Violence Escalates against Surgeons and Other Healthcare Workers

Healthcare violence is on the rise, and it is adversely affecting the personal and professional lives of healthcare workers in clinics, hospitals, and other medical facilities across the country.

Although nurses often receive the brunt of the violence, which includes verbal abuse, threatening behavior, and physical assaults, physicians—especially surgeons—have increasingly become targets as well. This behavior can come from patients, visitors, outsiders, intimate partners, and coworkers.

Healthcare workers are five times more likely to experience workplace violence than employees in other industries, and they account for 73% of all nonfatal workplace injuries and illnesses due to violence, according to federal government reports.¹ These statistics are from 2018, before healthcare workers began to see incidents of violence ramp up during the COVID-19 outbreak.

“Surgeons being assaulted, battered, or killed is a fairly new phenomenon within civilian hospitals,” said Jay J. Doucet, MD, MSc, FRCSC, FACS, director of the trauma division at the University of California (UC) San Diego Health. “We've had six surgeons killed in the last few years.”

Healthcare workers are often the target of angry patients coming into the hospital with violent intent, especially in emergency rooms and trauma bays. “These attacks are often directed at members of the healthcare team by dissatisfied clients or people unhappy with something about the healthcare system and taking it out on healthcare providers,” Dr. Doucet said.

This troubling pattern of hostility and violence toward physicians and members of the healthcare team was highlighted in the Executive Director column, “How the ACS Can Help Surgeons Address Workplace Violence,” published in the September 2023 issue of the Bulletin.

Role of the Pandemic

The problem of violence against healthcare workers escalated during the pandemic, especially during the uncertainty of the first year, said Carter Lebares, MD, FACS, a surgeon and director of the Center for Mindfulness in Surgery at UC San Francisco.

General respect for the sacrifices of healthcare workers was replaced by a more negative attitude that developed and spread on social media, Dr. Doucet added.

“Doctors were framed not as hard-working individuals trying to help solve this medical mystery but as somehow complicit in hiding information and not being straightforward,” Dr. Lebares said. “It’s a travesty, and that sentiment has persisted.”

Some patients question the motives of healthcare workers for recommending masks and vaccinations and accuse them of receiving kickbacks from the drug industry, Dr. Doucet said. Tensions also rose over the overturning of Roe vs. Wade and controversy over gender reassignment procedures.

Since violent incidents are typically underreported, it’s possible the problem may be much worse than what statistics and personal anecdotes reveal.

“Workplace violence is going unreported because people feel that there is no effective system in place to make the effort of reporting it worthwhile,” Dr. Lebares said. “People don’t expect anything to be done about it.”

Limited available data demonstrate a substantial increase in violence against healthcare workers since 2019. A survey of American College of Emergency Physicians membership showed that 85% of emergency physicians think there's been a general increase in the past 5 years, and 91% report they've been victims of violence in recent years. A 2024 nationwide survey conducted by National Nurses United found that in 2023, 81.6% of nurses have experienced at least one type of workplace violence incident, and nearly half have seen a rise in rates of violence.²

Impact of Violence on Healthcare

Aside from the direct physical and psychological impact of this behavior, the rise in violence has led to an increase in stress, burnout, job dissatisfaction, and turnover among healthcare workers, including surgeons.³ Hospital violence has led more than 26% of healthcare workers to consider quitting, Dr. Doucet said.

Six in 10 registered nurses report having changed or left their job or profession or considered doing so due to workplace violence.² Due to a lack of data, it’s unclear if the rising violence is having the same effect on physicians and surgeons. Dr. Doucet worked on a surgeon survey to better understand the impact of workplace violence in trauma centers; the results have been collected and are expected to be published soon. See the sidebar above for survey highlights.

Increased turnover has led to staff shortages at medical facilities, resulting in disruptions in patient care, increased absenteeism, and higher turnover rates among staff, said Nathan J. Powell, DO, FACS, an attending trauma and acute care surgeon at the Saint Francis Health System in Tulsa, Oklahoma. This trend could disproportionately hurt urban trauma centers, where many of the violent incidents occur, which in turn, could further widen disparities in care in urban areas.

“Attrition is very expensive for hospitals, especially if you're losing skilled nursing and physicians,” Dr. Doucet said.

Hospital operations and staff are already stressed by a “corporatization of healthcare” trend that is contracting resources and has led to overcrowded hospitals, long wait times for patients, insufficient staffing—all of which have become worse since the pandemic, said Dr. Lebares. See the March 2024 Bulletin article on corporatization of healthcare.

Add healthcare violence to that scenario—especially the increasingly antagonistic attitude toward providers from patients—and there is a potential to weaken or even break the traditional bond of trust between healthcare workers and patients.

“Medicine would become closer to being a business where there is a transaction but not a whole lot of soul,” Dr. Lebares said.

Strategies for Prevention and Mitigation

Overall, the best way to combat the rise in violence against healthcare workers is for employers to take appropriate caution. One of the best protections employers can offer healthcare workers is to establish a zero-tolerance policy toward workplace violence that covers everyone within the facility.

“A well-written and implemented workplace violence prevention program is key,” said Dr. Powell. “But it's critical to ensure that all workers know the policy, and that they understand that all claims of workplace violence will be investigated and remedied promptly.”

In January 2022, The Joint Commission began enforcing new and revised workplace violence prevention standards applicable to all hospitals accredited by The Joint Commission and critical access hospitals, including:

• Workplace assessment: Hospitals must conduct an annual worksite analysis related to their workplace violence prevention program, and then take action to mitigate or resolve workplace violence safety and security risks. This may include enhancing security measures such as redesigning hospital layouts, increasing security, implementing alarm systems, and tightening access.
• Monitoring: Hospitals must continually monitor, report, and investigate workplace hazards such as safety and security incidents, including those related to workplace violence.
• Education and training: Hospitals must provide training, education, and resources to address prevention, recognition, response, and reporting of workplace violence, including training in de-escalation, nonphysical and physical intervention skills, and response to emergency incidents.
• Response plans: Hospital response plans must specify policies and procedures to prevent and respond to workplace violence, analyze incidents and trends, and provide follow-up and support to affected victims and witnesses.

Dr. Powell was at Saint Francis on June 1, 2022, when Preston J. Phillips, MD, an orthopaedic surgeon, was shot and killed at the hospital by a man on whom he performed back surgery. Suffering from the aftermath of that event, which claimed three other lives in addition to the shooter, continues today, Dr. Powell shared.⁴ Since the event, Saint Francis administrators have implemented a number of workplace violence prevention strategies, such as:

• Onsite training for the local police department, which had not been familiar with the layout at Saint Francis during the 2022 shootings
• Increasing shooter response training from being offered quarterly to weekly and requiring it for all healthcare workers
• Developing a new text message alert system for all employees
• Instigating tighter access control, including locks on numerous doors and badge access on entrances
• Flagging patients in electronic health records that have exhibited aggressive behavior
• Devising a new lobby guard system that includes a simplified emergency code system

Are Metal Detectors Worth the Expense?

The rise in workplace violence has led many hospitals to add weapon detection systems at high-risk entry points such as emergency departments (EDs), said Amy E. Liepert, MD, FACS, a trauma and acute care surgeon and former chief of the Division of Acute Care Surgery at the University of Missouri Health Care in Columbia.

Even so, fewer than one in three hospitals have metal detection systems.⁵

In 2022, UC San Diego Health installed metal detectors in the main entrance to its Level I Trauma Center, which has an estimated 45,000 ED visits per year, Dr. Doucet said. Previously, security at the hospital screened suspected high-risk patients, such as those with a history of violence, mental illness, or substance abuse.

“Since metal detection was put in, the number of weapons detected has gone up dramatically,” he added.

In the 8 weeks before the metal detector was installed, 511 patients were screened by security; they confiscated 15 weapons. In the 8 weeks after the metal detectors were installed, 13,149 people were screened and 194 weapons were confiscated, according to Dr. Doucet.

A big obstacle posed by metal detectors is the cost. In addition to paying for the physical equipment, they require staffing from additional security agents.

For example, one hospital that has not yet added metal detectors is Saint Francis, the site of the mass shooting in 2022. The discussion about metal detectors is still ongoing, Dr. Powell said.

“I don’t know all of the reasons why we don’t have them, but a lot of it has to do with staffing,” he said.

Metal detectors at entrances are less effective if access to the building is not controlled. Most hospitals have dozens of entrances on the main floor, including employee entrances. Simply adding a metal detector does not provide complete security, Dr. Doucet said.

More Support for Those Exposed to Violence

When violence does occur, healthcare employers need to provide better responses for affected staff, including enhanced security, legal support, and counseling support services, according to Dr. Liepert.

This support starts with not blaming the victim for the incident, Dr. Doucet said. “They say, ‘You know, you shouldn't have said that, or you shouldn't have gotten close enough to get punched.’”

Specific forms of support for healthcare workers could include stress mitigation and mindfulness training. One study looking at surgeons undergoing the stress of surgical training found that mindfulness training decreased both physiological and psychological measures of stress, according to Dr. Lebares.

In two randomized trials of surgical residents trained in mindfulness-based stress-resilience skills, stress was reduced as evidenced by functional neuroimaging findings, circulating biomarkers, and subjective reports of feeling less stressed, she explained. Similar findings, from equally rigorous studies, have shown the minimization of post-traumatic stress disorder (PTSD) severity and even evidence of preventing PTSD in military veterans. In fact, the strength of this research lies behind Comprehensive Soldier Fitness—the US Army’s long-standing program which includes mindfulness-based stress-resilience training techniques for exactly this purpose.⁶

“Few things are effective in PTSD, but studies show that mindfulness-based interventions work,” Dr. Lebares said.

Role of Surgeons in Their Healthcare Institutions

Surgeons should help lead violence prevention initiatives within their institutions, Dr. Powell said.

This role could include ensuring that healthcare organizations follow The Joint Commission standards, where applicable, and the laws coming from the state and federal levels. Employers are responsible for the safety of employees and patients. Violence is a workplace issue, not a personal issue, Dr. Liepert said.

But some healthcare leaders don't want crimes reported or prosecuted, fearing it will affect the reputation of their institutions, Dr. Doucet said, adding that they may not want it known that violence is taking place in their hospitals or that their patients are being prosecuted.

Healthcare facilities, though, are more likely to experience violence if their administration ignores concerning behaviors, tolerates bullying, lacks a reporting system for violent incidents, has inadequate training, security, and threat management, and does not have fair and consistent disciplinary practices.

“We need to hold our organizational leaders accountable,” Dr. Doucet suggested.

Role of Surgeons in the Community

Advocacy and leadership in the community should come from surgeons, according to Dr. Doucet, adding that surgeons should partner with hospitals, nurses, law enforcement, mental health professionals, and community organizations to address the underlying issues of healthcare violence.

One tactic to deter healthcare violence is by increasing the penalties for it, Dr. Powell said. A variety of state and federal bills address healthcare workplace violence by, at least in part, making penalties for assaulting healthcare workers equivalent to those for attacking police and EMTs.

The ACS endorsed the Safety from Violence for Healthcare Employees (SAVE) Act, currently before US Congress, which would provide federal protections for healthcare workers who are victims of violence and intimidation in the workplace. The SAVE Act would make physically assaulting a healthcare worker punishable by up to 20 years in prison. 

In addition to offering federal level protections to healthcare workers, the SAVE Act would provide grants to hospitals for programs to help reduce the incidence of violence in care settings. These grants could be used for training hospital personnel, coordinating with state and local law enforcement, and purchasing equipment or technology that would help create a safer environment.

“It would make intentionally assaulting a physician or nurse in the emergency department a felony,” Dr. Doucet said. “In my state, California, it's not a felony—it's not even a serious misdemeanor, it’s a lesser misdemeanor.”

In some parts of California, the maximum sentence for punching a surgeon in the face in the ED is 6 months, Dr. Doucet said, further explaining that some district attorneys won’t even bother prosecuting that due to crowded jails.

“I'm aware of surgeons who have been assaulted and don't even bother reporting the crime,” he added.

Dr. Doucet supported state legislation in California to make this kind of assault a more serious crime. AB 977, which would increase penalties for those convicted of assaulting emergency department healthcare workers, passed both houses of the California legislature and is on Governor Gavin Newsom’s desk awaiting signature. Currently, 38 states have laws increasing penalties for assaults on certain healthcare workers—the majority of which make it a felony offense. For more information, see the article "Surgeons Help ACS Drive State Advocacy Efforts on Scope of Practice, Other Issues."

Some argue that anti-stalking laws also need to be made tougher. Dr. Liepert continues to be stalked across country by a former patient—a man on whom she performed surgery in 2018 at the University of Wisconsin Health Level I Trauma Center in Madison. She has been forced to take numerous measures to protect her personal privacy and safety. Despite anti-stalking laws, she had challenges engaging law enforcement to protect her from the stalker. For example, when her stalker crossed state lines to pursue her, Dr. Liepert was unable to get federal prosecutors to take the case because stalking is regarded as a federal add-on charge, not a standalone charge.

“I was told if you're assaulted or murdered or raped, then call us back,” she said.

Dr. Liepert was able to get the stalker successfully prosecuted at the state level, a rare victory that may reflect her status as a surgeon, she said. But the ongoing legal ramifications of the stalking played a part in her decision to leave her job as an academic surgeon to address ongoing security issues and work as a surgeon on a per diem basis to maintain her personal security.

“There needs to be legislation that makes stalking healthcare workers a standalone crime and violence against healthcare workers punishable by severe penalties,” Dr. Lebares said.

Dr. Powell agreed that “healthcare workers have a right to provide care in a safe setting.”

For more information on violence in healthcare and maintaining a safe workplace environment, attend the Clinical Congress 2024 session, “Violence in the Healthcare System: Recognition, Prevention and De-escalation for Providers” on Monday, October 21, at 8:00 am or view on demand soon after. Clinical Congress is Sunday–Tuesday, October 19–22 in San Francisco, California.

Jim McCartney is a freelance writer.

References

1. US Bureau of Labor Statistics. Workplace Violence in Healthcare, 2018. April 2020. Available at: https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm. Accessed August 23, 2024.
2. National Nurses United. High and Rising Rates of Workplace Violence and Employer Failure to Implement Effective Prevention Strategies is Contributing to the Staffing Crisis. February 2024. Available at: https://www.nationalnursesunited.org/sites/default/files/nnu/documents/0224_Workplace_Violence_Report.pdf. Accessed August 23, 2024.
3. Caruso R, Toffanin T, Folesani F, Biancosino B, et al. Violence against physicians in the workplace: Trends, causes, consequences, and strategies for intervention. Curr Psychiatry Rep. 2022;24(12):911-924.
4. A doctor who loved jazz, a mother of two: What we know about the Tulsa shooting victims. The Oklahoman. June 2, 2022. Available at: https://www.oklahoman.com/story/news/2022/06/02/victims-of-tulsa-shooting-oklahoma-names-released/7484558001/. Accessed August 23, 2024.
5. Fiorino D, Easter J, Kehr W. Metal detectors improve patients’ sense of safety in the emergency department. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. (2022); 23 (5.1). Available at: https://escholarship.org/uc/item/50b1m4v5. Accessed August 23, 2024.
6. Seppälä EM, Nitschke JB, Tudorascu DL, Hayes A, et al. Breathing-based meditation decreases posttraumatic stress disorder symptoms in US military veterans: A randomized controlled longitudinal study. J Traumatic Stress. 2014;27(4): 397-405.