Risky Business: Working Where Violence is the Norm


Systemic ED violence highlights the need for increased training and legal protection

On Tuesday, January 20, cardiac surgeon Michael J. Davidson was shot at his clinic at Brigham and Women’s Hospital in Boston. The shooter, who also took his own life, was the son of 78-year old Marguerite Pasceri, who had died shortly after a procedure Dr. Davidson had performed in November.

My mom lives in the area, and was pretty rattled by the news. She remembered some of the stories I’d told her, about patients I’d seen in the ED – violent drunks, criminals in custody, victims of gang violence. She called me up, wanting to know what kind of safety precautions we had in place.


“The Brigham clinic didn’t have metal detectors!” she said. “Your department must have that, right?”

I explained that, no, we didn’t. I wasn’t really sure why – probably because of logistic difficulties, with so many different entrances to the ED. And metal detectors wouldn’t really send a welcoming message to patients and families, would they? Besides, we are skilled at defusing situations. And security comes quick when we call them. And the sedatives work well.

As I was talking to her, though, I saw a parade of faces from my shifts, spitting, punching, and biting. And threats – many just bluster, but some coldly specific. So far, no one had followed through. I was trying to convince my mom that it was skill that protected me, but as I spoke it really felt more like luck – and I certainly knew colleagues who hadn’t been as lucky.


Statistics about violence towards police reached mainstream news outlets after two NYPD officers were killed on the job in December. But what about emergency care personnel? How at risk are they to violence in our own emergency departments? For whatever reason, I hadn’t really considered healthcare workers as a vulnerable population – until the shooting in Boston.

ED workplace violence, in numbers and stories
As it turns out, healthcare workers in general, and ED staff in particular, face a huge risk of violence. In 2004, OSHA reported that healthcare and social service workers account for nearly half (48%) of all non-fatal injuries reported in the US, from workplace violence and assaults [2]. Healthcare worker deaths seem relatively rare – the Bureau of Labor reports 154 nursing, psychiatric and home health aide fatal injuries from work-related incidents from 1995-2004 [3]. But ICN noted in 2009 that “healthcare workers are more likely to be attacked at work than prison guards and police officers [4].”

Reports of workplace violence in the ED are also widespread. An ED nurse is considered the second most dangerous US civilian occupation, behind NYC cab driver [5]. Surveys have shown somewhere between 42-78% of ED workers report physical assault over the past 12 months [6-9], with many reporting more than one episode. Up to 96% reported a violent assault at some point in their careers [10]. And verbal abuse – be it profanity or specific threats – is even more common.

Definitions of workplace violence vary. Some separate verbal abuse from physical, some don’t. There’s inherent difficulty in measuring when someone feels intimidated or threatened, and retrospective surveys aren’t ideal methods to capture incidence. Memories get fuzzy, some may exaggerate to provoke change, others may ignore surveys rather than relive traumatizing events. When Kowalenko et al looked prospectively at the problem, across a wide variety of ED settings and job roles, they found a high but somewhat lower rate of violent events per ED worker compared to earlier surveys [11]. They were able to extrapolate to about five violent events per year per worker, with four of them being threats. Workers filed a safety report just 42% of the time, with a police report filed just 5% of the time [11].


Kowalenko’s research has helped challenge some preconceived notions. It turns out the night shift may not be more violent than the day shift and urban EDs don’t seem to be more dangerous than rural ones. The data clearly suggest nurses are more at risk for violent events than physicians, though it seems women are at no more risk than males.

Why should the ED be such a risky place to work? The ENA has sketched out the different risks involved [12]:

  • Patient factors: Such as access to substances and weapons
  • Environmental factors: Such as close contact with dangerous patients and families, unrestricted movements, crowding, delays in care leading to frustration, and limited security
  • Staff risk factors: Lack of training, inadequate staffing, and working alone

The literature also supports another key reason for the widespread nature of ED violence; it persists, because it’s tolerated. In a poignant piece by Wolf et al in JEN last year [13], entitled “Nothing Changes, Nobody Cares,” Wolf et al wrote:

“Many nurses described responses from immediate supervisors that were well intentioned and supportive, only to be undercut by hospital administrative responses that discouraged nurses from pressing charges or public officials (eg, police, state attorneys, or judges) who would not charge the perpetrators.”

Examples from nursing narratives abounded in Wolf’s paper. One judge dismissed a complaint with, “Well, isn’t that the nature of the beast, being in the emergency room and all?”

Whether it’s a judge or a DA or a hospital administrator, I suspect it only takes a few experiences like this, where one’s concerns are ignored, to become deeply cynical about ED workplace violence.

But there is room for optimism, and a growing body of research and legislation is pointing the way to potential solutions.

Legislative fixes
State legislatures are stepping up to help address the threat of healthcare workplace violence, particularly in the ED.

California’s OSHA has already implemented a number of measures in that state to reduce workplace violence, with results showing effectiveness in several industries [14]. Last year, motivated by the strangling death of psychiatry tech Donna Gross in 2010, California Governor Jerry Brown signed several laws relating to psychiatry healthcare workers. One law included a requirement that every state hospital establish an “Enhanced Treatment Unit” for aggressive patients who threaten themselves, other patients or staff [15].

Late last year the Georgia state senate convened a committee to hear testimony and make recommendations about the violence in healthcare facilities [16]. That report, which is now online, presented more remarkable statistics. At Northeast Georgia Medical Center, in 2013, for instance, there were 2092 calls for security to help handle combative or aggressive patients. At Grady memorial, 98 physical altercations were recorded in the first 10 months of 2014 – about one every three days [17].

Georgia already elevates the misdemeanor crime of battery felony punishment when it’s against health care workers. The committee recommended that Georgia enact legislation making physical harm or a threat against clinical or non-clinical healthcare workers during the performance of their duty a felony, and they specifically highlighted that security and EMS personnel should be included in this list. Harsher penalties toward those who assault of healthcare workers seems reasonable, but critics allege these measures won’t deter patients who can’t control their actions, and simply criminalize mental illness [18]. Others have noted that few patients are prosecuted for assaulting healthcare workers, regardless of the penalty-the hospital, the police, prosecutors and judges all seem reluctant to move cases forward [19,13]. Still, its hard to read about particular cases and not seek harsher penalties. In Oregon, a woman who broke the arm of a nurse, and repeatedly threatened an ED doctor and his family at home over the phone, was sentenced to anger management classes and five years’ probation. The Oregon ENA supports a bill before their state legislature, SB 132 expanding the definition of third degree assault to include the injury of a healthcare worker [20]. Besides tougher penalties, other legislative solutions may exist. The Georgia panel also recommended following Nebraska’s lead and posting large, visible signs throughout health facilities stating that violence will not be tolerated and violators will be held accountable to the fullest extent of the law. The Georgia panel also recommended that all threatening and violent incidents be reported, and annual training be instituted to help staff identify violent patients and circumstances, and attempt de-escalation.

Research on local solutions
While there is not much literature on the effectiveness of these various measures, the Minnesota Nurses’ Study did find a significant decrease in physical assaults in the workplace after a zero-tolerance policy was enacted [21]. The CDC and NIOSH have sponsored more research on better reporting of violent events in healthcare, specifically reducing healthcare violence against nurses [22].

In a thorough review of interventions to decrease ED violence, Kowalenko et al noted that 70% of US workplaces do not have a formal policy to address violence [11].  A smart first step for the ED is to adopt OSHA’s general recommendations for a workplace violence prevention program with management support, local worksite analysis and site-specific ideas for improvements.

OSHA has specific recommendations for hospitals and healthcare settings, however, including the above recommendations for site-specific ideas for improvements, engineering controls, personal protective equipment, as well as training for violence prevention, stress management, early recognition, and post-incident procedures [23]. OSHA isn’t just posting recommendations, however. They’ve taken to hitting hospitals where it hurts most. Brookdale University Hospital in New York was fined $78,000 after 40 violent incidents unfolded in the spring of 2014 [24]. In a statement, OSHA area director Kay Gee said, “Brookdale management was aware of these incidents and did not take effective measures to prevent assaults against its employees. The facility’s workplace violence program was ineffective, with many employees unaware of its purpose, specifics or existence [25].”

There’s a cynical interpretation – that the more OSHA institutes rules and fines about ED work-place violence the less those incidents will be reported. Not because their measures are working, but because administrators will discourage reporting. But these measures are necessary for culture change, and in an era of ubiquitous smartphones and easy, anonymous reporting, it seems impossible to keep a lid on dangerous conditions. And while some officials may continue to act indifferently toward attempts at prosecuting violent patients, I doubt many would turn a blind eye to a whistleblower who gets punished by hospital administration.

Improving Security In Your ED
Some security recommendations make so much sense it’s a wonder they haven’t been more widely adopted. A security chief in a Massachusetts clinic set up a security hotline that was easy for staff to remember in the heat of the moment – x4911. He also instituted Code NORA – short for Need an Officer Right Away. Hearing “Nora, please report to the Emergency Department” is at once less cryptic than “Code Silver” or other security alerts, and yet wouldn’t be alarming to patients and families [26].

There’s also great potential for electronic health records to flag patients who had been violent to staff on prior occasions. The minute such a patient returns to the ED, they can be safely sequestered and screened. Staff would stay protected while still delivering the care the patient needs.

Other commonly-discussed measures aren’t as clearly effective. Kowalenko noted that metal detectors have shown promise in a couple of case reports but administrators remain wary about how these detectors will be perceived, and many EDs may not have the layout or security staff to implement metal detectors at each entrance [7].

ACEP weighed in on some measures for reducing workplace violence in 2007 [27]. Among suggestions like “trust your senses” and “keep a safe distance” their brief review included a discussion about arming security guards:

“The New York City Health and Hospitals Corporation estimated that to arm 1,200 hospital police officers in New York City would cost $800 for firearms certification; $500,000 for firearms, ammunition and equipment; and $700,000 for psychological/physical screening, background investigations and use of training ranges… Many hospital staff believe there is increased liability if officers are armed, especially if they take guns home.”

While guns may be cost-prohibitive and introduce additional risks, Tasers used by security has been studied in one urban hospital [28]. Surveyed witnesses felt that Taser use likely prevented injuries (and, in one case, a suicide). Notably, personnel injury rates declined after Tasers were introduced.

Changing the Culture
In the February issue of EPM, Greg Henry [29] drew some comparisons between ED work and police work, and recounted a few stories about how the police had helped him – and how he’d helped them. He wrote:

“In the end, what those in law enforcement and emergency medicine really have in common is a set of fears. Will we go home tonight? Will we be well? Very few people have to think in these terms. We are outliers. While the rest of society depends more and more on modern technology our job remains low tech, high touch, where ever encounter is face to face, one problem at a time.

Go home and ask your non-medical neighbors how many of them have ever been assaulted on the job. See how many of them live in fear of simply being at work. Trust me, they won’t even understand the questions.”

I wholeheartedly agreed with this, and when I read it, I took a measure of pride in it. Now I’m not so sure that was the appropriate response.

violence chart w

In all this reading, I kept coming back to some of the anecdotes and narratives collected by researchers [13]. Two quotes stood out:

Another nurse in the ER gave me a hard time and said if I “couldn’t handle it, I should get out of emergency medicine.” I continue to hear other nurses say violence is “part of the job,” which I find maddening.

“Cues, or precursors to violence, were often missed or ignored in nurses’ narrative ac-counts. A notable category around cue recognition was “without provocation” in which nurses detailed clear cues of threats yet appeared completely taken by surprise at the violent attack or verbal outburst by the patient.”

Consider the lengths we’ll go, as ED physicians, to avoid missing coronary events, or PE, or cord compression, or dissection. Consider the time and expense we take to risk-stratify patients, to reach an appropriate, high threshold for safe disposition. From that perspective, it’s puzzling why we don’t go to the same lengths to protect ourselves from violence.

How did this cowboy mentality – that threats and violence should be tolerated – take hold? Is it a holdover from our training, when we wanted to prove our mettle? Maybe we were concerned that if we made too much noise about feeling unsafe in the workplace our superiors would think we weren’t cut out for working in the ED. Maybe we were alone, unsupervised, and handled a potentially violent situation – and convinced ourselves that we were learning another necessary skill, rather than taking an unnecessary risk.

However we got here, we’ve come to accept a situation that wouldn’t be tolerated anywhere else in the hospital, let alone in other industries.

We may not have the same evidence base or risk calculators for violent events as we do for chest pain, but we still can make an informed guess regarding risk factors for violent outbursts. Maybe it’s a history of violence, or intoxication, or schizophrenia, or a report from EMS or a prior visit. When we see these risk factors, we should take steps to mitigate that risk – perhaps work closely with security, or see patients in pairs. If we’re not sure, we can play it safe for now, and wait for studies on true risk factors before relaxing precautions.

For my part, I’ll look into my institution’s policies regarding workplace violence and see if there are any opportunities to improve safety. I’ll see what training options are available and ask leader-ship what courses on early recognition and de-escalation they plan on mandating. And I’ll make sure, on my shifts, that staff feel safe-that they feel comfortable sharing their concerns, that we all know how to report threats and other violent events up the chain, and that administrators are monitoring these reports and taking action.


  1. Freye, FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. Boston Globe, January 20, 2015. http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html
  2. https://www.osha.gov/Publications/osha3148.pdf
  3. US Bureau of Labor and Statistics. Anne B Hoskins. Occupational injuries, illnesses, and fatalities among nursing, psychiatic, and home health aids, 1995–2004. US Bureaua of La-bor and Statistics Website. Available at: http://www.bls.gov/opub/mlr/cwc/occupational-injuries-illnesses-and-fatalities-among-nursing-psychiatric-and-home-health-aides-1995-2004.pdf
  4. International Council of Nurses (2009) Nursing Matters: Violence: A World- wide Epidemic. Available at: http://www.icn.ch/images/stories/documents/publications/fact_sheets/19k_FS-Violence.pdf
  5. Carlson J. Security lapses; critics urge execs to take safety issues more seriously. Modern HealthCare.com Web site. http://www.modernhealthcare.com/article/20111017/MAGAZINE/310179953
  6. Taylor JL, Rew L. A systematic review of the literature: workplace violence in the emergency department. J Clin Nurs. 2011 Apr;20(7-8):1072-85.
  7. Kowalenko T, Cunningham R, Sachs CJ, Gore R, Barata IA, Gates D, Hargarten SW, Jo-sephson EB, Kamat S, Kerr HD, McClain A. Workplace violence in emergency medicine: current knowledge and future directions. J Emerg Med. 2012 Sep;43(3):523-31.
  8. Fernandes CM, Bouthillette F, Raboud JM, Bullock L, Moore CF, Christenson JM, Grafstein E, Rae S, Ouellet L, Gillrie C, Way M. Violence in the emergency department: a survey of health care workers.  CMAJ. 1999 Nov 16;161(10):1245-8.
  9. Mayer BW, Smith FB, King CA. Factors associated with victimization of personnel in emer-gency departments. J Emerg Nurs. 1999 Oct;25(5):361-6.
  10. Renker P, Scribner SA, Huff P. Staff perspectives of violence in the emergency department: Appeals for consequences, collaboration, and consistency. Work. 2014 Jun 16.
  11. Kowalenko T, Gates D, Gillespie GL, Succor P, Mentzel TK. Prospective study of violence against ED workers. The American Journal of Emergency Medicine, Volume 31, Issue 1, January 2013, Pages 197–205
  12. Emergency Nurses Association. Position statement: violence in the emergency care setting. Emergency Nurses Association Website. Available at: http://www.ena.org/SiteCollectionDocuments/Position%20Statements/ViolenceintheEmergencyCareSetting.pdf
  13. Wolf LA, Delao AM, Perhats C. Nothing changes, nobody cares: understanding the experi-ence of emergency nurses physically or verbally assaulted while providing care. J Emerg Nurs. 2014 Jul;40(4):305-10.
  14. http://www.dir.ca.gov/dosh/dosh_publications/worksecurity.html
  15. http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140AB1340
  16. http://www.fiercehealthcare.com/story/states-seek-solutions-hospital-violence/2014-10-06
  17. http://media.morristechnology.com/webmedia/upload/gainesville/article/2015/01/12/0113PANELDOC.pdf__.pdf
  18. http://www.disabilityrightsnebraska.org/what_we_do/high_priority_bills/lb_752_assault_bill.html
  19. http://thefirsttosayno.com/2014/03/11/useless-laws/
  20. http://www.oregonlive.com/portland/index.ssf/2015/01/woman_who_attacked_nurse_gets.html
  21. Nachreiner NM, Gerberich SG, McGovern PM, et al. Relation be- tween policies and work related assault: Minnesota Nurses’ Study. Occup Environ Med 2005;62:675–81.
  22. http://www.cdc.gov/niosh/topics/violence/traumaviol_research.html
  23. https://www.osha.gov/Publications/osha3148.pdf
  24. http://www.fiercehealthcare.com/story/are-hospitals-responsible-preventing-workplace-violence/2014-08-13
  25. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=26514
  26. Dooley C. Making contact with security. J Healthc Prot Manage. 2014;30(2):117-9.
  27. ACEP 2007 – http://newsroom.acep.org/index.php?s=20301&item=30010
  28. Ho JD, Clinton JE, Lappe MA, Heegaard WG, Williams MF, Miner JR. Introduction of the conducted electrical weapon into the hospital setting. J Emerg Med 2011;41:317–23.
  29. Henry, G. The Thin Blue Line. Emergency Physicians Monthly 2014; 2:1.


SENIOR EDITOR Nicholas Genes is a specialist in emergency medicine informatics in New York City. Dr. Genes is EPM's resident tech guru and can be found sharing his wit and wisdom all over the web.


  1. Jack Poma, RN, MSA on

    This is a very well thought out and research article. I agree with the conclusions in “Nothing Changes, Nobody Cares”. Until zero tolerance policies are adopted by both healthcare institutions AND state legislatures, the rates of violence against healthcare workers, especially ED personnel, will not change.

  2. I have been verbally threatened in my ER twice due to a narcotic related issue. I decided to get a concealed weapons permit. Although a sticker on our sliding door says ” no weapons allowed “, I have very little faith that a violent person will he’d our request

  3. Charles Nozicka DO on

    Agree with the above comment completely. We all must advocate for a zero tolerance policy, this should be federally mandated legislation. Thank you for such a well referenced and well written essay. Its time to change the culture, we do care.

  4. Livia Santiago on

    For years, I have been raising the question of security in the ED, and specifically whether there may be a role for non-lethal defensive strategies, including Tasers. For years these concerns have been treated as litte more than the punch line of a joke, or worse, evidence that I am a terrible doctor or a terrible person. In what other setting do you have security guards or police who refuse to get involved with a violent patient unless the clinician has their hands on the patient? Is the security guard at the bank holding off on jumping in until the teller has the robber restrained?
    This discussion has been awakened by the death of a respected physician colleague in Boston. Let’s not wait for a next casualty in order to act.

  5. I’m in a gun friendly state, but on the door to my ER it says that no one can take a gun inside, and that includes me. When I enter, I’m alone. There is no security guard. The police are 10-15 minutes away. I don’t care how many laws you pass to “protect” me, those laws don’t protect me if I’m dead. You might send the perpetrator to jail, but I’m still dead. I want permission to bring my firearm into work. I carry it to church. I conceal it at the store. It’s in my car. I’m retired military and with all my years of having a firearm in my possession I’ve never shot it at anything other than a target. I’m safe and the gun won’t kill anyone by itself. I want the state to allow me to carry that pistol at work. Some of my nurses break the law and carry, because they would rather go to jail than be dead. I’m the fool since I obey the law that says I have to leave that tool of safety in the car. That’s the law that has to be changed. No once can protect me like me. At the Univ of VA the floor where the murders took place was crawling with cops, but not one of them had a gun, because the university forbade it and state law supported the university. Where’s common sense? The same will happen in my ER. That crazy will come in firing and we’ll duck, but eventually he’ll win and kill us because there’ll be no help in the building.

  6. ER’s by their nature are High Stress, High emotion, environments.. Zero tolerance policies will not change that. Feel good bull crap.. Training will change things. Every punk ( Male or Female ) telegraphs/ tells you what they are going to do.. The Nurses ignored it or did not see it.. Read the books by Gavin De Becker The gift of fear and by Rory Miller Facing violence.. That is the start.
    After 38 years as a PA-C in ER and now Urgent Care, I have seen every type and I can tell you which one is trouble.. You can too if you study and train.. That is your best defense, as well as Martial arts,street fighting training to protect yourself and Firearms training with a concealed carry permit.. Cause bad guys don’t pay attention to laws or warnings unless it is backed up by good people capable of defending themselves and their follow front line soldiers.. Train, educate and prepare yourself. today may be your last day. This is your life we are talking about..

  7. Thank you, Jack! One small step I’ve started taking, in an attempt to bring more attention to the problem locally, is to just report every threat and potentially dangerous situation. We have a reporting system for near-misses and adverse events, my bet is most EDs have something similar. It may not bring much change, and certainly won’t work quickly, but it’s a start.

  8. Nick, So you’re the one person in the country who accually reads my column. Stimulation of thought is all I can ask and it seems I got from you. Thanks. Greg

  9. Mona Kelley, MSN, RN on

    Thank you for the references to the hard work ENA has done to promote safety within our Emergency Departments. Training to recognize the three levels of agitations well as de-escalation techniques and self defense techniques to minimize injury will go far to help when people take it seriously. Zero tolerance policies will help, effective legislation will help, but we also have to have “buy-in” from the C-Suite that violent behavior is not acceptable and we should not be expected to think “it is part of the job.” Great article, thanks!

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