In April this year, I published an article in the New England Journal of Medicine entitled “Workplace Violence Against Healthcare Workers in the United States” that addressed the universal problem of workplace violence (WPV) perpetrated by patients or family members against medical providers. The article depicts the prevalence of violence in all areas of medicine and highlights studies showing that the emergency department (ED) may be the most violent setting overall.¹ The statistics are alarming: Nationwide, 78 percent of emergency physicians reported being targets of WPV in the previous 12 months.² Outside of law enforcement, such numbers do not exist in any other industry.

Recently, Congress asked the Government Accountability Office to study the effectiveness of the Occupational Safety & Health Administration (OSHA) in its ability to recognize, respond, and correctively manage workplaces that are deficient in worker protection. The report, released this March, recommends that OSHA reevaluate its overall efforts in reducing WPV.³ OSHA does currently provide guidelines to health care employers about how to reduce WPV, but the guidelines are only voluntary.⁴ When deficiencies that put employees at risk are found, OSHA doesn’t have adequate policies in place to ensure that citations against employers can be levied consistently or appropriately, nor does it follow up with formally cited employers to ensure the hazards have actually been addressed.
So what’s an emergency physician to do to keep the ED as safe as possible? The first step is to define exactly what does and does not constitute WPV.

Standard Definition

A consensus definition of WPV has been elusive. The National Institute for Occupational Safety and Health (NIOSH) definition is “violent acts including physical assaults and threats of assaults directed toward persons at work or on duty.”⁵ Many WPV researchers have developed definitions that are more specific and include specific acts such as kicking, squeezing, spitting, throwing objects, etc.

Two problems exist, however: First, there’s no accepted standard definition of assault, physical assault, battery, threat, or harassment among governmental agencies. This makes comparing studies difficult or impossible. Second, the definitions used don’t correlate with the legal classifications of these acts (ie, assault and battery), which seems unnecessarily complicated and certainly confusing. In my opinion, establishing standardized definitions is the logical next step for research and tracking purposes. And since we’re dealing with criminal acts in many cases, we should refer to them using criminal law–based definitions.

Criminal Versus Non-criminal Offenses

Differentiating between intentional and inadvertent violence can be challenging. As specialists trained in both acute and chronic causes of altered mental status (AMS), we can often determine if an action was intentional or not. Studies have shown that providers tend not to report events when they feel that AMS, a medical problem, is a contributing factor to violence. But are we really qualified to judge? If a nurse is beaten by a psychotic patient who later screens positive for PCP, shouldn’t the criminal justice system determine whether the act meets the required elements for battery?