• To improve your understanding of the causes and risk factors for violent or aggressive patient behaviour
• To identify strategies that nurses and healthcare organisations can use to reduce violence and aggression
• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Half of all reported violent incidents in healthcare settings occur in the emergency department (ED), so ED nurses are disproportionately affected by violence and aggression. Violence and aggression can cause physical injury, psychological harm, delays to patient care, eroded staff morale, increased sick leave and low staff retention. This article explores potential causes and risk factors for violent or aggressive behaviour from patients and visitors in the ED. It discusses risk assessment tools, management approaches and risk reduction strategies that can be used in the ED to tackle violence and aggression. The article also features a case study describing a successful small-scale trial of body-worn cameras at an East London ED.
Emergency Nurse. doi: 10.7748/en.2021.e2094Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Carver M, Beard H (2021) Managing violence and aggression in the emergency department. Emergency Nurse. doi: 10.7748/en.2021.e2094
Published online: 19 August 2021
This article aims to outline factors that can contribute to violence and aggression against nurses in the emergency department (ED) and describe strategies that can be used to manage incidents of violence and aggression in the ED and reduce the risk of such incidents occurring in the first place. After reading this article and completing the time out activities you should be able to:
• Understand the legal and policy framework protecting staff and patients from violence, including the zero-tolerance approach.
• Describe internal and external factors that may give rise to violence and aggression.
• Understand the effects violent and aggressive behaviours have on ED staff.
• Use relevant risk assessment tools to assess the risk of violence and aggression in the ED.
Reflect on a violent incident that you have witnessed in your workplace. What happened? What do you think may have triggered the incident? What was the response at the time of the incident and afterwards? How do you feel about it now?
• Causes of violence and aggression from patients include social, physiological and environmental factors
• Healthcare organisations have a duty to protect their staff against violence and aggression, but a zero-tolerance approach is not always achievable
• Managing violence and aggression involves the identification of warning signs, clear handover to colleagues, early review by a senior colleague and an interdisciplinary approach
• Conflict management training and post-incident debriefs have been shown to benefit staff exposed to violence and aggression
• Practical changes to the environment can reduce frustration, confusion and stress in patients and visitors
• There is increasing interest in the use of body-worn cameras to reduce violence and aggression against staff in the emergency department
‘Violence and aggression’ refers to ‘a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear’ (National Institute for Health and Care Excellence (NICE) 2015). In 2016 there were 70,555 reported incidents of violence against NHS staff (NHS Protect 2016) and there has been no tangible reduction in the rates of violence against hospital workers since (Spelten et al 2020). Half of all reported violent incidents in healthcare settings occur in the ED (Daniel et al 2015).
Violence and aggression can cause physical injury, psychological harm including post-traumatic stress disorder (PTSD), delays to patient care, eroded staff morale, increased sick leave and low staff retention (Angland et al 2014, Ashton et al 2018). In one study, 41% of nurses who had experienced a physical assault reported subclinical or probable signs of PTSD (Gillespie et al 2013). Violence and aggression reduces the quality of care patients receive and increases the overall cost of healthcare (Anderson et al 2010).
Among nurses, the prevailing attitude is one of acceptance that violent and aggressive behaviour is an occupational hazard (Richardson et al 2019) and an inevitable part of the job (Ashton et al 2018). This may be because most incidents of violence and aggression appear to come from patients with varying levels of clinical need, some of whom may have physical and/or psychological health risk factors for violent or aggressive behaviour (Ferns 2005), as opposed to strangers who just walk in from the street.
According to the Health and Safety at Work Act 1974, all employers have a duty to protect the health and safety of their staff. With The Management of Health and Safety at Work Regulations 1999, employers became legally required to assess the health and safety risk in the workplace, including the risk of violence against staff. In addition, NHS trusts are expected to implement the Improving Working Lives Standards (NHS Staff Council 2009), including a zero-tolerance approach to violence against staff and an expectation that all physical assaults are reported.
There is no clear definition of a zero-tolerance approach to violence against staff in the legal and policy framework. In 2018, the Department of Health and Social Care announced a zero-tolerance approach designed ‘to protect the NHS workforce against deliberate violence and aggression from patients, their families and the public, and to ensure offenders are punished quickly and effectively’ (Department of Health and Social Care 2018). However, a zero-tolerance approach may not always be achievable. In 2015-16, of 70,555 physical assaults on NHS staff, two thirds involved patients who had medical factors contributing to their behaviour, such as confusion caused by an underlying illness or injury (NHS Protect 2016). While published guidelines indicate that medical care can be withheld in exceptional circumstances, the response will vary between locations and NHS trusts, and implementing a zero-tolerance approach may infringe on the rights of patients or visitors to complain about an inadequate service (Whittington 2002).
The purpose of the Assaults on Emergency Workers Act (Offences) 2018 was to increase the severity of sentencing, including custodial sentences, against those who injure or threaten to kill emergency workers, including NHS staff. However, tougher sentencing does not seem to have had an effect on the levels of violence against emergency staff: according to provisional data from the National Police Chiefs’ Council (2020) for England and Wales, there had been a 31% increase in assaults against emergency service staff in the four weeks to 2 August 2020 compared with the same period in 2019.
There is no single reason why a patient or other visitor may exhibit violent or aggressive behaviour, which is part of the challenge in addressing these behaviours. Some of the causes of violent or aggressive behaviours can be classified as intrinsic, in reference to the internal thought processes, emotions and reactions of a person. Other causes can be classified as extrinsic, in reference to external factors that may affect a person’s behaviour.
Violent or aggressive behaviour may be due to an underlying physiological cause, such as an imbalance in neurological or hormonal function. A physiological cause of violent or aggressive behaviour may be acute – for example, in hypoxia-related agitation – or chronic – for example, following a traumatic brain injury (Hodge and Marshall 2007).
• <30 years old
• Problems with authority
• Previous arrests
• History of violence
• Alcohol and substance abuse issues
• Organic disease
• Brain injury
• Mental illness
• Drug withdrawal or intoxication
(Adapted from Hodge and Marshall 2007)
A qualitative research study conducted in 2020 identified that perpetrators of violence against ED nurses tended to fall into one of six categories (Spelten et al 2020):
• Violence or aggressive behaviour that cannot be explained by an underlying health issue.
• Violence that is related to underlying mental health issues.
• Violence that is related to underlying physical health issues.
• Violence that is related to addiction and substance abuse.
• Violence that is related to a complexity of issues.
• Violence that is related to repeat visitors/offenders.
As well as there being certain characteristics associated with violence and aggression, there are certain times when they are more likely to occur. Hyland et al (2016) found that violence and aggression in the ED is much more likely to occur in the early morning and in the evening. They also found that most violence and aggression tends to happen early during a patient’s stay, usually within the first hundred minutes or so (Hyland et al 2016). Some risk factors for violence and aggression can be identified in the early stages of the patient journey. Indeed, triage nurses have been found to accurately identify potentially violent patients (Daniel et al 2015).
In some patients who regularly attend the ED with complex medical or behavioural needs, there may be a dynamic of aggressive behaviour: patients realise that their previously aggressive behaviour has led to them being seen and treated more quickly, which confirms them in their aggressivity (Ferns 2007).
For patients who may not clinically present with any risk factors for violence and aggression but may be exhibiting some concerning behaviour, such as impulsive behaviour or irritability, formal risk assessment tools can be used to assess the risk of violence and aggression in the ED.
The Dynamic Appraisal of Situational Aggression (DASA) tool (Ogloff and Daffern 2006), which is traditionally used in psychiatric inpatient settings, has been found to have predictive validity for use in the ED setting (Connor et al 2020). Box 2 outlines the DASA tool.
Nurses should ask whether any of these seven behaviours apply to the patient:
• Irritability – easily annoyed
• Impulsivity – sudden or unpredictable behaviour
• Unwilling – angry or aggressive when asked something
• Sensitive – seeing other people’s actions as deliberate or harmful
• Easily angered – delay in addressing the patient’s requests leads to anger or aggression
• Negative attitude – towards others
• Verbal threat – verbal aggression or outbursts
Each ‘yes’ answer scores one point up to a total of seven and the total score is interpreted as follows:
0-1 – low risk of aggression, no action needed
2-3 – medium risk of aggression, alert other members of staff and monitor the patient
4-7 – high risk of aggression, medical action may be needed to manage the risk
(Adapted from Connor et al 2020)
The STAMP framework (Luck et al 2007) is another risk assessment tool that ED nurses can use to identify potentially violent patients. The acronym stands for five ‘components of observable behaviour’ that indicate a potential for patient violence in the ED – see Box 3. These components are cumulative, so the more components are identified, the higher the risk of patient violence (Luck et al 2007). The STAMP framework was the most frequently cited in a literature review of patient aggression risk assessment tools in the ED (Calow et al 2016).
The acronym STAMP stands for five ‘components of observable behaviour’ that indicate a potential for patient violence in the emergency department:
• S – staring and eye contact; any prolonged staring
• T – tone and volume of voice; sharpness, sarcasm, volume
• A – anxiety; hyperventilation, rapid speech, grimacing
• M – mumbling; talking under one’s breath or repeating phrases
• P – pacing; walking in a confined area, repeatedly approaching staff
(Adapted from Luck et al 2007)
As some of the healthcare professionals who work closest with patients and visitors, nursing staff tend to be those who experience most incidents of violence and aggression, although reception staff and doctors are also affected (Gates et al 2006). Most patients who physically assault staff are either removed from the hospital or leave without being seen by a clinician (Ferns 2005). For those who do not or cannot leave, nurses need to respond in a way that will be the most therapeutic for patients while also preserving the safety and well-being of others (Hodge and Marshall 2007). Because of the multitude of potential causes, nurses cannot approach every incident of violence and aggression in the same way. The root causes and response will differ depending on the circumstances. For example, patients presenting to the ED with a primary mental health issue wait far longer to be seen and treated than patients with physical health needs (Ferns et al 2005), which nurses need to consider in their communication with, and care of, patients.
Nurses’ approach to managing violence and aggression in real time needs to encompass (Rintoul et al 2009):
• The early identification of warning signs.
• A clear handover to colleagues.
• An early review by a senior colleague.
• An interdisciplinary approach to managing the patient.
An early review by a senior colleague will ensure that a decision can be made, with the patient’s best interests in mind, as to whether the patient needs to remain in the ED to receive care – and therefore their violent or aggressive behaviour needs to be managed – or whether they can be removed from the ED. Using de-escalation techniques and boundary setting may be sufficient to manage the violent or aggressive behaviour and prevent escalation. If not, support from internal security or the police may need to be sought.
If the patient displaying violent or aggressive behaviour is unwell and requires medical care, then the most appropriate response may be pharmacological or physical restraint, particularly if the patient is considered to lack mental capacity. Here again the patient’s best interests must be considered (Mental Capacity Act 2005).
Physical restraint can have severe and long-lasting negative effects on patients, physically and psychologically (Wong et al 2020). NICE emphasises that restrictive interventions such as physical restraint should only be used when all other forms of de-escalation have been attempted without success (NICE 2020). All physical interventions and forms of restraint must be the least restrictive possible and must be proportionate to the risk and potential seriousness of harm (NICE 2020).
A different approach to managing violence and aggression may be needed if the patient is intoxicated. A meta-analysis found that intoxicated people are less reflective, so they may not respond rationally to a request to modify their behaviour (Rintoul et al 2009). These patients need to be promptly identified and managed to minimise stimulation. Staff need to be confident in their ability to use de-escalation techniques and identify the causes of violent or aggressive behaviour – for example, is the behaviour caused by intoxication or is there another underlying cause such as a head injury, a mental health issue or pain (Rintoul et al 2009).
Think about the layout of your ED and environmental factors that may contribute to frustration, confusion or stress among patients and visitors. Can you think of practical changes that would be likely to reduce their frustration, confusion or stress? How would you go about implementing these changes?
There are several strategies EDs can implement to reduce the risk of violence and aggression, three of which are discussed below.
Beyond individual patient characteristics – described earlier in this article– the Design Council (2021) identified several environmental triggers (external risk factors) that may increase the risk of violence and aggression:
• Clash of people.
• Lack of progression and/or long waiting times.
• Inhospitable environments.
• Dehumanising environments.
• Intense emotions in a practical space.
• Unsafe environments.
• Perceived inefficiency.
• Inconsistent response to ‘undesirable’ behaviour.
• Staff fatigue.
• Clear signage.
• Comprehensive information about the ED’s physical layout, waiting times and treatments in digital and printed form.
• Training for clinical and clerical staff on how to support patients and visitors to orientate and respond to their queries.
Macro-level environmental changes to an ED that can contribute to reduce violence and aggression and improve the response to incidents include hospital security guards and elements such as door locks, panic buttons, CCTV, protective windows and multiple exits (Hyland et al 2016). Partridge and Affleck (2017) conducted a study in Australia on the rates of verbal abuse and physical assault, perceptions of safety and attitudes towards security in the ED. They found that a permanent or increased security presence in the ED increased feelings of safety, even after incidents of violence and aggression had occurred. Staff who felt that the security service at their hospital responded in a timely manner were more than three times likely to feel safe at work (Partridge and Affleck 2017).
In 2011, two UK hospitals received support from the Design Council and the Department of Health and Social Care to improve the physical environment of EDs to reduce violence and aggression. The solutions included improving signage and guidance around the department, training new staff to understand the culture and layout of the hospital, and developing a design toolkit to support future changes to the ED’s layout (Design Council 2021). An evaluation of these changes found that 75% of patients said the improved signage reduced their frustration during waiting times and that threatening body language and aggressive behaviour fell by 50% post-implementation (Design Council 2013).
In 1997 the Health Services Advisory Committee recommended that conflict resolution training should become part of mandatory training and cover the causes of violence, recognition of early warning signs and details of working practices, control measures and incident reporting procedures (Ferns 2007). A literature review that evaluated interventions designed to reduce workplace violence against ED nurses found five studies that had investigated staff training programmes, of which two had led to a reduction in violent incidents and an improvement in staff’s feelings of safety (Anderson et al 2010). Further evidence of the benefits of training were provided by Hu (2016), who found that staff who had been trained and felt comfortable in dealing with violence and aggression were much less likely to become the victims of assault.
In terms of the type of training for supporting teams to respond to behavioural emergencies in the ED, simulation has been found to provide trainees with safe but authentic scenarios that they can observe, take part in and reflect on (Wong et al 2015). An evaluation of an educational programme for nurses in Iran identified that listening skills, sympathy towards disagreement, respect of personal space, avoiding overstimulation and agreeing on boundaries were important preventive measures for staff to be taught (Sharifi et al 2020).
It has been shown that many incidents of violence and aggression towards nurses are not reported, notably because of the time and effort involved in reporting, a level of tolerance towards minor incidents, concern for the perpetrator, and an expectation that violence is inevitable in a healthcare setting (Morphet et al 2014). The expectation that violence is inevitable has been linked to a lack of support from the organisation (Ashton et al 2018), with reports of nurses feeling isolated when managing violence and aggression. It has also been shown that nurses predominantly report violent incidents only if these have resulted in physical injury (Wong et al 2015) and that nurses are sometimes encouraged not to report incidents (Hogarth et al 2016).
Nurses have identified informal debriefs, with a peer or a supervisor, as an adequate response from their organisation after incidents of violence and aggression (Ashton et al 2018).
A quality improvement initiative was conducted to reduce violence and aggression in the ED of an East London hospital. Violence and aggression against ED staff had been increasing, causing distress, negatively affecting staff morale and prompting a fear of escalating incidents. A Violence and Aggression Working Group was set up to:
• Provide a forum for staff to express their concerns and ideas.
• Develop a quality improvement initiative to reduce violence and aggression.
• Improve the safety of staff and patients.
The quality improvement initiative used the model for improvement recommended by NHS England and NHS Improvement (2018), which includes plan, do, study, act (PDSA) cycles. PDSA cycles enable staff in healthcare settings to test changes on a small scale and adapt practice from what they have learned in a clear and structured way (Taylor et al 2014).
There is increasing interest, within the nursing community, in body-worn cameras, as shown by a comment piece published in Nursing Standard asking nurses to keep an open mind regarding their use (Hulatt 2019). A report published by the Health Service Journal and Unison (Cowper 2018) suggested that the use of technology including body-worn cameras could reduce violent attacks. Ariel et al (2019) found that the introduction of body-worn cameras for staff at railway stations had reduced the number of incidents of physical violence by 47%, which led them to recommend their use for any public-facing role. In 2016, body-worn cameras were introduced for security staff at a London hospital due to a rising number of violent incidents (Keogh 2016).
Following discussions with clinical staff in the ED, the Violence and Aggression Working Group decided to trial six body-worn cameras for clinical staff during a six-week period. The cameras were worn in various areas of the ED and signs throughout the department informed patients and visitors of their use. All clinical staff in the ED were informed of the trial via email and face-to-face at daily morning handovers. Training on how to use the cameras was provided to staff before implementation.
If staff felt they were in a situation that could develop into violence and aggression, they would switch the camera on and start recording. Staff were encouraged, when switching the camera on, to make a simple statement such as ‘I am wearing a body-worn camera and recording this incident for the safety of everyone’. Footage obtained from the cameras was uploaded to a digital folder that could only be accessed by a designated manager.
The hospital has an online incident reporting system in place, but ED staff were often not reporting incidents of violence and aggression. Before the start of the body-worn camera trial, staff were encouraged to report all incidents using the online incident reporting system so data would more accurately reflect the number of incidents. Staff continued to be encouraged to report all incidents throughout the trial. If staff had any urgent safety concerns, they could report them to the Violence and Aggression Working Group. Incident reports were collected daily for six weeks before the trial and for the duration of the trial. At the end of the trial, an analysis of the data was conducted. In the six weeks before the trial, 156 incidents of violence and aggression had been reported. During the six-week trial period, 76 incidents had been reported – a reduction of 49%.
A short online questionnaire was sent to all clinical staff before and after the trial to establish how they felt about safety at work and whether they felt body-worn cameras were necessary. The questionnaire was sent out to all clinical staff in the ED, approximately 120 nurses and 50 medical staff. Of these, 59 staff responded to the pre-trial questionnaire and 21 responded to the post-trial questionnaire.
The questionnaire contained ten questions designed to obtain quantitative and qualitative data. Before the trial, 39% of respondents felt body-worn cameras were necessary. After the trial, 100% of respondents felt body-worn cameras were necessary. Table 1 shows the breakdown of responses to question 9 in the post-trial questionnaire, which asked ‘What do you think of the below statements?’.
Following data analysis, it was deemed that body-worn cameras had reduced the incidence of violence and aggression against ED staff and made them feel safer. Some of the footage has since been used to support the trust’s violence and aggression policy and assist the police in securing convictions. Data from the incident reporting system and staff questionnaires were presented to the hospital executive board with details of costs. A cost-benefit analysis was conducted and the executive board approved the routine use of body-worn cameras in the ED. Body-worn cameras have now been purchased.
There are various factors that can bring about violent or aggressive behaviours from patients or visitors in the ED, including individual characteristics and environmental factors. Risk assessment tools can support ED nurses to assess the risk of violence and aggression in the ED. Environmental and organisational changes, such as improved signage and post-incident debriefs for staff, may be needed to reduce the risk of violence and aggression in the ED. Training staff to manage violent or aggressive behaviours can improve their confidence and reduce their likelihood of becoming victims of assault. A small-scale trial of body-worn cameras for nurses in an East London ED has shown that this technology may reduce violence and aggression and make staff feel safer.
Consider how managing violent or aggressive patient behaviour in the ED relates to the Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) or, for non-UK readers, the requirements of your regulatory body
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
Views of specialist head and neck nurses about changes in their role
The Cancer Reform Strategy (Department of Health 2007)...
Emergency assessment bay for cancer patients
The annual Quality in Care (QiC) Excellence in Oncology...
The role of lung cancer nurse specialists
A report published by the National Lung Cancer Forum for...
Assessing the value of offering art activities to patients and carers
Aim The aim of this study was to determine if patients who...
Emergency care of patients with gunshot wounds
This article provides an overview of the mechanism of...