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Workplace and community violence in American hospitals not only inflicts pain and trauma on healthcare workers. It also drives costs higher for an already stretched hospital system. 

A recent research report from the American Hospital Association found the financial costs and other impacts of workplace and community violence in hospitals totaled nearly $20 billion in 2023. This figure was composed of $3.67 billion that hospitals spent prior to events on prevention and $14.65 billion they spent after events on healthcare, work loss, case management, staffing, and infrastructure repair. The report acknowledges, meanwhile, that some of the most significant costs, including potential damage to public perception and to recruiting capabilities, as well as to provider morale in this time of record burnout, are harder to quantify but just as important.

Clinicians, administrators, and security professionals in hospitals all over the country, in both urban and rural settings, have to contend with workplace violence. Just because a hospital has a bucolic setting doesn’t mean its staff is able to avoid this ever more pervasive issue. And although workplace violence in rural hospitals is less researched than that in city treatment centers (see the “Rural Emergency Department Nurses’ Experiences With Workplace Violence” study published in 2023 in the Online Journal of Rural Nursing and Health Care), it seems that most are facing the exact same challenges on a proportional basis.

The differences instead may be in the resources available at urban vs rural hospitals to apply to both prevention and aftercare, with funding for rural hospitals becoming more and more perilous.

Typical Patterns of Violence

Consulting multiple studies on workplace violence at urban hospitals spells out a pattern that Catrina Bonus, vice president of safety and security at the 11-hospital University of Maryland Medical System (UMMS), spelled out: These encounters typically begin with some sort of verbal challenge, which can escalate to mental or emotional violence against a hospital staff member, which then in turn can progress into physical assault.

Bonus, who came to UMMS after a 27-year career with the US Secret Service, said that all of UMMS’ efforts and trainings are geared toward de-escalating these situations as quickly — and with as much empathy — as possible.

“We completely have compassion and an understanding that we’re giving them bad news and it’s their worst day sometimes, but also, we have an expectation of clear behavior that we expect,” Bonus said.

New employees must take de-escalation training, and refreshers are held throughout the year. The training is tailored by team and applies to more than just clinical staff.

“Those who may not experience workplace violence incidents may get online training; those who experience it more are going to get hands-on, in-person training,” she said.

Giora Netzer, MD, vice president and chief experience officer at UMMS, which had 500 incidents across all its campuses last year — on par with the national average — added that the system’s response model is structured on trauma-informed care, which is at the backbone of the training given to all its 29,000 employees. Bonus said that Netzer has been instrumental in sharing this crisis intervention piece with the security staff.

“It’s a multitiered approach where we’re thinking about it from every point of contact: How do we create connection, how do we create psychological safety, and how do we prevent it from getting any further? That’s first,” Netzer said.

Brock Slabach, MPH, chief operations officer of the National Rural Hospital Association, said that the organization’s members reported that, like at urban hospitals, workplace violence occurs primarily in their emergency departments.

“That’s not surprising, given that hospital emergency rooms have become really the location of last resort for many of society’s social problems,” he said. “We’re seeing a lot of violence due to mental illness that’s not being effectively treated in the community setting, and that gets played out in terms of risk to those who are taking care of these patients,” Slabach said.

Slabach also said that some of the people served by rural hospitals are frustrated by the “lack of access to coverage for treatment for important conditions,” including mental health, which is one of the reasons they show up at the emergency department. “Patients who don’t have insurance are worried about the cost of the care that they’re getting. Sometimes that can create frustrations for patients, being uncertain as to how they’ll pay for care — there’s just a general level of anxiety around those issues,” he said. “Again, because some of these medical conditions can be stored up, the frustration grows as they sit at home not taking care of something, and then it grows into something far more acute that can lead to more serious illness.”

Slabach said rural staff are also trained to interrupt this pattern as early as possible.

“It could start out with verbal abuse, and then it escalates from there if the situation isn’t tended to,” Slabach said. “Hospitals have become very aware of, or more sensitive to, the problem of violence and are interceding much earlier in the cycle than they would have, say, 10 years ago.”

He said part of the training staff members receive is also to recognize when they need backup in more serious instances.

“I also think hospitals have improved the presence of security, providing, again, escalation paths for the staff to begin earlier in the process to intervene in the potential for bad behavior. Training is an important part of recognizing the characteristics, recognizing the behaviors, and not only exercising techniques that can defuse a situation but also being quick to understand when help needs to be applied to correct a problem or to improve the behavior of the patient,” Slabach added.

Leaders of both urban and rural systems agree that underreporting of workplace violence has historically been an issue. Studies indicate that this seems to be especially true of nurses and especially of nurses in the emergency department, as Slabach, Bonus, and Netzer all mentioned that some staffers seem to think these incidents are “just part of the job.” All expressed that hospital personnel are doing their best to erase that idea and encourage reporting. “Unless we have that data, we don’t know what responses we need to apply,” said Bonus.

Prevention and Response

It’s in these areas that the paths of urban and rural hospitals diverge. As previously discussed, UMMS has a multilayered training program wherein the entire staff has trauma-informed skills and is trained on de-escalation strategies. Should those approaches fail, the next level of response at UMMS is a Behavioral Emergency Response Team. These teams are composed of personnel from psychiatry, pastoral care, and someone from security, with the trio banding together to respond to the situation at hand in a collaborative manner.

“The intent is to de-escalate as much as possible and then determine a future care plan and allow for remediation and for that patient or visitor to change their actions and their behavior and just go back to day-to-day support for that patient in care,” Bonus said.

Bonus noted that those remediation-type items could include things like a patient treatment agreement, a sort of contract between the patient and the care staff wherein the hospital agrees to treat the patient as long as the patient adheres to specific standards of behavior, a contract that can be flexed to apply to a family member or other member of the patient’s support team if necessary; visitor restrictions and visitor cooling-off periods; establishing a rule for two staff members to always enter the patient’s room at a time; and similar regulations. Everything is based on very clear, and clearly expressed, expectations, with no judgement.

“The idea here is we talk about the person in context; all of us have a lived experience that’s different, and I think by creating a sensitivity among our teams, I think it helps prevent us from getting to a place where we need to start creating treatment agreements and start having safe spaces,” Netzer said.

However, depending on the severity of the incident, law enforcement and legal remedies can certainly be engaged at UMMS. While the “Rural Emergency Department Nurses’ Experiences With Workplace Violence” study has a very small sample size and a very narrow scope, the anecdotes revealed are suggestive of an outsized reliance on law enforcement in rural hospitals, due to a lack of in-house resources to assist with de-escalation. As Slabach noted, clinicians and staff members at rural hospitals are, however, receiving training.

“One of the issues that has been really problematic, particularly in the pandemic, is that we’ve lost good employees, some of them with many years of experience, who’ve said it’s just not worth it. I didn’t come to work to get beaten up,” he said. “That is something that hospitals take very seriously, and now they understand this to be very acutely a matter of retention. If they’re going to retain good healthcare workers, they’re going to have to make sure to ensure their safety.”

However, he said, if a hospital’s revenue margins shrink, there are increasingly limited resources to pay for more training and more security staff.

“It could continue to put further strain on the finances of the facility,” he said.

According to the rural nurses’ study, “When addressing violent patients in the ED [emergency department], those in urban and suburban facilities had a reliance on in-hospital security, which is not an option in a large number of rural facilities. Instead, nurses in rural facilities reported a heavy reliance on community law enforcement for protection.”