Earlier this month, a CDC employee was shot and killed at a medical facility in Atlanta, and four others were wounded. In June 2022, two doctors, a receptionist, and a visitor were killed in a Tulsa, Oklahoma medical building, and in October of that same year, two healthcare workers were shot and killed in the maternity unit of a hospital in Dallas.
These are the cases that make the news. However, violence and abusive threats against healthcare workers are nearly daily occurrences. Of all workplace violence, 73% occurs against healthcare workers. Every year, 13% of nurses suffer physical assaults, and 38.8% of nurses experience non-physical violence such as verbal threats, abuse, and sexual harassment.
Emergency department (ED) providers are particularly vulnerable. Federal legislation such as the Emergency Medical Treatment and Labor Act (EMTALA) requires that every patient who presents to a Medicare-participating ED receive a medical screening exam and stabilization of emergency medical conditions. These laws do not provide exceptions for patients who are violent, or who make physical or sexual threats against healthcare staff. An August 2022 survey showed that 55% of emergency medicine physicians, including one of us, have been personally assaulted while at work, and nearly 80% have witnessed an assault on a colleague.
Due to the interpretation of EMTALA laws, healthcare workers are forced to provide screening exams to patients who have previously made threats against them or a colleague. Furthermore, if a medical emergency exists, the workers must continue to stabilize and treat the patient through continued aggression until that condition does not exist or the patient is stable enough to be transferred. Many healthcare workers continue to provide medical care to patients who have verbally or physically assaulted themselves or a colleague. While some of the patients are psychiatric patients presenting in crises, others have medical emergencies but are acting out for other reasons.
Despite providing a mandate for EDs to evaluate everyone, the federal government has not provided any legal protections for the staff to do so safely. The Occupational Safety and Health Administration guidelines acknowledge the hazards of workplace violence, but state that the "risk of assault can be prevented or minimized if employers take appropriate precautions." The Joint Commission further provides tips on how to prevent injury from patients, such as "providing comfortable waiting rooms" and "discouraging staff from wearing necklaces to prevent strangulation." In doing so, they remove the patient's responsibility, place the protective burden on hospitals, and may even blame the healthcare worker for a violent incident.
As it stands, healthcare workers do not have access to any extra federal protections for violent crimes against them. The on-the-ground perception by healthcare workers is that law enforcement and the hospital itself are reluctant to take reports for things that are not considered criminal offenses, which means that verbal abuse and slurs often go unreported, as do physical assaults that lead to no lasting injury. Around 88% of workplace violence in healthcare workers goes unreported formally.
In June 2022, the U.S. House of Representatives introduced a bill, H.R. 7961, to establish federal and criminal penalties for those who assault hospital employees. The proposed legislation was modeled after protections for aircraft workers. No action has yet been taken on it. Prior to that was the failed bill H.R. 1195, which proposed that a standard be issued by the Secretary of Labor to require healthcare industries to develop a workplace violence prevention plan. In addition, six states introduced bills that would increase penalties for violence against healthcare workers.
However, these measures all relegate the safety of the frontline healthcare workers to their corporate or hospital employers. This structure is inherently flawed. The financial motives of these large corporations usually do not align with their frontline employees: gun detectors, safe rooms, increased staffing, video cameras, and multiple security guards are expensive. In addition, hospital security guards do not have the equivalent authority of law enforcement in a true emergency. Nor should the responsibility for safety fall on the healthcare workers alone.
If we see movement on and eventually the passage of H.R. 7961, this would be a good start and would hopefully increase reporting of abuse. But more change will be needed. Every instance of verbal and physical abuse against a healthcare worker must be documented and categorized. Three serious strikes should raise a flag. Every visit involving a person with a "flag" must have a security officer present on site or present in the room, as per the comfort of the provider, and such protection should be mandated by federal law. In addition, EDs should be equipped with a direct emergency line to law enforcement, along with video feeds of public areas like hallways and waiting rooms, to facilitate action when required.
If the federal government requires that all patients be seen, then the government must assume some responsibility for the frontline staff who see them.
Sawali Sudarshan, MD, PhD, is a board-certified emergency medicine physician and assistant professor at the George Washington University School of Medicine & Health Sciences. Y. Tony Yang, ScD, LLM, MPH, is a professor of health policy at the George Washington University School of Nursing and Milken Institute School of Public Health.