Accident and Emergency Nursing (2004) 12, 67–73

Accident and
Emergency
Nursing

www.elsevierhealth.com/journals/aaen

Violence towards emergency department

nurses by patients
Julia Crilly RN, MN (Emergency) Honours (Research Assistant and
Emergency Nurse)*, Wendy Chaboyer RN, PhD (Associate Professor,
Director), Debra Creedy RN, PhD (Professor, Dean, Faculty of Nursing
and Health)

Centre for Clinical Practice Innovation, Griffith University, Gold Coast Campus,
PMB 50 Gold Coast Mail Centre, Qld. 9726, Australia

Received 7 June 2003; received in revised form 9 September 2003; accepted 20 November 2003

KEYWORDS Summary Emergency department (ED) violence is a significant problem in many

Violence; hospitals. This study identified the incidence of violence by patients towards nurses
Abuse; in two EDs. Patient factors related to violence were identified and the circum-
Emergency department stances surrounding the violent incident were described. Of the 71 ED nurses who
participated, 50 (70%) reported 110 episodes of violence in a five-months period.
That is approximately five violent incidents per week. Violence was reported most
often on evening shifts (n ¼ 41, 37%). The nurses’ perceived that the perpetrators of
violence were under the influence of alcohol (n ¼ 30, 27%) and drugs (n ¼ 27, 25%)
and displayed behaviours associated with mental illness (n ¼ 42, 38%). Nurses in this
study were sworn at (n ¼ 67, 61%), pushed (n ¼ 11, 10%), hit (n ¼ 3, 3%), and kicked
(n ¼ 3, 3%). Identification of trends and patterns of violence is necessary so that
better health care planning and service provision as well as effective preventative
and safe strategies for nurses in the workplace can be implemented.

c 2004 Elsevier Ltd. All rights reserved.

Introduction tered nurses that involved violence were higher

Violence is an occupational health and safety issue
that all nurses face in their day-to-day activities.
Australian Workers Compensation claims of regis-
* literature related to hospital violence has pre-
Corresponding author.
E-mail addresses: juliacrilly@hotmail.com (J. Crilly);
W.Chaboyer@griffith.edu.au (W. Chaboyer); D.Creedy@griffith.
edu.au (D. Creedy).
than that of police and prison officers (Perrone,
1999). Compensation claims from the health in-
dustry have increased 6.8% between 1992 and 1995
(WorkCover NSW, 1997). Emergency department
(ED) nurses are said to experience some form of
violence weekly (Lyneham, 2000). The plethora of
dominantly focused on a range of issues related to
changes in the skills and knowledge of staff, pa-
tient characteristics, as well as models of health

0965-2302/$ - see front matter c 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aaen.2003.11.003
68
care service delivery. The purpose of this study was
to identify the incidence and characteristics of vi-
olence in the ED as reported by nurses.
Literature review
From a review of the literature, four aspects of
violence in the ED are apparent and relate to how
violence is defined, how it is reported, character-
istics of patients committing the violence and or-
ganisational characteristics. Significantly, a
standardised definition of workplace violence is not
evident in the literature and various terms identi-
fied include assault, abuse, and aggression. A re-
cent definition of violence used in an international
study is “. . . an act that includes physical force such
as slapping, punching, kicking and biting; use of an
object as a weapon; aggressive behaviour such as
spitting, scratching and pinching; or a verbal threat
involving no physical contact” (Nolan et al., 2001,
p. 421).
While the incidence of violence in EDs varies
according to the definition used, the actual re-
porting of violence is a significant factor in obtain-
ing the incidence rate. The International Council of
Nurses (1999) estimates that only 20% of violent
incidents are reported by nurses. There are several
reasons for the under-reporting of violence. These
include the perceived degree of the patient’s intent
to commit harm; staff being accustomed to vio-
lence; peer pressure not to report; differential re-
porting based on gender of the victim; fear of
blame; excessive paper work; and incomplete or
invalid information on reports completed by per-
sons not witness to the event (Lanza, 1992; Lyne-
ham, 2000; Forrester, 2002). In Australia, Lyneham
(2000) proposed that ED nurses might believe
nothing would be done if they report the incident or
perceive violence to be part of the job.
Patients who are under the influence of alcohol
or drugs can be violent (Lyneham, 2000; Murray and
Snyder, 1991). The Australian College of Emer-
gency Medicine (ACEM, 2000) and the National
Committee on Violence (1989) acknowledged that
intoxication may provoke or magnify aggressive
behaviour, that alcohol is the most commonly
consumed drug in Australia, and some violent of-
fences are associated with alcohol consumption.
In one study, substance abuse was a primary or
secondary diagnosis in 73% of patients who were
violent (Drummond et al., 1989). Murray and Snyder
(1991) found that violent patients had a history of
drug abuse in 10% of the cases and a history of al-
cohol abuse 30% of the time. A more recent study by
J. Crilly et al.
Lyneham (2000), conducted in New South Wales,
Australia, examined the nature and extent of vio-
lence in hospital EDs. Of the 226 nurse respondents,
88% believed that alcohol was a precipitating factor
and 79% believed drugs were a precipitating factor
in violent incidents. These were perceptions only
and no confirmatory evidence was identified.
In addition to patient characteristics, organisa-
tional characteristics may also influence violence.
Triage is the first point of public contact with the
ED and triaging determines waiting time. Lavoie
et al. (1988) identified that 78% of violent incidents
occurred within 1 h of presentation. Service de-
livery has also been influenced by the trend to-
wards deinstitutionalisation for people with mental
health needs (Jones and Lyneham, 2000). The
Australian Institute of Health and Welfare (AIHW) is
a national agency for health and welfare statistics
and information. Its function is to provide statis-
tical information which governments and the
community can use to track workforce issues.
During 1998–1999 there were 169,000 psychiatric
care admissions and 83,000 general admissions in-
volving mental health related conditions to Aus-
tralian hospitals (AIHW, 1999). However, a report
of Mental Health Services in Australia 1989–1999,
estimated that the number of beds available in
public psychiatric institutions had declined by 65%
in the last decade (AIHW, 1999). In the new
structure of integrated mental health services, EDs
are used as medical clearance sites for patients
with a mental illness (Lyneham, 2000), and yet
many ED nurses do not have mental health training.
As a consequence of mental health education and
training deficits, signs of disturbed behaviour and
potential violence may be missed (Lyneham, 2000).
In summary, both the definition used to define
violence and a propensity to under-report violence
has been identified. The use of drugs and alcohol by
patients may precipitate violence. Mental health
issues and long waiting times have also been im-
plicated in violence against nurses in the ED.
Clearly, there is a need for further research in this
area. This paper reports on a study of violence
towards ED nurses by patients.
Method
A descriptive, longitudinal cohort design study was
conducted in two public EDs in South East
Queensland, Australia. Collectively, approximately
80,000 patients a year present for treatment. The
university and participating hospital human ethics
committees approved this study.
Violence towards emergency department nurses by patients
Inclusion criteria
All Registered and enrolled nurses who had patient
contact and were employed in the ED setting were
invited to participate in the study. Forty-seven
nurses from Hospital A and 61 nurses from Hospital
B met the inclusion criteria. After explaining the
study, informed consent was obtained.
Exclusion criteria
Nurses who were employed by the hospital on a
casual basis and thus had no set working hours in
the ED were excluded.
Procedure
Four instruments were developed and included a
demographic details form, a brief violence record,
data extraction form, and a violence question-
naire. A pilot study ascertained the reliability and
validity of the instruments developed. Information
sessions were conducted and an information sum-
mary, consent form and demographic details form
were distributed to all ED nurses at the beginning
of the study. After signing the consent form, par-
ticipants completed the demographics form. The
brief violence record was completed after nurses
were subjected to violence. The researcher at-
tended each ED weekly, collected the brief vio-
lence records, completed the data extraction
form, and distributed the detailed violence ques-
tionnaire to nurses who reported violence. In order
to determine the total number of presentations
to the ED during the five months of the study
period, the hospital electronic database system
was accessed.
Instruments
The instruments used in this study were guided by
the literature review. Instrument one was a De-
mographic Details Form and included age, gender,
current employment status, length of employment
in the current ED, and completion of any training in
managing violence. It was adapted from Murray and
Snyder’s (1991) study. Instrument two was a Brief
Violence Record that identified the date and time
of the incident, the nurse’s hospital identification
number, and the patient’s unit record (UR) num-
ber. Instrument three was a Data Extraction Form.
It was used to obtain the patient’s waiting time and
triage category. Inter-rater reliability was estab-
lished to demonstrate the association between the
researcher’s time and the nurses’ time by using the
69
Pearson’s correlation (r ¼ 0:96). This was statisti-
cally significant as p < 0:001. Hence, the use of this
method of data collection was deemed reliable.
For the patient’s triage category, the inter-rater
reliability of nursing triage was established using
the Kendall’s tau-b and yielded the result of 0.86.
This was statistically significant as p < 0:01.
Instrument four was a Violence Questionnaire
also adapted from Murray and Snyder (1991) and
included the nurse identification number, location
of the incident, type of incident (verbal/physical),
and nature of the incident (spat at, yelled at etc.).
This instrument also identified whether the nurse
perceived the patient to display any behaviours
associated with a mental illness or were under the
influence of alcohol or drugs as well as perceptions
of any pre-incident characteristics the patient
displayed. The management strategies nurses im-
plemented, as well as subsequent treatment the
nurses received and required, was determined. The
content validity of this form was assessed by having
ten ED nurses complete and identify any omissions
of content. It was then piloted and revised. Test-
retest reliability for this questionnaire was estab-
lished by determining stability over time and the
percentage of agreement was 91% indicating good
consistency.
Results
A total of 108 nurses from two EDs were invited to
participate in this study. Seventy-one (66%) nurses
completed and returned the demographic details
form, 50 (70%) of whom reported violence in the
five months. Table 1 includes AIHW data to allow
comparison between study data and Australian
workforce statistics. It shows that the demo-
graphics of nurses participating in this study were
similar to those of all nurses throughout Australia.
The majority of ED nurses who reported violence
were in their mid-30s, female, relatively experi-
enced and working part-time. The sample of nurses
who reported violence were compared to nurses
who did not report violence. No statistical differ-
ence in these nurse characteristics identified in
Table 1 were found using v2 and t-test statistics.
Over the five months, there were 45,047 patient
presentations to the two EDs. Of these, 86 patients
were responsible for the 110 violent incidents re-
ported by ED nurses. This was a rate of violence of
0.2%, or, two episodes of violence for every 1000
patients who presented and approximately 5 vio-
lent incidents per week. Nurses provided descrip-
tive data on 87 of the 110 (79%) reported incidents
70 J. Crilly et al.

Table 1 Demographic characteristics for nurses in the study

Nurse demographics Reported violence n ¼ 50 Violence not reported n ¼ 21 AIHWa
Average age (years) 37 (9) 38 (10) 40
Gender
Female 43 (86%) 17 (81%) 92%
Male 7 (14%) 4 (19%) 8%
Average years of experience 16 (10) 16 (9) n/a
Average years of ED experience 9 (7) 8 (6) n/a
Part-time 32 (64%) 14 (67%) 44%
Full-time 18 (36%) 7 (33%) 56%
n/a: Not available.
a
Australian Institute of Health and Welfare.

of violence. A total of 58 (53%) episodes of verbal

Table 3 Types of violence
violence and 29 (26%) episodes of both verbal and
physical violence were reported. Only one episode Forms of violencea Type of violence
of physical violence without verbal violence was Verbal Both verbal and
reported. The evening shift (1500–2300) was when physical
most violence of all types was reported, while the Verbal violence
day shift (0700–1500) was when least violence was Sworn at 42 (38%) 25 (23%)
reported. Detail about the time when violence Yelled at 40 (36%) 23 (21%)
occurred is reported in Table 2. Physical violence
Data relating to the types of verbal and physical Pushed n/a 11 (10%)
violence displayed by patients are presented in Object thrown n/a 4 (4%)
Table 3. The type of violence most frequently re- Slapped n/a 4 (4%)
ported was verbal. Being sworn at was the most a
% Add up to >100 because more than one response could
common form of verbal violence whilst being pu- be chosen.
shed was the most common form of physical vio-
lence. Many incidents involved multiple forms of
violence. Nurses who reported both verbal and
physical violence most frequently described being Table 4 Location of reported violence
sworn at and pushed.
Location of Type of violence Total
Locations within the EDs where violence was
violent incident Verbal Both verbal
reported can be seen in Table 4. Verbal violence
was most often reported in the triage area. Loca- and physical
tions where both physical and verbal violence oc- Triage 18 (16%) 6 (5%) 24 (22%)
curred most frequently were in the accident and Accident area 13 (12%) 8 (7%) 21 (19%)
triage areas. Other 24 (22%) 15 (14%) 40 (36%)
No details 25 (23%)
reported
Total 55 (50%) 29 (26%) 110 (100%)
Table 2 Occurrence of violence
Shift violence Type of violence Total
occurred Verbal Both verbal The average waiting time of patients reported to
and physical be perpetrators of violence was 66.2 min
Evening 24 (22%) 17 (15%) 41 (37%) (SD ¼ 115:7). Approximately one quarter of the
(1500–2300) violent incidents (n ¼ 26, 24%) involved patients
Night 13 (12%) 10 (9%) 23 (21%) who did not wait to see a doctor. Patients given a
(2300–0700) triage three (n ¼ 37, 34%) or four (n ¼ 37, 34%)
Day (0700–1500) 20 (18%) 2 (2%) 22 (20%) category were the most frequent perpetrators of
No details 24 (22%) violence. Over half of all types of violence involved
reported patients who had prolonged waiting times as evi-
Total 57 (52%) 29 (26%) 110 (100%) denced by a wait in excess of that recommended by
the ACEM (2000) Guidelines.
Violence towards emergency department nurses by patients
Table 5 Percentage of patients perceived to be under the influence of alcohol and drugs who were verbally
violent and both verbally and physically violent
Patient characteristics Type of violence
Verbal
Under influence of alcohol 16 (28%)
Under influence of drugs 13 (22%)
Neither drugs or alcohol 29 (50%)
No details reported
Total 58 (100%)
If a violent incident occurred, the nurse was
asked questions relating to the patient’s charac-
teristics. Table 5 shows that ED nurses frequently
perceived that alcohol and drug use was involved in
the violent incident.
When asked what general behaviour patients
displayed, nurses reported that demanding behav-
iour and requesting attention (n ¼ 48, 44%) was
involved in verbal as well as verbal and physical
violence. Behaviours associated with mental illness
were also believed to play a role in violence. Of
these, irrational behaviour was perceived to be
involved in 21 (19%) of all violent incidents.
Discussion
Violence in hospitals is of concern both nationally
and internationally. Front-line nurses, such as
those in the ED, are often the targets of violence.
The incidence of violence reported in this study is
low when compared to retrospective studies (e.g.
Lyneham, 2000). However, it did indicate that 50
of the 71 (70%) nurses participating during the five-
months study period, reported violence. Perhaps
this difference can be explained by under-reporting
and other factors that attempt to identify why
nurses don’t report violence (Lanza, 1992; Lyne-
ham, 2000; Forrester, 2002). However, this study
identified that ED nurses are at risk of violent
attacks.
Precipitating patient factors associated with vi-
olence that were investigated in the present study
included waiting times, alcohol, drugs and behav-
iour associated with mental health illness. This
information allows a description of the perpetra-
tors of violence to emerge. Waiting times of pa-
tients who present to the ED have been frequently
cited as a precipitating factor to violence (Lavoie
et al., 1988; Lyneham, 2000; Mayer et al., 1999;
Yassi et al., 1998), however there has been sur-
prisingly little empirical research to substantiate
71
Total violent incidents
Both verbal and physical
14 (48%) 30 (27%)
14 (48%) 27 (25%)
1 (4%) 25 (23%)
23 (21%)
29 (100%) 110 (100%)
this correlation. One study conducted by Lavoie
et al. (1988) identified that 78% of violent incidents
occurred within 1 h of presentation, which is sim-
ilar to the results of the present study. Around 67%
of patients who exhibited violent behaviour either
did not wait for treatment, or had been in the ED
for less than 1 h. In 39% of these cases, patients
waited over the amount of time determined ap-
propriate by their triage category. Although the
triage process is a system acceptable to those in
the medical profession, it may not be acceptable,
or well understood by members of the general
public whose definition of an emergency may be
different to those of health care professionals.
The perpetrator was often perceived by nurses
to be under the influence of alcohol or drugs. In
total, alcohol appeared to be a factor in 27% of all
violent incidents in this study. Similar results were
identified in other research (Murray and Snyder,
1991; Zernike and Sharpe, 1998). It is well known
that alcohol impairs a person’s judgement and has
a disinhibiting effect on behaviour (National Com-
mittee on Violence, 1989). Thus, a patient under
the influence of alcohol may display exaggerated or
inappropriate responses such as violence.
ED nurses in this study perceived the patient to
be displaying behaviours associated with mental
illness in 44 (40%) of the 110 reports of violence.
This was a much higher perception than that re-
ported by Pane et al. (1991) where 26% of the 686
violent incidents involved patients awaiting psy-
chiatric clearance. Lyneham’s (2000) study also
presented a lower association where only 8% of
nurses believed patients with a mental illness
precipitated violence. Changing health policy re-
lated to institutionalisation of individuals with a
mental illness may partially explain the higher rate
in this study.
The most frequently cited patient characteristic
reported by nurses was demanding behaviour or
requesting attention. These results are similar to
those of Murray and Snyder (1991) but differ to
Yassi et al. (1998). The results of the present study
72 J. Crilly et al.

indicate that ED nurses were aware of the patients’
behaviour but did not expect violence in the ma-
jority of occasions.
The most frequent types of verbal violence ex-
perienced by ED nurses in the present study in-
cluded being sworn at, yelled at, threatened, and
intimidated. Zernike and Sharpe (1998) also iden-
tified sexual innuendo as part of verbal violence.
O’Connell et al. (2000) suggested that some of
these types of violence have ramifications beyond
the initial incident and result in emotional trauma
for victims of violence. Perhaps repeated episodes
of verbal violence, associated under-reporting and
insufficient support mechanisms, leads nurses to
suppress emotions for fear of being labelled as not
coping which may add further stress associated
with the event. Whilst nurses may wish to clarify a
situation to a verbally violent patient, they may
feel that a somewhat passive or submissive role to
be the best approach to use as that is what had
been taught/demonstrated by colleagues. Re-
searchers have identified that strategies such as
avoidance mechanisms are utilised by individuals to
avoid tasks that exceed their capabilities (Bandura,
1977). Furthermore, fear of reprimand has also
been identified in the literature as to why nurses
accept violence to be ‘part of the job’ (Jones and
Lyneham, 2000).
A total of 21 ED nurses were either pushed,
slapped, kicked or hit by patients. These findings
were consistent with those identified by other re-
searchers (Murray and Snyder, 1991; Nolan et al.,
2001; O’Connell et al., 2000; Zernike and Sharpe,
1998). At present, 24 h onsite ED security personnel
is not available at either participating site in this
study. Whilst they may be beneficial when patients
are physically violent, there will be occasions when
the timely assistance of security is not possible and
nursing interventions are the first line of manage-
ment.
The present study identified a high proportion of
verbal violence and both verbal and physical vio-
lence most commonly took place in the triage area.
This was the area where most ambulatory patients
are first seen by ED staff and was staffed by a
maximum of two nurses at any one time in both
participating EDs. Pane et al. (1991) conducted a
retrospective study of 686 episodes of violence and
found 18% of episodes occurred in the triage area.
It was suggested that the ED environment was un-
pleasant and may be a contributing factor to vio-
lence. This may also have been the case in the
present study with a lack of toys, magazines, sep-
aration of family from patients, and lack of un-
derstanding of triage system.
While this study provides more insight into ED
violence, several limitations must be acknowl-
edged. Firstly, only two hospitals were studied,
neither of which were located in a capital city.
Secondly, only violence by patients towards nurses
was examined. Nothing is known about other ED
visitors. Thirdly, this study relied on self-reports
and as such, no data to confirm or refute under-
reporting was utilised.
Recommendations
This study identified key issues, supported other
research on violence towards ED nurses and pro-
vides a foundation for future work in the area. As a
result of this study, recommendations for future
research and practice have emerged that relate to
enhancing the safety of nurses. These are sum-
marised in Table 6.

Table 6 Recommendations
Research
• Follow a consistent operational definition of violence so that comparisons across studies can be made
• Compare different areas of the hospital to ascertain whether the ED is a ‘high risk” area for nurses to work
• Include relatives and other visitors in a study of violence towards all ED staff
• Use structured observation to overcome under-reporting
• Consider a case control study whereby violent cases are identified and matched to patients who are not violent
Practice
• Develop a comprehensive program of continuing professional education on de-escalation and aggression
management, skill acquisition, peer mentoring and support
• Develop appropriate policies and procedures to be taken prior to and once a violent situation arises
• Re-examine staffing levels in the triage area. Approaches whereby more nurses’ work at triage to manage the
increasing load of patient presentations, warrants consideration
• Establish a ‘Violence Management Team,’ as a way of ensuring effective patient management and protecting the
health and safety of staff (Brayley et al., 1994)
Violence towards emergency department nurses by patients
Conclusion
Violence towards ED nurses by patients is perceived
as a problem but reporting of incidents continues
to be poor. Nurses must report violence to inform
hospital administration as well as society of the
extent and nature of the problem. Nurses in this
study were pushed, slapped, kicked and sworn at
by patients. Patient factors, such as long waiting
times, alcohol, drugs and mental health issues
were perceived by nurses to be related to violence.
Most violent patients were triaged at category 3 or
4, and their average waiting time was just over 1 h.
Medical professionals may view this as an accept-
able waiting time, but this research suggests that
the waiting time for some patients may be involved
with violence. ED nurses manage complex human
situations that can be exacerbated when individu-
als suffer from a mental illness or are under the
influence of alcohol or drugs. Identification of
trends and patterns of violence can contribute to
better health care planning and service provision
so that more effective preventative and safe
strategies can be developed. Nurses, as all other
workers in society, have a right to safety in their
workplace.
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