Ashleigh Watson, MD

Violence against health care workers is an ever-present threat that has been increasing over the past several years. The majority of physicians and nurses report that they have been victims of workplace violence at least once throughout their careers. Such violent attacks negatively affect the delivery, quality, and accessibility of health care. Certain factors such as substance abuse and intense emotions increase an individual’s risk of committing an act of workplace violence against a health care worker. Encountering violent individuals has legal implications and can compromise the moral framework of physicians. With action from institution administrations, advocates, leaders, and government, this issue that detrimentally affects health care can be combatted and reduced. By implementing required staff training, increasing security, strengthening the doctor-patient relationship, using medical chaperones, and reforming policy, positive changes can be made to protect health care workers and the health care system.

The support of health care administrators, leaders, and national advocates is essential and necessary for tackling health care workplace violence and protecting health care workers.

Hospitals need to implement required staff training, increase security, strengthen the doctor-patient relationship, use medical chaperones, and reform policy, among many constructive steps necessary to decrease the incidence of violence against health care workers.

The Occupational Safety and Health Administration defines workplace violence (WPV) as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide.”

 In 2014, it was reported that workers in the medical field encounter more nonfatal incidents of WPV than workers in any other profession.

 The risk of health care workers encountering violence in the hospital is ever present, and it appears that this violence is actually increasing.

 In this article, we will discuss the pandemic of violence and strategies that a physician can use to control explosive situations.

Violence against health care workers, especially in the hospital setting, is a global issue that affects both developed and developing countries. A comprehensive literature review shows that research studies have been conducted in the United States, United Kingdom, China, Iraq, Germany, Ethiopia, Jordan, Palestine, Nigeria, and many more nations, all indicating that the majority of physicians and health care workers have experienced some form of WPV. In fall 2014, a poll found that 71% of physicians in the United States had experienced at least 1 incident of violence at some point during their careers.

 Of the physicians in Michigan surveyed in 2002, 75% were victims of at least 1 incident of verbal threatening during a 12-month period, whereas 28.1% of respondents experienced physical assault.

 Nurses typically sustain the most WPV compared with other health care workers. A study in 2000 found that 82% of US nurses had been assaulted at least once during their careers, and 73% believed that assault was just part of their job.

 For physicians, the rate of violence is highest in the emergency department and among less-experienced physicians.

 Studies have shown that the most common acts of violence against nurses were shouting or yelling (60.0% by patients, 35.8% by visitors), swearing (53.5% by patients, 24.9% by visitors), and grabbing (37.8% by patients, 1.1% by visitors).

In 2016, 16,890 workers in the private industry experienced WPV that required days away from work. Of those victims, 70% worked in the health care and social assistance industry, according to the CDC.

The implications of WPV against health care workers are detrimental to not only the victimized individual but also the entire health care system. From physical injuries to psychological trauma, violence can lead to demotivation, poor job satisfaction, and early physician burnout.

 Overall, WPV affects the delivery of health care, decreasing quality and accessibility.

Numerous factors contribute to the escalating levels of violence against health care workers in the hospital setting. The majority of attacks come from patients or family members who have problems with substance abuse, a mental illness, or drug-seeking habits.

 Furthermore, the generalized fear, helplessness, and stress felt by individuals seeking medical attention and by their loved ones, especially when the patient is critically ill and there is frustration with the health care system, lead to increased risk of WPV in hospitals.

 These strong emotions and anger that individuals may harbor can emerge and be inappropriately directed toward health care workers. Additionally, a history of violence increases the risk that an individual will commit an act of WPV.

Currently, only 26 of 50 US states have any law to protect health care workers from assault,

 and the laws in the majority of these states protect only a small sector of the health care field. For example, penalties in Louisiana apply only to emergency department workers and those in Kansas apply only to mental health employees.

 In many states, the right to refuse treatment of abusive patients is allowed by law; however, under the Emergency Medical Treatment and Labor Act of 1986, emergency departments must treat all patients who present for care, regardless of abusive actions.

Encountering violent patients has serious ethical implications for physicians, potentially compromising the moral framework on which the practice of medicine was founded. The Hippocratic Oath clearly delineates that a physician should treat every patient, and no patient should go without the care they need. Physicians have an ethical obligation to practice nonmaleficence and beneficence regardless of minimal personal risk. However, if a patient or their family member is acting violently or aggressively at the hospital and abusing the physician, nurses, or other staff members, a personal decision can be made to refuse treatment during their violent episode. When contemplating refusing treatment, the welfare of the physician and staff must outweigh the responsibility to care for the patient. Complete termination of the patient-doctor relationship should be executed only in extreme circumstances, as abandonment of a patient is not ethically or legally permitted.

Physicians are also ethically obligated to respect patients as individuals and to exercise compassion and empathy in their interactions. When working with an abusive patient, physicians must block their personal emotions and assess some ethical challenges: Is the behavior voluntary? Does failure to assign responsibility to the patient undervalue them as an individual? Should they be held responsible for their actions or are they victims of their environment? The answers to these questions may differ with each incident, but they should be used to evaluate behavior and to judge the necessary steps for advancing with care.

Violence against health care workers at hospitals is a preventable problem, and the incidence rate can be diminished with collaboration, change, and reform. Required training that focuses on recognizing and responding to abusive patients and family members would better prepare health care workers to respond to violent individuals and mitigate escalation. Some hospitals use flagging systems that alert medical staff about patients’ histories of violence.

 This way, clinicians can be better prepared to defuse difficult situations. At the Portland Veterans Affairs Medical Center, for instance, the staff was alerted about patients with a history of violence; this resulted in reducing the number of violent attacks by 91.6%.

Increased security has also been proposed as a way to decrease WPV in health care environments.

 Henry Ford Hospital in Detroit, Michigan, recently installed metal detectors, and a New York City hospital also increased its security by effectuating an identification badge system, limiting patients and visitors to specific floors of the hospital. This effort reduced violent crimes by 65% over 18 months.

In addition, making subtle changes to the doctor-patient relationship may be advantageous in decreasing WPV. For instance, practicing increased empathy, shared understanding, and cooperation may help decrease patient and guest frustration, stress, and other potentially volatile emotions. This is evident from the results of a 2012 study concluding that nurse-patient relations have a significant impact on WPV and that empathic communication with patients can significantly reduce the chances of violent behavior.

 The use of a medical chaperone may also decrease the risk of WPV, potentially protecting the physician from abuse and violence. From personal experience, patients and families can experience less anger and frustration when health care professionals take some time to sit with them, show sympathy, listen, and potentially involve the palliative care team.

Motivating the leaders of health care institutions is instrumental in enacting positive change to combat the increasing levels of violence. If hospitals enforced a mandatory reporting policy in which the administration would fully support staff, WPV in the health care setting would be better documented and the necessary actions against offenders would be taken more effectively.

 Postevent counseling should also be mandated, given the high percentage of health care workers who suffer from psychological trauma and decreased job satisfaction after experiencing WPV; efforts need to be taken to focus on the mental health and wellness of employees. In addition, the attitudes of both staff and society regarding WPV in health care settings need to be addressed. Violence should not be considered just “part of the job” from the perspective of health care workers, and society needs to know that it is unacceptable to treat health care workers in a violent or abusive manner.

The National Health Service of the United Kingdom launched its Zero Tolerance Policy in 1999 in hopes of protecting its employees and eliminating the “fear of violence, abuse, and harassment from patients or their relatives.” The Zero Tolerance Policy allows health care facilities to freely seek police assistance, remove violent patients from their practice if necessary, and encourage and enforce reporting of WPV.

The problem of violence against health care workers, especially in critical care units, prevails and escalates across the world. It has been confirmed time and again that the vast majority of physicians, nurses, and supporting staff fall victim to WPV during their careers. Patients, family members, and visitors commit these violent and abusive attacks due to substance abuse, mental illness, and/or powerful emotions that manifest themselves in destructive ways. Violence challenges the moral and ethical obligations of physicians, leading to difficult decisions that may need to be made to protect others. The power and support of administrators, leaders, and national advocates are essential and necessary for tackling this issue and protecting health care workers. Implementing required staff training, increasing security, strengthening the doctor-patient relationship, using medical chaperones, and reforming policy are constructive steps that will decrease the incidence of violence against health care workers.


 Department of Pediatrics, Medical College of Wisconsin (AW), Milwaukee, WI; McMaster University (MJ), North York, Ontario, Canada; Department of Neurosurgery, University of Texas Health Science Center at San Antonio (AS), San Antonio, TX.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (AS); acquisition of data (AW, MJ); analysis and interpretation of data (MJ); drafting of the manuscript (AW, MJ, AS); critical revision of the manuscript for important intellectual content (AW, MJ, AS); and supervision (AS).

 Ali Seifi, MD, University of Texas Health Science Center at San Antonio, Mailbox 7483, San Antonio, TX 78229. Email: seifi@uthscsa.edu.

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