World Report
www.thelancet.com Vol 383 April 19, 2014 1373
Published Online
April 16, 2014
http://dx.doi.org/10.1016/
S0140-6736(14)60658-9
For the study by Spector and
colleagues see http://www.
journalofnursingstudies.com/
article/S0020-7489(13)00035-
7/fulltext
For the WHO study see http://
www.who.int/violence_injury_
prevention/violence/activities/
workplace/WVsynthesisreport.
pdf
For more on the Hong Kong
initiative see http://www.wma.
net/en/20activities/40healthsyst
ems/60violence/Proceedings_
Violence_Health_Sector_2010.
pdf
Tackling violence against health-care workers
Globally, health-care workers experience high rates of violence and abuse in the workplace. More
focus should be put on preventing such attacks, say experts. Roxanne Nelson reports.
It was a night shift like any other, in
the emergency room at a large, urban
academic medical centre in the USA.
Stanley Johnson, a nurse who had been
employed by the facility for nearly two
decades, accompanied an intoxicated
20-year-old man to the phone so he
could call his mother to pick him up.
The man took the phone, and then
punched Johnson in the face.
But all things considered, apparently
Johnson was lucky. In the emer gency
depart ment waiting area for another
hospital, the Bronx-Lebanon Hospital
Center in New York, a man entered
carrying a concealed weapon. Once
in the waiting room, he pulled it out
and fi red into the crowd, wounding
a nurse and a security guard. In the
state of Texas, the 22-year-old son
of a patient went on a knife-slashing
rampage in the Ambulatory Surgical
Center of Good Shepherd Medical
Center. He stabbed one of the nurses
in the chest and killed her, and
wounded four others.
What is most disturbing about these
incidents is that they are not unique
or isolated events. Physical violence
against nurses and other medical
workers has become an endemic
problem in health care. In addition,
nonphysical assaults, such as bullying
and sexual harassment, are also
common. Although some countries
are beginning to address the problem,
much remains to be done to encourage
reporting of incidents and to prevent
them from happening in the fi rst place.
Global problem
The USA has a less than stellar
reputation for violence, and the
workplace is a common site of
violence, with health-care settings
particularly prone to it. The rate of
assaults on health workers is higher
than that of other occupations—eight
assaults per 10 000 workers compared
with two per 10 000 for the general
workplace.
There were 91 shooting incidents
inside US hospitals between 2000 and
2011. But even though they receive
a great deal of publicity, shootings
are relatively rare events. And despite
having a culture of violence, the USA is
not alone in dealing with this situation.
Violence against health personnel
is a widespread problem throughout
the industrialised world, as well as in
developing and transitional countries,
and affects health-care workers
in nearly all work environments.
Although guns can make an attack
more lethal, assault can take the
form of intimidation, harassment,
stalking, beatings, stabbing, and rape.
Perpetrators tend to be primarily
patients, their families, and visitors.
In a large review published in 2013,
Paul Spector, a professor of psychology
at the University of South Florida, FL,
USA, and colleagues analysed data for
more than 150 000 nurses, drawn from
160 global samples. They found that
overall, about a third of nurses have
been physically assaulted, bullied, or
injured, while around two-thirds have
experienced nonphysical assault.
Even though assault can and does
occur in all settings, most violence
occurs in a small number of areas, says
Spector. “The emergency department
and geriatric and psychiatric units
have high rates”, he says. “Many other
settings have relatively little violence.
Nurses in high-risk settings are
working with people who are in pain,
under stress, and often feel they have
lost control of their lives. Geriatric and
psychiatric patients often have poor
impulse control.”
The diff erent types of violence also
varied by region. The highest rates
of both physical violence and sexual
harassment were in the “Anglo”
region, which included Australia,
England, Ireland, USA, Canada, New
Zealand, and Scotland. Bullying was
lowest in Europe, but highest in the
Middle East, and the rate of sexual
harassment was lowest in Europe.
An earlier country case study
undertaken by WHO and several
partner agencies, reported that more
than half of responding health-care
personnel experienced at least one
incident of physical or psychological
violence in the previous year: 76%
in Bulgaria; 67% in Australia; 61% in
South Africa; 60% in health centres
and 37% in hospitals in Portugal; 54%
in Thailand; and 47% in Brazil.
Greatly underreported
The actual rate of assaults is probably
much higher than in the published
literature, due to underreporting. “It
is believed that 70 to 80% of assaults
Accident and emergency departments are high-risk environments for violence
“‘...Nurses in high-risk settings
are working with people who
are in pain, under stress, and
often feel they have lost control
of their lives...’”
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1374 www.thelancet.com Vol 383 April 19, 2014
World Report
are never reported”, says Lesley Bell,
a consultant with the International
Council of Nurses in Geneva. “Often
nothing is done to help the person
who has been attacked, and hospitals
may even discourage workers from
reporting it.”
As a group, nurses are often the
most likely to experience an assault
in the workplace, and many believe
that being assaulted may just be part
of the job, explains Bell. In addition,
many also believe that taking legal
action against an attacker can cost
them their jobs.
“It goes back to how we are valued
as a profession”, says Bell. “And we
are seeing the societal tolerance for
violence spilling over. Physical assault
is one of the things that historically
has been accepted as part of the job for
nurses. In home health, for example,
nurses are often expected to go into
areas where police won’t even go.”
A 2011 survey by the Emergency
Nurses Association in the USA found
that most nurses did not fi le a formal
report when assaulted, but did notify
someone. The survey also found that
in nearly half of all cases of physical
violence, no action was taken against
the perpetrator. Nurses also received
no response from the hospital about
the assault in about 70% of cases.
Reversing the trend
In the USA, 30 states have now
passed laws making it a felony to
assault hospital workers and some
individual facilities have begun
to take workplace violence more
seriously. The American College
of Emergency Room Physicians
has recommended interventions
such as increasing the number
of security officers, closed circuit
television cameras with 24-hour
trained observers, panic buttons, and
better control of the entry into the
emergency department. The Henry
Ford Hospital in Detroit implemented
metal detectors in an eff ort to prevent
weapons from entering the facility.
In their fi rst 6 months of screening,
officials confiscated 33 handguns,
1324 knives, and 97 chemical sprays.
“In Europe and in the UK, we
do have anti-bullying laws”, says
Cary Cooper, distinguished professor
of Organisational Psychology and
Health at Lancaster University,
UK. “And it can be physical or
psychological. If it’s psychological,
it has to be persistent, but if it’s
physical, one act is enough.”
In emergency areas, where a large
percentage of incidents occurs, Cooper
points out that the wait is often long,
people are sick, injured, anxious,
worried, intoxicated, and it is easy to
see how the aggression builds up.
“In other areas, a patient may also
have to wait a long time for care”,
he says. “And if the nurse doesn’t
explain why the wait is long, or maybe
why the care isn’t given fast enough,
that can also lead to a buildup in
aggression.”
There are many reasons why people
become violent, but the key is how
to deal with it, Cooper says. Facilities
have to be fi rm in not tolerating that
behaviour, regardless of the reason.
“You do see signs in hospitals saying
that abuse will not be tolerated,
and making it clear that it is not
acceptable”, he said. “And in the UK
people are arrested for assaulting
health-care workers.”
But preventing attacks pre-
emptively would be the best strategy.
“Violence can be reduced by skilful
interpersonal treatment of patients,
such as providing information and
showing concern”, says Spector.
“Many of the same factors that aff ect
the patient also affect family and
friends. Like the patient, they can be
under emotional distress and feel loss
of control. They also can react to the
treatment of the patient. Practices to
help sooth patients can also be used
by family or friends.”
In Hong Kong, where workplace
violence is common in acute
psychiatric wards, a working group
was formed in one acute admission
unit of Castle Peak Hospital, and
an integrative programme was
developed. The goal was to prevent
both patient and staff injury due
to violence, as well as developing a
harmonious working atmosphere,
and building up trust and respect
between patient and staff . Part of the
plan was also to develop competence
among staff in managing workplace
violence, and one of the interventions
was to hold “drills”, so that workers
would have an opportunity to practice
their learned skills and techniques in a
clinical environment. In turn, these
practice session would empower
them to respond appropriately in
actual situations.
But for the emergency depart ments,
where workers face the highest risks,
Cooper advocates taking prevention
a step further. “The fi rst port of call is
the most important one, which would
be the receptionist or the person who
does intake”, he says. “Those persons
can be trained to recognise a problem
and try to diff use it before it escalates
into violence. This will help reduce the
risk of danger.”
Roxanne Nelson
“‘Violence can be reduced by
skilful interpersonal treatment
of patients, such as providing
information and showing
concern’...”
Around 70–80% of assaults on health-care workers are never reported
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