Early in her career, Rita Manfredi, MD, worked an emergency room shift. Two police officers brought in a female patient needing a psychological evaluation. Manfredi, who was 5 months pregnant at the time, still remembers the patient sitting between the officers, wearing boots and a navy-blue jumper. Manfredi leaned forward to speak to her, and the patient kicked her in the neck as hard as she could. 

Manfredi put her chin down just in time to protect her trachea and larynx. Had she not, they could have been fractured. “I would have been a CPR [cardiopulmonary resuscitation] case,” she said.

Manfredi, now a professor of clinical emergency medicine at the George Washington University School of Medicine and Health Sciences, Washington, DC, remembers walking out of the exam room that night with rubbery knees. On the verge of tears, she called for backup. No one ever debriefed her. No one followed up about the violence she’d experienced.

“When I walked through the door at home that night, my husband was there, and I just started weeping. It was so traumatic for me,” Manfredi said.

While hospitals are meant to heal, for many providers they’ve become places of danger and trauma. Data collected over the past 15 years consistently showed that more than 70% of workplace assaults in the US happen in healthcare settings. Healthcare workers are five times more likely to experience workplace violence than those in other fields.

National Nurses United gathered data in 2023, which showed that 8 in 10 nurses had experienced workplace violence within the previous year. And as of 2024, almost all emergency room physicians said it had happened to them or a colleague.

For many, trauma lingers, leading to anxiety, flashbacks, and ongoing fear at work.

Yet, despite rising rates of violence, institutional protection is absent in healthcare. Most physicians and nurses cope quietly, leaning on each other for support and guidance to fill that void. Recently, Medscape Medical News spoke with providers to learn how they get by and the systems that are needed to keep them safe.

What Workplace Violence Looks Like for Medical Staff

Violence in healthcare can come in many forms, from verbal harassment, name-calling, and expletives to threats, stalking, or physical assault. A 2024 study led by Joanne DeSanto Iennaco, PhD, associate professor of nursing and psychiatry at Yale University, found that on-site healthcare staff faced two to three aggressive incidents per day — about one for every 40 hours worked. Some of Iennaco’s research has suggested that two-thirds of assaults were verbal and one third were physical.

Barbara White, PhD, RN, chief nurse administrator at Indiana University South Bend, said that nurses, in particular, navigate daily verbal assaults. Nurses often must wear “emotional armor” to do their jobs, White explained, judging when to protect themselves and when to let their guards down. “The trick is, how do we stay alert and keep ourselves, our coworkers, our patients, and our families safe while also not walking around expecting hostility all the time?” she asks. “I sometimes let my armor down at the wrong time, and I sometimes leave my armor up at the wrong time. There isn’t a good answer.”

Iennaco, who researches workplace violence, has experienced multiple incidents herself as a nurse, including an episode in which a patient made a graphic and abusive sexual threat early. “It was quite horrible,” she recalled. “While I was always completely safe, it stayed in the back of my mind. At that time, I thought, ‘I’m never going in that person’s room alone.’” 

Sometimes, the mere threat of violence is enough to create worry. Harry Severance, MD, adjunct assistant professor at Duke University School of Medicine, Durham, North Carolina, said three patients had arrived at his clinic open-carrying guns in the past year. “With one, I felt he was subtly implying, ‘If you don’t do what I need, I’ve got this gun on my hip.’”

Iennaco also remembered seeing a psychiatric patient of hers walking near her home multiple times.

Physical violence is a very real threat in medical settings, too. Years after her initial injury, Manfredi experienced another violent episode when an agitated patient threw her against a wall, did the same to a nurse, and tried to choke a physician assistant, tearing apart a stethoscope in the process. “We called security, and they came and stood in the doorway,” Manfredi said. “It was very distressing.”

In 2021, Kelsey Springer, BSN, RN, CCRN, was working in the ICU when a patient punched her in the face, severely damaging her jaw. She required reconstructive surgery and will eventually need a total joint replacement. Unable to chew normally, she says she now follows a restricted diet. “That experience changed a lot of things for me,” she said. “As nurses, we never want to harm a patient, but I didn’t think about my own safety the same way — until it happened to me.”

Springer said she took a few days off work after her assault. When she returned, she quickly had another incident where she was nearly kicked in the face. “I was still in that adrenaline-trauma response,” Springer said. “We’re really good at just facing trauma and then going right back into the thick of it.”

The Invisible Aftermath

Beyond the immediate harm, workplace violence often leaves long-term damage, affecting how healthcare workers think, feel, care for patients, and live their own lives. Manfredi and Springer both said they experience posttraumatic stress disorder.

Manfredi has flashbacks. Sudden noises scare her. She tends to keep her distance from patients now, staying at the door of a room when possible, and there’s always a nagging thought in the back of her mind: Will I get hurt?

“Sixty-eight percent of staff report being moderately to extremely bothered by memories or images of an assault,” said Iennaco of her research. “Ninety-five percent of those who were assaulted experience flashbacks, and nearly 60% avoid talking about it.” 

These emotional consequences don’t just affect individual providers but also impact the healthcare system as a whole.

“Burnout, mental duress, rising suicide rates, and depression in healthcare workers — these are symptoms of bad workplaces,” said Severance. “People keep showing up and trying, but things never get better.”

Attrition is also a growing problem that has been linked to unsafe working conditions. “Workplace violence is a direct threat to maintaining a healthy nursing workforce,” said White, stressing how it fuels burnout and high turnover. Up to half of nurses leave the profession within 3 years.

Springer, now a clinical nurse educator — a nonpatient-facing role — isn’t sure she could ever return to bedside care.

Manfredi said everyone involved in one of her violent incidents has since left emergency medicine.

‘There’s No Help From Leadership’

Many healthcare workers Medscape Medical News spoke with feel unsupported by the institutions meant to protect them. Although the majority of US hospitals and health systems have workplace violence prevention initiatives, according to the American Hospital Association, many in healthcare feel these programs are not methodical or widely effective. 

Two evidence-based approaches have shown promise in reducing workplace violence, said Iennaco. The Six Core Strategies, developed by Kevin Ann Huckshorn, PhD, MSN, RN, mental health clinician and hospital administrator, uses trauma-informed care, staff training, and debriefing to prevent conflict and reduce the use of restraints and seclusion. The Safewards model, developed by Len Bowers, emeritus professor of psychiatric nursing at King’s College London, London, England, also focuses on identifying and defusing “flashpoints” that can trigger aggression. Both emphasize relationship-based care and de-escalation to keep patients and staff safe.

Many healthcare settings also use risk assessment tools, such as the Brøset Violence Checklist or the Dynamic Appraisal of Situational Aggression, to flag individuals at higher risk for aggression. “The goal,” Iennaco explained, “is to develop a plan of care to prevent further escalation.”

Training, she added, is critical. “Every clinician should know how to manage and de-escalate a situation. Some of the better systems are offering de-escalation, prevention, and communication training from day one. That’s a good thing.”

White’s team is also focused on prevention through education. As part of a new grant, they’re training nursing students, faculty, and staff in Mental Health First Aid and Question, Persuade, Refer suicide prevention, sometimes called “CPR for suicide.” 

The goal is to give future nurses practical tools to recognize and respond to mental health crises in themselves, their colleagues, and their patients. “Mental Health First Aid gives people a basic understanding of mental health problems and how to interact with someone who’s struggling,” White said. “We want our students and staff to have tools in their tool belt to manage difficult situations in hospitals — before they escalate.”

Currently, White noted, “Nobody feels like they have all the skills they need to handle these situations,” she said, having never received any formal training herself. White’s 40 years of experience have helped her pass on practical strategies to nursing students, but only now can she begin workplace violence training through her team’s new grant.

Manfredi pointed to physical safeguards, such as clear signage stating that violence won’t be tolerated, panic buttons, metal detectors, and well-trained security teams, as tangible ways to protect staff.

While these strategies are working in some areas, healthcare workers say what’s more common is the absence of a cohesive strategy.

In its place, those Medscape Medical News spoke with described a quiet, informal network of support: colleagues calling or texting one another after incidents, impromptu peer debriefs, social media groups, and workers learning as they go.

“I’ve called peers of mine across the country who’ve been through something similar for support,” said Manfredi. “It’s what I call learned helplessness. There’s no help from leadership.”

What’s Missing? ‘Compassion and Empathy’ 

The Occupational Safety and Health Administration has published guidelines for preventing workplace violence for healthcare and social service workers, outlining a framework and insisting that prevention must be systematic. The guidelines are voluntary.

In fact, there’s no national mandate for what institutions must provide in terms of workplace violence training, a situation that Springer feels leaves healthcare workers “forgotten.” “We have standards for doing CPR training,” she said. “I see this as much the same.”

That gap extends to reporting, too. Iennaco’s research has found that roughly 75% of violent incidents go unreported, leaving administrators without the data needed to understand the problem. “We rely on what I call proxy measures, like when a staff member is injured, security is called, or a patient is restrained,” she said. “But the number of events that actually occur compared to what’s reported is dramatically different.”

“Many colleagues don’t report incidents that weren’t physically violent,” Springer added, “but those matter, too.”

Manfredi would like to see more formalized support after incidents and is helping the American College of Emergency Physicians (ACEP) develop a peer-to-peer program to help clinicians recover. “Structured peer outreach lets clinicians talk openly with someone who understands the work,” she said. “If you can’t do anything else, you can at least do that, and every department can.”

“After an event occurs, there should be a debriefing and support for the individual worker,” Iennaco said. “Each unit has its own culture, and part of quality improvement should involve learning from difficult situations together.”

But support must start at the top. “It’s a moment of deep disappointment and grief to realize that administration might not have our backs,” said Manfredi. “In many places — though not all — leaders don’t go out of their way to provide the support we need. What’s missing is a real commitment to respond with compassion and empathy.”

That accountability extends to policymakers, too. The ACEP supports the Safety from Violence for Health Care Employees Act, which, if passed, would make violence against clinicians a federal crime. More than half of the US states now have laws addressing assault on healthcare workers, many making it a felony. But enforcement and implementation vary widely.

Still, progress can feel out of reach. Severance recalled visiting Congress with the Society of Emergency Physicians and hearing lawmakers suggest that physicians simply needed to “grow thicker skin.”

That attitude, he said, reflects both medicine’s culture of toughness and a broader societal misunderstanding of what healthcare providers should be expected to endure. “The ongoing failure by our stakeholders, political and healthcare leaders, to address these issues could be catastrophic for the future of healthcare delivery,” he said.

Ultimately, experts agree, providers shouldn’t have to rely on self-care and peer support to feel safe at work.

“My personal wellness activities will never be enough if the system doesn’t put in stopgaps for physician well-being,” said Manfredi. “You can be the most well person in the world, but if you go into an unwell workplace, you won’t be well anymore. That’s the problem.”