How the hidden epidemic of violence against nurses affects health care

Nurses in the United States face a high rate of burnout. Hirung via Getty Images

“Violence is just part of the job. Every nurse and health care worker experiences it at some point.”

Sentiments like this echo across American hospitals and health care facilities, capturing a disturbing and growing reality. Though Americans think of nursing as the most trusted profession, we often fail to see that it’s also one of the most dangerous.

An alarming 8 in 10 nurses face violence at work. As a result, health care workers are more than four times as likely to be injured by workplace violence than workers in all other industries combined.

Despite these staggering numbers, the full extent of this epidemic may not be fully understood because nurses and other health care workers chronically underreport violent encounters. The American Nurses Association estimates that only 20% to 60% of incidents are accounted for. Additionally, there is no agreed-upon definition for workplace violence or clear way of tracking it on a national level.

As a practicing bedside nurse, I have experienced my fair share of workplace violence. As a professor of nursing, my research shows that violence has become a normalized but underreported part of working in health care and that it affects the care patients receive in pervasive ways.

What really counts as workplace violence in health care?

When people think about workplace violence, they often imagine dramatic physical assaults. Assaults do happen, but violence directed at workers can take many other forms, including verbal threats, intimidation, sexual aggression and bullying.

What makes defining and measuring workplace violence especially difficult in health care settings is the range of people involved. Violence may stem from patients, their families, co-workers or even disgruntled members of the public.

Nurses and health care staff work with people during incredibly stressful moments in their lives. Sometimes patients are experiencing medical conditions that may cause them to act out or be confused, such as dementia, delirium, psychosis or even postoperative reactions to anesthesia.

Too often, nurses who are threatened or hurt at work do not report the event.

Some health care organizations use vague definitions, such as “workplace violence is any violent act or threat of violence,” while nursing organizations advocate for tiered definitions delineating between perpetrator and intent.

Although not all employees can recite their organization’s official definition of workplace violence, ask a nurse whether they have ever experienced a threatening situation at work and they will likely have stories at the ready. In my 14 years of nursing practice, nurses shared many different types of threatening encounters. They reported being screamed at by distraught visitors and having their hair and wrists grabbed by patients who are trying to bite or spit at them. I have personally experienced having objects thrown at me from across the room and being threatened with retribution by patients’ family members.

Nurses also shared more extreme experiences in which they or their co-workers were injured in the course of trying to simply deliver care. Many described the emotional impact of watching a co-worker hurt badly enough to require medical attention.

From my observations, it’s not just the major incidents but the countless small threats or insensitive behaviors that add up over a nurse’s career. These seemingly less-threatening events are much harder to document, and many nurses shrug them off, but the small infractions take a toll when they happen repeatedly.

Breaking the culture of silence

A culture of silence makes such incidents hard to track.

The medical-surgical nursing unit at the hospital where I conducted my research has a healthy and supportive culture. Yet in my ongoing doctoral work, which will be published in May, of the 74% percent of staff that acknowledged experiencing workplace violence in the past year, only 30% reported the event.

When nurses stay silent, whether from fear, futility or institutional pressure, violence becomes an accepted part of the job. Without accurate data, health care facilities don’t understand the true extent of the problem, can’t implement effective safety measures, and struggle to support their workers in meaningful ways.

There are common themes as to why nurses underreport violence. Some nurses think reporting does not make a difference. Others find the lack of clarity in defining workplace violence or reporting policies demotivating and confusing.

Nurses also report a lack of support from management, a fear of reprisal or a sense of shame when reporting. Commonly, many nurses simply find reporting tools to be too difficult and time-consuming to use.

Nurses are the largest segment of the health care workforce in the U.S.
Frazao Studio Latino via Getty Images

The hidden costs to health care

For health care workers, the consequences extend far beyond physical injuries.

Workplace violence in all its forms contributes to anxiety, depression or PTSD, as well as job dissatisfaction. Dangerous workplace violence trends are a contributing factor in 55% of health care workers feeling burned out and 18% of newly licensed registered nurses leaving the profession within the first year.

That is a huge problem, considering that the United States is projected to have 193,100 nursing job openings per year until 2032, yet will produce only roughly 177,400 new nurses in that time frame. This also has vast repercussions for patient care.

During my nursing career, I observed my peers developing complex strategies to protect themselves while trying to provide compassionate care. Like me, they tended to carefully position themselves near doorways, maintained constant awareness of their surroundings and silently assessed each new interaction for potential risks.

These invisible precautions reflect the far-reaching effects of health care violence. When nurses are hypervigilant about their safety, they have less emotional energy for patient care. When they’re rushing between rooms due to short staffing caused by violence-related turnover, they have less time for each patient. When they are worried about what the next patient encounter may bring, they are increasing their anxiety, fear and stress rather than focusing on delivering quality care.

Creating safer health care together

Each health care visit is a chance for patients and their families to improve nursing care for everyone.

When you visit a hospital or clinic, try to understand the stress that health care workers are under and express your needs and concerns calmly. You never know what your nurse is dealing with in their interactions with other patients. They try to compartmentalize and give you their full attention, but they might also be experiencing a difficult and traumatic situation right next door.

It also helps to share information that might be relevant to caring for your family member, such as whether their medical condition is causing them to act differently than normal. And you should speak up if you witness any forms of aggressive behavior. These actions might seem small, but they support health care staff and help prevent violence in health care settings.

Nurses are trained to keep information private, to be problem-solvers and to bear the burden of the job, so they don’t always seek support. If you have a nurse or health care worker in your family or circle of friends, let them know you care. Supporting their safety validates their work and leads to better care for everyone.

Jason Blomquist is affiliated with the American Nurses Association, Idaho chapter as a member of the board of directors. This affiliation has not influenced or overlapped with the work described in this article.