Violence Against Healthcare Workers
While working in healthcare has always carried an inherent amount of danger, I can tell you with certainty that the last time I was a staff nurse (in the spirit of transparency—it’s been a while) I never once feared going to work. The worst thing that might happen to me on my shift was a patient spitting their applesauce at me while I tried to give them their medications. I never worried about getting shot, stabbed, beaten, or raped.
Violence toward our workforce is unacceptable and is one of the most pressing issues of our time. The International Association for Healthcare Security and Safety Foundation’s (IAHSSF) 2019 Healthcare Crime Survey showed assault rates of 11.7 per 100 beds, the highest since IAHSSF began collecting this data in 2012. The report also showed an all-time high rate of disorderly conduct (e.g., disturbing the peace, use of profanity) of 45.2 per 100 beds.1 The U.S. Bureau of Labor and Statistics reported that 16,890 private industry workers experienced nonfatal trauma from workplace violence in 2016, with 70% of these workers from the healthcare and social assistance industry.2
Keep in mind, this is only what gets reported. One study in Michigan showed the rate of injury among healthcare workers was up to three times higher than what was reported by the Bureau of Labor and Statistics.3 Another study from two large health systems in North Carolina and Texas showed 50.4% of respondents experienced type 2 violence—physical assault, physical threat, and verbal abuse—during their careers, and 39% of respondents experienced the same in the previous 12 months. Only 19% of these incidents were reported into their formal reporting structure, and 38% of thesthese workplace violence victims feared for their safety.4
Think about that for a moment—38% of respondent victims are working in fear. If staff are constantly worried about their own physical safety, and that of their coworkers and patients, how can they be expected to concentrate during a 12-hour shift? Studies show exposure to violence impacts healthcare workers and leads to missed time, burnout, decreased productivity, and an overall reduction in job satisfaction.5,6,7 This is nothing less than a crisis.Tackling Violence
So, what can we do? There are no easy answers. Violence in our society is a multifactorial problem that requires broad-based intervention. Research on reducing workplace violence is limited or difficult to find. One recent study, conducted by the College of Human Medicine at Michigan State University, examined seven hospitals’ efforts to standardize workplace violence reporting and prioritize areas of risk using a risk matrix strategy.10 The next phase observed the ability of specific interventions to reduce workplace violence. Key takeaways included: specific unit-level data was provided to each intervention group; unitlevel action planning reflected guidelines from the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control, National Institute for Occupational Safety and Health (CDC, NIOSH); and, while the incidence rate of events and injuries did not show a decrease from baseline in the intervention group, the control group did show a significant increase in incidence rate of post-intervention events and injuries.11 While this study makes an important contribution to the field, more research must be done. A lot more. This, however, cannot be an excuse for inaction.
Hospitals, communities, and legislators will have to work together to even begin to make a dent. There are numerous resources available for hospitals through sources such as OSHA, professional societies, and local and state law enforcement agencies, but their use isn’t mandated. Federal bills H.R. 1309 and S. 851, the Workplace Violence Prevention for Health Care and Social Service Workers Act, which would require certain healthcare facilities to develop and implement workplace violence prevention plans, were introduced on February 19, 2019, and March 14, 2019, respectively; despite bipartisan support, both sit in committee.8,9
Several bills to prohibit violence against healthcare practitioners are also currently pending in Pennsylvania. These include Senate Bill 351 and House Bill 1879, which would expand current legislation to upgrade penalties for assault against all healthcare practitioners,12,13 and House Bill 39, Senate Bill 842, and House Bill 1880, which would allow healthcare employees to omit their last names from hospital ID badges.14-16
To reduce violence in healthcare, we must also address violence in the community. Just as healthcare doesn’t stop at the hospital exit, our societal problems don’t stop at the entrance. One relatively simple but critical starting point may be partnering with key stakeholders and conducting community health needs assessments (CHNAs). Interestingly, in a study of the CHNAs of 77 hospitals in 20 high-violence U.S. cities, only 32% identified violence as a high priority, and 26% of the CHNAs made no mention of violence at all. This study concludes that hospitals may not see violence as an actionable item that they can address.11 We must resolve this disconnect.
Unfortunately, not all dangerous situations are avoidable. There are times that involuntary mental impairments prohibit a person from knowing they are committing an act of violence. The patient who spit their applesauce on me had advanced Alzheimer’s disease. Some patients have terrible, uncontrollable, and unpredictable reactions to general anesthesia that make them hallucinate and become violent as they awaken. Others can experience episodes of acute delirium due to disease process or medications. Those situations are not the same as willfully harming staff, including when under the influence of illegal drugs and alcohol. Someone’s accountability for their actions doesn’t stop at the point of intoxication just because they are in a hospital, the same as accountability doesn’t stop when they are behind the wheel of a car. Those patients may no longer be in control, but that should not absolve them of the consequences of their actions. We need to support our staff and hold perpetrators accountable to the full extent that the law allows.
Clearly, our work is cut out for us.
What practices have you put in place to reduce violence? We would love to read about your studies, your stories, and your opinions related to this critical issue. Send them to PatientSafetyJ@pa.gov.
Vallani KH. 2019 Healthcare Crime Survey. International Association for
Healthcare Security & Safety; April 5 2019. IAHSS-F CS-19. Available from:
The National Institute for Occupational Safety and Health. Occupational
Accessed: Oct 11, 2019.
Rosenman KD, Kalush A, Reilly MJ, Gardiner JC, Reeves M, Luo Z. How
Much Work-Related Injury and Illness Is Missed by the Current National
Surveillance System. J Occup Environ Med. 2006;48(4):357-365.
Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya
M. Physical Assault, Physical Threat, and Verbal Abuse Perpetrated
Against Hospital Workers by Patients or Visitors in Six U.S. Hospitals. Am J
Ind Med. 2015;58:1194-1204
Eker HH, Özder A, Tokaç M, Topçu İ, Tabu A. Aggression and Violence
Towards Health Care Providers, and Effects Thereof. Arch Psychiatry
Wolf L, Delao AM, Perhats C. Nothing Changes, Nobody Cares: Understanding
the Experience of Emergency Nurses Physically or Verbally
Assaulted While Providing Care. J Emerg Nurs. 2014;40(4):305-310.
Nachreiner NM, Gerberich SG, Ryan AD, McGovern PM. Minnesota Nurses’
Study: Perceptions of Violence and the Work Environment. Ind Health.
Workplace Violence Prevention for Health Care and Social Service
Workers Act, H.R.1309. https://www.congress.gov/bill/116th-congress/
Workplace Violence Prevention for Health Care and Social Service Workers
Act, S. 851(2019). https://www.govtrack.us/congress/bills/116/s851.
Accessed: Oct 23, 2019.
Arnetz JE, Hamblin L, Ager J, et al. Application and Implementation
of the Hazard Risk Matrix to Identify Hospital Workplaces at Risk for Violence.
Am J Ind Med. 2014(57):1276-1284.
Arnetz JE, Hamblin L, Russell J, et al. Preventing Patient-to-Worker
Violence in Hospitals: Outcome of a Randomized Controlled Intervention.
J Occup Environ Med. 2017;59(1):18-27.
Senate Bill 351. https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.
cfm?sYear=%202019&sInd=0&body=S&type=B&bn=0351. Accessed: Oct
House Bill 1879. https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.
cfm?sYear=2019&sInd=0&body=H&type=B&bn=1879. Accessed: Oct 11, 2019.
House Bill 39. https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.cfm?sYear=
&sInd=0&body=H&type=B&bn=0039. Accessed: Oct 11, 2019.
Senate Bill 842. https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.
cfm?sYear=2019&sInd=0&body=S&type=B&bn=0842. Accessed: Oct 11, 2019.
House Bill 1880. https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.
cfm?sYear=2019&sInd=0&body=H&type=B&bn=1880. Accessed: Oct 11, 2019.