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Workplace Violence in Nursing on the Rise

“I wish the general public knew how much [workplace violence] happens and how much it hurts. It is not even the physical part because I think people can relate, but it harms nurses emotionally, sometimes to the point that we are physically safe, but it impacts our ability to work.”

Gordon Gillespie, PhD, DNP, Interim Dean and Professor at the University of Cincinnati College of Nursing

Workplace violence and aggression are increasingly becoming an issue in the healthcare industry. Nurses, a vital component of the healthcare system, are particularly at risk when it comes to verbal or physical abuse from either patients or family members. The National Nurses United’s (NNU) 2022 survey of 2,500 nurses found that nearly half of respondents reported increased workplace violence. According to this survey, workplace violence has increased a staggering 119 percent since March 2021.

“Since Covid, the violence has gotten worse. I would have assumed it would have improved because when the acute crisis was over, and emergency department volumes dropped, but in reality, Covid made things worse,” shares Dr. Gordon Gillespie, interim dean and professor at the University of Cincinnati College of Nursing. “Unfortunately, Covid became political. And it’s not just in the US. In Mexico, if you were a healthcare worker walking home wearing your scrubs, people would attack you because they would say you caused the pandemic. Nurses in Mexico had to change before leaving work and hide anything that made them look like nurses for their safety.”

In 2022, the American Association of Nurse Practitioners Board of Directors stated that all healthcare settings should foster respect for patients and care providers and be free from violence or threats. The statement urged all healthcare facilities to implement comprehensive violence prevention programs and measures to protect staff from violent attacks.

Unfortunately, despite facilities and executives’ best efforts, workplace violence is a constant worry for all nurses: “I wish the general public knew how much it happens and how much it hurts. It is not even the physical part because I think people can relate, but it harms nurses emotionally, sometimes to the point that we are physically safe, but it impacts our ability to work,” says Dr. Gillespie. “This can put other patient’s health at risk because of someone else enacting harm. We all need to work together to keep our nurses safe.”

Keep reading to learn about the prevalence of workplace violence against nurses, the types of violence, and the causes, effects, and ways to prevent it.

Meet the Expert: Gordon Gillespie, PhD, DNP, RN

Dr. Gordon Gillespie has been a registered nurse for over 25 years, working in emergency departments, public health, and academic settings.

His work has been cited by the Occupational Safety and Health Administration, the U.S. Government Accountability Office, the American Nurses Association, and practitioners and researchers across six continents. He has chaired the national workplace violence conference, guest edited two interprofessional journal issues on workplace violence, co-chaired the Registered Nurses’ Association of Ontario’s second edition of the Best Practice Guideline “Preventing and Managing Bullying and Violence in the Workplace,” and served as an international director of the Emergency Nurses Association.

Prevalence of Workplace Violence in Nursing

According to the American Nurses Association, at least one in four nurses reported being physically assaulted in 2019, but that number is grossly underreported. Dr. Gillespie believes, sadly, that it will happen to most nurses: “Everyone will be victimized. When I talk to people, it’s not about if—it’s about when and how you prepare for it,” he says. “You are going to be physically assaulted at some point, but how do you minimize the risk so that when it does happen, you’re not injured or emotionally scarred.”

Despite the pervasiveness of workplace violence, Dr. Gillespie doesn’t believe nurses have to resign themselves to this reality. “We won’t accept it as a normal course of business. We need to accept that bad things happen, but we don’t need to accept it’s part of the job that we have to put up with. When it happens, we need to learn from it on how to prevent a future act so that maybe you’ll be 20 years into your career as a nurse before something bad happens to you,” he says.

Workplace Violence Types

Workplace violence against nurses is divided into four types for research and tracking purposes. Dr. Gillespie explains that these types are based on the relationship between the healthcare worker and the aggressor. “Type one is criminal intent. It doesn’t happen as often, but it is things like somebody robbing a pharmacy. They’re not customers, and they’re there to commit a crime,” he says. “Type two is the one that’s most often talked about, and that’s from the customer or client. This includes verbal abuse, assault, and threats against you. Type three is coworker-on-coworker, which has had more talk lately. That includes bullying and incivility against one. Lastly, type four is intimate partner violence, and that’s rarely talked about. That’s where a current or past intimate partner comes into the workplace to harm you.”

The definition of workplace violence is more comprehensive than many people might assume. “If it happens while on duty or at the workplace, it is considered workplace violence. Even if you’re getting off work or walking to your car, it doesn’t matter who the person is,” explains Dr. Gillespie. “If you’re traveling between locations or moving between buildings, that’s time on the clock and included.”

Most Common Workplace Violence Against Nurses

Due to underreporting and the lack of studies comparing workplace violence against nurses, it can be hard to decipher what type is the most prevalent. “Historically, the most common type of violence we see is from patients and visitors against the worker. We hear more about bullying between nurses, so it’s hard to say which is greater right now. Because there are not a lot of studies that look at them together, it’s hard to say,” says Dr. Gillespie.

He posits that violence from visitors and patients might be more simply because of numbers. “Think about how many patients you have on a shift compared to how many co-workers you might have. You might have one or two toxic coworkers, but that’s one or two people versus a whole group of patients that say whatever they want to say, do whatever they want to do, and don’t recognize that their behavior is inappropriate,” he says.

Causes of Workplace Violence In Nursing

According to Dr. Gillespie, the primary causes of workplace violence against nurses include stress or crisis, response to physical or mental distress, and a combination of entitlement or lack of education on how to behave appropriately.

Some departments have a higher chance of encountering patients with one or more of these issues. “In the emergency department and psychiatric units, we are dealing with people who aren’t their normal selves because of instability in medications, a brain disorder, a chemical imbalance, mental health disease, withdrawal, or dementia. All those things contribute to the way they act. We understand it’s still unacceptable, but it tends to happen often because of the environment,” he says. “Sometimes they’re responding to painful stimuli like you’re putting in an IV catheter, and they swipe at you.”

Stress and crisis also contribute significantly to a patient’s misbehavior: “In the emergency department, you just have crisis after crisis. If your three- or four-year-old got hit by a car, and they were in the emergency department, you wouldn’t take well to a ‘Please sit down. We will be with you in a while’ from the staff. You’re going to get angry. You’ll probably call them some words you didn’t mean to. How many people will kick down a door when they hear their son or daughter cry?” asks Dr. Gillespie.

Sometimes, entitlement or lack of education and understanding about different medical departments can be the catalyst for workplace violence: “People will present to the emergency room for a toothache and ask for pain medication when what they really need is an antibiotic and to have a tooth pulled or cleaned. Or they have an injury from a couple of years ago, and It’s still bothering them, and they want an MRI. That’s not an emergency. If we don’t do a good job communicating why we can’t provide the care they want, they will not be receptive to it and resort to being aggressive.”

Consequences of Violence Against Nurses

Violence against nurses in healthcare settings has serious consequences: “Nurses are getting tired of arguing with people about their disease diagnoses, and they’re now thinking maybe it’s time to find a different job or change departments or hospitals,” says Dr.Gillespie. “Some are returning to school for different careers because they just can’t take it anymore. Now, we have this massive staffing shortage. Part of it, too, is older adult nurses, with more years of experience, are not willing to risk themselves anymore.

The staffing shortage further exacerbates workplace violence. “Now nurses are working more often on short-staffed shifts, and when you’re short-staffed, that’s a precursor to violent events because people’s needs and wants can’t be addressed. It creates a spiral,” he explains. “Rates of PTSD are increasing amongst nurses because they’re now exposed to these traumatic events.”

Not only are nurses leaving because of workplace violence, but there has been a decrease in enrollment in nursing programs. The American Hospital Association notes a 1.4 percent decrease in baccalaureate program enrollment in 2022, the first time in 20 years there has been a decrease. Dr. Gillespie reports that programs he has known to be full for years have open seats they are desperate to fill. “Applicants absolutely consider workforce issues such as violence. They recognize that may not be what they want in life and will seek an alternative career,” he says.

Ways to Decrease Workplace Violence Against Nurses

“There are many different ways to decrease violence against nurses. One of the primary ways to do this is through prevention. It starts with the education for nurses and how they interact with patients. You have to decide: do you need to win this argument, or do you want to go home alive?” Dr. Gillespie asks.

“We need to think about it like standard customer service skills and education for communication. Ask, ‘What do you need? What do you want?’ And if there is disagreement, then agree to disagree and offer to follow up later. This is probably a five- to ten-minute conversation, which can be exhausting, but think of the time and people it takes to restrain someone. If ten people are managing one person for half an hour, that’s 300 minutes of care loss. That could have been prevented with a short conversation.

In addition to nurse training and education, facilities and managers can help as well: “A lot of hospitals do a lot to change the environment to reduce risk. One that works well is screening tools that help evaluate if a person is likely to become volatile,” shares Dr. Gillespie. “However, we need more education with our patients and visitors to clarify what the healthcare system can do for them. Whether you’re in the emergency department mental health unit, med surg, or perioperative care unit, they need to know what they will be doing today.”

Lastly, Dr. Gillespie firmly believes that including patients and visitors in workplace violence vigilance can have a significant impact: “A sign that says we do not tolerate violence or assault and we will prosecute is a threat. If we flip it and say, ‘In our commitment to create a culture of safety, if you see anyone causing harm against someone else, please tell us right away’—that tells people everyone around you is watching you. That decreases a different sense that you can get away with something because everyone will report you. There are ways to communicate positively that we’re here to create a culture of safety for patients, family, visitors, and our staff.”

Kimmy Gustafson

Writer

Among her many diverse writing endeavors, Kimmy Gustafson has also lent her expertise to NPSchools.com since 2020, providing insightful and engaging content about the significant role of education in shaping our future generations of nurse practitioners. Many of her pieces include interviewing experts on timely topics such as healthcare workplace violence and moral distress.

Kimmy has been a freelance writer for more than a decade, writing hundreds of articles on a wide variety of topics such as startups, nonprofits, healthcare, kiteboarding, the outdoors, and higher education. She is passionate about seeing the world and has traveled to over 27 countries. She holds a bachelor’s degree in journalism from the University of Oregon. When not working, she can be found outdoors, parenting, kiteboarding, or cooking.