8th June 2018, Volume 131 Number 1476

Sandra K Richardson, Paula C Grainger, Michael W Ardagh, Russell Morrison

Incidents of violent and aggressive behaviour are well recognised in healthcare, with the emergency department (ED) setting acknowledged as an area of particular risk.1–3,16 Despite this, such incidents continue to…

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Staff working in emergency departments are exposed to a constant level of violence and aggression. This includes verbal threats and harassment that have become seen as a normal part of the work environment, and in many cases there is a failure to report the full extent of aggression that occurs. When reporting is not provided, there is the potential for management and DHBs to misinterpret the level of violence in the workplace, and be unaware of the need to respond appropriately.



To examine levels of reporting of violence and aggression within a tertiary level emergency department in New Zealand, and to explore staff attitudes to violence and reporting.


A one-month intensive, prospective audit of the emergency department’s violence and aggression reporting was undertaken and compared with previously reported data.


There was a significant mismatch between the number of events identified during the campaign month and previously reported instances of violence and aggression. The findings identified that failure to report acts of violence was common.


Reports of violence and aggression in the emergency department underestimate the true incidence. Failure to report has potential impacts on organisational recognition of risk and the ability to develop appropriate policy responses.

Author Information

Sandra K Richardson, Nurse Researcher, Emergency Department, Christchurch Hospital, Canterbury District Health Board, Christchurch; Senior Lecturer, Centre for Postgraduate Nursing Studies, University of Otago; Paula C Grainger, Nurse Coordinator Clinical Projects, Emergency Department, Christchurch Hospital, Canterbury District Health Board, Christchurch;
Michael W Ardagh, Professor of Emergency Medicine, University of Otago, Christchurch; Emergency Medicine Physician, Emergency Department, Christchurch Hospital, Canterbury District Health Board, Christchurch; Russell Morrison, Injury Management Co-ordinator, Canterbury District Health Board, Christchurch.


Dr Sandra Richardson, Emergency Department, Christchurch Hospital, Canterbury District Health Board, Riccarton Ave, Christchurch 8022.

Correspondence Email


Competing Interests



  1. Nelson R. Tackling violence against health-care workers. Lancet. 2014; 383:1373–1374.
  2. Kowalenko T, Cunningham R, Sachs C, et al. Workplace violence in emergency medicine: current knowledge and future directions. Journal of Emergency Medicine. 2012; 43:523–531.
  3. Swain N, Gale C, Greenwood R. Patient aggression experienced by staff in a New Zealand Public hospital setting. NZMJ 127:10–18.
  4. Stene J, Larson E, Levy M. et al. Workplace violence in the Emergency Department: Giving Staff the tools and support to report. Perm J. 2015; 19:e113–e117.
  5. Stirling G, Higgens JE, Cooke MW. Violence in A&E departments: a systematic review of the literature. Accident and Emergency Nursing 2001; 9:77–85.
  6. Ray MM. The Dark Side of the Job: Violence in the Emergency Department. Journal of Emergency Nursing. 2007; 33:257–261.
  7. Phillips JP. A safe space: Violence toward emergency department providers isn’t just part of the job. ACEP Now 2016; http://www.acepnow.com/violence-toward-emergency-department-providers-isnt-just-part-job/ accessed 20/02/2018.
  8. Kennedy M. Violence in emergency departments: Under-reported, unconstrained, and unconscionable. MJA 2005; 183:362–5.
  9. Hogarth KM, Beattie J, Morphet J. Nurses’ attitudes towards the reporting of violence in the emergency department. AENJ 2016; 19:75–81.
  10. Speroni KG, Fitch T, Dawson E, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
  11. Wolf LA, Delao AM, Perhats C. Nothing Changes, Nobody Cares: Understanding the Experience of Emergency Nurses Physically or Verbally Assaulted While Providing Care. Journal of Emergency Nursing. 2014; 40:305–310.
  12. Morphet J, Griffiths D, Plummer V, et al. At the cross roads of violence and aggression in the emergency department: perspectives of Australian emergency nurses. Australian Health Review. 2014; 38:194–201.
  13. Pich J, Hazelton M, Sundin D, et al. Patient-related violence against emergency department nurses. Nursing & Health Sciences. 2010; 12:268–274.
  14. ACEM Policy on violence in Emergency Departments. 2011. Document no.P32. http://www.acem.org.au/getattachment/7b0819a6-93cc-4d89-8fe8-22c6ea307a22/Policy-on-Violence-in-Emergency-Departments.aspx accessed 20/02/2018
  15. Bentley T, Forsyth D, Tappin D, et al. Report on the 2011 New Zealand workplace violence survey. Palmerston North: Healthy Work Group, School of Management, Massey University; 2011. 
  16. Egerton-Warburton D, Gosbell A, Wadsworth A, et al. Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations. Medical Journal of Australia 2016; 204:155. 
  17. ACEP. Emergency department violence: an overview and compilation of resources. 2011. www.acep.org/content.aspx?id=81782 accessed 02/06/2016.
  18. Emergency Nurses Association. Position statement: Violence in the emergency care setting. 2009. Author.
  19. Esposito P, Canton AD. Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology. World J Nephrol 2014; 3:249–255.
  20. Copeland D, Henry M. Workplace violence and perceptions of safety among emergency department staff members: experiences, expectations, tolerance, reporting, and recommendations. Journal of Trauma Nursing 2017; 24:66–77.
  21. Kvas A, Seljak J. Unreported workplace violence in nursing. International Nursing Review 2014; 61:344–351. 
  22. Knowles E, Mason SM, Moriarty F. “I’m going to learn how to run quick”: exploring violence directed towards staff in the Emergency Department. Emergency Medicine Journal. 2012; 30(11):926–931 6p. doi:10.1136/emermed-2012-201329
  23. Watson K. Gallows humor in medicine. The Hastings Center Report. 2011; 41(5):37–45.
  24. Piemonte NM. Last laughs: Gallows humor and medical education. J Med Humanit 2015; 36:375–390.
  25. Luck L, Jackson D, Usher K. Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence. Journal of Clinical Nursing 2008; 17(8):1071–1078.
  26. Martinez AJS. Managing Workplace violence with evidence-based interventions. A literature review. Journal of Psychosocial Nursing and Mental Health Services, 201; 54(9):31–36.
  27. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence Against Nurses Working in US Emergency Departments. Journal of Nursing Administration, 2009; 39(7/8):340–349.
  28. Gates DM, Gillespie GL, Succop P. Violence Against Nurses and its Impact on Stress and Productivity. Nursing Economics 2011; 29(2):59–66.
  29. Martin A, Gray C, Adam A. Nurses’ Responses to Workplace Verbal Abuse: A Scenario Study of the Impact of Situational and Individual Factor. Research and Practice in Human Resource Management 2007; 15(2):41–61.


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