International Emergency Nursing 54 (2021) 100942

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International Emergency Nursing

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Factors influencing violence at emergency departments: Patients’

relatives’ perspectives
Serap Bingöl a, Serpil İnce b, *
a
Akdeniz University Hospital of Emergency Department, Campus/Antalya, Turkey
b
Fundamentals of Nursing Department, Akdeniz University Nursing Faculty Antalya, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: In hospitals, the places where the highest rate of violence is perpetrated are emergency departments
Health workers (EDs). Evaluating patient relatives’ perceptions of violence and obtaining their views about how to prevent
Nurse violence incidents are important in terms of uncovering the factors that increase violent behaviors. This study
Emergency department
was aimed at determining the factors increasing violence in the emergency department (ED) from the per­
Violence
Patient relatives
spectives of patient relatives.
Methods: The sample of this study consisted of 520 individuals who brought a relative to the Adult ED of Akdeniz
University Hospital in Turkey between April 2017 and June 2017. Data was collected using a two-part ques­
tionnaire prepared by the researcher. The first part consists of 15 items questioning the demographic charac­
teristics of the participants. The second part consists of 20 statements asked the participants to rate the reasons
urged patients or their relatives to perpetrate violence in the emergency department. Numbers and percentage
calculations were used to evaluate the data.
Results: Of the participants, 55.6% were men and 54.7% were married. According to the participants’ statements,
of the relatives of the 520 patients, 141 (27.1%) witnessed verbal violence against emergency department staff,
76 (14.6%) witnessed physical violence against emergency department staff, 9 (1.7%) witnessed verbal threat
against emergency department staff, especially against nurses. According to the participants, the primary factor
causing people to perpetrate violence at EDs was that patients or their relatives were not adequately informed
about the patient’s condition. More than 40% of patients’ relatives said that anxiety and nervousness arising from
being a patient’s relative, and stress and sadness they suffered were among the leading factors causing people to
perpetrate violent incidents.
Conclusion: In order to prevent and decrease incidents of violence in the emergency departments, healthcare
systems should be reviewed and revised. Our study revealed that informing patients and their relatives about the
patient’s condition and empathic approaches displayed by healthcare employees towards patients reduced the
number of incidents of violence. Unlike other studies, this study addresses the negative experiences of patients’
relatives in the emergency department and the factors influencing these experiences. Obtaining the opinions of
the patients’ relatives about possible solutions to the violent events in the ED makes this study unique.

1. Introduction [4–6]. Workplace violence is defined as any act or threat of physical

The increasing violence in workplaces in recent years has been an
important health issue all over the world [1,2]. Abuses, assaults, and
threats that put the health and safety of managers, coworkers, and
customers at risk during work activities are identified as “workplace
violence” [3]. Violence in healthcare settings is defined as verbal or
behavioral threat, and physical or sexual assault between health workers
and their coworkers, patients or patients’ relatives, or third parties
violence, harassment, intimidation, or other threatening and disruptive
behavior in the workplace [7]. The emergency department (ED) is one of
the high-risk areas in a hospital for workplace violence [8]. These as­
saults most frequently occur in EDs, where health professionals already
suffer high levels of stress due to having patients that need immediate
treatment or face high risk of death or have injuries, psychiatric ill­
nesses, and drug and alcohol addictions for which they seek medical
treatment [1,4,9–13]. Therefore, emergency department staff are at

* Corresponding author: Dumlupınar Boulevard, Akdeniz University Campus Konyaalti/Antalya, Turkey.

E-mail address: serpildogan@akdeniz.edu.tr (S. İnce).

https://doi.org/10.1016/j.ienj.2020.100942
Received 2 November 2019; Received in revised form 28 September 2020; Accepted 21 October 2020
Available online 8 December 2020
1755-599X/© 2020 Elsevier Ltd. All rights reserved.
S. Bingöl and S. İnce
great risk due to the fact that they care for acutely ill and injured patients
with a broad spectrum of medical conditions, social issues, and psy­
chiatric diseases that may cause these individuals to become unpre­
dictably aggressive or violent during their stay at the ED [14].
Shortcomings in the physical environment, resources and structural re­
quirements [11], and long waiting times for health care service or pa­
tient discharge are among the factors urging people to perpetrate
violence in emergency departments. Given these circumstances, emer­
gency departments are stressful environments not only for patients and
their relatives but also for those working there. In the emergency room,
anxious patients and their relatives may perceive prolongation of
treatment due to examinations and consultations as late intervention.
Studies report that long waiting times are an important factor which
makes patients’ relatives impatient, anxious and aggressive
[3,10,15,16]. In addition, patients’ relatives may perceive the causes of
deaths in emergency departments as inadequacy of treatment. Holding
healthcare professionals responsible for this situation may increase the
tendency of relatives to become violent. Conditions they work in,
overtime schedules and work overloads of healthcare professionals in
emergency services are another factor that increases stress. Intense shifts
consume the healthcare workers’ energy and reduce their ability to
empathize. Health workers expect to be understood by people they
provide care [17]. In addition, personnel shortage and coordination
problems between different occupational groups (medical team, nursing
team, medical secretaries, security, cleaning and administrative staff,
etc.) are among the causes of violence incidents since these factors
interfere with the fulfillment of responsibilities toward patients and
their relatives [10].
Violence in the workplace affects health workers’ morale negatively,
causes loss of labor, dissatisfaction, and burnout, reduces productivity
by reducing job satisfaction, and adversely affects safe and competent
caregiving [15,18]. It is imperative for health personnel to work will­
ingly, effectively, and efficiently to increase the quality of services
provided in health institutions, and to achieve their goals [6]. Incidents
of violence and aggression result in negative situations such as tempo­
rary or permanent physical disability, death, psychological disorders,
loss of trust in management or staff, and financial damage [9]. These
consequences caused by violence lead to a decrease in the quality of the
service provided and large financial losses in the health sector, and risk
the health care provided [6,15,19].
It is emphasized that development and implementation of efficient
policies against violence, availability of administrative support, training
of health workers and related individuals [20], and adoption of legal
policies [21] are effective strategies to prevent violence. Providing
efficient information for patients and their relatives waiting in emer­
gency departments to get health care service assures patients, reduces
stress and anxiety, increases satisfaction, and lays the groundwork for
the interaction between the health worker and patient, and provision of
effective health care [22]. Several studies in the literature have inves­
tigated the violence that health care workers suffer [3,9,11,13]. In
research on the prevention of violence, it is stated that the risk of
violence may be reduced by effective health institution management,
and effective violence prevention measures, and by training health
personnel to raise their awareness of risky situations and how to cope
with such situations [15,23]. Current studies focus on the reasons that
drive people to perpetrate violence, determination of risk groups, and
suggestions on the prevention of violence. Studies on violence against
health workers are generally based on the opinions of healthcare pro­
fessionals. Only in a limited number of studies, the violence-related
opinions of patients’ relatives who come into emergency departments
to receive health services for their patients have been investigated. The
findings of the present study are important in terms of evaluating the
viewpoints of the society about violence incidents and revealing the
factors that increase tendencies that cause violence. Allowing patient
relatives, who take the first place in perpetrating violence, to express
their expectations, and taking into account the reasons and suggestions
2
International Emergency Nursing 54 (2021) 100942
for the prevention of violence from their point of view are expected to
make a significant contribution to the development of more effective
programs aimed at preventing violence, and to trainings aimed at raising
awareness of staff, patients and patient relatives.
2. Aim
The aim of the authors of this study is to determine the factors
increasing violence in the emergency departments from the perspectives
of patient relatives.
3. Research questions
1. What are the causes of violence in the ED according to patients’
relatives?
2. What are the factors that increase violence in EDs?
4. Method
4.1. Study design
In this the cross-sectional study, descriptive survey methodology was
used to investigate patient relatives’ immediate experiences of violence,
reasons that drive people to perpetrate violence and recommendations
for the prevention of violence.
4.2. Study sampling
The sample of this study consisted of 520 individuals who brought a
relative to the Adult ED of Akdeniz University Hospital between April
2017 and June 2017 and agreed to participate in the study.
Patient relatives who were at least 18 years old and were in the ED
waiting room during the aforementioned dates were asked whether they
would volunteer to participate in the study. The number of patient rel­
atives contacted between the aforementioned dates was 585, 40 of
whom did not agree to participate. Of the 545 questionnaires, 25 were
excluded because they were filled incorrectly or incompletely. The
response rate to the survey was 88.8%.
4.3. Study setting
Akdeniz University Hospital is the only university hospital in Ant­
alya, a province located on the Mediterranean coast of south-west
Turkey. Approximately 300 patients present to the adult emergency
unit daily. The number of patients served annually is 100,000–110,000.
The adult ED has a triage, green-yellow and red areas. It also has special
rooms such as resuscitation room, intervention room, gynecology room,
etc. Triage is a medical process in which patients are assessed and sorted
out depending on their need for immediate medical treatment.
The green-yellow area is where patients are treated as outpatient,
prescribed medicine and discharged. In the red area, patients are
observed using a monitor. The unit has 41 stretchers in total; 13 in the
red area, two in the resuscitation room, three in the intervention room,
one in the gynecology room, three in the special room and 19 in the
green-yellow area.
In the different departments of the adult emergency unit, 30 regis­
tered nurses work in two shifts. From 8:00 a.m. to 8:00p.m., eight nurses
work in the department: two in the triage area, three in the green-yellow
area, and three in the red area. From 8:00p.m. to 8:00 a.m., five nurses
work in the department: one in triage, two in the green-yellow area, and
two in the red area. The number of patients to whom a nurse gives daily
care varies from department to department (yellow, red, or green area)
they work in.
S. Bingöl and S. İnce International Emergency Nursing 54 (2021) 100942

4.4. Data collection
Data were collected by one of the researchers (SB). After the par­
ticipants were informed about the aim of the authors of the study,
informed consent was obtained from them. Of the patient relatives,
those that agreed to participate in the study completed the paper-based
survey questionnaire while their patients received treatment. It took
about each participant 20 min to fill in the questionnaire.
relating to the causes of violence perpetrated in the emergency room.
The items marked positively as “Effective” and “Very Effective” were
considered as “Yes”, and the items marked negatively as “Very Ineffec­
tive” and “Ineffective” were considered as “No”.
5. Results
5.1. Demographic characteristics of the patient relatives

4.5. Data collection tools
The data was collected using a two-part questionnaire prepared by
the researcher based on the pertinent literature. The questionnaire was
reviewed by three experts (an emergency doctor, an emergency nurse
and an expert researcher who had a PhD). These experts were chosen
because they were experienced in emergency medicine. The data
collection form was finalized after it was revised in line with suggestions
made by the three experts. Then, after the questionnaire was pilot tested
with 10 relatives to find out whether the statements were clear and easy
to understand, it was administered to the other participants.
In addition to the questions about the participants’ demographic
characteristics (sex, marital status, employment status, education level,
the degree of kinship), the first part of the questionnaire had eight open-
ended questions asked to determine the violence incidents patients’
relatives experienced. Questions were asked to determine what the
causes of violence incidents in the ED were, and how the participants
reacted if their rights were violated. Closed questions (yes/no) were
asked about whether participants perpetrated or witnessed verbal or
physical violence against healthcare professionals and whether their
patients were subjected to verbal or physical violence. The relatives of
the patients who responded as yes to these questions were asked to state
who perpetrated violence incidents and why he or she perpetrated them.
In the second part, in line with the pertinent literature, there are 20
statements regarding the reasons for violence the patient or the patients’
relatives perpetrated in emergency departments. The patients’ relatives
were asked to state the extent to which these statements were effective
(“Very Ineffective”, “Ineffective”, “Neutral”, “Effective” and “Very
Effective”) in terms of violence in the emergency room. In addition, an
open-ended question was asked to determine suggestions made by the
participants for the prevention of violence in the emergency
departments.
4.6. Ethical considerations
Demographic characteristics of patients’ relatives are given in
Table 1. The mean age of the participants was 32.83 ± 0.495 years. Of
them, 55.6% were men, 54.7% were married, 33.9% were high school
graduates, 31.6% had a bachelor’s degree, 25.2% were laborers and
28.8% stated that the person they brought to the emergency department
was their spouses.
5.2. Violence-related experiences of the patient relatives
According to our findings about previous incidents of violence, 7.7%
(n = 40) of the patients’ relatives were involved in verbal argument, and
1.3% (n = 7) were involved in physical violence. Of those who were
involved in verbal argument, 37.5% (40:15, n = 15) had a conflict with
the ED staff, and 57.1% (7:4, n = 4) with the security staff. Of them,
27.1% (520:141, n = 141) had witnessed verbal violence against ED
staff, 14.6% (520:76, n = 76) had witnessed physical violence against
ED staff; 11.3% (141:59, n = 59) had witnessed verbal abuse nurses
were exposed to, and 40.8% (76:31, n = 31) had witnessed physical
violence against physicians. Of the relatives, 2.9% stated that they or
their patients were exposed to verbal abuse or threat previously and
40.0% of such incidents were committed by the ED staff. Of the patient
relatives, 9 (1.7%) witnessed verbal threat against emergency depart­
ment staff, especially against nurses previously, 6 (1.2%) stated that
they or their patients were previously exposed to physical violence, and
4 (0.8%) witnessed attempts of physical violence against ED staff pre­
viously (Table 2).
Responses given to the question “Who do you think violence or at­
tacks in the emergency department mostly are perpetrated by?” revealed
that they were perpetrated by patients (520:25, 4.8%), patients’
Table 1
Demographic characteristics of the patient relatives (n = 520).
n %

Sex
The study was conducted in accordance with the Declaration of Female 231 44.4
Helsinki. Ethics committee approval was obtained from the Akdeniz Male 289 55.6
University’s Clinical Research Ethics Committee (decision date: March Marital Status
Married 285 54.7
22, 2017, decision no: 176). In addition, permission was obtained from Single 236 45.3
the institution where the study was to be conducted (dated April 12, Educational Status
2017, numbered 26708535-010.99-E.49453). Written informed consent Elementary School 73 14.1
was obtained from all the participants. High School 176 33.9
Associate Degree 77 14.8
Bachelor’s Degree 164 31.6
4.7. Statistical analysis Master’s Degree 29 5.6
Employment status
Data obtained from the questionnaire was analyzed with the SPSS Student 109 21.0
23.0 using number and percentage calculations. The data was entered Housewife 49 9.4
Unemployed 18 3.5
into the SPSS by the first researcher. The second researcher verified the Labourer 131 25.2
correctness of the data entered into the SPSS by comparing it with the Civil Servant 79 15.2
data in the questionnaires. Retiree 29 5.6
The responses given to the yes/no questions and to the open-ended Self-employed 104 20.0
Kinship with Patient
question “who perpetrated violence” in the first section were pre­
Spouse 117 22.5
sented as numbers and percentage values. The participants’ responses Parent 24 4.6
related to the causes of violence and their suggestions on the prevention Sibling 62 11.9
of violence were categorized and presented by the researchers. Child 150 28.8
Percentage and frequency distributions were used to analyze the Friend 120 23.0
Relative 48 9.2
responses given to the questions in the second part of the questionnaire

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S. Bingöl and S. İnce International Emergency Nursing 54 (2021) 100942

Table 2
Experiences of patient relatives on violence.
Type of Violence Encountered Patient
Relatives Doctor Nurse Staff Security Secretary Patient Unknown
Who Relative Person
Previously
Experienced
Violence
n % n % n % n % n % n % n % n %
**
Verbal violence in emergency department 40 7.7 11 27.5 10 25.0 15 37.5 10 25.0 7 17.5 – – 5 12.5
Physical violence in emergency department 7 1.3 1 14.3 3 42.9 2 28.6 4 57.1 – – – – 1 14.3
Witnessing verbal violence incidents against emergency 141 27.1 43 30.5 59 11.3 30 21.3 36 25.5 21 14.9 9 6.4 31 22.0
department staff
Witnessing physical violence incidents against emergency 76 14.6 31 40.8 28 36.8 13 17.1 22 28.9 6 7.9 2 2.6 16 21.1
department staff
Experiencing verbal abuse/threat towards themselves or 15 2.9 4 26.7 4 26.7 6 40.0 2 13.3 – – – – 4 26.7
their patient
Using verbal violence against emergency department staff 9 1.7 2 22.2 3 33.3 2 22.2 1 11.1 2 22.2 – – 2 22.2
Experiencing physical violence towards themselves or their 6 1.2 1 16.7 – – 2 33.3 2 33.3 – – – – 1 16.7
patient
Using physical violence against emergency department staff 4 0.8 1 25.0 – – 1 25.0 – – – – – – 2 50.0

*Those who answered “yes” to the type of violence experienced by patients’ relatives have marked more than one option while reporting who / with whom they
experienced the violence.
**
Percentages were taken from the relatives of the patients who marked the experience of violence as “yes”.

relatives (520:442, 85.0%), health care personnel other than physicians
and nurses (520:72, 13.8%), physicians (520:9, 1.7%), security staff
(520:12, 2.3%), secretaries (520:4, 0.8%), and nurses (520:5, 1.0%).
When asked “How do you react when you think you or your patient
has been treated unfairly by the health care staff in an emergency
room?”, the responses given by the patients’ relatives were as follows: “I
get into verbal arguments” (520:157, 30.2%), “I get into physical ar­
guments” (520:22, 4.2%), “I complain to the hospital management”
(520:359, 69.0%), “I try solving the problem by talking first” (520:26,
5.0%), “I do nothing” (520:7, 1.3%), and “I warn them” (520:23, 4.4%).
When the relatives of the patients were asked about violence they
were involved in or they witnessed in the emergency department, they
stated who they had argument with, but half of them did not mention
what the reason was.
According to the statements of the participants (n = 40) who had a
verbal argument in the emergency room, the reasons were as follows:
being neglected, being scolded, being exposed to disrespectful or rude
behaviors, long waiting times, incompetence of the medical personnel,
wrong intervention, and not being given adequate information about the
patient’s condition. Only three out of seven participants who got into
physical argument stated the reason why they did. The reasons they
stated were as follows: suffering swelling in the arm after the vascular
access was established, health care personnel’s mistaking them for
another patient’s relatives, and health care personnel’s not giving pri­
ority to their patient although he or she is prioritized.
The patients’ relatives (n = 141) who witnessed emergency room
workers’ being exposed to verbal threats stated that they witnessed
people raising their voice or shouting at them. They stated that this was
due to being neglected, long waiting times, not being given adequate
information about the patient’s condition and displaying mutual disre­
spectful behaviors.
5.3. Factors that affect violence in emergency departments
According to the patients’ relatives, the key causes of violence at EDs
were not giving adequate information about the patient’s condition to
patients or their relatives at emergency departments (77.7%), negative
attitudes of health workers (69.4%), responses given by health workers
in a loud voice (66.4%), attitudes of doctors, nurses, secretaries, staff, or
security (72.7%), health workers’ lack of empathy (71.2%), and over­
crowding of the ED (78.2%) (Table 3).
When the patients’ relatives were asked to state their opinions about
possible reasons for violence perpetrated by them or their patients at
EDs, more than 75% of them stated that anxiety and nervousness

Table 3
Influencing factors that affect violence at emergency departments according to patient relatives.
Very Ineffective Neutral Effective Very
Ineffective Effective

n % n % n % n % n %

Insufficient informing of patients/relatives of patients at emergency department 23 4.4 42 8.1 51 9.8 180 34.6 224 43.1
Lack of empathy at health workers 33 6.3 59 11.3 57 11.0 160 30.8 210 40.4
Apathy at health workers 49 9.4 59 11.3 67 12.9 161 31.0 183 35.2
Loud responses of health workers 56 10.8 51 9.8 67 12.9 132 25.4 213 41.0
Negative attitudes of health workers 58 11.2 44 8.5 56 10.8 150 28.8 211 40.6
Attitude of doctor, nurse, secretary, staff or security 42 8.1 36 6.9 64 12.3 168 32.3 210 40.4
Insecurity towards medical treatment 74 14.2 66 12.7 102 19.6 143 27.5 135 26.0
Dissatisfaction towards medical treatment 58 11.2 64 12.3 87 16.7 178 34.2 133 25.6
Crowdedness of emergency department 32 6.2 38 7.3 43 8.3 202 38.8 205 39.4
Doctor’s wrong diagnosis 83 16.0 74 14.2 132 25.4 87 16.7 144 27.7
Professional inexpertness of health workers 85 16.3 77 14.8 105 20.2 114 21.9 139 26.7
Appearance of health workers 242 46.5 124 23.8 53 10.2 58 11.2 43 8.3
Lack of explanations to patients about waiting reasons at primary assessment area in emergency 55 10.6 5 10.6 67 12.9 170 32.7 173 33.3
department
Not allowing relatives of patients to see their patients after first response 56 10.8 85 16.3 91 17.5 177 34.0 111 21.3
Lack of appropriate communication between patient/relatives of patient and health staff 38 7.3 39 7.5 69 13.3 174 33.5 200 38.5

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S. Bingöl and S. İnce International Emergency Nursing 54 (2021) 100942

resulting from being a patient’s relative, and stress and sadness they
suffered provoked violence. The top three factors specified as strongly
provocative among the reasons for violence at emergency departments
related to patients and their relatives were long waiting times (82.2%),
sadness and nervousness suffered by the patients and their relatives
(79.6%), and patients’ and the relatives’ opinions that their priority for
medical treatment was violated (70.4%). Patients’ and their relatives’
lack of knowledge about the functioning of emergency health services
(triage) (67.1%) also provoked the occurrence of violence (Table 4).
5.4. Recommendations of patient relatives on violence prevention in
emergency departments
In this study, the relatives of the patients were asked to state sug­
gestions on how to prevent violence in the emergency departments, 480
participants made recommendations. The patient relatives emphasized
the importance of healthcare professionals’ having appropriate
communication skills, paying attention to how to approach patients and
their relatives, and receiving training in communication. Some state­
ments of the patient relatives regarding these recommendations are
given below:
“All healthcare professionals should understand the situation (mood) of
patients and their relatives by empathizing and perform their tasks with an
approach that values people. There are problems caused by patient rela­
tives. The solution is education and tolerance. People should be made
aware of this issue”.
“Patients and their relatives should be informed about the examinations
and results of examinations in such a way that they can understand them.
Patients should be given the feeling that they are being taken care of
(treated) appropriately. Healthcare professionals should communicate
with patients and their relatives more carefully and they should be trained
about communication methods”.
The patient relatives’ recommendations regarding health institutions
were as follows: Physical conditions of emergency departments should
be improved. The number of healthcare professionals working in EDs
should be increased. Their working conditions should be rearranged.
Security personnel should be trained on how to treat patients and their
relatives.
“Working hours, shifts and rest periods of healthcare professionals should
be arranged”.
“The physical environment of the emergency departments can be arranged
to separate physicians, nurses or other personnel from patient relatives in
such a way to prevent them from being attacked. If the ED had waiting
rooms with a comfortable, spacious and calming effect, and if bulletin
boards to provide information about the patient regularly are installed,
then the tension of the relatives of the patients can be reduced. Keeping the
contact of the healthcare personnel with patient relatives at a minimum
level and informing them about the patient’s condition could be a solution.
I think that architectural solutions together with security measures will be
beneficial”.
The patient relatives stated that it is important to raise public
awareness about the emergency department. Some recommendations of
the patient relatives regarding on this issue are given below:
“The value of healthcare professionals in the society is eroding. I think the
visual media add fuel to the fire. The low education level of the public also
increases these problems”.
“News programs constantly include violence news. However, if the
recovered patients visited their physicians to thank them and if such news
were given in news programs, this might have an impact on the society.“
“If it were easier to make an appointment with outpatient clinics, the
crowding of these clinics would be reduced, and thus public’s perception
that they could find solution to their health problems more easily and
faster in emergency departments would be changed. I think this might
partly reduce the overcrowding of EDs”.
In the present study, the patient relatives were aware of the causes of
the violent incidents occurring in emergency departments. Taking into
account the suggestions of individuals who receive healthcare services
will be an effective strategy in preventing violence.
6. Discussion
Although there has been an increase in violence perpetrated in health
settings in our country, Turkey, and in the other countries of the world in
recent years, emergency departments take the lead among these settings
where incidents of violence occur. It has been reported that healthcare
professionals are mostly exposed to violence perpetrated by patient
relatives, and that the type of violence they are frequently exposed to is
verbal violence [24].
In the present study, it was observed that the rate of witnessing the
emergency room workers being under verbal or physical threat by the
patient relatives was significantly higher than the rate of their
committing verbal or physical threats to the emergency department
workers. In their study, Özdemir et al. [25] reported that the reason
behind the responses given to the question “Have you ever perpetrated
violence against a healthcare professional?” might be similar to that
behind those given to the question “Have you ever witnessed violence
perpetrated against a healthcare professional?” It should be kept in mind
that the patient relatives participating in the study may have been
hesitant to answer this question or perhaps they may have tried to hide
the incident they experienced. In the light of this fact, the low rate of
relatives who had previously had a verbal argument with a healthcare
professional can be interpreted as an expected result. In this case, that
the frequency of violence witnessed by the patient relatives was higher
supports this opinion. Likewise, the ratio of perpetrating physical

Table 4
Reasons of violence at emergency department arising from patient/patient’s relatives
Violence Reasons Arising From Patient/Patient’s Relatives Very Ineffective Neutral Effective Very
Ineffective Effective

n % n % n % n % n %

Anxiety arising from being a patient’s relative 56 10.8 24 4.6 45 8.7 174 33.5 221 42.5
Nervousness arising from being a patient’s relative 51 9.8 31 6.0 31 6.0 183 35.2 224 43.1
Sadness and nervousness of patient/patient’s relatives 36 6.9 33 6.3 37 7.1 155 29.8 259 49.8
Educational status of patient/patient’s relatives 58 11.2 60 11.5 55 10.6 129 24.8 218 41.9
Opinions of patient/patient’s relatives about their priority for medical treatment 49 9.4 58 11.2 47 9.0 133 25.6 233 44.8
Long waiting times for patient/patient’s relatives at emergency department 23 4.4 26 5.0 44 8.5 149 28.7 278 53.5
Opinions of patient/patient’s relatives about the apathy towards themselves at emergency department 42 8.1 38 7.3 57 11.0 178 34.2 205 39.4
Precipitousness of patient/patient’s relatives at emergency department 57 11.0 69 13.3 64 12.3 160 30.8 170 32.7
Lack of knowledge of patient/patient’s relatives about emergency health services (Triage) 37 7.1 52 10.0 77 14.8 132 25.4 222 42.7
Psychological problems of individuals who seek treatment at emergency department 67 12.9 65 12.5 122 23.5 131 25.2 135 26.0
Attitudes of patient/patient’s relatives who have alcohol or substance addiction 47 9.0 35 6.7 104 20.0 121 23.3 213 41.0

5
S. Bingöl and S. İnce
violence (0.8%) to witnessing physical violence (14.6%) can be inter­
preted similarly.
The World Health Organization (WHO) states that the healthcare
workers who are most at risk in terms of being exposed to violence are
nurses, emergency department personnel and coworkers of healthcare
professionals. In emergency departments, nurses in particular are health
workers in the high risk group who are subjected to physical and verbal
assault by patients and their relatives [2,6,8,13,16,26]. According to the
analysis of the findings of the present study about the violence experi­
ences of the patient relatives, they witnessed that among the emergency
department workers, those who were exposed to both verbal and
physical threat most were nurses. In their study, Walters et al. [27] re­
ported that nurses working in the emergency department in Minnesota
were exposed to physical attacks 4 times more than did nurses working
in other departments of the hospital. As was reported in a study con­
ducted in Australia, 70 percent of nurses working in the emergency
department were exposed to violence in the previous five months [28].
In a qualitative study, emergency department personnel stated that they
resigned themselves to the inevitability of violence and aggression
because of the high frequency of violent incidents and the lack of
perceived organizational preventive measures and consequences [24].
Among the leading factors that increase the frequency of violent
incidents in emergency departments are dissatisfaction with the
healthcare service and the perception of neglect due to the inadequacy
of information provided to the patients and their relatives [29,30]. In
our study, according to the patients and their relatives, the leading cause
of the violence taking place in the emergency department was the fact
that they were not adequately informed about the condition of the pa­
tient, which was consistent with findings in the literature [25,31,32].
Angland et al. [29] demonstrated that giving patients and their relatives
a brochure or information guide explaining why patients have to wait in
emergency departments can help them be more understanding.
In a qualitative study conducted to determine nurses’ perceptions of
the factors that cause violence and aggression in emergency de­
partments, the participating nurses stated that long waiting times, lack
of communication and triage were the leading factors [29]. In that
study, it was recommended that electronic cards indicating approximate
waiting times could be useful in eliminating the aggression that might
arise from long waiting times. It is stated that an information booklet
that describes the working system and geography of an ED can improve
patients’ understanding of why they have to wait [33].
It is very natural that the patient relatives who wait without knowing
the condition of their patient are tense and stressed. The patient rela­
tives’ stating that stressful and tense waiting was the leading cause of
violence perpetrated by them shows that both data support each other.
In a study conducted by Corbett et al. [22], it was determined that
showing an educational videotape to patients and their relatives in the
waiting room of the emergency department decreased their anxiety
levels. Furthermore, it is thought that if more emphasis is laid on the
satisfaction of patient relatives regarding the healthcare service offered,
the violence against health workers will be significantly reduced.
In particular, patient relatives’ demanding that they should be given
healthcare as soon as possible is leading cause of most of the incidents of
violence. In a study conducted to determine the Irish nurses perceptions
of the factors that cause violence and aggression in the emergency
department, the nurses stated that the patients’ and their relatives’
being impatient, and desiring for individualized urgent attention was
the driving factor for their aggression [29].
In our study, the patients’ relatives stated that the excessive number
of patients admitted to the emergency departments adversely affected
patients and their relatives. These findings suggest that the public is not
adequately knowledgeable about the triage system. The patient relatives
stated that the public’s lack of knowledge about the provision of health
services was a very effective factor leading to the occurrence of incidents
of violence, which supported this idea. If violence in healthcare settings
is to be prevented, it is necessary to inform the public about the
6
International Emergency Nursing 54 (2021) 100942
functioning of emergency health services, and to tell them that the
emergency service is not the only place for the solution of health
problems. It is also necessary to ensure the creation and functioning of a
multi-level health system in which health problems can be solved more
appropriately. At this point, raising public’s awareness of violence
against health professionals, making such violence visible and drawing
the public’s attention to it are among the most important and funda­
mental initiatives in combating violence. It is obvious that the print and
visual media should include not only negative aspects of emergency
departments but also news supporting health services given in emer­
gency departments and health professionals working there.
In our study, among the factors stated to lead to violence in emer­
gency departments by the patient relatives, the leading one is the poor
communication between healthcare professionals and patients / patient
relatives. In a study on the views of patients and staff involved in cases of
aggression in psychiatry clinics, whose findings are consistent with those
of our study, patients stated that interpersonal conflicts were an effec­
tive factor triggering aggressive behaviors. In those studies, patients
recommended that interpersonal conflicts should be settled, patients
should be listened to and allowed to express themselves more, and they
should be helped for their needs [31]. It is stated that strategies for
effective management of workplace violence (WPV) should give priority
to training courses focusing on the improvement of the healthcare
worker-patient relationship, employees’ communication skills, the
working atmosphere with the participation of employees. A WPV pre­
vention program and attitudes of healthcare professionals in assessing
and managing WPV have been determinant in minimizing risk [34].
Wong et al. [35] demonstrated the effectiveness of healthcare pro­
fessionals’ behavioral attitudes towards patients presenting to the
emergency department through a better understanding of the factors
contributing to patient aggression.
All healthcare professionals should also be trained that they should
behave carefully towards their colleagues in case WPV occurs. Health
workers who are assaulted are often exposed to feelings of fear, anger,
guilt and helplessness. These feelings experienced by healthcare pro­
fessionals can reduce their ability to empathize [34]. Therefore, lack of
empathy can prevent healthcare professionals from establishing a
healthy and appropriate communication with patients and their rela­
tives, which increases the stress suffered by the patient / patient rela­
tives due to the tension and anxiety caused by being a relative, and thus
causes violence.
Healthy communication is a very important element in both in­
dividuals’ sharing their own situation with others and perceiving what is
said by others. Individuals unable to communicate appropriately and
express themselves cannot express what their health service demands
are and therefore they cannot be understood by healthcare workers well,
which leads to problems arising from the lack of communication, one of
the important causes of violence [20]. Healthcare professionals believe
that inappropriate communication is among the main causes of violence
as do patient relatives [29]. Researchers stated that the violent incidents
especially occurred when the relatives of the patients could not get in­
formation from or communicate with a healthcare professional during
the treatment of their patients. In a study conducted to investigate pa­
tient rights boards’ view regarding communication problem-related
applications, Uludağ [5] revealed that given the contents of the com­
plaints made by the patients, the problem with the highest rate (40.4%)
was poor communication. In addition, the noteworthy suggestion made
by the patient / patient relatives was that a communication officer
should be included in the emergency department staff. Meek and Tor­
sello [36] reported that the presence of a communication officer in the
emergency department improves communication between healthcare
personnel and patients / their relatives, and the perception of care given
to them. It is stated that focusing on patient-centered care and
communication skills in communication workshops and trainings given
to healthcare staff on the management of aggression may be beneficial
[32].
S. Bingöl and S. İnce
Patients’ relatives stated that the attitude of patients with alcohol or
substance dependence or mental problems who visited the emergency
department with their relatives could be a provocative factor in the
violence that occurred but they were not sure how prevelant these sit­
uations might be. The literature reports that alcohol and substance
dependence are strongly associated with abusive and violent behaviors
[28,37].
In the literature, the importance of limiting the patient relatives’
access to the treatment area by security guards is emphasized. The
possibility of patients’ and visitors’ accessing the patient treatment area
is perceived by ED workers as a threat to their safety [29,38,39]. Gil­
lepsie et al. [39] demonstrated that emergency nurses felt unsafe and
thought there was a high risk of physical attack when access was not
controlled and patients and visitors could freely enter the treatment
area. In our study, the patients’ relatives emphasized the necessity of
having security guards in the ED and recommended that the number of
security guards should be increased. On the other hand, their stating that
security guards’ lack of communication was an important cause and
source of violence in the ED was noteworthy. It was an important finding
that security guards whose task was to prevent a violent incident were
also a source of violence. Therefore, training of not only healthcare
workers but also security guards whom patients and their relatives first
meet when they present to the emergency room on establishing healthy
communication plays a key role in the prevention of violence in the ED.
Health institutions where a great number of employees work are one
of the work places where violence is most common. Causes of violence
perpetrated against emergency service workers are as follows: providing
24-hour uninterrupted healthcare service, the presence of stressed pa­
tients and their relatives, patients’ waiting for a long time and not
benefitting from care services sufficiently, work overload, shortage of
personnel, working in an overcrowded environment, inadequate
training in dealing with violence and insufficient number of security
personnel [4,40]. Among the important factors that increase violence
against healthcare workers are that current laws on the prevention of
violence against healthcare workers are not deterrent enough, that the
current healthcare system cannot meet the expectations of the society,
and that health policies aimed at preventing and managing violence are
insufficient [3,11,41].
6.1. Limitations and future research
The results of this study include analysis of the causes of violence
from the perspectives of patient relatives. Obtaining their recommen­
dations on violence/aggression incidents perpetrated by patient rela­
tives in written increased the strength of the study. On the other hand, a
significant limitation of the research may be the bias the patients’ rel­
atives had about violence when the questionnaire was completed. In the
study, these relatives described situations of verbal or physical violence
they experienced or witnessed. Therefore, the fact that negative
thoughts about the healthcare workers expressed by the patients’ rela­
tives who had previous negative experiences in the ED may have caused
a biased response. Another important limitation of this research is that
the number of the relatives who stated the causes of the violent incidents
they experienced or witnessed was limited. It is considered that there is a
need for future studies which the opinions and solution suggestions of
both patients’ relatives and ED staff regarding violence in EDs are
investigated.
7. Conclusion
The present study conducted to determine the causes of violence in
an emergency department and the influencing factors from the
perspective of the patient relatives revealed that the patient relatives
were aware of violent incidents occurring in emergency departments.
The relatives of the patients made applicable recommendations for the
prevention of such incidents.
7
International Emergency Nursing 54 (2021) 100942
According to the patients’ relatives in the present study, their being
informed about their patient’s condition inadequately was the main
reason for the violence experienced in emergency departments. In
particular, the fact that relatives want their patients to be taken care of
as soon as possible is another reason for violent events. The participants
stated that the overcrowding of the emergency departments had a
negative effect on the patients and their relatives. In addition, the pa­
tients and their relatives recommended that a communication officer
should be appointed to the emergency department. On the other hand
while the participants stated the need for security officers in the ED.
They criticized them for provoking violence in the ED.
Most of the studies conducted on the issue in the literature were
aimed at determining the views of healthcare professionals on violence.
What makes the present study different from studies in the literature is
that in the present study, violent incidents occurring in emergency de­
partments were investigated from the perspective of the relatives of the
patients, and that it included some statements reflecting their opinions
of violent incidents and solution-oriented approaches.
Ethical statement
Not applicable.
Funding
No.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgment
Thanks to all of patient relatives who participated in the study. We
would like to thank the experts who reviewed the questionnaire form
used in the study and gave expert opinions. Thank to very much to
presenting her views while creating the study design, Prof. Dr. Sebahat
Gözüm, Prof. Dr. Selma Öncel and Assoc. Prof. Gülten Sucu Dağ.
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