{
  "abstract": "Background\n\nWorkplace violence and aggression are escalating in emergency departments (EDs) globally, yet the self-reported psychological and behavioural responses in clinicians to such stressors remain underexplored. Trauma theory conceptualises stress responses as fight, flight, freeze, and fawn (4Fs); but how these responses manifest in ED staff before, during and after violent incidents has received limited empirical attention.Methods\n\nThis mixed-methods study analysed data collected between 2019 and 2023 across four emergency departments within one Australian local health district. Data sources included semi-structured interviews (2019; n = 20), focus groups (2021; n = 30 participants), a cross-sectional survey (2023; n = 61), and follow-up interviews (2023; n = 12). Qualitative data were analysed using Braun and Clarke's six-phase thematic analysis, applying a deductive framework informed by the 4Fs. Quantitative survey data were integrated to examine the distribution of stress responses across reported incidents.Results\n\nAcross all data sources, 123 ED staff described 145 coded instances of the 4F stress responses: fight (n=94); flight (n=24), freeze (n=15), and fawn (n=12). Four overarching themes that underpinned these responses were identified: 1) Moral and emotional impact on clinicians, 2) Safety systems interface, 3) Organisational constraints and environment and 4) Patient Complexity. Participants described sustained hyperarousal, anticipatory vigilance, moral distress, emotional withdrawal, and appeasement behaviours arising from repeated exposure to violence. While Code Black responses were viewed as a structured and effective \"organised fight\" mechanism, this was compromised by inconsistent training, role ambiguity, and limited post-incident support which contributed to burnout, disengagement, and workforce attrition.Conclusion\n\nEmergency department clinicians operate in persistently threatening environments that drive recurrent activation of fight, flight, freeze, and fawn responses with cumulative individual and system-level consequences. Behavioural emergencies warrant the same level of preparation, standardisation, and organisational support as other high-risk clinical events, such as a Code Blue - a life-threatening medical event with a responding Medical Emergency Team. Trauma-informed education team-based training, and embedded post-incident support are critical to safeguarding staff wellbeing and sustaining the ED workforce.",
  "abstract_shown": true,
  "affiliations": [
    "Research and Education Network, Western Sydney Local Health District, Sydney, NSW, Australia.",
    "School of Medicine at Western Sydney University, Sydney, NSW, Australia.",
    "School of Medical Sciences in the Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.",
    "Emergency and Critical Care Unit, North Sydney Local Health District Sydney, Sydney, NSW, Australia.",
    "School of Nursing and Midwifery, University of Technology Sydney, Sydney, NSW, Australia."
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 4,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Jennifer Davids"
    },
    {
      "affs": [
        0,
        1
      ],
      "name": "Greg de Moore"
    },
    {
      "affs": [
        2
      ],
      "name": "Martin Brown"
    },
    {
      "affs": [
        0,
        3,
        4
      ],
      "name": "Margaret Murphy"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/3vhq5j4n1yvhs.bib",
  "cited_by": 0,
  "doi": "10.3389/fpsyt.2026.1952758",
  "fulltext_url": "https://europepmc.org/articles/PMC13680432",
  "id": "3vhq5j4n1yvhs",
  "issns": [
    "1664-0640"
  ],
  "landing_url": "https://europepmc.org/article/MED/42903170",
  "language": "eng",
  "licence": "CC-BY",
  "licence_label": "CC BY",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "3312|Workplace Violence and Bullying"
    ]
  ],
  "openalex": "W7220730822",
  "pdf_url": "https://europepmc.org/articles/PMC13680432?pdf=render",
  "pmcid": "PMC13680432",
  "pmid": "42903170",
  "published": "2026-10-06",
  "publisher": "Frontiers Media SA",
  "ris": "https://research.draconitic.com/paper/3vhq5j4n1yvhs.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:19:57Z",
      "native_id": "MED:42903170",
      "source": "europepmc",
      "url": "https://europepmc.org/article/MED/42903170"
    },
    {
      "first_seen": "2026-10-30T12:20:18Z",
      "native_id": "10.3389/fpsyt.2026.1952758",
      "source": "crossref",
      "url": "https://www.frontiersin.org/articles/10.3389/fpsyt.2026.1952758/full"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "issn:1664-0640",
      "subfield": "psychiatry"
    }
  ],
  "title": "Fight, flight, freeze, fawn: mapping emergency department staff stress responses to workplace violence - a mixed-methods study.",
  "title_text": "Fight, flight, freeze, fawn: mapping emergency department staff stress responses to workplace violence - a mixed-methods study.",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:20:18Z",
  "url": "https://research.draconitic.com/paper/3vhq5j4n1yvhs",
  "venue": "Frontiers in psychiatry",
  "versions": []
}