A scoping review of risk determinants for workplace violence in emergency departments

Abstract

Workplace violence refers to physical violence, verbal abuse, threats, or other aggressive behaviors directed toward healthcare workers in the workplace. It is a critical occupational and public health hazard, disproportionately affecting emergency departments (EDs) worldwide. This scoping review aimed to synthesize evidence on the prevalence of ED violence and to map its risk determinants through the lens of ‘Who, When, and Why’. We conducted a scoping review following PRISMA guidelines, including qualitative, quantitative, and mixed-method studies on risk determinants for ED violence. PubMed, Scopus, Embase, and Web of Science were searched from inception to June 2025. English-language studies reporting prevalence or risk factors of ED violence were included. Titles and abstracts were screened using ASReview. Twenty-one studies were included, reporting workplace violence prevalence ranging from 72.5% to 91.5%. Thirty-four influencing factors were identified across four dimensions: individual characteristics (perpetrator traits: male gender, middle age, psychiatric illness, substance use; healthcare worker traits: provider gender), temporal triggers (night shifts, weekends, long waiting times), spatial vulnerabilities (triage and treatment areas, overcrowded or poorly monitored spaces), and situational/psychological drivers (pain, fear, unmet expectations, miscommunication). Workplace violence in EDs is a multifactorial phenomenon shaped by individual vulnerabilities, environmental pressures, and systemic factors. This review highlights the persistent normalization of violence against frontline staff and underscores the need for immediate protective measures and systemic reforms.

Introduction

‘In no other profession is being spat on, shouted at, or punched viewed as just part of the job. Yet for emergency nurses and physicians, workplace violence has become normalized and dangerously accepted’. Emergency departments (EDs) stand at the front line of healthcare, where staff face clinical urgency alongside a constant threat of aggression, jeopardizes safety and morale [1].

The WHO defines workplace violence as work related abuse, threats, or assaults against health workers, including physical, sexual, verbal, psychological abuse, and harassment [2,3]. EDs are particularly vulnerable due to 24-hour operations, unrestricted access, high-stress environments, unpredictable patient conditions, and emotionally charged interactions. Staff often manage critically ill patients under intense time pressure while facing frustrated family members and individuals with complex social or psychological issues.

Evidence shows the scale of the problem. In China, 49.4% of emergency nurses experienced workplace violence in the previous year, with 49.0% facing physical assaults [4]. Similar trends exist globally. In Italy, two-thirds of ED nurses report mostly verbal violence [5]. In the USA, ED workers are five times more likely to experience injuries from violence compared with the general workforce [1]. In Australia, overcrowding and patient frustration frequently trigger aggression, much of it unreported [6].

Workplace violence causes profound consequences beyond physical harm, including psychological distress, emotional exhaustion [7], burnout, job dissatisfaction, absenteeism, and impaired patient care [8]. It has also been linked to treatment delays, clinical errors, and adverse patient outcomes [9,10]. It also increases healthcare costs and erodes trust in health systems [11].

Despite growing attention, research often focuses narrowly on victim or perpetrator characteristics, neglecting broader contextual factors such as environmental conditions, organizational practices, and cultural attitudes. This scoping review addresses these gaps by examining who is involved in ED violence, when and where it occurs, why it happens, and the measures used to address it. Clarifying these dimensions can support more effective strategies to prevent and manage violence in emergency settings.

Methods

This scoping review followed PRISMA-ScR guidelines (checklist in File S1, Supplemental Digital Content 1, https://links.lww.com/EJEM/A538) and Arksey and O’Malley’s framework, covering study selection, data charting, and synthesis. The protocol was preregistered on OSF (20 June 2025; OSF registration: https://osf.io/nhgf8; DOI: https://doi.org/10.17605/OSF.IO/NHGF8).

Data sources and search strategy

PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies on workplace violence in emergency settings. Search terms included keywords related to workplace violence (‘aggression’, ‘violent behavior’, ‘workplace violence’, ‘assault’, ‘hostility’) combined with terms for emergency settings and staff (‘emergency department’, ‘emergency room’, ‘ED’, ‘emergency nurse’, ‘triage nurse’). The final search was completed in June 2025. Full search strategies for all databases are provided in File S2, Supplemental Digital Content, https://links.lww.com/EJEM/A539.

Eligibility criteria

We included peer-reviewed quantitative, qualitative, or mixed-method studies reporting workplace violence against ED staff (physical, verbal, or psychological), including prevalence, patient characteristics, or triggers. English-language studies were included without date or location restrictions.

We excluded studies conducted outside ED settings, not targeting staff, or lacking ED-specific data, as well as gray literature, case reports, conference abstracts, editorials, and dissertations

Study selection

After database searches and deduplication in EndNote, titles and abstracts were screened using ASReview (v1.0), an active-learning tool based on Term Frequency-Inverse Document Frequency extraction. Two reviewers independently screened records, initially labeling 10 relevant and 10 irrelevant studies to train the algorithm. Screening continued until 150 consecutive exclusions was reached. Decisions were cross-checked (≥80% agreement), with discrepancies resolved by discussion or third-reviewer. Full texts of potentially eligible studies were then independently assessed, and reasons for exclusion were recorded.

Data extraction

Data from included studies were charted into a structured Excel sheet capturing: author, year, country/setting, study design, violence type, prevalence, patient characteristics and precipitating factors.

Data synthesis

Due to heterogeneity across studies, results were synthesized narratively, focusing on patterns in prevalence, patient characteristics, and triggers of workplace violence in emergency departments.

Results

Search results

A total of 4452 records were identified, with 2006 remaining after duplicates were removed. Titles and abstracts were screened using ASReview, yielding 78 full texts for assessment. Twenty-one studies were included (Table 1; Fig. 1), reporting 34 contributing factors to ED workplace violence across five domains: individual, temporal, spatial, organizational, and psychosocial/societal (Table 2).

Table 1.

Summary of results on prevalence and different types of violence

First author	Published year	Country	Sample size	Prevalence of workplace violence	Different types of violence
Dhossche [12]	1999	USA	311	31% of psychiatric emergency patients	Physical, verbal
Kleissl-Muir [13]	2019	Australia	548	3.4 per 1000 ED presentations	Verbal, physical, self-harm
Pich, J. V [14].	2017	Australian	537	87% of nurses	Verbal, sexual, physical
Ikpae, E. B [15].	2023	Nigeria	51	72.5%	Verbal, physical
Ismail Öztas [16]	2023	Turkey	120	90%	Verbal, physical
Koyuncu [17]	2025	Turkey	872	–	Verbal, psychological
Bingöl [18]	2021	Turkey	520	–	Verbal, physical, threats
Nikathil [19]	2017	Australia	1853	103 per 10 000 ED visits	Physical, psychological
Ahmed MM [20]	2020	Iraq	218	37.6% physical; 73.3% nonphysical	Physical, nonphysical
Yan, S [21]	2023	China	14 848	90.4% of any type	Verbal, physical, threats, sexual harassment
Boes BS [22]	2025	USA	17 873	–	Verbal, physical
Kaeser, D [23]	2018	Switzerland	83	–	Verbal, physical, threats, sexual
Chazel, M [24]	2023	France	35	–	Verbal, physical
Turgut, K [25]	2021	Turkey	157	–	Verbal, physical
Leuchter, F [26]	2021	German	7793	1.2% of deployments involved violence	Verbal, non-verbal, physical, obstruction
Dawson [27]	2018	USA	251	9% exhibited violent behavior	Verbal, physical
Imani Carey [28]	2023	USA	1.14 million	15% of healthcare worker injuries due to violence	Physical
Altaf O. Assil [29]	2022	Egypt	108	–	Verbal, sexual, physical
Zihui Lei [30]	2022	China	20 136	79.39% of ED nurses	Verbal threats, physical, verbal sexual harassment
Nicola Ramacciati [31]	2018	Italy	1100	91.5% of Emergency nurses	Verbal, physical
Brodie Thomas [32]	2022	Australia	18	–	Verbal, physical

Fig. 1.

Process of article selection.

Table 2.

Main factors, sub-factors, and factors affecting workplace violence in ED

WHO
Sub-factor	Detailed factors	References
Victim-related	Nurses, physicians, female staff, security staff, junior or senior staff, high stress/burnout, poor health, CHD.	[14,15,17,19,21,24,28,32]
Perpetrator-related	Male, younger, substance use, psychiatric illness/ antisocial traits, poor impulse control, low education, unemployment, single, family/companions, suicide attempts, migratory background cultural/language barriers.	[12,13,14,15,16,17,19,20 21,22,23,25,26,29,30,31 [32]
WHEN & WHERE	Detailed factors.	References
Sub-factor
Temporal factors	Shift work/night shifts/shift transitions, January/December/February.	[14,16,18,21,23,25,26,29 [30]
Spatial factors	Overcrowding, limited facilities, the triage/waiting/resuscitation area/ambulance bay.	[14,16,18,22,26,30,31]
WHY	Detailed factors.	References
Sub-factor
Healthcare-related	Poor communication/lack of information/fatigue, workload, patients illness/death, lack of security/protocols/training/policy gaps, cost, long waiting, noise, access barriers, lack of privacy.	[14,15,16,17,18,20,21,25 [26,29–32]
Social & emotional factors	Patient/relative emotional/stress/pain/fear, family escalation, unrealistic expectations/low public awareness, media mixture.	[18,24,25]

CHD, coronary heart disease; EDs, emergency departments.

Figure 2 provides an integrated visual summary of the identified determinants, illustrating how perpetrator characteristics (who), temporal-spatial patterns (when/where), and underlying reasons (why) interact to drive workplace violence in EDs.

Fig. 2.

Violent dynamic chain (classic scene).

Discussion

Incidence of workplace violence in the emergency department

The ED is a high-pressure unpredictable environment where patient distress and operational demands contribute to frequent workplace violence. Overall exposure to workplace violence among ED staff ranges from 72.5% to 91.5% [15,16,21,30,31]. Verbal abuse is the most prevalent form, reported by approximately73.3–94.4% [15,16,20,21,29,31] of ED staff across studies, and is often normalized within clinical culture. Physical violence occurs less frequently but remains substantial, affecting roughly15.5–48.2% [15,16,20,29–31]of staff. Sexual harassment has been reported by up to 48.1% [29] of ED workers, while sexual assault, though less common, has been reported by 19.4% [21] in some studies. Incident-based data further indicate a high burden of violence in busy EDs, with up to 103 violent episodes per 10 000 visits reported in high-volume centers [19]. However, most evidence relies on self-reported questionnaires, and formally reported incidents consistently underestimate true prevalence. The lack of standardized definitions and longitudinal data limits cross-study comparability and obscures temporal trends, highlighting the need for consistent reporting frameworks and routine monitoring.

Who: understanding victims and perpetrators of emergency department violence

Victims: front line staff under threat

All ED staff are vulnerable to workplace violence, but risk varies by role and exposure. Nurses consistently report the highest rates, across studies, nurses accounted for 37.6–87% of victims, depending on setting and reporting method [14,15,24]. Physicians are also frequent targets, particularly for verbal threats and hostility related to clinical decisions [14,21,33]. Support staff, such as receptionists and security personnel, face risk through frontline roles in access control and patient flow [24]. Work experience influences vulnerability. Inexperienced staff may lack de-escalation skills, and fail to recognize early warning signs, while senior staff accumulate exposure over time and may be perceived as less approachable during peak periods [14,15]. Gender further shapes risk patterns. Female staff report higher rates of verbal abuse and sexual harassment, whereas male staff experience more physical violence. Intentional injury rates among men have been reported as more than twice those among women, particularly for force-related assaults [28]. Overall, workplace violence reflects intersecting role-based and individual factors, indicating that prevention strategies must address multiple dimensions of risk.

Perpetrators: patients and visitors

Most ED workplace violence is perpetrated by patients or accompanying family members. Aggressors are predominantly male adults, with up to 70.3% reported as male, and the majority aged around or below 45 years, representing a predominantly middle-aged working-age population [12,13,23–25]. Family members and visitors play a substantial role, sometimes more than patients [15,16,20,25,31]. About 94.4% of nurses identified relatives as perpetrators, compared with 73.1% for patients [16]. Verbal aggression is especially common among companions. Male gender, low education, unemployment, and single status are associated with a higher violence risk [17,20]. ED violence results from complex interactions. Visitors may escalate tensions due to emotional involvement or perceived advocacy for the patient [18]. This shows the need to look beyond static perpetrator profiles and consider situational triggers.

When and where: temporal and spatial patterns of violence in the emergency department

Workplace violence in EDs shows clear temporal and spatial patterns. Night shifts are highest-risk period [16,21,23,29,30], with over half of incidents occurring between 11 p.m. and 7 a.m. [23], and evening shifts are also hazardous, as 87.5% of staff report exposure [16]. Weekends, particularly Saturdays and shift handovers represent additional high-risk times due to delays, miscommunication, and patient frustration [26]. Seasonal trends are less clear, with one study noting incidents in January–February [25], but this was based on a single year and may reflect temporary factors rather than a stable trend. Multi-year data are needed to confirm consistent seasonal peaks.

Spatially, triage zones, waiting rooms, ambulance bays, treatment, and resuscitation areas are most prone to violence [14,16,22], with nurses engaged in patient triage having nearly three times higher odds of experiencing a violent episode [14]. Factors such as overcrowding, long waits, invasive procedures, poor visibility, and delayed security response amplify risk [14]. Violence often occurs when high-stress periods coincide with vulnerable locations, night shifts in treatment zones, weekends in waiting areas, and shift transitions at nurse stations [16,21,22]. These high-risk intersections highlight the need for staffing adjustments, environmental improvements, and targeted de-escalation protocols (Table 3). Statistical adjustments for confounding were not performed due to lack of raw data, but these intersections represent the most frequently reported contexts for violent incidents.

Table 3.

High-risk intersections of time and space for workplace violence in emergency departments

Temporal factors	Spatial factors	Risk characteristics
Night shifts	Treatment/Resuscitation zones	High-intensity care + low staffing
Weekends & holidays	Waiting areas	Overcrowding + long waiting times
Shift transitions	Nurse stations	High workload+ communication breakdown
Pandemic peak periods	Low-visibility corridors	System overload + delayed intervention

Why: underlying mechanisms of workplace violence in the emergency department

Clinical and psychological triggers

Workplace violence in EDs stems from biological and acute psychological distress. Substance use is a key trigger. Over 60% of incidents involve alcohol or drugs [12–14,17,19,20,23,26,31], with alcohol causing nearly half [19]. Acute psychiatric conditions and emotional distress contribute to about 80% of episodes [16,19]. Stimulants like methamphetamine also contribute. Intoxicated men, in particular, are disproportionately linked to severe incidents requiring restraint [13,19]. Mental health disorders increase risk. Patients with schizophrenia, bipolar disorder, or borderline personality disorder are more prone to aggression during acute episodes [16,19]. Emotional distress matters as well. Fear, anxiety, and helplessness are reported by nearly 80% of patients and families as major causes [16]. Acute physical conditions can trigger agitation. Severe pain, trauma, or critical illness may provoke aggression, especially if needs are unmet [14,27]. Yet violence does not always reflect clinical severity, one study found two-thirds of violent patients reported no significant pain. While this review aggregates most staff-related aggression, a fundamental distinction exists between intentional violence by competent individuals and pathological aggression caused by cognitive impairments like delirium or dementia [14,27,32]. Although the physical impact is identical, the variance in perpetrator intent necessitates specialized management strategies tailored to the underlying cause.

Systemic weaknesses

Workplace violence often emerges from systemic failures in processes, staffing, and the care environment. Poor communication, unclear wait times, and inadequate explanations frustrate patients and relatives [14–18,25,29]. Up to 61.2% of relatives cite insufficient information as a trigger [17]. Long, unexplained delays sharply increase frustration, and nurses consistently identify these delays as critical flashpoints [14,15,25]. Shift handovers are another point of vulnerability [17]. Under staffing, excessive workloads, and an unbalanced skill mix reduce conflict management, increase care delays, and heighten patient dissatisfaction, placing triage nurses at high risk [15]. The absence of clear protocols leaves staff without reliable de-escalation strategies [16,23]. This is compounded by widespread underreporting, as staff are often discouraged from reporting or view reporting as futile, leaving over 80% of incidents undocumented1 [15]. Environmental factors, including overcrowding and disorganized layouts, intensify patient anxiety [14,29]. While inadequate security and protective infrastructure further undermine staff morale 1 [18,23]. Addressing violence requires systemic changes in workflows and staffing, rather than relying on individual staff.

Societal and cultural factors

Societal and cultural factors shape how patients perceive emergency care and respond to frustration, delays, or unsatisfactory outcomes, thereby increasing the risk of violence when trust is low and tensions are high [25,32]. Public distrust in healthcare institutions is a major contributor. Media emphasis on medical errors and patient–provider conflicts reinforces perceptions of staff indifference and unsafe care, predisposing patients and families to defensive or aggressive reactions [32]. One study reported that 63.2% of patients and relatives attributed workplace violence to communication failures, closely linked to loss of trust [29]. Cultural norms further normalize aggression as a means of gaining attention or faster service. In some settings, patients or families believe disruptive behavior leads to priority care, a belief reinforced by prior experiences [21]. More than half of healthcare workers identified ‘patient culture’ as a key driver of workplace violence [29]. Financial stress also intensifies hostility: high costs, unclear billing, and fear of unaffordable care heighten anxiety, with 45.4% of patients citing medical expenses as a contributing factor [30]. When combined with perceived neglect, these pressures can precipitate violent behavior.

How: current measures to address workplace violence

Current literature has shifted from documenting incidence to recommending preventive and mitigative strategies, grouped into three domains. Primary prevention targets systemic and environmental triggers, such as improving communication, providing clear updates, using electronic signage for wait times, and controlling access to treatment zones [18]. Risk stratification places high-risk patients, like those with mental health issues or intoxication, in specialized areas [14,19]. Secondary prevention addresses imminent aggression. Staff training in de-escalation, communication, and safety protocols reduces violence risk [21]. Trained security personnel are also essential, though their interactions must be carefully managed. Tertiary prevention involves systemic change supported by policy and legal frameworks. Underreporting, driven by fear, stigma, and perceived futility, remains a barrier [21,23]. Accessible reporting systems and supportive culture are critical [16,19]. For substance-related incidents, ED screening and legal measures are recommended [19]. Public awareness campaigns emphasizing ED roles and the seriousness of violence are also essential strategy [18,24]. Practical measures with evidence of effectiveness include clear communication, regular staff training, simple reporting systems, and optimized triage and environmental design, especially for high-risk patients. These strategies represent feasible priorities for reducing workplace violence in EDs.

Limitations of the study

This review has some limitations. Gray literature and non-English studies were excluded, which may omit relevant evidence. Many included studies relied on self-reported, nonstandardized data, potentially introducing reporting bias. National reports and institutional datasets were also excluded. These limitations should be considered, but the review still identifies consistent patterns and risk factors relevant for future research and interventions.

Conclusion

Workplace violence in emergency departments is a complex problem that stems from individual vulnerabilities, environmental stressors, and systemic failures. Its high frequency and normalization underscore the urgent need for immediate protective measures and long-term structural reforms. Effective prevention requires strategies that protect both healthcare workers and patients, strengthen healthcare systems, and foster safe, supportive environments.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.