When the Caregiver Becomes the Victim: Hospital Action to Prevent Workplace Violence


Hospitals are places of healing and safety for patients, caregivers and visitors, but are not immune to violence from our communities. That is why Maryland’s hospital leaders elevated workplace violence prevention in their strategic plan for the field.

Maryland’s violent crime rate has been above the national average for 30 years.1 The effects of violence take a toll on individuals and communities. When that violence extends into the workplace, the effects can be increased staff turnover, lost productivity, absenteeism, poor employee morale and burnout. 2, 3

The U.S. Department of Labor defines workplace violence as “an action, whether verbal, written or physical, that is intended to control, cause or is capable of causing death or serious injury to the aggressor, others or property.”4 75% of workplace violence incidents reported to the Occupational Safety and Health Administration occur in health care or social services settings.5 One security officer at a Maryland community hospital reported recovering three to four weapons per week—mostly knives or other cutting objects.


Violence harms the physical and emotional well-being of staff, patients, visitors and the community. To ensure a safe and healing environment, Maryland’s hospitals have changed polices, implemented multidisciplinary response teams, increased staff training and raised spending on security, including staffing, infrastructure, and technology.

Protecting and preserving the hospital’s healing environment comes at a cost. A 2017 Milliman Research Report on the Cost of Community Violence to Hospitals and Health Systems estimated that U.S. hospitals and health systems spent $1.1 billion preserving the safety of patients, visitors and employees on hospital premises through security and training costs. The same report estimated approximately $2.7 billion hospitals spent addressing violence, both within the hospital and the community.9 In a 2019 MHA survey, 92% of hospitals reported increased spending on security over the past five years. That included hiring additional security officers for evening and weekend shifts, installing security cameras in key locations, and issuing personal panic alarms to staff.


Hospitals offer a safe and healing environment for patients, visitors and staff.

Many of Maryland’s hospitals have protocols and resources to identify violent patients. Some use identifiers in the electronic medical record that ensure patients get specialized help and alert staff to take extra safety precautions.

Some hospitals take novel approaches, like symbolic signage within or outside of a patient’s room to alert staff so they engage appropriately and prevent escalation to the best of their ability. Hospitals are also changing policies and procedures to encourage staff to report all incidents and promote a culture of zero tolerance.

When an incident requires legal action, hospitals often offer support because there is no formal, statewide response to assist victims of workplace violence. At many hospitals, security personnel assist the employee, involving law enforcement as needed. Some also accompany victims to court and pay for transportation to court proceedings. Many hospitals offer peer support programs and other services.


Tackling workplace violence is a multi-stakeholder process. We need our partners—front-line staff, nurses, physicians, law enforcement, members of the legal system, elected officials and others—to raise awareness and help us prevent and respond to incidents of workplace violence.

To ensure violence is not a part of the job for our state’s caregivers, we need:

  • A legal remedy to keep hospital workers safe from those threatening to return and cause harm on our premises
  • A single point of contact within each jurisdiction to help hospital staff navigate the legal process after an incident of workplace violence

The rate of serious workplace violence incidents is 4x greater in the health care field than in private industry.

Violence in the Hospital: By the Numbers

The American College of Emergency Physicians 2018 Survey 6
47% Emergency physicians that have been physically assaulted at work
97% Of assaults were committed by patients; 28% also involved a patient’s family member/friend
83% Emergency physicians that said the patient threatened to return and harm them or other staff
71% Emergency physicians that have witnessed an assault at work

Four Types of Workplace Violence

The type is defined based on the relationship between the perpetrator and the victim: 7

Type I: No legitimate relationship exists (criminal intent)
Type II: Customer, client or patient on worker violence
Type III: Worker on worker violence
Type IV: A personal relationship exists

88% of all hospital assaults were Type II— by patients against workers 8

Impact of violence in one Maryland community hospital

2019 MHA Survey
181 Incidents of violence against hospital employees by patients over two years
40% Incidents occurred in the emergency department

Maryland’s Hospitals: Keeping Employees Safe

  • Identifying high-risk individuals and establishing a preventive plan of action
  • Increasing security coverage, especially at night and on the weekends
  • Reducing entry points and requiring visitor identification bands
  • Modifying unit layouts to better protect staff, provide clear lines of sight
  • Building multi-disciplinary team responses to emergency codes
  • Reviewing each incidence of violence to determine contributing factors
  • Establishing and evaluating evidence-based quality improvement initiatives
  • Training all staff in de-escalation, self-defense and active shooter
  • Hosting community townhalls
  • Creating peer-to-peer support programs

Footnotes and Sourcing

[1] America’s Health Rankings. (2019). State Findings: Maryland, 2019 americashealthrankings.org/explore/annual/measure/Crime/state/MD

[2] Milliman Research Report. (July 26, 2017). Cost of Community Violence to Hospitals and Health Systems: Report for the American Hospital Association. aha.org/system/files/2018-01/community-violence-report.pdf

[3] The Joint Commission. (April 17, 2018). Sentinel Event Alert: Physical and Verbal Violence Against Health Care Workers. jointcommission.org/-/media/tjc/idev-imports/topics-assets/workplace-violence-prevention-implementing-strategies-for-safer-healthcare-organizations/sea_59_workplace_violence_4_13_18_finalpdf.pdf

[4] Ibid.

[5] Ibid.

[6] American College of Emergency Physicians. (September 2018). ACEP Emergency Department Violence Poll Research Results. emergencyphysicians.org/globalassets/files/pdfs/2018acep-emergency-department-violence-pollresults-2.pdf

[7] Centers for Disease Control and Prevention. Workplace Violence Prevention for Nurses. cdc.gov/niosh/topics/violence/training_nurses.html

[8] International Association for Healthcare Security and Safety – Foundation. (n.d.) 2019 Healthcare Crime Survey, iahssf.org/crime-surveys/2019-healthcare-crime-survey

[9] Milliman Research Report. (July 26, 2017). Cost of Community Violence to Hospitals and Health Systems: Report for the American Hospital Association. aha.org/system/files/2018-01/community-violence-report.pdf