Jones & Bartlett Learning Health Blog

    Teaching About Violence in Healthcare Settings

    Posted by sharonb on Feb 3, 2014 12:00:28 AM

    Sharon New Head Shot 2013Almost daily, it seems the media is filled with reports of violence, so much so that we almost become numb to them. An active shooter in a popular mall. A disgruntled employee returns to his former place of employment armed to kill. A student with mental health problems murders a favorite teacher, a classroom full of students, or goes on a campus rampage. However, when violence hits in healthcare settings, we are shocked and ask, How did this happen? These institutions, these sacred places, are supposed to serve and care for our loved ones. Yet in many instances they cannot protect our loved ones because of the nature of the settings themselves. As the incidence of violence rises, we are doing a disservice to our students by not talking about this elephant in the room, violence in health care settings. The purpose of this blog is to provide a brief overview of violence in healthcare settings, raise your awareness of this phenomenon, and encourage faculty to include it in their courses and curriculum.

    What is Violence in Health Care Settings?

    One of the challenges in writing about statistics on violence in healthcare settings is that the data are not always collected in the same manner, using the same definitions across various reporting agencies and authors. For this post, I'm using data from the Bureau of Labor Statistics (BLS), the Bureau of Justice Statistics, the Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health (NIOSH), the National Violence Against Women Survey, and peer-reviewed literature published by epidemiologists, physicians, nurses, attorneys, law enforcement officers, criminologists and forensic psychologists, as well as important papers from professional organizations.

    The Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH) (2001) defines “workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or duty. In reality, violence in healthcare settings can occur against workers, clients/residents, visitors, relatives, i.e., anyone physically present in a healthcare setting.

    In 2007, the BLS Census of Fatal Occupational Injuries data showed healthcare settings had the following fatality rates:  ambulatory health care services, 48 per 6,013,000 workers, or a fatality rate of 0.8; hospitals, 29 per 5,169,000 workers, or a fatality rate of 0.6; and nursing and residential care facilities, 18 per 2,256,000 or a 0.8 fatality rate (BLS, 2007).

    These rates are low when compared to workplace violence statistics overall. Consistent with the BLS data, the Bureau of Justice Statistics found homicides represented less than 1% of workplace violent crimes, or about 900 work-related homicides annually.  “Between 1993 and 1999 in the United States, an average of 1.7 million violent victimizations per year were committed against persons age 12 or older who were at work or on duty, according to the National Crime Victimization Survey (NCVS)” (Duhart, 2001, p. 1). Workplace violence accounted for almost a fifth (18%) of all violent crime during the time period under review. In other words, victims of violent crimes have a one in five chance of being at work when the attack occurs.

    Types of Workers

    When I looked at types of workers, I found that for the same time period (1993 to 1999) physicians experienced a rate of 16.2 per 1000 workers of violent victimizations in the workplace. For the same time period, nurses experienced a rate of 21.9 per 1000. While the rate was not statistically different from that of physicians, it was “72% higher than medical technicians and more than twice the rate of other medical field workers” (Duhart, 2001, p. 4). Mental health workers experienced higher rates of violence than their peers, and have “higher assault rates than all other occupations—except law enforcement” (Duhart, 2001, p. 5). Rates for these workers were: mental health professional workers, 68.3 per 1000; mental health custodial workers, 69.0 per 1000; and other mental health workers, 40.7 per 1000 (Duhart, 2001).

    Mental health and emergency room workers have similar risks in part due to the fact that violence from the street often follows patients into the ER; however, the data on ER workers are dearth. According to the Emergency Nurses Association (2008), threats and violence are underreported because some employees assume that it’s part of the job, or are fearful of reporting the incident to their supervisor because they are afraid of poor performance appraisals.  In 2005, the Michigan College of Emergency Physicians Workplace Violence Taskforce surveyed ER physicians and asked how often members experienced work-related violence in the past year. Of the 171 physicians who completed the survey, three-quarters indicated they were victims of verbal abuse; slightly over a quarter indicated they were physically assaulted; and 3.5% indicated they were stalked (Kowalenko, Walters, Khare, & Compton, 2005). Clearly, more data are needed to have a better understanding of the patterns and perpetrators of violence in these volatile areas of healthcare.

    Types of Crimes

    Between 1993 and 1999, the “majority (94%) of workplace crimes were simple and aggravated assaults” (Duhart, 2001, p. 5).  There were 4 simple assaults for every aggravated assault. Assault rates, as noted before, were highest among mental health care workers. ER physicians also reported high rates of assault, with 1 in 4 responding physicians having been physically assaulted (Kowalenko, Walters, Khare, & Compton, 2005). The BJS found assailants were most likely to be male, most likely to be of a similar racial group to the victim, most likely to be young, and had a about a one in three chance of being under the influence of alcohol or drugs at the time of attack (Duhart, 2001).


    In the National Violence Against Women Survey noted earlier, using a strict definition of stalking, i.e., the victim felt a high level of fear, the authors found that “8 percent of the women surveyed were stalked versus 2 percent of men have been stalked at some point in their life” (Tjaden & Thoennes, 1998, p. 3). About half of the victims of stalking, both male and female reported their concerns to police. Police were more likely to intervene when the victim was a woman. Of those who did not report their complaints, the top 3 reasons for non-reporting were: “did not think it was a police matter, thought police couldn’t do anything, or feared reprisal from stalker” (Tjaden & Thoennes, 1998, p. 10). When compared to individuals who had never been stalked, stalking victims reported “more fears for their personal safety and being stalked, carried something on them for personal safety, and felt things had gotten worse in general for men and women with regard to personal safety ” (Tjaden & Thoennes, 1998, p. 11).

    Stalking is an under-reported phenomenon (Davis & Chipman, 1997). Victims are embarrassed, unwilling to disclose their concerns for fears of being ridiculed or worse, fear losing their job. In addition, victims are often in the throes of domestic troubles that may have already spilled over into violence, and fear reprisal from their stalkers. Stalking can last an average of 2 years and can escalate into aggravate assault and homicide, especially if the stalker is an intimate partner (Tjaden & Thoennes, 1998).  Concannon (2005, p. vi) found "individuals who engaged in stalking behaviors with greater frequency over the course of one year were significantly more likely to be violent than were those who did not engage in such behaviors or who engaged in such behaviors on a less frequent basis." Fear of the stalker, feelings of helplessness and being overwhelmed contribute to the victim's fear of job loss—if they dare to share their terror. The National Center for Victims of Crime has a Stalking Resource Center which includes definitions, data, and resources for stalking victims.

    In the case of healthcare professionals, stalkers are more common among mental health professionals. One of the few available studies on the actual prevalence of stalking of mental health professionals found that “5% of counseling center staff had been stalked by current or former clients, 8% had a family member stalked, and over half (65%) had experienced harassment” (Romans, Hays and White, 1996, p. 595). Stalking can last over a period of a few months to several years (McIvor & Petch, 2006; Mullen, Mackenzie, Ogloff, Pathe´, McEwan & Purcell, 2006). The obsessive stalker can be male or female, personality disordered and/or substance abusing, and may be in search of “intimacy or are ex-partners unwilling to abandon the lost relationship” (Mullen, Mackenzie, Ogloff, Pathe´, McEwan & Purcell, 2006, p. 440).


    With respect to females, while their overall numbers were lower than males for violent crime, when they were targets of violence in the workplace, women are more likely to be killed at work and were more likely to be killed by someone they know and/or intimate partner. "One-third of women killed in U.S. workplaces were killed by a current or former intimate partner according to one multi-year study.  Another study found that nearly one in four large private industry establishments reported at least one incidence of domestic violence, including threats and assaults"( Office of Violence Against Women, 2013). According to NIOSH (n.d.), “homicide accounts for 40% of all workplace deaths among female workers; over 25% of the homicide victims are assaulted by people they know, and 16% are victims of domestic violence that spills over into the workplace.” At some point in a tumultuous relationship, intimate partners became murderers. Oftentimes before the murder occurs, there have been warning signs, such as harassment; emotional, psychological and physical abuse; and, stalking. Many women are reluctant to tell co-workers they are going through an ugly separation or divorce. This shame can cost them their lives and the lives of others.

    Consequences, Costs, and Planning

    In addition to the physical consequences of assault, emotional and mental sequelae take a significant toll on victims and witnesses of violence (Gillespie, 2008). From a financial perspective, workplace violence has a large impact on the bottom line of an organization causing increasing absences from work, greater use of workman compensation claims, sick time and personal injury lawsuits. From a business perspective, it makes good sense to have a violence prevention plan in the workplace. Which means we need our health care management students to be prepared to develop or update these plans.

    Many excellent resources for developing workplace violence prevention plans are available online. The Emergency Nurses Association has an ENA Workplace Violence Toolkit, which provides healthcare professionals with a step-by-step plan for addressing violence in the ED. In addition, OSHA (2004) has Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers, the New York Department of Labor has Workplace Violence Prevention Program Guidelines, to name but a few.

    If you have little room in your curriculum as many of us do, you might begin with the video from the Department of Homeland Security on active shooter scenarios for a class discussion. Planning and operations courses can utilize the workplace violence prevention planning resources noted above. In addition, you can assign case studies on this topic for your courses to address multiple competencies required for program assessment. Whether we want to think about it or not, workplace violence in healthcare settings is a real phenomenon that won't go away by ignoring it. Isn't it time we began a conversation about it with each other and our students?


    Sharon Buchbinder is Professor and Program Coordinator for the MS in Healthcare Management at Stevenson University in the Graduate and Professional School and former chair of the Association of University Programs in Health Administration (AUPHA). She is also the author of three books from Jones and Bartlett: Introduction to Health Care Management (with Nancy H. Shanks), Career Opportunities in Health Care Management (with Jon Thompson) and Cases in Health Care Management (with Nancy H. Shanks and Dale Buchbinder).

    Here are some additional resources if you are interested in this topic.

    Adler, F., Mueller, G.O.W., Laufer, W.S. (2004). Types of crimes. In Adler, F., Mueller, G.O.W., Laufer, W.S. (Eds.) Criminology and the Criminal Justice System. New York (NY): McGraw-Hill, 237-258.

    Basile K.C., & Saltzman L.E. (2002) Sexual violence surveillance: uniform definitions and recommended data elements version 1.0. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

    Baum, K., Catalano, S., & Rose, K. (2009). Stalking victimization in the United States. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, Special Report.

    Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH). (2001). Women’s safety and health issues at work.

    Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH). (2002). Violence: Occupational hazards in hospitals.

    Concannon, D. (2005). The association between stalking and violence in interpersonal relationships. (Doctoral dissertation, Alliant International University, Fresno, CA, 2005). Dissertation Abstracts International: Section B: The Sciences and Engineering, 67 (2-B), 2006, 1203.

    Duhart, D.T. (2001). Violence in the workplace, 1993-1999. U.S. Department of Justice,Office of Justice Programs, Bureau of Justice Statistics, Special Report.

    Emergency Nurses Association. (2010). Position Statement: Violence in the emergency care setting.

    Emergency Nurses Association. ENA Workplace Violence Toolkit.

    Smith, J.G., Juarez, A.M., Boyett, L., Homeyer, C., Robinson, L., MacLean, S.L. (2009). Violence against nurses working in US emergency department. JONA: Journal of Nursing Administration 39 (7/8), 340-349.

    Gillespie, G.L. (2008). Consequences of violence exposures by emergency nurses. Journal of Aggression, Maltreatment & Trauma 16 (4), 409-418.

    Kowalenko, T., Walters, B. L., Khare, R. K., & Compton, S. (2005). Workplace violence: A survey of emergency physicians in the state of Michigan. Annals of Emergency Medicine, 46, 142-147.

    McIver, R.J., & Petch, E. (2006). Stalking of mental health professionals: an underrecognized problem. British Journal of Psychiatry 188, 403-404.

    Mullen, P.E., Mackenzie, R., Ogloff, J.R.P., Pathe´, M., McEwan, T., & Purcell, R. (2006). Assessing and managing the risks in the stalking situation. J Am Acad Psychiatry Law 34 (4), 439–50.

    Mullen, P.E., Pathe´, M., & Purcell, R. (2001). Stalking: new constructions of human behavior. Australian and New Zealand of Psychiatry 35, 9-16.

    National Center for Victims of Crime Stalking Resource Center. (n.d.)

    Occupational Safety and Health Administration (OSHA). (2004). Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers.

    Romans, J.S.C, Hays, J.R., & White, Tamiko. (1996). Stalking and related behaviors experienced by counseling center staff members from current or former clients. Professional Psychology: Research and Practice 27(6), 595-599.

    Rugala, E. (2002, September 26). Emerging trends in employment and labor law. Congressional Testimony.

    Spector, P.E., Coulter, M.L., Stockwell, H.G., & Matz, M. W. (2007, Apr-Jun). Perceived violence climate: A new construct and its relationship to workplace physical violence and verbal aggression, and their potential consequences. Work & Stress, 21 (2), 117-130.

    Tjaden P., & Thoennes N. (1998a).  Stalking in America: findings from the National Violence against Women Survey, Research in Brief, Washington, D.C.: U.S. Department of Justice, National Institute of Justice, Publication No.: NCJ 169592.

    Tjaden P., & Thoennes N. (1998b).  Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey Washington (DC): Department of Justice (US). Publication No.: NCJ 172837.

    Tjaden, P. & Thoennes N. (2000). Extent, nature, and consequences of intimate partner violence: findings from the National Violence against Women Survey. Washington (DC): Department of Justice (US). Publication No.: NCJ 181867.

    U.S. Department of Justice, Federal Bureau of Investigation (FBI) (2004). Uniform Crime Reporting Handbook.

    U.S. Department of Justice, Office of Violence Against Women (OVW). (2013, November).

    U.S. Department of Labor, Bureau of Labor Statistics, Census of Fatal Occupational Injuries (CFOI) (2007). Fatal Occupational injuries, employment, and rates of fatal occupational injuries by selected worker characteristics, occupations, and industries, 2007.

    U.S. Homeland Security. (2013, March). Options for consideration: Active shooter training video

    Wattendorf, G.E. (2000, March). Stalking-investigation strategies. FBI Law Enforcement Bulletin, 69 (3), 10-14.

    Topics: administration, Author, author, health administration, Sharon Buchbinder Blog, Violence in healthcare settings

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