Workplace Violence in an Urban Community Emergency Department: A Deeper Dive into the Antecedents and Circumstances of Violent Behaviors

Background

Workplace violence (WPV) in emergency departments (EDs) is a growing concern, with significant impacts on staff safety and patient care. While previous studies have largely focused on tertiary care centers, data on WPV in community EDs remain limited. Understanding the characteristics and circumstances surrounding WPV events is critical for developing effective prevention and mitigation strategies.

Methods

We conducted a retrospective observational study of WPV incidents at an urban community teaching hospital ED in Boston, Massachusetts, from January 2021 to April 2023. Using hospital police and security and risk management databases, we identified cases involving completed physical violence against staff. Chart reviews were performed to extract demographic, clinical, and encounter-related data. Circumstances surrounding the violent episodes, including psychiatric holds, substance use, length of stay, and use of pharmacologic and physical interventions, were analyzed.

Results

During the 28-month study period, 58 unique ED encounters involved at least one physical assault, resulting in 121 distinct assault incidents. Most patients involved in WPV had significant psychiatric comorbidities, with 50% diagnosed with a schizophrenia spectrum disorder and 70% on involuntary psychiatric holds. Boarding for psychiatric placement was a major risk factor, with 78% of assaults occurring during prolonged ED stays. Most incidents were triggered by behavioral redirection or agitation management. Nurses (46%) and security officers (42%) were the most frequent victims. Pharmacologic interventions were inconsistently administered before assaults, and a substantial proportion of patients ultimately exhibited clinical improvement.

Conclusion

WPV in the ED disproportionately involves patients with significant psychiatric illness, prior trauma, and social vulnerability. Psychiatric boarding and prolonged ED stays appear to be key contributors to violent incidents in the community setting. Our findings highlight the need for systemic interventions, including improved psychiatric bed access, structured agitation management strategies, and staff training in de-escalation.