Since the beginning of medicine all those within the healthcare system take the Hippocratic Oath to “do no harm,” which speaks to providing ethical based care devoid of harm (Walton & Kerridge, 2014). Unfortunately, this sacred oath was instilled only for patient care, and instead should have been expanded to include those providing the care to “do no harm” amongst themselves. Violence is defined by the World Health Organization (WHO) as the deliberate use of physical force of power, against oneself, another person, or against a group or community, that has consequences that can result in injury, death, mental distress, or deprivation (Lim et al., 2022). There are different categories and levels of violence such as: type I: committed by individuals with criminal intent who have no relationship to the business or its employees; type II: involves a customer, client, or patient who becomes violent while receiving services; type III: involves worker-on-worker violence; and type IV: individuals involved have a relationship to each other outside of the business (ANA, 2021). In Maslow’s hierarchy of needs, the need for safety is second only to the basic physiological needs of food, shelter, and water and is why workplace safety is of tantamount importance to workers.
Currently, the healthcare and social service industries are notorious for having the highest rates of workplace violence injuries, with workers in these industries being five times more likely to be injured than other workers (Lim et al., 2022). Many healthcare workers are victimized first, by the perpetrator and secondly, by their workplace. Currently, 80% of all reported workplace violence in the U.S. is perpetrated against healthcare workers. In a survey conducted by the American Nurses Association (ANA), only 20% of nurses reported that they felt safe at work, and data from other countries also demonstrates higher than average rates of workplace violence against healthcare workers (ANA, 2021). Institutions of higher healthcare services gasconade as places of healing and compassion, yet they also boast high levels of psychological verbal abuse (61.2%), psychological violence (50.8%), threats (39.5%), physical violence (13.7%), and sexual harassment (6.3%) (Lu et al., 2020). Rather than tackling the insidious violence permeating throughout their institutions many have created a formal incident reporting system, where individuals can report incidents in the forms of bullying, verbal abuse, and harassment. (Lim et al., 2022). Healthcare violence faces the same stigma that causes other violence to go unreported, and many healthcare workers who are the victims of violence feel guilt and shame in the aftermath of the incident. As a consequence, only an estimated 20% of violent incidents are ever officially reported (OSHA, 2016). Healthcare workers stated that their primary reasons for not reporting were fear of an effect on customer service scores, ambiguous reporting policies, fear of retaliation, perception that it would reveal their incompetence, and a lack of managerial support for reporting (Arnetz et al., 2015; Gacki-Smith et al., 2009). Our societal lack of concern for violence against healthcare workers reflects the attitudes that are directed towards all stigmatized violence (Arnetz et al., 2015; Gacki-Smith et al., 2009).
Although retaliation is illegal under both state and federal law and is objectively immoral, many of these corporations masquerading as a healthcare system actively participate and encourage this dissenting behavior. For example, in January 2016, RN Sue McIntyre spoke at a conference where she discussed workplace violence and abuse towards nurses which sparked a media conversation about the violence in healthcare. This led to media coverage and led to Sue’s employer to fire her for making “inappropriate, inaccurate and unprofessional” statements (Frieda, 2018). She eventually regained her job back after navigating a two-year lawsuit (Frieda, 2018). This demonstrated the devilish lengths institutions will go to avoid accountability for cultivating and perpetuating a cycle of violence against those that strive to provide aid to patients. Furthermore, there are additional factors that healthcare workers have stated contribute to the underreporting, such as patients who are under the influence of drugs or alcohol or individuals suffering from mental illness, cognitive impairment, dementia, or delirium that participate in violence and cannot be held accountable for their actions (Arnetz, 2022). Reporting systems are often convoluted and time consuming, making them difficult for health care employees working under duress to actually use(Arnetz, 2022). Employee perceptions that reporting never leads to any improvements or the belief that violence is an expectation and “part of the job” further limits reporting and results in inaccurate workplace violence statistics (Arnetz, 2022). The combination of multiple forms of violence, preparators, factors, and barriers presents a complicated challenge that will require a multi-layered approach to effectively curtail the consequences of workplace violence.
The true cost of violence in healthcare is measured in absenteeism, lostproductivity, job dissatisfaction, low morale, injury, and moral suffering (Beattie et al., 2018; Gates, Gillespie, & Succop, 2011). Workplace violence is highly prevalent within our healthcare system, and leads to physical and psychological issues in healthcare professionals and can even impact the quality of care provided (Ramzi et al., 2022). The unnecessarily high prevalence of violence against healthcare workers prevents them from providing desirable nursing care. Additionally, it causes psychological disorders in healthcare workers, reducing their quality of life, endangering patients lives by increasing the risk of medication errors (Ramzi et al., 2022). Furthermore, the costs to patients, direct or indirect, can vary from direct injury from violence to gaps in care associated with staff absenteeism motivated by violence in the workplace. Staff absenteeism can be motivated by violence as it has been documented that on average 13% of missed days of work in the healthcare sector are due to workplace violence, and clinicians who have experienced violence are more likely to make mistakes and to leave their current position, increasing total costs of violence (Beattie et al., 2018; Gates, Gillespie, & Succop, 2011). The financial detriment of workplace violence highlights the burden it has perpetuated as the cost for a single report of assault can be up to $30,000 (Beattie et al., 2018; Gates, Gillespie, & Succop, 2011). Additionally, current estimates of costs associated with non-fatal workplace violence in health care settings range from $109,000 per year for treatment and indemnity among injured nurses to over $330,000 per year in a single hospital system (Arnetz, 2022). These estimates do not include the immeasurable costs of the psychological trauma, fear, and work dissatisfaction that may develop as an employees’ response to workplace violence. Therefore, it is imperative to initiate protective measures in hospitals and medical centers and provide solutions on how to reduce and navigate workplace violence.
Failing to prevent and denying the existence of workplace violence further victimizes those among us who are already most at risk to experience violence. Violence is a systemic problem, and therefore requires a systemic response. Discussing violence as an individual unavoidable problem removes responsibility from the system. The Joint Commission created a violence prevention standard that encompasses five new elements of performance (EP) requirements. The development of these standards represents an important development in that they hold hospitals accountable for workplace violence and provide a structured approach to addressing workplace violence (Lim et al., 2022). It is undeniable that workplace violence needs to be addressed more comprehensively, involving shared responsibilities from all levels such as government legislators, healthcare managements dedication to policy changes, updated awareness and knowledge regarding workplace violence, and the provision of technical support and assistance from professional organizations and the community (Lim et al., 2022). These collaborators can effectively create solutions that address safe staffing, as appropriate workload and adequate staff for healthcare workers of all disciplines reduces their odds of experiencing violence (Nowrouzi-kia et al., 2019; Occupational Safety and Health Administration, 2016). Hospital administrators can cultivate safety by creating clear visitation policies, providing consistent enforcement of policies, and investigation of all incidents so the root causes of violence can be identified and addressed (Nowrouzi-kia et al., 2019; Occupational Safety and Health Administration, 2016). Ultimately the knowledge and resources to reduce the number and severity of violent events is accessible and the burden lies on the institutions to improve physical and psychological safety of their staff so that violence never becomes the norm. The hope is that these new standards can help hospitals achieve a stronger culture of safety and violence prevention. This will in time ultimately remove the mindset that violence is an expectation of the job, and rather as another occupational hazard with solutions to effectively manage and prevent in the future (Arnetz, 2022).
Violence that is perpetuated against healthcare workers has become an epidemic of terrifying proportions. The long term determinants are evident in the emotional distancing, avoidable mistakes, exhaustion, and departures that have plagued the workers in the system. Violence has an effect on everyone that utilizes the healthcare system and therefore needs unified condemnation and resolvement. Workplace violence within the healthcare system is a systemic problem that necessitates a systemic solution.
- American Hospital Association (2021). House passes workplace violence prevention bill.
- Arnetz J. E. (2022). The Joint Commission's New and Revised Workplace Violence Prevention Standards for Hospitals: A Major Step Forward Toward Improved Quality and Safety. Joint Commission journal on quality and patient safety, 48(4), 241–245. https://doi.org/10.1016/j.jcjq.2022.02.001
- Arnetz, J.E., Hamblin, L., Ager, J. et al. (2015). Underreporting of workplace violence: Comparison of self-report and actual documentation of hospital incidents. Workplace Health and Safety, 63(5), 200-210.(4), 241–245. https://doi.org/10.1016/j.jcjq.2022.02.001
- Beattie, J., Innes, K., Griffiths, D. & Morphet, J. (2018). Healthcare providers’ neurobiological response to workplace violence perpetrated by consumers: Informing directions for staff well-being. Applied Nursing Research, 43, 42-48.
- Frieda Paton, M. C. (2018, February 19). Nurse fired for speaking out on workplace violence wins her job back. Nurseslabs. Retrieved April 25, 2023, from https://nurseslabs.com/nurse-fired-speaking-workplace-violence-wins-job-back/
- Gacki-Smith, J., Juarez, A.M., Boyett, L. et al. (2009). Violence against nurses working in U.S. emergency departments. Journal of Nursing Administration, 39(7), 340-349.Arnetz, J.E., Hamblin, L., Ager, J. et al. (2015). Underreporting of workplace violence: Comparison of self-report and actual documentation of hospital incidents. Workplace Health and Safety, 63(5), 200-210.
- Lim, M. C., Jeffree, M. S., Saupin, S. S., Giloi, N., & Lukman, K. A. (2022). Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures. Annals of medicine and surgery (2012), 78, 103727. https://doi.org/10.1016/j.amsu.2022.103727
- Lu, L., Dong, M., Wang, S. B., Zhang, L., Ng, C. H., Ungvari, G. S., Li, J., & Xiang, Y. T. (2020). Prevalence of Workplace Violence Against Health-Care Professionals in China: A Comprehensive Meta-Analysis of Observational Surveys. Trauma, violence & abuse, 21(3), 498–509. https://doi.org/10.1177/1524838018774429
- Nowrouzi-Kia, B., Isidro, R., Chai, E., Usuba, K. & Chen, A. (2019). Antecedent factors in different types of workplace violence against nurses. Aggression and Violent Behavior, 44, 1-7.
- Occupational Safety and Health Administration (2016). Guidelines for preventing workplace violence for healthcare and social service workers. U.S. Department of Labor. https://www.osha.gov/sites/default/files/publications/osha3148.pdf
- Walton, M., & Kerridge, I. (2014). Do no harm: is it time to rethink the Hippocratic Oath?. Medical education, 48(1), 17–27. https://doi.org/10.1111/medu.12275