As National Nurses' week comes to a close, more attention needs to be brought to increasing rates of violence against employees in the field of healthcare.
Studies show violence against healthcare employees is more common that most people realilze, and advocacy groups say it's time for policymakers to act on this growing but underreported problem. While 75% of nearly 25,000 workplace assaults occur annually in healthcare settings, only 30% of nurses and 26% of emergency department physicians have reported incidents of violence.1 Those unfamiliar with daily events in healthcare institutions may be shocked to learn that violent altercations are so common that most employees in the field consider them to be simply part of the job.
“Workplace violence against nurses has been going on for decades,” said Michelle Mahon, RN, nursing practice representative for National Nurses United, in an interview with The American Journal of Managed Care® (AJMC®). “A physician heard a nurse being verbally abused by a patient. She walked up to the nurse, put her hand on her shoulder, and asked her if she was OK. The nurse shrugged it off and said that is happens all the time.”
The World Health Organization (WHO) defines workplace violence as, “Incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health.”2 WHO considers both physical and psychological harm, including attacks, verbal abuse, bullying, and both sexual and racial harassment, to be workplace violence.2
According to the American College of Emergency Physicians (ACEP), nearly 7 out of 10 emergency physicians believe that emergency department violence is increasing.3 About 80% of these physicians acknowledged that these events have also taken a toll on patients. Over 50% said that patients have been physically harmed. Also, 47% of physicians have said that they’d personally been physically assaulted at work.
The government has taken initiatives to help protect employees in the healthcare field, but advocacy groups have stressed that more meaningful changes are needed. In March, ACEP sent a letter of support for the Workplace Violence Prevention for Health Care and Social Service Workers Act, which asked Congress to consider how emergency departments (EDs) are staffed to ensure that the main provisions of the legislation could be appropriately implemented.3 Near the beginning of April 2019, the Nevada Assembly’s Committee on Commerce and Labor passed a violence prevention bill that would make employers more accountable for the safety of their employees, according to a statement.
In an interview with AJMC®, Leigh Vinocur MD, national spokesperson for ACEP, said more attention has been brought to the issue. “We’re bringing this up again because we want people to take notice. There are some bills in Congress about assaulting emergency medical services or healthcare workers. Maybe there needs to be some of that muscle behind it and people need to understand,” she said.
Types of Workplace Violence
According to a study in the New England Journal of Medicine, there are 4 types of violence that can occur in the workplace.5 The first type is by perpetrators who have no association with the workplace or employee. In the second type, the assailant is a customer or a patient of the workplace or employee. A third type is when the attacker is a current or former employee of the workplace. The fourth type occurs when the perpetrator has a personal relationship with the employee but not with the workplace.
The second type of violence, usually committed by patient, their families, or their friends, is most prevalent against healthcare workers. However, acts of violence also occur between staff members. “I was previously assaulted by a physician,” Mahon mentioned.
Identifying the Causes
A hospital setting creates extreme levels or stress for patients, their families and friends, and employees of the institution. Fear and illness are major contributors of agitation and aggression from patients. While there are many causes act of violence, dire, emotional circumstances an addition to an overly stressful environmental are main contributors. “It makes sense because the healthcare setting and the ED specifically is a very emotionally volatile experience for people. Patients are at their worst, they’re feeling horrible, they’re ill, they’re frightened and vulnerable. Their family members are also frightened and stressed out, and people lash out. We see psychiatric issues because of lack of behavioral health, gang violence,and gun violence." Mahon said.
“It’s not always a criminal element that’s lashing out. These are frightened and scared sick people, frightened family members that are screaming,” Vinocur mentioned.
Previous measures taken by employers to reduce acts of violence have also been criticized by employees. “Safety interventions that hospitals have taken are failing. Acts of violence that occur are brought up the executive level daily, but that does nothing to prevent workplace violence. It’s a response not a prevention measure,” Mahon stressed.
“The violence that’s occurring is coming from sick people that are not in their right mind the majority of the time. It is not our patients. Many people are taking the approach of criminalizing our patients. It does not prevent violence to charge patients with a felony.” Mahon said. “It could be you. You can get your wisdom teeth pulled and be out of your head from that anesthesia drug and not in a good decision-making capacity. You could be confused, not understand what’s happening, and assault your nurse.”
Major design flaws in the current healthcare system have also been blamed for creating negative care settings. “Healthcare is not focused on wellness. The system creates a situation where there is so much stress, where people can’t get preventive care, where they’re worried about whether or not they’re going to have to file bankruptcy because their wife is sick and in bed, getting a surgery that they need. People suffer with food insecurity. There are no resources to take care of their family member or their loved one or themselves. This type of stress is leading to violence, and it all comes together in that hospital room. The system is broken. Our healthcare system has warped priorities.”
Frequency of Verbal and Physical Attacks
Whether the abuse suffered by healthcare employees may be verbal or physical, every single day employees in the healthcare field are assaulted in the United States.
In an interview with AJMC®, Schipp Ames, vice president of Communications, Education and Member Services for the South Carolina Hospital Association noted the alarming reports of gun violence that occurred in South Carolina hospitals in April 2019. “Within 48 hours we had 2 hospital shootings in South Carolina. Something like that happens once and everybody’s antenna goes up. Something happens like that twice in that quick of a timeframe and people start to get very scared. To see that happen 2 times on back-to-back days like that when we’ve never had a hospital shooting, as far as I’m aware, in our history in 1 of our hospitals, it’s pretty hard to comprehend.”
Ames addressed the frequency of violent acts in healthcare settings. “I’ve been asked the question, ‘how often does this happen?’ and I think I shocked the reporter from South Carolina who asked. I said, 'This happens every day whether its physical or verbal assault. It just so happens that this time the gun was a weapon, but in the past it’s been a towel rack that was ripped off the wall and used to beat a nurse.' These were very deadly and very dangerous incidents that involved guns, so they got more attention, but I think a lot of folks don’t realize how much doctors and nurses jeopardize their own safety every day when they make that vow to go and serve patients,” Ames said.
Addressing the frequency of violent incidents, Vinocur said, “I would say that you can’t go through a shift without being sworn at or spit on. If you consider verbal abuse, it’s probably daily. Eighty percent of emergency room doctors have at some point been involved in workplace violence.
"If you look at labor and statistics after police and things like that, healthcare workers are on top of the list, from years back, being known as a dangerous profession. It isn’t just the ER, it’s all of healthcare. We put up with it but it’s a tragedy that we, as a nation, have to look at and assess," Vinocur said.
“It’s very prevalent, it’s a very big problem, It’s really common. I was also held at gunpoint in my workplace. The inpatient room, then the psychiatric unit, and the emergency department, in that order, is where most instances of violence occur,” Mahon pointed out.
The Effect on Moral and Burnout in the Field
Mahon addressed the effect that frequent acts of violence against employees can have on their morale over time. “Emergency care is one of the specialties that does have a high burnout rate. How many other places do you go to work, and it’s commonplace and almost accepted that people are going to swear and scream at you? Eighty percent of the emergency physicians say that patients threaten them or threaten to return to the emergency department to harm them. The cumulative effect of both kinds of violence does wear and it creates burnout. I think it’s contributing to nurses leaving the profession.”
She also recalled a devastating situation that she witnessed. “My coworker on my unit was shot in the head in the lobby of the hospital by their husband. It was at a world class institution, a place that you think these types of things wouldn’t happen. The response is that it can result in post-traumatic stress disorder (PTSD)."
“I think it definitely does affect morale,” Vinocur agreed. “That is probably 1 factor related to burnout in our profession of emergency medicine aside from the inundation of patients, lack of follow-up care, access to care, which is critical, and boarding psychiatric patients all night. It’s a piece of it and it contributes to it. It’s always a tragedy. It’s always something. I was there when there was a shooting within the hospital.”
Ames also cited the long-term effects of trauma, mentioning, “We’ve had a number of nurses that have come forward and said that they’ve been diagnosed with PTSD by their therapists.” He also noted that many hospital workers have moved on to outpatient care. “From a hospital perspective, you are seeing folks leave the traditional hospital bedside setting for different opportunities in outpatient settings, in clinics, in special surgery centers, and other facilities that don’t have these same types of hazards, that don’t have the same type of open-access to the public. I’m speaking as the husband of a nurse practicioner who worked in a hospital doing 12-hour shifts for several years. After several incidents, the quality of life is just different sometimes when you work in 1 of these outpatient facilities. It makes us question sometimes whether we have a nursing shortage or whether we’re just seeing more healthcare clinicians or nurses leave the bedside.”
ACEP has stated that while 70% of emergency physicians have reported acts of violence against them, only 3% pressed charges. “I think it’s underreported because physicians and nurses go into healthcare to help people. We feel compassion for our patients. We understand if they’re acting out its because they’re ill or impaired and we have this ethical duty to do no harm. We don’t go into healthcare to police them or report them. It’s no excuse that you’re impaired or you’re ill but we understand it a little more and I think we tolerate it a lot longer than other professions might,” Vinocur said.
Beyond many healthcare workers believing that workplace violence is “just part of the job,” there is another driving force, a type of negative reinforcement, that has created barriers to reporting acts of violence. Many workers feel that they will suffer consequences if they speak out about what has happened to them. However, any act of retribution may not seem obvious. While retribution may not include written documentation of insubordination, supervisors have punished employees that have spoken out in other ways. For example, their hours may be cut or they may be forced to work schedules that they protest against. “I know a nurse that was hospitalized after being beaten and kicked with broken ribs from a psychiatric patient. She was made to care for that patient again when he returned, and when she objected, she was disciplined. It fundamentally goes back to the lack of respect that employers have for nurses and for their workforce,” Mahon stressed.
Ames suggested that a major societal flaw has contributed to rising acts of violence against healthcare employees. “We’ve recognized there’s a culture where clinicians believe that this is part of the job and there’s a culture among some of the patient community where it seems to be OK to treat clinicians subpar. Our communications campaign is a direct aim at that culture with signs that say ‘you report, we support’ with a picture of the CEO because 1 of the biggest challenges is how low reporting is. Any nurses’ group will tell you that so many of them go unreported because they feel like it’s just part of the job. They don’t want to stigmatize mental health patients. They’ve been taught to do no harm so much throughout their career that even when a patient could present a danger to them, they are still programmed to protect that patient. A lot of people don’t understand that we don’t have accurate data to know how big the problem is because so much goes unreported.”
Evaluating High-Risk Patients
Patients showing signs of agitation or aggression should be identified as “high-risk” to prevent an act of violence. Those who were given drugs that could cause impairment should be regarded as potentially dangerous. “One of our nurses who was injured very severely was attacked by a patient recovering from anesthesia from a simple procedure. In that scenario, the patient is not in their full faculties. This brings them confusion, agitation, and ultimately then violence. There was only 1 nurse there and the security staff were told that they were not permitted to touch the patient. Any type of illness or injury that creates confusion could exhibit temporary psychosis,” Mahon said.
Patients who have used illegal drugs could also pose a major threat. “During residency I was choked by a patient. That didn’t stop me from my residency,” Vinocur said. “It was somebody impaired, and it was a busy intercity hospital and he came in as an overdose. Normally you put on some light restraints when you’re reversing them with Narcan. He kind of popped up, didn’t have restraints. I was closest to him and he starts screaming that we ruined his ‘high’ and grabbed me by the throat. I don’t think he was cognoscente because he was still groggy. He ended up ripping my necklace off. Lucky we had security and I could feel him loosening, but I had scratch marks and little broken blood vessels in my eyes. That was the last time I wore jewelry to work because it cut into my throat too.”
Efforts to Reduce Acts Of Violence
WHO has stated, “An integrated approach should be actively pursued at all levels of intervention based on the combined and balanced consideration of prevention and treatment.” Therefore, WHO holds employers accountable for both ensuring the safety of their employees and acting to treat them after an act of violence has occurred.2
A hospital employee was excited that the administration created a phone application with an alarm system. However, during a time of crisis, the usefulness of these technologies is questionable. “I’m a nurse that’s been personally attacked a number of times. First of all, many nurses are not permitted to carry their phone with them during work hours,” Mahon said. When the administrator said that they were changing that policy, Mahon responded by making a valid point. “If I were being choked by my patient and held at my throat, how would I open my phone to access this app and operate it? That’s an actual situation that I was in. It’s something that’s going on during an act of violence, not a preventive measure. The best type would be a device where you can simply press a panic button and get help. However, even the efficacy of the best safety intervention technology would come into question depending on the response time of security or other individuals who could help.”
While enhanced security measures have been taken by many major hospitals, the cost can be staggering. Ames noted, “It’s extremely difficult from a cost standpoint for a lot of hospitals if you consider rural hospitals. The cost of outfitting with metal detectors and adding a lot of these security measures is really not in the budget for a lot of smaller facilities. Some type of armed or unarmed security prevalence is becoming more common in hospitals, and that’s not cheap either.”
Ames said that remedying a complication situation before it leads to an act of violence is the most common intervention. Vinocur agreed, saying “Communication is the key. You need to learn to de-escalate. Create programs where you’re training the staff and everyone in the department to learn to recognize signs of agitation and potential violence. It’s a struggle because you’re dealing with so many different emergencies and critical issues all the time. Teaching, recognizing when people are getting agitated irritated and training in de-escalation and constant communication and all of those techniques need to be an important part of training for everyone that work in the health system."
Ames discussed an initiative that the South Carolina Hospital Association has taken to reduce violence against their employees. “We’ve launched an entire campaign called ‘Hospital Safe Zones.’ It is an operational communications campaign on how to implement different strategies to reduce violence. It is a way to centralize incidents of healthcare violence and analyze and treat them differently than other incidents in hospitals. We believe that by putting a focus on this issue, and bringing more awareness to it that we can increase reporting in our facilities and see a significant reduction in silent incidents by creating a culture of zero tolerance.”
Ensuring that healthcare settings have an ample amount of employees can also help reduce acts of violence. “Hospitals must provide safe staffing, which they do not in most cases. Most employers are failing to listen to direct input of the care staff, the people who are there who understand how violence is occurring. They understand what’s happening in their unit,” Mahon mentioned. "The surveillance and monitoring of the right amount of staff, and intervening before a patient becomes too agitated is the single best intervention to preventing violence in the workplace. Having the time to teach people, talk to them, educate them so that they don’t become anxious or upset, this is the best type of intervention. But nurses don’t have time for this type of care because they don’t have enough people around to provide that kind of care."
In discussing the design of a workplace violence prevention plan, Mahon explained, "First, there must be unit-specific plans that include meaningful input by direct-care staff. Two, those plans must be available and re-evaluated and see if they’re effective, or working, or need modification at least quarterly. There needs to be a guarantee that there will be no retaliation for reporting incidents of workplace violence, including from other workers in the healthcare facility. It must include transparency. When nurses aren’t safe, patients aren’t safe. When a work environment is not safe, the hospital is not safe. Workers and patients have the right to know what measures are being taken and if this facility is safe or not. It must include fines for the failure to comply. It must include mechanisms for remediation,” Mahon said.
“Healthcare is becoming more like factory work,” Mahon pointed out. “Work faster, patients are sicker, do more with less, deal with it. If you can’t, there is a culture that if you are unable to just roll through something like this happening and continue to be a fully productive worker, that you’re defective.”
1. Physical and verbal violence against healthcare workers. The Joint Commission. www.jointcommission.org/sea_issue_59/. Published April 17, 2018. Accessed May 3, 2019.
2. Framework guidelines for addressing workplace violence in the health sector. Geneva, Switzerland: International Labour Office (ILO), International Council of Nurses (ICN), World Health Organization (WHO), Public Services International (PSI); 2002. who.int/violence_injury_prevention/violence/activities/workplace/en/. Accessed May 3, 2019.
3. Violence in the emergency department: resources for a safer workplace. American College of Emergency Physicians (ACEP). acep.org/administration/violence-in-the-emergency-department-resources-for-a-safer-workplace/. Accessed May 2, 2019.
4. Nevada healthcare workplace violence bill passes committee, heads for floor vote [news release]. Nevada, Nation Nurses Organizing Committee; April 12, 2019. nationalnursesunited.org/press/nevada-healthcare-workplace-violence-bill-passes-committee-he ads-floor-vote. Accessed May 2, 2019.
5. Phillips J. Workplace violence against health care workers in the United States. N Engl J Med. 2016;374:1661-1669. doi: 10.1056/NEJMra1501998.