Nurses Warn: 'Never Safe' in a Health-Care System in Crisis

The Crisis of Violence in Nursing

Two weeks into her emergency department orientation at a Seattle hospital, Kelsey, a 21-year-old nurse, was already starting to worry she might not leave work alive that day. Her patient, bound in six-point restraints, hurled threats at Kelsey, telling her that she was going to come to her house and skin her with a razor blade. Trying to compartmentalize her fear, Kelsey followed orders to sedate the patient. As she approached her with the syringe, the patient, who had managed to free herself from the restraints, grabbed Kelsey’s arm and attempted to turn the syringe to inject Kelsey instead. Security was able to wrestle the syringe from the patient, but that didn’t prevent more attacks for the remainder of Kelsey’s shift—she recalls dodging punches from the patient before another nurse called a “code gray,” a signal used in hospitals to indicate a security concern, like a combative patient.

“I just remember walking out of that room, and my preceptor [a supervising nurse] was like, ‘Yep, welcome to nursing,’ ” Kelsey says. In the aftermath, Kelsey spent months trying to parse her feelings about the incident. Who was to blame? Her coworkers discouraged her from filing an incident report. Many of them had already experienced countless violent situations in their hospital, and management rarely acted on their concerns or increased staff safety measures. It would have been easy for Kelsey to villainize the patient, but she knew the individual was sick. Still, both of them had been put at risk that day, and Kelsey had been left without adequate training or resources to handle the violence.

In hospitals across the country, nurses are being threatened, punched, kicked, and even killed. It’s a crisis hiding in plain sight—and on our television screens. This violence has become such a normalized part of a nurse’s job that it’s now highlighted on Max’s new hit hospital drama, The Pitt. Viewers watch as charge nurse Dana Evans gets brutally punched in the face by an angry patient during a particularly chaotic shift.

True to the pop culture depiction, assaults by patients and family members alike have become terrifyingly common in the nursing world. These incidents, which were already on the rise pre-2020, accelerated during the pandemic, and many hospitals still lack effective reporting systems or adequate responses from management. Nearly half of respondents in a recent National Nurses United (NNU) survey reported a rise in violence from the previous year, with 26.3 percent saying violence “increased a lot,” yet union occupational health professionals estimate that up to 90 percent of these incidents go unreported, according to Jane Thomason, lead industrial hygienist at NNU.

The Impact on Nurses’ Mental Health

Between 2021 and 2022, health care professionals experienced more incidents of workplace violence than employees in any other sector of private industry, according to the U.S. Bureau of Labor Statistics. Over a three-month period in 2022, roughly 57 assaults on nurses occurred each day across the country, meaning that more than two nurses were assaulted every hour, found a study from Press Ganey. And 8 in 10 nurses experienced some degree of workplace violence in 2022, revealed the NNU survey.

Despite all this, there are no strict federal guidelines for health care employers regarding the reporting of workplace violence, which results in an epidemic of issues occurring on the regular—especially in emergency rooms. Is it any wonder that we’re dealing with a nurse shortage in the U.S.?

An Empty Bench—and a Looming Chasm

Yes, nurses are leaving the field at an alarming rate, exacerbating the staffing shortages and putting an already struggling health care system in even more dire straits. Federal authorities warn that the nation will need more than 63,000 additional nurses by 2030—a shortfall that’s driven by deteriorating working conditions, including workplace violence. Of course, there are countless ripple effects too. Fewer staff means longer hospital stays, higher patient mortality rates, and more preventable medical errors. And if there aren’t enough nurses to meet demand, a health care system collapse isn’t farfetched.

Several nurses interviewed for this article say that nurses entering the field are ill-equipped to deal with the job’s brutal realities. There’s also a lack of mentorship from more experienced peers, partly due to working conditions that don’t allow the necessary time for this. Nurses still in orientation have to care for patients they aren’t yet prepared to handle. It’s not exactly a selling point for the profession. Retaining new nurses has become especially challenging, says Kerrie, a Boston emergency room nurse. “Everyone’s job is difficult enough,” she says. “Then you throw on this aspect of the abuse—nobody wants to go to work every day and deal with that.”

The Psychological Toll

Indeed, it’s not only nurses’ physical health that is at risk from one of these traumatic events. More than 65 percent of nurses in the NNU survey reported fear and anxiety on the job based on their experiences with violence in 2022. Another study estimated that 28.4 percent could meet the criteria for post-traumatic stress disorder, with 15.4 percent experiencing severe symptoms. Repeated exposure to verbal abuse, profanity, and emotional mistreatment from patients—something Farinaz Havaei, PhD, an associate professor at the University of British Columbia School of Nursing, calls “chronic microaggressions”—significantly increases mental health issues among nurses.

When it comes to the type of intense attacks that Kelsey, the Seattle nurse, endured, “the primary consequence is going to be PTSD,” Havaei says. The psychological impact can be so severe that nurses actually have a term to describe the distress: moral injury.

For her part, Kelsey started going to therapy and taking antidepressants. Still, she has nightmares almost every night. One time, she and 30 other nurses joked about their therapy sessions. “I was like, ‘Hey, raise your hand if there are things that you don’t tell your therapist because you’re afraid of traumatizing your therapist,’ ” Kelsey recalls. Every single person raised their hand.

Even if their workplaces happen to offer mental health resources, many nurses say those measures feel limited or out of touch, like having pizza parties or providing self-care tips instead of addressing the deeper, systemic issues.

Legislative Efforts and the Road Ahead

While the Occupational Safety and Health Act, signed into law in 1970, requires under its General Duty Clause that employers provide a workplace “free from recognized hazards that are causing or are likely to cause death or serious physical harm,” there are no specific standards or guidelines when it comes to incidents of workplace violence. So, the responsibility for preventing them falls on the employer. Enforceable standards from the Occupational Safety and Health Administration (OSHA) would require employers to have a plan to prevent workplace violence, something union reps say employers are not doing on their own.

Currently, hospitals have to report only fatalities and severe injuries (those requiring treatment beyond first aid) to OSHA. Proposed federal funding cuts by the House of Representatives include a 12 percent decrease in OSHA’s budget, which would further impact its ability to enforce safety standards and prevent workplace injuries.

At a Kansas hospital, a veteran nurse named Shelly says that until last year there was no system for reporting violent incidents to management, and she wonders how the problem can be addressed without a way to track it. “It’s the hospital’s responsibility to have a safe place for nurses to work,” Shelly says. Employees at the hospital have since unionized to fight for a safer environment.

Since 2024, their contracts have included provisions for better protecting nurses from violence and for reporting incidents, but the union is fighting for a more comprehensive reporting system. “What we need is an enforceable mandate [from the government] to clarify for employers what they need to be doing,” says Thomason. “Because right now, they’re not doing what they need to do voluntarily.”

So far, only eight states require that health care employers have violence protection guidelines, which mandate the reporting of violent incidents. “We need an enforceable mandate to clarify for employers what they need to be doing. Because right now, they’re not doing it voluntarily.” Jane Thomason, NNU

In 2014, California passed a law increasing workplace safety regulations after a nurse named Cynthia Palomata was murdered by an inmate at the Contra Costa County Jail, where she worked. The inmate had faked a seizure and then fatally struck Palomata on the head with a table lamp. The state, which NNU considers to be the gold standard when it comes to workplace violence prevention laws, now demands that employers take comprehensive violence prevention measures, including maintaining sufficient staff, identifying environmental risks, mandating de-escalation training, and requiring the reporting of every violent incident to California’s OSHA division through a public reporting process.

Legislators in other states, like Oregon, are pushing for laws requiring workplace violence prevention plans and funding for metal detectors in hospitals. In February, Washington passed a bill requiring health care facilities to develop and implement workplace violence prevention plans, including security, staffing, training, and incident reporting provisions.

In New York, violence-related coverage is limited to workers in publicly funded health care facilities, so those working in private hospitals have a more challenging time pursuing legal recourse. And since hospitals rarely report low-level violent incidents, like verbal assaults or minor physical altercations, to OSHA, the agency rarely gets involved, according to a representative from the New York Committee for Occupational Safety and Health (NYCOSH), a nonprofit founded to improve workplace safety conditions.

New York’s Department of Labor does have a bureau that can enforce OSHA safety standards, called Public Employee Safety & Health (PESH), but it’s available only to public sector workers. Independent agencies like the not-for-profit Joint Commission also conduct hospital inspections to evaluate patient and staff safety. But a NYCOSH representative says its assessments generally don’t yield much change, partly because many employers know when the visits will occur and plan accordingly: Patients crowding the hallways of the emergency department evaporate, and non-nurse staff are brought in to monitor aggressive patients. “Everything’s hunky-dory when the Joint Commission shows up,” the representative says.

With no recourse, nurses have little choice but to shift matters into their own hands.

Taking Charge

In October 2018, after 34 years of working in the mental health department at a state hospital in Massachusetts, a nurse named Karen had finally had enough. Throughout her career, she’d noticed that the violent incidents typical of psychiatric units or emergency departments were infiltrating all areas of health care. Karen says she’s been punched, spat on, kicked, and had weapons pulled on her. She’s even seen colleagues suffer career-ending traumatic brain injuries and one lose peripheral vision after being assaulted while treating patients. For years, Karen’s husband and son grew increasingly concerned for her safety, to the point where her son once asked if anyone had tried to kill her that day.

At Karen’s workplace, she says, incidents reported to management almost never receive a follow-up. If a nurse wants to call the police or file charges as a last resort for getting help, Karen says, doing so is the nurse’s burden, so her colleagues rarely take that step.

Lexi, the pediatric nurse in Seattle, was forced to call the police when a young patient began aggressively wielding a scale and had to be barricaded in his room. She issued a “code silver”—used for patients with weapons—but says hospital leadership pushed back, claiming it applied only to guns. Lexi knew that wasn’t true, insisting the code was for all weapons, and management eventually acquiesced.

When a police officer arrived, he was perplexed to find the nurses wearing hockey helmets. “The officer was like, ‘Oh my gosh, so exciting that you could play hockey on the unit.’ And we were like, ‘This is [to prevent] concussions,’ ” Lexi says, adding that the volume of incidents each day makes it hard to remember them all.

“I’ve seen friends of mine dragged by their hair through the unit at least, like, three or four feet by a patient until someone was able to get the patient off of them,” she says. “I’ve had probably over 20 of my friends concussed. I’ve had two friends drop out of school because their cognitive function changed after an assault.”

Kerrie, the emergency room nurse in Boston, says she pressed charges against a patient who verbally assaulted her and threatened to kill her. She says her ER’s conditions are “deplorable” and security is inadequate. “I’ve just reached a point, like, when it’s every single day, every single shift that somebody in that department is getting abused,” Kerrie says. She recalls a security guard once commenting that dealing with the chaos of a violent patient is what nurses signed up for. “We signed up to take care of patients,” she told him. “We didn’t sign up to come into work to be threatened and assaulted.”

Hospital management seems to have “forgotten that the true mission is to take care of patients,” says Kerrie.

What It’ll Take to Change an Industry

Without adequate reporting systems, change—including new legislation—that could better protect hospital staff is an uphill battle. Thankfully, a new generation of nurses is starting to speak up, and those in power have begun paying closer attention. “They’re demanding safety, and they’re demanding more resources, and they’re demanding better staffing, and if they don’t get it, they leave,” says Kerrie.

Legislators are aware of these long-standing issues, but major shifts take time. “For years, employers have refused to work with us to implement workplace violence prevention plans and to address the staffing crisis that creates the conditions for workplace violence,” said Nancy Hagans, the president of NNU, in an April press release. “Congress can support frontline health care workers by requiring employers to invest in proven measures to prevent violence in our workplaces.”

Congressman Joe Courtney, a Democrat from Connecticut, introduced the Workplace Violence Prevention for Health Care and Social Service Workers Act, which passed in the House of Representatives with bipartisan support in 2019 and 2021 but is still awaiting action in the Senate. It would require the Department of Labor to mandate that health care employers document and investigate violent incidents, provide prevention training, and implement safety measures. “I have been married to a nurse practitioner for 35 years and heard from my wife about the abuse and risk of harm that has become commonplace in health care,” Courtney said in a statement to Women’s Health. “Workplace violence is not a ‘fact of life’—we can significantly reduce it with smart, enforceable protections.”

As new systems and procedures are developed at the federal and employer level, nurses say it is essential that they be involved. “They are the ones with firsthand experience,” says Havaei, of the UBC School of Nursing. “Unless nurses are able to actually speak to their experiences and give recommendations in terms of what they think is going to make a difference, we’re not going to be able to tackle this issue.”

In a recent survey of 800,000 nurses, 40 percent said they plan to leave the industry by 2029.