In order to provide effective care and service to those in need, the safety and well-being of health care workers must be guaranteed. The physical and emotional safety of health care workers is nonnegotiable. Violence directed at nurses and other health care workers cannot be allowed. Verbal and emotional abuse cannot be tolerated. Practices that place both patients and providers at risk, including unsafe staffing levels, are unacceptable. As we begin a new year, it is time to move to action in improving the environments in which health care is delivered to acknowledge and address the needs of nurses, physicians, and all members of the health care team.
Health care providers seek to improve outcomes for the people, families, and communities they serve. Health care has historically been anchored in altruism, illustrated by the Nightingale Pledge in nursing and the Hippocratic Oath in medicine. The original 1893 Nightingale Pledge ends with a promise that the nurse will “devote myself to the welfare of those committed to my care.”1 A 1935 version updated this phrase to state, “as a ‘missioner of health’ I will dedicate myself to devoted service to human welfare.”1 A modern (1964) version of the Hippocratic Oath expresses altruism in this sentence: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”2
As health care providers, we recognize the importance of prioritizing the needs of our patients and families. Although there were many stories of personal sacrifice in delivery of health care during the COVID-19 pandemic, self-sacrifice has been present and idealized since Florence Nightingale was depicted as the Lady with the Lamp. The goal of meeting needs of patients is not in opposition to a healthy work environment for health care providers. Rather, patient care is optimized in health care environments where the safety and well-being of nurses are also optimized.
The relationships of nursing, medicine, and other health professions to the larger society have traditionally been governed by social contracts. The nature of the social contract between society and health care professionals was captured by the 2010 Lancet report on health professional education, which stated, “Beyond the glittering surface of modern technology, the core space of every health system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them. This trust is earned through a special blend of technical competence and service orientation, steered by ethical commitment and social accountability, which forms the essence of professional work.”3(p1925)
“Despite a decade of expressions of concern, violence against nurses has escalated to an all-time high in 2022.”
In return for altruistic, competent, and ethical care, health care professionals earn the trust and respect of the public as well as recognition of their professions. The theoretical underpinnings of nursing’s social contract were explicated by the American Nurses Association in 1980 with the publication of the first social policy statement; several updates have been published as the nursing profession has matured.4 A recent publication, Guide to Nursing’s Social Policy Statement: Understanding the Profession From Social Contract to Social Covenant, describes the evolution of the relationship between nursing and the society we serve.5
However, the mutual understandings embodied in nursing’s social contract appear to be fraying. Nurses, who make up the majority of providers and spend the most time with patients and families, bear the brunt of a recent rise in violence and abuse that undermines the social contract and the ability of nurses to provide care.
Two shocking and disturbing illustrations of the risks that nurses face in the workplace occurred in October 2022. In 2 separate incidents, nurses were murdered at their workplaces while providing care. On October 18, 2022, June Onkundi, a psychiatric/mental health nurse practitioner at an outpatient clinic in Durham, North Carolina, was stabbed to death by a patient.6 Four days later, on October 22, 2022, Jacqueline Ama Pokuaa and Katie Annette Flowers were fatally shot by a visitor on a maternity ward in Dallas, Texas, following his assault of a patient who had just given birth.7,8
Nurses are often the target for violence and abuse. Since 2006, the American Association of Critical-Care Nurses (AACN) has periodically conducted national surveys of the critical care nurse work environment. The most recent AACN study,9 completed in October 2021, showed dramatic declines in all aspects of the health of nurse work environments since the 2018 study. In response to a question about experience with workplace violence and abuse, 72% of the nurses reported that they had experienced at least 1 negative incident in the last year. Verbal abuse was reported by 65%, and 28% had experienced at least 1 episode of physical violence. Perpetrators were most often patients or family members but also included other members of the health care team.
National nursing professional organizations, including AACN10 and the American Nurses Association,11 have recognized the increase in violence directed at nurses and have issued communications addressing this threat to the nursing workforce. Despite a decade of expressions of concern, violence against nurses has escalated to an all-time high in 2022, with data from a 2022 Press Ganey report indicating that an average of 2 assaults on nurses occur every hour.12
This escalation in violence and abuse comes at a time when the nursing profession has faced the most serious challenges in recent history. Both the COVID-19 pandemic and ongoing nursing shortages have had particularly dire effects on critical care. Nurses have been blamed collectively by health systems and individually by patients and families for problems that lie outside of nurses’ control. Shortfalls in staffing are not the fault of the nurse at the bedside—but the bedside nurse becomes the target of dissatisfaction accompanying short staffing. While health system and media portrayals of nursing concerns frequently center on financial compensation, in fact recent nursing work stoppages have had safe staffing levels as their primary demand.
Violence and abuse against nurses intensify the nursing shortage by exacerbating burnout and leading more nurses to report that they intend to leave the profession. Although the pipeline of individuals interested in becoming a nurse remains strong, an exodus of early- and mid-career nurses is underway. Nurses who have continued to work beyond retirement age are also reconsidering that decision. In AACN’s 2021 survey, participants were asked about intent to leave their current position, and 67% responded that they intended to leave within 3 years: 20% expressed intent to leave in the next 6 months, another 16% in 7 to 12 months, and an additional 31% in the next 3 years.9 Furthermore, many nurses are considering leaving the profession entirely, through retirement or change to nonclinical employment. Improving the health care work environment is crucial to both recruitment and retention of nurses.
“Improving the health care work environment is crucial to both recruitment and retention of nurses.”
What can be done? First, physical safety of all health care providers must be ensured in every clinical setting. There must be zero tolerance of violence, abuse, and incivility. Health care systems must address safety as a foundational aspect of the work environment. Second, all clinicians must work together to build a culture of respect and support for every member of the health care team. Third, research is needed regarding violence, abuse, and incivility directed at nurses and other members of the health care team. We need research to understand the magnitude of the problem, effects on patient outcomes and provider well-being, and direct and indirect costs to health systems. We need research to develop, test, and implement interventions designed to prevent, deescalate, and respond to violence in the health care setting.
As we begin a new year, let us resolve that we will work to make health care environments safe for all health care workers. We cannot build healthy work environments without meeting the fundamental need for safety at work for nurses and all members of the health care team. Without this foundational step, we cannot serve our patients or maintain our health care systems. Stop the violence now.
The statements and opinions contained in this editorial are solely those of the coeditors in chief.
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