1. Kirton, Carl A. DNP, MBA, RN, ANP


Taking the next step in protecting health care workers.


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Let me begin by telling you facts that you already know and, unfortunately, may have firsthand experience with. Violence against nurses and other health care personnel is on the rise and is a significant workplace safety issue. In a study by Byon and colleagues (Workplace Health and Safety, 2022), 44.4% and 67.8% of 373 nurses reported experiencing physical violence (with or without weapons) and verbal abuse, respectively. Even more intimidating is the rise in verbal threats of violence by patients, family members, or visitors directed toward the nurse or the nurse's family. We know less about these types of threats because there is no systematic collection of this type of information.

Figure. Carl A. Kirt... - Click to enlarge in new windowFigure. Carl A. Kirton

Recently the Centers for Medicare and Medicaid Services (CMS) issued guidance on workplace violence in hospitals, stressing the importance of health care facilities' role in ensuring that staff and patients provide and receive care in safe spaces. The guidance cites specific actions a facility can take, such as education and training, risk assessment of environments and patients, and adequate staffing, and concludes by stating that the CMS will cite facilities failing to do so. Although well intentioned, is this enough? What is needed are bold and inventive solutions to this growing social ill.


Flight crews face a similar problem in the sky. We can all recall the number of air rage incidents that escalated during the COVID-19 pandemic, many of which resulted in cabin disruption and physical violence toward the flight crew. Both flight attendants and nurses have an important role in ensuring the safety of those in their charge but often experience harm from the very individuals they are meant to protect. Nurses, however, are not afforded the same level of protection by their regulatory agencies as flight attendants are. Amid the increase in violence on airplanes, the Federal Aviation Administration, which regulates all aspects of aviation safety, sanctioned a zero-tolerance policy, pursuing legal action against "any passenger who assaults, threatens, intimidates, or interferes with airline crew members."


In this month's issue of AJN, Miranda Squire and Karen Hessler use a qualitative approach to explore the experience of violence by nursing personnel during one-to-one assignments. The article highlights an interesting juxtaposition of a strategy meant to keep patients safe that has itself become a safety issue for the staff performing it. There are many lessons to be learned from the staff's perspective on what needs to be done about this "silent epidemic." Some hospitals and states have begun to take stronger actions against patients who initiate violence against staff. In November 2022, Mass General Brigham in Boston implemented an explicit patient code of conduct that identifies specific behaviors that are not tolerated at the facility. When behavior is egregious and substantiated, the facility's leadership will ask the patient to seek nonemergency care elsewhere. While patient code-of-conduct policies are not new, their enforcement has been weak at best, primarily due to fear of litigation and concern over protection of patients' rights. Brigham's commitment, and communication, to its employees and patients seems almost palpable-not just words. (For more, see


At the state level, Maryland is the only state to adopt regulations permitting health care workers to display only their first name, nickname, or last name on their identification badge. While not fully protective, it is one step further in offering staff a sense of protection from stalking or cyberbullying. Impactful? Ask a Maryland nurse.


Currently there are no federal protections for health care workers. The Safety from Violence for Healthcare Employees (SAVE) Act (HR 7961) has been introduced in Congress and would establish federal criminal penalties for people who knowingly assault hospital workers; the bill remains in committee. Federal backing would be a big step toward sending a strong zero-tolerance message to the public and potentially serves as a deterrent to this growing epidemic.


Health care facilities, of course, have an enormous responsibility to stop the violence by implementing strategies to protect employees and patients. An effective strategy would go one step further, holding willfully violent patients, family members, and visitors accountable for bad behaviors, with strong, enforceable, and protective actions that safeguard workers and their facilities, as well as the patients they care for.