The Spirit of Fear: Nurses and Workplace Violence

Bruised nurse

In a previous blog, Nursing: The Finest of the Fine Arts, I reflected on the insight of Florence Nightingale, the founder of modern nursing, as I explored the nature and practice of the profession. I’d like to turn to Nightingale’s timeless perception again; but this time in relation to the harrowing subject of workplace violence and abuse against nurses.

How very little can be done under the spirit of fear?” she wondered.

Nurses face fear on two fronts. They are confronted with a growing and legitimate fear of workplace violence and abuse. And equally as troubling, many nurses do not report violent incidents due to fear of inaction, retribution, and even termination. Sadly, there is a perception among some administrators that violence is simply part of the job.

Despite this culture of indifference and the potentially paralyzing nature of these competing fears, nurses continue to do their utmost to provide the best patient care possible. However, when nurses do experience violence and abuse, they are not without recourse. In this blog, I examine some of causes of workplace violence against nurses and explain how risk assessments, reporting and other safety measures can create safer working conditions.

Background and Causes

Workplace Violence Defined

Ontario’s Occupational Health and Safety Act, states that workplace violence includes the following conduct and behaviour:

  • Using, or attempting to use, physical force against a worker which causes, or could cause, physical injury to the worker.
  • Making statements or behaving in such a way that could reasonably be interpreted as a threat to use physical force which could cause physical injury to the worker.

The Act also defines workplace harassment as a “course of vexatious conduct or comment.” In many instances of workplace harassment, there is an escalation from abusive language and behaviour to aggression and violence.


According to recent news reports and statistics, between 2008 and 2013, there were more than 4,000 reported incidents of workplace violence against Canadian nurses. To put this number into perspective, it exceeds the number of cases reported by police officers and firefighters combined. The Ontario Nurses’ Association reported that workplace violence increased by 6.4% in 2014, and anticipated that it would continue to rise. This violence and abuse occurs in hospitals, long-term care facilities, during in-home visits, and elsewhere in the community.

Types of Violence and Abuse

While caring for patients and carrying out their professional duties, nurses have suffered the following kinds of serious violent attacks and abuse at the hands of patients, patients’ family members, or visitors:

  • Stabbing;
  • Punching;
  • Kicking;
  • Slapping;
  • Hitting with objects;
  • Strangling;
  • Groping;
  • Spitting;
  • Biting;
  • Bullying;
  • Stalking;
  • Yelling, profanity, and other verbal abuse; and
  • Intimidation and threats.

While the majority of this behaviour comes from patients or their visitors, nurses also experience workplace violence and emotional abuse from doctors, co-workers, and superiors. Not surprisingly, the effects of these incidents vary, and can include minor physical injuries, serious physical harm, temporary and permanent physical disability, psychological and emotional trauma (depression, anxiety, anger, tension, sleep disturbance, and mental fatigue), and death.

Causes of Workplace Violence

Patients who are psychiatric, geriatric, drug/alcohol-affected, or who have a history of violence are the chief perpetrators of violence and abuse. In addition, some studies show that organizational and environmental factors also contribute to the potential for violence against nurses, including:

  • Antiquated and/or inadequate communication systems;
  • Understaffing (particularly, in high-risk areas or during periods of increased activity);
  • Isolated work assignments (a nurse working alone and without support is vulnerable);
  • Poorly managed patient allocation/placement and/or transport;
  • Unrestricted public access to all areas of health care facilities;
  • Insufficient lighting in hallways, rooms, elevators, and parking lots; and
  • Inadequate security.

Violence and abuse in hospitals can also be department-specific. For example, emergency room nurses face a higher risk of personal injury arising from assaults by patients and patients’ visitors because they are on the “front lines” of medical care. Similarly, nurses who work in psychiatric departments and long-term care homes are at a greater risk of physical harm due to the unpredictable and aggressive nature of mentally/cognitively impaired patients.

Safety Recommendations


To address the systemic problem of violence against nurses, a comprehensive and effective violence prevention strategy, which includes training and education, must be implemented. The first step is for administrators to conduct a risk assessment of the entire facility, and develop protocols and procedures to address and control identified risks. The Occupational Health and Safety Act sets out a minimum standard of protocols and procedures which employers must implement and follow.


Nurses, like all workers, are duty-bound by the Occupational Health and Safety Act to report workplace hazards, including violent incidents and threats of violence. It is imperative to make these reports in writing so that administrators comply with the requirements of the Act. Prevention can only occur if potential hazards, physical or otherwise, are documented and employers are held accountable for them.

Regardless of severity, personal injuries arising from workplace violence and abuse must also be reported (immediately following medical treatment). It is critical, from medical, legal and preventative stand-points, to document such incidents so that any future physical or psychological complications can be addressed, administrators can be held accountable, and appropriate policies can be developed.

Safety Controls, Measures, and Protocols

The following safety controls, measures, and protocols, should be undertaken by employers/administrators to protect nurses:

  • Establish effective communication networks which incorporate:
    • Personal alarms equipped with panic/emergency buttons
    • Voice-activated communication devices (radio/cell phone)
    • A flagging system for violent history which features electronic file alerts and visual markers, such as coloured wristbands and signs on a patient’s door
    • Panic stations
  • Address staffing issues (adequate coverage and appropriate support)
  • Ensure appropriate patient allocation/placement through increased diligence and double-checks
  • “Patient-proof” the physical workspace:
    • Install shields or barriers
    • Utilize furniture that is padded and anchor it to the floor wherever possible
    • Organize workstations to minimize physical contact (high counters, wide desks)
  • Increase/enhance lighting in hallways, rooms, elevators, and parking lots
  • Enhance security measures:
    • Restrict access to the facility and departments with electronic passes and/or keys
    • Install video surveillance
    • Implement a visitor sign-in log

Although these types of actions can help to assuage nurses’ competing fears of violence and indifference, the unfortunate reality is that workplace violence and abuse does and will continue to occur. The physical and emotional fallout from such traumatic events can be long-lasting and it is critical that you receive the support that you need and deserve.

Renée Vinett is a partner at Howie, Sacks & Henry, LLP. In addition to being a lawyer, she has been a registered nurse for over 30 years with experience in disability management in both the U.S. and Canada. Renée’s practice is devoted to fighting for the rights of injured accident victims and their families in a wide range of personal injury matters. If you have any problems or questions, feel free to contact her at 416-361-7560 or

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