Violence Against Nurses: The Global Evidence, Your Rights and What Actually Works

Ask a room of nurses whether they have ever been hit, kicked, spat at, threatened or verbally abused at work, and almost every hand will go up. Health workers are among the occupations at highest risk of workplace violence worldwide, and nurses, who spend the most time with patients and families, bear the brunt. Yet many nurses still do not report incidents, because they have been told, explicitly or implicitly, that violence is “part of the job”. It is not, and it never should be.

This in-depth guide looks at the global evidence on violence against nurses, why it happens, its effects on nurses and patients, what the law says, how to protect yourself, what to do after an incident, and which workplace measures have been shown to reduce harm.

What counts as workplace violence?

The International Labour Organization (ILO), World Health Organization (WHO), International Council of Nurses (ICN) and Public Services International define workplace violence in the health sector broadly. It includes:

• Physical violence: hitting, kicking, slapping, stabbing, shooting, pushing, biting, pinching, spitting and other physical attacks
• Psychological violence: verbal abuse, threats, bullying, mobbing, harassment and intimidation
• Sexual harassment and assault
• Racial and other discriminatory abuse
• Online abuse and harassment, which has grown since the COVID-19 pandemic

Violence can come from patients, relatives and visitors (external or “type II” violence), from colleagues and managers (lateral or horizontal violence and bullying), or from strangers and criminals entering health facilities. In conflict zones, it includes deliberate attacks on health facilities and health workers.

How common is it?

Estimates vary by country, setting and how violence is defined and measured, but the picture is consistent: violence against health workers is widespread.

• WHO estimates that between 8 and 38 percent of health workers suffer physical violence at some point in their careers, and many more are threatened or verbally abused.
• Large systematic reviews and meta-analyses have found that more than half of nurses report experiencing some form of workplace violence in the previous year, with verbal abuse the most common type.
• In the United States, health care and social assistance workers experience a disproportionately high share of non-fatal workplace violence injuries that require time off work, according to the Bureau of Labor Statistics.
• In the United Kingdom, the NHS Staff Survey consistently finds that around one in seven staff report experiencing physical violence from patients, relatives or the public in the past year, with higher rates among nurses, ambulance staff and staff in mental health settings.
• Studies in countries including China, India, Nigeria, Pakistan, Brazil and Turkey report high rates of violence, with some high-profile attacks on health workers leading to protests and strikes.

Underreporting is a major problem. Many studies suggest that most incidents, especially verbal abuse, are never formally reported.

Where and when violence is most likely

• Emergency departments
• Mental health and psychiatric units
• Older people’s care and dementia units
• Ambulance and pre-hospital care
• Community and home visits, especially lone working
• Waiting areas with long delays
• Night shifts and periods of low staffing
• Times of bad news, such as breaking news of a death
• Settings where alcohol and drug use are common

Why violence happens

Violence is rarely random. Understanding contributing factors helps prevent it.

Patient and visitor factors

• Pain, fear, anxiety and frustration
• Confusion from delirium, dementia, head injury, low blood sugar or hypoxia
• Intoxication or withdrawal from alcohol or drugs
• Some mental health conditions, particularly during acute crises
• Previous history of violence
• Grief and shock

System factors

• Long waiting times and overcrowding
• Understaffing and lack of security
• Poor communication and lack of information for families
• Unclear processes, such as visiting rules or discharge decisions
• Costs of care in systems where patients pay out of pocket
• Poor environmental design, such as isolated rooms, no panic alarms, and furniture that can be thrown
• A culture that tolerates abuse and discourages reporting

Wider social factors

• Declining trust in health systems and misinformation
• Political polarisation, as seen during the COVID-19 pandemic
• Gender: nursing is a female-dominated profession, and gender-based violence and harassment are part of the picture
• Racism: nurses from minority ethnic backgrounds and internationally educated nurses report high levels of racial abuse from patients and the public

The cost of violence

For nurses

• Physical injuries, from bruises to fractures, head injuries and, in rare cases, death
• Anxiety, depression, post-traumatic stress, sleep problems and burnout
• Fear and hypervigilance at work
• Reduced job satisfaction and intention to leave
• Time off work and financial loss

For patients and health systems

• Lower quality and safety of care when staff are frightened, distracted or absent
• Loss of experienced nurses from high-risk specialties
• Higher costs from sick leave, turnover, agency staffing and legal claims
• Difficulty recruiting into emergency, mental health and community roles

What the law says

Laws vary greatly between countries, but trends include:

• Employer duties: in most countries, employers have a legal duty to protect the health and safety of their workers, including assessing and reducing the risk of violence.
• Specific offences: some countries have created specific offences or tougher penalties for assaulting health workers. For example, the UK’s Assaults on Emergency Workers (Offences) Act 2018 increased sentences for assaults on emergency workers, including nurses. Several Indian states have laws protecting medical professionals and institutions, and many US states have made assaulting a nurse a felony.
• Sector regulations: some jurisdictions, such as California, require health facilities to have workplace violence prevention plans. A federal US law requiring such plans has been proposed in Congress several times but, as of late 2026, has not been enacted.
• International standards: the ILO Violence and Harassment Convention, 2019 (No. 190), the first international treaty recognising everyone’s right to a world of work free from violence and harassment, has been ratified by a growing number of countries.
• Conflict settings: international humanitarian law protects health workers and facilities in armed conflict. UN Security Council Resolution 2286 (2016) condemned attacks on health care and called for accountability.

Check what laws and employer policies apply where you work. Your professional association or union can advise.

Protecting yourself: practical strategies

Recognise early warning signs

• Raised voice, swearing, pacing, clenched fists, staring
• Rapid breathing, flushed face, restlessness
• Refusing to communicate or making threats
• Invading personal space
• History of previous violence (check records and handover)

De-escalation techniques

• Stay calm and keep your own voice low and steady
• Keep a safe distance, at least an arm’s length or more
• Position yourself with a clear exit; do not let the person stand between you and the door
• Use open, non-threatening body language; avoid crossing arms or pointing
• Listen actively and acknowledge feelings: “I can see you are really worried about your mother”
• Explain what is happening and give realistic information
• Offer choices where possible
• Avoid arguing, sarcasm or ultimatums
• Know when to stop trying to de-escalate and remove yourself

Practical safety measures

• Know where panic buttons and personal alarms are, and carry one if available
• Know how to call security quickly
• Do not wear items that can be grabbed, such as long necklaces, loose lanyards (use breakaway lanyards) or earrings in high-risk areas
• Tell colleagues where you are, especially when working alone
• For community visits, follow lone working policies: share your schedule, check in and out, and leave if you feel unsafe
• Flag patients with a known history of violence in records, following local policy

Your right to withdraw

In most settings, you have the right to remove yourself from a situation where you are at immediate risk of serious harm. Your safety comes first. Ensure the patient is safe as far as possible, call for help, and inform your manager.

After an incident: what to do

• Get to safety and seek medical attention for any injury, including needlestick or bite injuries, which may need blood tests and preventive treatment
• Report the incident through your organisation’s reporting system, as soon as possible, even if you were not physically hurt
• Report to the police if you were assaulted or seriously threatened; you are entitled to do this, and your employer should support you
• Record details: date, time, location, what happened, witnesses, injuries
• Access support: occupational health, employee assistance programmes, peer support and counselling
• Take time if needed: you may need time off; do not feel pressured to continue a shift after a serious incident
• Talk to your union or professional association if you need advice or feel unsupported

Why reporting matters

Many nurses do not report because they believe nothing will change, fear being blamed, or feel it is not serious enough. But reports create the data that drive change: staffing, security, environmental improvements and policies depend on evidence. Reporting also protects you if you develop longer-term health problems or need to take legal action.

Recovering emotionally

Reactions after violence can include shock, fear, anger, guilt, difficulty sleeping, intrusive memories and avoidance of the place where it happened. These are normal responses to an abnormal event. Most people recover with time and support. If symptoms persist for more than a few weeks or interfere with work and life, seek professional help; trauma-focused therapies are effective. Peer support programmes, where trained colleagues check in after incidents, can be very helpful.

What organisations should do: evidence-based measures

Individual nurses cannot solve workplace violence alone. Responsibility lies primarily with employers and health systems. Approaches with the best evidence combine several measures.

Leadership and culture

• A clear zero-tolerance policy that is backed by action, not just posters
• Senior leaders visibly committed to staff safety
• A culture where reporting is easy, encouraged and followed by feedback
• No blame for staff who are assaulted

Risk assessment and planning

• Regular workplace violence risk assessments for each area
• Written prevention plans involving frontline staff
• Analysis of incident data to identify patterns

Environment and security

• Panic alarms and personal alarms that actually work and are tested
• Rapid response security or trained response teams
• Good lighting, clear sightlines, controlled access and safe rooms
• Comfortable waiting areas with information about waiting times
• CCTV in high-risk areas, used in line with privacy laws
• Securing furniture and objects that could be used as weapons

Staffing and processes

• Safe staffing levels; overcrowding and long waits increase violence
• Avoiding lone working in high-risk situations
• Regular communication with waiting patients and families
• Alerts for patients with a history of violence

Training

• De-escalation and conflict resolution training for all patient-facing staff
• Training in safe restraint and breakaway techniques where relevant, used as a last resort and in line with legal and ethical standards
• Training in recognising delirium, intoxication and mental health crises

Support after incidents

• Immediate check-in and debrief
• Access to occupational health and psychological support
• Support with police reporting and legal processes
• Paid time off where needed

Studies of multi-component programmes in hospitals and mental health services show reductions in violent incidents and injuries when these measures are implemented together and sustained.

Bullying and violence between colleagues

Not all violence comes from patients. Bullying, harassment and incivility from colleagues and managers are also common in nursing and can be deeply harmful. They include belittling, exclusion, unfair workloads, public humiliation and sabotage. Newly qualified nurses, students and internationally educated nurses are often targets. Organisations should have clear anti-bullying policies, confidential reporting routes, and leaders who model respectful behaviour. If you experience bullying, keep a record, seek support, and use your organisation’s grievance or speak-up processes.

Racism and discrimination

Many nurses from minority ethnic backgrounds report racial abuse from patients and relatives, including refusals of care based on race. Employers have a duty to protect staff from racial harassment. Patients do not have a right to refuse care from a nurse because of their race, although clinical and safety considerations may occasionally require adjustments. Staff should be supported to report racist abuse, and incidents should be treated as seriously as physical violence.

Violence against health care in conflict

In armed conflicts, nurses face bombing of hospitals, shooting, abduction and detention. The WHO Surveillance System for Attacks on Health Care has recorded thousands of attacks on health care in recent years in countries including Ukraine, the occupied Palestinian territory, Sudan, Myanmar and the Democratic Republic of the Congo, with many health workers killed. ICN and other bodies have repeatedly called for adherence to international humanitarian law and accountability for attacks.

Violence in specific settings

Emergency departments

Emergency nurses consistently report the highest rates of violence. Crowding, long waits, intoxication, pain and fear create a volatile mix. Measures that help include visible security, clear and frequent updates about waiting times, triage nurses with de-escalation training, separate areas for intoxicated patients, and design features such as protected reception desks and secure entrances. Some departments use “safety huddles” at the start of shifts to identify patients who may become aggressive.

Mental health settings

In mental health units, violence often occurs during acute crises, admission against a person’s will, or when restrictions are imposed. Approaches such as Safewards, a model of interventions designed to reduce conflict and containment on psychiatric wards, have been shown in studies to reduce incidents. Building therapeutic relationships, involving patients in decisions, reducing boredom and restrictive practices, and having enough staff are central. Restraint and seclusion should be used only as a last resort, as they carry risks for both patients and staff.

Dementia care

People living with dementia may hit out when they are frightened, in pain, confused or do not understand what is happening, particularly during personal care. Understanding the person’s history, communicating slowly and simply, approaching from the front, explaining each step, managing pain and avoiding rushing can prevent many incidents. Behaviour is often a form of communication. Staff still deserve protection and support when they are hurt.

Community and home care

Nurses visiting homes work alone, often without immediate backup. Risk assessment before first visits, lone working devices, sharing schedules, visiting in pairs when risks are known, and the right to leave immediately if unsafe are key. Dogs, weapons, intoxicated family members and domestic violence in the home are common hazards.

Maternity and paediatrics

Violence also occurs in maternity units and children’s wards, often from distressed family members. Clear communication, involving families in care and supporting staff during difficult news are important.

Students and newly qualified nurses

Nursing students on placement and newly qualified nurses are particularly vulnerable. They may not know reporting procedures, may feel they have to tolerate abuse to pass placements, and may lack confidence to challenge colleagues. Universities and employers should include violence prevention and reporting in training, and mentors should check in with students after difficult incidents. If you are a student, you have the same right to safety as any member of staff.

Online abuse

Nurses increasingly face abuse online, including harassment after appearing in media, posting about professional issues, or being identified in videos filmed by patients or visitors. During the COVID-19 pandemic, many health workers received threats for promoting vaccination. Keep personal details private, review privacy settings, do not engage with abusers, save evidence, report abuse to platforms and, where threats are made, to the police and your employer. Some employers now have policies to support staff targeted online.

A checklist for nurse managers

• Do all staff know how to call for help and where alarms are?
• Are incidents reviewed, with feedback to the person who reported?
• Is staffing adequate at the times violence is most likely?
• Have staff received de-escalation training in the past year?
• Is there a process to check on staff after every incident?
• Are patients with a history of violence flagged appropriately?
• Do waiting patients and families receive regular updates?
• Do staff feel safe to report abuse from colleagues, including managers?

Answering “no” to any of these questions points to an area where action could make your unit safer.

Frequently asked questions

Is verbal abuse really workplace violence?

Yes. Verbal abuse, threats and harassment are recognised forms of workplace violence and can cause significant harm.

Can I refuse to care for a violent patient?

You can withdraw from immediate danger. Ongoing care should be planned so the patient receives treatment safely, for example with additional staff or security, while protecting staff.

Should I press charges against a patient?

That is your decision. Clinical factors, such as confusion or psychosis, are considered, but you have the right to report assaults to the police.

Will reporting affect my career?

Reporting should never be held against you. If you experience retaliation, seek advice from your union or professional association.

But will anything really change?

Change is possible, and it is happening in places where nurses, unions and leaders have pushed for it: laws have been strengthened, security improved, staffing increased and cultures shifted. But it depends on violence being seen, counted and taken seriously. Every report, every conversation and every refusal to accept abuse as “part of the job” contributes to a safer future for nurses and patients alike.

Related: De-escalation with difficult patients and families · Raising concerns as a nurse

Sources: World Health Organization (preventing violence against health workers; Surveillance System for Attacks on Health Care), International Labour Organization (Convention No. 190), ILO/ICN/WHO/PSI Framework Guidelines for Addressing Workplace Violence in the Health Sector, International Council of Nurses, US Bureau of Labor Statistics, NHS Staff Survey, UN Security Council Resolution 2286.