Emergency department workplace violence: Clinician-endorsed strategies informing prevention mandates

Abstract

Background:

State legislation such as the Pennsylvania Healthcare Worker Violence Prevention Act would mandate hospital reporting of workplace violence (WPV) incidents and require committees that advance safety measures.

Purpose:

Since it is unknown what interventions should be prioritized by hospital committees if such legislation were passed, we described strategies that hinder or facilitate the prevention and de-escalation of WPV.

Methods:

Qualitative, descriptive study using individual and focus group interviews with emergency department (ED) nurses and physicians (n = 23) at a level I trauma center ED in Pennsylvania between August 2023 and February 2024.

Discussion:

Five clinician-informed themes were identified: a) clinical protocols, b) clinician conflict in addressing WPV, c) social vulnerability in emergency care, d) resources and throughput, and e) the presence and responsibility of security.

Conclusion:

Priority interventions included WPV clinical protocols; holding hospital administrators accountable to support clinician decision-making during WPV events, safe nurse staffing levels, and cross-disciplinary training of security personnel.

Introduction

Healthcare professionals are five times more likely to experience workpalce violence (WPV) than those in any other United States industry (McLaughlin & Khemthong, 2024; US Bureau of Labor Statistics, 2018). WPV is heightened in emergency departments (EDs), which serve as a primary entrance into hospitals where the nature of care is high-stress, uncertain, and fraught with complexities (American College of Emergency Physicians [ACEP], 2022; Kowalenko et al., 2012; Muir et al., 2022). While interventions have been proposed and implemented across health systems to reduce violent incidents, WPV between patients and clinicians continues to worsen in prevalence and severity. Common interventions to address WPV include verbal de-escalation trainings, self-defense skills training, metal detectors, and hospital reporting mechanisms; however, there are no universal standards for hospital implementation of such interventions (Fricke et al., 2023).

In May 2025, the Pennsylvania House of Representatives passed the Healthcare WPV Prevention Act (Rock, 2025; Scicchitano, 2025). If successfully passed through the Senate and implemented, the legislation would require that all health care facilities in Pennsylvania establish WPV committees focused on preventing WPV and that they perform annual risk assessment reports. It also requires that health care facilities establish a WPV prevention committee, conduct regular risk assessments, and post signage indicating that assault of a health care worker is a felony. The legislation would strengthen hospital reporting of WPV incidents, which is important given that underreporting of WPV is common in health care. Since there are no national standards for WPV safety prevention in hospitals from the Occupational Safety and Health Administration (OSHA), the passage of such legislation at the state level is essential to protect the safety of health care workers and patients (Varrati, 2024).

Policy Overview

The presence of policies at the local hospital, state, and federal levels in the United States informs WPV prevention and management in health care. Although the Occupational Safety and Health Act of 1970 (OSH) Act established OSHA to promote safe working conditions, there are no federal standards for WPV prevention in health care in the United States (Occupational Safety and Health Administration, n.d.). However, the Workplace Violence Prevention Health Care and Social Service Workers Act (HR 1195) and the Save Healthcare Workers Act (HR 3178) have been introduced previously in Congress (Congress.Gov, 2021, 2025). HR 1195 passed in the House in 2021 but has since stalled in the Senate. The legislation would require that OSHA establish a prevention plan for WPV that protects health care workers. HR 3178 would establish federal criminal penalties for assaults against health care workers, develop grants to support health care safety, and model protections implemented in the airline industry.

At the state level, policies most commonly establish a punishment for violence against health care workers and/or establish standards/requirements for health care facilities to prevent WPV (Ninan et al., 2024; OgleTree Deakins, 2025). Penalties include criminal charges, fines, and/or serving time in prison. Where states require that hospitals establish measures to prevent WPV, such strategies include mandatory annual risk assessments in health care facilities and mandatory de-escalation training for health care workers. While some states establish penalties for individuals who harm a health care worker, others such as New Jersey (2023 Health Care Heroes Prevention Act) establish a criminal offense for threatening health care workers. All states except Wyoming have state laws that fall into one or both of these categories.

Most states require that hospitals establish a WPV policy within their institution; however, what each policy entails can vary given a lack of uniform guidelines established at the state or federal level (Phillips, 2016). States such as PA are increasingly considering legislation requiring that health care facilities establish WPV prevention committees so that policies align with priorities and needs of clinicians and patients. To advance the work of these committees, it is important to understand frontline clinician perspectives on the strategies that help and hinder workplace safety.

To date, the majority of WPV literature focuses on the prevalence of assaults among clinicians. One study by Kim et al. (2022) identified that 39% of nurses and 14% of physicians experienced physical violence from a patient in the past year. Another study by Pascale et al. (2025) used the National Databases of Nursing Quality Indicators to study assaults from nursing personnel between 2019 and 2023. They found that WPV assaults increased from 13,434 in 2019 to 23,767 in 2023. Additionally, patients were the assailants of 95% to 98% WPV incidents toward nurses annually. Although these studies examine the prevalence of WPV at the institutional and state level, there is a literature gap in describing what clinicians most impacted by WPV report would facilitate preventing and de-escalating assaults in the workplace.

Understanding what clinicians need to feel safe at work is important to develop and successfully promote legislation and interventions to protect health care workers in the United States. The purpose of this qualitative, descriptive study was to determine the strategies that ED nurses and physicians in a single Pennsylvania hospital report either hinder or facilitate the prevention and de-escalation of WPV. Our objective was to determine actionable strategies that WPV hospital committees in Pennsylvania could advance under the requirements of the proposed legislation, informed by clinicians working in a high-volume, stressful acute care environment.

Although nurses experience the highest rates of WPV compared with other clinician colleagues, emergency medicine is a highly interdisciplinary and team-based field. Mitigating and de-escalating WPV in EDs is contingent upon not only understanding nurses’ individual experiences but also the perspectives of physicians who work alongside nurses. Physicians often are charged with placing orders and making high-level decisions influencing the work of nurses and patient care trajectories. Whether or not ED nurses and physicians align in their reports of their clinical work environment is empirically associated with patient care quality and safety and clinician job outcomes such as burnout and intent to leave (Muir et al., 2025). Therefore, our analysis focused on both clinician groups.

Methods

Study Design and Data Collection

This qualitative study consisted of in-depth individual interviews and focus groups with ED nurses and physicians employed at an urban, academic, level 1 trauma center in Pennsylvania between August 2023 and February 2024. We focused on ED clinicians as this health care setting experiences high rates of WPV, and thus participants may provide informative insight into WPV prevention and de-escalation strategies (Phillips, 2016). The study protocol was deemed exempt by the University Institutional Review Board Human Subjects Review (protocol number 853905; Exempt #2). Reporting was conducted in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Participants were recruited through purposive and snowball sampling approaches facilitated by in-person (i.e., unit huddle meetings) and email (Holloway & Galvin, 2016). Participants were compensated for their participation in the study with a $50 gift card. The primary sample included ED registered nurses and attending physicians. Inclusion criteria included being 18 years of age or older, English-speaking, working at the study setting for at least 6 months, and spending at least 50% of work duties providing direct patient care.

An interview guide (Table 1) was developed by the study authors based on the social ecological model (SEM) as a conceptual framework (Golden et al., 2015). The interview guide was also informed by the study team’s a priori knowledge of existing WPV interventions on the unit based on prior research (Maccarone et al., 2025).

Table 1.

Study Interview Guide

Social Ecological Model Level: Individual

If comfortable sharing, can you describe an incident where you experienced WPV of any kind?

What interventions to WPV would you personally prioritize and why?

Social Ecological Model Level: Interpersonal

How would you describe team collaboration during WPV events?

What helps or hinders your ability to quickly assess a WPV incident in the department?

Social Ecological Model Level: Systems

What does a culture of patient safety look like to you?

How are certain clinician roles or patient populations impacted by WPV, if at all?

Tell me some things that have worked in addressing workplace. What interventions do not work and why?

Note. WPV, workplace violence.

Interview guide for in-depth interviews. Focus group interviews were centered mostly in the “Systems” level.

The SEM was used to examine WPV through the lens of individual clinician perceptions and attitudes toward WPV prevention and de-escalation; the interpersonal experiences of WPV from patient/family member-to-clinicians, clinicians-to-clinicians, clinicians and higher management/institutional employers, and systemically (i.e., larger health care and societal dynamics). Interview questions were developed across SEM level, with a focus on clinician perceptions of workplace safety, experiences with WPV, and specifically challenges and enabling factors to advance WPV interventions. The interview guide was developed by the lead study author and revised after separate review and discussion by the senior author.

The data sources were in-depth interviews with individual clinicians and three focus groups comprising four to five emergency nurses and physicians together. There were 21 in-depth interviews and 3 focus groups. Interviews took place over a virtual conferencing platform (30–60 min each), led by the lead study author who is trained in qualitative methodology. One of the focus groups took place in-person, while the remaining two took place virtually to accommodate clinician schedules. Participants provided verbal informed consent and were informed that they had a right to refuse responding to questions and that they could terminate participation from the study at any time. Participants self-reported demographic information (race, age, gender, role, years of experience, and education). Race was self-reported by study participants to further contextualize participant violence experiences by sample characteristics (Flanagin et al., 2021). The lead author documented jottings during the interview that were transcribed for analysis. Supplemental file 1 provides detailed information on the focus group facilitation and data saturation process.

Data Analysis

All interviews were transcribed and de-identified and hand-reviewed for errors. The transcription interviews were then uploaded and stored in Dedoose, an encrypted qualitative data storage and analysis program (Dedoose, 2016). The data analysis began with an initial open coding process of the first 5 interviews wherein two study authors labeled data in the interviews with simple codes or labels to identify initial concepts in the data (e.g., patient–-clinician violence event, reporting WPV, solutions to WPV) (Leavy & Saldaña, 2014). An initial codebook was generated based on these open codes and discussed with the study team (Leavy & Saldaña, 2014). A second round of data analysis was then conducted using inductive and deductive approaches (informed by the SEM and literature reviews of WPV) to expand the codebook to 13 codes (Corbin & Strauss, 2012). Once consensus was gained on the codebook, two study authors coded the remaining interviews. Using thematic analysis, groups of study codes were subsequently collapsed into categories (Braun & Clarke, 2006). Two study authors discussed memos and notes on the study categories to develop themes representing groups of categories and representative codes. Disagreements were resolved through member checking with participants and through discussions with the study research assistant (Morse, 2015; Sandelowski,1993).

Methods to uphold rigor in qualitative research included study team reflexivity of biases (e.g., acknowledging insider or outsider status with the participant sample) and assumptions surrounding WPV. An example of the reflexivity exercise is that one study author was a clinician in the setting, and therefore recruitment was conducted by the study author unknown to the participants after conducting this reflection of potential bias. Member checking was conducted during a one-time meeting where participants were read quotes from the early data analysis and asked to reflect on the themes that they represented. This meeting also facilitated a negative case analysis (e.g., identifying and describing what did and did not describe a facilitating strategy) (Lincoln & Guba, 1985).

Results

In this qualitative study of 23 emergency clinicians (Table 2) recruited to participate in individual interviews and three interprofessional focus groups, there were 12 nurses and 11 physicians working in an urban, level 1 hospital ED in Pennsylvania. The mean age was 38.7 years (SD 8.3), and participants were predominately White (18 [78.3%]) and female (13 [56.5%]), with 11.7 years of overall work experience (SD 7.3). No participants dropped out during the study period.

Table 2.

Emergency Nurse and Physician Sample Characteristics

Characteristics	All Clinicians (n = 23)
Age (years), mean (SD)	38.7 (8.3)
Gender, No. (%)
Female	13 (56.5)
Male	9 (39.1)
Other	1 (4.4)
Role, No. (%)
Nurse	12 (52.2)
Attending physician	11 (47.8)
Race, No. (%)
Asian	4 (17.4)
Black or African American	1 (4.3)
White	18 (78.3)
Overall experience (years), mean (SD)	11.7 (7.3)
Experience at institution (years), mean (SD)	7.6 (6.7)

Note. No., number; SD, standard deviation.

Five themes (Figure 1) were identified describing strategies that hinder and facilitate WPV prevention and de-escalation in the ED: a) clinical protocols, b) clinician conflict in addressing WPV, c) social vulnerability in emergency care, d) resources and throughput, and e) the presence and responsibility of security and are described with exemplar quotes (Table 3). Pragmatic strategies to address WPV are provided Table 4, informed by the study themes.

Figure 1.

Study themes. WPV, workplace violence.

Table 3.

Exemplar Quotes From Emergency Clinicians on Facilitators and Hindrances to Prevent and De-escalate WPV

Theme and Subtheme	Exemplar Quote (Participant)
Theme 1: Clinical Protocols (Social Ecological Model Levels: Individual, Interpersonal, Systemic)
Subthemes
Bedside response	Oftentimes the bedside staff nursing is calling the [bedside response] just because the patient starts walking out the room and starts yelling. And I want to respect the legitimate concern for their personal safety that they, you know, call that code for a reason. But it’s very, very hard to de-escalate from that, because you get an audience, you get security people, it just becomes a confrontation, even if there was an opportunity to de-escalate. [Physician #113]
Behavioral flags and safety letters	I feel like a lot of times nursing and techs are like, well, “he has a [behavioral] flag”, and it’s like, they get mad at you taking time to say, “Hold on, hold on, let me see”, you know, it’s just like, “let’s kick him out.” I know I have that pressure on me of people wanting that person to be out immediately, because they have this, this flag or this notification. [Physician #118]If a patient’s had a violent encounter, inappropriate or like sexual…so anything that’s not normal…they’ll put flags on the chart, so that if they come in the future, if you open that chart, there’s an FYI that they’ll get a letter saying that that behavior is not going to be tolerated. Leadership looks it over, and then they’ll actually send [patients] a letter. When you open the chart. You’ll see a copy of that letter. [Nurse #103]
Theme 2: Clinician Conflict in Addressing WPV (SEM Levels: Interpersonal, Systemic)
Subthemes
Nurse–physician hierarchy	I feel like if I’m calling a [rapid response] on somebody, it’s because I don’t feel and I feel like they [patient] should be escorted from the department. But I have seen a lot of like, negotiating. I don’t want anyone to leave if they’re unsafe to leave. I know my doctor colleagues feel the same way. But at the same time there’s I think this like, desire to at least, like complete [patient] treatment. [Nurse #109]
Physician’s legal concerns	I think when you ask people in the moment, like, “Why did or didn’t you eject that person?”… EMTALA is sort of a boogeyman [Physician #117]I think as a new attending, it was very stressful to figure out the [safety letter]… we are so afraid of making the wrong decision [with medical screening exams].” [Physician #111]I think it would be helpful if there was some insight about like I guess just more empathy about where the liability stands and our obligation to follow EMTALA [Physician #113]
Theme 3: Social Vulnerability in Emergency Care (SEM Levels: Interpersonal)
Subthemes
Consequences of racial bias	I think we need a better definition of this [safety letter] issue, and transparency and report of who’s on the [safety letter] for what reason? Yeah. And then when someone’s identified as being a perpetually violent person, we need a standard way of addressing that…is that person allowed to be triaged, is that person allowed to check in? Is that person taken to a different room? Is this person coming in with some kind of sequestration? [Physician #120]
Social support	The population that [we] presently serve has a lot of mistrust in health care, validly so, and I think that plays into it as well, because they feel…I don’t want to leave my family member here. And not know that they’re getting the right care. [Nurse #104]
Theme 4: Resources and Throughput (SEM Levels: Systemic)
Subthemes
Lack of staffing	If you have a 4 patient assignment, and just one of those patients is like, ICU level care…the other 3 are neglected, you know, and it’s not intentional. It’s just that you’re only one person, so just having enough staff to like just be able to like, answer, call bells and just check in on people and say, “Hey, are you?” You know? [Nurse #103]
ED crowding and boarding	Right now I have people who are waiting 30 h for a bed-that tends to make people upset [Nurse #102]
Theme 5: Presence and Responsibility of Security (SEM Levels: Interpersonal, Systemic)
Subthemes
Security ownership	I think several of my colleagues share this frustration that it seems like at times the security staff…it almost seems like, they want to take a hands-off approach to someone, you know, if we asked for someone to be escorted out. [Physician #119]I used to feel like security always had my back. I always felt protected by them. Like, they’re part of the team. They’re amazing. They’ll jump in there, they’ll make sure we’re not hurt. But…it’s a completely new staff lately. They’ve just hired all new people. I don’ even know any of these people. So the camaraderie is not there. I feel like they’re not being trained efficiently. [Nurse #114]
Increased responsiveness	…but lately security, when we’ve been calling them over the past couple of times, and they haven’t really been responding with as many security guards as we need [Nurse #102]

Note. Exemplar quotes from participant interviews.

Table 4.

Clinician-Informed Strategies Based on Study Theme

Study Theme	Clinician-Informed Strategies
Theme 1: Clinical Protocols SEM levels: Individual, interpersonal, systems	• Standardizing the use, implementation, audits, and de-escalation of protocols • Measuring the effectiveness of protocols over time and tailoring them as needed
Theme 2: Clinician Conflict in Addressing WPV SEM levels: Interpersonal, systems	• Providing nurses with autonomy to advance care protocols (e.g., pain management, WPV workflows) without physician approval • Outward support by hospital administrators for clinicians’ decision-making promoting workplace safety and reducing WPV
Theme 3: Social Vulnerability in Emergency Care SEM levels: Interpersonal, systems	• Healthcare institution collaboration with communities to identify social and health care needs • Developing resources outside of the ED to address social needs • Elevating community voices to address social vulnerability
Theme 4: Resources and Throughput SEM levels: Systems	• Safely staffing nurses in EDs • Holding hospitals accountable to minimize hospital crowding as a contributor to WPV • Transparent reporting of nurse staffing levels • Transparent reporting of hospital crowding measures
Theme 5: Presence and Responsibility of Security SEM levels: Interpersonal, systems	• Training security in health- and trauma-informed care and de-escalation approaches • Involving security in WPV protocols • Measuring the frequency and type of security interventions to ensure that security presence is minimized • Implementing cross-disciplinary training among security personnel and health care professionals

Note. ED, emergency department.

Theme 1: Clinical Protocols

Subtheme: Bedside Response

A strategy that facilitated WPV de-escalation was a clinical protocol that quickly brought large numbers of clinicians to the bedside when a colleague needed help. The rapid response protocol was activated by an overhead page bringing clinicians and security to the bedside to address a violent event. As stated by a nurse in the study:

Nursing staff always shows up first. Every time I hear it, I’m running towards wherever it’s supposed to be. Because if I was in that situation, I would never want a colleague to be alone. [Nurse #109]

Having a team of clinicians at the bedside provided “power in numbers”; however, increased numbers were not always beneficial nor necessary for each incidence of violence. As one nurse reported, the rapid response protocol could escalate a patient’s disposition:

Oftentimes [rapid response protocol] makes things worse because security and everybody like staff that don’t need to be there are often just sticking their noses in and being like, “What’s going on?” and that’s very intimidating and off-putting and escalates the patient even more. [Nurse #112]

Subtheme: Behavioral Flags and Safety Letters

A second clinical workflow that supported clinician workplace safety in addressing WPV was electronic health record-based behavioral flags and safety letters. A behavioral health flag was placed in the chart by a clinician if a patient exhibited a form of violence in the past, intended to increase clinicians’ awareness ahead of the next encounter. If a patient exhibited a severe form of violence during an encounter, the institution sent a safety letter to the patient’s home reinforcing a “no tolerance” violence policy in the hospital. One physician stated:

The [safety letter] is useful because that changes our workflow; you’ve demonstrated so much violence to some degree that we are now giving you this streamlined version of care, whereas the [general] chart flag is just kind of like an FYI, which I think that biases us when someone might have had a bad day, especially. [Physician #106].

Patients with severe violence in the past who received a safety letter would subsequently undergo a brief medical screening exam when representing to the ED to assess for an acute medical emergency. As one physician stated,

…we have to draw the line somewhere. And I think if we were to tell the public who we’re [sending safety letters], these are patients that have set fires, thrown feces, violently attack staff, like there just has to be a line somewhere. [Physician #113]

Clinicians felt supported by the behavioral flag system in having standardized processes around violent patient encounters. As stated by one nurse, “I think there should be like a threshold that a patient has to meet in order to receive one of those and get one. It demonstrates significant violence against staff. I think that’s something that should be upheld whenever possible.” [Nurse #104].

Theme 2: Clinician Conflict in Addressing WPV

Subtheme: Nurse–Physician Hierarchy

Nurses highlighted that hierarchy across roles in medicine—-requiring that nurses ask physicians for orders and approvals to address a violent patient incident—was a hindrance to de-escalating WPV. One nurse described the variation in physician response to patient violence:

“Obviously, you need to involve the doctor, and again their responsiveness to facilitating that can vary” [Nurse #105]

Physicians described the hierarchy in decision-making around WPV as one that misrepresented those most impacted by violence incidents, such as nurses. One physician stated:

The power dynamic in healthcare is weird, because it’s like, if it’s happening to the nurses, why am I the one then? Why am I the boss that decides, right? …it’s almost like, it should be not me? You know what I mean? [Physician #111]

Subtheme: Physician’s Legal Concerns

Physicians described legal concerns as a hindrance to preventing WPV and de-escalating. Making a decision that impacted the safety of another team member (i.e., a nurse)—such as deciding to keep or discharge a violent patient—was considered a high-pressure and high-stakes moment for physicians. As one physician stated, “I think it’s just the legalities of like, if that person walks out and drops dead, then it’s on us, because we asked them to leave.” [Physician #104].

Physicians described that the Emergency Medical Treatment and Labor Act (EMTALA) impacted their decision-making to keep a patient in the ED or discharge them before they escalated to potentially harm a colleague. As one physician stated:

Based on the way that we feel like we need to be beholden to EMTALA…there’s basically no line in the sand, where we would have a “no tolerance” policy for a particular type of violence. Literally, if a patient’s shot another person, I think we would still feel obligated to like, keep them in the department potentially. [Physician #113]

Theme 3: Social Vulnerability in Emergency Care

Subtheme: Consequences of Racial Bias

Behavioral health flags and safety letters sent to patient homes were both hindrances and facilitators to prevent and de-escalating WPV. Flags were placed in the chart to inform clinicians of a patient’s previous violence. While a form of communication, the flags were not always truly reflective of a patient’s disposition and represented a potential care bias:

“I realized these notes and safety letters that are in there are old…they come in today, they’re not as violent as they were in 2009.” [Nurse #110]

Safety letters were sent to the homes of patients after they exhibited significant violence or harm to a clinician, advising them that their behavior would not be welcome in a further encounter. The use of such letters could be biased, per respondents, given patients’ social and medical backgrounds. One physician stated:

I think it’s a double-edged sword. I think that [a safety letters] has the potential to be problematic, because a lot of the people who experienced these things also have other behaviors that put them at risk for like, serious injury and illness, mental illness. [Physician #111]

Subtheme: Social Support

Investing in preventative social health services upstream, such as primary care, mental health services, and insurance, were potential facilitators to prevent patient’s reliance on emergency care and potential opportunities for violence:

We’re like primary care for all of the unhoused people, we are a primary care for the people who have such significant psych issues that they can’t keep it together, we are a primary care for undocumented people, like, we see all the people who just don’t have the ability to go to primary care, because they work difficult hours and don’t have insurance. [Physician #111]

Theme 4: Resources and Throughput

Subtheme: Lack of Staffing

Safe nurse staffing ratios were an implied identified facilitator to prevent WPV. With insufficient staffing in the ED, clinicians reported the inability to respond to patient’s needs quickly. A lack of responsiveness contributed to patient’s frustrations and violent behaviors:

Patients go hours where they’re like, “What the heck, like, what am I waiting for?” There’s no updates because nurses have more patients than we should have and than we can reasonably be expected to manage. And so patients become frustrated because they’re not being served well, because the nurses are stretched so thin. [Nurse #112]

Subtheme: ED Crowding and Boarding

Addressing hospital crowding was an implied strategy to prevent WPV as it contributed to longer wait times and delays in care, exacerbating patient uncertainty and violent behaviors. As one nurse described,

I think there’s like such an influx of patients now that we don’t have the staff, we don’t have the resources, we don’t have the bed availability. So now in the ER, we have a lot of patients boarding. The patient staying in the ER for one day, two days, three days before they get a bed, I can see why they are frustrated and violent. [Nurse #115]

Theme 5: Presence and Responsibility of Security

Subtheme: Security Ownership

Inadequate training among security personnel hindered safety. Clinicians described the need for security personnel to have tailored training in health care interventions, rather than generalized security training. As one nurse described, “I think that our security team are third party contractors… and I think that there are certain parameters, where it’s like, they’re not allowed to lay hands-on patients, unless we’re putting them in hard restraints.” [Nurse #109].

Subtheme: Increased Responsiveness

Violence incidents required quick action among the team, and clinicians reported that delays in security response eroded the culture of workplace safety. As one nurse described, “If you just call security on the phone and say, ‘Hey, I have a patient, they’re being discharged and not going to be happy about it. I would love to have some backup. Sometimes it can take a little bit too long to get a response.’” [Nurse #112].

Discussion and Recommendations

The Pennsylvania Healthcare Worker Violence Prevention Act would mandate that hospitals commit to WPV safety measures through established hospital committees, but to date, it is unclear what prevention strategies such committees should prioritize for clinician safety. Clinicians in our study identified priority strategies that would help advance workplace safety strategies. Those that hindered safety should be de-emphasized by hospital committees interested in preventing and de-escalating WPV.

Among the strategies that facilitated safety, clinical protocols were a priority endorsed by clinicians. Specifically, rapid response mechanisms were effective in bringing co-worker help to the bedside when a patient was escalating. This finding is supported by prior studies demonstrating that established workflows can advance team cohesion during crisis response (Okundolor et al., 2021). EHR-based behavioral flags and safety letters had a mixed response among respondents in terms of effectiveness but were viewed favorably as a communication mechanism to potentially prevent WPV or bring awareness to clinicians about risk. Prior work has separately highlighted a specific positive impact these flags have had on ED nurse perceptions of safety but also concerns related to the unintended consequences related to bias and equity (Agarwal et al., 2023; Gonzales et al., 2024; Seeburger et al., 2023). To reduce potential biases or overuse of clinical protocols, hospitals must conduct continual audits and evaluations of the effectiveness of such strategies over time. Furthermore, system-based standards on the creation of EHR-behavioral flags, duration of flag presence in the chart, and quality-based review would help address biases while also supporting the bedside nursing concerns.

Respondents also stated that supporting nurses with safer patient-to-nurse staffing ratios would reduce patient escalation and violence events because nurses could attend to patients in a timely manner. This finding is contextualized by over two decades of prior evidence demonstrating that when nurses care for fewer patients at a time, they can advance patient throughput processes, leading to shorter patient lengths of stay and favorable patient quality and safety outcomes (Brom et al., 2021; McHugh et al., 2021; Muir et al., 2023). Similarly, addressing the systemic issue of hospital crowding was essential to reduce opportunities for patient escalation.

The nurse–physician hierarchy was a hindrance to preventing and de-escalating WPV. This study was unique as it invited nurses and physicians to have a collaborative discussion on WPV. Prior evidence demonstrates that nurse–physician collegiality is a core component of the nurse work environment, associated with outcomes for patients and clinicians (Lake et al., 2021; Muir et al., 2025; Olds et al., 2017). Clinical practice inherently places nurses with patients more frequently and for longer durations as compared with physicians. Therefore, the likelihood of nurses experiencing instances of WPV is higher, though it is a clear concern for both roles, but it is linked to physician actions and practice.

One approach to strengthen nurse–physician collaboration is to provide nurses with greater autonomy to address WPV in the moment, rather than over-relying on physician orders. For example, protocolized care pathways empowering nurses to advance pain management independently may decrease time delays that contribute to patient frustration and agitation (Douma et al., 2016). Empowering nurses to identify situations that may escalate to WPV and react to them proactively with physician support provides a mechanism to systemically mitigate WPV within clinical care settings.

A legal hindrance to decision-making with WPV encounters was EMTALA policy. Physicians encountered challenges upholding EMTALA policy at the expense of compromising team member safety in the ED. Beyond signage indicating zero-tolerance policies, clinicians need genuine support from hospital leadership that their decisions to protect their individual and team’s safety during a WPV event are supported, rather than a legal concern for the institution.

A hindrance to de-escalating WPV was a lack of specialized training of hospital security personnel. Clinicians identified that security should be trained in standardized protocols for WPV to promote teamwork and collaboration during WPV events. Greater tailoring of security personnel training is needed to promote clinician safety while minimizing potentially traumatic and inequitable encounters for patients (Okundolor et al., 2021). A thoughtfully trained security presence is needed in hospital EDs, in addition to close monitoring to ensure unjust and inequitable interactions between law enforcement and patients are eliminated. Cross-training between health care professionals and security personnel is needed in the ED such that both groups understand the demands and experiences of each role during a WPV experience and bridge gaps in interprofessional collaboration during such events (Roberson & Esmail, 2021).

Finally, there are opportunities for hospitals to reduce upstream drivers of violence, such as a lack of access to core social determinants of health resources for patients. Respondents in our study identified that social vulnerability was a significant driver of patient over-reliance on emergency care for core medical and behavioral health services. Healthcare institutions should participate in initiatives to expand social opportunities for the populations they serve (transportation, housing, mental health, and food resources). They must also partner with community leaders and organizations to develop clinics and care pathways that transition patients to care-aligned care areas outside of the ED (Loo et al., 2023). Additionally, the role of social workers within EDs may be leveraged to address the social needs of patients contributing to violence through on-the-shift consultative services or referrals (Prater et al., 2024).

Our findings advance existing literature that predominately focuses on the prevalence of WPV by suggesting actionable strategies to reduce WPV incidences (Kim et al., 2022; Pascale et al., 2025). Participants in our study reported that WPV is most commonly perpetuated by patients or visitors, also known as type II violence, which is supported in extant literature (Kim et al., 2022). We also found, similar to Mitra et al. (2018), that security is most commonly asked to intervene on a WPV incident in the context of behavioral/social factors such as patient drug and alcohol use. Our findings further contextualize these occurrences by highlighting the social vulnerability of communities and populations that rely on ED care for primary care, urgent care, and social services. Ninan et al. (2024) report that patient wait times can be triggers of aggression. The authors also state that understaffing can be a contributing factor to WPV as nurses may have weaker relationships with patients and limited time to assess a patients’ status. Our study themes identified similarly that the under-resourcing of nurses and hospitals (i.e., due to crowding) influences patient escalation in the ED.

In conclusion, should the Pennsylvania Healthcare Worker Violence Prevention Act be implemented, there are modifiable factors of WPV that are under the purview of WPV prevention committees in hospitals, as identified in our study. A focus on clinical protocols (individual, interpersonal, and systems’ SEM levels) that bring clinician support swiftly to the bedside is a crucial investment in hospitals. Investments in tailored security specifically trained in de-escalating WPV (interpersonal and systems level) are an additional factor to focus intervention efforts. Committees can also influence employer investments in adequate nurse staffing and the mitigation of hospital crowding (systems level). Finally, more system issues that may require collaboration with community organizations, hospitals, and clinicians include upstream investments in neighborhood social determinants of health, including housing security, reliable transportation, and behavioral health resources for patients (systems level).

A next phase of research needed in this area is to study the implementation of WPV policies that exist at the local hospital level and state levels. Future research is needed to quantify the extent to whether the number of assaults change after policies are implemented to protect health care workers.

Limitations

Although this qualitative study was conducted at one academic-level I trauma center ED, the characteristics of the study institution allowed for rich, in-depth exploration of WPV strategies informative to Pennsylvania. Furthermore, while our sample size is small and limited to one institution, qualitative inquiry is inherently focused on deep, thick data collection surrounding a phenomenon of interest rather than advancing data collection for the purpose of obtaining a large sample size (Sandelowski, 1995). The distribution of our participant sample was comprised predominately of individuals identifying as White and female in this study, which could reflect the population of registered nurses in the United States for a subset of our sample (Auerbach et al., 2024). Additionally, clinicians who identify as female may have been more inclined to participate given their reported increased exposure to WPV incidents in health care as reflected in empirical studies (Mento et al., 2020). Nevertheless, the perspectives reflected in our study findings may be limited in diversity and lived experience, thus impacting generalizability to all clinicians. Our study was conducted in a large urban city that experiences moderate-to-high rates of interpersonal violence (e.g., firearm injury). The demographic profile of the hospital may hinder generalizability to other settings in rural health care areas or different urban settings.

Conclusions

As hospitals and states consider policies that require intentional action to reduce WPV, our study identified priority strategies to prevent and de-escalate WPV. As endorsed by our interdisciplinary team of respondents, key strategies include standardized care protocols, safe staffing ratios for nurses, institutional backing of clinicians for zero-tolerance of WPV, community collaboration to address social needs, and a trauma-informed security presence.

Supplementary Material

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.outlook.2025.102539.

Abbreviations:

ED

emergency department

EMTALA

Emergency Medical Treatment and Labor Act

SEM

Social Ecological Model

US

United States

WPV

workplace violence