I tap my badge against the scanner, and the hospital doors open mechanically. As the on-call psychiatry resident, I’ve been asked to evaluate a patient in one of the emergency departments where I work. I approach the designated stretcher and can make out the shape of a person under the blankets.
“Hi there, my name is Dr. Morris. How are you doing tonight?” I ask.
“Hello,” I repeat. “Do you have a moment to chat?”
I wait. Still no response.
“Excuse me,” I lightly tap the railing on the stretcher. Suddenly, the patient swivels over and throws a punch at me. I duck out of the way, and security officers rush over.
Violence from patients is a big problem in U.S. health care. According to the Occupational Safety and Health Administration, health-care and social assistance workers experience violent injuries that require days away from work at four times the rate of workers in the broader private sector. Assaults from patients can be particularly prevalent in high-risk settings, such as psychiatric units and emergency departments. The Bureau of Labor Statistics reports that psychiatric aides and technicians endure workplace violence at a rate 69 times greater than the national average. In a 2018 poll of more than 3,500 emergency physicians, 47 percent reported having been physically assaulted at work and 71 percent said they had witnessed another assault.
After an assault from a patient, health-care workers face a complicated question: Should they press charges?
Across the country, dozens of states have laws that specifically criminalize violence against health professionals. In recent years, states including Alaska, Hawaii, New York and Utah have rolled out harsher penalties for such assaults, including making it easier to prosecute these crimes as felonies, which can incur years of prison time. North Carolina expanded its felony criteria from assaults against “emergency department personnel” to assaults against any “hospital personnel.” In Tennessee, assaulting a health professional carries similar penalties as attacking a law enforcement officer, including thousands of dollars in potential fines.
Legal frameworks for prosecution may be available, but choosing to press criminal charges against patients can be a difficult decision for health professionals.
Criminal prosecution is just one option available to health-care workers affected by violence from patients. Clinicians can take administrative actions after a violent incident, including reporting the event to supervisors or flagging a patient’s chart for past violence. Alternative legal remedies are also available, such as restraining orders, that may carry less punishment for assaultive patients while potentially keeping staff members safe.
In the 2018 survey of emergency physicians, respondents said that hospitals had responded in some way to physical assaults in 70 percent of cases. Among those responses, 21 percent involved arrest and 3 percent involved hospital security pressing charges.
Health-care workers may have different reasons for pursuing criminal charges against violent patients.
Prosecution might teach patients that violent behaviors carry consequences and may deter future assaults. As an example, some patients are repeat offenders, their charts littered with flags noting past instances of behavioral agitation or violence; legal action might be necessary to protect staff members and to demonstrate that violence is not tolerated in health-care settings. It’s important to note that violent patients may assault not only staff members, but also other patients; pressing criminal charges could protect vulnerable patients from such violence, as well.
But it is often unclear whether violent patients deserve to be prosecuted for their behaviors. Should a delirious patient in an intensive care unit undergo criminal prosecution for striking a staff member? Or a patient with psychosis who kicks a doctor who he believes is trying to harm him? Or an elderly patient with dementia who pushes a staff member when trying to escape from the hospital?
Some patients who harm staff members may do so accidentally when disoriented or confused as a result of medical illness. Criminal statutes related to attacking health professionals often include language such as “knowingly and willfully assault” or “intentionally causes physical injury.” Certain types of violence in health care might fall along these lines, especially involving shootings; as an example, a man who allegedly shot through a Bakersfield, Calif., hospital door and then threatened people inside with a rifle in 2017 was charged with 17 felonies.
“It’s not always easy to tell the difference,” said Paul Appelbaum, the Elizabeth K. Dollard professor of psychiatry, medicine and law at Columbia University. “There’s no question that it can be a difficult determination.”
Amid this ambiguity, health-care workers — often the ones who have been victimized — may be left to decide whether to pursue legal action.
Furthermore, health professionals train and work in a culture of caregiving, so the idea of prosecuting patients can be uncomfortable to some. From this perspective, hospitals and clinics are supposed to be places of healing, rather than retribution.
“It is often not easy for hospital staff who see themselves as helpers of their patients to move into a very different role of complainant in a criminal case,” Appelbaum said. “That switch is often accompanied by a great deal of guilt.”
In surveys, health-care employees often say that workplace violence is “part of the job,” and many are not even aware that violent acts can be prosecuted. Some health professionals who have been assaulted and wish to pursue prosecution may encounter resistance from supervisors or public officials. Others may fear retaliation from colleagues or patients for reporting assaults. These factors probably contribute to widespread underreporting of violent incidents in clinical settings.
“If people report and nothing happens, they stop reporting,” said Pam Cipriano, president of the American Nurses Association. “It has to be easy for people to report that they have been injured, and immediate action should be taken.”
Indeed, health-care facilities can help their workers who face such violence on the front lines. Examples include developing hospital protocols to determine when prosecution may be appropriate after violent incidents and, if possible, enabling hospital administrators to pursue legal action on behalf of assaulted staff members.
In 1991, Appelbaum co-wrote a paper about a model hospital policy by Worcester State Hospital in Massachusetts regarding the prosecution of patients; the policy included a statement of ethical principles for determining whether to prosecute patients and a 16-step procedure for pursuing criminal charges.
But these types of policies appear to be the exception. Surveys suggest many health-care facilities either lack clear policies for responding to violent incidents against staff or, if these policies exist, they are not enforced.
Nonetheless, tackling the root of the problem through violence prevention is key. If successful, violence prevention means clinicians do not have to endure these kinds of assaults in the workplace or face tough decisions over whether to press criminal charges against their patients.
“One of the most important things we can do is to encourage our leaders to truly adopt a culture of safety,” Cipriano said. “We’ve got to keep our workplace safe.”
In April, the Joint Commission, an institution that accredits U.S. health-care organizations, released a “sentinel event alert” about workplace violence and called for restructuring to cut down its incidence. These recommendations include training staff members in de-escalation techniques and establishing systems for reporting workplace violence. Other suggestions include identifying environmental changes that might improve workplace safety (such as installing keypad access to doors or metal detectors) and providing support to workers affected by violence.
This last suggestion seems so important. Being assaulted by a patient can be a shattering experience for any health professional. Health-care workers generally are not taught to fear patients, let alone take legal action against them. After these incidents, it is important for health professionals to debrief and to talk about what happened. Whether with colleagues or counseling, assaulted clinicians need to process these experiences. Acknowledging the hardships that come with violence in health care — and helping assaulted staff members navigate subsequent steps — can go a long way.
Back in the emergency department, the security officers and I managed to calm the patient who nearly hit me. But it is not long before my pager goes off again. There is another agitated patient whose behavior is escalating and may need rapid tranquilization. Security has already been called.
I head in that direction.
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.