Journal of General and Emergency Medicine

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Research Article

Violence and Abuse against Staff in the Emergency Department, a Descriptive Analysis of a Two-Centre Staff Survey

Pourya Pouryahya, Alastair D McR Meyer, Simon Sherington

Correspondence Address :

Pourya Pouryahya MD
GC ClinEpi, CCPU, M Trauma
FACEM, Emergency Medicine Consultant
Department of Emergency Medicine
Casey Hospital, Monash Health, Adjunct Lecturer
School of Clinical Sciences, Department of Medicine, Monash university
Director of Emergency Medicine Research (DEMR), Casey hospital, Monash Health
62-70 Kangan drive, Berwick, Victoria 3806, Australia
Tele: +61 (03) 8768 1869
Email: Pourya.Pouryahya@monashhealth.org, Pourya.Pouryahya@monash.edu

Received on: April 15, 2019, Accepted on: April 22, 2019, Published on: April 29, 2019

Citation: Pourya Pouryahya , Alastair D McR Meyer, Simon Sherington (2019). Violence and Abuse against Staff in the Emergency Department, a Descriptive Analysis of a Two-Centre Staff Survey

Copyright: 2019 Pourya Pouryahya et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Background: "Violence" and "Abuse" against staff in the emergency department (ED) is not uncommon, however, there is a lack of data regarding the prevalence and characteristics of such incidents.
Objectives: To estimate the prevalence, type, and effect of violence and abuse experienced by staff during each shift in two emergency departments in the Monash Health network.
Method: During two separate two-week periods surveys were distributed to ED staff in two metropolitan Melbourne hospitals. Staff were identified by shift, area, and role. Staff were asked if they had experienced violence or abuse during that shift, how many times this occurred, whether it was initiated by a patient or accompanying person, the type of violence or abuse, whether alcohol or drugs were involved, if any injury or emotional effect resulted, and whether the incident was reported.
Results: 362 responses were recorded among ED staff during the study periods, of which, 36.5% reported some kind of violence or abuse. Majority of the victims were nursing staff with the type of violence predominately being verbal abuse. Among those, 22.1% of participants had been affected emotionally and 1.5% were physically injured.
Conclusion: Experience of violence and abuse against staff in the ED is frequent and affects ED workers in every shift. The vast majority of the incidents were not formally reported, and any future studies assessing incidence of such events cannot rely on formal reporting alone.
The risk of occupational violence and abuse have long been known as an issue in the healthcare sector and particularly within the emergency department 3. These are often accepted as a part of working in the ED.
Recent publications have demonstrated that almost all ED workers will experience violence or abuse during their working life [1-5], and that nurses are at greatest risk. The most recent Australian evidence is a survey of ED staff in four Queensland hospitals recording that 88.1% experienced verbal abuse and 42.7% experienced physical violence [5]. Multiple studies have documented that alcohol and other drugs are commonly involved in incidents within the ED [1, 4, 6]. At the time of writing, no previous study had examined the situation in Victoria, and the experience of violence or abuse has yet to be evaluated on a shift-by-shift basis.
This study examines the incidence of violence and abuse among all ED staff and within each shift. Primary aims of this study includes: description and characteristics of the incidence across each shift, as well as, their effect on victims. We also aimed to identify the staff members experiencing the most incidents.


Monash Health is a large health network in south-east Melbourne, Australia, with an annual emergency department network census of about 220,000 presentations comprising three hospitals: Monash Medical Centre (tertiary referral), Dandenong and Casey hospitals (district hospital). Because of some witnessed but unreported violence and abuse by patients or their relatives against ED staff and inadequate data regarding these incidents, after interviewing some affected staff as well as auditing reported
incidents, a single page survey (figure. 1) was designed and made available in the main clinical area at the end of each shift during
two separate two-week periods (period 1: August 15th– August 28th, 2016 and period 2: February 20th -March 5th, 2017) within
the ED of Casey and Dandenong hospitals.
Including nurse and consultant (Emergency physician) in charge of each shift usually, there are about 18 nursing staff on the floor on dedicated areas including triage, resus, main cubicles, ambulance off load, fast track and short stay/observation unit; as well as 4 Senior and between 5-7 Junior medical staff in 2 main groups, fast track and short stay/observation unit. These numbers will decrease to 16 nursing staff and 5 medical staff during the night shift.
An education session was conducted prior commencement of the study. All staff were also reminded to complete surveys by research groups as well as the consultant and nurse in charge at the beginning of each shift.
This study was approved by the Monash Health and Monash University Human Research and Ethics Committees (Ethics Approval 16248Q).
Staff were asked to voluntarily fill in the date, the shift they were undertaking AM (08:00-16:00), PM (16:00-00:00) or night shift (00:00-08:00), as well as, the site at which they were working. Staff were also asked to define their role in the ED, and in which clinical area (in charge of the shift, triage, resus cubicles, high acuity area including monitored cubicles, low acuity area including non-monitored beds, adult or paediatric Short stay units and fast track) they were working on that date.
The survey consisted of seven questions and a free text area for additional comments. At the beginning of the study the types of "violence" and "abuse" were defined. Staff were also allowed to report any type of violence or abuse, which was affecting them either physically or emotionally. A free text section was provided for any comments at the bottom of the survey. Returning a completed survey was considered indicative of consent.
Each staff could complete and return only one form during the study period with the number of incidents at the end of each shift. In terms of incident reporting there are multiple ways depending on the type and severity of incidence, mainly using the "Riskman" portal for capturing and classifying adverse incidents. This portal also addresses 2 other key elements of effective risk management: Feedback Management (e.g. Complaints, Compliments, Suggestions, Enquiries through the Feedback module); and Risk Register for proactive risk identification.


During the study period, 364 survey forms were returned, two of which were excluded for not answering any of the questions. Of the 362 satisfactorily completed surveys most responses came from Dandenong hospital. The staff who responded were predominately nursing staff (Table 1). A similar number of surveys were completed during and after all three shifts.
The incident of violence and abuse were reported (a "positive" response) by 132 respondents (36.5%) during their shift. Most episodes were experienced by nursing staff, particularly registered nurses. Incidents were experienced by 47.0% of night staff, 43% of afternoon staff, and 23.1% of those on the morning shift. Those who reported an episode of violence or abuse in a shift, often reported experiencing multiple incidents. Seventy positive reports did not specify the number of incidents which was counted as one per report. The remaining 62 reported 183 separate incidents (SD 3.1).
Verbal abuse was far more common (97.2%) than physical violence (17.6%) for the 108 reports that described the type of abuse. One staff member experienced violence but did not specify the type of physical or emotional affect, the remaining 131 positive reports, 22.1% reported that they had been emotionally affected. Physical harm was reported just in 2 (1.5%) of victims. Staff experienced the violence of abuse, reported that drugs and/or alcohol, were a contributing factor in 46.2% of reported incidents. 57.2% of incidents had been reported which 15.3% of them following the formal reporting process using the Riskman portal.
The free text section in the survey was rarely used by participants. A few respondents further described the incident or their reactions, some mentioned that they had not formally reported the incident as they believed nothing would be done and several expressed the belief that this survey would not change the rate of violence and abuse in their work. None of the staff described any other type of reporting (i.e. reporting to police or legal actions).


This survey recorded presence of verbal violence and abuse in every shift and small but notable instances of physical violence, consistent with previous research outside Victoria [1-5]. These results indicate that experiencing abuse or violence is a daily occurrence among ED staff, often multiple times in a single shift; and also support the observations of previous research that highlight intoxication with drugs and alcohol is very common in patients perpetrating incidents of violence and abuse [1, 4, 6].

Managing the issue

Our data confirms previous observations that recurrent exposure to violence and abuse is most commonly experienced by nurses [5,7]. This has been flagged as an issue for improvement since at least 1999 [7]. ED directors are often unhappy with the security of emergency departments and are often only partially compliant with Australian College of Emergency Medicine guidelines [8]. Previous studies have trialled education programs in nursing staff such as the Management of Clinical Aggression - Rapid Emergency Department Intervention (MOCA-REDI) [9], showing that nursing staff feel they have more understanding and are better able to manage patient violence after the program, though none were associated with a statistically significant reduction in violence, and nursing staff have been shown to believe that violence cannot be prevented [10].
The lack of incident reporting in this study suggests that the "zero tolerance to violence policy" expressed by many organisations and employers is clearly not enforced. Over half the violent and abusive incidents during each shift went unreported in this study. This suggests that staff are tolerating such behaviour, perhaps due to the widely held belief that it is "just a part of the job" [2, 11]. Importantly, it indicates that any attempt to formulate management strategies towards violence and abuse in the ED based solely on formal reporting underestimates the true enormity of this issue. Encouraging staff to formally report more (ideally all) incidents of violence and abuse and ensuring that reporting leads to a positive resolution may be an important step in developing appropriate strategies to mitigate this recurring problem. Zero tolerance policy, reporting to police, as well as legal actions and pressing charges could be some of the actions that can be taken facing these incidents.


This study was designed as a voluntary survey; overall 20.7 % of the survey forms have been returned. The majority of staff in each shift did not participate and some did not satisfactorily complete sections of the survey, particularly with regard to number of incidents and the type of violence or abuse experienced. It is unknown whether the experience of these individuals differs significantly from our results. We also were aware of potential inclusion and reporting bias. Further to this the hospitals involved were part of the same health organisation, with surveyors (Authors) being part of the network but not participating in the study, our results may not be valid external to our organisation. Despite this our data is consistent with similar research undertaken in different cohorts and locations.
Allowing staff to determine what they considered violence, abuse and harm introduces the potential for over or under-reporting, especially given the previously documented tendency for emergency workers to consider incidents as "just part of the job". Differences in attitudes to violence and abuse between working roles may create differing levels of misreporting for our survey, altering our comparison between roles and individuals. Likewise, not defining formal and informal reporting on the survey may have influenced the responses received. In addition, having no section to describe the reporting method in detail means we are largely unaware of what form formal or informal reporting took.


This study adds to previous evidence that emergency staff, particularly nurses, are subject to regular violence and abuse on a daily basis. Violence and abuse are often associated with drug and alcohol use and were more common in the overnight and afternoon shifts. The type of violence and abuse were similar to those experienced in other Australian studies, suggesting that it is a reoccurring phenomenon across as all Australian Emergency departments.
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Tables & Figures
Table 1: Distribution of respondents by hospital, role, and shift.

Figure 1: The survey as it was presented to staff.

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