Workplace Violence Is Not Just ‘Part of the Job’

I (Doehring) remember his denim overalls and the sound of muddy boots hitting the emergency department (ED) floor as he suddenly lunged out of the gurney with his big hands stretched toward my neck. He was intoxicated, which made him slower, thankfully. His words were profane and offensive. I was a young, slightly built, new mother of two with flight reflexes that saved me from physical injury that day. More than 20 years later, I can still see his face.

All I had done was walk toward his bed in the large ward filled with 15 other patients, planning to introduce myself as his emergency physician and begin his ED evaluation. At the time, I shrugged and moved on without much thought. After all, I worked in a busy, urban ED, and it was “just part of the job.” But this act of workplace violence clearly affected me, as the memory remains vivid 2 decades later.

Compared to many others, this is a relatively tame story of workplace violence from the front lines of medicine. The ED is the front door of the hospital. Anyone can walk, roll, or be carried in and rightly expect to receive expert medical care at any time for any reason. The medical professionals who work in EDs across the U.S. experience workplace violence on a regular basis. It is underreported and under-addressed. Workplace violence is routinely and wrongly accepted as “part of the job” for front-line healthcare workers.

Our research team took on the challenge of prospectively studying the frequency of verbal and physical workplace violence perpetrated against healthcare workers in a large urban ED. We also asked healthcare workers about themselves, whether they felt the workplace violence was biased, and how a violent event impacted their shift. The headline finding was that healthcare workers, on average, were victims of a violent event more than once every four shifts worked. These results are an alarming call to action for all who are interested in protecting our healthcare workforce from verbal and physical abuse that would not be tolerated in any other industry.

Not surprisingly, nurses experience workplace violence more frequently than other healthcare workers. They are at the bedside responding to call lights, updating relatives, assessing and reassessing their patients, administering medications, and completing a host of other vital duties. We have heard both female and male nurses called almost every imaginable expletive, slur, and insult. Patients frequently mock, comment on, and ogle the physical appearances of their caregivers.

Our nurses endure highly offensive statements from their patients, remarking upon their skin color, body size, accent, and presumed sexual orientation. Biased workplace violence was not uncommon in our study, with sexist or racist bias reported in 25% and 7% of events, respectively. The healthcare workers in our study gave descriptions of verbal abuse that were too disturbing or X-rated to be published in a medical journal. We listed a few in our article, but believe us, there were more and worse.

The impact of workplace violence on healthcare workers has not been well-studied. Our colleagues reported that they were affected by the incident moderately or severely in 24% of events. Interestingly, we coded the “severity” of events, and there was no correlation between the coded severity of the event and the personal impact the healthcare worker reported. This highlights the need to address all forms of workplace violence, not just the more “severe” types like physical aggression.

The physical abuse that healthcare workers experience is appalling. Spit, blood, urine, and feces are hurled at healthcare workers. Medical equipment such as EKG machines, carts, and IV poles become weapons. Kicking, punching, pinching, and groping the bodies of clinicians who are trying to provide care to their patients is egregious and should not be tolerated. The level of violence in the ED is shocking to anyone outside of medicine, although those of us in healthcare have become largely numb to its impact. If an airline passenger committed similar acts or made threats against a flight attendant, they would be restrained for the remainder of the flight and met by a small army of law enforcement officers to escort them to jail upon landing.

Workplace violence is an ongoing issue in EDs and has worsened over time. Staffing shortages, which have worsened since COVID-19, result in increased wait times that often lead to frustration from patients and their families. Many patients who commit workplace violence are intoxicated, suffering a mental health crisis, or medically ill, but this does not negate the significant harm these frequent, repeated events cause our colleagues.

Regardless of the causes of increased workplace violence in the ED, healthcare workers who care for the sick and dying deserve action towards tangible reforms and protections. In 2023, representatives Larry Bucshon, MD, (R-Ind.) and Madeleine Dean (D-Pa.) introduced the bipartisan Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S. 2768), which, like the protections for those in the airline industry, would create legal penalties for individuals who knowingly and intentionally assault or intimidate hospital employees. The SAVE Act was referred to the House Judiciary Committee in April 2023 with no further action to date.

What is the answer to such a disturbing and prevalent problem for our ED colleagues? The evidence regarding the prevention of workplace violence is not robust. A multidisciplinary team of bedside caregivers, hospital administrators, legal experts, legislators, and policymakers should come together to develop solutions that protect and support healthcare workers. Preventing the ensuing burnout and attrition of talented and highly trained healthcare workers who are caring for the sickest patients at their most vulnerable times is a challenge. It will require creativity and cooperation, and should start with the rejection of accepting workplace violence as “part of the job.”

Marla C. Doehring, MD, is an associate professor of clinical emergency medicine at the Indiana University School of Medicine and a practicing emergency medicine physician at Sidney and Lois Eskenazi Hospital in Indianapolis. Megan M. Palmer, PhD, is senior associate dean of faculty affairs and professional development at the Indiana University School of Medicine, and an associate professor and vice chair in the Department of Emergency Medicine. She leads and has expertise in medical education, faculty vitality, and faculty development.