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.