Violence: Recognition, Management and Prevention| Volume 64, ISSUE 2, P236-245, February 2023

Safe and Sound: An Improvisational Theater-Based Curriculum and Behavioral Intervention to Address Violence in the Emergency Department

  • Charles Sanky
    Reprint Address: Charles Sanky, Departments of Emergency Medicine and Medical Education, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029
    Departments of Emergency Medicine and Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
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Published:November 13, 2022DOI:


      Background: Emergency department (ED) workplace violence has become increasingly prevalent in the United States, warranting the development of legislation, policy, and advocacy to protect health care workers. Solutions to address ED violence remain limited, and staff-oriented trainings often exist as short, one-time didactic sessions, which are not practical nor often applicable to the ED setting. There is a paucity of evidence-based interventions that incorporate behavioral-based training to adequately prepare staff for the complicated, multifactorial presentation of violence in the ED. Objective: This pilot study sought to assess the feasibility of an improvisational theater–based, simulation intervention for health care professionals to address ED violence. Methods: A longitudinal curriculum for ED violence was developed in collaboration with a committee of emergency medicine (EM) faculty, EM simulation experts, hospital security and police personnel, professional theater and improvisational performers, resident physicians, and medical students. This pilot intervention was tailored to new EM residents (n = 25) at a large, urban, academic medical center. Sessions were led by facilitators trained in group facilitation, simulation, and improvisation. Results: Participants felt the curriculum was helpful (82.6%), engaging (91.3%), applicable (73.9%), and enjoyable (82.6%). Participation primarily by residents identifying as female and people of color suggested the efficacy of creative expression and nontraditional modalities in engaging diverse learners. Ninety-five percent of participants expressed interest in future sessions. Conclusions: A multidisciplinary workplace violence intervention leveraging principles of improvisational theater, health equity, organizational psychology, and EM simulation may prove useful in preparing health care professionals for violence in the ED.



      Emergency Department (ED), Emergency Medicine (EM)
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      1. U.S. Bureau of Labor Statistics. Fact Sheet, Workplace Violence in Healthcare, 2018. April 2020. Accessed August 2022.

        • Stephens W.
        Violence against healthcare workers: a rising epidemic.
        Am J Managed Care. 2019; (Published May 12 Accessed August 2022)
        • Schnapp BH
        • Slovis BH
        • Shah AD
        • et al.
        Workplace violence and harassment against emergency medicine residents.
        West J Emerg Med. 2016; 17: 567-573
        • Sklar DP
        • Crandall C
        • Target S.
        What do we know about emergency department safety. Agency for Healthcare Research and Quality: Mortality and Morbidity Rounds on the Web.
        August 2022. 2010; (Accessed)
        • Watson A
        • Jafari M
        • Seifi A.
        The persistent pandemic of violence against health care workers.
        Am J Manag Care. 2020; 26: e377-e379
      2. U.S. Department of Labor: Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. OSHA 3148-06R, April 2016. Accessed August 2022.

      3. The Joint Commission. Workplace Violence Prevention Standards. R3 Report, Issue 30 (1-6). June 2021. Accessed August 2022.

      4. Hartnett E, Jasani G. Emergency Medicine on the Frontline: Workplace Violence in the Healthcare Setting. 2018. Accessed July 2022.

        • American College of Emergency Physicians
        Violence in the Emergency Department: Resources for a Safer Workplace. 2022; (Updated September Accessed August 2022)
      5. Emergency Medicine Residents Association. Policy Compendium. April 2021. Accessed August 2022.

        • Emergency Medicine Residents Association
        Staying safe on the Job.
        in: Chung AS EMRA Wellness Guide. 2019 (Accessed July 2022)
        • The Joint Commission
        New Requirements for Preventing Workplace Violence.
        The Source. 2021; 19 (Accessed August 2022): 1-6
      6. U.S. Congress. H.R.1195 - Workplace Violence Prevention for Health Care and Social Service Workers Act. April 2021. Accessed August 2022.

        • Omar H
        • Yue R
        • Amen AA
        • Kowalenko T
        • Walters BL.
        Reassessment of violence against emergency physicians.
        Ann Emerg Med. 2018; 72 (Published October 2018. Accessed August 2022): S144
        • Querin LB
        • Dallaghan GB
        • Shenvi C.
        A qualitative study of resident physician and health care worker experiences of verbal and physical abuse in the emergency department.
        Ann Emerg. 2022; 79: 391-396
        • Sachdeva S
        • Jamshed N
        • Aggarwal P
        • Kashyap SR.
        Perception of workplace violence in the emergency department.
        J Emerg Trauma Shock. 2019; 12: 179-184
      7. Marketing General Incorporated. ACEP Emergency Department Violence Poll Research Results. September 2022. Accessed October 2022.

      8. U.S. Department of Labor: Bureau of Labor Statistics. The Employment Situation – July 2022. USDL-22-1585. August 2022. Accessed September 2022.

      9. Feingold JH, Peccoralo L, Chan CC, et al. Psychological impact of the COVID-19 pandemic on frontline health care workers during the pandemic surge in New York City. Chronic Stress (Thousand Oaks) 20215:2470547020977891. doi:10.1177/2470547020977891.

        • Berlanda S
        • Pedrazza M
        • Fraizzoli M
        • de Cordova F.
        Addressing risks of violence against healthcare staff in emergency departments: the effects of job satisfaction and attachment style.
        BioMed Res. 2019; 5430870
        • Speroni KG
        • Fitch T
        • Dawson E
        • Dugan L
        • Atherton M
        Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
        J Emerg Nurs. 2014; 40: 218-228
        • Weyand JS
        • Junck E
        • Kang CS
        • Heiner JD.
        Security, violent events, and anticipated surge capabilities of emergency departments in Washington state.
        West J Emerg Med. 2017; 18: 466-473
        • Cabilan CJ
        • Johnston AN.
        Identifying occupational violence patient risk factors and risk assessment tools in the emergency department: a scoping review.
        Emerg Med Australas. 2019; 31: 730-740
      10. Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985: Emergency Medical Treatment & Labor Act (EMTALA). Pub. L. No. 99–272,§ 9121, 100 Stat. 164–67 (1986) codified at 42 U.S.C.§ 1395dd.

        • Nishisaki A
        • Keren R
        • Nadkarni V.
        Does simulation improve patient safety?: self-efficacy, competence, operational performance, and patient safety.
        Anesthesiol Clin. 2007; 25: 225-236
        • Wayne DB
        • Didwania A
        • Feinglass J
        • Fudala MJ
        • Barsuk JH
        • McGaghie WC.
        Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study.
        Chest. 2008; 133: 56-61
        • Boal A.
        Theatre of the Oppressed.
        3rd edn. Pluto Press, 2000
        • Love KI.
        Using Theater of the Oppressed in nursing education: rehearsing to be change agents.
        J Learn Through Arts. 2012; 8: n1
        • Bhukhanwala F
        • Dean K.
        • et al.
        Theater of the Oppressed for Social Justice Teacher Education.
        in: Kitchen J Berry A Bullock SM International Handbook of Self-Study of Teaching and Teacher Education Practices. Springer International Handbooks of Education, 2020: 713-735
        • Cynkutis Z
        • Allain P
        • Tyabji K.
        Acting with Grotowski: Theatre as a Field for Experiencing Life.
        Routledge, 2014
      11. Common Program Requirements – Residency: Section VI. July 2017. Accreditation Council for Graduate Medical Education. Accessed August 2022.

        • Boal A.
        Games for Actors and Non-Actors.
        Routledge, London1992
        • Hogan R.
        Hogan Development Survey Manual.
        Hogan Assessment Systems, 2009
        • Connor KM
        • Davidson JR.
        Development of a New Resilience Scale: The Connor-Davidson Resilience Scale (CD-RISC).
        Depress Anxiety. 2003; 18: 76-82
        • R Core Team
        R: A Language and Environment for Statistical Computing.
        2016 (Accessed July 2022)
        • Phillips JP.
        Workplace violence against health care workers in the United States.
        N Engl J Med. 2016; 374: 1661-1669