View the methods and findings by clicking on the second link below.

Continuing the effort to further under the breadth of the problem of workplace violence against emergency nurses, ENA initiated the Emergency Department Violence Surveillance study in 2009. Data was collected quarterly via an online survey on the occurrence of violence toward emergency nurses and the processes used to respond to workplace violence. The second report (third link below) represents analysis of the first eight consecutive rounds of data collected approximately three months apart (May 2009 - January 2011).

Reviewing and familiarizing yourself with these ENA resources are important first steps in helping you, as the project leader, defend the scope and magnitude of this issue in your own emergency department. These resources will help you punctuate the need for a proactive program that addresses the violence prevention, response and reporting needs in your own hospital.

Occupational Safety and Health Administration

The U.S. Department of Labor charges the Occupational Safety and Health Administration (OSHA) with setting standards for workplace safety for the American workforce. In 2004, OSHA released guidelines to help employers "establish effective workplace violence prevention programs adapted to their specific worksites." The guidelines issued by OSHA specifically address the violence inflicted by patients or clients against staff although it does suggest that a zero tolerance policy be established for violence against workers from all sources. OSHA acknowledges that assaults represent a serious safety and health hazard within the health care industry. In response, they have developed the following guidelines for employers to consider when developing a violence prevention program. We suggest you review these recommendations as part of developing your action plan and review the emphasis that OSHA places on institutional elements that can affect the successful implementation of a violence prevention program. There are target areas for consideration outlined in this document located under the section links and we will refer to these as we proceed through the steps of the toolkit.

The Joint Commission

ENA is not alone in recognizing the importance of initiating violence mitigation programs in emergency departments across the United States. A recent Sentinel Event Alert was issued by The Joint Commission identifying the rising rate of violent crimes in health care institutions and offering a list of thirteen suggested actions that organizations can take to prevent violent crimes in their health care facilities.

As an organization, The Joint Commission has always recognized the importance of providing a safe environment for the patient. In an informal review of the standards for accreditation of hospitals, the ENA work team has revealed several areas where a lack of a workplace violence mitigation initiative could negatively affect the accreditation process as a deficiency. Conversely, we believe that engaging in workplace violence initiatives proactively, like using this ENA toolkit to map an improvement project, could provide the evidence of ongoing quality improvement that would reflect favorably during the accreditation process, especially when you use this process as a guide and complete the documentation templates in the toolkit.

This ENA work team review of the standards for accreditation resulted in a list of potential areas where a workplace violence project could contribute to a successful Joint Commission accreditation. The link for this list is at the end of this section below. Note that we have referenced the toolkit concepts or solutions that would contribute to a best response to that standard.

Certainly, the primary goal of this toolkit is to help you construct an initiative that has a direct, positive effect on the safety of your emergency department with regard to workplace violence. So why worry about whether standards are being met? Because hospital accreditation is often critical to a hospital's financial survival. Earlier, we discussed the importance of identifying the stakeholders in your workplace violence initiatives and building "buy-in" from emergency department management and hospital administration. While we all see the obvious value of keeping our employees safe, being able to tie this project into an administrative necessity, like accreditation, will build support from the administrators that are charged with the viability of the hospital. And promoting this initiative, giving it visibility and "top down" support from your hospital management helps us meet the safety goals and objectives you will be outlining for your department, your hospital, your staff.


American College of Emergency Physicians

Our medical colleagues at the American College of Emergency Physicians (ACEP) have a position statement and and have worked through local chapters to change laws that govern the prosecution and penalties associated with violent acts against health care workers.


The Occupational Safety and Health Administration (OSHA) has published the Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, which includes policy recommendations and practical corrective measures to help prevent and mitigate the effects of workplace violence. The guidelines are voluntary. While implied in The Joint Commission certifications standards and the criteria for Magnet status acquisition, health care workers and their professional organizations believe that safe practices should not be voluntary guidelines or recommendations. Nursing and other health care professional organizations and unions are advocating for federal standards and regulations that require health care institutions to practice effective violence prevention and response.

  1. Emergency Department Violence Surveillance Study
  2. Emergency Nurses Association Position Statement: Violence in the Emergency Care Setting
  3. Violence Against Nurses Working in US Emergency Departments, Journal of Nursing Administration, July/August 2009
  4. The Joint Commission: Sentinel Event Issue 45, June 3, 2010 "Preventing Violence in the Healthcare Setting"
  5. Review of The Joint Commission 2010 Hospital Accreditation Standards Related to Workplace Violence
  6. OSHA Guidelines for Preventing Workplace Violence for Health Care and Social Workers: A Summary of Recommendations
  7. ACEP Policy Statement: Protection from Physical Violence in the Emergency Department Environment

In this step, we have identified that an important beginning to a workplace violence initiative is to become familiar with the issue of violence in the workplace, the emergency department, and review the steps that have been taken by other organizations to analyze this growing concern. At the completion of this step, you should have the resources to discuss factual information about the issue of workplace violence and have the resources to validate a quality improvement initiative addressing this problem.

  • As the leader of this initiative, you must be an expert in the issue and this section of the toolkit has provided you with several resources to familiarize yourself and be prepared to discuss this issue with administration, managers and staff.
  • Reviewing this section will help you understand the importance of addressing this issue on three fronts; hence, the ENA Toolkit direction of Prevent. Respond. Report. A comprehensive knowledge, assessment and plan needs to cover all three of these perspectives on workplace violence.
  • Download the articles and guidelines that are presented in this step to share with key stakeholders that will assist you in building a work team to address this issue or participate in the team as a working member.

In the next step of this toolkit, you will be given the information and tools to assess your own emergency department's status in a variety of ways--staff, culture, environment--and when completed, will product the information needed to create an action plan targeted at your department's specific needs.

Evaluating your emergency department's present status