What is workplace violence in healthcare?
The World Health Organization (WHO) defines workplace violence as “incidents where
staff are abused, threatened or assaulted in circumstances related to their work, including
commuting to and from work, involving an explicit or implicit challenge to their safety, well-being
or health”. 1 According to the US Centers for Disease Control and Prevention (CDC), workplace
violence can further be broken down into different types: criminal intent, customer/client, worker-
on worker, and personal relationship.
The most common type of workplace violence seen in the healthcare setting is
customer/client, also known as client-on-worker-violence. This type of violence occurs when a
patient, patient family member, friend of the patient, or other visitor is violent towards the
healthcare worker(s) treating them, or present in the area of their treatment. Healthcare settings
which are at highest risk and expectation of experiencing workplace violence include
emergency, psychiatric, and geriatric settings. 2 In a survey of emergency physicians, the most
commonly reported forms of violence were verbal threats, with 74.9% of polled physicians
reporting having experienced it in the last 12 months. Of these same physicians, 11.7%
indicated they were victims of physical assault as well. 3
According to the CDC, another commonly reported form of workplace violence in
healthcare settings is the worker-on-worker, also known as lateral (or horizontal), violence which
may include bullying, verbal abuse, and emotional abuse (most typically “unfair, offensive,
vindictive, and/or humiliating” words). 4 Resident physicians are particularly vulnerable to this
type of violence due to their position “on the food chain” in clinical settings. A study which
assessed workplace violence and harassment against emergency medicine residents found that
97% of the residents in the study experienced some form of threats, with 78% experiencing
verbal threats, and 52% experiencing sexual harassment. 5
How workplace violence impacts physicians:
Workplace violence can have a negative impact on the mental and physical health of
health care professionals, including physicians. Beyond the obvious physical and mental
implications which workplace violence may have, it is equally important to discuss its role in
Burnout Syndrome is emotional exhaustion, depersonalization, and reduced personal
accomplishment in the setting of the work-place. 6 Burnout within the medical community has
been a particularly pernicious phenomenon, and one which has only been exacerbated by the
COVID-19 pandemic. Studies show physicians who experienced workplace violence were more
likely to be at a higher risk of burnout. 7 8 Consequences of physician burnout are increased
medical errors, poor patient care, decreased physician productivity and job satisfaction,
increased odds of physician alcohol abuse, and increased risk of suicidal ideation. 9 Considering
this, it seems clear that highlighting and addressing the issue of workplace violence with
practical and culture changing solutions is one of the most important challenges the medical
community must grapple with.
Workplace violence, physician burnout, and the role of gender
Female physicians experience burnout more frequently than male physicians, and
although many factors may contribute to this imbalance, workplace violence may play a
significant role. Female physicians are often the victims of workplace violence, including
physical and sexual abuse 10 11 As Asha George and colleagues’ paper states, this “violence
against female healthcare workers is the tip of the iceberg of gender power imbalances”. 12 By
addressing gender differences in workplace violence and burnout, the medical community can
work to fight gender inequities in healthcare.
What can we do about it?
One of the most important next steps we as a community can all take is to educate
healthcare professionals regarding the problem of work-place violence, particularly as it is a
topic of discussion that seems so seldomly scrutinized. It is especially important to have
education regarding workplace violence education early in medical training as students, in order
to ensure the principles are ingrained early in future generations of physicians. Medical schools
can include workplace violence education within their curriculum to educate students on how
they may protect themselves during medical school, as well as during their careers. Equally vital
is to convey and train physicians on the importance of creating an environment free of any and
all forms of violence.
Moreover, stressing the importance to all healthcare professionals the need to report
workplace violence and the negative consequences which can occur if it is not reported should
be incorporated into any healthcare (hospital or clinic) training. Together, we can work to
decrease the prevalence of workplace violence and create a safer working environment for all.
International Labour Organization, International Council of Nurses, World Health Organizations, and Public Services International. (2002) Framework Guidelines for Addressing Workplace Violence in the Health Sector. Retrieved from: https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/normativeinstrument/wcms_160908.pdf
Occupational Safety and Health Act. (2016) Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA 3148-06R 2016)
Kowalenko T, Walters BL, Khare RK, Compton S; Michigan College of Emergency Physicians Workplace Violence Task Force. Workplace violence: a survey of emergency physicians in the state of Michigan. Ann Emerg Med. 2005 Aug;46(2):142-7. doi: 10.1016/j.annemergmed.2004.10.010. PMID: 16046943.
Department of Health and Human Services, Centers for Disease Control, National Institute for Occupational Safety and Health. Violence—occupational hazards in hospitals. April 2002
Schnapp, B. H., Slovis, B. H., Shah, A. D., Fant, A. L., Gisondi, M. A., Shah, K. H., & Lech, C. A. (2016). Workplace Violence and Harassment Against Emergency Medicine Residents. The western journal of emergency medicine, 17(5), 567–573. https://doi.org/10.5811/westjem.2016.6.30446
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual, 3rd ed. Palo Alto, CA: Consulting Psychologists Press, 1996.
Gan, Y., Jiang, H., Li, L., Yang, Y., Wang, C., Liu, J., Yang, T., Opoku, S., Hu, S., Xu, H., Herath, C., Chang, Y., Fang, P., & Lu, Z. (2019). Prevalence of burnout and associated factors among general practitioners in Hubei, China: a cross-sectional study. BMC Public Health, 19(1), N.PAG. https://doi-org.proxy.lib.fsu.edu/10.1186/s12889-019-7755-4
Hacer TY, Ali A. Burnout in physicians who are exposed to workplace violence. J Forensic Leg Med. 2020 Jan;69:101874. doi: 10.1016/j.jflm.2019.101874. Epub 2019 Oct 14. PMID: 31669822.
West, CP, Dyrbye, LN, Shanafelt, TD. (Mayo Clinic, Rochester, MN; and Stanford University Medical Center, Stanford, CA, USA). Physician burnout: contributors, consequences and solutions (Review). J Intern Med 2018; 283: 516– 529.
Komaromy, M., et al. (1993). "Sexual Harassment in Medical Training." New England Journal of Medicine 328(5): 322-326.
Phillips, S. P. and M. S. Schneider (1993). "Sexual Harassment of Female Doctors by Patients." New England Journal of Medicine 329(26): 1936-1939.
George A S, McConville F E, de Vries S, Nigenda G, Sarfraz S, McIsaac M et al. Violence against female health workers is tip of iceberg of gender power imbalances BMJ 2020; 371 :m3546 doi:10.1136/bmj.m3546