From Situational Awareness to Structured Action: Developing a Nurse-Led Trigger-Based Pathway for Dynamic Violence...

Workplace violence remains a persistent threat in emergency departments (EDs), yet violence risk is often assessed only at triage as a single-time-point activity. In practice, risk frequently evolves during care, shaped by situational stressors and interactional dynamics. How frontline situational awareness can be translated into structured, actionable risk management within ED workflows remains insufficiently explored.

To develop and pilot a nurse-led, triage-embedded, trigger-based pathway for dynamic violence risk management in the ED.

A mixed-methods study was conducted. Quantitative data (September-October 2025) captured trigger-initiated reassessments using the Dynamic Appraisal of Situational Aggression (DASA) during routine care. Qualitative focus groups explored trigger recognition, reassessment decision-making, and feasible responses. Findings were integrated to inform pathway development and refinement, followed by a one-month pilot.

Among 8443 adult ED encounters, 172 (2.0%) involved at least one trigger-initiated reassessment. Reassessments most commonly occurred during waiting and transitional phases of care and were frequently associated with increases in DASA scores. Nearly all aggressive incidents occurred in encounters that underwent trigger-initiated reassessment rather than baseline triage assessment alone. Qualitative findings indicated that reassessment was prompted by cumulative behavioural, interactional, and contextual changes, reflecting nurses' situational awareness. Reassessment was valued for formalizing intuitive concern, supporting communication, and legitimizing proportionate early action, while feasible responses were concentrated at lower to moderate perceived risk levels.

Violence risk in the ED is dynamic and closely linked to workflow and situational context. A trigger-based pathway that operationalizes nurses' situational awareness into structured reassessment and proportionate response may support earlier, more feasible violence risk management within routine emergency care.

This study was reported in accordance with relevant reporting guidelines for mixed-methods research, including the STROBE checklist for the quantitative component and the COREQ checklist for the qualitative component.