Violence against clinicians: It's more than the Tulsa shooting

On June 1, 2022, in Tulsa, Oklahoma, a man who was angry with the outcome of his surgery shot and killed four hospital employees, including his surgeon.^[]

This shooting occurred weeks after a racist massacre in Buffalo, New York, an attack at a California church, and a mass killing at a Uvalde, Texas, elementary school.

And unfortunately, more healthcare professionals (HCPs) are becoming targets of violence while attempting to respond to these and other crises.

A dark trend

Weeks before the Tulsa killings, the American Hospital Association issued a letter to US attorney general Merrick Garland outlining the epidemic of violence against HCPs.^[]

The letter told of a Georgia nurse who was grabbed by the wrist and kicked in the ribs, a nurse in South Dakota who was thrown against a wall and bitten, and a Thai medical student in New York who was called a racist epithet and knocked to the ground, suffering injuries.

“We have been hit, bitten, choked, shoved, kicked, spit upon, and concussed,” said one Maine nurse.

These are more than one-off anecdotes. Data substantiate these stories and demonstrate a chilling pattern.

A 2021 Workplace Health & Safety study found that among a group of 373 RNs, 44.4% and 67.8% of respondents said they had experienced physical violence and verbal abuse, respectively, between February and May/June 2020.^[]

Overall, CDC data indicate that most HCPs—nurses, especially—are at an increased risk of workplace violence when compared with other professions.^[] For example:

• There were 207 deaths due to workplace violence in the healthcare and social assistance industries between 2016 and 2020.

• In 2020, out of every 10,000 full-time HCPS and social assistance workers, 10.3 suffered injuries stemming from assaults and violent acts. The rate stood at 21.8 for nursing and personal care facility workers.

• For RNs and LPNs, the rate of physical assaults stood at 13.2 per 100 nurses per year. The rate of non-physical violent events such as threats, sexual harassment, or verbal abuse stood at 38.8.

Unfortunately, HCPs may not be disclosing all incidents, according to the Workplace Health & Safety study. Researchers discovered that one in 10 nurses felt reporting incidents was more difficult during the pandemic.

“The harmful but pervasive belief that violence is part of nursing may have solidified during the pandemic, and the nurses might have felt that they had to provide compassionate health care to the sick, even to those whose behaviors were violent,” researchers wrote.

What can be done to stop the violence? According to the AHA and researchers, it will require a concerted effort.

Congressional response

In the same letter to US attorney general Garland, the AHA called for legal protection against violence for HCPs that’s comparable to that provided for flight crews and airport workers.

Representatives Madeleine Dean (D-Pa.) and Larry Bucshon, MD, (R-Ind.) are attempting to answer that call with the Safety from Violence for Healthcare Employees Act, which was proposed June 7, 2022.

As of the writing of this article, a draft of the legislation is not available. However, a news release from Dean’s office indicates that the bill, if enacted, would afford the same legal protections to HCPs that aircraft and airport workers have.^[]

Bucshon, who was a cardiothoracic surgeon prior to joining Congress, said his co-sponsorship of the bill stems from his more than 15 years of experience in practice.

“These rising levels of violence negatively impact the ability of our nation’s physicians, nurses, and other health care professionals—who are currently experiencing record levels of stress and burnout—to provide quality care for their patients,” Bucshon said in the news release.

The AHA and the American College of Emergency Physicians have endorsed the bill, as have several state-level organizations in Pennsylvania and Indiana.

Congressional wheels turn slowly, however, raising the question of what HCPs should do in the meantime to stem the violence.

Taking action

According to a 2021 JAMA perspective, the first priority is for HCPs to report all instances of abuse and violence.^[] This is the only way policymakers will know about the true severity of the problem.

Terry Kowalenko, MD, professor and chair of emergency medicine at the Medical University of South Carolina in Charleston, was interviewed for the JAMA perspective and offered this rule of thumb: “If you wouldn’t let someone do it on the street, you shouldn’t accept it in the clinic, and it should be reported even if perpetrated by people who cannot help themselves,” the author wrote.

The perspective also stressed that acts of violence should be reported regardless of whether the perpetrator is confused, has dementia, or is a small kid.

Helpful mitigation tactics include making sure that visitation policies are in place and are uniformly enforced, and offering training to providers in how to recognize when patients may become violent and ways to deescalate tense situations.

The JAMA perspective also highlighted the importance of active shooter training for HCPs, an unfortunate reality highlighted by the attack in Tulsa.

The perspective piece quoted Jimmy Choi, MD, an EM physician and martial arts trainer, who called for improved training for security personnel on addressing such worst-case scenarios. He said such training should focus on “when and how to run, hide, or fight.”