While there is general consensus that violent incidents against healthcare workers are underreported, a closer look reveals a more nuanced view of the problem.

Many incidents are actually reported by word of mouth and even documented in various logs and systems. The problem is that these incident data too often remain in separate silos and are not compiled into systemwide active surveillance that could reveal a more complete picture of violence in a healthcare facility, says Lisa A. Pompeii, PhD, the lead author of a new study1 on reporting of violence in healthcare.

As it currently stands, violent and threatening incidents, if they are mentioned at all, may be reported to “solo databases” such as security, employee health, and nurse managers, says Pompeii, an associate professor in the Southwest Center for Occupational and Environmental Health at the University of Texas Health Science Center in Houston.

“What OSHA recommends, and I agree with, is that all the disparate pieces of information and lists need to be collected in one place,” she says. “[That way] you have some oversight of all the different places of where it is being reported and you can get a better picture of these events.”

In addition, there are signs that the work culture in some hospitals and healthcare settings may contribute to an escalation of violence. A review article2 published earlier this year found that “episodes of workplace violence of all categories are grossly underreported.” The author noted that nurses cite fear of retribution from supervisors and disapproval of administrators as barriers to reporting, possibly due to a prevailing “the customer is always right” mentality.

While agreeing with the review paper and the importance of the findings, Pompeii and co-authors dug deeper into the issue of incident reporting. “Our findings contradict prior findings that workers significantly underreport violent events,” they noted. “Coordinated surveillance efforts across departments are needed to capture workers’ reports, including the use of a designated violence reporting system that is supported by reporting policies.”

Reporting, But to Whom?

To address the issue, Pompeii and colleagues used surveys and focus groups to examine reporting of Type II violence (patient/visitor to worker) among 11,000 healthcare workers at six U.S. hospitals. Of the 2,098 workers who experienced a violent event, 75% indicated they reported to managers, co-workers, security, or in the patient medical record. However, only 9% reported it into their occupational injury and safety reporting systems. Workers were unclear about when and where to report, and relied on their own judgment and tolerance in deciding whether an event was violent and whether to report it.

“We found that everyone has a different ‘threshold’ [of what is a violent incident] and they have a different threshold for reporting,” Pompeii says.”

For example, a nurse in one focus group said she was called a “bitch” by a patient, but did not report it and dismissed the incident.

“A nurse in another focus group said, ‘If you call me a bitch I’m going to report you,’ Pompeii says. “Everyone has a different threshold and that’s why a workplace violence reporting policy is needed that actually defines what workplace violence is according to the hospital, and when they want it reported.”

With these subjective thresholds in play, it follows that there are a variety of reasons healthcare workers do not report incidents.

“The main reasons they don’t report are pretty established,” Pompeii says. “They don’t report because of the fear of retribution, it takes too much time, they don’t think the managers will listen, or they don’t think it was serious enough.”

The retribution may be fear of the patient, but also fear of running afoul of hospital management. The aforementioned perception that the patient/customer is “always right” resonated in the surveys and focus groups.

“There really is a heavy emphasis on customer service — the customer is first — and that is how the worker perceives it,” she says. “When we did our focus groups we found that some workers were not comfortable coming forward because they did not feel their managers were supporting them. Or they felt that immediate management supported them, but those above them would give them a hard time. But I think they are also afraid of the patients.”

Interestingly, the researchers found a “witness effect,” as workers who were accompanied by a colleague when the incident occurred were more likely to report it.

“But a significant finding was that if the worker was alone, they were less likely to report it,” she says. “I think they are afraid they are not going to be believed.”

Healthcare workers may also be conflicted about “telling on” a patient under their care. The upshot of all of these factors is that in absence of clearly delineated policies, reporting of violent incidents is beset by a host of variables and subjective perceptions.

“I think hospitals need to stop relying on traditional reporting systems,” Pompeii says. “They need to reach out more to workers, they need to survey on a routine basis, maybe anonymously, about the events and what they are experiencing.”

This proactive effort can be an adjunct to established reporting systems, but the main thing is that violence prevention policies clearly define violence and emphasize when and where it should be reported, she says.

“They need to be real clear and train their workers on that,” she says.

Better documentation could provide needed detail to the scope of a problem that is concerning enough in its general, undefined state.

Citing the increasing threat of violence in healthcare, The Joint Commission (TJC) recently launched a workplace violence prevention portal to help hospitals respond and prepare through a variety of resources. (The portal can be viewed at: http://bit.ly/2d8U2IW.)

“The violent situations occurring across our country spill over into our emergency departments, behavioral health settings, and elsewhere,” Ann Scott Blouin, RN, PhD, FACHE, wrote in a TJC blog post. “In a matter of seconds, your patients, staff, and visitors can become victims in these frightening, and often devastating, situations.”

The Joint Commission portal is comprised of various resources and strategies from researchers and clinicians in the field. Nurses on the frontlines of healthcare are the group most likely to be confronted with violence. In that regard, TJC cites a 2009 poll that 80% of nurses did not feel safe at work.

The problem does not appear to have improved. Between 2010-2014, TJC received reports of 19 shootings in accredited healthcare settings, resulting in 27 fatalities, Blouin notes. In addition, Ron Wyatt, MD, MHA, DMS, medical director of TJC Division of Healthcare Improvement, reports there has been an increase in violent crime, from 2.0 events per 100 beds in 2012 to 2.8 events per 100 beds in 2015.

As lead author of a new study3 posted on TJC’s violence portal, Wyatt also noted that incident reporting is an ongoing problem.

“[HCWs] underreport violent events because they believe these experiences are part of the job, reporting is either cumbersome or unlikely to result in action from leadership, or they fear retaliation for reporting,” Wyatt and co-authors noted. “For these reasons, reporting systems should be simple, trusted, secure, and with optional anonymity; result in transparent outcomes and delivery of a report confirmation; and be fully supported by leadership, labor unions, and management.”

Workplace violence prevention should be included in all new-employee training and in ongoing education of all employees. “Programs aimed at prevention of workplace violence should include employee training and awareness, reporting, threat assessment, management plans, and a communication strategy. All employees should have training relevant to the risk for violence that may exist in their respective workplaces,” Wyatt emphasized in the paper.

Close Encounter

Wyatt spoke on the critical role of hospital leadership in an interview on Radio Health Journal, saying, “Leadership is at the table. They’re not saying, ‘Go have a meeting on this every quarter and let me know what you decided.’ Leadership has to be at the table actively engaged in the entire process if you want to build what we call a robust workplace violence prevention program.” (Audio and transcript of the interview can be found at:

He also recalled a harrowing encounter that ended without injury, but took a strange turn when he entered an exam room to see a new patient, an older woman accompanied by her husband.

“When I walked in she reached in a shopping bag and pulled out this really large photograph of a former patient of mine,” Wyatt said in the radio interview. “I immediately recognized the patient. How could I not? Because she was a young woman who died quite unexpectedly. I said to them, ‘I can’t talk to you about this patient.’ At that point the gentleman moved behind me, and in a soft voice he said, ‘You’re going to talk to us, or you’re not going to leave this room.’ I did not have in that setting any way to alarm the staff. What I chose to do was sit and talk to them. One of the concerns was well, if this guy has a gun, or she has a gun in the bag, then I’m going to put other people at risk if I start to fight with them to get out of that room.”

The couple left without incident after he showed them computer records of everything that had been done to try to save their daughter. He never saw them again, he said.


  1. Pompeii LA, Schoenfisch A, Lipscomb HJ, et al. Hospital Workers Bypass Traditional Occupational Injury Reporting Systems When Reporting Patient and Visitor Perpetrated (Type II) Violence. Am J Ind Med 2016;59(10):853-865.
  2. Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med 2016;374:1661-1669.
  3. Wyatt R, Anderson-Drevs, Male LMV. Workplace Violence in Health Care: A Critical Issue with a Promising Solution. JAMA 2016;316(10):1037-1038.