Why do patients and visitors become aggressive in emergency departments? Often, the answer lies not in the individual but in the environment — and how staff manage the five core social triggers first identified by neuroscience.
The Information Gap
In a MORI opinion poll, patients indicated that they want to feel a close presence of clinical staff and to receive better communication. When that doesn’t happen, anxiety rises — and with it, the risk of conflict.
Information is crucial — lack of information contributes to anxiety and discomfort of patients and carers who are waiting.
Staff generally circulate well within Emergency Departments during quieter periods. But when the ED gets busy, fewer staff are visible — and fewer are available for patients and visitors to stop with questions. It is precisely at these peak times that information from staff becomes most critical.
We often notice that information screens — the queuing system in Triage, the message screens in ambulance triage, and those in Majors and Minors — sometimes display little or no useful information from the patient’s perspective. This absence increases the need for personal reassurance from a member of staff, adding pressure to an already stretched system.
The takeaway is simple: clear, timely information about what is happening with a patient’s care should always be a priority. It is one of the most effective ways to reduce hospital violence triggers before they escalate.
What Happens at the First Interaction
Our team observed an interaction at an Ambulant Triage area that illustrates the problem vividly. A woman approached the desk, speaking for her friend: “My friend has redness and swelling to her face and arms — can she see someone?”
The nurse’s response was three words: “You must register” — accompanied by a gesture pointing around the corner.
In that single exchange, the nurse:
- Had not smiled
- Had not offered any welcome or greeting
- Had not introduced herself
- Had issued a three-word command, not a request
- Had not expressed any empathy toward the afflicted person
- Gave no clarity or certainty about how things work
Clear opportunities to reduce stress — at the very first point of contact — were missed entirely. If every subsequent interaction during that patient’s journey followed the same pattern, the cumulative effect on tension levels is easy to imagine. A basic reminder of customer-service skills can go a long way toward reducing the incidence of status-induced aggression.
The SCARF Framework for Hospital Violence Reduction
Neuroscience research identifies five core social domains that, when threatened, trigger a fight-or-flight response. By addressing these proactively, staff can dramatically reduce the conditions that lead to conflict:
💡 The SCARF Model for peaceful interactions:
Status — Welcome, hospitality, respect, privacy
Certainty — Timely information and clarity about what happens next
Autonomy — Options, alternatives, and genuine choice
Relatedness — Warmth, cultural understanding, empathy
Fairness — Consistent rules, promises kept, give-and-take when necessary
Of course, these ideals are not always achievable in a pressured clinical environment. But for the majority of frustrated patients and visitors, focusing on these five domains provides a practical pathway to a more peaceful emergency department.
When staff approach each interaction with Status, Certainty, Autonomy, Relatedness, and Fairness in mind, they address the root causes of hospital violence — before it has a chance to take hold.
About the Author
Gerard O’Dea is a conflict management, personal safety, and physical interventions training consultant. He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes, and the European Adviser for ‘Verbal Defense and Influence’, a global programme addressing the spectrum of human conflict. www.dynamis.training