Emergency Nurses’ Experiences Managing Workplace Violence and Aggressive Patients

Introduction

Workplace violence, encompassing verbal abuse, threats, and physical assault, is disproportionately common in emergency department nursing relative to most other healthcare and non-healthcare occupational settings, with survey-based research consistently documenting that a substantial majority of emergency nurses have experienced some form of patient- or visitor-perpetrated violence within a given year of practice (Gacki-Smith et al., 2009; Phillips, 2016). National surveillance data collected by professional nursing organizations have similarly documented high rates of physical and verbal violence specifically within emergency care settings, reinforcing workplace violence as a persistent, specialty-specific occupational hazard rather than an occasional or isolated event (Emergency Nurses Association, 2011).

While this survey-based literature has been essential in establishing the scope of workplace violence as a measurable occupational exposure, a smaller body of qualitative research has explored how emergency nurses themselves experience and make sense of this exposure as a recurring feature of daily practice, rather than as a series of discrete, isolated incidents. Prior qualitative work has identified a troubling pattern of normalization, in which emergency nurses come to regard verbal aggression, and at times physical aggression, as an unremarkable, expected part of the job rather than as a reportable occupational hazard warranting formal response (Wolf et al., 2014; Angland et al., 2014).

Complementing this normalization pattern, prior research has also documented substantial underreporting of workplace violence incidents relative to their actual frequency, with formally documented incident reports capturing only a fraction of the violence nurses describe experiencing when surveyed directly (Arnetz et al., 2015; Copeland & Henry, 2017). Understanding the specific reasoning and experience underlying this underreporting, alongside the felt experience of managing aggression in real time and the institutional response, or lack thereof, following an incident, is important for designing workplace violence prevention and support strategies that address the actual, lived structure of this occupational hazard rather than treating it as a simple incident-counting problem. The purpose of this study was to use reflexive thematic analysis to explore emergency department nurses’ experiences of managing workplace violence and aggressive patients, including how they navigate real-time safety decisions and how they experience the aftermath of a violent incident.

Methods

Design. This study used a qualitative design employing reflexive thematic analysis, following the approach described by Braun and Clarke (2006, 2019), selected for its flexibility in identifying patterned meaning across a moderately sized sample while remaining attentive to the researchers’ own active, interpretive role in theme construction.

Setting and sample. Participants were registered nurses recruited from emergency departments across four hospitals within two health systems between March and September 2025. Purposive sampling targeted variation in years of emergency nursing experience, shift pattern (day, evening, night), and personal history of direct workplace violence exposure. A total of 22 nurses participated.

Data collection. Individual, semi-structured interviews, lasting 45 to 60 minutes, were conducted by a researcher not employed at any participating site, using an interview guide addressing participants’ general experience of aggression and violence in their practice, their approach to a specific, memorable incident, their experience following that incident, and their perspective on incident reporting. Interviews were audio-recorded and transcribed verbatim.

Data analysis. Transcripts were analyzed using Braun and Clarke’s six-phase reflexive thematic analysis approach: familiarization with the data, generation of initial codes, construction of candidate themes, review of themes against the coded data and full data set, definition and naming of themes, and final write-up. Two researchers independently coded an initial subset of transcripts, compared and discussed coding decisions, and jointly developed a coding framework applied to the remaining transcripts, with themes iteratively refined through team discussion across the full data set.

Trustworthiness. Trustworthiness was supported through investigator triangulation during coding, a reflexive journal documenting analytic decisions and researcher assumptions, member checking with a subset of six participants who reviewed a summary of preliminary themes, and an audit trail linking themes to supporting excerpts.

Ethical considerations. The study was approved by the relevant institutional review boards. Written informed consent was obtained from all participants. Given the sensitive nature of the topic, participants were offered the option to pause or end the interview at any time, and information regarding professional support resources was provided following the interview. Pseudonyms are used throughout.

Findings

Reflexive thematic analysis of the 22 interviews resulted in four themes, illustrated in Figure 1. Theme prevalence across the interviews is summarized in Figure 2.

Theme 1: Violence as an Expected Part of the Job

Nearly every participant described verbal aggression, and many described physical aggression, as an unremarkable, expected feature of emergency nursing rather than a notable or reportable event. Several participants described this normalization as something that developed gradually over their career, with early incidents that once felt alarming eventually blending into an accepted, background feature of a typical shift. This normalization was frequently expressed through minimizing language, with participants describing even physically threatening encounters using terms like “just part of the job” or “nothing new,” language several participants recognized, upon reflection during the interview, as somewhat at odds with the seriousness of what they were actually describing.

Theme 2: Reading the Room — The Real-Time Work of De-escalation

Participants described a continuous, largely unacknowledged form of skilled labor involved in reading early behavioral and environmental cues, a patient’s tone shifting, a family member’s posture changing, a waiting room growing louder, and calibrating their own approach, tone, and physical positioning in response, often before any overt aggression had occurred. Several participants described this as a constant background cognitive load running underneath their clinical tasks, distinct from and in addition to their direct patient care responsibilities, a form of labor they felt was rarely recognized as a distinct skill set warranting its own formal training or acknowledgment.

Theme 3: Invisible Afterward — the Absence of Institutional Response

Many participants described feeling largely unseen by their institution in the aftermath of a violent incident, describing an absence of structured debriefing, follow-up, or explicit acknowledgment from leadership, in contrast to the more visible institutional response they associated with other types of clinical adverse events. Several participants specifically contrasted the attention given to a medication error or a clinical safety event with the comparatively minimal formal response following an assault against themselves personally, a contrast several described as reinforcing their own sense that violence against nursing staff was treated as a lower institutional priority than other categories of harm.

Theme 4: Why We Don’t Report — the Logic of Underreporting

Despite the frequency of aggression participants described experiencing, many acknowledged reporting only a small fraction of actual incidents, citing several interconnected reasons: the normalization described in Theme 1, a perceived futility given the absence of visible institutional response described in Theme 3, the time burden of the reporting process itself during an already demanding shift, and, for several participants, an internalized belief that reporting a verbal or minor physical incident might be perceived by colleagues or leadership as an overreaction. Several participants specifically described reserving formal reporting only for the most severe physical incidents, effectively applying their own informal threshold well above what official reporting policy would suggest.

Discussion

This reflexive thematic analysis found that emergency nurses experienced workplace violence not as a series of discrete, reportable incidents but as a normalized, continuous undercurrent of their daily practice, sustained by an absence of institutional acknowledgment following an incident and by a reporting process participants did not experience as meaningfully responsive. This pattern is consistent with, and extends in experiential depth, prior qualitative research documenting a similar normalization phenomenon among assaulted emergency nurses (Wolf et al., 2014; Angland et al., 2014), while adding a more explicit account of the specific institutional-response gap and reporting logic underlying that normalization.

The reading the room theme’s characterization of de-escalation as a continuous, largely invisible cognitive and relational labor, distinct from direct clinical care tasks, offers a useful reframing for institutional training and staffing conversations. Rather than treating de-escalation competency as a discrete skill applied only once overt aggression has emerged, this finding suggests de-escalation functions more as an ongoing background vigilance that consumes cognitive and emotional resources throughout an entire shift, a framing consistent with prior qualitative work identifying environmental and interpersonal cue recognition as central to emergency nurses’ violence management practice (Pich et al., 2017; Angland et al., 2014).

The invisible afterward theme, and participants’ specific contrast between institutional response to clinical adverse events and institutional response to violence against staff, points toward a structural and cultural gap distinct from any lack of de-escalation skill or training. This finding is consistent with broader occupational safety literature identifying insufficient post-incident support as a persistent gap in healthcare workplace violence prevention programs, despite regulatory guidance explicitly recommending structured post-incident response as a component of a comprehensive violence prevention program (Occupational Safety and Health Administration, 2015; Ramacciati et al., 2018).

The underreporting theme’s specific, interconnected logic, normalization, perceived futility, time burden, and fear of being seen as overreacting, extends prior quantitative documentation of the gap between actual and reported incident frequency (Arnetz et al., 2015) by illuminating the reasoning underlying that gap directly in participants’ own terms. This finding has a specific and important implication for incident reporting system design: simply encouraging nurses to report more consistently is unlikely to succeed without also addressing the perceived futility and absent follow-through that several participants identified as their primary reason for not reporting in the first place.

Several limitations should be considered. This study was conducted within four emergency departments across two health systems within a single general region, and transferability to emergency departments with substantially different security infrastructure, patient population, or existing violence prevention programming should be considered carefully rather than assumed. As with all retrospective interview-based research, participants’ accounts reflect their current sense-making of past experience rather than a direct, contemporaneous record of their thinking at the time of a given incident. The semi-structured interview format, while allowing rich exploration of shared themes, may not have fully captured the most severe or traumatic incidents, which some participants may have found too difficult to discuss in detail during a single interview.

Future research should evaluate whether structured post-incident response protocols, explicitly modeled on the institutional response given to clinical adverse events, measurably improve emergency nurses’ sense of institutional support and, in turn, incident reporting consistency. Extending this thematic approach to include emergency department leadership and security staff perspectives would help clarify whether the institutional invisibility participants described reflects a genuine absence of response or a response that exists but is not effectively communicated to bedside staff. Taken together, these findings suggest that reducing the toll of workplace violence on emergency nurses may depend as much on shifting the normalized culture and institutional response surrounding violence as on incident-specific de-escalation training or security measures alone.

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