Patient-related violence against nursing staff working in emergency departments: a systematic review

    loading  Checking for direct PDF access through Ovid



The healthcare industry has been identified as one of the most violent workplace sectors1, with emergency departments (EDs) ranked as one of the areas with the highest risk for such violence.2Patient-related aggression and violence have been identified as common behaviors in the modern ED.3Within this context, nursing has been identified as the occupation with the most risk of patient-related violence, with 60-90% of nurses reporting exposure to verbal and physical violence.2Emergency department nurses have been identified as having the most stressful workplace setting of all nurses4, and are exposed to a disproportionate amount of violence.5High levels of verbal abuse and threatening behavior are reported6,with up to 90% of ED nurses having experienced violence at some point in their careers and all have reported experiencing verbal abuse.7


The purpose of this review was to identify, appraise and synthesize the best available evidence on the impact of patient-related violence against nurses working in EDs.

Inclusion criteria

Types of participants

Inclusion criteria

This review included studies on nurses working in EDs regardless of gender, age, classification or level of experience.

Inclusion criteria

Types of intervention(s) / phenomena of interest

Inclusion criteria

The review considered studies that evaluated emergency nurses' experiences with patient-related violence.

Inclusion criteria

Types of studies

Inclusion criteria

The review included primary quantitative, qualitative and mixed methods studies.

Inclusion criteria

Types of outcomes

Inclusion criteria

The review included studies that reported factors and outcomes associated with patient-related violence including:

Inclusion criteria

• Frequency of episodes of violence

Inclusion criteria

• The types of violence - physical and verbal

Inclusion criteria

• Organizational reporting of episodes of violence

Inclusion criteria

• Antecedents and risk factors

Inclusion criteria

• Impact and sequelae of violence: psychological and physical effects

Inclusion criteria

• Prevention and control measures to manage episodes of violence.

Search strategy

A three-stage comprehensive search strategy was utilized to search across seven electronic databases. English language studies published between January 2001 and December 2011 were considered for inclusion.

Methodological quality

Two independent reviewers assessed the methodological quality of each study selected for retrieval using standardized Joanna Briggs Institute critical appraisal tools.

Data collection

Data were extracted from studies using the standardized data extraction tools from the Joanna Briggs Institute.

Data synthesis

It was not possible to undertake meta-analysis due to a lack of homogeneity between studies. Findings are therefore presented in a narrative form.


Eighteen studies were eligible for inclusion in this review. This included 11 quantitative, four qualitative and three mixed methods studies. Violence against ED nurses occurs frequently and includes episodes of both verbal abuse and physical violence, with verbal abuse experienced by the majority of participants across all studies. In addition, many episodes are not reported due to a perceived lack of follow-up by management. Antecedents and risk factors include patient, staff and organizational related issues. The effects of violence on nurses can be long lasting and can affect the quality of patient care provided. It is difficult to define the impact of preventative and control measures; however security and training are typically used.


Due to limitations in the studies, the results of this systematic review do not support the development of best practice guidelines on the topic. However, the results of this review should be considered as an information source in the development of healthcare organizational policies and practices, in conjunction with other information sources, potentially with greater methodological rigor. These results call into question the effectiveness of policies such as Zero Tolerance and the ability of hospitals to provide a safe working environment as required under Workplace Health and Safety legislation. Employers should ensure that prevention strategies are adequate and given that the impact of patient-related violence on ED nurses can be long-lasting in nature, provide support and follow-up for those affected. Emergency department nurses report being fearful and feeling unsafe at work and with patient-related violence perceived to be increasing in frequency and intensity, ongoing research in this area is essential. The use of prospective studies with large sample sizes will help to provide a more accurate understanding of the phenomenon and provide an impetus for change in attitude from healthcare employers and government.

    loading  Loading Related Articles