Features
Hazardous to Your Health:
Violence in the Health-Care
Workplace
The headline-making events are familiar and chilling: a
Boston cardiologist murdered in a hospital by the son of
a deceased patient; an Indiana physician shot for refusing
to prescribe opioids to the killer’s wife; a Texas surgeon
shot and killed while riding his bicycle, the act perpe-
trated by a man nursing a 20-year grudge over the care
his family member received. These events are thank-
fully rare but, for the many medical providers across the
country who experience intimidation or overt verbal and
physical violence, the threat of workplace violence exacts
an immense toll.
Despite these extreme examples, violence against
health-care providers is underreported, understudied,
and undertreated. Data collection is inconsistent and
spotty, making it difficult to find effective strategies for
preventing and managing outbreaks of violence.
“In my experience, this problem is getting worse, but
I can only speculate because there aren’t good data about
violence in the health-care workplace,” said James P.
Phillips, MD, from the George Washington University
Hospital in Washington, DC. As an emergency medicine
specialist, Dr. Phillips is on the “front line” of workplace
violence but, he said “with no universal system for defin-
ing the issue, there is no way to definitively say if it’s
getting worse, better, or staying the same.”
Part of the issue is that violence against health-care
workers is so common, it’s become normative. Among
victims of violence in medical settings, only 30 percent
of nurses and 26 percent of physicians reported the inci-
dents ( SIDEBAR 1 ). 1
“We need to change the employee’s mindset from
‘violence is a part of the job’ to ‘violence is a problem that
needs to be managed,’ ” said Judy Arnetz, PhD, in a web-
inar sponsored by the Occupational Safety and Health
Administration (OSHA) and the Joint Commission. 2
Dr. Arnetz researches violence in health-care settings at
Michigan State University.
The first step toward that goal, she believes, is to im-
prove reporting. “If you don’t have any data, there simply
is no problem! The data are your evidence.”
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ASH Clinical News
ASH Clinical News spoke with Dr. Phillips, Dr.
Arnetz, other health-care practitioners, labor lawyers,
and security specialists about the prevalence and causes
of workplace violence. disability, and leave time (excluding long- and short-
term disability), which was 60.4 hours more per year
than counterparts who had not experienced workplace
violence.
An Expansive, Expensive Problem Violence Hotspots
Workers in the medical field, compared with other work-
place settings, are particularly vulnerable to violence.
According to data collected by the U.S. Bureau of Labor
Statistics about the incidence of intentional injury by
other people, the health-care and social assistance indus-
try had the highest rate of nonfatal injury cases of any
industry in 2014, at 8.2 cases per 10,000 full-time workers
and more than 11,000 injuries. 3
In 2013, 27 out of the 100 fatalities in health-care and
social service settings that occurred were due to assaults
and violent acts. 4
These data are corroborated by a 2011 National
Crime Victimization Survey, which estimated that
between 1993 and 2009, health-care workers had a
20-percent higher rate of workplace violence than the
average seen by all workers. 5 Workers in certain sec-
tors of the health-care industry are more vulnerable to
these attacks – for example, for those working in mental
health-care settings, their experience of workplace
violence rivals that of law-enforcement officers, security
guards, and bartenders.
As a consequence, the health-care sector spends bil-
lions of dollars related to managing workplace violence.
A 2017 report prepared for the American Hospital
Association estimated that workplace violence cost U.S.
hospital and health systems approximately $2.7 billion in
2016, including $280 million related to preparedness and
prevention, $852 million in unreimbursed medical care
for victims, $1.1 billion in security and training costs,
and an additional $429 million in medical care, staffing,
indemnity, and other costs related to violence against
hospital employees. 6
Further, health workers who were victims of violence
experienced an average of 112.8 hours per year of sick, In certain health-care settings, workers are more vulner-
able to violence; still, no setting is completely safe.
According to the “Guidelines for Preventing
Workplace Violence for Healthcare and Social Service
Workers” published by OSHA, “While no specific diagno-
sis or type of patient predicts future violence, epidemio-
logical studies consistently demonstrate that inpatient
and acute psychiatric services, geriatric long-term care
settings, high-volume urban emergency departments,
and residential and day social services present the highest
risks.” 4
Organizational factors that contribute to a higher
risk of violent incidents include: high worker turnover;
inadequate security and mental health personnel on site;
and lack of policies and staff training for recognizing and
managing escalating hostile and assaultive behaviors from
patients, clients, visitors, or staff.
“The most intentional violence we see in the emer-
gency department seems to come from people who are
intoxicated,” Dr. Phillips noted. One might think that a
strong security presence in the emergency department
would solve the problem, but according to Dr. Phillips,
police and security guards can only offer so much
assistance.
“In my career, I have never seen a patient arrested
in the emergency department,” he said. “I have had one
patient convicted of felony assault against me and had
another patient [against whom] I should have pressed
charges for felony assault against me.” In the second
incident, the patient was being restrained by police and
intentionally spit hepatitis C–positive blood into Dr.
Phillips’s face.
“Just two weeks ago, a patient threw a full can of
Coke at my head,” he added. “Two psychiatric patients
December 2018