RESEARCH
NOTHING CHANGES, NOBODY CARES:
UNDERSTANDING THE EXPERIENCE OF
EMERGENCY NURSES PHYSICALLY OR VERBALLY
ASSAULTED WHILE PROVIDING CARE
Authors: Lisa A. Wolf, PhD, RN, CEN, FAEN, Altair M. Delao, MPH, and Cydne Perhats, MPH, Des Plaines, IL
Introduction: Workplace violence has been recognized as a
violent crime that requires targeted responses from employers,
law enforcement, and the community. According to data from the
Bureau of Labor Statistics, the most common source of nonfatal
injuries and illnesses requiring days away from work in the health
care and social assistance industry was assault on the health care
worker. What is not well understood are the precursors and
sequelae of violence perpetrated against emergency nurses and
other health care workers by patients and visitors. The purpose of
this study was to better understand the experience of emergency
nurses who have been physically or verbally assaulted while
providing patient care in US emergency departments.
work. Narrative analysis and constant comparison were used to
identify emerging themes in the narratives.
Results: “Environmental,” “personal,” and “cue recognition”
were identified as the themes. Overall, nurses believed that
violence was endemic to their workplace and that both limited
recognition of cues indicating a high-risk person or environment and
a culture of acceptance of violence were barriers to mitigation.
Discussion: These findings are consistent with the extant
Methods: The study was conducted using a qualitative
literature but with an added contribution of clearly identifying
an underlying cultural acceptance of violence in the emergency
department, as well as a distinct lack of cue recognition, in this
sample of emergency nurses.
descriptive exploratory design. The sample consisted of 46
written narratives submitted by e-mail by emergency nurses
describing the experience of violence while providing care at
Key words: Emergency nurse; Violence; Qualitative; Cue
recognition; Assault
he National Institute for Occupational Safety and
Health defines workplace violence as “an act of
aggression directed toward persons at work or on
duty, ranging from offensive or threatening language to
homicide.” 1 Workplace violence is generally defined as any
physical assault, emotional or verbal abuse, or threatening,
harassing, or coercive behavior in the work setting that
T
Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute for
Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.
Altair M. Delao is Senior Associate, Institute for Emergency Nursing
Research, Emergency Nurses Association, Des Plaines, IL.
Cydne Perhats is Senior Associate, Institute for Emergency Nursing Research,
Emergency Nurses Association, Des Plaines, IL.
For correspondence, write: Lisa A. Wolf, PhD, RN, CEN, FAEN, 915 Lee St,
Des Plaines, IL 60016; E-mail: lwolf@ena.org.
J Emerg Nurs ■.
0099-1767/$36.00
Copyright © 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.11.006
■
■ • ■
causes physical or emotional harm. 1-6 In recent years,
workplace violence has been recognized as a violent crime
that requires targeted responses from employers, law
enforcement, and the community. 6 According to data
from the Bureau of Labor Statistics, the most common
source of nonfatal injuries and illnesses requiring days away
from work in the health care and social assistance industry
was assault on the health care worker. 7 Over 70% of
emergency nurses reported physical or verbal assault by
patients or visitors while they were providing patient care in
the emergency setting. 8,9
A search of the literature using the search terms
“violence,” “emergency department,” “nurses,” “assault,”
and “qualitative” yielded only 7 qualitative and/or mixedmethods studies that addressed workplace violence among
nurses from 2004-2012. Of these, only 2 were conducted in
the United States. The remaining studies were conducted in
Australia (3), Spain (1), and the United Kingdom (1). Only
1 of the US studies was specific to emergency nursing. 10 The
extant qualitative data support findings in the quantitative
literature that indicate precipitating factors to the occurrence
of violence include such factors as long waiting times,
WWW.JENONLINE.ORG
1
RESEARCH/Wolf et al
psychiatric patients, and patients under the influence of
drugs or alcohol. 10-12 There is a consistent theme of
vulnerability felt by the nurse and the nurse's perceived lack
of safety. 10,11,13 In addition, a common thread among these
studies was how nurses viewed the violent incident, which
affected how they processed the current event and
anticipated future instances. 14-17 What is not well understood are the precursors and sequelae of violence perpetrated
against emergency nurses and other health care workers by
patients and visitors. It is known that ED incidents of
violence cause physical and psychological damage and that
emergency nurses leave the profession as a result. 10,11,13
Given the need for more effective protection for
emergency health care workers, it is important to more fully
understand the experience of violence in US emergency
departments. The purpose of this study was to better
understand the experience of emergency nurses who have
been physically or verbally assaulted while providing patient
care in US emergency departments.
Methods
The study was conducted using a qualitative descriptive
exploratory design. In the fall of 2012, a sample of
emergency nurses was recruited by e-mail from the
membership roster of the Emergency Nurses Association
(ENA) and by a call for participants on the ENA Web site.
Narratives from 46 English-speaking emergency nurses—
8 men (17.4%), 37 women (80.4%), and 1 nurse of
unknown gender (2.2%)—who had been physically or
verbally assaulted by patients or visitors while providing care
in the emergency department were submitted by e-mail to
the Institute for Emergency Nursing Research. These
narratives ranged from 1 paragraph to over 15 pages in
length. The question asked of all participants was as follows:
“Tell me about your experience of violence in the
emergency setting.” The participants were asked to describe
the incident itself, including the setting, characters, and
process of the incident; what happened at work after the
assault; the leadership and institutional response; and the
effects of the incident at the present time.
Institutional review board approval was obtained
before recruitment of study participants (Chesapeake
Institutional Review Board, Columbia, MD). Each
narrative was reviewed by the principal investigator and
by at least 1 other member of the research team. Narrative
research 18 and constant comparison were used to uncover
commonalities, themes, and the signs, symbols, and
expressions of feeling in language to develop an understanding of the meaning of the experience. Emerging
themes were identified by consensus.
2
JOURNAL OF EMERGENCY NURSING
Results
A total of 46 respondents submitted narrative accounts
of an episode of physical or verbal violence that occurred
while providing care in the emergency setting. Structurally, most of the narratives began almost immediately
with a description of the incident, with little introduction of the narrator or background leading up to the
incident. The narratives most frequently discussed 1 or 2
similar incidents in chronologic order of events, told in
the past tense, clearly to an outsider/researcher. In most
narratives the central character was the perpetrator of the
violence.
Three broad themes emerged from the data: “environmental,” “personal,” and “cue recognition.” The environmental theme described the physical environment of the
emergency department and the institutional culture of the
emergency department. In addition, this theme encompassed the legal system/security, both inside the emergency
department and externally, including the legal system, law
enforcement, and the judicial system. The personal theme
described the impact of the event on the nurse with regard
to job performance, coping, and feelings with regard to the
interaction with the legal and judicial systems, law
enforcement, or institutional culture. The third thematic
category, cue recognition, described the recognized or
unrecognized antecedents to the violent event in terms of
characteristics of either the perpetrator or the environment
in which the event took place.
ENVIRONMENTAL
Categories in the environmental theme were identified as
“culture of acceptance”; “unsafe workplace”; and “nobody
cares, nothing changes.” The narratives of participating
emergency nurses uncovered common factors that were
antecedents to violence in their emergency departments,
including long waiting times, the presence of psychiatric
patients and patients with a history of violence, and the
presence of patients or visitors who were under the influence
of drugs or alcohol. There were many descriptions of a legal/
judicial system that was unwilling to pursue charges against
patients or family members who assaulted nurses; thus the
focus on legislation to make assault of a health care worker a
felony crime may have limited efficacy unless efforts are
made to address societal complacency toward violence
against nurses. 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
■ ■ •
■
Wolf et al/RESEARCH
public officials (eg, police, state attorneys, or judges) who
would not charge the perpetrators.
I received a call from the district attorney's office some
months later and was informed I could pursue charges
but likely there would be no penalty or “sentencing”
related to the charges so I elected not to pursue it
further.—Participant A
I was later called by the DA [district attorney], who
wanted nothing to do with the case, since he thought it
was a waste of taxpayer dollars, as the man would just cop
a plea, get his hands slapped, and nothing further would
happen.—Participant B
In another instance, a judge said to a nurse (participant
C), “[W]ell, isn't that the nature of the beast, being in the
emergency room and all?” Participant C said, “Gosh . . . I
almost feel like a rape victim in court. . . . ”
Nurses who experienced this lack of support from
public officials expressed feelings of frustration, anxiety, and
reinforcement of their perception of an unsafe workplace.
One nurse who was assaulted in the emergency department
of a children's hospital where he worked described the lack
of response from his administration:
Because they want the Children's Hospital to appear
friendly, they have not secured the doors. . . . [T]hey
refuse to install weapons detectors, even though on
more than one occasion weapons have been found. . . .
[A]dministration will only take action when some lethal
event happens.—Participant B
Another nurse (participant D) found her supervisor's
reaction focused more on the impact of the incident causing
bad publicity or trouble for the hospital: “[The Chief
Nursing Officer] seemed to be more concerned that I was
filing a police report than over the fact that I was assaulted.”
This perceived lack of concern about nurses' safety
resonated throughout the narrative accounts. Participants
described unsafe work environments, where safety measures
were put into place (eg, security cameras or panic buttons)
but were not maintained or enforced. One nurse described
posted signs placed after her assault that were not enforced:
[The signs stated,] “We won't tolerate violence,
acting out, threats or cursing.” The sign also stated that
if you acted in any of these ways, you were going to be
escorted out by security and police. I have yet to see this
happen. I finally asked if we were ever going to act on
these signs and I was told that basically they were just
put up for show.—Participant E
■
■ • ■
A few participants had been assaulted more than once
and were frustrated by the lack of any real change in security
or environmental protective measures.
I wanted to meet with the head of security and the
CEO [chief executive officer] of the hospital. I wanted
them to see my face and see my bruising. . . . [A]fter
all . . . this would not be the first meeting I have had
with the head of security. We had met on another
incident several years back when a patient pulled a
knife out in triage.—Participant C
It just seems to be getting worse and no one
cares.—Participant E
PERSONAL
Categories in the personal theme included lingering trauma;
permanent injury and loss; denial of impact; and changes in
job responsibilities, hours, or location (eg, moving to a
different department or hospital).
Respondents described lingering psychological trauma
that continues to impede their ability to work in the
emergency setting.
I have never been afraid to come to work before but
now I find myself fearful and reluctant to come in to a
violent situation.—Participant F
I found it difficult to work in triage where the nurse
worked alone, in a location where she is unseen, and
where most often people behave boldly and badly. I
managed to handle these situations as they occurred, but
would become diaphoretic, shaky, and feel palpitations
afterward.—Participant G
A female patient . . . came in to be treated. For some
reason this triggered a post traumatic reaction for me. I
instantly became very shaky, nauseated, and started
crying. . . . I then went to counseling for a couple of
months, I think. My biggest hurdle . . . was [that I felt],
and I still do, feel like a victim, rather than getting to be in
the “superman” role.—Participant H
In some cases, there appeared to be a denial of impact
around violence in the emergency department from the
respondents themselves or their colleagues. This denial
seemed to result from an expectation of violence in the
environment and ranged from acceptance of the risk of
assault as part of the job to resignation to the reality of the
unsafe nature of the workplace.
We all know this is the chance we take every day in
our job as ED nurses.—Participant F
WWW.JENONLINE.ORG
3
RESEARCH/Wolf et al
Another nurse in the ER [emergency room] gave me
a hard time and said if I “couldn't handle it, I should
get out of emergency medicine.”—Participant G
I continue to hear other nurses say violence is “part
of the job,” which I find maddening.—Participant G
all fours, tried to leave and started yelling and swearing.
Myself and a tech [technician] went into the room to
calm her down and she swung at us, hitting the tech in
the face and me in the shoulder.—Participant L
Respondents described both acute and permanent
physical injuries to hips, shoulders, necks, and arms that
rendered some nurses unable to work without pain.
A second, frequent scenario was the lack of institutional
recognition of the high-risk patient, leaving the nurse in a
vulnerable position without resources or recourse. For
example, one participant described a patient who had been
brought in for a psychiatric evaluation, had been verbally
abusive to the paramedics on the ride in, and was cursing at
the primary nurse because he did not want to be confined to
a room. The patient swung at the primary nurse and was told
by the charge nurse that this was “unacceptable behavior”;
the charge nurse then left the room, leaving the primary
nurse alone with the patient. Another participant described
being assaulted by a homicidal patient who was brought in
by police but who was initially calm and cooperative and so
was not provided with a sitter or a security presence. To the
patient’s dismay, he was admitted and proceeded to attack
the nurse (Participant M): “[H]e sucker punched me right in
the eye . . . started to run out the door . . . and turned back
around to attack [me] further. . . . ”
I missed a week of work due to my injuries.—
Participant I
I ended up tearing cartilage in my left knee, ended
up having surgery. I work with chronic pain and will
need a knee replacement. The hospital took months to
recognize my injury through the worker's comp format.
I limped for months but still worked full time following
the hospital mission.—Participant J
I . . . after many trigger point injections for pain
control had to quit my job as a Field Nurse since I now
had decreased strength in my right arm and leg due to
injuries suffered during this attack. I ended up with
torn muscles from my right scapula and separation to
my sacroiliac joint. To this day I have discomfort in my
shoulder and especially my hip.—Participant D
CUE RECOGNITION
Discussion
Cues, or precursors to violence, were often missed or
ignored in nurses' narrative accounts. 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.
The narratives of participating emergency nurses in this
study show common characteristics leading up to violence
in their emergency departments, including contributing
factors to violence such as long times waiting to be seen, the
presence of psychiatric patients and patients with a history
of violence, and the presence of patients who are under the
influence of drugs or alcohol. Nurses describe environments
in which either individual or environmental cues go
unrecognized or unaddressed. If violence occurs, it is
consistently accompanied by a lack of both administrative
support and judicial recourse. A primary concern in the
findings of this study is a consistently reported lack of cue
recognition that would suggest repeated exposure to highrisk patients (eg, history of violence, brought in by police,
under the influence of drugs or alcohol, or suicidal or
homicidal ideation) or high-risk environments (eg, crowding, boarding patients, isolated treatment areas, lack of
security personnel, or nonfunctioning security equipment).
Without awareness of and responsiveness to high-risk
persons or environments, emergency departments cannot
plan effective interventions to prevent violent behavior
directed at health care workers. Prevention of workplace
violence must be a significant priority given the difficulty in
prosecuting offenders, as described by participants.
A young woman with a polypharmacy ingestion was
placed in the trauma room, and placed in soft restraints
to prevent harm to herself and others. Security was in the
room with us but when his back was turned to wash his
hands the patient broke her wrist restraint and struck me
in the mouth and jaw and cut my lip. She also kicked the
security officer in the chest before we could re-restrain
her.—Participant K
I was at work and received a call that an overdose
patient was coming to the ED. This was a 23 F
[23-year-old woman] who took some pills and drank
some alcohol. Upon patients [sic] arrival, she was
cooperative . . . changing into a gown and giving us a
urine sample. Pt [patient] stated she was under a lot of
stress and wanted to kill herself. At that time, security
was called and they sat outside her room. All of a
sudden, she started acting out. She knelt on the bed on
4
JOURNAL OF EMERGENCY NURSING
■ ■ •
■
Wolf et al/RESEARCH
A clearer understanding of the lived experience of these
nurses yields important information about this phenomenon,
which may have implications for education, practice, research,
and policy. Specifically, it describes the confluence of highrisk environments and persons as precursors to violence. The
findings from this study identify some of the physical and
psychological long-term consequences of violence experienced
by nurses while they are providing patient care. These
consequences lead to lost productivity, contribute to attrition
from the emergency nursing profession, and impede nurses'
ability to effectively deliver patient care. 8
The findings from this study can be placed in the context
of the current literature as underscoring precipitating factors for
violence as both environmental and patient specific; in
addition, our findings are consistent with the conclusions of
other qualitative studies regarding the perceived vulnerability of
nurses in the emergency care environment. Further research
needs to focus on the evaluation of interventions designed to
allow nurses, ED managers, hospital administrators, and other
health care workers to recognize potentially violent persons or
environments. With the clear and long-lasting impact of
workplace violence, it is imperative that hospitals and
emergency care workers address the issue preemptively through
adoption of violence prevention education, zero-tolerance
policies, safety measures, and procedures for reporting and
responding to incidents of workplace violence when they do
occur. Such actions are necessary to help nurses recognize
incipient violence and may be more immediately helpful and
attainable than post-assault legislative consequences, which are
more difficult to achieve and enforce.
LIMITATIONS
This study included a self-selecting sample of nurses who
were reporting a traumatic experience. It is acknowledged in
the analysis of narratives that for this sample, perception is
reality. Although many respondents provided demographic
information, it was not collected as part of the study;
therefore any associations between experience and education and the description of events cannot be made.
IMPLICATIONS FOR EMERGENCY NURSES
This study highlights the persistence of a culture of
acceptance around workplace violence for emergency
nurses. Priorities for practice include training for both
staff nurses and nursing managers in cue recognition to
identify high-risk patients and situations. Interventions
on both personal and institutional levels should be
developed to address high-risk situations to recognize
and mitigate violence, rather than manage post-event
sequelae. In addition, addressing a prevalent culture of
■
■ • ■
acceptance of violence toward emergency nurses and
other health care workers will be necessary to make
progress in reducing incidents of workplace violence in
emergency departments.
Conclusion
Violence while providing care in emergency departments is
not uncommon; there appears to be an underlying
normalization of this phenomenon in both the healthcare
and law enforcement systems which prevents effective
interventions. Further research on interventions which
identify and mitigate high risk situations are needed.
Acknowledgments
The authors acknowledge Paul Clark, PhD, MA, RN, for his expert review
of this manuscript. They also acknowledge Leslie Gates for her assistance
with this study.
REFERENCES
1. Centers for Disease Control and Prevention, National Institute for
Occupational Safety and Health. Violence: occupational hazards in
hospitals. Available at: http://www.cdc.gov/niosh/pdfs/2002-101.pdf.
Accessed July 12, 2013.
2. McPhaul KM, Lipscomb JA. Workplace violence in health care: recognized
but not regulated. Online J Issues Nurs. 2004;9(3):7. Available at: http://
www.nursingworld.org/MainMenuCategories/ANAMarketplace/
ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/
ViolenceinHealthcare.html. Accessed July 12, 2013.
3. Lipscomb J, Silverstein B, Slavin T, Cocy E, Jenkin L. Perspectives on
legal strategies to prevent workplace violence. J Law Med Ethics.
2003;30(3):166-72.
4. Anderson C. Workplace violence: are some nurses more vulnerable?
Issues Ment Health Nurs. 2002;23(4):351-66.
5. DelBel JC. De-escalating workplace aggression. Nurs Manage.
2003;34(9):30-4.
6. US Department of Justice, Federal Bureau of Investigation. Workplace
violence: issues in response. Available at: http://www.fbi.gov/statsservices/publications/workplace-violence. Accessed July 12, 2013.
7. US Department of Labor, Bureau of Labor Statistics. Nonfatal
occupational injuries and illnesses requiring days away from work,
2010. Available at: http://www.bls.gov/news.release/archives/
osh2_11092011.pdf. Accessed July 12, 2013.
8. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L,
MacLean SL. Violence against nurses working in US emergency
departments. J Nurs Adm. 2009;39(7–8):340-9.
9. Emergency Nurses Association, Institute for Emergency Nursing
Research. Emergency Department Violence Surveillance Study. Des
Plaines, IL: Emergency Nurses Association; 2011. Available at: http://
WWW.JENONLINE.ORG
5
RESEARCH/Wolf et al
www.ena.org/IENR/Documents/ENAEDVSReportNovember2011.
pdf. Accessed July 12, 2013.
10. Catlette M. A descriptive study of the perceptions of workplace violence
and safety strategies of nurse working in Level I trauma centers. J Emerg
Nurs. 2005;31(6):519-25.
14. Badger F, Mullan B. Aggressive and violent incidents: perceptions of
training and support among staff caring for older people and people with
head injury. J Clin Nurs. 2004;13(4):526-33.
15. Demir D, Rodwell J. Psychosocial antecedents and consequences of
workplace aggression for hospital nurses. J Nurs Scholarsh. 2012;44(4):1-9.
11. Chapman R, Styles I, Perry L, Combs S. Nurses' experience of adjusting
to workplace violence: a theory of adaption. Int J Ment Health Nurs.
2010;19(3):186-94.
16. Luck L, Jackson D, Usher K. Innocent or culpable? Meanings that
emergency department nurses ascribe to individual acts of violence J Clin
Nurs. 2007;17(8):1071-8.
12. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence at
triage: a qualitative descriptive study. Int Emerg Nurs. 2009;19(1):12-9.
17. Waschgler K, Ruiz-Hernández JA, Llor-Esteban B, García-Izquierdo M.
Patients' aggressive behaviours towards nurses: development and
psychometric properties of the hospital aggressive behaviour scale- users.
J Adv Nurs. 2013;69(6):1418-27.
13. Zuzelo PR, Curran SS, Zeserman MA. Registered nurses' and
behavior health associates' responses to violent inpatient interactions
on behavioral health units. J Am Psychiatr Nurses Assoc.
2012;18(2):112-26.
6
JOURNAL OF EMERGENCY NURSING
18. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among
Five Approaches. 2nd ed. Thousand Oaks, CA: Sage Publications; 2007.
■ ■ •
■