Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center

Becky Lowry, MD; Leigh M. Eck, MD; Erica E. Howe, MD; JoHanna Peterson, MD; Cheryl A. Gibson, PhD


South Med J. 2019;112(6):310-314. 

In This Article

Abstract and Introduction


Objectives: Healthcare professionals are at higher risk for workplace violence (WPV) than workers in other sectors. This elevated risk exists despite the vast underreporting of WPV in the medical setting. The challenge of responding to this risk is compounded by limited empirical research on medical training environments. Understanding trainees' experience and educating them on workplace safety, WPV reporting, and awareness of resources are shared goals of educational and institutional leadership. In our setting, clear understanding and education were urgent after the enactment of a statewide "constitutional carry" law affording individuals a right to carry concealed firearms in all state-owned universities and hospitals, beginning in July 2017. We sought to examine the incidence of WPV affecting Internal Medicine trainees to understand the types of violence encountered, reporting rates, and the factors that influence reporting.

Methods: We conducted a cross-sectional online survey of Internal Medicine residents and fellows in practice for the previous 12 months. Survey items included both forced choice and open-ended questions. Descriptive statistics were calculated and used to summarize the study variables. χ 2 tests were performed to examine whether sex differences existed for each of the survey questions. Qualitative responses were content analyzed and organized thematically.

Results: Of 186 trainees, 88 completed the survey. Forty-seven percent of respondents experienced WPV, with >90% of cases involving a patient, a patient's family member, or a patient's friend. Verbal assault was the most common type of incident encountered. Trainees formally reported fewer than half of the violent incidents disclosed in the survey. Major factors that influenced reporting included the severity of the incident, condition of the patient, and clarity of the reporting mechanism.

Conclusions: Previous research indicates similar amounts and types of WPV. Likewise, a large percentage of the incidents are not reported. Addressing the key factors related to why physicians underreport can inform institutions on how to make systematic changes to reduce WPV and its negative impact. Future research is needed to examine whether specific interventions can be implemented to improve reporting and reduce the incidence of WPV.


In 2013, the state of Kansas enacted a law requiring public buildings to allow concealed guns if they lacked metal detectors or security personnel. According to this law, all state-owned universities in Kansas, beginning in July 2017, were required to allow individuals to carry a concealed weapon into buildings, which included physicians' offices and patient rooms, regardless of whether they had a permit or training. State-owned hospitals were not excluded from the expectation for allowance of "constitutional carry," resulting in an increased sense of vulnerability and apprehension about the potential for workplace violence (WPV) against healthcare professionals. In the months that preceded the end of the grace period to comply with the concealed gun law, we began to examine our knowledge and understanding of WPV in the hospital setting.

Our research review revealed that violence in the medical setting is a vastly underreported problem.[1–3] Despite the lack of reporting, the US Bureau of Labor Statistics indicates that healthcare employees are at an increased risk for WPV compared with workers in other sectors. According to data from 2002 to 2013, incidents of serious WPV, defined as those requiring days off for the injured worker to recuperate, were 4 times more common in health care than in private industry.[4] Estimates of workplace assaults between 2011 and 2013 were approximately 24,000 annually, with approximately 75% committed in healthcare settings.[5]

A survey of 170 university hospitals in the United States in 1988 revealed that 57% of all emergency department employees had been threatened by weapons.[6] In a more recent study of acute care hospital shooting events in the United States between 2000 and 2011, investigators identified 154 hospital-related shootings, resulting in 235 injured or dead victims.[7] Hospital employees made up 20% of victims, whereas physician (3%) and nurse (5%) victims were less frequent. Approximately one-third of events took place in emergency departments (29%), followed by parking lots (23%) and patient rooms (19%).

Concerning assaults by healthcare specialty, a 2012 systematic review indicated that patient assaults are commonly experienced by residents in training, with rates ranging from 16% to 40% reported among IM trainees.[8] This review, however, identified studies published >15 years ago that examined patient assaults against IM trainees.

Other investigators have found the effects of violence on physicians to result in increased stress and anxiety, minimizing communication and contact with patients, and feelings of hopelessness and disappointment.[9,10] Because of the considerable consequences to physicians' well-being, quality of patient care, and job retention, investigators stress that it should not be assumed that incidents of verbal abuse are not as serious as physical assaults or threats.[11,12]

Although reports indicate that violence is prevalent among healthcare professionals,[13] there is a paucity of empirical research on violence experienced by nonpsychiatric specialties and nonemergency medicine personnel. In addition to the lack of knowledge about the frequency of violent incidents, there are few interventions in place to address them when they do occur. In response, the objective of this study was to assess how often WPV occurs, the types of violence encountered, whether it is reported, and what factors may influence reporting violent incidents.