A study published by the New England Journal of Medicine found surprisingly high rates of workplace violence against healthcare workers, especially those in emergency department and psychiatric wards.

The paper cites the murder of a surgeon at Brigham and Women's Hospital in Boston by the son of a deceased patient. While the story got media attention, reports did not link the incident with statistics that show violence against medical care providers is a real concern.

Healthcare workers are most frequently victims of what is called "type II assaults," those in which the perpetrator has an established relationship with the business. In a 2014 survey on hospital crime, type II workplace violence accounted for 75 percent of aggravated assaults and 93 percent of all assaults against employees. In recent years, the number of assaults averaged 24,000, with 75 percent being committed in a healthcare workplace, as opposed to outpatient and home settings.

The study, trying to answer why such risks are not widely known, cited a lack of statistics on the subject. Data from the Bureau of Labor Statistics are inconsistent. For example, one study claimed investigators found the actual number of reportable injuries were three times greater than what the federal survey reported.  The industry lacks a singluar measureable instrument that can used in every study on workplace violence in the emergency department.

The study offered a number of surprising statistics, including:

• 46 percent of nurses reported some type of workplace violence in their five most recent shifts; one-third of these nurses were physically assaulted;
• Emergency department nurses reported the highest rates of assault, with 100 percent reporting verbal incidents and 82.1 percent reporting physical abuse in the last year;
• 78 percent of emergency department physicians reported being the target of workplace violence in the past year;
• 40 percent of psychiatrists reported physical assault;
• The rate of workplace violence among psychiatric aides is 69 times higher than the national rate;
• 61 percent of home healthcare workers reported violence annually;
• Emergency departments and psychiatric wards consistently showed the highest levels of violence, and nursing aids are at highest risk, especially those in psychiatric wards.

Another factor in the inaccuracy of statistics is the fact that many incidents go unreported. Only 30 percent of nurses and 26 percent of physicians repot incidents of workplace violence.

“Underreporting is due in part to a healthcare culture that is resistant to the belief that providers are at risk for patient-initiated violence and to a complacency in thinking that violence is ‘part of the job,'” wrote James P. Phillips, MD, and colleagues.

“Providers are sometimes uncertain what constitutes violence, since they often believe that their assailants are not responsible for their actions in such cases. Perpetrators most commonly have a diagnosis of psychosis, substance-use disorders or dementia, and perhaps events are not reported because providers believe that these patients are not in full control of their faculties,” wrote Phillips and colleagues. “Nurses have cited fear of retribution from supervisors, the complexity of the legal system and disapproval of administrators as barriers to the reporting of workplace violence.”

The NEJM study argues reventative measures against workplace violence should be a main concern of healthcare facilities, but protocols are often neglected or nonexistent. In 2008, only 15 percent of emergency departments used metal detectors. With the exception of laws regarding workplace violence in a few states, healthcare organizations are not required to have highly specific prevention strategies.

Suggested solutions include training in aggression de-escalation and self-defense; installing fences, security cameras and metal detectors; hiring guards; and banning all firearms from the workplace, except those used by law enforcement.

“Healthcare employers who are eager to ensure safe working environments for their employees may help to do so by adopting simple incident-reporting procedures that protect complainants from retribution, ensure comprehensive managerial support and support the implementation of cost-effective, evidence-based solutions as they are discovered,” said Phillips and colleagues. “Future research efforts should be devoted to unbiased data collection, experimental designs and improved reporting processes.”