Addressing Violence Against Healthcare Workers

Kicking. Hitting. Screaming. Even spitting.

No, we’re not talking about a disturbance at a local bar. This kind of behavior is happening in hospitals all over the country. It has become far too commonplace. Although healthcare workers have long been used to this kind of violence and consider it an unavoidable part of the job, it’s never acceptable.

Unfortunately, since the beginning of the COVID-19 pandemic, the healthcare field has seen an increase in workplace violence. With higher numbers of patients, a shrinking workforce, and visitors’ patience stretched thin by nearly three years of mandates and restrictions, the entire healthcare system has endured significant stress. As a result, people have often misdirected their frustration at workers just doing their jobs.

Recent studies indicate, for example, that 44% of nurses reported physical violence and 68% reported verbal abuse during this pandemic. Data from the Bureau of Labor Statistics show that healthcare workers are five times more likely to experience workplace violence than employees in all other industries. Workplace violence has severe consequences for the entire healthcare system. Not only do violence and intimidation cause physical and psychological injury to workers, they also make it more difficult for nurses, doctors, and other clinical staff to provide quality patient care.

In some situations, patients, visitors, and family members have attacked healthcare staff and jeopardized their ability to provide care. Pandemic or no pandemic, employees have a right to be treated with dignity and respect — at all times — and should be enabled to do their jobs without physical or verbal abuse.

Violence in the workplace doesn’t just impact healthcare workers but has severe consequences for the entire healthcare system. Healthcare workers cannot provide attentive care when they are afraid for their personal safety, distracted by disruptive patients and family members, or traumatized from prior violent interactions. In addition, violent interactions at healthcare facilities tie up valuable resources and can delay urgently needed care for other patients. Studies show that workplace violence reduces patient satisfaction and employee productivity and increases the potential for adverse medical events.

What is workplace violence?

There are four general categories of workplace violence as recognized by researchers and the Centers for Disease Control and Prevention (CDC).

1. Criminal intent. In this case, the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with violence (robbery, shoplifting, or trespassing). In healthcare settings, this type occurs less frequently compared to other types of violence. For example:

  • An assault on a nurse in the hospital parking garage.
  • A mugging of a home healthcare nurse during a home visit.
  • A robbery of a pharmacy or emergency department due to the presence of drugs and cash.

2. Customer/client. This kind of violence is by far the most common in healthcare settings and often occurs in the course of a worker’s normal duties. The CDC considers customer/client relationships to include patients, their family members, and visitors and is typically referred to as CLIENT-ON-WORKER VIOLENCE.

According to a report from the Occupational Safety and Health Administration, nurses are four times more likely to be victims of client violence than the average private sector employee. Research shows that this type of violence occurs most frequently in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings, but is not limited to these areas.

Healthcare can be a stressful environment, which is a large factor in increasing the likelihood of violence. When things like food, water, or pain medication are restricted, a violent reaction is often triggered. However, patients are unlikely to abuse without issues such as psychosis, dementia, drug or alcohol abuse, mental health issues, or other factors that affect decision-making capability. Examples include:

  • A distraught family member assaults a triage nurse in the emergency room because his spouse is in pain and has been waiting a long time to be seen.
  • An agitated dementia patient hits the doctor examining him.
  • A patient threatens to harm a psychiatrist who refuses to refill a prescription for benzodiazepines.

3. Worker-on-worker. Violence between coworkers is commonly referred to as lateral or horizontal violence. It includes bullying and frequently manifests as verbal and emotional abuse that is unfair, offensive, vindictive, and/or humiliating. It can also become as severe as homicide.

Worker-on-worker violence is often directed at persons viewed as being “lower on the food chain,” such as in a supervisor-to-subordinate or doctor-to-nurse interaction. In addition, incidents of peer-to-peer violence are also common. This violence is often manifested as bullying and ranges from verbal abuse and intimidation to homicide.

4. Personal relationship. In this type, the perpetrator has a relationship to the worker outside of work that spills over into the work environment. For example, the husband of a nurse follows her to work, orders her home, and threatens her. These acts include implications for not only the nurse but also for her coworkers and patients.

An alarming trend

One needs to look no further than the news to see real-life examples of violence against healthcare workers. Day after day, the media reports about patients or family members physically or verbally abusing hospital staff. Here are a few examples:

  • A patient grabbed a nurse in Georgia by the wrist and kicked her in the ribs.
  • A nurse in South Dakota was thrown against a wall and bitten by a patient.
  • A medical student in New York who came from Thailand was called “China Virus,” kicked, and dragged to the ground, leaving her hands bleeding and legs bruised.
  • An Oklahoma man opened fire at a medical office, killing a doctor and three others before turning the gun on himself. Police said the shooter had complained multiple times about pain following back surgery and sought additional treatment in the days prior to the attack.
  • An employee at Mission Community Hospital in Panorama City, CA, was stabbed multiple times before the assailant fled on foot, according to a press release from the Los Angeles Police Department.
  • Two Dallas hospital employees were shot and killed by a man whose girlfriend was giving birth in the hospital. Responding police shot and wounded the male suspect.

The violence isn’t always physical. Earlier this year, officials and healthcare providers at a South Dakota hospital were the target of a protest campaign by the wife of a man who had been treated for Covid-19 in the facility. According to a news article, the woman criticized the care her husband had received in numerous online videos and postings. She also held signs outside the hospital, posted the name and phone number of the patient liaison, and urged people to call and complain on her behalf.

What’s being done to help?

While most hospitals have instituted some measures against violence, there’s still much more to do. The American Association of Critical Care Nurses offered a position statement, “Preventing Violence Against Healthcare Workers,” urging hospitals to do the following:

  • Educate staff on how to recognize the potential for violence, how to employ de-escalation techniques, and how to seek assistance to prevent or respond to violence.
  • Establish a clear and consistent reporting structure for workplace violence, with easy-to-understand policies and procedures on how to report violent incidents to law enforcement.
  • Encourage employees to press charges against persons who assault them and support staff members who do.
  • Provide resources and support programs for employees to help them cope with violent incidents.
  • Evaluate staffing and patient classification systems that could increase or reduce the risk of violence.
  • Ensure the presence of sufficient security systems, including alarms, emergency response, and available security personnel.

The American Organization for Nursing Leadership and the Emergency Nurses Association have identified the following principles for hospitals and health systems as they build on their existing violence prevention efforts:

  • Ground workplace violence prevention programs using evidence-based strategies.
  • Employ comprehensive solutions, recognizing the intersecting layers of intrusive, consumer, relational, and organizational violence.
  • Mitigate workplace violence by establishing preventative support throughout the organization.
  • Promote a culture of safety to create a healthy work environment.
  • Ensure interprofessional teams (leadership, staff, patients, and visitors) are committed to reporting incidents of violence and acting to prevent it in the workplace.
  • Emphasize accountability, regardless of staff members’ roles or disciplines, to uphold foundational standards of nonviolent behavior.

In addition, the American Hospital Association is urging Congress to enact the Safety from Violence for Healthcare Employees Act, which provides protections similar to those that exist for flight crews, flight attendants, and airport workers. Despite the incidence of workplace violence and its harmful effects on our healthcare system, no federal law protects healthcare employees from workplace assault or intimidation. By contrast, there are already federal laws that criminalize assault and intimidation against airline employees.

Attorney General Merrick Garland recently directed Department of Justice prosecutors to prioritize prosecutions under those statutes, given the rise in violent behavior on commercial aircraft during the COVID-19 pandemic. Vigorous enforcement of these federal laws creates a safe traveling environment, deters violent behavior, and ensures offenders are appropriately punished.