The study was conducted at six Midwestern U.S. EDs. Three settings served a general population: one urban teaching hospital, one suburban hospital, and one rural free-standing ED. An additional three sites included an adult-focused teaching hospital, a pediatric ED within an urban teaching hospital, and a pediatric ED within a suburban free-standing ED. Approximately 900 ED workers were employed across the six study sites. The study used convenience and snowball sampling methods to recruit up to 50 respondents per site. Non-physician, adult employees who had been employed full-time, part-time, or per diem in the ED for at least six months were eligible for recruitment into this study. Traveling/temporary or other persons who were not permanent employees of the ED were excluded from participation.

Following in-person recruitment at the start of their shift, participants signed an informed consent document. They then were provided a paper version of the survey packet, which they completed during break periods. At the end of their shift, the survey packets were collected.

Respondents confidentially completed an adapted version of the Survey of Violence Experienced by Staff to measure the prevalence and impact of verbal abuse, threats, and assaults (Hahn et al., 2011). Panel experts from the European Violence in Psychiatry Research Group determined content validity and the internal consistency reliability of the tool to be 0.87–0.91 (Hahn et al., 2011). The survey included items on the prevalence of WPV (Gillespie et al., 2017), emotional impact of WPV, perceived support following WPV, and demographic information.

Respondents rated the emotional impact of a WPV incident from 0 (no impact) to 100 (significant negative impact) based on the worst WPV incident they experienced per category (verbal abuse, threat, assault). Emotional impact was managed using two strategies. First, emotional impact was dichotomized as (a) verbal abuse only and (b) any threat or assault (with or without verbal abuse). Second, emotional impact was limited to cases where respondents experienced all three categories of WPV: verbal abuse, threat, and assault.

Respondents rated the need for support following WPV and their perceived satisfaction of support following WPV using a Likert scale. Support was classified as available/unavailable, discussed/not discussed, needed/not needed, and supportive/unsupportive. Each item was scored using a 5-point Likert-scale ranging from strongly agree to strongly disagree. Support provided was further defined as support from managers, colleagues, family/friends, or others. Participants responded ‘yes’ or ‘no’ to indicate whether they had used each support person/category.

Data analysis included descriptive statistics, t-test, and Kendall’s test. An independent-samples t-test was computed to compare the emotional impact of verbal abuse to threats/assaults. A Kendall’s test was computed to compare correlations in mean rank. Alpha was set at 0.05.

Respondents predominantly agreed or strongly agreed that support was available following WPV (n=129, 63.2%) when needed (see Table 1). For example, 95.1% (n=196) of respondents believed support was needed following a physical assault, whereas 81.0% (n=166) of respondents believed support was needed for people who were verbally abused, and 88.8% (n=183) of respondents believed support was needed following threats. However, the need for support varied by category of WPV. For example, more than half (n=121, 59.6%) of respondents believed the support varied based on the type of WPV (verbal abuse, threats, or assault).

Respondents proactively sought support from a variety of sources after experiencing WPV, and for some incidents they sought support from multiple persons (see Table 2). The predominant source of support was another colleague from the department (n=127, 62.3%). In comparison, only 30.4% (n=62) of respondents used supervisors and 44.1% (n=90) used partners/family members as a source of support. Some respondents (n=36, 17.6%) reported not seeking any support person after WPV.

Respondents’ perceptions of who provided support following WPV varied depending on the category of WPV. For example, 47.1% (n=96) of respondents indicated they agreed/strongly agreed that managers were supportive following verbal abuse, and 63.6% (n=126) indicated that managers were supportive following assault. About 75% (n=154) of respondents indicated they disagreed/strongly disagreed that colleagues were unsupportive after verbal abuse, and 85.1% (n=171) disagreed/strongly disagreed that their colleagues were unsupportive after assaults. Additional findings of perceived support following WPV are provided in Table 3.

The emotional impact of verbal abuse and threats/physical assaults was similar. The mean score for the emotional impact of verbal abuse was 33.5 (SD=29.1, n=89) with a range from 0 to 100. The mean score for the emotional impact for threats/assaults was 34.1 (SD=31.0, n=117) with a range from 0 to 100. The mean scores for the emotional impact of verbal abuse and threats/assaults were not statistically different, t (204) = −.135, p = 0.893. See Figure 1 for a distribution of the emotional impact scores. There were 46 respondents who experienced all three categories of WPV. When comparing the correlations in mean rank for the emotional impact of verbal abuse (mean rank = 1.91), threat (mean rank = 1.92), and assault (mean rank = 2.16), no statistical correlations were found (W = .034, p = 0.212).

Forensic nurses practice in a variety of settings including hospitals, EDs, long-term care, prisons, and industry (Forensic Nursing Scope and Standards Task Force, 2017). Unfortunately, not every practice setting will be able to employ a full-time, specially trained forensic nurse. In some EDs, the forensic nurse’s primary employment role may be that of an emergency nurse. Whether their primary role is forensic nurse or emergency nurse, they need to understand the “the scope of practice, roles, and responsibilities of forensic nursing in the emergency setting including proper identification, collection, and preservation of forensic evidence” (Navarroli, 2023, p. 2). These skills can be employed particularly following a physical assault to be used with reporting to local law enforcement. They also need to “be educated in trauma-informed care in order to provide appropriate care to all patients who experience intentional or unintentional violence” (Navarroli, 2023, p. 2). Price and Maguire (2016) further explained that forensic nurses may work in industrial settings such as the ED and have a responsibility for risk management, injury prevention, and investigations. This expertise will allow the nurse to transition from role of emergency nurse providing care of patients to forensic nurse addressing the aftermath of a violent incident including trauma-informed care to victimized ED coworkers.

Forensic nurses and emergency nurses with forensic nursing training are situated to combine their expertise in trauma-informed care, evidence collection, and expert testimony to support victimized ED workers. Forensic nurses can explain to victimized ED workers that anger and crying can be a normal manifestation of the emotional impact of WPV (Demirci & Uğurluoğlu, 2020). Support for victimized workers can be demonstrated by colleagues covering their assignment while they take a break to recover (Gillespie & Palazzo, 2022). In addition, forensic nurses and emergency nurses with forensic nursing training can collaborate with employers to provide a safe, quiet room where workers can reflect and/or cry as needed. Not all workers will show their symptoms of stress following WPV. As a result, forensic nurses and emergency nurses with forensic nursing training along with charge nurses and managers can purposefully round the department to inquire how ED workers are doing following incidents of WPV. They also can offer personal support and referrals for professional counseling to ED workers who experienced WPV as well as those workers who witnessed the event (Gillespie et al., 2019; International Association of Forensic Nurses, 2023; Powell et al., 2023). For some workers, witnessing WPV may be as traumatic as being the target of WPV. The need for trauma-informed care/support should not be limited to WPV involving threats and/or assaults; verbal abuse can have a significant emotional impact and thus warrants support being offered. It is possible that some ED workers may not ask for support, because they believe their colleagues will not know how to provide emotional support to them. This perceived lack of effective emotional support could be mitigated through training sessions with ED workers led by forensic nurses and emergency nurses with forensic nursing training (Graham, 2017).

Forensic nurses and emergency nurses with forensic nursing training can leverage their expertise to partner with an interprofessional team of ED workers, security personnel, and risk management to design a violence prevention, management, and recovery program (Demirci & Uğurluoğlu, 2020; International Association of Forensic Nurses, 2023). This program can include training in interpersonal relations to prevent interpersonal violence, conflict resolution, and self-defense strategies (Demirci & Uğurluoğlu, 2020). Navarroli (2023) recommended that workers receive training on evidence collection and preservation, which will be particularly beneficial for documenting physical injuries due to WPV. Photos should be taken over the course of several days, because the visualization of the injury can evolve (Adams et al., 2023). The training also can include information on how to file a police report and testify in legal proceedings should victimized workers choose to press charges against the patient/visitor offenders (Navarroli, 2023; Powell et al., 2023).

There were three key limitations for this study. First, the study design was cross-sectional, which limited the ability to determine cause and effect between WPV and emotional impact. Second, the details of WPV incidents were not explored, which could have explained why some incidents of verbal abuse were rated as higher than some incidents of threats and assaults when rated by the same ED worker. Third, sexual abuse was not measured. This limited the ability to realize the full scope of potential WPV enacted by patients and visitors in ED settings.