According to recent surveys done by ACEP and ENA, nearly 70% of ED nurses and almost half of Emergency Physicians have been assaulted while on the job. These results led to a joint campaign to stop attacks and protect ED professionals and patients called, “No Silence on ED Violence”. Workplace violence researchers have noted that health care providers severely under report violence for many reasons.

Some of these are:

  • There’s often no reporting mechanism in place for employees—and if one exists, employees may not be trained how to use it.
  • Reporting violence is time-consuming and may even require the victim to appear in court.
  • Studies have shown there is a large number of employees who feel that nothing will be done about it anyway, so they choose not to report incidents to supervisors, managers, security, or law enforcement.


What can be done on a systems level?:

  • High-risk environments:
    • Large security force
    • Metal detectors
    • Bulletproof Plexiglas in triage areas
    • Keypad security entry system
    • Monitoring entry into the ED
    • Strong barriers to prevent cars from driving into the department
    • General prevention measures:
  • Security personnel:
    • A well-trained and responsive security force is a key element of any security system. Nevertheless, security personnel constitute a significant expense, and their services are often curtailed or eliminated when hospitals face fiscal difficulties.
  • Alarm systems:
    • Alarm systems are commonly used in the ED and psychiatric wards. The goal of any alarm system is to obtain rapid assistance. Panic buttons in each room activate a central buzzer in the ED. Every ED should have at least one telephone with a direct line to police or security in case additional personnel are needed.
  • Caretaker education:
    • Regular, brief education sessions with clinicians, nurses, and ancillary staff to train them in the prevention and management of agitated and violent patients may reduce the incidence of violence and improve work satisfaction.
  • Establish a WPV committee:
    • Creating a multidisciplinary WPV committee should be the first step for each facility or practice, and it should meet regularly. The committee should include security/police, patient relations, nursing, physicians, ancillary staff, legal, and hospital administration.
  • Perform a hazard vulnerability analysis:
    • A hazard vulnerability analysis is a tool facilitating regular analysis of deficiencies to prepare for unwanted events. The WPV committee can evaluate for facility and unit-level vulnerabilities in infrastructure, security/police, staffing, reporting, case review, and necessary interventions. Deficiencies are scored and prioritized, and funds are applied where they would be the most impactful.
  • Guarantee reviews:
    • In addition to efficient reporting methods, there must be a guarantee that each incident will undergo review to ensure that appropriate action is taken. Results of this process should include follow-up with the complainant, with referral for psychological support and debriefing, flagging of the patient’s chart to alert other providers, discussion with the patient if possible, and legal action if appropriate.
  • Expand WPV training to medical students/interns:
    • It’s incredible to realize that health care WPV is rarely, if ever, discussed in medical school and residency-training programs. It seems bizarre that such a serious, widespread issue is completely unknown to students entering the field. It’s even more concerning that EM residents can graduate without ever understanding there’s even an issue—but there will certainly be WPV victims among them. We need to inform residents about the reality that they have a high likelihood of experiencing violence during their career and how to avoid it.


What can be done on an individual level?:

  • Identify risk factors
    • Substance use
    • Male gender
    • Acute psychosis
    •  Delirium
    •  Dementia
  • Known psychiatric illness such as:
    • Schizophrenia
    • Personality disorders
    • Mania
    • Psychotic depression
    • History of violence
      • NOTE: Ethnicity, age, marital status and education do not reliably predict violent behavior!
  • Set up a safe environment for patient evaluation:
    • Ensure the patient is disarmed
      • Metal detectors
      • Place patient in gown
        • Setting of interview should be private, but not isolated
          • Seclusion room, if possible
          • Door open
          • Remove glasses, earrings, neckties, and necklaces
          • Beware of anything that you are carrying that could be used as a weapon
            • Pens
            • Watches
            • Belts
            • Trauma shears
        • Sit between the patient and the door
          • Room should not contain heavy objects that may be thrown
        • Mechanism for alerting others of danger
          • Panic button
          • Code word or phrase that instructs others to call for security
    • Continuously observe for signs of impending violence:
      • Provocative behavior
      • Angry demeanor
      • Loud, aggressive speech
      • Tense posturing:
        • Gripping arm rails tightly
        • Clenching fists
    • Frequently changing body position/pacing
    • Aggressive acts:
      • Pounding walls
      • Throwing objects
      • Hitting oneself


Methods of De-escalation:

    • Verbal techniques
      • Respect personal space
      • Do not be provocative
      • Establish verbal contact
      • Use concise, simple language
      • Identify feelings and desires
      • Listen closely
      • Set clear limits
      • Offer choices and optimism
      • Debrief the patient and staff
      • The 3 F’s
        • Feel, felt, found
          • “I understand how you could feel that way. Others in the same situation have feltthat way too. Most have found that doing ___ can help.”
        • Philosophy of yes
          • “Yes, as soon as …”
          • “Okay, but first we need to …”
          • “I absolutely understand why you want that done, but in my experience, there are better ways of getting what you need.”
        • Physical restraints:
          • Indications for emergency seclusion and restraints:
            • Imminent harm to others
            • Imminent harm to the patient
            • Significant disruption of important treatment
            • Damage to the environment
          • Should be applied systematically:
            • Starting with a preassigned extremity
            • Restraint should be tied to solid frame of bed
            • Whenever possible, treating physician should not be part of the restraint team
          • Restrained patients under the influence of cocaine, amphetamines, or other stimulants appear to be at particularly high risk for adverse outcomes. Increased sympathetic tone and altered pain sensation may allow exertion beyond normal physiologic limits in these patients and may cause vasoconstriction that impedes the clearance of metabolic waste products. Altered respiratory mechanics due to a restrained posture in an academic patient may impair respiratory compensation.
          • Monitoring:
            • Frequent position changes
            • Basic needs
            • Medical management
              • Vitals
              • Neuro checks
              • Glucose
              • Remove ASAP


Chemical restraints:

    • Benzodiazepines
    • First-generation (typical) antipsychotics
    • Second-generation (atypical) antipsychotics
    • Ketamine


Common Mistakes:

  • Failing to address violence directly
  • Arguing, machismo, condescension, or commanding the patient to calm down
  • Threatening to call security
  • Criticizing or interrupting the patient
  • Responding defensively
  • Taking the patient’s agitation personally
  • Not clarifying what the patient wants before responding
  • Lying to a patient
  • Not taking threats seriously


Defense against assault:

  • Maintain a sideward posture
  • Keep arms ready for self-protection
  • For punches and kicks – deflect with an arm or a leg
  • For choking – tuck chin to protect airway and carotid arteries
  • For biting – push toward the mouth and hold the nares shut to entice opening of the mouth
    • DO NOT pull away
  • If threatened with a weapon:
    • Try to appear calm
    • Comply with demands
    • Adopt a non threatening posture
    • Avoid sudden movements
    • DO NOT attempt to reach for the weapon
  • If taken hostage:
    • Attempt to establish a human connection with the hostage taker
    • Offer to administer to ill or injured hostages
    • DO NOT bargain, make promises, or lie.
    • Reassure the hostage taker that someone authorized to hear his or her complaints or demands should arrive promptly


Listen to the Episode


  1. Moore, G. & Pfaff, J.A. (2020). Assessment and emergency management of the acutely agitated or violent adult. In T.W. Post, R. S. Hockberger, & J. Grayzel (Eds.), UptoDate. Available from
  2. d’Ettorre, G., & Pellicani, V. (2017). Workplace Violence Toward Mental Healthcare Workers Employed in Psychiatric Wards. Safety and health at work, 8(4), 337–342.
Workplace Violence

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