Fight, flight, freeze, fawn: mapping emergency department staff stress responses to workplace violence - a mixed-methods study.
5 affiliations
- 1Research and Education Network, Western Sydney Local Health District, Sydney, NSW, Australia.
- 2School of Medicine at Western Sydney University, Sydney, NSW, Australia.
- 3School of Medical Sciences in the Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
- 4Emergency and Critical Care Unit, North Sydney Local Health District Sydney, Sydney, NSW, Australia.
- 5School of Nursing and Midwifery, University of Technology Sydney, Sydney, NSW, Australia.
Abstract
Background
Workplace 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
This 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
Across 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
Emergency 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.
Related
- A Mixed Methods Evaluation of a Model of Care for Domestic Violence Within the Emergency Department
- The relationship between violence proneness and history of violence in emergency department patients
- Association between workplace violence and harassment and hypertension-related outcomes: a scoping review
- Exposure of unmonitored workers to ionizing radiation due to portable X-ray machine use and area dose mapping in an emergency department in King Abdulaziz Medical City, Jeddah
- Verbal de-escalation techniques for the prevention and management of workplace violence in healthcare: a systematic review
BibTeX
@article{davids2026fight,
title = {{Fight, flight, freeze, fawn: mapping emergency department staff stress responses to workplace violence - a mixed-methods study.}},
author = {Jennifer Davids and Greg de Moore and Martin Brown and Margaret Murphy},
journal = {Frontiers in psychiatry},
year = {2026},
month = oct,
doi = {10.3389/fpsyt.2026.1952758},
url = {https://europepmc.org/article/MED/42903170},
note = {CC BY},
}
RIS
TY - JOUR
TI - Fight, flight, freeze, fawn: mapping emergency department staff stress responses to workplace violence - a mixed-methods study.
AU - Jennifer Davids
AU - Greg de Moore
AU - Martin Brown
AU - Margaret Murphy
PY - 2026
DA - 2026/10/06
JO - Frontiers in psychiatry
DO - 10.3389/fpsyt.2026.1952758
UR - https://europepmc.org/article/MED/42903170
AB - Background Workplace 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 This 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 Across 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 Emergency 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.
SN - 1664-0640
ER -