Violence
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The epidemic of violence against
healthcare workers
D M Gates
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No longer silent
S
taggering rates of verbal and phy-
sical violence are documented in
the study by Gerberich and collea-
gues,1 published in the June issue of
OEM, and yet most nurses and other
healthcare workers state that the pro-
blem highlighted by this research is not
new. Although many healthcare work-
ers believe that workplace violence is
increasing, there is a paucity of existing
evidence to support these claims due to
low reporting rates. Gerberich and col-
leaguess’ 15% report rate for physical
assaults against nurses supports other
studies that also found low rates.2 3
Compared to physical assaults, non-
physical violence is documented even
less, although researches such as
Gerberich et al found that the negative
consequences associated with such vio-
lence are substantial. When healthcare
workers are asked why they don’t report
violence they most commonly state that
the incident is not associated with
injury or lost work, reporting is too time
consuming, reporting lacks supervisory
support, and reporting won’t make any
difference. Most incredible, nurses indi-
cate that violence is to be expected. In
the Gerberich et al study, 44% of nurses
do not report physical violence because
it is just ‘‘part of the job’’. An additional
alarming finding from this study is that
only 27% of the nurses perceive violence
to be a problem in their workplace,
even though 13% experienced physical
assaults and 38% experienced non-phy-
sical violence during the previous year.
Unfortunately, these findings suggest
that violence may not be identified as
a problem until there is a critical
incident with casualties.
So what are the reasons for the recent
attention to the problem and why are
these recent studies that document the
magnitude of the problem, such as one
by Gerberich and colleagues1 so impor-
tant? The answer to these questions
involves consideration of several com-
plex issues.
First, experts believe that the risk of
verbal and physical violence is increasing
across diverse types of healthcare set-
tings. For example the most assaulted US
worker is the nurse aide working in a
nursing home and the perpetrator is
most often an elderly patient, often with
dementia. Fifty nine per cent of nurse
aides report being assaulted once a week
and 16% report that they are assaulted
daily.3 The number of elderly in long
term care and other healthcare settings
will increase dramatically as the US
population ages. In addition to nursing
home employees, emergency department
(ED) workers also voice increasing con-
cern about violence from patients and
visitors and many report that they
seldom or never feel safe at work.4
These workers believe that the escalating
risk in their environments is due to
increased drug and alcohol use by
patients and visitors, presence of weap-
ons, poor patient and visitor coping skills,
long wait times, and the increasing
number of patients with dementia and
psychosis. There is mounting concern
that the heightened level of community
violence is being brought into and
mirrored in the ED, a common entry
into the healthcare setting. And for
community workers, whereas in the past
many wore uniforms and other forms of
identification to increase their safety,
today many home health workers state
they feel safer without identification that
targets them for perpetrators looking for
money, drugs, or drug paraphernalia.5
When patients and visitors use health-
care services it is often with feelings of
anxiety, frustration, and loss of control;
they frequently encounter long waiting
lines, high medical costs, fragmented
services, and understaffed and frustrated
workers. Several US states have con-
cealed weapon laws; persons in our
communities are carrying guns in their
pockets, purses, and briefcases, making
them too easily available when tensions
are high. Healthcare settings today
are places where everyday encounters
between patients, visitors, and staff could
easily evolve into a threatening situation.
Second, recent media attention to
school and workplace shootings raised
the level of civic consciousness regard-
ing the adverse effects of violence. Most
Americans know that the phrase ‘‘going
postal’’ indicates an employee who
becomes hostile at work. However the
public focus is on occupational environ-
ments that are exclusive of healthcare
sites. As the media remains instrumen-
tal in drawing attention towards
violence in selected settings, OSHA
concurrently influences safety by writ-
ing violence prevention guidelines for
high risk workplaces, including health-
care. However, despite the collective
impact of the OSHA guidelines6 and
the media, Gerberich and colleagues1
and other researchers find that the rates
of violence for healthcare workers
remain high and prevention efforts
low. Studies as those by Gerberich et al
emphasise the need for further research
to examine workplace violence explicit
to the healthcare industry.
Third, healthcare workers’ experiences
with non-physical and physical violence
are being increasingly recognised for
their association with decreased job
satisfaction, increased occupational
strain, and poor patient care outcomes.7
Gerberich and colleagues1 found that
adverse consequences of violence (for
example, turnover) are common and
interestingly more prevalent with non-
physical than physical violence. An
alarming finding is that much of the
violence encountered by healthcare
workers is from co-workers and man-
agers. Gerberich and colleagues1 found
that 33% of non-physical violence experi-
enced by nurses was perpetrated by
visitors, co-workers, physicians, and
managers. Nurses recently told me that
administration’s response to their com-
plaints of frequent verbal and physical
sexual harassment by a physician was
that the violence must be tolerated
because that individual brings substan-
tial dollars into the hospital system.
Similarly, nurse aides report that violent
visitors (relatives) are tolerated in nur-
sing homes because of the administra-
tion’s financial pressure to keep beds
filled. Such violence would not be
tolerated at other workplaces; employees’
contracts of employment would be ter-
minated and visitors refused access.
Violence in healthcare settings needs to
be similarly dealt with so that these
environments will become safer, more
civil, and desirable places to work. The
serious shortage of healthcare workers
will not improve until the workplace
culture is administratively addressed.
Fourth, as studies such as the one
published by Gerberich and colleagues1
become more widely circulated, perhaps
a larger cadre of healthcare workers will
recognise violence as a problem and
refuse to accept violence as ‘‘part of the
job’’. The difficulty in dealing with vio-
lence often stems from the realisation
that violence from patients cannot be
totally eliminated as there will always be
non-intentional verbal and physical
EDITORIAL 649
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assaults from patients with diseases,
such as dementia or psychosis. In order
to cope with this type of inherent
violence, workers need supportive envir-
onments that promote employee, admi-
nistrative, and organisational awareness
that violence is often traumatic. During a
recent conversation I had with an ED
manager she described to me how one of
her nurses was punched in the face by a
patient. She continued to describe how
the nurse’s co-worker told her ‘‘maybe
she could have prevented it’’ and ‘‘to get
over it; is not a big deal’’. Blaming the
victim is a common and unacceptable
approach. As research into violence con-
tinues, healthcare workers will hopefully
demand that their employers do more to
protect them from violent patients, visi-
tors, and co-workers. Use of OSHA’s
guidelines for engineering controls, work
practices, training, and policies will help
to decrease the violence. In turn, employ-
ees need to be encouraged to document
violence so that successful prevention
and management efforts can be imple-
mented.6
In conclusion, if agreed that all vio-
lence against healthcare workers is not
likely to be eliminated, the questions
remains: What kind and how much
violence should be tolerated? To what
degree are healthcare facilities expected
to act to protect workers from violence?
OSHA’s General Duty law states that
employers are liable if they know work-
ers are at risk of harm and do not take
action to decrease the workers’ risk. The
majority of healthcare workers are at risk
for violence and healthcare employers
need to do more. Period.
Occup Environ Med 2004;61:649–650.
doi: 10.1136/oem.2004.014548
Correspondence to: Dr D M Gates, College of
Nursing, University of Cincinnati Medical
Center, 212 Procter Hall ML 0038, 3110 Vine
Street, Cincinnati 45221-0038, USA; donna.
gates@uc.edu
REFERENCES
1 Gerberich SG, Church TR, McGovern PM,
et al. An epidemiological study of the
magnitude and consequences of work
related violence: the Minnesota Nurses’
Study. Occup Environ Med
2004;61:495–503.
2 Lanza ML. Nurses as patient assault victims:
an update, synthesis, and recommendations.
Arch Psychiatr Nurs 1992;6:163–71.
3 Gates D, Fitzwater E, Telintelo S, et al.
Preventing assaults by nursing home
residents: caregivers’ knowledge and
confidence—a pilot study. Journal of the
American Medical Directors’ Association
2002;3:366–70.
4 Gates E, McQueen L, Ross S. Violence
against emergency workers. Unpublished
document. 2004.
5 Fitzwater E, Gates D. Violence and home
healthcare. Home Healthc Nurse
2000;18:596–605.
6 OSHA. Guidelines for preventing workplace
violence for healthcare and social service
workers. OSHA 31, 48-1996. Washington,
DC: US Department of Labor, Occupational
Safety and Health Administration, 1996.
7 Gates D, Fitzwater E, Succop P. Predicting
assaults against caregivers in nursing
homes. Issues Ment Health Nurs
2003;24:775–93.
Making Health Care Safer 2004
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