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Violence Against Nurses in the Workplace

Potera, Carol

AJN The American Journal of Nursing: June 2016 - Volume 116 - Issue 6 - p 20,21
doi: 10.1097/01.NAJ.0000484226.30177.ab
AJN Reports

Consolidated approaches are needed from employers, victims, and the political system.



“A young man on a behavioral health unit stabs a sleeping fellow patient with a piece of broken glass. When a nurse on duty hears screams and rushes to help, the man slashes her face, breaking her nose.”

—SeattlePI, June 24, 2015

“A patient wielding a pole rushes a nurses’ station and begins swinging; four nurses are injured. Police respond and give chase to the intruder, who ultimately dies after being tackled and handcuffed outside the hospital.”

—, November 7, 2014

Examples of violence in health care settings, such as those described above, are not isolated incidents. Nor are they particularly rare. In its most recent report on workplace violence (, the Bureau of Labor Statistics found that the rate of injuries and illnesses from violence in health care settings was more than three times greater than the rate in private industries.

According to a July 2015 report from the American Nurses Association (ANA), Position Statement on Incivility, Bullying, and Workplace Violence, 43% of nurses and nursing students had been verbally or physically threatened by a patient or a patient's family member, and 24% had been assaulted. More than 70% of ED nurses report physical or verbal assault by patients or visitors.

A survey study by Gacki-Smith and colleagues in the July–August 2009 issue of the Journal of Nursing Administration found that 25% of ED nurses experienced physical violence more than 20 times and 20% encountered verbal abuse more than 200 times within three years. According to a report by Papa and Venella in the January 31, 2013, Online Journal of Issues in Nursing, 80% of violence in health care settings occurs in EDs, although labor-and-delivery and maternal–child care units and psychiatric settings also present high risks. And workers who float from one unit to another are assaulted three times more than permanent workers, according to the ANA report.

Workplace violence takes a serious toll on its victims; among many reported sequelae are headaches, poor sleep, intestinal problems, depression, fear, and anxiety. Victims take more sick time and may use drugs or alcohol to cope. The psychological and emotional toll of violence can lead to patient safety errors as well, according to the ANA.

The costs of workplace violence to employers—stemming from lost time, productivity, and turnover of trained staff—can be considerable as well. Rainford and colleagues, writing in the February 2015 Journal for Nurse Practitioners, state that replacing one nurse can run from $22,000 for a new nurse to $64,000 for an experienced nurse. The ANA report cites a study showing that at one hospital with 5,000 nurses, the treatment of workplace violence cost $94,156 annually. Many nurses quit after being victimized, increasing workloads for coworkers and lowering morale.

The situation only seems to be getting worse. The April 24, 2015, Morbidity and Mortality Weekly Report notes that injuries from workplace violence in nurses and nurse assistants almost doubled between 2012 and 2014. Active-shooter drills to protect staff and patients from weapons-carrying intruders are becoming more familiar to hospital staff, and the idea of arming hospital security guards, albeit highly controversial, is emerging as a way of dealing with violent behavior. (See the February 12 New York Times: Short of such dramatic institutional solutions, over which nurses may have little control, what can nurses do to protect themselves?

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Employers, organizations, and individuals are beginning to pay more attention to the problem, and it is clear that the issue must be approached from several directions.

Reporting. Employers must set up a clear reporting process that enforces a zero-tolerance policy. It should treat violence in a consistent manner and never include retaliation against workers who report problems, says the ANA position paper.

“Without a clear policy, nurses don't have the support they need,” Ruth Francis, MPH, senior policy advisor at the ANA, told AJN. And nurses are more willing to speak up, she says, if a reporting system is in place. The ANA advises nurses to report a problem as soon as possible. They should describe the event, the date, and the names of all people involved—including witnesses. They should ask witnesses to document what they saw and sign their reports. The ANA offers several tools and resources for dealing with workplace violence (See Resources for Combating Workplace Violence).

Training. ED nurses need better training to recognize cues, or common precursors, to violence. The Emergency Nurses Association (ENA), too, offers programs designed to keep nurses safe. “Workplace violence is not part of the job, and nurses should not accept it,” says Lisa Wolf, PhD, RN, director of the ENA's Institute for Emergency Nursing Research. Wolf herself was kicked in the head by an ED patient. “This is common for an emergency nurse,” she says. In a report in the July 2014 Journal of Emergency Nursing, Wolf notes that nurses have endured injuries to hips, shoulders, necks, and arms that make it difficult to work without pain, yet when they report attacks, supervisors often want to avoid bad publicity for the hospital instead of expressing concern for the nurses.

An ENA online course, Workplace Violence Prevention: Know Your Way Out (, better prepares nurses to spot cues. “Patients who are drunk, swinging, or in handcuffs are not ones you want to turn your back on,” says Wolf.

Legislation. Laws that address safety in health care facilities can help end workplace violence, and recent gains have been seen on that front. In Massachusetts, where 85% of nurses report being punched, spit on, groped, or kicked, a 2010 law made assaulting a nurse a felony. Other states, most recently North Carolina, New York, and New Jersey, have passed laws elevating the penalties for violence against health care workers.

The Massachusetts Nurses Association (MNA) has now thrown its support behind a new bill designed to prevent assaults. It requires health care employers to identify factors that put nurses at risk, develop written violence prevention plans, and create in-house crisis response teams to help victims of workplace violence.

The MNA's campaign was inspired by numerous assaults on nurses that were ignored by employers who should have protected them. For example, a patient at a mental health facility slammed a nurse's head into a wall. The nurse went to court, but the judge dropped the case because he believed that such incidents were simply part of the job. “A nurse being assaulted at work is no different than if a clerk in a supermarket is assaulted by a customer,” says David Schildmeier, spokesperson for the MNA.

Many health care facilities also want nurses who are attacked to get permission from hospital administrators before filing a police report. The MNA advises nurses to report assaults independent of such approval. “Hospitals may resist steps to provide protection,” says Schildmeier. Ultimately, though, “it's the hospital's job to keep workers safe.”—Carol Potera

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Resources for Combating Workplace Violence

  • The American Nurses Association (ANA) offers tools and other resources:
  • “The Hard Truth: Bullying and Workplace Violence in Health Care” is a YouTube video from the ANA:
  • The Centers for Disease Control and Prevention provides an online course, Workplace Violence Prevention for Nurses:
  • The Occupational Safety and Health Administration offers general guidelines on combating workplace violence (
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