essay on nursing workplace violence

Workplace violence: A nurse tells her story

It’s not okay, and it is a big deal..

By Lillee Gelinas, MSN, RN, CPPS, FAAN

“Personal boundary violation is not part of our job description. That statement is powerful because boundary setting is a part of our job. I believe that if we fail to establish and maintain personal boundaries, then we’ve compromised the safe and therapeutic environment in which we’re able to truly care and advocate for our patients. We have an obligation to stand up against that which is unsafe, and I believe that ending nurse abuse is critical.”

That’s how my conversation began with Karen*, an emergency department (ED) nurse who recently experienced on-the-job violence. I promised her that her story is not over. Nor is the story of thousands of nurses who have been harmed by patients while at work. The importance of the American Nurses Association (ANA) #EndNurseAbuse movement became very real for me the day I spoke with Karen.

Out of the blue

workplace violence nurse story

Karen worked as a nurse extern for 4 years, volunteering in the ED and in other settings to get real-world experience before becoming an RN. She’s the type of nurse I try to hire as frequently as I can because she’s enthusiastic about the profession, worked hard to become a nurse, and strives to be the best she can be. But this shining star in the nursing universe has lost some of the glow after her experience.

Out of the blue, a patient hit her hard in the jaw while she was trying to perform an electrocardiogram. The violence was so unexpected that she immediately left the bedside in disbelief. Karen says she was “overwhelmed by my feelings of being hurt.”

Karen says “it’s the aftermath” that’s so important. Being angry with the patient at first is easy, but Karen says, “I can’t stress enough how much this event hurt my feelings, and I’m still not fully over it months later.” The physical injury may have healed, but the emotional injury still stings.

Our role as nurses is to establish a trusting relationship with patients, and when that relationship is compromised after an assault, we may be left with a lasting fear for our personal safety. When you walk into a patient’s room, you enter with a sense of confidence. But this type of event jars that confidence. Getting back to the level of how it felt pre-assault takes a long time and may require long-term support systems that healthcare facilities may not yet have in place.

In addition to ANA’s call to action ( read the American Nurse Today  article ), The Joint Commission issued a Sentinel Event Alert to bring more awareness to the seriousness of the issue and outline seven actions every healthcare setting must implement to create safer workplaces. ( Read the alert .)

According to the Occupational Safety and Health Administration, 75% of nearly 25,000 workplace assaults reported annually occur in healthcare and social service settings. But we know that number is grossly underreported because only about 30% of nurses report violent incidents. ANA President Pam Cipriano, PhD, RN, NEA-BC, FAAN, states the urgency best: “Abuse is not part of anyone’s job and has no place in healthcare settings. Time’s up for employers who don’t take swift and meaningful action to make the workplace safe for nurses.”

I agree. And Karen agrees. We add the following: It’s not okay, and it is a really big deal.

Lillee Gelinas, MSN, RN, CPPS, FAAN Editor-in-Chief [email protected]

*Name has been changed.

2 Comments .

I was assaulted in 2015 while working inpatient behavioral health. It occurred in an area where there had been previous problems. In order to discredit me and a co-worker who came to my aid, we were fired. I was never given an opportunity to tell my story. I was blamed for the incident and reported to my Board of Nursing. My employer presented falsified documentation and lied. I spent $10,000 and over a year fighting for keep my license (which I eventually did). I suffered a head and neck injury which has caused me permanent difficulty. My four top front teeth and my glasses were broken. Compared to the emotional hell I went through because of my employer and the Board’s “investigation,” my injuries were nothing. Oh, the Board’s investigator had just started her position and was a former associate of my employer. I live in a small state. My employer has a lot of clout and there is little protection for workers in any field. I never felt to alone.

Thank you for the editorial. A similar incident occurred early in my practice while I was performing a bedside cardiac assessment. Shock is probably the best way to describe my initial reaction. I took a step back, rubbed my jaw in disbelief and actually wondered out loud, “Why would you do that?” Many years have come and gone and I no longer remember the answer, as if it could possibly have made any sense. I don’t remember being angry, I felt, if anything a bit foolish that a 100 pound little lady well into her 80s, who was so sweet earlier in the shift, took me off guard, and hit me so squarely with such force. It did, however, make me realize that it was important to be vigilant in assessing the potential for physical violence at ALL times – even from those that might not fit the standard profile. Looking back and having heard many similar stories from my colleagues that resulted in more significant injury (both physical and emotional), I realize that I was fairly lucky to learn such a valuable lesson for no more cost than both a bruised ego and jaw.

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essay on nursing workplace violence

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essay on nursing workplace violence

Nursing Workplace Violence

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NurseJournal Staff

Contributing Writer

Learn about our editorial process .

Published December 21, 2021

Reviewed by

Elizabeth M. Clarke

Contributing Reviewer

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Workplace violence in nursing has escalated during the COVID-19 era. Use this guide to learn about the impact of workplace violence and what can be done to prevent it.

While workplace violence in healthcare has been a persistent problem for many years, the rates have spiked during the COVID-19 pandemic. Nurses report escalating rates of COVID-related violence directed at them by frustrated and angry patients and their families.

A 2021 Workplace Health & Safety survey of registered nurses reports that 44% experienced physical violence at least once during the pandemic from patients, family members, or visitors. Over two thirds encountered verbal abuse at least once. RNs who provided direct care for patients with COVID-19 experienced more violence than nurses who did not care for these patients. Nurses also faced difficulty reporting these incidents to management.

The healthcare industry leads all other sectors for non-fatal workplace assaults. Within healthcare settings, violence in emergency departments has reached epidemic proportions during the pandemic. Emergency nurses are particularly vulnerable. Nearly 70 percent of emergency nurses report being hit or kicked at work.

Workplace violence injures healthcare professionals physically and psychologically, resulting in lost workdays, burnout, and turnover. The escalating rates of violence undermine efforts to provide quality patient care and hinder effective responses to combatting the COVID-19 virus.

Fast Facts About Workplace Violence Against Nurses

  • During the pandemic, 44% of RNs have reported experiencing physical violence and 68% have reported experiencing verbal abuse.
  • Nurses who provide care for COVID-19 patients experience higher rates of violence than those who do not.
  • Nurses exposed to workplace violence are two to four times more likely to experience post-traumatic stress disorder, anxiety, depression, and burnout than nurses with no exposure.

Sources: Nurses' Experience With Type II Workplace Violence and Underreporting During the COVID-19 Pandemic | The COVID-19 Effect: World’s nurses facing mass trauma, an immediate danger to the profession and future of our health systems

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The state of workplace violence against nurses.

The rates of workplace violence have increased rapidly since the pandemic began. In August 2021 at a hospital in San Antonio , Texas, family members of COVID-19 patients physically and verbally abused healthcare workers for enforcing mask and visiting restrictions. Across the country, healthcare professions who advocate for vaccination and masking mandates have been subjected to online verbal abuse and threats of physical harm toward them or their family members.

Incidents of workplace violence are not restricted to the United States. A patient with COVID symptoms in Naples, Italy grew impatient waiting for treatment and spat at a doctor and nurse. His actions led to a shutdown of the entire ward and quarantine of all staff. In the United Kingdom, patients spat at and verbally abused staff who asked that they wear masks. In Mexico, healthcare workers accused of spreading the virus, have been assaulted and doused with bleach on public streets.

Nurses have become especially vulnerable to these kinds of physical and verbal assaults. Tina M. Baxter, an advanced practice registered nurse who provides consulting services for healthcare organizations, attorneys, and insurance professionals, has personally experienced workplace violence on several occasions.

— "Nurses are the most convenient target as we are with the patients the majority of the time. It is often the nurse who is tasked to enforce the rules about visitation, masking, and other mandates."

–Tina Baxter, APRN, GNP-BC

She points out that "violence as a whole has increased during the pandemic and the lack of civil discourse in society, too often resorting to violence has become the first instinct instead of the last resort…Nurses are the most convenient target as we are with the patients the majority of the time. It is often the nurse who is tasked to enforce the rules about visitation, masking, and other mandates."

A recent brief prepared by National Nurses United (NNU) support's Baxter's observations. NNU identifies multiple factors fueling COVID-related workplace violence. Nurses constantly face patients and families reacting with anger related to understaffing and increased wait times for care. They frequently deal with aggressive family members who refuse to adhere to visiting and masking requirements. The pandemic fatigue felt by many people and the misinformation spread by untrustworthy media and online outlets have also escalated the violent incidents.

The Influence of COVID on Rising Verbal and Physical Attacks

The recent Workplace Health & Safety survey connects COVID-related violence to the strained relations between nurses and patients. Over 67% of the nurses reported incidents of physical violence or verbal abuse between February and June 2020.

One in ten RNs indicated that reporting the violent incidents to management has become more difficult during the pandemic than before. Underreporting violence during the pandemic may be due to busy workloads, non-standardized reporting procedures, unclear definitions of what constitutes violence, and a perceived lack of management support.

Stressful conditions and more intense patient and family interactions are among the major forces behind the increased risks for aggression and violence toward nurses during the pandemic. Priscilla Grace Barnes, a registered nurse, personal trainer, and nutrition coach, explains that "part of being a nurse isn’t solely caring for the patient, it’s educating and communicating with the family. Many times this communication involves difficult situations around rules and regulations nurses have no control over. We are put in very tough situations."

The pandemic may have helped spread the mistaken assumption that violence is part of the nursing profession . Many nurses believe that they have a responsibility to provide compassionate care even to those exhibiting violent behavior. As a result, nurses feel they must tolerate unsafe and dangerous conditions, rationalizing that the increase in violence stems directly from the anger and frustration experienced by patients and their families.

The Long-Term Impacts of Nurse Violence

A 2021 research study published in Healthcare reports that nurses who have experienced direct and indirect exposure to workplace violence are two to four times more likely to experience post-traumatic stress disorder, anxiety, depression, and burnout than nurses with no exposure.

According to the International Council of Nurses (ICN), rates of anxiety, trauma, and burnout have spiked dramatically since the onset of the pandemic. ICN data shows that the number of nurses reporting mental health distress has increased from 60% to 80% in many countries. Failure to address these mental health pressures will impact the already existing nursing shortage. ICN estimates a potential shortfall of 14 million nurses by 2030, which amounts to half the current nursing workforce.

— "Working in a hospital I often felt like I was pouring into a cup that had holes in the bottom of it - no matter how much I gave, the cup was never full."

–Priscilla Barnes

Government, healthcare organizations, and nursing associations must address the pressing need for mental health support and preventive care for nurses. Barnes argues that healthcare facilities must promote psychological wellness to ensure nurse safety: "Nurses are caregivers. We live to serve. But caregivers have to be well. Working in a hospital I often felt like I was pouring into a cup that had holes in the bottom of it - no matter how much I gave, the cup was never full. This only leads to burnout of those who are the lifeline to the hospital – nurses."

Despite the generally high regard for nurses held by the general public throughout the pandemic, negative public perceptions have also emerged about workplace safety and mental health challenges in the nursing profession. These unfavorable views may deter prospective nurses from entering the field at the time when they are most needed.

Preventing Workplace Violence Against Nurses: What Needs to Happen?

Even before the pandemic, healthcare workers experienced one of the highest rates of workplace violence compared to all other U.S. workers. According to a 2018 report by the Bureau of Labor Statistics , the number of violent injuries has steadily increased since 2011. Because the problem has reached epidemic proportions, nurses, medical facilities, and government agencies must work together to develop concrete measures to prevent the escalation of workplace violence.

— "Workplace violence should not and does not 'come with the territory’ of being a nurse."

–Rhonda Collins, DNP, RN, FAAN

One of the first issues to address is the culture of acceptance about violence in nursing. Rhonda Collins, the chief nursing officer at Vocera Communications, a healthcare technology company, cautions that "workplace violence should not and does not 'come with the territory' of being a nurse. Healthcare leaders must aggressively act to address this epidemic by validating concerns and ensuring nurses are heard and respected when reporting violent acts."

What follows are some suggestions for proactive approaches to prevent workplace violence.

  • At the individual level:

Nurses should also be aware of their surroundings, taking into account poorly-lit areas, placement of emergency exits, and crowded public spaces. Nurses can minimize risks by avoiding clothing or jewelry that can be grabbed or pulled. They should exhibit caution when dealing with patients and others who exhibit aggressive verbal cues (e.g., swearing or threatening language), and non-verbal behaviors (e.g., indications of drug or alcohol abuse or throwing objects.)

  • At the employee level:

Nurses should become familiar with their employer's health and safety policies, report any incidents, and support employees who have experienced violence. Nurses need to become involved in the development of safety policies, procedures, and emergency plans. All personnel should take advantage of available employer-sponsored programs or professional development opportunities on how to respond and prevent violence and how to use de-escalation techniques.

  • At the employer level:

Collins and other nursing leaders argue that healthcare organizations must adopt a "zero-tolerance policy" on workplace violence. In addition to sponsoring educational and support programs, healthcare facilities must develop clear procedures for reporting violent incidents. To combat underreporting, employers must respond to violence seriously. Management has a responsibility to encourage staff to press charges against persons who commit assaults and to support employees when they report these incidents to law enforcement.

Healthcare facilities should upgrade and maintain security procedures and security systems, develop emergency response protocols, and hire sufficient security personnel. Collins suggests that employers provide nurses "with a wearable panic button that calls safety and security personnel so nurses don’t have to reach for a light on the wall when in distress."

  • At the legislative level:

The Occupational Health and Safety Administration does not require employers to implement violence prevention programs, but it provides voluntary guidelines and may cite employers who fail to maintain a safe workplace environment. In early 2021, the House of Representatives passed the Workplace Violence Prevention Act for HealthCare and Social Workers, but it has not yet received Senate approval.

Although no federal laws currently protect healthcare worker safety, several states have passed legislation to protect them from workplace violence. These measures include the establishment of penalties for assaults on nurses, creating a disturbance inside a healthcare facility, or interfering with ambulance service. Only a small number of states require employer workplace prevention programs.

Nurse Resources for Preventing Workplace Violence

In response to the expanding awareness about workplace violence, several government agencies, professional nursing associations, and other special interest groups have developed resources to address safety concerns and violence prevention.

Addressing Workplace Violence During COVID and Beyond

The COVID-19 pandemic has exacerbated the problem of escalating workplace violence in nursing. The healthcare industry and the nursing profession must embrace a cultural shift toward accountability and responsibility, providing a safe environment for all healthcare personnel, promoting positive patient care outcomes, and increasing the effectiveness of nursing practice.

Addressing the problem of workplace violence in nursing is in everyone's interest. Nurses deserve to work in safe settings, performing their duties without fear of injury. Healthcare organizations will face greater nursing shortages due to injury or burnout, impacting the quality and cost of patient care. Effective workplace violence prevention initiatives must include transparent zero-tolerance policies, clear communication and procedures for incident reporting, and educational and support programs.

Meet Our Contributors

Portrait of Priscilla Barnes

Priscilla Barnes

Priscilla Grace Barnes is a registered nurse who graduated with a bachelor of science in nursing and a bachelor of arts in Spanish from the University of Texas at Austin. With over 11 years experience, she has worked from the smallest of patients in the neonatal intensive care unit to the largest of life events with pediatrics and adults in the surgical setting. With a passion for helping others in and out of the hospital, Priscilla also founded Wellness in Bloom(WIB) where she is a personal trainer and nutritional coach. WIB promotes preventative medicine in a friendly environment, by replacing the stress that so often accompanies health and wellness goals with foundational habits that promote sustainability.

Portrait of Tina Baxter, APRN, GNP-BC

Tina Baxter, APRN, GNP-BC

Tina Baxter is an advanced practice registered nurse and a board-certified gerontological nurse practitioner through the American Nurses Credentialing Center. Baxter resides in Indiana and has been a registered nurse for over 20 years and a nurse practitioner for 14 years. She is the owner of Baxter Professional Services, LLC, a consulting firm which provides legal nurse consulting services for attorneys and insurance professionals, among other services. She is also the founder of The Nurse Shark Academy where she coaches nurses to launch their own businesses.

Portrait of Rhonda Collins, DNP, RN, FAAN

Rhonda Collins, DNP, RN, FAAN

Rhonda Collins, DNP, RN, FAAN has served as chief nursing officer since 2014. As CNO, Dr. Collins is responsible for working with nursing leadership groups globally to increase their understanding of Vocera solutions, share clinical best practices and to bring their specific requirements to Vocera's product and solutions teams.

Dr. Collins holds a doctor of nursing practice from Texas Tech University Health Sciences Center and a master’s degree in nursing administration from the University of Texas. A registered nurse for 28 years, Dr. Collins is a frequent speaker on the evolving role of nurses, the importance of communication, and how to use technology to improve clinical workflows and care team collaboration.

Reviewed by:

Portrait of Elizabeth M. Clarke, FNP, MSN, RN, MSSW

Elizabeth M. Clarke, FNP, MSN, RN, MSSW

Elizabeth Clarke (Poon) is a board-certified family nurse practitioner who provides primary and urgent care to pediatric populations. She earned a BSN and MSN from the University of Miami.

Clarke is a paid member of our Healthcare Review Partner Network. Learn more about our review partners .

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Combating Workplace Violence in Nursing: The Impact of Policies, Legislation, and Organizational Culture

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Workplace violence has been a serious occupational hazard for many decades that endangered healthcare staff during their professional activities. The nursing personnel, and emergency staff, in particular, remain the vulnerable category of workers experiencing violence in the workplace. The state of affairs in this field is risky, so it requires urgent measures as a response. Enacted by the authorities, various healthcare policies, legislations, and legal issues greatly contribute to decreasing rates of violence in the nursing workplace. Regulatory environments, controls of healthcare delivery, and the support made by leading healthcare institutions have a serious beneficial effect in preventing workplace violence that the nursing staff sometimes experiences.

Healthcare policies and legislation significantly affect healthcare delivery and patient outcomes. Organizational arrangements are the background of a healthcare institution’s and its personnel’s activities. During the past decade, the authorities have introduced numerous laws that facilitated healthcare delivery and positively affected patients. Specifically, Medicare, Medicaid, and the Affordable Care Act aimed to support patients. Nevertheless, while helping individuals needing medical assistance, the legislation paid little attention to the nursing personnel who often experienced violence in the workplace. The term’ workplace violence’ denotes any case or threat of physical violence and harassment as well as intimidation or other dangerous insulting conduct in the work environment (Occupational Safety and Health Administration, n.d.). This category of wrongdoing includes a range of overt and covert conduct. Based on its degree, workplace violence may vary from verbal harassment to even murder.

The authorities create an effective legislative base to decrease the high rates of violence in the nursing workplace. According to statistical reports, the number of individuals who work in the healthcare field is approximate “four times more likely to be injured and require time away from work as a result of workplace violence (WPV) than all workers in the private sector combined”. The authorities have initiated legislation that prosecutes wrongdoers to cope with this negative phenomenon. For example, in 2013, in Texas, House Bill 705 was voted into law that declared an assault against ED personnel a third-degree felony. This legislative act produced a beneficial effect by supporting healthcare workers. However, establishing, developing, and changing the culture within healthcare institutions depends on their administration’s policies.

Personnel education plays an important role in solving the high rates of violence in the nursing workplace. According to the Joint Commission, a healthcare organization’s leadership is responsible for ensuring a culture free of violence in their departments. As an effective measure, cultural changes will be provided at healthcare institutions’ executive and organizational levels. Personnel training is to be directed to avoid violence in the workplace or stop it properly.

The authorities must remove several key factors to make workplace violence prevention programs effective. First, activities, which are suggested by such programs, are not introduced into practice, thus remaining useless. Second, workplace violence exists in various forms, and individuals demonstrate different attitudes to this felony. Third, bullying is a typical and extremely painful form of workplace violence. Fourth, profit-driven management models do not contribute to escaping violence in the workplace. Finally, poor management accountability and weak social service and law enforcement methods of dealing with mentally ill individuals create obstacles to producing a positive effect. All these factors must be decreased to receive a positive effect in the field.

The community realizes the strong necessity of protecting the medical staff against violence in the workplace. The Occupational Safety and Health Administration (OSHA) draws public attention to the fact that approximately 2 million US citizens suffer from workplace violence annually. OSHA gas-guided activities to prevent such violence to decrease this negative phenomenon. The main components of this guidance include legislative advocacy, workplace policy, and education. In the spring of 2014, the American Nurses Association expressed strong concern about incivility, bullying, and violence in the workplace. The 441 advisory committee members analyzed the key challenges in the field and created guidance for establishing a healthy environment free of workplace violence. Useful recommendations of the ANA contribute to establishing effective safety policies and provide protocols for preventing and responding to this issue in the healthcare field.

The safety policy insists on adopting goodwill and communicating respectfully. The personnel is advised to participate actively in meetings and discussions while considering the opinion of minorities. In strong disagreement with the state of affairs, opponents are advised to suggest solutions to the challenge. Such a respectful attitude towards each other would help establish a positive environmental culture and decent communication traditions and avoid many violent forms such as harassment, intimidation, manipulation, and threats.

To sum up, healthcare policies have focused on supporting patients as the most vulnerable category for decades. Despite the fair intentions of this step, the authorities have paid little attention to the nursing personnel who often experience workplace violence of various degrees. To solve this challenge, a range of legislative acts were adopted. The measures for decreasing violence include several competencies, such as legislative advocacy, workplace policy, and nursing training. The measures mentioned above contribute to improving the situation in the healthcare sector.

📎 References

1. Blando, J., Ridenour, M., Hartley, D., & Casteel, C. (2015). Barriers to effective implementation of programs for the prevention of workplace violence in hospitals. Online Journal of Issues in Nursing, 20(1), 1–11. 2. Doby, V. (2015). Leadership’s role in eliminating workplace violence and changing perceptions in the emergency department. Journal of Emergency Nursing, 41(1), 7. https://doi.org/10.1016/j.jen.2014.08.013 3. Magnavita, N. (2014). Workplace violence and occupational stress in healthcare workers: A chicken-and-egg situation-results of a 6-year follow-up study. Journal of Nursing Scholarship, 46(5), 366–376. https://doi.org/10.1111/jnu.12088 4. Occupational Safety and Health Administration. (n.d.). Workplace violence. Retrieved from https://www.osha.gov/SLTC/workplaceviolence/ 5. Papa, A., & Venella, J. (2013). Workplace violence in healthcare: Strategies for advocacy. Online Journal of Issues in Nursing, 18(1), Manuscript 5. 6. Saltzberg, C. W., & Clark, C. M. (2015). A Bold Call to Action: Mobilizing Nurses and Employers to Prevent and Address Incivility, Bullying, and Workplace Violence . American Nurse Today, 10(8).

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Incivility toward nurses: a systematic review and meta-analysis

Foroozan atashzadeh shoorideh.

1 Professor, Department of Psychiatric Nursing and Management, School of Nursing and Midwifery, Shahid Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Soolmaz Moosavi

2 Assistant Professor, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Labbafinezhad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Abbas Balouchi

3 Student Research Committee, PhD Student of Nursing, School of Nursing and Midwifery, Iran University of medical sciences, Tehran, Iran.

One important part of a nurse’s job is to create and help maintain a safe work environment. Evidence shows that negative behaviors such as incivility are not uncommon in the nursing profession. This systematic review and meta-analysis aimed to examine the prevalence of incivility toward nurses. For this purpose, all observational studies that primarily investigated the rate of incivility toward nurses were selected. The electronic databases PubMed, Embase, Web of Sciences, Magiran, IranDoc, and Scopus were searched for studies published during the period of January 1, 1996 to December 31, 2019. The quality of studies was assessed using Hoy’s Critical Assessment Checklist. The study was undertaken using the random effects model, and data were analyzed using STATA14. Data on 60 articles, including data on 30801 individuals, published between 1997 and 2019, entered the study. The findings showed the prevalence of incivility to be 55.10% (95%, CI: 48.05, 62.06).

Due to the high prevalence of uncivil behavior, especially of the verbal type, nursing managers should identify risk factors in the workplace. Planners should develop programs to increase workplace safety, especially in centers that are most exposed to these behaviors. It is also recommended that future studies focus on implementation of effective evidence-based interventions based on organizational culture.

Introduction

Civility is defined as being polite and kind in disposition and speech. Civil behavior refers to polite behavior toward others and ensuring that their dignity is maintained. On the contrary, incivility is defined as the negative behavior of insulting others or violating the common norms of behavior in the workplace ( 1 ). Incivility is a new concept in the psychology of occupational health ( 1 ) with most of the related literature being published at the beginning of the current century. In recent years, the increasing number of publications on this topic indicates that incivility occurs more frequently than other extreme behaviors in the work environment. A study by Bjorkqvist et al., showed that 32% of university employees had experienced incivility ( 2 ). A study conducted by Duncan reported the rate of incivility toward nurses to be higher than 46% and stated that one-third of nurses had been exposed to physical violence. This study reported that 100% of ER nurses had been exposed to verbal violence and more than 80% to physical violence ( 3 ).

Incivility was first defined by Anderson and Pearson as “negative behaviors with low-intensity and unclear intention that damage the targeted person” ( 4 ). Some of the terms used to describe incivility are lateral violence, disruptive behavior, abuse, conflict, bullying and aggression. These behaviors occur frequently in healthcare environments, lead to numerous negative consequences and can lead to more severe violence ( 4 , 5 ).

Uncivil behaviors include verbal abuse, nonverbal abuse, sexual harassment, and passive aggressive behavior. Verbal abuse involves shouting, raising one’s voice in a hostile manner, threatening a person verbally and overtly scolding or criticizing them, as well as using insulting and disgracing words, disrespectful tones, impoliteness, sarcastic behavior and humiliation ( 6 ). Nonverbal abuse includes raising the eyebrows, screwing up the eyes, scowling, creating physical distance, excluding someone from conversations, and/or invading someone’s privacy ( 7 ).

Sexual harassment may be manifested in the form of inappropriate behaviors that could be construed to have sexual intention, offensive sexual jokes, words that are sexual in nature, unwanted sexual advances, requests for sex and accidental sexual contact ( 7 ).

Passive aggressive behaviors in the workplace are among uncivil behaviors that can be particularly destructive. They include lack of support for colleagues, plotting against work rivals, refusing to communicate with an individual, impatience with other people’s questions and manifesting a negative attitude, all of which affect colleagues’ confidence ( 8 ).

Studies on incivility in the work environment suggest that it is often produced by emotionally annoying interactions due to inappropriate demonstrations of anger and anguish, tension, heavy workload, lack of communication, occupational insecurity, organizational change, poor task management, differences in social power and reciprocal relation of duties ( 1 ). These variables, as stressors, may lead to depression and undesirable physical symptoms. Experience of incivility in the work environment is negatively correlated with psychosomatic health ( 2 ) and is recognized as the prerequisite for aggressive behaviors and violence in the workplace ( 5 ).

Individuals enter the workplace with experiences related to their family life, personal values, communication styles, cultural or ethnic prejudices and other events that can affect their attitudes and practices and lead to destructive behaviors in the workplace ( 9 , 10 ). In addition, organizational factors such as power position and a number of irregularities and even some performance improvement schemes such as feedback and incentive systems may lead to non-civil behavior by increasing competition ( 11 ). On the other hand, an individual experience of incivility can lead to the continuation of this chain and its expansion by creating a motivation for retaliation ( 12 , 13 ). Generally, creation and maintenance of a safe work environment is included in the nursing role. Disruptive behaviors negatively affect patient outcomes and nursing performance. Therefore, nurses should support patients and help them deal with disruptive behavior to create and maintain a safe environment for giving quality care.

A review of previous studies showed that few studies have focused on incivility. Azami et al.’s study investigated incivility toward nurses in Iran; they found that in 26 studies, the rate of prevalence of examined variables including violence and verbal, physical, sexual and racial threat in the work environment were 80.8%, 24.8%, 6.14%, and 44%, respectively ( 14 ).

A systematic review was carried out by Dalvand et al., to assess violence in Iranian nurses’ work environment. The results showed that 74% of the nurses had been exposed to verbal, and 28% to physical violence. Previous research had also showed a high prevalence of workplace violence toward nurses ( 15 ).

The systematic review by D’ambra and Andrews was aimed at assessing the effect of incivility on recently-graduated nurses. In this study, sixteen papers were extracted that demonstrated incivility in the workplace to be an important predictor of low job satisfaction among beginner nurses ( 16 ).

The systematic review by Edward et al. was conducted on the correlation between workplace violence and nurses’ anxiety. The results demonstrated that nurses in emergency wards were more frequently exposed to verbal violence than other wards. The most frequent time of exposure to violence was reported to be the point of direct care of patients, and violence was committed either by the patients or their attendants. As a rule, nurses did not report the violence due to various organizational reasons ( 17 ).

The review study of sources by Hawkins et al. assessed beginner nurses’ experiences of negative behaviors. The findings suggested that between 3% and 57% of the nurses had experienced negative behaviors leading to depression, anxiety and work leave ( 18 ).

The systematic review by Zhu et al. aimed to explore the experience of incivility in nursing students. The results showed that nursing students experienced incivility during their clinical training and confirmed the importance of the managers’ role in reducing these behaviors ( 19 ).

Finally, a systematic review was conducted by Hodgins et al. to assess effective interventions for decreasing violence and incivility in the workplace. The results revealed that weak interpersonal communication was one of the most important causes of incivility, and that training and awareness of incivility and violence can be effective in reducing the incidence of these behaviors ( 20 ).

In summary, a review of previous studies shows that systematic reviews on incivility toward nurses are few. Several studies have examined the prevalence of incivility toward specific groups of nurses or in certain countries, regions and limited wards. However, to the best of our knowledge, there have been no studies on the global prevalence of incivility toward nurses. Also, non-civil behavior in the workplace leads to negative outcomes such as low productivity, conflict, reduced job satisfaction and less organizational commitment; therefore, awareness of this ethical problem can help with the assessment of the current situation as well as effective and realistic planning to prevent and also follow up on the consequences. Subsequently, our systematic review and meta-analysis aimed to determine the prevalence of incivility toward nurses.

Design of the Study

This systematic review and meta-analysis was conducted on observational studies concerning the prevalence of incivility in nurses’ workplace. In this systematic review and meta-analysis, observational studies were selected based on Condition, Context, Population (CoCoPop) ( 21 ). The review question was: What is the prevalence of incivility toward nurses working in health centers? To achieve the goals, the guideline “Meta-Analysis of Observational Studies in Epidemiology (MOOSE)” was used ( 22 ). 

Inclusion Criteria

All observational studies (descriptive and analytical) focusing on investigation of the rate of prevalence of incivility toward nurses were selected, regardless of the sampling method they had used.

Exclusion Criteria

Letters to the editor, protocols, review studies, case series, case reports and studies with sample volumes less than 25 were excluded from the study. In addition, studies were excluded if they used researcher-made instruments to examine incivility, were repetitious, or involved non-reporting of incivility. There were no limitations in the language of the studies as we used free translators like ImTranslator, Bing, Google Translate, and Applied Languages to translate papers into other languages. 

Search Strategy

In this study, the databases including Medline (via PubMed), Embase, Scopus, Web of Science, IranDoc, and Magiran were searched for works published from January 1, 1996 to December 31, 2019. Moreover, related studies, dissertations and conference papers were searched. The search strategy is given in the following Medline Script:

((Incivility[Title/Abstract] OR Uncivil Behavior*[Title/Abstract] OR Workplace Incivility [Title/Abstract] OR Rudeness [Title/Abstract] OR Bullying[Title/Abstract] OR abuse [Title/Abstract] OR lateral violence [Title/Abstract] OR horizontal violence [Title/Abstract] OR relational aggression [Title/Abstract] OR workplace violence [Title/Abstract] OR negative act* [Title/Abstract] OR negative behavior* [Title/Abstract] OR disruptive behavior* [Title/Abstract] OR horizontal hostility [Title/Abstract])) OR incivility [MeSH Terms])) AND (Nurs* [Title/Abstract] OR Personnel Nurs* [Title/Abstract] OR Registered Nurs* [Title/Abstract] OR caregiver* [Title/Abstract])) AND (prevalence [Title/Abstract] OR incidence [Title/Abstract] OR frequency [Title/Abstract] OR occurrence [Title/Abstract] OR burden [Title/Abstract] OR epidemiology [Title/Abstract]))

Data Extraction

Two independent researchers (SM, AB) completed the initial screening of the studies based on titles and abstracts. In the next stage, two researchers (SM, FA) studied the full texts of papers presumed to have reported consequences in more detail. Then, the relevant papers were outlined in a checklist.

Only studies that examined the prevalence of non-civil behavior were included. Data such as study features including author(s), publication date and type of journal, setting of the study, goal(s), design and type of study, sample volume, sampling method, and characteristics of the participants such as age, gender, ward and work experience were extracted. In all of these stages, any disagreement or conflict between the two researchers was settled by consensus via bilateral debate or by a third party. 

Qualitative Assessment

The selected studies were assessed qualitatively using Hoy’s Critical Assessment Checklist in 10 items. Items 1 - 4 assess external validity (target population, sampling framework, sampling method, and bias of lack of responding), items 5 - 9 assess internal validity (data collection method, case definition, and instruments), and item 10 evaluates analytical bias. Each question is given a score of "0" (Yes) or "1" (No), which indicate low risk and high risk, respectively. An overall score between 0 and 3 indicates low risk, a score between 4 and 6 indicates moderate risk, and a score between 7 and 9 indicates high risk ( 23 ).

Description of the Studies

At first, 6876 studies were identified across electronic databases. After removing duplicate studies and those not meeting the inclusion criteria, a total of 60 studies remained, which were covered in this review. The numbers of the extracted studies categorized by database were as follows: PubMed: 1391; Web of Science: 225; Scopus: 3190; and EMBASE: 2070. After omitting 3451 repetitious studies, 3425 studies entered the screening phase and 3235 irrelevant studies were excluded. Next, 190 studies entered the full text reading stage, of which 130 studies were excluded due to differences in participants (70 cases) and study design (60 cases), so that finally, 60 studies entered the study ( Figure 1 ). 

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The search flowchart for articles in databases based on the PRISMA 2009 checklist

These studies had been conducted between 1997 and 2019 on 30801 participants. The characteristics of the selected works are presented in Table 1. The largest and smallest numbers of participants were 3835 and 80, respectively. Most studies pertained to Asian countries (n = 31) ( 24 - 54 ), followed by the United States (n = 15) ( 55 - 69 ), Africa (n = 8) ( 71 - 78 ), Europe (n = 2) ( 79 - 80 ), and Eurasia (n = 4) ( 81 - 84 ). Among the Asian countries, Iran (n = 6) ( 25 , 26 , 33 , 36 , 41 , 54 ) and Taiwan (n = 5) ( 24 , 27 , 29 , 35 , 50 ) had the greatest number of studies. It should be added that 30 studies had been conducted in developed, and 30 in developing countries. 21 studies used random sampling ( 26 , 27 , 30 - 33 , 36 , 37 , 41 , 42 , 47 , 54 - 56 , 58 , 59 , 60 , 63 , 70 , 71 , 73 , 74 , 79 ), eight used census sampling ( 35 , 53 , 65 , 66 , 72 , 76 ), and 23 used convenient sampling ( 24 , 28 , 29 , 34 , 39 , 44 - 47 , 49 , 51 , 52 , 61 , 62 , 64 , 67 , 69 , 75 , 77 , 78 , 81 - 83 ). Eight studies did not announce which sampling method they had used ( 25 , 38 , 40 , 43 , 50 , 57 , 68 , 80 ). Forty studies used cross-sectional design ( 25 - 27 , 29 , 31 - 40 , 42 - 47 , 49 - 51 , 53 , 57 , 61 , 62 , 66 , 68 , 70 , 70 - 73 , 77 , 78 , 80 - 83 ), and twenty studies were descriptive ( 24 , 28 , 30 , 41 , 52 , 54 - 56 , 58 - 60 , 63 - 65 , 67 , 69 , 74 - 76 , 79 ). The minimal rate of response was 3% and the maximal rate was 100%. Three studies did not report the response rate. Six studies were performed in the psychiatric ward, 6 in emergency care, and 2 in ICU. Most studies (n = 46) involved general hospitals and all wards. The most frequently used instruments were “Workplace Violence in the Health Sector” developed through the collaboration of the International Labor Organization (ILO), the WHO, the ICN, and the PSI in 2003 (27 cases), and “Negative Acts Questionnaire” (10 cases). 

Risk of Bias and Publication Bias 

The qualitative assessment of the studies by Hoy et al.’s instrument showed a low rate of statistical bias in the studies ( Table 1 ).

Studies dated 1997 - 2019 included in the systematic review (n = 60)

* by ILO/ICN/WHO/PSI/2003

As shown in Figures 2 , and based on the Egger test, there was no publication bias in the studies. 

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Funnel plot of publication bias of studies of the prevalence of incivility

Subgroup analysis of incivility prevalence according to characteristics of included studies

Subgroup analysis of incivility prevalence according to type of incivility

CI: Confidence Interval

Based on the results displayed in Table 3, there was high heterogeneity in the studies, and therefore the random effects model with reverse variance was used. Thus, the total prevalence of incivility was 55.10% (95% CI: 48.5, 62.06), and the prevalence rates of verbal, physical and sexual incivility and mobbing behavior were 61.63% (95% CI: 56, 95, 70), 15.24% (95% CI: 33.17, 70.31), 67.13% (95% CI: 52.8, 77.19), and 69.35% (95% CI: 23.21, 60.51), respectively ( Figures 3 ). 

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Forest plot based on the population studied for the prevalence of incivility in the range of 95% confidence interval

The results of heterogeneity of the studies are presented in Tables 3. Since there was an expressive heterogeneity in the studies, the subgroups were analyzed according to country classification, instrument, setting and sampling methods. The results demonstrated that the greatest and smallest prevalence rates of incivility pertained to verbal and sexual aspects, respectively. The prevalence of incivility was higher in studies that used random sampling, in psychiatric wards, and in developing countries. The meta-regression test indicated a correlation between publication date and the prevalence of incivility, in that the latter decreased over the recent decades ( Figure 4 ).

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Forest plot based on the population studied for the prevalence of physical incivility in the range of 95% confidence interval

This systematic review and meta-analysis assessed the prevalence of incivility and violence toward nurses by examining 60 studies. The findings of the study showed a higher-than-average rate of incivility toward nurses. The highest rate pertained to violence and verbal abuse, experienced by almost all nurses, and the lowest rate pertained to sexual violence. Moreover, the prevalence of incivility in the form of mental abuse was greater than physical violence and threat. The study by Li et al. suggested that although the rate of violence against physicians and nurses is high, the rate of incivility toward nurses is higher than physicians ( 84 ). Taylor and Rew asserted that more than 80% of nurses consider their workplace unsafe and believe the prevalence of verbal and physical threat to be high ( 85 ). The study by Pompeii et al. revealed that the greatest rate of incivility pertained to violence and verbal threat ( 86 ). It appears that poor communication skills, devoting insufficient time to one’s duties, and delay in sharing information may foster the incidence of verbal incivility. The search process showed that there were more studies targeting nurses compared to other health professionals. Even the number of studies on nursing students was greater than the studies on other groups of students. The studies showed a higher prevalence of incivility toward nurses than other healthcare staff. It seems that the more time the staff spend with patients and other individuals, the greater will the rate of incivility be ( 87 ). The behavioral patterns of managers and supervisors can also affect both employees and those who monitor their actions and help to spread the prevalence of uncivil behavior. Other possible reasons may be job insecurity or high workload along with low autonomy, which exposes a person to non-civil behavior ( 88 ).

Meta-regression based on publication date indicated that the rate of incivility and violence has decreased over time. One of the reasons that the prevalence of violence has diminished in recent years may be nurses’ increased awareness of the rules and regulations in the profession, and legal mitigation and pursuit. Awareness of rules and laws enables nurses to defend their own rights and therefore reduce incivility. Nonetheless, the rate of prevalence of verbal violence has not decreased tangibly. One reason for conducting research on the subject is raising the awareness of nurses and managers in this regard. Managers’ and policymakers’ awareness about their importance as role models in reinforcing polite behavior can also be effective in reducing the prevalence of non-civil behavior. Jenkins et al. found that training in the subject of incivility and its importance and consequences, as well as teaching stress management and coping strategies can help reduce the prevalence of incivility ( 89 ).

Our findings showed that most primary studies had been carried out in general hospitals on nurses in various wards, but the prevalence of incivility and violence was greater in psychiatric wards. Furthermore, the incidence of physical incivility was greater in these wards compared to other types of non-civil behavior. Verbal incivility occurred more frequently than other behaviors in the ER and ICU because ER patients experience critical situations, and it is highly important to settle their anxiety as quickly and efficiently as possible. The nature and sensitivity of the ER is such that any shortcoming in organizational and manpower factors can lead to disastrous consequences. Chaotic situations, unpredictable conditions, stressful atmospheres, and limitations in therapeutic processes for evaluating the effect of interventions and care may expose the ER staff to verbal incivility. Some studies report that nurses in the ER, mental health inpatient units, and pediatric, neurology and neurosurgery departments are subject to violence more frequently. This may well deter young nurses from working in such environments ( 90 ). It seems that the critical condition of patients admitted to these wards, as well as the stress and anxiety of their companions, causes verbal abuse and increases the incidence of incivility in these wards.

While our findings suggested a great prevalence of incivility in developing countries, the prevalence of verbal, physical and sexual incivility was higher in developed countries. Decreased reports of sexual violence in some countries may be attributed to cultural reasons. The variety and great number of studies in different countries show that incivility and violence toward healthcare providers and caregivers are quite common in most clinical environments. Our findings demonstrated that Asian countries, especially Iran and Taiwan, had the greatest number of studies in this field. This can be due to the high prevalence of non-civil behavior in these countries, which may be attributed to personal factors as well as heavy workload, shortage of manpower, poor team-work skills, or lack of programs to manage healthcare violence ( 85 ).

In studies on sexual harassment, publication bias can occur as a result of socio-cultural factors. Physical and psychological problems, decreased motivation and commitment to the workplace, and work leave are among the consequences of sexual harassment. Organizational factors such as social support and workplace reporting systems, as well as people’s vulnerability in terms of race, marital status, age, etc. can affect the reporting of this event. Studies have shown the importance of an organization’s atmosphere, its sensitivity to the issue, and its support in reducing sexual harassment and encouraging the reporting of its incidence ( 91 ).

Incivility not only creates a hostile workplace for nurses, but also forms a dangerous environment for patients, leading to diminished patient satisfaction ( 7 ). Clark and Springer concluded that inappropriate behaviors might result in medical and nursing errors and poor patient outcomes ( 9 ). On the other hand, legal mitigation by victims in hostile environments may impose some costs on hospitals. Additionally, work leave, nurse transfer and hostile environments can affect employment in the organization, and the nurse victims may seek legal consultation, possibly affecting the financial affairs, reputation and credibility of the center ( 7 ).

Consequently, incivility is associated with overwhelming healthcare costs, compensatory payments related to tension among the staff, increased numbers of legal lawsuits, and poor-quality care ( 91 ). The results of studies demonstrate that incivility is the most important factor that negatively affects occupational satisfaction among nurses ( 90 ), resulting in lack of commitment and more frequent work leaves, finally influencing quality of care, costs and organizational reputation both directly and indirectly. Members of the staff that experience incivility in the workplace deliberately reduce the quality of their work, which will lead to diminished efficacy ( 92 , 93 ). However, parameters such as social and organizational support, transparent rules, enhanced communication skills, increased level of abilities and empowerment of nurses can attenuate the rate of incivility ( 85 ).

In many cases, nurses cannot pursue issues related to incivility due to absence of centers and committees for recording and managing violence, or due to individuals’ request for non- pursuit of the problem. Finally, studies report that many nurses stated there was no particular place within the organization to report incivility and they were puzzled who to turn to in such conditions. Therefore, many incivility cases remain unreported. Also, junior nurses experience higher rates of incivility but cannot take appropriate action due to poorer communication skills and lack of support from their coworkers and the organization. Hence, the incidence of such behaviors is seldom substantiated in the organizational culture.

Limitations of the Study

One limitation was inaccessibility of the full texts of some of the papers, which was resolved through communication with the author(s). In addition, the diverse terms used to assess the extent of non-civil behavior have made the studies heterogeneous in this area. Lastly, the nurses' perceptions of the concept of non-civil behavior were very different.

The findings of the systematic review and meta-analysis showed that the prevalence of incivility toward nurses was higher than the average rate. Given the wide range of studies in terms of time, setting and environment, it appears that planners and policy-makers need to develop programs to decrease violence and increase workplace safety. Healthcare managers and supervisors should be aware that disruptive and threatening behaviors are a serious problem in the healthcare system. For instance, verbal abuse, refusal to help the staff perform their specified duties and physical threats induce failure of teamwork and harm the interaction and cooperation required for care provision. Nurses play a highly significant role in caregiving, and therefore deserve to have a safe work environment. Consequently, nursing managers ought to identify the risk factors in the workplace and pay due attention to nurses’ concerns in this regard.

In view of the high prevalence of non-verbal incivility in recent years, nursing managers should identify the risk factors in the workplace, especially in critical wards. In addition, creating a responsive and supportive organizational environment can help prevent or reduce incivility and even encourage staff to report such behaviors. Managers and policy makers should also support nurses and plan for their empowerment and education to deal with non-civil behavior and report violence. Finally, future studies should focus on identification and implementation of effective evidence-based interventions in keeping with the respective organizational culture.

Acknowledgments

The authors would like to acknowledge the efforts of Dr. Mahmoud Yousefifard and Georgina Riley for their diligent and thoughtful editing of the manuscript.

Citation to this article:

Conflict of Interests

There is no conflict of interests to declare. All authors worked in close collaboration and were responsible for critical revision of the manuscript.

Competing Interests

The authors have no competing interests to declare.

Ethics Approval

Consent to participate was not applicable in this study. The research was approved by the Organizational Ethics Committee of Shahid Beheshti University of Medical Sciences (No. IR.SBMU.REC.1398.143).

Funding Statement

This research received no grant from any funding agency in the public, commercial or not-for-profit sectors.

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Commentary | Seema Pillai: CT health care workers need and…

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Commentary | state police charge ct man with sexually assaulting young girl, asking her to send nudes on snapchat, commentary | seema pillai: ct health care workers need and deserve better protection.

A nurse holds an elderly person's hand.

On Oct. 28, 2023, Joyce Grayson was killed in the line of duty in Willimantic. Joyce was a home health nurse who had gone to a halfway house to medicate one of her patients. She was found dead in a halfway house for sex offenders.

Violence against health care workers has increased exponentially since the COVID pandemic. A 2022 survey found that nearly half the nurses reported an increase in workplace violence, a 119 percent increase since March 2021. According to the Bureau of Labor, healthcare and social service industry workers are five times as likely to suffer a workplace violence injury than workers overall. However, some sources indicate that this number may be much higher with health care employees being 20 times more likely to experience workplace violence compared to any other profession.

As a nurse leader working in an acute care hospital, every single day I work with frontline clinicians who regularly are verbally abused, assaulted, called racial slurs and body shamed by patients, family members and visitors — for simply doing their job. This is not fair, not safe and certainly not acceptable. This narrative needs to change and it needs to change now.

Violence against health care workers doesn’t just impact providers but is also detrimental to patient safety. Being a health care provider is stressful enough given the acuity and complexity of patient care. In this environment, when we have to deal with angry, rude and hostile clientele, it creates anxiety, causes distraction and leads to errors, thereby impacting patient safety and quality of care. It is no surprise then that workforce safety is one of the foundational focus areas in the National Action Plan to Advance Patient Safety.

Workplace violence also has major impact on the turnover rate, at a time that the health care industry is reeling under a massive staffing shortage. Annual nursing turnover rate related to violence is estimated between 15 percent and 36 percent. Having to deal with workplace violence on a daily basis significantly contributes to burnout. How do we hope to attract and retain talented individuals if we cannot, at a very minimum, assure them a physically and psychologically safe workplace?

CT visiting nurses seek protection in wake of brutal slaying. ‘People forget about the dangers’

It is critically important to take more emphatic action at the federal, state and organizational level that will require health care organizations to develop and implement comprehensive violence prevention programs. Employers need to offer ongoing, evidence-based education and training to health care workers. Research indicates that appropriate training helps boost knowledge, skills, behaviors and confidence of providers. There is a crying need to have immediate and meaningful counseling and mental health support on-site. None of these interventions are possible without immediate attention and adequate resource allocation to this burgeoning crisis.

There are no federal regulations that criminalize violence against health care workers. The American Hospital Association supports the enactment of Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S.2768). If passed, this act would extend to healthcare workers the same protection that’s afforded to airline and airport workers.

While we continue to champion for federal action, we need to keep the momentum going at the state level. Health care workers need and deserve better protection. Joyce Grayson would probably be alive today had a police officer escorted her to her patient’s location. But she did not have that option due to budget cuts and staffing challenges.

The Connecticut legislative session started on Feb. 7 and will adjourn on May 8. It is a short session and legislators are discouraged from introducing bills. Every day that goes by without stringent, enforceable and impactful regulations, we are endangering the health and safety of the individuals who were hailed as heroes not so long ago. In Connecticut, it is a class C felony to assault healthcare workers. However, without posted signs, how are we educating the public?

According to data from Press Ganey, on average, two nurses per hour are assaulted. This statistic has to get better. If it doesn’t, the implications are ominous for the health and well-being of our communities and reflects poorly on the values of a civil society. The death of Joyce Grayson cannot be in vain.

Seema Pillai, a registered nurse with a Master’s in Nursing and an MBA, is from Fairfield.

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