Exploring the Impact of Workplace Violence in Urban Emergency Departments: A Qualitative Study

Brendan Lyver; Brendan Singh; Nathan Balzer; Manu Agnihotri; Jennifer Hulme; Kathryn Chan; Rickinder Sethi; Charlene Reynolds; Jennifer Haines; Robert Whiteside; Marc Toppings; Christian Schulz-Quach

doi:10.20944/preprints202501.1640.v1

Submitted:

21 January 2025

Posted:

22 January 2025

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Abstract

Background Workplace violence (WPV) in healthcare, particularly in emergency departments (EDs), is a growing and complex issue that significantly impacts healthcare providers (HCPs). Following the COVID-19 pandemic, rates of WPV have increased globally, contributing to increased burnout, reduced morale, and heightened challenges in staff retention within EDs. Objective This study aimed to explore HCPs’ perspectives on WPV in EDs. The insights gathered were intended to inform targeted interventions in a quality improvement initiative focused on addressing WPV in our healthcare institution. Methods A qualitative study involving semi-structured interviews was conducted with 52 HCPs across two urban EDs at a multi-site academic health center. Participants from various roles and shifts shared experiences related to safety, leadership, training, and security. Interviews were recorded, transcribed, anonymized, and thematically analyzed to identify key themes surrounding WPV in EDs. Results The thematic analysis identified 4 main themes including (1) Violence is Part of the Job, (2) Leadership Dynamics regarding WPV, (3) Disconnect Among ED Staff During WPV Response, and (4) Enhancing Systems and Culture for Effective WPV Management. These themes provide a comprehensive view of HCPs’ experiences and offer actionable recommendations for healthcare organizations seeking to address WPV. Conclusion The study provides valuable qualitative insights into WPV in EDs, emphasizing the importance of addressing cultural, structural, and procedural gaps. These findings can guide the development of more supportive and effective strategies to create a safer environment for ED staff. Further rounds of interviews are planned post-intervention to assess changes in HCPs’ perceptions and experiences.

Keywords:

workplace violence in health care

;

emergency medicine

;

pandemic recovery

;

qualitative research

Subject:

Public Health and Healthcare - Health Policy and Services

Introduction

Problem Formulation

Workplace violence (WPV) in healthcare is a growing challenge that poses significant risks to patient care and healthcare provider (HCP) well-being and burnout [1,2]. Since the COVID-19 pandemic, healthcare institutions globally have experienced an increase in WPV, particularly in emergency departments (EDs) [3,4]. This issue has led to multiple negative outcomes for patients, visitors, HCPs and healthcare institutions [1]. Specifically, HCPs who experience more WPV have reported higher levels of burnout, poor mental health, lower quality of care and healthcare institutions are experiencing high turnover rates in acute care settings such as the ED [5].WPV can have multiple definitions [6], however for the purpose of this study, we will define WPV as any act of physical, verbal, psychological, and/or sexual violence committed by patients or visitors against HCPs. Additionally, HCPs will be used to describe all ED staff interviewed in this study.

Addressing WPV effectively requires a systems-level approach that considers its multifaceted nature and is guided by a data-driven strategy [1]. Quantitative organizational data may serve as the foundation for these efforts, offering essential insights into the prevalence, frequency, and patterns of WPV incidents and informing areas that require targeted intervention [7]. However, this data often reveals only broad trends, lacking the nuance needed to tackle the complex and multifaceted nature of WPV effectively [1]. To bridge this gap, a bottom-up approach incorporating qualitative studies is essential, as qualitative data provides a deeper understanding of the lived experiences and challenges faced by HCPs, insights that quantitative methods alone cannot capture [1,7]. Engaging healthcare providers in such studies is crucial, as their frontline perspectives can uncover underlying causes of WPV and inform mitigation strategies [8]. Furthermore, longitudinal qualitative data collection enables the identification of changes over time, validating and enriching trends observed, ensuring interventions remain impactful and adaptive [1].

Purpose

This study aims to explore ED HCPs’ lived experiences with WPV and deepen our understanding of WPV within our healthcare institution. We examined HCPs' sense of support and safety, perceptions of security, and personal expectations for necessary changes to address WPV. Employing a bottom-up qualitative approach, we seek to generate institution-specific insights that will guide the development of actionable interventions to enhance both the workplace environment and ED staff well-being.

Materials and Methods

Qualitative Approach and Research Paradigm

This study was conducted as part of a larger quality improvement initiative addressing WPV at the University Health Network (UHN), a multi-site academic health science center in Toronto, Canada [1]. As one of 12 subprojects, we employed a phenomenological approach to explore HCPs' lived experiences of WPV in EDs. Phenomenology was selected for its focus on understanding how individuals perceive and make meaning of their experiences, aligning with the study's objective to capture the impacts of WPV on HCPs’ mental health as well as their role. This study employed a qualitative research design, guided by the Standards for Reporting Qualitative Research (SRQR) guidelines [9], to explore experiences and perceptions of WPV among HCPs in two urban EDs of a multi-site academic health science center.

Researcher Characteristics and Reflexivity

We conducted the study as an interdisciplinary team comprised of two staff psychiatrists, a Security Director, a Chief Legal Officer, a Project Manager, a Research Analyst, and a Research Assistant. The Research Analyst led the study and conducted all qualitative interviews, as a non-clinician with no prior experience in the EDs or any pre-existing relationships with their staff, ensuring a neutral position during data collection. The Research Analyst was a master’s student in the Psychology and Neuroscience of Mental Health program with one year of experience in quality improvement projects in healthcare and a foundational understanding of WPV in healthcare. Thematic analysis was conducted collaboratively by the Research Analyst and a Research Assistant. The Research Assistant was an undergraduate student in Psychology with no prior experience in clinical settings, quality improvement projects or the ED environment but possessed a fundamental knowledge of WPV in healthcare. This combination of foundational knowledge and novice perspectives supported a balanced and thorough analysis, minimizing potential biases and enhancing the study’s rigor.

Additional team members contributed to the iterative development of the semi-structured interview guide and offered critical feedback during the thematic analysis process, enhancing the depth and validity of the findings.

Context

We conducted this study at UHN’s two urban EDs, which collectively served 158,000 patients in 2022. Following the COVID-19 pandemic, these EDs experienced a significant increase in WPV incidents, with reported rates rising from 0.43 to 1.15 incidents per 1,000 ED visits (p < .0001), reflecting global trends [1].

In response to this alarming rise, the UHN Department of Security Operations formed a QI team in November 2022 to address WPV in healthcare settings. One of the team’s initial initiatives was to collect data directly from frontline ED staff to guide the development of a comprehensive QI strategy and ensure staff felt heard and supported in addressing and managing WPV.

Sampling Strategy

This study used a convenience sampling approach to accommodate the demanding nature of HCP’s work in the ED. We conducted interviews on-site during staff shifts to maximize participation while minimizing disruption to personal time. However, this strategy introduced the limitation of a reliance on staff availability during shifts, which may have influenced both the representativeness of the sample and the completeness of the data.

We included participants with a minimum of three months of ED experience who were willing to share their WPV experiences. We excluded HCPs on leave, those with less than three months of ED experience, and agency staff.

We continued sampling until reaching data saturation, which the researcher determined when no new, relevant information or themes emerged from the interviews. Throughout the process, the researcher evaluated whether additional data would contribute unique insights to the study’s objectives. Once further interviews no longer added new perspectives on workplace violence, we deemed additional sampling unnecessary.

Ethical Issues Pertaining to Human Subjects

The study received formal exemption from the Research Ethics Board and approval from the organization’s Quality Improvement Review Board (QI ID: 22-0499). We provided all participants with a detailed consent form outlining the quality improvement project purpose, objectives, procedures, potential risks, and their right to withdraw at any time without consequence. To protect participants' confidentiality, we stored all data on a secure server only accessible to the QI team.

Data Collection Methods

Participants were initially informed about the study during daily huddles held in the EDs, and those interested were invited to participate in on-site, in-person interviews during their shifts. All interviews were conducted in a private interview room within the ED to maintain confidentiality. To accommodate ED staff, virtual interviews were also offered via Microsoft Teams. Interviews lasted between 30 minutes and 2.5 hours, depending on participant availability and the depth of the discussion.

Data Collection Instruments and Technologies

A semi-structured interview guide was collaboratively developed with the QI team, organizational WPV experts, and ED leadership, undergoing iterative refinement to ensure its relevance and applicability to WPV in healthcare (Appendix 1). Vignettes from Code White: Sounding the Alarm on Violence Against Healthcare Workers [10] were incorporated to prompt realistic discussions, with all receiving prior approval. Interviews were recorded using Zoom or Microsoft Teams, depending on the format. A Shure SM57 microphone and Steinberg UR12 interface were used to record in-person sessions.

Units of Study

Interviews were conducted in December 2022 with participants (n=52) representing HCPs from two urban EDs, spanning a broad range of professions (n=9) and capturing the diverse experiences of patient-facing staff in the ED (Table 1). To ensure diverse perspectives, both day shift (n=37) and night shift (n=15) staff were included.

Data Processing

An auto-transcription software was used to transcribe recordings, all transcripts were anonymized and reviewed for accuracy. MAXQDA qualitative analysis software was used for data organization and management.

Data Analysis

We conducted a thematic analysis following the framework outlined by Kiger and Varpio [11]. We chose this approach for its flexibility in analyzing diverse data and its suitability for both inductive and deductive exploration of patterns and themes. The Research Analyst and Research Assistant collaborated on the analysis, with the latter providing an external perspective to minimize potential biases and support the robustness of the analysis. Both researchers independently coded the interview data and resolved any discrepancies through discussion until reaching consensus.

To enhance the validity of the findings, we employed triangulation of sources and methods. We integrated multiple data sources, including input from ED staff, psychiatrists, and mental health directors, who provided additional perspectives on the emerging themes. We held peer debriefing sessions with two ED members, two psychiatrists, and a director from the Center for Mental Health to discuss findings, explore alternative interpretations, and refine the analysis.

Techniques to Enhance Trustworthiness

To enhance the trustworthiness and credibility of the thematic analysis, we conducted inter-rater reliability to ensure consistency in coding and theme development. Two researchers independently analyze the data and compare their findings to ensure that the themes identified were both reliable and accurately represented the participants' experiences.

Additionally, we reviewed and discussed all emerging themes with two ED HCPs members, two psychiatrists, and a director from the Center for Mental Health. This process of member checking and peer debriefing helped to validate the findings and ensure that the interpretations aligned with the lived experiences of the participants and the expertise of those working in the field.

Results

Synthesis and Interpretation

Following a thematic analysis and member checking, we identified four main themes including (1) Violence is Part of the Job, (2) Perceived Leadership Dynamics regarding WPV, (3) Disconnect Among ED Staff During WPV Response, and (4) Enhancing Systems and Culture for Effective WPV Management.

Violence is Part of the Job

The first main theme explores the perspectives of ED HCPs on WPV. ED HCPs reported widespread desensitization to the WPV they experience in their daily work. Although personal safety remains a concern, they often prioritize patient care over their own well-being. WPV is described as an unavoidable aspect of their profession. This mindset significantly influences their sense of well-being, both within and beyond the workplace. We identified three subthemes: (1.1) Desensitization to WPV in the ED, (1.2) A Prevailing Sense of Hopelessness, and (1.3) Moral Injury and Moral Distress.

Desensitization to WPV: The first subtheme emphasizes that high WPV occurrence rates among ED HCPs leads to the acceptance that it is considered an inevitable aspect of their job. This normalization is reinforced by the regularity of WPV incidents, including Code White events that often go unreported or are not formally called. Additionally, the absence of follow-up or debriefing after such events contributes to a culture where WPV is normalized rather than addressed as a serious concern requiring organizational attention. Verbal WPV, in particular, is so frequent that it was often described as unavoidable and part of the job, further desensitizing ED HCPs to the abuse that they routinely encounter while in the workplace.

Prevailing sense of hopelessness: ED HCPs express skepticism about the effectiveness of potential WPV interventions. They describe the ED as a fast-paced, high-pressure environment where high patient volumes and complex, unpredictable patient populations create seemingly insurmountable barriers to addressing WPV. Staff highlight particular challenges in managing patients with substance use or mental health conditions, anticipating that interventions will prove ineffective due to patients’ lack of responsiveness or coherence. Consequently, they view measures like awareness posters and educational initiatives as unlikely to create meaningful change. The perceived absence of robust organizational initiatives or communication about WPV reinforces these feelings of hopelessness.

Moral injury and moral distress: WPV in EDs contributes to job-related burnout, diminishes mental health and well-being, and reduces self-efficacy among HCPs, highlighting the emotional and physical toll of these events. Acceptance culture within the ED often discourages open discussions about WPV, leaving HCPs to process traumatic WPV events on their own time, with their own resources. Furthermore, ED HCPs prioritize patient care over their own safety and well-being due to feeling it is their duty and an expectation of the job. This creates a challenging dynamic where providing high-quality care becomes increasingly difficult while managing the threat of WPV.

Leadership Dynamics Regarding WPV

ED HCPs expressed mixed perceptions of leadership support in addressing WPV. Although many staff members reported feeling adequately supported by ED management, there was a prevalent sense of being overlooked by the broader organization. This perceived lack of initiative from the organization contributed to feelings of frustration and neglect among staff. The subthemes include (2.1) Support from ED Management, and (2.2) Perceived lack of Organizational Initiative with regards to WPV.

Support from ED Management: ED HCPs spoke highly of ED management due to their ongoing support regarding WPV. Staff noted that management ensures they are accessible and approachable, offering support to staff in addressing challenges related to WPV. Additionally, ED managers were recognized for their responsiveness to staff concerns and their visible presence following severe WPV incidents, which provided reassurance and reinforced a sense of support during critical times.

Perceived Lack of Organizational Initiative: In contrast, ED HCPs expressed frustration with the perceived lack of initiative from the organization in addressing WPV. Many reported that hospital management failed to actively support staff, citing a lack of acknowledgment of WPV incidents and the physical absence of leadership following severe events. Staff perceived that submitted incident reports disappear into a void and they felt that there was a lack of follow-up from leadership, leading to staff feeling dismissed. Perceived limited communication on WPV prevention and inadequate investment in intervention and training programs further reinforced these concerns. The discontinuation of in-person training after the beginning of the COVID-19 pandemic, combined with the evaluation that on-boarding training was minimal left staff with a feeling of being forgotten and unsupported. Additionally, staff felt that a lack of resources, such as panic buttons and metal detectors, further demonstrated the organization’s lack of initiative.

Perceived Disconnect Among ED Staff During WPV Response

HCPs expressed a strong sense of camaraderie with their colleagues, emphasizing team unity and the absence of an occupational hierarchy . While HCPs recognized security as an essential part of the medical team, security personnel felt disconnected from the broader healthcare team, a sentiment echoed by ED staff. Additionally, a lack of awareness of other professions’ roles and limitations led to confusion during WPV and Code White incidents. The subthemes emerged: (3.1) Interactions between members of the healthcare team in the ED, and (3.2) Role Confusion during WPV Incidents.

HCPs report strong teamwork as a key strength, with no clear positional hierarchy, especially during WPV incidents. They attribute higher WPV rates among nurses to more frequent patient interactions rather than occupational hierarchy.. Staff linked the high prevalence of WPV against nurses to time spent with patients, as well as that patients may be less likely to behave violently toward physicians, nurse practitioners, and physician assistants because they rely on them for specific needs. Additionally, societal views of women were highlighted as a contributing factor, with male nurses reporting lower rates of WPV due to patients often perceiving them as doctors.

HCPs and security guards maintain critical relationships for effective de-escalation. HCPs acknowledge security’s importance in ensuring safety, noting that security guards: actively patrol the ED, maintain a calm demeanor, use effective de-escalation methods, and assist in implementing protective measures to ensure patient safety during care provision. Additionally, ED HCPs highlighted that the presence of uniformed team members can positively influence patient behaviour. While HCPs valued security’s role in de-escalation, describing guards as integral members of the medical team and contributed to their sense of safety (Table 3), security guards often felt like outsiders, disconnected from the healthcare team and underappreciated. Although HCPs recognized the value of security’s de-escalation expertise, security personnel were unaware of the impact their skills had on the team, creating a divide between the groups.

Table 2. ED staff perceptions of security guards.

ED Staff Perceptions of Hospital Security	Yes	No	Unsure	N/A
Security is part of the Medical Team	31	3	6	6
Security increases staff sense of safety	37	1	1	7

Table 3. ED staff responses to proposed WPV prevention interventions.

Suggested Intervention	Yes	No	Unsure	N/A
Environmental Indicators for harm reduction	27	17	2	0
Personal Panic Alarms for ED Staff	43	2	1	0
Additional Security Guard in the ED	29	15	1	1
Wearable Devices for Security Guards	19	12	12	3
Flagging Patients with Behavioural Issues	42	1	0	3
De-Escalation Training	38	4	2	2
Code White Simulations	41	3	0	2
Code White Governance Committee	38	2	4	2
Updating Incident Reporting	37	2	4	3
Routine Check-in with ED Staff	40	2	0	4

Despite the sense of camaraderie among HCPs, there was confusion regarding the role delineation during a Code White or WPV responses. Miscommunication led to uncertainty about each person’s responsibilities and areas of control, particularly between HCPs and security guards. This confusion was heightened by unclear interdisciplinary role limitations and discord regarding the most appropriate de-escalation techniques.

Enhancing Systems and Culture for Effective WPV Management

The final theme focuses on areas for improving systems and culture to enhance the prevention of WPV in UHN EDs. HCPs reported mixed feelings about safety, highlighting gaps in current security measures, de-escalation knowledge, and organizational support. Subthemes include (4.1) Current Measures and Feelings of Safety, (4.2) Areas for Improvement and Prospective Measures, (4.3) Need for Education, (4.4) Streamlined Code White Process, and (4.5) Environmental Concerns.

While current security measures like guard presence and Behavioral Safety Assessments (BSAs) are considered effective, HCPs reported gaps in de-escalation knowledge and response strategies. A stronger organizational culture and improved management support were seen as critical for enhancing staff safety and confidence in handling WPV.

ED HCPs identified several key areas for improvement in WPV management. Staff expressed feeling severely understaffed, which hampered their ability to ensure both patient and personal safety. Additionally, there was a strong call for additional security guards to support the ED team. The proposed interventions, such as body-worn cameras, improved BSAs with de-escalation strategies tailored to the patient, and personal panic buttons, were viewed as critical to improving staff safety, increasing confidence in WPV management, and fostering a greater sense of organizational support. Furthermore, ED HCPs called for policy changes regarding WPV and Code White responses, requesting clear protocols and follow-up after incidents. The professional standards and training of security staff also need to be improved. Proactive strategies, such as building rapport with patients, checking in with staff, and maintaining visible and accessible presence to ED HCPs, were viewed as essential for improving the overall WPV management approach.

A lack of ongoing WPV prevention training, particularly after onboarding, was a prevalent concern among staff. HCPs emphasized the need for comprehensive, in-person de-escalation training to bridge the knowledge gap between senior and newer staff. Additionally, HCPs reported the need for training to address stigmatization of patients with mental health or substance use issues. Furthermore, it was emphasized that ongoing refreshers would be necessary to ensure effectiveness of training.

Additionally, ED HCPs highlighted the contrast between Code White and Code Blue responses, noting that Code Blues (i.e. medical emergency response) follow a more streamlined and systematic process. In contrast, Code White responses were perceived as ambiguous and, at times, chaotic. Staff identified key differences that could improve Code White responses, including a more structured response, clearly defined roles and steps, debriefs following incidents, and case reviews with organizational feedback on how to improve or prevent future occurrences. ED HCPs believed these changes would enhance de-escalation efficacy and reduce confusion regarding roles during Code White incidents.

Lastly, ED HCPs expressed concerns about the physical environment, acknowledging that while these issues are difficult to change, they would enhance feelings of safety. Key concerns included panic buttons that are either not accessible due to location or not always functional, and the physical layout of rooms and floors that creates blind spots and limits exits. Staff noted that beds can obstruct access to panic buttons or exits, and doors near the Rapid Assessment Centre are not locked 24/7, allowing easy access for unwanted visitors. Additionally, staff identified weapons of opportunity, such as IV poles, scalpels, and needles, which are sometimes left in the open.

Quantitative Findings

Several questions were posed to gather feedback on potential WPV prevention interventions, with the goal of evaluating their level of support from ED staff. The results offer valuable insights into staff perspectives on effective WPV prevention interventions.

Links to Empirical Data

The four themes capture the experiences, perspectives, and needs of ED HCPs regarding WPV. Table 4 summarizes these themes, accompanied by quotes that substantiate the findings from the thematic analysis.

Discussion

Integration with Prior Work, Implications, Transferability, and Contributions to the Field

This study enhances our understanding of WPV in EDs by exploring the perspectives of ED HCPs. Our analysis reveals a culture where WPV is normalized, provides insights into the dynamics between ED HCPs and leadership, and highlights the interactions between roles in the ED. Moreover, it identified actionable changes necessary to address WPV. These qualitative findings complement quantitative data by addressing gaps and offering a foundation for designing a comprehensive, systems-based strategy to mitigate WPV.

Addressing WPV in healthcare requires an urgent and complex approach, considering numerous factors at the systems level [1]. Effective WPV management necessitates a comprehensive strategy [1,12,13]. Designing such an approach requires defining the problem and finding the data [1]. While top-down methods using organizational data offer valuable insights, they are often limited by underreporting of WPV by staff, which can skew metrics and misrepresent the true extent of the issue [7,14,15]. This underscores the necessity of qualitative approaches like this study to build a more accurate and actionable understanding of WPV.

Building on these insights, the remainder of this discussion investigates key findings of this study, examining their implications in the context of existing literature. By situating these results within broader research, we aim to highlight how the perspectives of ED HCPs deepen our understanding of WPV and inform actionable strategies for addressing this pervasive issue.

A prevalent theme among participants was the normalization of WPV in the ED, paired with a perceived lack of organizational response, which contributed to both moral injury and moral distress among ED HCPs. The widespread belief that WPV is an unavoidable aspect of the job created a culture of acceptance and hopelessness, where frequent verbal abuse and unreported Code White events were viewed as routine rather than as crises requiring intervention. This normalization increased moral distress, as HCPs were required to prioritize their professional duty to patient care over their own safety and well-being [16]. While HCPs expressed general support for interventions (Table 3), there was a common belief that they would be insufficient to address the challenges posed by high patient volumes and the complexity of working with patients affected by mental health or substance use disorders. This sense of hopelessness illustrates the moral injury experienced by staff, who felt powerless to safeguard their personal safety while fulfilling their ethical obligation to provide adequate patient care. An example of moral injury is evident in participants' responses when asked whether they would press charges against a patient who had physically assaulted them. While many acknowledged that such actions constituted a crime, they expressed hesitation, feeling either that taking legal action was at odds with their responsibilities as caregivers or that their organization would disapprove as HCPs should prioritize the patient’s needs over the HCP’s well-being. This internal conflict exemplifies the strain of moral injury, which can result in burnout, post-traumatic stress disorder, and other trauma-related conditions, ultimately compromising both the mental health of HCPs and the quality of care they provide [17].

The perception that the organization does not support ED HCPs extended beyond the belief that the organization would disapprove of HCPs taking legal action against patients. ED HCPs felt that the organization did not prioritize addressing WPV in the ED and that little initiative was being taken at the organizational level. Despite this, ED HCPs often viewed ED leadership as supportive, primarily due to observed actions taken within the ED and their physical presence and more visible ‘acts of solidarity’. They were less aware of their influence on broader organizational efforts. For example, when an additional security guard was introduced to the ED, HCPs attributed this initiative to ED leadership rather than the organization. This may suggest an attribution error, specifically the fundamental attribution error [18], where individuals overemphasize internal factors, such as ED leadership actions, and underestimate external factors, like the organization’s role. Frustration with understaffing and the direct visibility of departmental actions likely contribute to this misattribution. Moreover, the fast-paced and tiresome environment of the ED makes it easier for HCPs to notice visible actions and advocacy efforts by ED leadership within their department, while broader organizational initiatives, being less visible, are more likely to be overlooked. Organizations need a cohesive and clear communication strategy to address this [1]. Transparent organizational communication can ensure that staff recognize the broader organization’s efforts to address their concerns. This approach fosters cohesiveness, enhances HCP buy-in, and strengthens organizational trust, ultimately helping HCPs feel more supported in addressing WPV [1,19,20]. Additionally, organizational leadership can adopt practices similar to those of ED leadership, such as making regular physical appearances and establishing clear communication channels to address staff’s WPV concerns, ensuring that ED HCPs feel supported and heard.

While previous literature has identified that hierarchical dynamics in EDs can contribute to certain roles, such as nurses, experiencing more WPV than others [10], respondents felt this was not the case in UHN EDs. Instead, ED HCPs reported a strong sense of mutual respect and camaraderie across professional roles. However, staff acknowledged that societal views of gender might contribute to the higher prevalence of WPV among nurses, particularly women. Male nurses noted feeling less likely to be targeted, as patients and visitors often assumed they were doctors, reflecting societal norms and gendered assumptions [21].

Additionally, ED HCPs with diverse intersectional identities reported experiencing verbal WPV directed at aspects of their identity, highlighting the influence of unconscious biases and intersectionality in WPV [21,22,23]. This is an example of a societal contributing factor to WPV that is difficult to address as it is out of the scope of a healthcare organization [10]. Nevertheless, organizations can support ED HCPs by offering resources such as counseling, leave of absence, and structured debriefs, alongside regular check-ins to provide ED HCPs with support [24,25,26]. As well, a multipronged approach to ameliorate WPV through WPV prevention training, environmental factors and organizational strategies such as policy changes can create a safer workplace for ED HCPs [1,12,25].

The presence of security in EDs is widely recognized as a crucial factor in enhancing workplace safety and preventing WPV [8,27], a finding reinforced by the themes identified in this study. However, our analysis uncovered a notable disconnect between HCPs and security personnel, an issue that remains underexplored in existing literature. While HCPs valued the sense of safety provided by guards' presence and de-escalation skills, security staff expressed feeling excluded from the medical team. Both groups identified a lack of role clarity during WPV events as a significant contributor to this disconnect. Factors such as siloed work culture and mistrust between colleagues may exacerbate this dynamic [28]. Additionally, high turnover rates in healthcare and ineffective team-building practices further hinder collaboration and reinforce feelings of isolation [29]. Respondents highlighted the urgent need for role clarification as part of broader WPV prevention education program and a coordinated Code White response structure. Existing literature points to a lack of practical, coordinated WPV response guidelines in healthcare systems, often due to the ambiguous nature of WPV events, which makes it challenging to implement consistent behavioral techniques across diverse scenarios [8].

Current literature aligns closely with our analyses in relation to the normalization of WPV within the ED. Factors related to ineffective organizational management, increased workload pressures and high patient volumes were cited as major contributors to WPV perpetuation [30,31]. Similar to our findings, the normalization of WPV has been noted to impact care delivery, job satisfaction and increased HCP turnover rates [30,32,33]. As a result, HCPs report a prevailing sense of hopelessness with current efforts to address and manage increasing WPV rates [30,31]. Additionally, studies have highlighted the role of societal factors in WPV, with many respondents attributing the responsibility for reducing WPV rates to societal change [30]. While many respondents in our study shared similar views, they also placed the responsibility on hospital management.

In relation to effective organizational and security measures to address WPV, another thematic analysis study highlighted similar effective security measures to our analyses. Key themes related to security interventions found that while alarm systems increased personal sense of safety, their placement and inaccessibility were noted as limiting factors to their use [8]. Additionally, behavioral reporting systems were considered effective measures to prepare HCPs before treating patients but presented limited descriptions of triggers and effective de-escalation techniques, both of which were barriers similarly found in our analyses [8]. Reported WPV response structure often took the form of a designated responder or de-escalation being conducted in pairs, however evidence-based guideline procedures for response efforts were not available or not regularly adhered to [8].

Prior literature has additionally highlighted staff presence and security patrols as a crucial resource for de-escalation, in turn increasing personal feelings of safety among HCPs [34,35]. Our analyses found that staff felt most vulnerable when shifts were understaffed or stretched thin when covering breaks or responding to other codes. Additionally, the ambiguity of WPV events results in senior staff generally taking leading roles in de-escalation due to past experience [36]. While experienced staff assume governing roles in de-escalation and use acquired techniques to aid de-escalation, there exists an increased need for generalized de-escalation skills and training in order to prepare junior and less experienced staff for potential events [36,37]. Literature has found that junior nurses report not being adequately prepared for WPV incidences and improved evidence-based de-escalation training is needed specifically at the onboarding and post-secondary level [38].

Peer support workers are emerging as a valuable resource in reducing WPV in emergency departments (EDs) and have been working in the UHN EDs since 2020 in a hospital-community partnership with The Neighbourhood Group. These individuals, who have lived experience with homelessness, substance use, or mental health challenges, provide specialized care and support for patients facing similar issues. By building trust and rapport with high-risk patients, peer support workers can help de-escalate potentially volatile situations before they escalate into violence. Their ability to relate to and communicate effectively with marginalized populations helps bridge gaps in understanding between patients and clinical staff, potentially reducing frustration and aggression. While we did not address the role of peer support workers in this study, early findings presented at the Canadian Association of Emergency Physicians (CAEP) 2024 conference suggest that peer support workers have a positive impact on patient care and staff experiences in the ED. The study found that peer support workers were able to de-escalate more than half (60.6%) of escalating situations with patients. Additionally, in over one-third (38.9%) of all patient interactions, peer support workers were able to share new information about the patient with the healthcare team, which could be crucial for providing appropriate care and preventing misunderstandings. Furthermore, the qualitative data from the study revealed that peer support workers contributed to improvements in care transitions, particularly during the discharge period, and created space for a trauma-informed approach to care delivery. Their ability to establish empathy and build trust between patients and the broader healthcare team was emphasized as a key strength of their role. Further studying the role of peer support workers in addressing workplace violence as part of multidisciplinary teams is an important priority for future research.

A more challenging factor to address is the environmental layout of the ED, which poses unique obstacles in mitigating WPV. Structural changes to existing facilities are often difficult to execute and costly, limiting the potential for improvements. Literature and our analysis highlight the importance of having clear sightlines, designated secure spaces, and accessible exits [10,39]. While structural changes to existing EDs may not be feasible, integrating feedback from HCPs during the design phase of new EDs can significantly improve safety protocols and contribute to a safer work environment for HCPs [39].

The findings of this study offer several actionable recommendations for healthcare organizations to address WPV. ED HCPs strongly endorsed interventions such as increased security presence, wearable devices like personal panic buttons, and WPV prevention training (Table 3). There was also significant support for improving debriefing processes and incident reporting systems, including implementing a call center to assist in completing reports. Additionally, understaffing emerged as a critical concern. Evidence supports many of these initiatives, however, literature consistently highlights that implementing a single initiative is unlikely to be effective in addressing workplace violence comprehensively [1,40,41]. While many of these initiatives require substantial funding, which may be a barrier for some organizations, the potential long-term benefits are noteworthy. Existing literature highlights the detrimental impact of burnout, WPV, trauma, and inadequate rest on HCP performance, including increased susceptibility to errors and reduced quality of care [10]. Investments in these interventions could yield significant long-term benefits, such as reducing turnover rates, improving workplace safety, and extending the careers of HCPs [10,15].

Limitations

This study has several limitations. The use of convenience sampling, while beneficial in facilitating participation among busy ED staff, may impact the generalizability of findings due to potential biases associated with participant availability. Furthermore, our sample consists exclusively of ED staff, with interviews conducted at two public hospitals in Toronto, Canada. As a result, the findings may have limited applicability to hospitals in non-urban settings or other geographic regions, as well as private hospitals. The timing of data collection, conducted during the COVID-19 pandemic, is another important factor to consider, as the pandemic likely influenced HCP perceptions and increased WPV incidents while straining healthcare resources, potentially intensifying the challenges reported by participants.

Conclusion

This qualitative study contributes to the understanding of WPV in healthcare by applying a bottom-up approach that focusses on the perspectives of frontline ED HCPs rather than relying on quantitative data. The thematic analysis highlights key insights from ED HCPs, offering valuable information to inform quality improvement strategies within healthcare institutions. Additionally, this study establishes a baseline for quality improvement efforts within our organization. Future rounds of interviews, conducted after the implementation of interventions, will assess the effectiveness of these initiatives from the ED HCPs' perspective, further contributing to the literature on WPV in healthcare and providing evidence-based strategies for other healthcare institutions.

Supplementary Materials

The following supporting information can be downloaded at the website of this paper posted on Preprints.org, Table 1: Roles of the interview participants (n=52). Table 2: ED staff perceptions of security guards. Table 3: ED staff responses to proposed WPV prevention interventions. Table 4: Summary of themes identified through thematic analysis, supported by representative quotes. Appendix S1: UHN Security Operations WPV Quality Improvement Semi-Structured Interview Guide Appendix S2: UHN Security Operations WPV Quality Improvement Intro and Consent Form

Author Contributions

Conceptualization, B.L., R.S., and C.S.-Q.; Methodology, B.L., and C.S.-Q.; Software, B.L., and B.S.; Validation, B.L., B.S., N.B., M.A., R.W. and C.S.-Q.; Formal Analysis, B.L., B.S., and C.S.-Q.; Investigation, B.L.; Resources, B.L., J. Haines, and C.S.-Q.; Data Curation, B.L., and B.S.; Writing – Original Draft Preparation, B.L., B.S., J. Hulme, K.C., & C.S.-Q..; Writing – Review & Editing, B.L., B.S., N.B., M.A., J. Hulme, K.C., R.S., C.R., J. Haines, R.W., M.T., and C.S.-Q.; Visualization, B.L.; Supervision, C.S.-Q.; Project Administration, B.L.; Funding Acquisition, B.L., R.S., J. Haines, R.W., M.T., and C.S.-Q. All intellectual content and critical analysis within this manuscript were developed solely by the authors. However, OpenAI's ChatGPT was utilized to enhance phrasing and ensure grammatical accuracy. The authors assume full responsibility for the final content and any errors. All authors have read and approved the final manuscript.

Funding

This research was funded by the UHN Quality Improvement Physicians Grant.

Institutional Review Board Statement

The study received formal exemption from the Research Ethics Board and approval from the University Health Network’s Quality Improvement Review Board (QI ID: 22-0499).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The thematic analysis and associated quantitative data supporting the findings of this study are included within the manuscript. Due to the sensitive nature of the qualitative data and to protect participant confidentiality, interview transcripts and coding files are not publicly available but can be accessed upon reasonable request to the corresponding author, subject to institutional review board approval and appropriate data-sharing agreements.

Acknowledgments

We would like to thank our colleagues for their contribution to the content of this article: Sam Sabbah, Sabrina Bennett, Michael DeWitt, Janet Pilgrim, Henry Hill, Licinia Simoes, John Shannon, Adebukola Adenowo-Akpan, Melanie Gruneir, Marnie Escaf, Diana Elder, Mark Spencer, the members of the Workplace Violence Prevention Advisory Committee, the members of the Code White Governance Committee, the members of the Workplace Violence Education Collaboration and, most importantly, the TeamUHN Emergency Department staff. This article is a revised and expanded version of a paper entitled Violence is Part of the Job: Investigating the impacts of Workplace Violence on Emergency Department Staff through Qualitative Interviews, which was presented at the Academy of Consultation-Liaison Psychiatry 2024, Miami, USA, on November 8th, 2024.

Conflicts of Interest

B. L. has received support from the Quality Improvement Physicians Grant, University Health Network. B. S. has received support from the Quality Improvement Physicians Grant, University Health Network. N.B. has nothing to declare. M.A. has nothing to declare. J. Hulme has received support for her role as Health Equity co-lead from the Emergency Department, University Health Network. K.C. has received support for her role as Health Equity co-lead from the Emergency Department, University Health Network. R.S. has received support from the Quality Improvement Physicians Grant, University Health Network. C. R. has nothing to declare. R. W. has nothing to declare. J. Haines has nothing to declare. M.T. is on the board of Health Insurance Reciprocal of Canada. C.S.-Q. has received education scholarship support from Academic Scholars Award, Department of Psychiatry, University of Toronto, and Young Leaders Program and Cancer Experience Program, Princess Margaret Cancer Center, University Health Network and the Quality Improvement Physicians Grant, University Health Network. He is on the board of directors for the Canadian Academy for Consultation and Liaison Psychiatry. He is the Provincial Quality Lead Psychiatry – Psychosocial Oncology at Ontario Health, Ontario, Canada. The sponsors had no role in the design, execution, interpretation, or writing of the study.

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Table 1. Roles of the interview participants (n=52).

Role	Number
Nurse	29
Psychiatric Emergency Service Unit Nurse	5
Physician	4
Medical Radiation Technician	3
Ward Clerk	3
Housekeeper	2
Security Guard	2
Social Worker	2
Learner	2

Table 4. Summary of themes identified through thematic analysis, supported by representative quotes.

Theme	Subtheme	Evidence
1. Violence is Part of the Job	1.1 Desensitization to WPV in the ED	“I think it's an interesting thing where we've had to just adapt to the reality that violence is like a normal part of your day. I've never been physically assaulted in the ED which I'm grateful for, but the risk is there and you hear of lots of situations so, you just kind of accept that potentially violent patients are here and we have to care for them.” (Interview #17)
	1.2 A Prevailing Sense of Hopelessness	“I think it just becomes normal in emerge now when a person is violent. That's just normal. Not that I don't think they're [management] taking it seriously, but I just think it's so busy now. No one has the time to do any debriefing, or counseling or following up on these incidents. So I think people just get left behind and their voice isn't really heard.” (Interview #28)
	1.3 Moral Injury and Moral Distress	“We've had quite a few situations over the past few years that have caused people to not even want to work in this environment. It leads to burnout and then it spirals into this process where people end up quitting because of the repeated workplace violence. And that's confounded by having to provide care for people who are sick. So when you're trying to deal with providing that care in addition to somebody who's aggressive and somebody who's violent, it kind of compounds all together." (Interview #23)
2. Leadership Dynamics regarding WPV	2.1 Support from ED Management	“I think they [immediate management] provide us with the support. Our leadership team has been pretty great and our security team has been really great in providing that support. I don't think the training that we receive before we start is sufficient, especially with the psych patients. Not everyone has a psych background and not everyone knows how to interact and what might trigger a psych patient. (Interview #43)
2. Leadership Dynamics regarding WPV	2.2 Perceived lack of Organizational Initiative with regards to WPV	“You do an incident report. But what’s the point? Management is supposed to get back to you… But nobody ever gets back to you. There’s nothing, there are no solutions. And then we ask how can we make it better? Again, there’s nothing. And then it happens again. So then what’s the point in completing one?” (Interview #41)
3. Perceived Disconnect Among ED Staff During WPV Response	3.1 Interactions between roles in the ED	“It just felt like there's way too many people around. When someone was escalating and then a lot of people showed up and like I said, I’m not really sure what they're supposed to be doing. There's one person that engages with the patient from what I had seen, so I'm not sure if that is the most beneficial in emerge when we already have a relationship with the patient. (Interview #38) “I think it's [workplace violence] because the nurses spend more time with patients in general. A doctor sees you for five minutes, but then we're the ones that have to assess you, do the orders, keep talking to you and convince you to take the medication or whatever may be. So we have to interact with them more, I think it's just the nature of our job.” (Interview #14)
	3.2 Role Confusion during WPV Incidents	“Security guards and nurses should work together during a code situation. However, sometimes we find that some security guards may take charge of situations and want to manage the Code White without really listening to the advice of nurses. It's good for nurses to give their medical advice as well and take charge so that we can de-escalate and provide other interventions. If the guards are aware of that, then that's better.” (Interview #37) “The other thing we do in a Code Blue that I have never seen done in a Code White situation is somebody identifying themselves as a team leader. In a Code Blue, when I walk into the room, I say my name is so-and-so and I'm one of the staff emergency physicians. I'm running this code so that people understand my role. But you never see a team lead identifying themselves in a Code White situation. You never see anybody identifying themselves in a Code White situation.” (Interview #52)
4. Enhancing Systems and Culture for Effective WPV Management	4.1 Current Measures and Feelings of Safety	”Overall, I think the guards are helpful. Our current one is obviously great, but two is getting towards being great just in terms of feeling safe and having someone around that can be like rougher with a patient, whereas we can't.” (Interview #2)
	4.2 Areas for Improvement and Prospective Measures	“I think that [body-worn cameras] would be useful. It could help deescalate situations quicker if the patients see that they're being recorded. Or staff think they're being recorded. I think it works for the police well.” (Interview #28) “I feel like that's [personal alarm systems] been helpful when I've worked on departments. I've worked on a locked psychiatric unit and everybody had them, and I feel like it was helpful to them. There are logistical things that go along with that, like false alarms and stuff. But I think for the number of times that it would be needed, it would be used and be functional (Interview #42)
	4.3 Need for Education	“Definitely NVCI (non-violent crisis intervention) and CPI (crisis prevention intervention) training would work. I've seen it work multiple times. I can even say I've seen it work on patients here and patients that are worse than what you might see as from a Code White here. So I'm a very strong believer in CPI and NVCI trainings if those courses are being done annually and are provided by UHN.” (Interview #49)
	4.4 Streamlined Code White Process	“One thing that I feel when we do health security on bedside there's kind of like a disconnect between who's supposed to lead, like who's talking. I feel like sometimes that can get a little messy with the patient. So knowing your role and being clear in that certainly would help. (Interview #13)
	4.5 Environmental Concerns	“I noticed when a patient escalates unexpectedly, there are no security buttons in a couple of locations where I would like them to be. So, I think a re-evaluation of where the security buttons are, in particular, subacute one and two, don't have them…If a patient's blocking your entry or exit from the room, there's no button inside the room or even just outside. I think that's something that should be re-evaluated too.” (Interview #40) “When you enter to see the patients, the way that the beds are put, sometimes you find yourself on the opposite side of where the entrance is. So, if you were in that sort of a situation, there is no easy way for you to escape…If a nurse goes in and she's for example, putting up leads to hook the patient up onto a cardiac monitor and if she was to be attacked by the patient, I can think of many of the areas and rooms around where she would not have easy access to be able to escape. Because she'd be locked or he'd be locked. You know what I mean? So those things have got to be thought out” (Interview #18) “I think stupid little mistakes that could be serious ones. I found a scalpel next to the printer and when I brought it to the charge nurse, it was just kind of like, oh, it's just a scalpel. And I'm thinking but if it didn't get used here, a patient who is totally messed up, they could have taken it outside the hospital. Stupid little mistakes, I think could cause something like so serious like leaving a needle, laying around. Like, I certainly don't want to be stabbed with that needle.” (Interview #5)

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