By Katherine Easton, MSW, LCSW, OSW-C 

The Associated Press provided the details of yet another incident of gun violence in a hospital. “The visitor opened fire, killing a security guard and injuring a nurse.” Only this time it was the hospital where I worked. The fragile glass of vulnerability had been broken at my workplace. A “code silver” had been called signaling to staff that there was an active shooter on campus. The result of the experience left us with a wave of emotions ranging from fear to grief and anger. Portland, Oregon, joined the growing list of cities impacted by violence against healthcare workers.  

Incidents of deadly violence against nurses, physicians and social workers in healthcare settings continues to rise as an unintended consequence of the pandemic. The World Health Organization (WHO) defines workplace violence as “incidents where staff are abused, threatened or assaulted in circumstances related to their work involving an explicit or implicit challenge to their safety, well-being, or health.” The WHO considers both physical and psychological harm, including attacks, verbal abuse, bullying and both sexual and racial harassment, to be workplace violence. Violence against healthcare workers is largely underreported and is often considered “part of the job” in serving patients and families in stressful environments. The perspective that many healthcare providers share is that patients we care for are often at their worst and therefore not accountable for abhorrent behaviors.  

The U.S. Bureau of Labor states healthcare workers are five times more likely than any other worker to be physically attacked on the job, however accurate data is challenging given that the majority of these events go unreported. Patient-satisfaction data drives decision-making in healthcare operations so there is little motivation to push back on difficult patients. Data on violence in outpatient settings remains largely anecdotal and lacks substantive research or systematic data collection. In 2018, the Joint Commission published a paper outlining the prevalence of workplace violence in healthcare with policy recommendations and standards to provide a framework for addressing the issue. These recommendations lie largely with the institutions themselves to develop and initiate. New workplace violence standards from the Joint Commission became effective in January 2022. Given the current state of healthcare services, many of these recommendations are cost-prohibitive to healthcare systems who lack the financial resources to invest in the infrastructure that aligns with providing the safest environment for their staffs. Many hospitals and healthcare systems are still continuing to try to recover from the financial fallout of the pandemic and are working to meet basic healthcare delivery with limited staffing. 

The causes of violent behavior toward healthcare workers is driven by a number of complex factors. Most hospital and emergency room settings are full of people who are sick and scared, their loved ones worried. Common contributors to violent behavior in healthcare settings involve a patient’s altered mental status from decompensating mental illness, delirium, psychosis or substance intoxication. The highest-risk environments include emergency rooms, psychiatric units and inpatient hospital units. In our hospital it was the maternity ward. Contributing factors also include limited staffing, patient wait times, crowded waiting areas, isolated workers, unrestricted public access to hospital rooms and clinics, inadequate security, limited time to care for patients, and lack of community mental healthcare. 

Assessing the impact on staff from violence in healthcare settings can be debated but studies have shown that many workers experience symptoms of PTSD. Workplace violence has also been considered to show an increase in missed work, job dissatisfaction, high turnover, decreased productivity, and feelings of fear on the job. 

Currently there exists no federal law to protect healthcare workers. In April 2023, the U.S. House of Representatives passed H.R. 2584, which directs the Secretary of Labor along with OSHA to develop a comprehensive workplace violence prevention program in healthcare settings. In September 2023, the Senate introduced the Safety from Violence for Healthcare Employees (SAVE) Act. This legislation would give healthcare workers similar federal protections afforded to airline employees and crews. The decision to care for the sick, injured and dying has often been associated with compassion and dedication. As incidents of violence against healthcare workers continue to rise, without a systemic change to the way we deliver care, secure our facilities and provide extensive training and resources for staff, our healthcare systems will be at risk of struggling to recruit and retain skilled and valued employees now and in the future. 

Reflecting on this episode of violence against staff, our institution was able to identify the critical gaps in safety that existed in our facility. The dedication of leadership has resulted in the initiation of several safety measures that may help reduce the risk of workplace violence in our hospital and clinics in the future. Increased security and metal-detector screening, utilizing badge-access only to clinical care settings, secured entrance and exits and the installation of panic buttons that will summon help are all part of the enhanced safety measures. Staff training in the response to “code silver” calls will also be a key factor in how we prepare for what has now become a significant threat to the delivery of healthcare services.  

References: 

Workplace Violence and Intimidation, and the Need for a Federal Legislative Response, American Hospital Association: Fact Sheet June 2022 

Workplace Violence against Healthcare Workers in the United States, James Phillips, MD, New England Journal of Medicine, April 2016 

The Joint Commission, Sentinel Event Alert, Physical and verbal violence against healthcare workers, April 17, 2018 

Violence Against Healthcare Workers: A Rising Epidemic, Annals of Medicine and Surgery, May 12, 2019