Violence against nurses is an escalating crisis in health care. Nurses are the foundational pillar of our health care system, providing the largest share of direct patient care and spending more time with patients than any other health care discipline.[1] This increased contact with patients and visitors exposes nurses to high-risk situations that endanger their safety. Hospital settings have one of the highest incidences of workplace violence.[2] Workplace violence in nursing is defined as "any act or threat of verbal or physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abusing or injuring the target."[3]

THE SCOPE OF THE PROBLEM

The statistics are alarming. On average, two nurses are assaulted every hour in the United States. The rate of serious injuries related to workplace violence is six times higher for hospital workers compared to all other private sector employees, with as much as 80% of incidents going unreported.[4] The American Hospital Association reports that health care workers suffer more workplace violence than any other profession.[5]

Since 2020, health care workers worldwide have reported a staggering uptick in violence, with nurses experiencing the most dramatic increase.[6] This surge has become one of the leading factors in nurse burnout.[7] With minimal improvement in safety over the past five years, nurses are now seeking support from their communities through collective action. At the time of this writing, nurses are striking in Michigan, California and New York, while strikes have been authorized or completed in Washington, Oregon, Massachusetts, Maine, Louisiana, Minnesota and Pennsylvania. All these labor actions cite nurse safety as a central concern.

CONSEQUENCES FOR NURSES AND PATIENTS

When nurses feel unsafe in the workplace, the consequences extend far beyond the immediate incident. After experiencing or witnessing violence, nurses report reduced sleep, disrupted eating patterns and increased risk of mortality associated with disease.[8] These factors accelerate nurse burnout and lead to declining quality of patient care, which, in turn, drives more nurses to leave the profession.

Workplace violence is directly linked to poor patient outcomes, unhealthy work environments, health care errors, decreased service quality, lack of job satisfaction and high employee turnover. Nurses who have suffered violence in the workplace commonly report anxiety, depression and unhealthy coping mechanisms.

LEGAL PROTECTIONS: INADEQUATE AND UNDERENFORCED

Forty states, including Oklahoma, have established some form of criminal penalty for assaulting nurses. However, seven of these states only apply protections when the assault takes place in emergency or mental health facilities. Despite these laws, statistics show that very few offenders face justice. Law enforcement is often reluctant to file police reports when assaults occur in medical facilities, typically citing the potential mitigating factor of the offender having an underlying medical condition. Even when reports are filed, authorities rarely bring charges, and cases that reach the court system frequently result in dismissals or plea bargains.[9]

OKLAHOMA'S LEGAL FRAMEWORK

Oklahoma Statute 21 O.S. §650.4 makes it a felony to assault a health care worker in the line of duty. Originally enacted May 30, 1990, and subsequently amended in 2000 and 2009, this statute was strengthened through the Medical Care Provider Protection Act (Senate Bill 1290) in 2020. Legislative notes accompanying the 2020 amendments recognized, "In Oklahoma City hospitals alone, between five and 10 assaults are reported every day, but it's a problem that impacts health care workers throughout the state." The notes further stated, "An estimated 75% of all workplace violence [in Oklahoma] occurs in health care."

The law makes it a felony to assault, batter or commit assault and battery against medical care providers (including doctors, nurses, emergency medical technicians, hospital staff and others) while they are performing their medical duties. Violations carry penalties of up to two years in prison and/or a $1,000 fine. For aggravated assault and battery or assault with a firearm or deadly weapon, Section 650.5 imposes enhanced penalties of two to five years imprisonment and/or a $1,000 fine.

Other states have taken varied approaches to this issue. Thirty states have enacted laws requiring workplace violence prevention programs, while 29 states have passed or are considering legislation allowing hospitals to establish independent police forces. Alaska has implemented mandatory minimum sentences for assault on medical professionals, and Michigan has doubled penalties for such assaults. Despite these state-level efforts, no federal law currently protects health care workers from workplace violence.

WORKERS' COMPENSATION: AN INADEQUATE RESPONSE

When nurses in Oklahoma are assaulted, the cases typically fall under workers' compensation rather than criminal prosecution. Under Oklahoma law, injured nurses receive only 70% of their average weekly wage – an amount that fails to account for shift bonuses, shift differentials between night and day shifts and compensation for credentials and patient acuity. This results in financial hardship on top of the physical and psychological trauma caused by the assault.

This stands in stark contrast to the protections afforded to other professions facing workplace violence. Police officers, firefighters, military personnel and political officials are protected by laws that make assaulting them in the line of duty a felony, with violators typically prosecuted to the fullest extent of the law. Some states have recognized this disparity. California and New York, for example, provide more robust compensation for law enforcement officers who are injured in the line of duty.

Oklahoma has recently taken steps to enhance workers' compensation for certain first responders. Beginning in 2025, S.B. 1457 provides special workers' compensation benefits for police officers, professional and volunteer firefighters and emergency medical technicians diagnosed with post-traumatic stress disorder (PTSD) connected to "responding to an emergency." The law defines the covered PTSD issues as "symptoms connected to witnessing or experiencing near-death, death, or threats to the physical integrity of others involving helplessness or horror." Benefits include up to 52 weeks of paid recovery time, medical treatment for PTSD, up to an additional $50,000 in benefits, up to $10,000 in prescription coverage and job protection. Additionally, an aspect of this law expansion requires employers to maintain health benefits when an employee is unable to return to work. Notably, nurses are excluded from these enhanced protections despite facing similar traumatic exposures in their daily work.

THE CULTURE OF ACCEPTANCE AND UNDERREPORTING

Nursing has become one of the few professions where violence is not only tolerated but expected as part of the job. This normalization sends a dangerous message that places implicit fault on nurses rather than on aggressors or the systems that fail to protect health care workers. When assaults occur and law enforcement declines to prosecute, it reinforces the perception that violence against nurses will rarely rise to a level requiring system-wide change.

Underreporting is a critical factor in the lack of effective interventions. Nurses report incidents through proper channels, but when nothing changes, they become discouraged and stop reporting altogether – a phenomenon known as learned helplessness. As one expert describes it, learned helplessness is "symbolized by battle fatigue, that moment when an issue is raised, people's eyes glaze over, and they say, 'You know what? We've had that issue forever and there is really nothing we can do about it. We just have to learn to live with it.'"[10]

Underreporting also stems from a lack of knowledge about workplace policies and uncertainty among administrators about how to pursue action against perpetrators.[11] When 80% of incidents are suspected to go unreported, the health care industry lacks the data needed to develop effective interventions.[12] Nursing leaders have little evidence about how to mitigate the negative effects of violence against nurses.[13]

COMPREHENSIVE REFORM

Despite attempts to curb workplace violence, incidents continue to increase.[14] The problem is escalating and requires a fundamentally different approach. Comprehensive reform would address multiple dimensions:

• Stronger enforcement of existing laws and accountability from law enforcement agencies
• Enhanced workers' compensation benefits that adequately reflect nurses' actual wages and the traumas they experience
• Mandatory workplace violence prevention programs with measurable outcomes
• Improved reporting systems that ensure incidents are documented and addressed
• Cultural change within health care institutions to eliminate the expectation that violence is simply "part of the job"
• Collaboration among facility management, nurses, lawmakers, patients and families to establish universal standards for how nurses will be treated while caring for patients

Reimagining nurse protection would require all stakeholders to work together for meaningful change. Outstanding care requires collaboration, dedication and a willingness to rethink old assumptions.

CONCLUSION

Everyone is a consumer of health care. We all have a vested interest in taking care of the people who care for our health needs. Nurses are being assaulted at alarming rates, suffering physical injuries, psychological trauma and financial hardship as a result. While laws exist to protect them, enforcement is inconsistent at best. Workers' compensation provides inadequate support, particularly when compared to the benefits afforded to other first responders. A culture of acceptance and underreporting perpetuates the problem, leaving nursing leaders without the data needed to develop effective interventions.

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ABOUT THE AUTHOR

Layla J. Dougherty brings an interdisciplinary perspective to law and health care as both an attorney and a critical care nurse. After nearly two decades of legal practice, she became a registered nurse in 2018, later completing her BSN and MSN. She serves as counsel to the Chapter 13 trustee for Oklahoma’s Eastern District, teaches critical care nursing and consults nationally on matters involving elder abuse and health care fraud. She is also an advocate for workplace safety and violence prevention for nurses and other health care workers.

 

 

 

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ENDNOTES

[1] Mercer University. (May 22, 2024). “Why Are Nurses Important in Healthcare? The Role of Nurses Explained,” https://bit.ly/3Oy2d7D.

[2] S. Zhang, Z. Zhao, H. Zhang, Y. Zhu, Z. Xi and X. Xiang. (2023). “Workplace violence against healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis,” Environmental Science and Pollution Research, 30, 54316-54331. https://bit.ly/4kwoxL1.

[3] M. Mustafa Al-Qadi. (2021). “Workplace violence in nursing: A concept analysis,” Journal of Occupational Health, 63(e12226), 1-11. https://bit.ly/4ty3VpW, page 1.

[4] American Nurses Association. (March 22, 2024). “ANA, ENA & ACEP sound the alarm on violence against nurses,” [News release]. https://bit.ly/3Oy33kN.

[5] A. Markovitz and C. Grimes, (Sept. 1, 2022). “Violence against healthcare workers is at an all-time high,” Forbes. https://bit.ly/4atr2sR.

[6] M. Crouch and C. Ledger. (Nov. 6, 2023). “Cursed at. Shoved. Punched. Bitten. Violence against doctors and nurses is rising. A new N.C. law aims to help protect them,” North Carolina Health News. https://bit.ly/3ZpbBwP.

[7] Agency for Healthcare Research and Quality. (January 2024). Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement. https://bit.ly/4rsxKqx.

[8] S. Zhang, Z. Zhao, H. Zhang, Y. Zhu, Z. Xi and X. Xiang. (2023). “Workplace violence against healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis,” Environmental Science and Pollution Research, 30, 54316-54331. https://bit.ly/4kwoxL1.

[9] M. Crouch and C. Ledger. (Nov. 6, 2023). “Cursed at. Shoved. Punched. Bitten. Violence against doctors and nurses is rising. A new N.C. law aims to help protect them,” North Carolina Health News. https://bit.ly/3ZpbBwP.

[10] C. Wakeman. (2010). “Reality-based leadership: Ditch the drama, restore sanity to the workplace, and turn excuses into results,” Jossey-Bass, page 14.

[11] S. Kafle, S. Paudel, A. Thapaliya and R. Acharya. (2022). “Workplace violence against nurses: A narrative review,” Journal of Clinical and Translational Research, 8(5), 421-424.

[12] J. E. Arnetz. (2022). “The Joint Commission's new and revised workplace violence prevention standards for hospitals: A major step forward toward improved quality and safety,” The Joint Commission Journal on Quality and Patient Safety, 48(4), 241-245. https://bit.ly/4aqrsAo.

[13] M. McCollum, K. McLaughlin, J. Garcia, A. Santos and J. Lesandrini. (2024). “Empowering nurses in an era of workplace violence: A pilot study,” Nurse Leader, 22(3), 251-257.

[14] American Nurses Association. (March 22, 2024). “ANA, ENA & ACEP sound the alarm on violence against nurses,” [News release]. https://bit.ly/3Oy33kN.