Workers in health care and social assistance settings are five times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations, according to the Bureau of Labor Statistics.

Nurses in the emergency department are disproportionately victims of workplace violence according to the Emergency Department Violence Surveillance Study, conducted by the Emergency Nurses Association, which found that 55.6 percent of nurses reported they had experienced physical violence, verbal violence or both. Furthermore, the study found that 57.6 percent of nurses surveyed rated the safety of their ED as a 5 out of 10 or lower (ENA, 2010).

Guidance Toward a Solution

The growing number of reported incidents of violence in the workplace is a clear indicator that hospitals need to make a concerted effort to raise their commitment toward eliminating workplace violence. The ENA, whose journal cover sports the phrase "Safe Practice, Safe Care," and the American Organization of Nurse Executives, whose goal is to "establish healthy work environments for all care providers," held a day of dialogue about workplace violence.

The day of dialogue was a forum for AONE and ENA representatives to talk about workplace violence. Participants, ED nurses and nurse leaders in the acute care setting discussed how incidents of violence are currently addressed in hospitals; the necessity of partnership between hospital leaders, especially nurse leaders and nursing staff; and the need to create an environment in which health care professionals, patients and families feel safe. Participants developed guiding principles and prioritized action items to assist all hospital leaders in systematically reducing lateral, or colleague-to-colleague, violence as well as violence perpetrated by patients and family members.

Fighting a Culture of Acceptance

There is an underlying cultural problem within the health care setting regarding workplace violence: Workers tend not to report incidents, specifically in the ED. Recent research indicates that many health care workers underreport violence because it is inconvenient and they accept such conditions as "part of the job," according to a Medscape Multispecialty report (quoted in Bird, 2015). The Emergency Department Violence Surveillance Study found that 65.6 percent of physical violence victims and 86.1 percent of verbal abuse victims did not file a formal report (ENA, 2010). This culture of acceptance among health care workers may contribute to the incidence and prevalence of workplace violence; it also may also contribute to the difficulty in enacting and enforcing felony laws related to the assault of health care workers.

Implications and Costs

The most devastating impact of violence to health care professionals is their inability to feel safe at work. One-third of emergency nurses surveyed considered leaving their ED or emergency nursing because of ED violence (ENA, 2010).

Costs to nursing in terms of physical injury and financial loss are significant. Staff turnover associated with bullying and sickness can cost between $60,000 and $100,000 for RN replacement, according to an AORN Journal editorial. Furthermore, this disruptive behavior can lead to increased lengths of hospital stay for patients, reduced patient satisfaction and facility reputation, and malpractice/negligence liability costs that can amount to more than $500,000. (Seifert, 2011.)

Involving Law Enforcement

Some states have sought legislative solutions including mandatory establishment of a comprehensive prevention program for health care employers, as well as increased penalties for those convicted of assaults of a nurse or other health care personnel. It is a felony to assault health care workers in 32 states.

"Anyone who has worked in a hospital setting recognizes that you never know who is going to walk through the doors and in what state of mind," said Sen.Alex Padilla in response to recent attacks in California hospitals (quoted in Simmons, 2014). Sen. Padilla authored California Senate Bill 1299, which requires additional safety training and greater employee security.

One incident of violence is one too many. Stressing a zero-tolerance policy supported and observed by every person in the organization is the first step toward enacting change and shifting away from a culture that accepts violence as a part of the job.

Pamela A. Thompson, M.S., R.N., C.E.N.P., F.A.A.N., is senior vice president of nursing and chief nursing officer at the American Hospital Association, and the CEO of the American Organization of Nurse Executives.

Visit to view the complete "Guiding Principles on Mitigating Violence in the Workplace" and the accompanying toolkit.


Bird, Julie (2015). "Nurses Under-report Violence, Saying It’s a ‘Waste of Time.’" FierceHealthcare, FierceMarkets Network, May 11, 2015.

Emergency Nurses Association, Institute for Emergency Nursing Research (2010). Emergency Department Violence Surveillance Study. Des Plaines, Ill.: ENA, 2010.

Seifert, Patricia C. (2011). "Reaping What We Sow: The Costs of Bullying." AORN Journal 94:4 (2011): 326–28.

Simmons, Christopher (2014). "California Legislation to Protect Healthcare Workers Signed into Law by Gov. Brown." California Newswire, Neotrope News Network, Oct. 1, 2014.