ArticlePDF AvailableLiterature Review

Workplace Violence against Health Care Workers in the United States


Abstract and Figures

Violence against health care professionals in the workplace is underreported and understudied. Additional data are needed to understand steps that might be taken to reduce the risk.
Content may be subject to copyright.
new england journal
n engl j med 374;17 April 28, 2016
Review Article
From Harvard Medical School and the
Department of Emergency Medicine, Beth
Israel Deaconess Medical Center — both
in Boston. Address reprint requests to
Dr. Phillips at the Department of Emer-
gency Medicine, Beth Israel Deaconess
Medical Center, 1 Deaconess Rd., Boston,
MA 02215, or at jpphilli@ bidmc . harvard
. edu.
N Engl J Me d 2016;374:1661-9.
DOI: 10.1056/NEJMra1501998
Copyright © 2016 Massachusetts Medical Society.
n January 2015, a surgeon at Brigham and Women’s Hospital in Bos-
ton was shot and killed at work by the son of a deceased patient. Even though
the event received substantial media coverage, reporters did not highlight the
fact that although the murder of a health care worker is rare, episodes of work-
place violence against medical providers happen daily across the country. Although
the majority of these incidents of workplace violence are verbal, many others con-
stitute assault, battery, domestic violence, stalking, or sexual harassment.
This review focuses on our current knowledge about workplace violence in
various health care settings, including the prevalence across professions, potential
risk factors, and the use of metal detectors in preventing violence. It also highlights
the difficulty researchers have encountered in developing experimental models
and the need for further evidence-based research.
Health care workplace violence is an underreported, ubiquitous, and persistent
problem that has been tolerated and largely ignored. According to the Joint Com-
mission, a major accrediting body for health care organizations, institutions that
were once considered to be safe havens are now confronting “steadily increasing
rates of crime, including violent crimes such as assault, rape, and homicide.”
though the health care sector is statistically among the industries most subject to
violence in the United States (aside from law enforcement),
researchers have yet
to discover statistically significant, universally applicable methods of risk reduc-
tion. To date, most research has been directed at quantifying the problem and
attempting to profile perpetrators and their victims. The few studies that have
focused on interventions to reduce violence have highlighted the unlikelihood of
finding a simple, one-size-fits-all solution to prevent this violence.
Research and Statistics
Experts have classified workplace violence into four types on the basis of the re-
lationship between the perpetrator and the workplace itself (Table 1). Most com-
mon to the health care setting is a situation in which the perpetrator has a legiti-
mate relationship with the business and becomes violent while being served by the
business (categorized as a type II assault).
The highest number of such assaults
in U.S. workplaces each year are directed against health care workers.
These epi-
sodes are characterized by either verbal or physical assaults perpetrated by patients
and visitors against providers. Although other types of workplace violence certainly
deserve attention, in a 2014 survey on hospital crime, type II workplace violence ac-
counted for 75% of aggravated assaults and 93% of all assaults against employees.
Among episodes of fatal violence against employed adults, nearly 25% occur at
their place of employment.
Between 2011 and 2013, the number of workplace as-
saults averaged approximately 24,000 annually, with nearly 75% occurring in
health care settings.
Data from the Bureau of Labor Statistics show that health
Dan L. Longo, M.D., Editor
Workplace Violence against Health Care
Workers in the United States
James P. Phillips, M.D.
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
new england journal
care workers are nearly four times as likely to
require time away from work as a result of vio-
lence as they are because of other types of injury.
However, inconsistencies in the existing data
can make interpretation of the findings quite
difficult. The Bureau of Labor Statistics and the
National Institute for Occupational Safety and
Health are among several federal agencies de-
voted to the collection of statistics on workplace
violence, and their results are disparate. The re-
sults of academic studies also vary considerably.
In addition, inconsistency in defining categories
of violence (e.g., verbal assault, threats, physical
assault, and battery) compromise reliability among
9-1 3
One review showed that no two stud-
ies have used the same instrument to measure
workplace violence in the emergency depart-
and nearly every study method was based
on voluntary retrospective surveys, an approach
that risks both selection bias and recall bias.
Furthermore, data from the federal Bureau of
Labor Statistics may be grossly inaccurate,
shown by one study in which investigators found
that the actual number of reportable injuries was
as much as three times the number in the fed-
eral sur vey.
Since the Bureau of Labor Statistics
does not record verbal incidents, the prevalence
of workplace violence cannot be reliably gauged
on the basis of data from the agency.
these limitations, the statistics on the prevalence
of workplace violence in the health care setting
remain alarming.
Most studies on workplace violence have been
designed to quantify the problem, and few have
described research on experimental methods to
prevent such violence. The most recent critical
review of the literature in 2000 identified 137
studies that described strategies to reduce work-
place violence. Of these studies, 41 suggested
specific interventions, but none provided empiri-
cal data showing whether or how such strategies
worked. Only 9 studies, all of which were health
care–related, reported data on interventions. Even
so, the conclusion of the 9-study review was that
each of the studies used weak methods, had in-
conclusive results, and used flawed experimental
A review of nursing literature had
similar conclusions: all the studies showed that
after training, nurses had increased confidence
and knowledge about risk factors, but no change
was seen in the incidence of violence perpetrated
by patients. There is a lack of high-quality re-
search, and existing training does not appear to
reduce rates of workplace violence.
Proving that prevention programs are effica-
cious and cost-effective requires scientific experi-
mentation, and designing such experiments has
proved to be challenging. Without standardized
definitions, it will remain difficult for research-
ers to combine or compare data, assess interven-
tions, and detect temporal changes. The use of
existing legal classifications of assault, aggravat-
ed assault, and battery may help to facilitate ac-
curate multidisciplinary work among researchers,
law enforcement, and policymakers.
Workplace Violence in
Non-Hospital Settings
Prehospital Settings
For many patients, medical events start with
emergency medical services. One prospective
study that was specifically designed to limit re-
call bias determined that 4.5% of violent en-
counters involving health care workers involved
violence directed against emergency medical ser-
vices personnel. Patients accounted for 90% of
this violent behavior.
A 2014 retrospective sur-
vey showed that the career prevalence of physical
violence toward emergency services personnel
was 80%, yet only 49% ever reported the incident
to the police.
Primary Care and Other Office-Based Practices
Workplace violence in outpatient practices is a
complex problem about which very little is known.
An extensive literature review was unable to
identify any peer-reviewed studies defining the
scope of the problem in office-based practices,
including primary care, family medicine, internal
medicine, and surgery and surgical subspecialties
Type Description Example
IPerpetrator has no association with the
workplace or employees Person with criminal intent
commits armed robbery
II Perpetrator is a customer or patient of
the workplace or employees Intoxicated patient punches
nurse’s aide
III Perpetrator is a current or former employee
of the workplace Recently fired employee as-
saults former supervisor
IV Perpetrator has a personal relationship with
employees, none with the workplace Ex-husband assaults ex-wife
at her place of work
* Data are from Howard
and Peek-Asa et al.
Table 1. Types of Workplace Violence.*
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
Workplace Violence against Health Care Workers
in the United States. Despite the lack of formal
reports, there is certainly reason for concern.
Just days before the murder at Brigham and
Women’s Hospital, a Veterans Affairs psycholo-
gist was killed in his clinic by a patient in El Paso,
Tex as.
Last month, a urologist in New Orleans
was shot and killed in his office by a former
patient, who then committed suicide. Many inter-
national studies have shown high rates of abuse
toward family physicians, particularly in Cana-
dian and Australian health systems, primarily by
patients with mental illness or displaying narcotic-
seeking behavior. Studies of the U.S. health care
system are needed to further define the extent
of such violence.
Home Health Care
Employment in the home health sector carries
particular risks. Because workers provide care in
the client’s home, the environment is compara-
tively uncontrolled. Overall, 61% of home care
workers report workplace violence annually.
Unique concerns include the presence of weap-
ons and drugs, family violence, robbery, and car
Homicide is the second leading cause of
workplace death in this group, exceeded only
by motor vehicle crashes.
Hospital Workplace Violence
Certain hospital environments are more prone to
type II workplace violence than are other settings.
The emergency department and psychiatric wards
are the most violent, and well-studied, hospital
environments. Within these locations, physicians,
nurses, technicians, and other staff members
may be victims. There is a paucity of research in
other hospital areas.
Against Nurses
Since rates of assault correlate with patient-
contact time, nurses and nursing aides are vic-
timized at the highest rates.
14,17,2 6 -3 0
In the Minne-
sota Nurses’ Study, the annual incidence of verbal
and physical assaults was 39% and 13%, respec-
In another large study, 46% of nurses
reported some type of workplace violence during
their five most recent shifts; of these nurses, one
third were physically assaulted.
Emergency department nurses reported the
highest rates, with 100% reporting verbal assault
and 82.1% reporting physical assault during the
previous year.
Nursing aides are also at very
high risk,
particularly those in nursing homes
that have dementia units.
Among nursing home
aides, 59% reported being assaulted weekly and
16% daily. In addition, 51% reported that they
had been physically injured by a patient, with
38% of those requiring medical attention.
Against Physicians
Physicians are also frequent targets of type II
workplace violence; approximately one quarter
of emergency medicine physicians reported be-
ing targets of physical assault in the previous
17, 27, 35
From 1993 through 2001, violence
against physicians occurred at a rate of 10.1 per
1000 workers, comprising 1.1% of all workplace
violence incidents.
In a study conducted by
Kowalenko et al. at the University of Michigan,
89% of assaults against physicians were perpe-
trated by patients, 9% by patients’ family mem-
bers, and 2% by patients’ friends.
78% of emergency department physicians re-
ported being targets of workplace violence in the
previous 12 months. Specifically, 75% reported
verbal threats, 21% physical assaults, 5% con-
frontations outside the workplace, and 2% stalk-
Of course, workplace violence is not limited
to emergency department physicians. For in-
stance, one third of pediatrics residents reported
being assaulted by patients or families during
their training.
A total of 71% of pediatrics
residents reported that they had not received any
type of training in workplace violence, and a
majority of these residents believed that they
might benefit from training in how to manage
client anger.
Psychiatric Settings
All employees who work in inpatient psychiatric
environments are at higher risk for targeted vio-
lence than are other health care workers.
Rates of workplace violence against physicians
in psychiatric settings may be even higher than
those in emergency department settings, with
40% of psychiatrists reporting physical assault
in one study.
A survey of all staff members at a
forensic psychiatric hospital showed that the an-
nual incidence of verbal conflict was 99% and
the annual incidence of physical assault was
Among psychiatric aides, the rate is 69
times the national rate of violence in the work-
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
new england journal
Barriers to Reporting
In order to assess progress in strategies to re-
duce workplace violence, we need accurate base-
line statistics to ascertain the true extent of the
problem. There are several reasons why this data
set has not yet been collected. Episodes of work-
place violence of all categories are grossly under-
reported.7,11,15,16,20,44 Only 30% of nurses report
incidents of workplace violence31; among physi-
cians, the reporting rate is 26%.37 Underreporting
is due in part to a health care culture that is re-
sistant to the belief that providers are at risk for
patient-initiated violence and to a complacency
in thinking that violence is “part of the job.”14
Providers are sometimes uncertain what con-
stitutes violence, since they often believe that
their assailants are not responsible for their ac-
tions in such cases.41 Perpetrators most common-
ly have a diagnosis of psychosis, substance-use
disorders, or dementia,26 and perhaps events are
not reported because providers believe that these
patients are not in full control of their faculties.
Nurses have cited fear of retribution from super-
visors, the complexity of the legal system, and
disapproval of administrators as barriers to the
reporting of workplace violence. Specifically, they
cite a lack of management accountability toward
such reporting41 and contend that the current
intense focus on customer service in health care
serves as a deterrent to reporting workplace vio-
lence, since the concept of customer service re-
sults in the mentality that “the customer is always
right.”45 Until these impediments are removed by
health care institutions, by legislation, or by pub-
lic demand after another highly publicized attack,
we should not expect a major change in report-
ing practices.
Characteristics of Violent
Offenders and Risk Factors
The characteristic that is most common among
perpetrators of workplace violence is altered men-
tal status associated with dementia, delirium,
substance intoxication, or decompensated men-
tal illness.7,9,32,33,37,46 The primary purpose of pro-
filing is to identify persons at high risk for com-
mitting workplace violence so that safeguards
can be implemented to prevent violence before it
occurs. Although specific environments such as
psychiatric units, nursing homes, and emergency
departments are at high risk,7 predicting the
likelihood of workplace violence according to
medical diagnosis or trait has proved to be elu-
sive and can lead to discrimination against par-
ticular types of patients. Studies that have been
performed in emergency departments have sug-
gested that long wait times, crowding, inade-
quate food quality, being given “bad news” related
to diagnosis or prognosis, low socioeconomic
status, presence of weapons, and gang activity are
possible risk factors for workplace violence.7,47 In
some studies, researchers have postulated that
patients with a previous history of violence14 are
at increased risk for committing violence toward
staff members; however, this association remains
unproven. Analyses of demographic data from
perpetrators and victims have not identified spe-
cific characteristics that are useful in predicting
the risk of workplace violence.48,49 However, spe-
cial consideration should be given to patients who
are in police custody, since such patients have
been involved in 29% of shootings in emergency
departments, with 11% occurring during escape
Regarding specific environmental risk factors
for workplace violence, the guidelines of the Oc-
cupational Safety and Health Administration
(OSHA) identify employment in a high-volume
urban emergency department as a specific risk
factor.7 However, a prospective study showed that
the rates of violence among emergency depart-
ment workers in suburban hospitals were similar
to those among their counterparts at both urban
and level-one trauma centers.17
According to the National Crime Victimiza-
tion Survey from 1993 through 1999, 80% of all
workplace homicides were committed with fire-
arms.51 Between 2000 and 2011, there were 154
shootings with injury either inside or on the
grounds of American hospitals, most frequently
outdoors on the hospital campus (41%), in the
emergency department (29%), or on inpatient
floors (19%). The most frequently ascribed mo-
tives were revenge (27%), suicide (21%), and
mercy killing (14%).52 In nearly 20% of the inci-
dents, the perpetrators did not bring their own
firearm to the hospital, and in 8% of all events
the perpetrator took the gun from a police or
security officer.50 In 28% of events involving
firearms, a law enforcement officer shot a per-
petrator in the hospital.52
Events involving active shooters garner tre-
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
Workplace Violence against Health Care Workers
mendous media attention but are actually quite
rare. The Federal Bureau of Investigation recog-
nizes a total of 160 active-shooter events between
2000 and 2013.
Response training for active-
shooter events is now nearly universal in hospi-
tals, even though only 4 of the 160 events (2.5%)
occurred at health care facilities. Although such
training is important, experts in the field rec-
ommend the adoption of a comprehensive “all
hazards” approach
in the teaching of general
skills to help protect workers from all causes of
workplace violence. They have also suggested that
hospitals prohibit all firearms from campus with
the exception of weapons used by law-enforce-
ment offers, which should be restricted from all
possible access by patients or other visitors. The
recommendations include the development of ra-
tional policies in coordination with law-enforce-
ment agencies along with secure weapons stor-
age for patrons and police.
Use of Metal Detectors
Hospital security discussions typically include de-
bate regarding the reliability, public perception,
and cost-effectiveness of metal detectors. Such
devices seem to be an obvious choice to keep
weapons from entering facilities illegally, and
security researchers have studied the use of de-
tectors far more than other implemented coun-
termeasures. Less than 15% of emergency de-
partments nationwide were using metal detectors
as of 2008 (the most recent year for which ac-
curate data are available).
Pediatric emergency
departments are not immune to weapons and
yet only 6% have installed metal de-
tectors. In a 2003 study, one emergency depart-
ment with a metal detector confiscated 3446
weapons in 8 months; of these weapons, 78%
were knives or other cutting implements. Fire-
arms were very uncommon (0.1%).
the key question remains: do metal detectors
reduce workplace violence in hospitals? A 1999
study showed no decrease in emergency depart-
ment violence despite a large increase in the
number of confiscated weapons after metal de-
tectors were installed.
In addition, 41% of
weapons were confiscated from patients who had
bypassed walk-through screening because they
arrived on a metal stretcher by ambulance.
Complicating the notion of metal-detector use is
the concern about negative public perception,
even though most patients and employees be-
lieve that metal detectors contribute to a safer
environment without undue invasion of their
The federal government recommends
that any metal-detection program also incorpo-
rate the use of radiographic equipment to ex-
amine bags and purses for contraband and that
each site be staffed with up to nine full-time
Although metal detectors may theoretically
mitigate violence in the health care workplace,
there is no concrete evidence to support this
expectation. Without evidence of benefit, health
care administrators are unlikely to favor the in-
stallation of metal detectors, given the financial
requirements for equipment and personnel to
monitor the machines and the need to close off
all unequipped entrances. Each facility along with
its catchment area is unique, and such security
measures may be more beneficial in areas where
weapons are more commonly carried and used.
However, since weapons are used in less than
1% of type II episodes of violence in the health
care workplace,
safety resources might be bet-
ter applied elsewhere.
Existing Guidelines
With the exception of laws regarding workplace
violence in a few states (Fig. 1),
health care
organizations are not required to have highly
specific prevention strategies in place.
has provided guidelines to reduce the risk of work-
place violence in health care settings.
these guidelines are voluntary, so administrators,
managers, and policymakers may be unfamiliar
with them.
The Joint Commission has vague
policy requirements regarding workplace vio-
lence, and these are open to interpretation.
Long-Term Effects of Workplace
Most studies have shown that after an episode of
workplace violence, there are increased rates of
missed workdays (Fig. 2), burnout, and job dis-
satisfaction along with decreased productivity
and overall feelings of safety among staff mem-
In response, fear at work
has even led some health care workers to protect
themselves by carrying weapons, typically knives
or firearms.
Injuries associated with workplace
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
new england journal
violence result in longer work absences than
other injuries.
Potential Solutions
Although there are numerous suggestions for
reducing type II workplace violence, few if any
have supporting evidence to document their ef-
ficacy. This fact is partly a result of the diffi-
culty experts have had in designing experiments
to test hypothetical interventions. Metal detectors
have received scientific attention, as mentioned,
and Kowalenko et al. have developed a tool that
uses filmed vignettes of violent acts in the emer-
gency department to gauge the reactions of health
care workers. The tool has been shown to be
accurate and reliable in characterizing such epi-
sodes across all demographic and employment
In the absence of other evidence-based
solutions, the opinions of experts matter, and
their suggestions could be used to direct new
research. A multifaceted, multidisciplinary ap-
proach to violence reduction is necessary to gen-
erate results, and any prevention program will
require individualization and customization.
The development of an appropriate program
to prevent workplace violence requires the con-
sideration of issues involving individual workers,
law-enforcement officials, and health care orga-
nizations to determine vulnerabilities and solu-
tions. Among strategies for individual workers
that have been proposed to reduce workplace
violence are training in aggression de-escalation
techniques and training in self-defense. Recom-
mendations for target hardening of infrastruc-
ture include the installation of fences, security
cameras, and metal detectors and the hiring of
guards. Perhaps most important are recommen-
dations that health care organizations revise
their policies in order to improve staffing levels
Figure 1. States with Enhanced Penalties for Violence against Health Care Workers.
Shown are states that have adopted enhanced penalties for violence against health care workers, including against
first responders and emergency medical services (EMS) workers only or against nurses and other specified workers
(with laws varying according to state). Also shown are states that have no enhanced penalties except for such spe-
cific acts as assault with bodily fluids (in Montana). Among laws that apply to specific types of health care workers
are those that call for enhanced penalties for violence against EMS workers and personnel at state mental health
facilities in Kansas and against EMS workers, public health personnel, and social workers in Mississippi. Adapted
from the Emergency Nurses Association.
Arizona Arkansas
Washington, D.C.
Illinois Indiana
New Hampshire
New Jersey
New Mexico
North Carolina
Rhode Island
South Dakota
North Dakota
New York
No enhanced penalties
Protection for first
responders and EMS only
Protection for nurses
and others (laws vary
by state)
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
Workplace Violence against Health Care Workers
during busy periods to reduce crowding and wait
times, decrease worker turnover, and provide
adequate security and mental health personnel
on site.
The answer probably involves a com-
bination of these ideas. In 2014, Arnetz et al.
described a large, randomized, controlled study
that is currently under way in a large U.S. hospi-
tal system that is aimed specifically at reducing
the prevalence and severity of workplace violence
with the use of a standardized intervention.
Ideally, policy changes and interventions would
be based on the results of such research studies.
Reporting and Redress
The importance of recognizing verbal assault as
a form of workplace violence cannot be over-
looked, since verbal assault has been shown to
be a risk factor for battery.
The “broken win-
dows” principle,
a criminal-justice theory that
apathy toward low-level crimes creates a neigh-
borhood conducive to more serious crime, also
applies to workplace violence.
When verbal
abuse and low-level battery are tolerated, more
serious forms of violence are invited.
threatening language and signs of agitation are
identified, interventions should be initiated
quickly. The cautious application of a so-called
zero tolerance reporting policy, in which all epi-
sodes of workplace violence are immediately re-
ported to supervisors and security personnel and
are addressed with the perpetrator, may prevent
All cases of workplace vio-
lence should be reviewed.
New Guidelines and Legislation
The American Nurses Association has petitioned
OSHA to require mandatory comprehensive pro-
grams to prevent workplace violence.
The Joint
Commission and other accrediting organizations
could assume responsibility to do the same. Al-
though laws that are designed to prevent vio-
lence in the health care workplace have been
adopted in only a handful of states, policymakers
could evaluate the effectiveness of such laws and
consider adoption of those that have been effec-
tive in mitigating workplace violence.
tion that makes battery against a health care
worker a felony offense could be considered by
all states to protect vulnerable providers.
At the facility level, supervisor support was
found to be protective against harassment and
all types of violence.
There is currently no
universally applicable training program that has
proved to be effective at reducing type II vio-
lence. In the absence of such evidence, hospital
employees should be encouraged to be vigilant
and to report incidents of workplace violence.
Health care facilities could devise a system of
flagging a patient’s chart if the person has previ-
ously been violent during health care interactions
in order to alert staff members to the potential
threat, since such measures have prevented recur-
rence in the Veterans Affairs system.
Like all other workers, health care employees
have a right to be safe on the job. In the absence
of data that define effective steps to prevent
workplace violence, approaches to the problem
may be considered at various levels. Legislators
may consider enacting harsher punishments for
violence against health care workers as a special
class of offense. Health care employers who are
eager to ensure safe working environments for
their employees may help do so by adopting
simple incident-reporting procedures that pro-
tect complainants from retribution, ensure com-
prehensive managerial support, and support the
implementation of cost-effective, evidence-based
solutions as they are discovered. Future research
efforts should be devoted to unbiased data collec-
Figure 2. Rates of Workplace Violence with Injury Requiring Missed Workdays.
Shown are the rates of violent episodes resulting in injury-related missed
workdays per 10,000 workers in private industries, state industries, private
health care and social services, and state health care and social services in
2012 through 2014. Data are from the federal Bureau of Labor Statistics.
Rate (per 10,000 workers)
All private
All state
Private health care
and social services
State health care
and social services
2012 2013 2014
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
new england journal
tion, experimental designs, and improved report-
ing processes.
No potential conflict of interest relevant to this article was
Disclosure forms provided by the author are available w ith the
full text of this article at
I thank Jonathan Edlow, M.D., and Gregory Ciottone, M.D.,
for their guidance and support; and Oluseyi Aliu, M.D., and
Timothy L. Weston, LL.M., for their assistance.
1. Rugala EA, Isaacs AR, eds. Workplace
violence: issues in response. Quantico, VA:
Critical Incident Response Group, National
Center for t he Analysis of Violent Crime, FBI
Academy, 2003 (https:/ / www .fbi .gov/ stats
-services/ publications/ workplace-violence).
2. Preventing violence in the health care
setting. Sentinel Event Alert 2010; 45: 1-3.
3. Harrell E. Workplace violence, 1993-
2009. Washingt on, DC: Department of Jus-
tice, Bureau of Justice Statistics, National
Crime Victimization Survey, 2011 (http://
www .bjs .gov/ content/ pub/ pdf/ wv09 .pdf ).
4. Howard J. State and local regulatory
approaches to preventing workplace vio-
lence. Occup Med 1996; 11: 293-301.
5. Peek-Asa C, Howard J, Vargas L, Kraus
JF. Incidence of non-fatal workplace as-
sault injuries determined from employer’s
reports in California. J Occup Environ Med
1997; 39: 44-50.
6. Vellani KH. The 2014 IHSSF crime
surve y. J Healthc Prot Manage 2014; 30: 28-
7. Occupational Safety and Health Ad-
ministration. Guidelines for preventing
workplace violence for healthcare and so-
cial service workers (OSHA, 3148-04R).
Washingt on, DC: OSHA, 2015 (ht tps:/ / www
.osha .gov/ Publications/ osha3148 .pdf)
8. Census of Fatal Occupational Injuries
(CFOI) — current and revised data. Wash-
ington, DC: Bureau of Labor Statistics,
2014 (http://www .bls .gov/ iif/ oshcfoi1 .htm).
9. Pompeii L, Dement J, Schoenfisch A,
et al. Perpetrator, worker and workplace
characteristics associated with patient and
visitor perpetrated violence (type II) on
hospital workers: a review of the litera-
ture and existing occupational injury data.
J Safety Res 2013; 44: 57-64.
10. Hahn S, Zeller A, Needham I, Kok G,
Dassen T, Halfens RJ. Patient and visitor
violence in general hospitals: a systematic
review of the literature. Aggress Violent
Behav 2008; 13: 431-41.
11. Ruser JW. Examining evidence on
whether BLS undercounts workplace inju-
ries and illnesses. Monthly Labor Review.
August 2008: 20-32 (http://www .bls .gov/
opub/ mlr/ 2008/ 08/ art2full .pdf).
12. Lau JB, Magarey J. Review of research
methods used to investigate violence in
the emergency department. Accid Emerg
Nurs 2006; 14: 111-6.
13. Taylor JL, Rew L. A systematic review
of the lit erature: workplace violence in the
emergency department. J Clin Nurs 2011;
20: 1072-85.
14. McPhaul KM, Lipscomb JA. Work-
place violence in health care: recognized
but not regulated. Online J Issues Nurs
2004; 9: 7.
15. Wuellner SE, Bonauto DK. Exploring
the relationship between employer record-
keeping and underreporting in the BLS
Survey of Occupational Injuries and Ill-
nesses. Am J Ind Med 2014; 57: 1133-43.
16. 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: 357-65.
17. Kowalenko T, Gates D, Gillespie GL,
Succop P, Mentzel TK. Prospective study
of violence against ED workers. Am J
Emerg Med 2013; 31: 197-205.
18. Runyan CW, Zakocs RC, Zwerling C.
Administrative and behavioral interven-
tions for workplace violence prevention.
Am J Prev Med 2000; 18: Suppl: 116-27.
19. Heckemann B, Zeller A, Hahn S, Das-
sen T, Schols JM, Halfens RJ. The effect
of aggression management training pro-
grammes for nursing staff and students
working in an acute hospital setting:
a narrative review of current literature.
Nurse Educ Today 2015; 35: 212-9.
20. Grange JT, Corbett SW. Violence
against emergency medical ser vices person-
nel. Prehosp Emerg Care 2002; 6: 186-90.
21. Furin M, Eliseo LJ, Langlois B, Fernan-
dez WG, Mitchell P, Dyer KS. Self-reported
provider safety in an urban emergency
medical system. West J Emerg Med 2015;
16: 459-64.
22. Thompson M. Killed in action, far
from the battlefield. January 9,
2015 (http://time .com/ 3661300/ veterans
23. Hanson GC, Perrin NA, Moss H, Lahar-
nar N, Glass N. Workplace violence against
homecare workers and its relationship
with workers health outcomes: a cross-
sectional study. BMC Public Health 2015;
15: 11.
24. Gross N, Peek-Asa C, Nocera M,
Casteel C. Workplace violence prevention
policies in home health and hospice care
agencies. Online J Issues Nurs 2013; 18: 1.
25. Hoskins AB. Occupational injuries, ill-
nesses, and fata lities among nursing, psy-
chiatric, and home health aides, 1995–
2004. Washington, DC: Bureau of Labor
Statistics, June 30, 2006 (http://ww w .bls
.gov/ opub/ mlr/ cwc/ occupational-injuries
-20 04 .pdf ).
26. Lehmann LS, McCormick RA, Kizer
KW. A survey of assaultive behavior in
Veterans Health Administration facilities.
Psychiatr Serv 1999; 50: 384-9.
27. Pompeii LA, Schoenfisch AL, Lips-
comb HJ, Dement JM, Smith CD, Upad-
hyaya M. Physical assault, physical threat,
and verbal abuse perpetrated against hos-
pital workers by patients or visitors in six
U.S. hospitals. Am J Ind Med 2015; 58:
1194-2 04.
28. Gates DM, Ross CS, McQueen L. Vio-
lence against emergency department work-
ers. J Emerg Med 2006; 31: 331-7.
29. Gerberich SG, Church TR, McGovern
PM, et al. An epidemiological study of the
magnitude and consequences of work re-
lated v iolence: the Minnesota Nurses’ Stud y.
Occup Environ Med 2004; 61: 495-503.
30. Lanza ML, Zeiss RA, Rierdan J. Non-
physical violence: a r isk factor for physical
violence in health care settings. AAOHN J
2006; 54: 397-402.
31. Duncan S, Estabrooks CA, Reimer M.
Violence aga inst nurses. Alt a RN 2000; 56:
32. May DD, Grubbs LM. The extent, na-
ture, and precipitating factors of nurse
assault among three groups of registered
nurses in a regional medical center.
J Emerg Nurs 2002; 28: 11-7.
33. Tak S, Sweeney MH, Alterman T, Baron
S, Calvert GM. Workplace assaults on nurs-
ing assist ants in US nursing homes: a multi-
level analysis. Am J Public Health 2010;
100: 1938-45.
34. Gates D, Fitzwater E, Telintelo S, Suc-
cop P, Sommers MS. Preventing assaults
by nursing home residents: nursing assis-
tants’ knowledge and confidence — a pilot
study. J Am Med Dir Assoc 2002; 3: 366-70.
35. Kowalenko T, Walters BL, Khare RK,
Compton S. Workplace violence: a survey
of emergency physicians in the state of
Michigan. Ann Emerg Med 2005; 46: 142-7.
36. Perkins CA. Weapon use and violent
crime: National Crime Victimization Sur-
vey, 1993-2001. Washington, DC: Depart-
ment of Justice, Off ice of Justice Programs,
Bureau of Just ice Statistics, September 2003
(http://www .bjs .gov/ content/ pub/ pdf/
wuvc01 .pdf ).
37. Behnam M, Tillotson RD, Davis SM,
Hobbs GR. Violence in the emergency de-
partment: a national survey of emergency
medicine residents and attending physi-
cians. J Emerg Med 2011; 40: 565-79.
38. Judy K, Veselik J. Workplace violence:
a surve y of paediatric residents. Occup Med
(Lond) 2009; 59: 472-5.
39. Nonfatal occupational injuries and
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
n engl j med 374;17 April 28, 2016
Workplace Violence against Health Care Workers
illnesses requiring days away from work,
2010. Washington, DC: Bureau of Labor
and Statistics, Department of Labor, 2011.
40. Gerberich SG, Church TR, McGovern
PM, et al. Risk factors for work-related as-
saults on nurses. Epidemiology 2005; 16:
41. Privitera M, Weisman R, Cerulli C,
Tu X, Groman A. Violence toward mental
healt h staff and s afety in the work envi ron-
ment. Occup Med (Lond) 2005; 55: 480-6.
42. Kelly EL, Subica AM, Fulginiti A,
Brekke JS, Novaco RW. A cross-sectional
survey of factors related to inpatient as-
sault of staff in a forensic psychiatric hos-
pital. J Adv Nurs 2015; 71: 1110-22.
43. Longton J. A look at violence in the
workplace against psychiatric aides and
psychiatric technicians. Monthly Labor
Review. March 2015 (http://www .bls .gov/
opub/ mlr/ 2015/ article/ a-look-at-violence-in
-and-psychiatric-technicians-1 .htm).
44. Findorff MJ, McGovern PM, Wall MM,
Gerberich SG. Reporting violence to a
health care employer: a cross-sectional
study. AAOHN J 2005; 53: 399-406.
45. Blando J, Ridenour M, Hartley D,
Casteel C. Barriers to effective implemen-
tation of programs for the prevention of
workplace violence in hospitals. Online J
Issues Nurs 2015; 20.
46. Violence: occupational hazards in hos-
pitals. Atlanta: National Institute for Oc-
cupational Safety and Health, April 2002
(http://www .cdc .gov/ niosh/ docs/ 2002-101).
47. Gacki-Smith J, Juarez AM, Boyett L,
Homeyer C, Robinson L, MacLean SL.
Violence against nurses working in US
emergenc y department s. J Nurs Adm 2009;
39: 340-9.
48. Hartley D, Doman B, Hendricks SA,
Jenkins EL. Non-fatal workplace violence
injuries in the United States 2003-2004:
a follow back study. Work 2012; 42: 125-35.
49. Gates D, Gillespie G, Kowalenko T,
Succop P, Sanker M, Farra S. Occupational
and demographic factors associated with
violence in the emergency department.
Adv Emerg Nurs J 2011; 33: 303-13.
50. Kelen GD, Catlett CL, Kubit JG, Hsieh
YH. Hospital-based shootings in the United
States: 2000 to 2011. Ann Emerg Med
2012; 60(6): 790-8. e1.
51. Duhar t DT. Violence in t he workplace,
1993-99. Washington, DC: Department of
Justice, Office of Justice Programs, De-
cember 2001 (http://www .bjs .gov/ content/
pub/ pdf/ vw99 .pdf).
52. Harnum J. Hospital gun discharge
events 2011-2013. J Healthc Prot Manage
2014; 30: 36-46.
53. Blair JP, Schweit KW. A study of active
shooter incidents, 2000-2013. Washing-
ton, DC: Texas State Universit y and Fed-
eral Bureau of Investigation, Department
of Justice, 2014 (https:/ / www .f bi .gov/
about-us/ office-of-partner-engagement/
active-shooter-incidents/ a-study-of-active
-shooter-incidents-in-the-u .s .-2000-2013).
54. Callaway DW, Phillips JP. Active shoot-
er response. In: Ciottone G, ed. Ciottone’s
disaster medicine. 2nd ed. Philadelphia:
Elsevier Health Sciences, 2015: 424-30.
55. Experts advise hospitals to heed warn-
ing signs, leverage security to prepare
against shootings. ED Manag 2014; 26: 97-
56. Kansagra SM, Rao SR, Sullivan AF,
et al. A survey of workplace violence across
65 U.S. emergency departments. Acad
Emerg Med 2008; 15: 1268-74.
57. Simon HK, Khan NS, Delgado CA.
Weapons detection at t wo urban hospi-
tals. Pediatr Emerg Care 2003; 19: 248-51.
58. Rankins RC, Hendey GW. Effect of a
security system on violent incidents and
hidden weapons in the emergency depart-
ment. Ann Emerg Med 1999; 33: 676-9.
59. Mattox EA, Wright SW, Bracikowski
AC. Metal detectors in the pediatric emer-
gency department: patron attitudes and
national prevalence. Pediatr Emerg Care
2000; 16: 163-5.
60. McNamara R, Yu DK, Kelly JJ. Public
perception of safety and metal detectors
in an urban emergency department. Am J
Emerg Med 1997; 15: 40-2.
61. Meyer T, Wrenn K, Wright SW, Glaser
J, Slovis CM. Attitudes toward the use of a
metal detector in an urban emergency de-
part ment. Ann Emerg Med 1997; 29: 621-4.
62. Green MW. The appropriate and ef-
fective use of securit y technologies in U.S.
schools: a guide for schools and law en-
forcement agencies. Washington, DC: De-
partment of Justice, 1999 (https:/ / www
.ncjrs .gov/ school/ 178265 .pdf).
63. State issues. Chicago: Emergency Nurs-
es Association (https:/ / ena .org/ government/
State/ Pages/ Default .aspx).
64. Peek-Asa C, Casteel C, Allareddy V,
et al. Workplace violence prevention pro-
grams in hospit al emergency depart ments.
J Occup Environ Med 2007; 49: 756-63.
65. McGovern P, Kochevar L, Lohman W,
et al. The cost of work-related physical
assaults in Minnesota. Health Serv Res
2000; 35: 663-86.
66. Blando JD, McGreevy K, O’Hagan E,
et al. Emergency department security pro-
grams, community crime, and employee
assaults. J Emerg Med 2012; 42: 329-38.
67. Campbell JC, Messing JT, Kub J, et al.
Workplace violence: prevalence and risk
factors in the Safe at Work Study. J Occup
Environ Med 2011; 53: 82-9.
68. Canton AN, Sherman MF, Magda LA,
et al. Violence, job satisfaction, and em-
ployment intentions among home health-
care registered nurses. Home Healthc
Nurse 2009; 27: 364-73.
69. Nachreiner NM, Gerberich SG, Ryan
AD, McGovern PM. Minnesota Nurses’
Study: perceptions of violence and the work
environment. Ind Health 2007; 45: 672-8.
70. Kowalenko T, Hauff SR, Morden PC,
Smith B. Development of a data collection
instrument for violent patient encounters
against healthcare workers. West J Emerg
Med 2012; 13: 429-33.
71. Henson B. Preventing interpersonal
violence in emergency departments: prac-
tical applications of criminology theory.
Violence Vict 2010; 25: 553-65.
72. 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: 1276-84.
73. Kelling GL, Wilson JQ. Broken win-
dows: the police and neighborhood safe-
ty. Atlantic Monthly. March 1982: 29-38
(http://www .theatlantic .com/ magazine/
archive/ 1982/ 03/ broken-windows/ 304465/ ).
74. Hesketh KL, Duncan SM, Estabrooks
CA, et al. Workplace violence in Alberta
and British Columbia hospitals. Health
Policy 2003; 63: 311-21.
75. Kowalenko T, Cunningham R, Sachs
CJ, et al. Workplace violence in emergency
medicine: current knowledge and future
directions. J Emerg Med 2012; 43: 523-31.
76. ANA reaffirms dedication to improving
staffing for RNs and their patients (press
release). Silver Spring, MD: American Nurs-
es Association House of Delegates, June
21, 2012 (http://www .nursingworld .org/
FunctionalMenuCategories/ MediaResources/
PressReleases/ 2012-PR/ ANA-Reaffirms
-Staffing-for-RNs-and-Their-Patients .pdf).
77. Casteel C, Peek-Asa C, Nocera M, et al.
Hospital employee assault rates before
and after enactment of the California
Hospital Safet y and Securit y Act. Ann
Epidemiol 2009; 19: 125-33.
78. Findorff MJ, McGovern PM, Wall M,
Gerberich SG, Alexander B. Risk factors
for work related violence in a health care
organization. Inj Prev 2004; 10: 296-302.
79. Deery S, Walsh J, Guest D. Workplace
aggression: the effects of harassment on
job burnout and turnover intentions. Work
Employ Soc 2011; 25: 742-59 (http://wes
.sagepub .com/ content/ 25/ 4/ 742 .short).
80. Mohr DC, Warren N, Hodgson MJ,
Drummond DJ. Assault rates and imple-
mentat ion of a workplace violence preven-
tion program in the Veterans Health Care
Admin istration. J Occup Envi ron Med 2011;
53: 511-6.
Copyright © 2016 Massachusetts Medical Society.
The New England Journal of Medicine
Downloaded from by JAMES PHILLIPS on April 27, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.
... Ülkemizde de sağlık çalışanlarına yönelik yapılan şiddet benzer şekilde önemli bir sorundur (9,10). Şiddet; sağlık hizmeti sunucularının itibarını, çalışanların güvenliğini, sağlık profesyonellerinin sağlık ve sosyal refahını baltalamakla kalmayıp aynı zamanda sağlık çalışanlarına yönelik tehdit edici ve saldırgan davranışlar, işgücünün elde tutulmasını ve katılımını etkileyen ve hasta güvenliğini hatta sağlık hizmeti kalitesini etkileyen bir olgudur (11,12). ...
... Çalışmamıza katılanlar şiddetin en önemli nedenlerini sağlık çalışanlarının hasta ile ilgilenmemeleri, hastaların sabırsız olmaları, çalışanların hastalara kötü davranmaları, uzun bekleme süreleri ve çalışanların güler yüzlü olmamalarına atıfta bulunarak açıklamaya çalışmışlardır. Diğer çalışmalarda da benzer bulgular mevcuttur (9,12,27,29,32,40,41,42,54,55 ...
Amaç: Bu kesitsel çalışma Konya il merkezinde toplumun sağlık çalışanlarına yönelik şiddet konusundaki görüş ve tutumlarını değerlendirmek amacıyla yapılmıştır. Gereç ve Yöntem: Çalışma Konya ilinde ikamet eden 420 gönüllü katılımcı ile gerçekleşmiştir. Veri toplama aracı olarak araştırmacılar tarafından literatürden yararlanılarak hazırlanan ankette; sosyo-demografik soruların yanı sıra katılımcıların sağlık çalışanına şiddet konusundaki düşüncelerini değerlendiren sorular yer almaktadır. Çalışmada SPSS 25.0 paket programından yararlanılarak veriler üzerinde tanımlayıcı nitelikte istatistikler yapılmıştır. Bulgular ve Sonuç: Katılımcıların %45’i 18-29 yaş aralığında, %50,2’si kadın, %63,8’i evlidir. Katılımcılardan %63,3’ü sağlık çalışanlarına yönelik herhangi bir şiddet olayına tanıklık etmediğini %36,7’si sağlık çalışanına yönelik olarak gerçekleştirilen şiddete şahit olduklarını belirtmişlerdir. Sağlık çalışanlarına şiddet sebebi olarak ilk üç sırada “çalışanların hastalarla ilgilenmemesi”, “hastaların sabırsızlıkları” ve “çalışanların hastalara kötü davranmaları” gelmektedir. Katılımcıların %6’sı sağlık çalışanına şiddet uyguladığını, uyguladıkları ve şahit oldukları şiddet türünün çoğunlukla (%91) sözel şiddet olduğunu belirtmiştir. Toplumda sağlık çalışanına yönelik şiddeti onaylamayan bir tutumunun olduğu, şiddetin önlenebileceğine inandıkları ve şiddeti bir hak arama yöntemi olarak görmedikleri belirlenmiştir. Sağlık kurumlarında şiddetin nedenlerinin araştırılmasında toplumun görüşlerine de yer verilmesi şiddeti önlemeye yönelik girişimlerin başarısı açısından önemlidir.
... These data, however, might reflect only the tip of the iceberg, as it has been found that the actual prevalence of workplace violent incidents was as much as three times that reported by the federal survey, since verbal incidents are not recorded [23]. As mentioned above, violent incidents increase further when focusing on high-exposure settings, including EDs, as confirmed by the American College of Emergency Physicians (5), and MHUs, where rates of workplace physical violence against physicians appear even higher than those in EDs, with 40% of psychiatrists reporting physical assaults over the course of their careers [24]. ...
Full-text available
Purpose Violence against healthcare professionals has become an emergency in many countries. Literature in this area has mainly focused on nurses while there are less studies on physicians, whose alterations in mental health and burnout have been linked to higher rates of medical errors and poorer quality of care. We summarized peer-reviewed literature and examined the epidemiology, main causes, consequences, and areas of intervention associated with workplace violence perpetrated against physicians. Recent Findings We performed a review utilizing several databases, by including the most relevant studies in full journal articles investigating the problem. Workplace violence against doctors is a widespread phenomenon, present all over the world and related to a number of variables, including individual, socio-cultural, and contextual variables. During the COVID-19 pandemic, incidence of violence has increased. Data also show the possible consequences in physicians’ deterioration of quality of life, burnout, and traumatic stress which are linked to physical and mental health problems, which, in a domino effect, fall on patients’ quality of care. Summary Violence against doctors is an urgent global problem with consequences on an individual and societal level. This review highlights the need to undertake initiatives aimed at enhancing understanding, prevention, and management of workplace violence in healthcare settings.
... Emergency department health personnel are frequent victims of violence perpetrated by visitors and patients, resulting in injuries, acute stress, and loss of productivity 3 . Violence against health personnel is a complex problem, and rigorous research is lacking to address this issue 5,6,7,8 . ...
Full-text available
Objective: Violence in the workplace has been an alarming phenomenon around the world. The aim of this study was to analyze the frequency of violence against health personnel in urgent and emergency departments, before and during the COVID-19 pandemic. Methods: This is an exploratory cross-sectional study including a structured online survey with the approval of the Research Ethics Committee. The sample was composed of health personnel over 18 years old who work in urgent and emergency departments. The survey was structured with sections: sociodemographic data, detailing of occupational data, and a survey of physical, verbal, sexual, and racial violence. Descriptive statistics included absolute frequencies and percentages for categorical variables and means with standard deviation for continuous variables. Results: A total of 114 participants, aged between 20 and 60 years, answered the questionnaire; 68.4% of them were women. Most of them were white (71.9%), married or living with a partner (70.2%), residing in the south or southeast regions (85.1%) of Brazil, 56.1% doctors, 11.4% nurses, and 12.3% nursing technicians. The incidence of violence before the COVID-19 pandemic was 60%. During the pandemic, the incidence suffered low variation, being 57.9%. Only 37.7% said that their workplace offers some procedure/routine to report acts of violence suffered at work. Verbal violence was the most reported among the participants. Anxiety, tiredness, fear, low self-esteem, loss of concentration, and stress are the most frequent consequences of aggression. Conclusion: Our results suggest that the COVID-19 pandemic did not potentiate the episodes of violence; however, episodes of violence continue to occur, and so management and prevention measures must be implemented.
... [28], Bangladesh (64.2%) [29], Gambia (62.1%) [16] and south-west Nigeria (67%) [18]. On the other hand, a lower prevalence was noted in the studies conducted in the USA (46%) [30], Hong Kong (44.3%) [31], Italy (42%) [32], and in 5 European countries (54%) [33]. This prevalence gap is possibly due to the socio-economic difference noted between the developed and developing countries and it might be related to the gap between the services demanded by the service user and the service provided by the nurses. ...
Full-text available
Background Workplace violence is one of the global health concerns. Although nurses are the backbone of the health care provision, they are highly subjected to workplace violence in healthcare. Nevertheless, there is a paucity of evidence on the extent of workplace violence against nurses in Ethiopia in general and Eastern Ethiopia in particular. Hence, this study aimed to assess the extent of workplace violence against nurses and its associated factors among nurse professionals working at public hospitals in eastern Ethiopia. Methods Hospital-based cross-sectional study was conducted among 603 nurses working in public hospitals in eastern Ethiopia. Nurses were recruited using a simple random sampling method at their workplace (health facilities). A pretested self-administered questionnaire was used to collect data. Descriptive, binary and multivariable logistic regression analyses were performed. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to declare significant association. Results Among the 620 estimated sample, 603(97.3%) of the nurses gave consent and completed the self-administered questionnaire. The prevalence of workplace violence against nurse professionals in the last 12 months was 64.0% (95%CI: 60.2–67.7%). Nurses who were working in surgical (AOR: 2.30, 95%CI: 1.01–5.26), psychiatric (AOR: 3.06, 95%CI: 1.11–8.46), emergency (AOR: 3.62, 95%CI: 1.46–8.98), and medical wards (AOR: 5.20, 95%CI: 2.40–11.27); being worried of workplace violence (AOR: 1.71, 95%CI: 1.09–2.69); witnessed of physical workplace violence (AOR: 5.31, 95%CI: 3.28–8.59); claimed “absence/not-aware” of reporting procedure on workplace violence (AOR: 2.24, 95%CI: 1.45–3.46); and claimed “absence/not-aware” of institutional policies against workplace violence (AOR: 2.68, 95%CI: 1.73–4.13) were factors associated with nurses’ experience of workplace violence in eastern Ethiopia. Conclusions Workplace violence against nurses was found to be unacceptably high in the study area (eastern Ethiopia). We suggest that stakeholders could work on early risk identification and management of violent incidents, establish violence reporting and sanction mechanisms using contextual strategies to prevent workplace violence against nurse professionals.
... Workplace violence (WPV) is defined as "incidents where staff is abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being, or health" (Wynne et al., 1997), including physical and verbal violence, psychological abuse, sexual harassment and assault, and homicide (Di Martino, 2002). Being recognized as a global public health problem, WPV has affected the health sector disproportionately and become a major problem (Phillips, 2016). Health sector workers include doctors, nurses, and other staff who may be in direct contact with patients and visitors. ...
Full-text available
PurposeThis paper is an exploratory study to investigate possible remedial measures accounting for a relatively favorable prognosis of health sector workers who have experienced physical WPV in Zhejiang province, China.Methods Following a proportionate stratified sampling strategy, five tertiary hospitals (in the developed capital city of Hangzhou and other prefecture-level cities), eight secondary hospitals (in counties), and thirty-two primary care facilities (16 urban community health centers and 16 rural township health centers) were conveniently selected. Among 4,862 valid respondents out of 6,089 self-conducted questionnaires, 224 health sector workers who have been directly exposed to physical WPV in the past year were included in the present study.ResultsThe present study has three major findings: (1) Victims’ satisfaction with the resolution of the physical WPV conflict was directly associated with the favorable prognosis. (2) Taking days off from work after the violence can promote victims’ satisfaction with the resolution of the physical WPV conflict. (3) Knowing that relevant departments investigated the case can promote victims’ satisfaction with the resolution of the physical WPV conflict.Conclusion We propose a combined gesture of “offering adequate days off work after physical WPV” and “every physical violence must be investigated” that should be taken by all medical institutions in China. Health sector workers who get involved in physical WPV incidents should prioritize their safety and avoid any behavior that may intensify the conflicts.
... Open access such as burnout, stress, violence, injuries and musculoskeletal disorders in the healthcare industry. [11][12][13] Furthermore, the issue of occupational injuries and exposures in the healthcare sector is a threat to both the high-income and low/middle-income countries. However, there has been much reduction in the occurrence of exposure and improvement in ways of mitigating the burden of the exposure in developed countries compared with developing countries, where occupational health and safety are not on the priority list. ...
Full-text available
Objective The strict implementation of occupational health and safety policy curbs exposure to occupational hazards. However, empirical evidence is lacking in the Ghanaian context. This review primarily aimed to explore exposure to occupational hazards among healthcare providers and ancillary staff in Ghana. Design A scoping review was conducted based on Arksey and O’Malley’s methodological framework and Levac et al ’s methodological enhancement. Data sources Searches were conducted of the PubMed, MEDLINE, CINAHL, Embase, PsycINFO and Scopus databases, as well as Google Scholar and websites of tertiary institutions in Ghana, for publications from 1 January 2010 to 30 November 2021. Eligibility criteria Quantitative studies that were published in the English language and focused on occupational exposure to biological and/or non-biological hazards among healthcare professionals in Ghana were included. Data extraction and synthesis Two independent reviewers extracted the data based on the type of occupational exposure and descriptive characteristics of the studies. The data are presented in tables and graphs. A narrative summary of review findings was prepared based on the review research questions. Results Our systematic search strategy retrieved 507 publications; however, only 43 met the inclusion criteria. A little over one-quarter were unpublished theses/dissertations. The included studies were related to biological, psychosocial, ergonomic and other non-biological hazards. 55.8% of the studies were related to exposure to biological hazards and related preventive measures. In general, health workers were reported to use and comply with control and preventive measures; however, knowledge of control and preventive measures was suboptimal. Conclusion Work is needed to address the issue of occupational health hazard exposure in Ghana’s health system. More research is needed to understand the extent of these exposures and their effects on the health system.
Background Patient and health care worker safety is an interconnected phenomenon. To date, few studies have examined the relationship between patient and worker safety, specifically with respect to work safety culture. Therefore, we examined patient safety culture, workplace violence (WPV), and burnout in health care workers to identify whether patient safety culture factors influence worker burnout and WPV. Methods This cross-sectional study used secondary survey data sent to approximately 7,100 health care workers at a large academic medical center in the United States. Instruments included the Hospital Survey on Patient Safety Culture, a WPV scale measuring physical and verbal violence perpetrated by patients or visitors, and the Emotional Exhaustion scale from the Maslach Burnout Inventory. Findings These analyses included 3,312 (47%) hospital staff who directly interacted with patients. Over half of nurse (62%), physician (53%), and allied health professional respondents (52%) reported experiencing verbal violence from a patient, and 39% of nurses and 14% of physicians reported experiencing physical violence from a patient. Burnout levels for nurses (2.67 ± 1.02) and physicians (2.65 ± 0.93) were higher than the overall average for all staff (2.61 ± 1.0). Higher levels of worker-reported patient safety culture were associated with lower odds of WPV (0.47) and lower burnout scores among workers ( B = −1.02). Teamwork across units, handoffs, and transitions were dimensions of patient safety culture that also influenced WPV and burnout. Conclusions/Application to Practice Our findings suggest that improvements in hospital strategies aimed at patient safety culture, including team cohesion with handoffs and transitions, could positively influence a reduction in WPV and burnout among health care workers.
Full-text available
Introduction: Violence against Healthcare Workers (HCWs) remains underreported globally, and calls for increased public awareness and education. We aim to report the nature of violence in the healthcare system, its risk factors, impact, and potential mitigation strategies. Methods: We conducted a global cross-sectional study called ViSHWaS - Violence Study of Healthcare Workers and Systems. The survey questionnaire was created using REDCap forms and distributed from June 5 to August 6, 2022. This study was exempted from Institutional Review Board. Findings: A total of 5,405 (79 countries) responses were analyzed, India, USA, and Venezuela were with the most responses. Of these, 53% were females, and the majority (45%) were within 26-35 years. The top four categories of respondents were medical students (21%), followed by consultants (20%), residents/fellows (15%), and nurses (10%). Fifty-five percent of HCWs reported experiencing violence first-hand, and 16% reported violence against their colleagues. Patients or their family members were described as the perpetrator in > 50% of cases, whereas 16% reported facing aggression from their supervisors. A majority (80%) reported that the incidence of violence has either stayed constant or increased during the COVID-19 pandemic. Fifty-five percent of HCWs who experienced violence felt less motivated or more dissatisfied with their job after the event, and an additional 25% were willing to quit. Interpretations: In a global cross-sectional study, violence against HCWs is reported by the majority of the HCWs. The incidence either increased or stayed the same during the COVID-19 pandemic. This has led to decreased job satisfaction.
Full-text available
Objectives This study is conducted to examine whether overall workplace violence (WPV) and its five types are associated with high burn-out among healthcare workers in China. Design A WeChat-based cross-sectional survey. Snowball sampling was used in this study. Participants Front-line healthcare workers (N=3706) from 149 cities across 23 provinces in China responded to the survey, and 22 questionnaires were excluded because of incomplete data. Primary and secondary outcome measures (1) The Chinese Maslach Burnout Inventory-General Survey was used to measure high burn-out. (2) WPV was assessed using the Chinese version of the Workplace Violence Scale. (3) An anonymous self-designed web-based questionnaire consisting of demographic, behavioural and occupational information was used to identify covariates. Results A total of 3684 front-line healthcare workers (934 physicians and 2750 nurses) were included. Of all participants, 13.3% (491/3193) experienced high burn-out. Adjusted logistic regression revealed that experience of WPV in the past year was associated with high burn-out (OR 2.10, 95% CI 1.69 to 2.62). Healthcare workers who had suffered emotional abuse, threat or verbal sexual harassment were more vulnerable to high burn-out. Conclusion This study finds that healthcare workers with WPV, especially emotional abuse, threat and verbal sexual harassment, are more likely to experience burn-out. These types of WPV should be considered in interventions to reduce and prevent burn-out for healthcare workers.
The Emergency Department (ED) is a stressful, safety-critical environment, which is often overcrowded, noisy, chaotic, and understaffed. The built environment plays a key role in patient outcomes, experiences, and the mental health of healthcare workers (HCWs). However, once a space is built, it is difficult to change it; so the modularity and adaptability of new technologies such as robots could potentially help stakeholders mitigate some of these challenges; yet, there is a lack of research in this area, particularly in the ED. In this paper, we address this gap by engaging HCWs in a research-through-design process, utilizing design fiction, to envision a future resilient ED. Here, robots scurry along the ceiling, provide help at the bedside, and smart furniture and walls provide spaces for privacy and calm. We co-created design prototypes of future intelligent systems that can modify the built environment to support resilience, which we then used to co-create a Design Catalog with HCWs, which contains a collection of future technology prototypes contextualized within the ED. We found that HCWs envisioned many ways for intelligent systems to help them reimagine the built environment, including ways to enhance HCW-patient communication, improve patient experience, support both HCW and patient safety, and use reconfigurable spaces to support privacy. We hope our work inspires further exploration into using new technologies to reimagine and reconfigure the built environment to support resilient hospitals.
Full-text available
Introduction: Emergency Medical Service (EMS) personnel often respond to dangerous scenes and encounter hostile individuals without police support. No recent data describes the frequency of physical or verbal assaults or which providers have increased fear for their safety. This information may help to guide interventions to improve safety. Our objective was to describe self-reported abuse and perceptions of safety and to determine if there are differences between gender, shift, and years of experience in a busy two-tiered, third service urban EMS system. Methods: This was a secondary analysis of an anonymous, cross-sectional work safety survey of EMS providers. This survey included demographics, years of experience, history of verbal and physical assault, safety behavior following an assault and perceptions of safety. Descriptive statistics were generated. Results: Eighty-nine percent (196/ 221) of EMS providers completed the survey. Most were male (72%) and between the ages of 25 and 50 years (66%). The majority of providers had worked in this service for more than five years (54%), and many for more than ten years (37%). Verbal assaults were reported by 88% (172/196, 95% CI [82.4%-91.6%]). Although 80% (156/196, 95% CI [73.4%-84.6%]) reported physical assaults, only 40% (62/156, 95% CI [32.4%-47.6%]) sought medical care and 49% (76/156, 95% CI [41%-56.6%]) reported the assault to police. The proportion of those who sought medical care and reported the assault to the police was not the same across years of experience (p
Full-text available
Background Consumer-driven homecare models support aging and disabled individuals to live independently through the services of homecare workers. Although these models have benefits, including autonomy and control over services, little evidence exists about challenges homecare workers may face when providing services, including workplace violence and the negative outcomes associated with workplace violence. This study investigates the prevalence of workplace violence among homecare workers and examines the relationship between these experiences and homecare worker stress, burnout, depression, and sleep.Methods We recruited female homecare workers in Oregon, the first US state to implement a consumer driven homecare model, to complete an on-line or telephone survey with peer interviewers. The survey asked about demographics and included measures to assess workplace violence, fear, stress, burnout, depression and sleep problems.ResultsHomecare workers (n¿=¿1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p¿<¿.001), depression (p¿<¿.001), sleep problems (p¿<¿.001), and burnout (p¿<¿.001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.Conclusions To ensure homecare worker safety and positive health outcomes in the provision of services, it is critical to develop and implement preventive safety training programs with policies and procedures that support homecare workers who experience harassment and violence.
Full-text available
AimTo understand staff factors associated with patient aggression towards the staff of an inpatient forensic psychiatric hospital.Background Violence by patients is a serious concern in psychiatric hospitals and staff are the most frequent targets of physical and verbal assault. Assault and its consequences can severely disrupt the hospital environment and impair the functioning of staff members and patients. This study examined the interplay of staff dispositional and interpersonal factors associated with patient violence.DesignThis cross-sectional study surveyed the staff of a large public forensic hospital.MethodsA sample of 348 psychiatric staff participated in an online survey about their workplace experiences, psychosocial characteristics and well-being. Data were collected from November – December 2011.FindingsNearly all staff reported verbal conflict with patients (99%) and 70% reported being assaulted during the previous 12 months. Verbal conflict with other staff (92%) was also high. Multiple regression analyses indicated that in addition to static risk factors (i.e. staff position, years of experience and gender), the risk of assault was associated with the frequency of conflicts with staff and patients, which in turn was moderated by personal stress reactivity.Conclusion Physical violence by patients was a pervasive threat for a high proportion of staff. Frequent conflict interactions with volatile patients contributed the most risk, but reactivity to conflict was a dynamic risk factor. The strain associated with assault risk and stress reactivity could be prospectively mitigated by resilience enhancement programming for staff.
Effective workplace violence (WPV) prevention programs are essential, yet challenging to implement in healthcare. The aim of this study was to identify major barriers to implementation of effective violence prevention programs. After reviewing the related literature, the authors describe their research methods and analysis and report the following seven themes as major barriers to effective implementation of workplace violence programs: a lack of action despite reporting; varying perceptions of violence; bullying; profit-driven management models; lack of management accountability; a focus on customer service; and weak social service and law enforcement approaches to mentally ill patients. The authors discuss their findings in light of previous studies and experiences and offer suggestions for decreasing WPV in healthcare settings. They conclude that although many of these challenges to effective implementation of workplace violence programs are both within the program itself and relate to broader industry and societal issues, creative innovations can address these issues and improve WPV prevention programs.
Conference Paper
Introduction Patient aggression is a longstanding problem in general hospital nursing. Staff training is regarded as important to tackle workplace aggression originating from patients or visitors, yet evidence on training effects is scarce. Aim of the study The aim of this study was: a: To review and collate current research evidence on the effect of aggression management training for nurses and nursing students working in general hospitals, and b: to derive recommendations to educators in practice from synthesised research results. Methods Systematic, narrative review. Embase, MEDLINE, the Cochrane library, CINAHL, PsycINFO, pubmed, psycArticles, Psychology and Behavioural Sciences Collection were searched for articles evaluating training programs for staff and students in acute hospital adult nursing in a 'before/after' design. Studies were eligible for inclusion if published between January 2000 and September 2011 in English, French or German. Review methods: The methodological quality of included studies was assessed with the 'Quality Assessment Tool for Quantitative Studies'. Main outcomes such as changes in attitudes, confidence, skills and knowledge were collated. Results Nine studies were included. Two had a weak, six a moderate, and one a strong study design. All studies reported increased confidence, improved attitude, skills, and knowledge about risk factors post training. There was no significant change in incidence of patient aggression. Discussion / conclusion Our findings corroborate findings of review studies focussing on training in mental health care, which point to a lack of high quality research. Training does not reduce the incidence of aggressive acts. Practical or academic relevance Training programs should include elements to foster healthy coping with aggression in the workplace
An elevated risk of patient/visitor perpetrated violence (type II) against hospital nurses and physicians have been reported, while little is known about type II violence among other hospital workers, and circumstances surrounding these events. Hospital workers (n = 11,000) in different geographic areas were invited to participate in an anonymous survey. Twelve-month prevalence of type II violence was 39%; 2,098 of 5,385 workers experienced 1,180 physical assaults, 2,260 physical threats, and 5,576 incidents of verbal abuse. Direct care providers were at significant risk, as well as some workers that do not provide direct care. Perpetrator circumstances attributed to violent events included altered mental status, behavioral issues, pain/medication withdrawal, dissatisfaction with care. Fear for safety was common among worker victims (38%). Only 19% of events were reported into official reporting systems. This pervasive occupational safety issue is of great concern and likely extends to patients for whom these workers care for. Am. J. Ind. Med. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
Effective workplace violence (WPV) prevention programs are essential, yet challenging to implement in healthcare. The aim of this study was to identify major barriers to implementation of effective violence prevention programs. After reviewing the related literature, the authors describe their research methods and analysis and report the following seven themes as major barriers to effective implementation of workplace violence programs: a lack of action despite reporting; varying perceptions of violence; bullying; profit-driven management models; lack of management accountability; a focus on customer service; and weak social service and law enforcement approaches to mentally ill patients. The authors discuss their findings in light of previous studies and experiences and offer suggestions for decreasing WPV in healthcare settings. They conclude that although many of these challenges to effective implementation of workplace violence programs are both within the program itself and relate to broader industry and societal issues, creative innovations can address these issues and improve WPV prevention programs. OJIN: The Online Journal of Issues in Nursing (American Nurses Association) Vol. 20 No. 1, available at:
BackgroundA key barrier to preventing workplace violence injury is the lack of methodology for prioritizing the allocation of limited prevention resources. The hazard risk matrix was used to categorize the probability and severity of violence in hospitals to enable prioritization of units for safety intervention.Methods Probability of violence was based on violence incidence rates; severity was based on lost time management claims for violence-related injuries. Cells of the hazard risk matrix were populated with hospital units categorized as low, medium, or high probability and severity. Hospital stakeholders reviewed the matrix after categorization to address the possible confounding of underreporting.ResultsForty-one hospital units were categorized as medium or high on both severity and probability and were prioritized for forthcoming interventions. Probability and severity were highest in psychiatric care units.Conclusions This risk analysis tool may be useful for hospital administrators in prioritizing units for violence injury prevention efforts. Am. J. Ind. Med. © 2014 Wiley Periodicals, Inc.