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Learn more: PMC Disclaimer | PMC Copyright Notice Health Aff Sch . 2026 Mar 31;4(4):qxag077. doi: 10.1093/haschl/qxag077 Search in PMC Search in PubMed View in NLM Catalog Add to search Workplace violence against nurses is a patient safety crisis, not “part of the job” Kathryn A Connell Kathryn A Connell 1 Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 2 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States Find articles by Kathryn A Connell 1, 2, 3, ✉, b , Juliana Gabrielle Byers Juliana Gabrielle Byers 4 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 5 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States Find articles by Juliana Gabrielle Byers 4, 5 , K Jane Muir K Jane Muir 6 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 7 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States 8 Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States Find articles by K Jane Muir 6, 7, 8 Author information Article notes Copyright and License information 1 Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 2 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States 4 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 5 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States 6 Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States 7 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States 8 Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States ✉ Corresponding author: Department of Biobehavioral Health Sciences, University of Pennsylvania; School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing; Leonard Davis Institute of Health Economics, Philadelphia, PA, United States. Email: [email protected] b Conflicts of interest: The authors have no conflicts of interest. Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials. Received 2026 Feb 3; Revised 2026 Mar 15; Accepted 2026 Mar 21; Collection date 2026 Apr. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc. 2026. This work is written by (a) US Government employee(s) and is in the public domain in the US. PMC Copyright notice PMCID: PMC13071812 PMID: 41982630 Abstract Workplace violence in healthcare settings has become widely normalized, which obscures its severity and undermines meaningful attempts at prevention. Thousands of healthcare workers a year experience workplace violence-related injuries, and many incidences go unreported altogether. As a result, the true risk and frequency of workplace violence are concealed and unaddressed, leading to inadequate allocation of resources toward prevention. The consequences of workplace violence extend beyond physical injury; lasting psychological harm such as post-traumatic stress symptoms and moral distress is common. State-level responses, including expanded criminal penalties and mandated employer-run prevention programs, have emerged in the absence of enforceable federal standards. Despite being framed as an unavoidable consequence of working in healthcare, workplace violence should be seen instead as an outcome of chronic mistreatment of healthcare workers, poor security infrastructure, and weak regulatory oversight. In hostile and dangerous work environments, patient safety and healthcare quality inevitably suffer. Workplace violence is therefore an urgent patient safety issue, and addressing it is integral to providing quality healthcare. Keywords: workplace violence, healthcare workforce, occupational safety, health policy, patient safety Key points. Workplace violence is a persistent structural problem in healthcare settings that often goes unreported and has serious consequences for clinicians and patients alike. Workplace violence is a structural consequence of healthcare environments that are understaffed, overwhelmed, and poorly supported by behavioral health, security infrastructure, and regulatory oversight. When clinicians must prioritize their own safety in a hostile work environment that fails to protect them, patient safety and healthcare quality inevitably suffer. When a patient in severe alcohol withdrawal struck Nurse X in the jaw, they did what nurses across the country have learned to do: stabilize the patient, finish the shift short-staffed, and quiet the tremor in their hands on the drive home. In the days that followed, they caught themselves scanning doorways before entering rooms and lying awake replaying the impact. Their colleagues felt no shock; several had been threatened or groped that same week. Recent events underscore just how routine such violence has become. In Philadelphia, three nurses were injured in a hit-and-run while stabilizing a patient outside the emergency department. In Western Pennsylvania, at UPMC Altoona, two nurses were assaulted within weeks of each other. All of the authors, who have practiced or currently practice at the bedside, have seen firsthand how violence that would halt operations in any other industry is too often treated as an unavoidable condition of clinical care. The familiar absence of alarm among clinicians reveals a more profound issue. Violence against healthcare workers has become so normalized that institutions respond with resignation rather than prevention. The true systemic failure lies not in the behavior of patients in crisis, but in this normalization itself. The gendered nature of the nursing workforce has shaped how nurses are perceived and treated within healthcare settings. 1 Importantly, it also influences the degree to which mistreatment toward nurses is tolerated or dismissed. The scale of workplace violence is stark in the latest federal data (2023). 2 Across all private industries, intentional violence caused 41 270 serious injuries: healthcare and social assistance alone accounted for 12,980, nearly one-third of the national total. Of the 15 470 injuries from unintentional or unknown person-initiated actions across all industries, 6780 occurred in healthcare. Together, these figures reveal that healthcare workers sustain more than 19 700 person-related injuries, representing a disproportionate share of the national burden and confirming that workplace violence is a structural, predictable occupational hazard in clinical settings. Yet these numbers underestimate reality. A meta-analysis in Critical Care found that up to 80% of violent incidents go unreported. 3 Nurses cite cumbersome reporting systems, cultures of inaction, fear of retaliation, and the belief that nothing will change. 4 This silencing is not benign: the underreporting of workplace violence obscures risk, inflates perceived safety, distorts organizational dashboards, and leads to the misallocation of resources based on only a fraction of the true hazard. The human toll is equally clear. Decades of research across emergency departments, intensive care units, medical-surgical units, and psychiatric settings show that a single violent episode triggers acute physiologic stress and days of hypervigilance. 5 The American Academy of Nursing has linked workplace violence to elevated rates of nurse suicide and substance-use disorders, framing this as a mental health crisis within the workforce rather than a cascade effect of a larger systemic issue. 6 , 7 Critically, these impacts extend beyond individuals to patients themselves. Violence reshapes how clinicians practice. An assaulted nurse may unconsciously shorten the next conversation, hesitate before entering a room alone, or avoid eye contact that invites disclosure. Over time, self-protection can replace the emotional presence that grounds therapeutic connection, and clinicians may also miss the micro-observations essential to early detection of clinical deterioration. Violence suppresses information in clinical care. When clinicians must repeatedly prioritize their own safety in a hostile work environment that fails to protect them, patient safety inevitably suffers. 8 Empirical evidence supports this link. In a study of 94 medical-surgical wards across 21 Australian hospitals, Roche and colleagues found that nurses' perceptions of violence were significantly associated with increased medication errors, patient falls, and delayed medication administration, with all 3 types of violence (physical assault, threats, and emotional abuse) linked to late administration of medications. 9 Importantly, violence correlated not with patient populations but with ward-level instability: fewer registered nurses, unanticipated changes in patient acuity, poor nurse-physician relations, and higher proportions of patients awaiting placement. 9 Liu and colleagues extended this work in a cross-sectional survey of 1502 nurses in 23 Chinese hospitals, demonstrating that workplace violence affected patient safety both directly and indirectly through the mediating pathways of nurse burnout and job dissatisfaction. 10 Together, these studies establish that workplace violence is not simply correlated with poor outcomes; it operates through degraded working conditions and depleted clinician well-being to produce measurable harm. The COVID-19 pandemic demonstrated how closely violence tracks with system strain. A 2023 National Nurses United survey documented a steep rise in workplace violence during the pandemic, with nearly half of hospital nurses reporting increased incidents. 11 Hospitals strained by staffing shortages, prolonged wait times, and public frustration saw predictable surges in aggression. 12 This pattern confirms what occupational safety experts have long argued: workplace violence in healthcare is not random. It is a structural consequence of environments that are chronically understaffed, overwhelmed, or poorly supported by behavioral health and security infrastructure. 13 Hospital leaders often frame violence as unavoidable, attributing it to patients with delirium, acute psychiatric distress, or intoxication. But the conditions under which those patients receive care are neither random nor inevitable; they reflect organizational design choices. 14 When behavioral health specialists are scarce, sitter coverage is unreliable, staffing is stretched thin, and security response is inconsistent, escalation becomes predictable. When patients are cared for in healthcare settings where clinicians are physically proximal to patients and work in teams that are adequately staffed, the risk of violence may be lowered. A recent 50-state review by Lombardi and colleagues found that as of June 2024, 48 states had enacted at least one workplace violence (WPV) law, but the overwhelming majority focused on penalizing individual perpetrators, 45 states had penalty laws, while only 27 had enacted prevention legislation and 23 had remediation laws. 15 Just 17 states had enacted all 3 types. The analysis revealed a temporal shift: before 2015, only 11 states had prevention-oriented laws, with most legislation narrowly targeting emergency departments. Since 2020, legislation has broadened to cover diverse healthcare settings, and prevention and remediation approaches have grown, but significant gaps remain. Only one state (Illinois) requires evaluation of its violence prevention programs, and only 11 states mandate centralized data collection, limiting any capacity to assess whether these laws actually reduce violence. This state-by-state patchwork, characterized by an overreliance on after-the-fact penalties and minimal evaluation infrastructure, has not demonstrably reduced workplace violence. The absence of enforceable federal standards is a root cause. Occupational Safety and Health Administration's (OSHA) current voluntary guidance carries no compliance obligation and no penalties for inaction. Congress should mandate that OSHA promulgate an enforceable workplace violence prevention standard for healthcare, requiring covered employers to conduct risk assessments, implement violence prevention plans, train staff, and report incidents, paralleling the structure of OSHA's Bloodborne Pathogens Standard, which transformed needlestick injury prevention after its 1991 enactment. Beyond OSHA, the Centers for Medicare and Medicaid Services (CMS) should integrate workplace violence prevention into its regulatory and payment frameworks. Specifically, CMS could incorporate violence prevention program requirements into hospital Conditions of Participation, establishing a baseline expectation that facilities receiving federal funds maintain safe environments for both patients and workers. Additionally, CMS could incentivize prevention through value-based payment programs, for example, by including the presence and rigor of WPV reporting systems and prevention program infrastructure as quality measures in the Hospital Value-Based Purchasing Program or as factors in the Hospital Star Ratings. At its core, workplace violence is not merely an occupational problem, but also a patient safety problem. A healthcare system that cannot protect its clinicians cannot protect its patients. Frontline workers are not asking for resilience narratives; they are asking for basic professional conditions: the safety and support required to deliver attentive, humane care. Safety is not an ancillary aspect of quality; it is its foundation. For hospital leaders and policymakers, addressing workplace violence can no longer be considered optional. It is a non-negotiable precondition for a functioning, humane, safe, and just healthcare system. Supplementary Material qxag077_Supplementary_Data qxag077_supplementary_data.zip (353.6KB, zip) Contributor Information Kathryn A Connell, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States; Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States. Juliana Gabrielle Byers, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States. K Jane Muir, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, United States. Supplementary material Supplementary material is available at Health Affairs Scholar online. Funding K01NR021419 (National Institute of Nursing Research) PI Kathryn Jane Muir Notes 1. Dunn J. Diminishment by design: the role of class, gender and architecture in shaping the nursing profession. Nurs Philos. 2025;26(4):e70042. 10.1111/nup.70042 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Survey of Occupational Injuries and Illnesses Data . Bureau of Labor Statistics. Accessed February 2, 2026. https://www.bls.gov/iif/nonfatal-injuries-and-illnesses-tables.htm 3. 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