healthcare violence essay

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• J Occup Health
• v.63(1); Jan-Dec 2021

Workplace violence in nursing: A concept analysis

Mahmoud mustafa al‐qadi.

1 University of Connecticut School of Nursing, Storrs CT, USA

To clarify the concept of workplace violence in nursing and propose an operational definition of the concept.

The review method used was Walker and Avant's eight‐step method.

Identification of the key attributes, antecedents, consequences, and empirical referents of the concept resulted in an operational definition of the concept. The proposed operational definition identifies workplace violence experienced by nurses as any act or threat of verbal or physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abusing or injuring the target.

Conclusions

Developing insights into the concept will assist in the design of new research scales that can effectively measure the underlying issues, provide a framework that facilitates nursing interventions, and improve the validity of future studies.

1. INTRODUCTION

Violence against nurses in their workplace is a major global problem that has received increased attention in recent years. 1 Approximately 25% of registered nurses report being physically assaulted by a patient or family member, while over 50% reported exposure to verbal abuse or bullying. 2 Nurses, who are primarily responsible for providing life‐saving care to patients are victimized at a significantly higher rate than other health‐care professionals, 3 and it is estimated that workplace violence causes 17.2% of nurses to leave their job every year. 4

In the United States, workplace violence increased by 23% to become the second most common fatal event in 2016, 5 accounting for 1.7 million nonfatal assaults and 900 workplace homicides each year. 6 In addition, there has been an increase in workplace violence in US hospitals, increasing from 2 events per 100 beds in 2012 to 2.8 events per 100 beds in 2015. 5 In 2016, hospitals and health‐care facilities invested $1.1 billion in security and training to prevent violence and had to spend $429 million on insurance, staffing, and medical care due to workplace violence. 7

The absence of a universal definition for workplace violence within health‐care settings and the ambiguity about what constitutes a violent event currently compromise research on the prevalence and magnitude of this phenomenon. Furthermore, varying definitions and unclear criteria may lead to nurses failing to identify their experience as a form of workplace violence, which prevents it from being reported.

Applying the concept analysis method to better understand the violence to which nursing staff are subjected in the workplace will demystify the factors at play, with the underlying intention of preventing such violence. Using concept analysis to address the theoretical background to such violence will aid the development of an operational definition that increases the validity of the concept. This study aims to elucidate the nature and form of workplace violence experienced by nurses and develop a precise operational definition of the concept in conjunction with a set of criteria that can be used to identify the phenomenon.

2. BACKGROUND AND SIGNIFICANCE

Violence is defined by the World Health Organization in the World Report on Violence and Health as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” 8 This definition emphasizes that a person or group must intend to use force or power against another person or group for an act to be classified as violent.

University of Iowa Injury Prevention Research Center 9 classified workplace violence into four basic types: Type I, Type II, Type III, and Type IV. Type I involves “criminal intent.” In this type of workplace violence, “individuals with criminal intent have no relationship to the business or its employees.” Type II involves a customer, client, or patient. In this type, an “individual has a relationship with the business and becomes violent while receiving services.” Type III involves a “worker‐on‐worker” relationship and includes “employees who attack or threaten another employee.” Type IV involves personal relationships. It includes “individuals who have interpersonal relationships with the intended target but no relationship to the business.” Types II and III are the most common in the health‐care industry.

Verbal abuse is the most common type of abuse directed toward nurses in health‐care settings. It is three times more likely to occur than physical violence. 10 In one study, 82% of nurses reported verbal abuse as being the most common type of abuse, 11 while 63.9% of nurses had been subjected to some form of verbal abuse by patients. 12 Behaviors such as swearing, shouting, or cursing have been identified as the most common form of verbal abuse 13 and have also been reported as the most violent type of verbal aggression. 14 Data collected from 349 nurses indicated that 79.5% had been subjected to verbal violence, while 28.6% had been exposed to physical violence. 15 Physical abuse often co‐exists with verbal abuse, suggesting that the latter might act as a predictor for potential physical abuse. 10 Of these behaviors, “being pushed or hit” has been identified as the most common type of physical abuse, 13 while the use of lethal weapons has been shown to occur mostly during night hours. 16

Many studies indicate that violence against nurses is underreported. 17 Emergency departments have been highlighted as locations where violent incidents are likely to be significantly underreported; the reasons given are: (a) nurses are not satisfied with how their previous violent events were handled as some cases were not treated with appropriate seriousness 15 ; (b) nurses’ belief that violence is part of the job 18 ; (c) nurses are discouraged from reporting such events as even if they do, there are no policies guaranteeing justice 19 ; (d) insufficient time 20 ; (e) nurses' belief that no harm was inflicted on them and they can handle it 21 ; and (f) nurses' ability to defend themselves by changing how they treat that particular patient. 12

Previous studies have reported that nurses consider the absence of assertive legislation, poor management of violent incidents, a lack of resources, such as insufficient equipment, medical errors, and a poor environment to contribute significantly to workplace violence. 22 Also, a lack of proper communication skills, lack of experience, lack of quality care, and shortage of nursing staff can also lead to workplace violence. 15 The shortage of nursing staff is a pertinent issue that has affected the majority of countries. The reviewed literature underlines how health‐care settings have witnessed high turnover rates among nurses. 23

The experience of workplace violence has physical, personal, emotional, professional, and organizational consequences that impact individuals and organizations. We argue that a definition to aid the recognition of workplace violence and the understanding of its attributes, antecedents, and consequences will assist in optimizing recognition and facilitate the formation of strategies to address the problem.

3. CONCEPT ANALYSIS METHOD

This study used Walker and Avant's 24 eight‐step method, which is commonly applied in the nursing context (see Table ​ Table1). 1 ). The concept analysis process helps to validate current nursing understanding, as well as support strategies for nursing interventions. Hence, this approach was utilized to analyze the current understanding of the workplace violence to which nurses are subjected as it offers an interactive process that can facilitate the development of an operational definition of a concept.

Walker and Avant's 24 eight‐step method

4. DATA SOURCES

Walker and Avant 24 suggest that all data sources should be fully utilized to ensure a thorough inventory of the relevant characteristics and variables is compiled. Studies were identified via a search of four key databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, PsycINFO, and Scopus using the following single and/or combined keywords: “nurses”; “nursing”; “nurse”; “violence”; “workplace violence”; “abuse”; and “assault.”

The eligibility of the studies was assessed based on the aims of the concept analysis. The following inclusion criteria were utilized: (a) studies published in peer‐reviewed journals between 2000 and 2020; (b) studies that are relevant to the topic and fit with the content of the analysis; (c) studies that included nurses experience of workplace violence; and (d) studies published in English. Papers were excluded if the study primarily focused on violence against nurses working in mental health settings on the basis that these had different and unique considerations (see Figure  1 ).

PRISMA diagram of search strategy adapted for use from Moher et al 25

Initially, 383 papers were identified. Once duplicates were removed, the titles and abstracts of the papers were reviewed. This resulted in 227 papers, which were reviewed in full against the inclusion criteria, after which a further 193 papers were excluded. Thus, a total of 34 papers met the inclusion criteria and were included in the concept analysis; see Figure  1 for a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram of the process. 25

The results of the concept analysis are presented according to the eight steps of Walker and Avant's 24 method.

5.1. Select a concept

According to Walker and Avant, 24 before a concept is selected its significance should be scrutinized across a variety of settings. The selected concept should reflect the area of interest addressed in the research question. Workplace violence experienced by nurses is the selected concept for this analysis.

5.2. Purpose of the analysis

The aims of the current analysis were to (a) clarify the concept of workplace violence experienced by nurses by defining its essential attributes, antecedents, consequences, and empirical referents; and (b) propose an operational definition of workplace violence.

5.3. Identifying uses of the concept

Under the next step in Walker and Avant's 24 method, the available literature is searched to outline the primary attributes of the concept and identify how it is used. Reviewing the existing studies generates an evidence base in relation to the essential attributes underpinning the concept; hence, it facilitates and validates the outcomes of the analysis.

5.3.1. Literature definitions

Violence in health care has been defined “as any incidents where the staff are abused, threatened, or assaulted in circumstances relating to their work involving an explicit or implicit challenge to their safety, well‐being, or health.” 26 This definition includes “any threatening statement or behavior which gives a worker reasonable cause to believe they are at risk.” 27 It also encompasses a broad range of behaviors 28 from physical assault or direct violence to nonphysical forms of violence such as verbal abuse and sexual harassment. 29 Workplace violence can be defined as any physical assault, threatening behavior, or verbal abuse that occurs in a work setting. 30

The Center for Disease Control and Prevention, 31 World Health Organization, 32 and Occupational Safety and Health Administration 33 define workplace violence as any act occurring in the workplace with the intention to harm someone physically or psychologically including attacks, verbal abuse, and both sexual and racial harassment. 34 Also, workplace violence is defined as, “Incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well‐being, or health.” 31 , 32 , 33

5.4. Defining attributes

The defining attributes are those critical qualities and characteristics that often emerge within a concept. Such attributes differentiate the concept from closely related notions, and elucidate its meaning. The literature review revealed that the three distinguishing qualities of the workplace violence experienced by nursing staff can be classed in distinct categories: (a) working relationship; (b) power and powerlessness; and (c) behavior.

5.4.1. Working relationship

One of the considered attributes is the working relationship, which is one of the contributors to violence against nurses. It involves the relationship between nurses and patients, nurses and the patient's family, physician and nurses, management and nurses, and nurses and other nurses, any of which can trigger violence. 35 Human beings differ in their response to emotions, 36 and dealing with them requires a certain level of discipline.

5.4.2. Power and powerlessness

Power is another defining factor. In any normal working environment, there should be someone superior who guides and directs the normal operations of the day. 37 However, misuse of this power can result in conflicts within the organization. 38 , 39 For example, conflicts tend to arise when multiple people want to wield power or when a superior rule in an unjust manner. Similarly, there may be others within the organization who intend to disempower the one bestowed with power. Such an intention results in organizational politics, which can have serious consequences for workplace performance. 40 Moreover, when members of one gender believe that they should rule over others, this destabilizes the unity within a health facility. In general, unequal power relationships contribute to violence against nurses. 41

5.4.3. Behavior

The final attribute is the behavior of the perpetrator. Behavior is defined as how a person acts or does things, whereby in this context the causative agent of the violence comes from an outside source. It can be in the form of physical or emotional violence. 42

6. CONSTRUCTED CASES

The defining attributes identified within the concept analysis can also be narrowed down through the identification of model, borderline, contrary, illegitimate, and invented cases. 24 The constructed cases facilitate efforts to delineate between the characteristics that represent key attributes and those that do not.

7. MODEL CASE

The model case should be a real example that, ideally, presents all the critical attributes. 24 Sarah went to see Julia, the charge nurse in her unit. Sarah reported that the workload in her assignment was becoming unsafe and unacceptable for practice and quality of care. Julia became defensive saying that Sarah was over‐dramatic and her noncompliance with following policies and procedures in the unit contributed to unsafe practice within the unit. This case is an example containing all the defining attributes of workplace violence: That is, a formal working relationship exists between Sarah and Julia, with Julia in a position of power. Julia's response to verbal abuse and horizontal violence professionally degraded Sarah and is again consistent with workplace violence.

8. BORDERLINE CASE

Borderline cases are those that present some, but not all, of the key attributes associated with the concept. They shed light on ideas related to the main attributes of the concept of interest by providing insights into how often it is misconstrued. 24 John was due for his surgery and was observed continuously pacing throughout the corridor looking very agitated and anxious. Jessica, a nurse, asked him if he was alright. John did not say anything and went back to his room but showed signs of autonomic arousal by continuing pacing throughout the hallway. However, while anxious and agitated, he has not acted abusively toward Jessica (the nurse), and therefore this cannot be considered workplace violence.

9. CONTRARY CASE

A contrary case is one that does not represent the defining attributes of the concept. In addition, it represents attributes that are not features of the concept. 24 A contrary case can give insights into the primary characteristics of the concept by highlighting contrary ideas.

9.1. Antecedents

Walker and Avant 24 describe antecedents as events or incidents that precede the concept's occurrence (see Figure  2 ). These can be defined as the fundamental and underlying factors that initialize violence against nurses. 43 For any form of violence to occur, there must be two parties; one party is the perpetrator, who aims to harm the other party, and the other is the recipient, who is on the receiving end of the act. Other contributors are the internal factors and the external factors.

Antecedents, empirical referents, attributes, and consequences of workplace violence

9.1.1. Two parties (perpetrators and nurses)

Two parties must be present in order for violence to occur, namely the perpetrator and the recipient. In this study, the recipient is the nurse, while the perpetrator could be a family member of the patient, the patient, management, other nurses, or even a physician.

Nurses are more vulnerable to violence as they communicate directly with patients and their families. 44 Sometimes, physicians use violence to achieve power, maintain their prestige, and abuse nurses to force them to perform better in their handling of not only patients but also the physicians themselves. 12

9.1.2. External factors (policies and workplace environment)

Some policies that are imposed within health‐care settings lead to nurses being subject to stress and can even affect patients negatively. For example, in some instances, nurses are expected to work long hours without rest 45 ; however, increasing the working hours impairs the performance of nurses. Similarly, restricting the visitation hours makes patients’ family members experience distress and resentment. They feel alienated and unvalued by the administration. A stressful situation also arises when patients are involved in painful invasive procedures. 46 All these situations can precipitate violence against nurses. Hence, the physical setting is important when it comes to health care, whereby the accessibility of working instruments and a good working atmosphere play a key role. If there is not enough medicine or if staffing levels are low, both nurses and patients may be negatively affected. The working environment can also discourage patients and even staff from being associated with the health facility as they feel that the quality of services is being compromised. Moreover, there is a lack of well‐structured policies, which contributes significantly to the violence experienced by nurses. 23 The result is conflict among different parties.

9.1.3. Internal factors (perpetrator or recipient characteristics)

Anything that causes stress can serve as a contributor to violence against nurses. These factors are not contributed externally but rather emanate from the thinking of individuals. Some of the causes for such behaviors are substance and drug abuse, feelings of powerlessness, frustration, fear, disorder, mental illness, and others. 44 These can affect the minds of individuals, which in turn impairs individual judgments. A perpetrator can become directly violent toward a recipient if he or she falls into one of the identified categories. The above behaviors are associated with perpetrators, who in this context are generally patients or their relatives. 47 On the other hand, the recipients, who are nurses, may display poor communication and a failure to perform, making them more vulnerable to violence. 22 For example, a nurse who fails to accomplish his or her task is prone to verbal violence from a senior nurse.

9.2. Consequences

Walker and Avant 24 refer to consequences as events or incidents which follow the occurrence of workplace violence. These consequences can be psychological, emotional, physical, organizational, or professional.

9.2.1. Emotional and psychological consequences

The emotional and psychological consequences are largely experienced by nurses, whereby psychological violence is the most common type of abuse reported by nurses in health‐care facilities. 48 They include, but are not limited to, stress, lack of sleep, and anger. Emotional and psychological consequences are more prevalent than physical consequences and represent the highest percentage of experienced consequences. Such consequences eventually affect the quality of work performed as a stressed nurse will not deliver as per the expected standards. 49 Violence also evokes feelings of humiliation, which can lead to an increase in absenteeism. 50

9.2.2. Physical consequences

Physical consequences are the result of an assault on nurses from external sources and include broken bones, headaches, wounds, and other injuries that are associated with physical harassment. 35 Nurses in the health‐care setting have reported being subjected to incidents of physical abuse, including the use of weapons, whereby most of the perpetrators of these violent incidents were patients. 3 Physical attacks on nurses within the health‐care setting have been reported to include lethal weapons, and most of these attacks occur between the afternoon and night time. 16 This is due to the fact that the majority of clinics do not accept patients after 4 PM, and the managers and administrators also finish work at that time. This results in a large number of patients visiting hospitals and requiring attention from nurses. 47 Pushing and hitting have been reported to be the most common forms of physical attacks. 13

9.2.3. Organizational consequences

Workplace violence is associated with a high turnover rate, lack of proper communication skills, lack of experience, and lack of quality care, 15 and thus it incurs additional operating costs. 7 It is expensive to replace a nurse as the new staff needs to be trained so that they can become acquainted with the normal operations of the health‐care setting. 51 The organization is thus negatively affected in terms of running costs. Furthermore, it can be difficult for the administration to source new and skilled nurses.

9.2.4. Professional consequences

The professional consequences of workplace violence are related to the delivery of services, manifested through increased sick leave, decreased job satisfaction, a high turnover rate, very low productivity, and an increase in error frequency by staff. 23 A nurse who feels threatened will not be inspired to work better. Instead, their motivation to work will decrease and they may opt to venture into other areas to find safety. 35 In addition, violence by perpetrators disrupts teamwork, thereby reducing the efficiency of service delivery.

9.3. Empirical referents

Empirical referents are categories of actual phenomena that may indicate the occurrence of the concept in its contextual framework and enable one to recognize or measure the defining attributes of the concept. 24 Although empirical referents are not themselves instruments for measuring the concept, they can be employed in the development of new measurement instruments or evaluation of existing ones. Empirical referents can be correlated to the theoretical foundations of the concept and contribute to the content and construct validity of the new measurement tool.

These are symptoms signifying that violence has occurred or might occur at any time and can be combined to form a tool that is used as part of the concept under discussion. Such observable cues are (a) humiliation, (b) verbal abuse, (c) physical abuse, and (d) horizontal violence and bullying. 23

9.3.1. Humiliation

Humiliation is an act aiming to belittle an individual as well as a failure to acknowledge achieved success. It may be presented in the form of words or actions directed at the victim. This mostly happens when a member of staff fails to appreciate the role of another or when someone is the subject of malicious rumors circulated by their colleagues. 13

9.3.2. Verbal abuse

Verbal abuse is also a sign of impending danger. 52 Patients or other staff members can decide to use abusive language against nurses. Family members of a patient can also become perpetrators by subjecting a nurse to verbal abuse.

9.3.3. Physical abuse

Physical abuse refers to the use of physical force, such as wounding a nurse or inflicting other forms of injury. This indicates the presence of violence. As stated earlier, this can come from patients who are angry with the nurse or even from the family members. The worst‐case scenario involves the use of weapons and the throwing of objects. 20

9.3.4. Horizontal violence and bullying

Horizontal violence can be an indicator of violence. This is mostly directed at vulnerable groups within the health‐care setting, 53 for example, when these are sidelined from major activities and are not consulted. Horizontal violence might involve the withholding of resources, exclusion from the organization's activities, and the belittling of nurses.

10. PROPOSED OPERATIONAL DEFINITION

The following is a proposed operational definition of workplace violence generated from the current concept analysis:

Workplace violence is any act or threat of physical violence (beating, slapping, stabbing, shooting, pinching, pushing, smashing, throwing objects, preventing individuals from leaving the room, pulling, spitting, biting or scratching, striking, or kicking; including sexual assault), harassment (unwanted behavior that affects the dignity of an individual), intimidation, or other threatening disruptive behavior that occurs at the worksite with the intention of abusing or injuring the target. It ranges from threats and verbal abuse (swearing, shouting, rumors, threatening behavior, nonserious threats, or sexual intimidation) to physical assaults and even homicide that creates an explicit or implicit risk to the health, well‐being, and safety of an individual, multiple individuals, or property.

11. DISCUSSION AND IMPLICATIONS

It is important to keep the working environment safe, cooperative, and respectful. 47 The relationships experienced among nurses, patients, and family members have a significant impact on cases of violence. 35 , 54 Failure to have a good working environment makes the professionals suffer, which can affect the organization negatively. Physical, emotional, and verbal violence are the most prevalent forms in health‐care settings. 46 Of the three, verbal abuse is the most frequent one and primarily affects the emotional strength of nurses. The consequences of workplace violence are classified as physical, professional, or organizational. Organizational consequences are by far the most detrimental to the running of a health‐care facility 16 because they range from cutting staffing levels to affecting the finances of the organization. They also result in an increased turnover rate and low retention of employees.

Workplace violence against nurses has been likened to other forms of violence like domestic violence and child abuse, although the element of sexual harassment does not feature greatly in workplace violence, 55 unlike in child abuse. Nevertheless, the consequences of the two are similar. Furthermore, the effects felt by the nurse due to humiliation are the same as those elicited by domestic violence, 49 indicating that there is a strong relationship between the two. Some scholars even argue that workplace violence is an extension of domestic violence.

Much has been written on horizontal violence, which refers to nurses exposing other nurses to violence. Power struggles largely contribute to this form of violence. Nurses often use abusive language to insult other nurses with the intention of lowering their morale. 51 Horizontal violence is also applied when there is a need to implement certain strategies. For instance, senior nursing staff impart a lot of pressure on juniors if they want certain standards to be attained, 36 and this trend is often maintained once the achievement has been made.

Workplace violence affects not only nurses but also the entire health‐care system. It may cause stress among the staff, which affects their performance, which in turn results in poor services. This also has an effect on recruitment as it becomes more difficult for the health‐care service provider to attract suitably skilled workers. Furthermore, the effects of workplace violence are sometimes felt directly or indirectly. Nurses who have experienced violence report symptoms related to stress, whereby some experienced trauma while others had difficulty sleeping. In addition, the majority of nurses who report their violent incidents are not satisfied with the way these are handled by their employers, with some of these cases not being treated with appropriate seriousness, meaning the nurses' claims are often swept under the carpet in favor of the patients and their families. 15 Identifying the factors that contribute to violence is necessary for policymakers as well as health‐care center administrators as this would help them develop strategies to address this phenomenon. To do so, they would also need to be aware of the concerns of the staff, who are in the firing line and thus subject to the consequences of workplace violence.

Violence against nurses can be reduced by addressing the factors contributing to the occurrence of this violence. For instance, researchers suggest that when there are enough staff and adequate training programs, abuse and violence can be greatly reduced by adding facilities like beds and other medical equipment, encouraging teamwork, and assigning work fairly. 15 They also recommend controlling the access of the public and limiting visitation hours, which would stabilize the situation in the hospitals and thereby ensure the safety of nurses. Implementing certain policies and legislation would also minimize workplace violence. For example, some of the studies reviewed here showed that withholding information from the family of a patient can trigger violence. 10 , 12 , 13 , 16 , 23

Some of the studies considered in this paper argue that the absence of legislation is one of the major contributing factors in violence against nurses. Most of the nurses who were asked why they did not come forward when abused reported that they are aware that nothing would be done. In other words, the absence of policies means the absence of justice. The weakness in this argument, however, is that there is no clear reason for the lack of policies on the abuse of nurses in health‐care settings. Hence, more research is necessary to determine why such policies are not being implemented. Enforcing security measures has also been suggested as one of the solutions to curb violence against nurses. 48

The proposed operational definition can be used in nursing research addressing the concept of workplace violence. The outcomes of this concept analysis could facilitate future research by providing insights that prompt new research avenues. Researchers need to conduct mixed‐method, qualitative studies to discern relationships between the concept and real‐life events as a means of better understanding the relationships between the key attributes in various nursing specialties which experience violence in the workplace.

One of the limitations of Walker and Avant's 24 concept analysis method is that it does not recommend a specific strategy to identify multiple uses of a given concept. The breadth of the articles studied in the literature review increased the rigor of the current analysis and was an attempt to overcome this limitation by enabling consideration of numerous examples of the concept. A further limitation associated with the concept analysis carried out for this study was that the cases presented were artificially constructed, which may limit their application in a real‐world setting. However, this concept analysis had many strengths. At the time this paper was written, the concept analysis presented herein was, to the best of the author's knowledge, the first of its type to use Walker and Avant's 24 method to assess workplace violence in the nursing setting.

“Nursing personnel play the vital role by together with other workers in the field of health, in the protection and improvement of the health and welfare of the population, and emphasize the need to expand health services through co‐operation between governments and employers' and workers' organizations concerned in order to ensure the provision of nursing services appropriate to the needs of the community, and recognizing that the public sector as an employer of nursing personnel should play a particularly active role in the improvement of conditions of employment and work of nursing personnel and noting that the present situation of nursing personnel in many countries, in which there is a shortage of qualified persons and existing staff are not always utilized to best effect, is an obstacle to the development of effective health services, and recalling that nursing personnel are covered by many international labor Conventions and Recommendations laying down general standards concerning employment and conditions of work, such as instruments on discrimination, on freedom of association and the right to bargain collectively, on voluntary conciliation and arbitration, on hours of work, holidays with pay and paid educational leave, on social security and welfare facilities, and on maternity protection and the protection of workers' health, and considering that the special conditions in which nursing is carried out make it desirable to supplement the above‐mentioned general standards by standards specific to nursing personnel, designed to enable them to enjoy a status corresponding to their role in the field of health and acceptable to them.” 56

Finally, social learning theory 57 is a theoretical framework that suggests that new behaviors are learned from other people. The theory is based on the hypothesis that people learn new behaviors through imitation and observation. 58 It is applied in understanding social behavior and learning processes. The social learning theory can also be used to understand health behaviors among individuals or members of a group. 59

Social learning theory indicates that responses to social stimuli or situations are motivated by prior experience. 60 Thus, nurses who appreciate social learning theory are likely to engage actively in collaborative learning and teamwork, which develop values such as participative decision‐making, communication, and cooperation in promoting the interests of patients. 61 According to the social learning theory, learning occurs best within social environments. 57

12. CONCLUSION

Workplace violence can take multiple guises and can be defined in a myriad of ways. In light of this, the objective of this paper was to delineate a clear definition of workplace violence that is derived from its prevailing characteristics. Acts of workplace violence can take various forms, including verbal and physical abuse, bullying, harassment, exclusion, and intimidation, and can be targeted at and perpetrated by a range of individuals, including patients, colleagues, patients’ family and friends, and management. Regardless of the form it takes, workplace violence can have far‐reaching emotional, professional, physical, and psychological consequences. The extant studies highlight the extent to which workplace violence remains an issue for members of the nursing workforce. However, addressing this issue will require a collaborative effort that involves a range of stakeholders, including administrators, nurses, leaders, educators, and other practitioners at both the community and national levels. The failure to address the prevalence of workplace violence in health‐care settings will have major ethical, legal, and moral implications for the industry and will ultimately undermine the quality of care provided.

The outcomes of this analysis provide the conceptual basis and standardized language required to develop and implement effective interventions in workplace violence as well as valuable insights that can guide future studies. As the main goal of the concept analysis was to develop an operational definition, the next step involves developing study instruments that accurately reflect the primary attributes of the concept. This will add to the validity of future studies.

Approval of the research protocol : N/A. Informed Consent : N/A. Registry and the Registration No. of the study/trial : N/A. Animal studies : N/A. Conflict of Interest : N/A.

ACKNOWLEDGMENTS

Al‐Qadi MM. Workplace violence in nursing: A concept analysis . J Occup Health . 2021; 63 :e12226. 10.1002/1348-9585.12226 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Violence Against Healthcare: A Public Health Issue beyond Conflict Settings

Affiliations.

• 1 Medical Epidemiologist, Independent Consultant, Geneva, Switzerland.
• 2 Microbiology Department, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, United Kingdom.
• 3 University of Sassari, Sassari, Italy.
• 4 University Health Agency Giuliano-Isontina (ASUGI), Public Health Department, Trieste, Italy.
• 5 University of Trieste, Department of Medical, Surgical & Health Sciences, Trieste, Italy.
• 6 College of Engineering and Technology, American University of the Middle East, Kuwait.
• PMID: 34814110
• PMCID: PMC8733548
• DOI: 10.4269/ajtmh.21-0979

A 3-year analysis released in August 2021 by the WHO indicated that more than 700 healthcare workers and patients have died (2,000 injured) as a result of attacks against health facilities since 2017. The COVID-19 pandemic has made the risks even worse for doctors, nurses, and support staff, unfortunately. According to the latest figures from the International Committee of the Red Cross, 848 COVID-19-related violent incidents were recorded in 2020, and this is likely an underrepresentation of a much more widespread phenomenon. In response to rises in COVID-19-related attacks against healthcare, some countries have taken action. In Algeria, for instance, the penal code was amended to increase protection for healthcare workers against attacks and to punish individuals who damage health facilities. In the United Kingdom, the police, crime, sentencing, and courts bill proposed increased the maximum penalty from 12 months to 2 years in prison for anyone who assaults an emergency worker. Measures taken by countries represent a good practical way to counteract this crisis within COVID-19. However, we stress the importance of primary prevention with the use of communication: social media and other communication channels are fundamentally important to combat violence against health professionals, both to inform the population with quality data and to disseminate campaigns to prevent these acts.

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• Trends and Characteristics of Security Incidents Involving Aid Workers in Health Care Settings: A 20-Year Review. Morokuma N, Chiu CH. Morokuma N, et al. Prehosp Disaster Med. 2019 Jun;34(3):265-273. doi: 10.1017/S1049023X19004333. Prehosp Disaster Med. 2019. PMID: 31204639
• Worldwide Trends in COVID-19-Related Attacks Against Healthcare: A Review of the Safeguarding Health in Conflict Coalition Database. Duffhues WAC, Barten DG, Cauwer H, Mortelmans L, van Osch F, Tin D, Koopmans MPG, Ciottone G. Duffhues WAC, et al. Health Secur. 2024 Aug;22(4):294-303. doi: 10.1089/hs.2023.0114. Epub 2024 May 7. Health Secur. 2024. PMID: 38717838
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• Open access
• Published: 11 June 2018

“Violence” in medicine: necessary and unnecessary, intentional and unintentional

• Johanna Shapiro   ORCID: orcid.org/0000-0002-8736-8427 1  

Philosophy, Ethics, and Humanities in Medicine volume  13 , Article number:  7 ( 2018 ) Cite this article

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We are more used to thinking of medicine in relation to the ways that it alleviates the effects of violence. Yet an important thread in the academic literature acknowledges that medicine can also be responsible for perpetuating violence, albeit unintentionally, against the very individuals it intends to help. In this essay, I discuss definitions of violence, emphasizing the importance of understanding the term not only as a physical perpetration but as an act of power of one person over another. I next explore the paradox of a healing profession that is permeated with violence sometimes necessary, often unintentional, and almost always unrecognized. Identifying the construct of “physician arrogance” as contributory to violence, I go on to identify different manifestations of violence in a medical context, including violence to the body; structural violence; metaphoric violence; and the practice of speaking to or about patients (and others in the healthcare system in ways that minimize or disrespect their full humanity. I further suggest possible explanations for the origins of these kinds of violence in physicians, including the fear of suffering and death in relation to vicarious trauma and the consequent concept of “killing suffering”; as well as why patients might be willing to accept such violence directed toward them. I conclude with brief recommendations for attending to root causes of violence, both within societal and institutional structures, and within ourselves, offering the model of the wounded healer.

What constitutes violence? The World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.” [ 1 ]. This definition is broader than that of the Oxford English Dictionary (“Behaviour involving physical force intended to hurt, damage, or kill someone or something”)., Its advantage is that by including the phrase use of… “power” it acknowledges that violence can be not only a physical act but an act of power of one person over another. The definition goes on to state that “intentionality” refers to the intent to employ physical force or exert power, but does not speak to motive, which may even, according to the perception of the perpetrator, be regarded as benevolent. Thus, WHO argues that while the action exercised (whether involving force or more generally “power”) must be consciously chosen, regardless of intent, anything that is injurious to another is an act of violence. In this case harm is not necessarily the intention, but the byproduct of action. Thus violence can occur without conscious intent and is not necessarily confined to physical harm.

We can find several examples in the literature of this kind of violence absent a conscious intention to harm. The nursing literature examines the concept of vertical violence, defined as “any act of violence, such as yelling, snide comments, withholding pertinent information, and rude, ignoring, and humiliating behaviors, which occur between two or more persons on different levels of the hierarchical system….” [ 2 ]. For decades, this same literature has also highlighted the problem of horizontal or lateral violence [ 3 ] in which “nurses covertly or overtly direct their dissatisfaction inward toward each other, toward themselves, and toward those less powerful than themselves.” [ 4 ].

Importantly, in both vertical and horizontal violence, such behaviors are not necessarily viewed punitively by their perpetrators, but rather as a rite of passage that builds “resilience” in young nurses [ 5 ]. In other cases, “the perpetrator of violence may be unaware that his/her actions are perceived adversely.” [ 2 ]. While lateral violence is usually attributed to the oppressed status of a particular group (such as nurses in the historically hierarchical structure of the healthcare system), it has also been argued that such violence is in part the result of the nursing profession’s preponderance of “walking wounded,” [ 6 ] individuals who have suffered secondary trauma as a result of their highly stressful work [ 7 ]. Increasingly, we have come to realize that, despite their privileged status in the healthcare hierarchy, physicians also suffer from secondary trauma and resultant burn-out, [ 8 , 9 ], making them vulnerable to committing acts of vertical (medical student) or horizontal (collegial) violence, regardless of how unintended.

A related concept, again using the term “violence” and again stressing its unintended nature, is organizational violence. In this case, researchers have discovered that bureaucracy, including that of healthcare institutions, can have unintended negative consequences that are morally problematic. Organizational violence derives from Bourdieu’s theorizing of symbolic violence, defined as “…the kind of gentle, invisible, pervasive violence that is exercised through cognition and misrecognition, knowledge and sentiment, often with the unwitting consent or complicity of the dominated…. [and] embedded in the very modes of action and structures of cognition of individuals.” [ 10 ]. This definition, notable for the apparently paradoxical pairing of “gentle” and “violence,” emphasizes the role of such “violent” acts as a tool of social control.

More recently, the term symbolic violence has been refined to refer to the misuse or abuse of symbolic power, i.e., power that is used to dominate rather than emancipate. This parsing of symbolic violence stresses that the exercise of power in clinical situations is not in and of itself wrong, harmful, or “violent.” “The structural and symbolic power wielded by doctors is legitimate, socially conferred and indispensable for help and healing to occur.” [ 11 ]. Thus, organizational violence is a special case of the exercise of symbolic power in which “rather than being responsive to patients, professionals are increasingly required to respond to the imperatives of the evaluative bureaucracy.” [ 12 ].

Other uses of the term violence have been linked to gentrification [ 13 ], cultural appropriation [ 14 ], and various forms of speech [ 15 ]. It is possible to worry that casting such a wide net to identify forms of violence runs the risk of the word becoming irrelevant [ 16 ]. While legal definitions of terminology must be narrow and precise, in larger discourse there may be important purposes to expanding definitional terms. One reason for calling unintended harms a kind of “violence” is to overcome the relative ease with which such events are ignored, dismissed, or trivialized [ 16 ]. Employing the word “violence” is a conscious way of highlighting a continuum of violence that we would prefer to ignore. Certain harms not traditionally labeled as violence may produce similarly devastating effects as acts of physical violence. Given the implications of social control implicit in the theories of Boudrieu and others, it is reasonable to argue that calling attention to these issues in a bold way is justified as a reminder that significant harm to others, especially vulnerable others, can occur in many forms.

In the light of the above discussion, it can be illuminating to examine various forms of violence in medicine and speculate about the functions such violence serve.

Acts of violence in medicine

It is a great irony that medicine, the epitome of a healing profession, is often filled with forms of violence, sometimes necessary, sometimes unintentional, almost always unrecognized or minimized. In these instances, the patient becomes a kind of victim, treated differently and damagingly by a physician who (usually unwittingly) has set aside the patient’s humanity. In one formulation, “Medical violence is a curious product of the physician’s arrogance, trappings of technique, and the laity’s faith that medicine can solve all problems” [ 17 ]. This early article acknowledges the sometimes dysfunctional dynamic at play between doctors and patients that can produce violent exchange. To more deeply understand violence in medicine, we must seek the roots of “physician arrogance;” why physicians utilize their “techniques” in certain ways; how the public can inadvertently collude with these processes out of its own largely unrecognized emotional and psychological needs; and how social and cultural capital inequalities make it difficult for patients to protest violent treatment.

Although little scholarly writing has been devoted to this topic, there are multiple examples of violence in medicine. From the dismembering of the human body that occurs in the first year of medical school during the anatomy course, to amputations, surgeries, and diagnostic or interventional procedures that cause pain, including the numerous uncomfortable and sometimes dangerous side effects of drugs intended to heal, there is a brutal dimension to medicine. Medicine often inflicts pain to avoid even greater pain or death; sometimes it succeeds in this goal and sometimes it does not. It could be argued that keeping people technically alive while prolonging a meaningless existence is in itself a type of violence. Most of these instances are clearly not designed to impose violence; indeed the intention is usually beneficent. Sometimes the violent act is necessary for the wellbeing of the patient; nevertheless, sometimes the violent act is unnecessary, and sometimes it results in harm.

Some of the more obvious examples of violence in medicine are violence to the body, represented in procedures and interventions that produce pain and sometimes long-lasting harm; structural violence, encompassing the systemic forces that especially disadvantage vulnerable and marginalized patients; metaphoric violence, the use of warlike, militaristic language in explaining disease and treatment; and the habit of speaking to or about patients (and others in the healthcare system, including medical students, nurses, and colleagues) in ways that minimize or disrespect their full humanity.

Violence to the body

“Aegrescit medendo,” wrote Virgil. “The remedy is worse than the disease” [ 18 ]. Many patients have experienced this feeling as they endure assessment procedures and therapeutic interventions that produce transitory or chronic pain or dangerous, even life threatening side effects. Physicians obviously do not take pleasure in causing this pain. But because they must, their brains actually change in the way they regard suffering. Studies conclude that the brains of physicians react to viewing pain in others much less strongly than the brains of laypersons [ 19 ]. While this is in some way an adaptive response so that physicians are able to function effectively in the face of another’s suffering, it may also lead to a general tendency to dismiss, ignore, or trivialize patients’ negative experiences. This in turn may result in language and interactions that are insensitive at best, and confrontational, harsh, and intimidating at worst.

The cognitive dissonance that results from physicians simultaneously knowing that they are practitioners of a healing profession, yet must often impose considerable pain on their patients, can result in defensive coping strategies that minimize, sanitize, or fail to acknowledge the suffering that results, of course to their patients, but also to themselves. Consider the pediatrician who reassures her little patient, “The injection is only a pinch,” only to be met with disbelieving howls. More seriously, the oncologist who encourages a patient into yet another round of chemotherapy in the absence of therapeutic response may be doing more harm than good. The consequence is a fundamental dishonesty that can contribute to patient mistrust and despair; [ 20 , 21 ] and to physician burn-out and cynicism [ 22 ].

It is worth asking whether intervention is always appropriate. Just because we can, should we? Is Virgil sometimes right? Over-diagnosis and overtreatment are growing concerns in medical practice [ 23 ]. If intervention is judged to be both necessary and beneficial, then should we look for a more honest balance in physician disclosures between unduly alarming the patient and preparing the patient for suffering? These issues obviously come into play in end of life scenarios, and present a telling example of how physicians’ conscious intention not to do harm by destroying hope can instead impose unintended violence on the patient [ 24 ].

• Structural violence

Structural violence refers to social structures that impede individuals, groups and societies from reaching their full potential [ 25 ]. In medicine, it means institutions and established societal modes of functioning that lead to impairment and limitations in human life [ 26 ]. Their existence is so normalized and established that they are almost invisible and therefore either willfully or naively overlooked or ignored [ 27 ]. Structural violence is based on the idea that certain societal patterns (of social relations and roles, economic arrangements, institutional practices, laws etc.) are so firmly entrenched that they are perceived as a “given,” just the way things are. Sources of suffering are deeply embedded in these ordinary, taken-for-granted patterns, including ill health and the inability to adequately access remedies.

The concept of structural violence encourages us to recognize that dimensions of life we might regard as disconnected are actually interrelated. The existence of structural violence makes it easier for privileged physicians to see themselves as distinct and separate from their patients, rather than implicated in the institutions they serve and the jobs they benefit from. When illness is perceived through an exclusively biomedical, molecular lens, it is unlikely physicians will emphasize the social determinants of illness [ 24 ]. These limits in perspective often result in physicians seeing under-resourced patients as responsible for their own problems, not “caring” about their health, or not choosing health as their highest priority. Structural violence results in harm to patients both directly, through disadvantaging them in terms of health and access to healthcare; and indirectly, by allowing physicians to adopt simplistic patient-blaming attitudes that ignore the larger structural issues.

Violence in language

We also find examples of linguistic violence in medicine, which take two forms: violent metaphors and punishing, bullying language.

Violent metaphors

Metaphors are commonly employed by physicians in clinical care [ 28 ] and research suggests patients like physicians who use metaphor better than those who do not. So it is important to ask, how do metaphors in medicine and violence intersect? A recent issue of the American Journal of Bioethics [ 29 ] was devoted to a discussion of the prevalence of military, warlike metaphors in medicine, and what this might mean for the practice of medicine. For example, in the metaphor “illness is war,” illness is what linguists refer to as the target conceptual domain and war is the source conceptual domain [ 30 ]. This means that insights about illness will come from what we know about war, thus fundamentally influencing our understanding of illness in a violent, combative direction. Similarly, as Fuks [ 31 ] points out, military metaphors may give undue emphasis to physical, biological aspects while ignoring psychological, spiritual, social dimensions of illness and healing. This imbalance may have the effect of silencing patients’ voices about subjective experiences of illness [ 32 ]. It has been argued that the reliance on war metaphors in medicine in medicine may contribute to patient anxiety and fear [ 33 ] as well as over-diagnosis and overtreatment [ 34 ].

Violent metaphors in cancer have been criticized because they imply that succumbing to the illness is a defeat and a failure [ 35 , 36 ]. Patients who view disease as an “enemy” have higher levels of depression and anxiety; patients encouraged to “fight” may feel they have to suppress their emotional distress and maintain a positive attitude to avoid upsetting family members and physicians [ 37 ]. A corpus analysis of physician writing and speech identifies the most prevalent violence metaphor as one of fighting and protecting [ 38 ]. Such metaphors put the physician in a heroic light, while the patient is reduced to a foot soldier, or worse, a battleground. More complex analyses, however, highlighting agency, point to the conclusion that physicians often employ violent metaphors as an acknowledgment of “institutional barriers to good care and …how current systems and practices do not always benefit patients” [ 39 ].

Bleakley et al. [ 40 ] offer some alternative metaphors, seeking to shift the way physicians think, the way they speak, and the way they behave by urging language of collaboration, exploration, and journey. These authors argue that collaboration metaphors may beneficially affect clinical practice by “turning attention away from an disembodied agent of illness that must be eradicated to an embodied person in need of care.” Nie et al. [ 32 ] also contribute the metaphor of a journey as one that emphasizes humanizing and personal growth dimensions of healing, while placing the patient rather than the physician at the center of the narrative.

Some scholars have made a case for the value of militaristic metaphors, observing that they can empower patients; [ 41 ] and might have special utility in emergent situations [ 42 ]. Perrault and O’Keefe [ 43 ] advocate for plural or mixed metaphors tailored to the needs of particular patients. These authors argue that metaphors are not inherently good or bad, but must be judged in the context of the particular patient and situation [ 44 ].

Demeaning interactions

Demeaning interactions with patients or disparaging comments about patients to learners, colleagues, or other health professionals fit the WHO definition of “use of power” resulting in psychological harm and deprivation of dignity, respect, and humanity. Familiar examples of such linguistic rationalizations include: “Patient is noncompliant,” “Patient does not appear to care about her health.” “Patient is demanding, uncooperative, hostile etc.” Other language may be considered violent, angry, confrontational, or bullying: [ 40 ] “Patient failed the chemotherapeutic regimen.” “Patient is a poor historian.”

Bleakley et al. [ 40 ] emphasize the link between metaphor and performance. When our thought patterns and verbalizations are grounded in combative, warlike metaphors, it is more likely that these will influence our interactions and behavior. These linguistic forms of discourse may result in patients feeling blamed for their lack of success in regaining health or intimidated by the physician [ 45 ]. This is a permutation of violence that demeans and belittles the other. Other targets of such bullying or intimidating interactions are medical students, [ 46 ] nurses, staff, and even colleagues [ 47 ].

Origins of violence in medicine

In this section, I try to look beneath the surface of the decision-making, actions, language, and even structures in medicine that can be conceptualized as violent or as having violent implications for patients, or certain categories of patients. These thoughts are not meant to replace sophisticated and complex analyses of structural violence or linguistic usage rooted in webs of economic and societal privilege; rather they are intended merely to add a further dimension for consideration and investigation. While I consider physicians and patients separately, my ultimate contention is that both groups share a common underlying fear of suffering and death related to the trauma of serious medical illness. This existential fear may predispose physicians to violent actions and patients to tolerance of such actions.

The role of vicarious trauma

Vicarious traumatization is a term that describes the undesirable outcomes of working directly with traumatized populations, including negative interactions with patients and colleagues, and deleterious personal consequences [ 48 , 49 ]. Although the literature tends to refer to specific types of traumatized patients, such as victims of physical/sexual abuse or natural/human-caused disasters, I maintain that simply by their very nature, suffering, pain, and dying can be traumatic events for many patients, regardless of the specific context in which they occur. By extension, healthcare itself, especially when provided by overworked, pressured, stressed care-givers, may produce vicarious trauma. Such secondary traumatic stress results in failures of empathy [ 50 ] which ultimately prepare the way for the above forms of medically-related violence.

Although physicians are professionally intimate with suffering and death, this does not mean that they necessarily become able to compassionately witness suffering or have resolved the fundamental dilemma in medicine that death will always be the final outcome for every patient. Indeed, some scholars have asserted that physicians enter medicine because of a particular fear of death [ 51 ]. Thus a deep-seated psychological cause of violence in medicine paradoxically may be inextricably tangled with the original raison d’etre for medicine – i.e., the alleviation of suffering and the resistance to death. The fear of suffering and death, as well as repeated exposure to the inevitability of these phenomena and the limits of medicine to forestall them, may lead some physicians to attitudes of defense and denial. The result is often callousness or even brutality, motivated by a need to “kill” or vanquish suffering, but which can all too easily become confused with the patient who is enduring (and thus confronting the physician with) said suffering.

To “kill” suffering, it is understandable that one might have to think of oneself as fundamentally different and separate from ordinary and vulnerable patients. By keeping a firm boundary between the roles of physician and patient, the physician may unconsciously attempt to insulate him or herself from the trauma of suffering and death. This may have to do with a deep fear of contamination [ 52 ] by the very person the physician is consciously trying to aid. Keeping the “other” carefully demarcated, even while attempting to assist them, can confer a sense of safety for the physician; but can also produce an objectification and diminution of the humanity of the patient. This understandable desire to avoid suffering may also be relevant in physicians’ resistance to structural interpretations of health and illness. As has been noted, structural violence injures some, but protects and benefits others. Acknowledging that one is implicated in the suffering of others is a painful realization. To safeguard themselves, many physicians might prefer to avoid it.

Aggressive action in medicine is aimed at “killing” suffering and vanquishing death. Violent metaphors support waging this battle. Bullying language pushes away the weak, undoctor-like patient who has succumbed to disease and vulnerability, Structural violence reinforces and protects physician privilege. These are all mechanisms for defending against physician existential vulnerability emanating from the experience of vicarious trauma while at the same time affirming their control and power.

Why patients sometimes tolerate medical violence

Physicians are not alone in their fear and subsequent denial of suffering and ultimately death. As a result of the inherent traumatic nature of experiencing illness, these anxieties are intensified in patients as well [ 53 ]. Although patients are the victims of violence in medicine, nevertheless their persistent beliefs about the power of medicine to eliminate suffering and postpone death may have the unintended consequence of allowing or enabling this violence. As an intrinsically vulnerable population, patients are susceptible to multiple forms of violence. Faced with the ordeal of ongoing distress and perhaps impending death, the willingness to make a trade-off between acceptance of a certain amount of violence for the potential reduction of such misery becomes understandable, even appealing.

Despite the fact that the god-like status of physicians so prominent in the second half of the twentieth century has become considerably qualified through concepts such as patient-centered medicine [ 54 ] and shared decision-making, [ 55 ] in extremis many patients and families want to believe that the physician is in control and can accomplish miracles that are beyond mere mortals. Thus they still sometimes reflexively enjoin physicians to do “everything possible” [ 56 ]. This understandable desire for life at times may result in problematic and ultimately futile treatments. It may also encourage the use of warlike metaphors on the part of patients and families, as well as physicians. It may even indirectly intimidate patients and families into accepting “violent” (in the sense of dehumanizing) interactions because of the need to perceive physicians as all-powerful and all-knowing. Thus patients, families, and physicians may collude in acts of unintentional violence with the goal of eliminating suffering and preserving life.

Further, the unequal distribution of power, entrenched throughout history in the relationship between physicians and their patients and exacerbated by issues of race, gender, and class, reinforces this tendency to tolerate rather than question medical violence. Social inequalities and differences in cultural health capital [ 57 ] disadvantage many patients. Patients and their families often feel at the mercy of their doctors and medical teams. Protesting a racially biased remark or a rough handling may pale in comparison to the perception that their life or the life of their loved one hangs in the balance.

The writer Daniel Jose Older argues that “the central act of violence is erasure.” The forms of violence described above often result in the erasure of the autonomy and dignity of those targeted intentionally or otherwise. Patients, family members, trainees and colleagues suffer the traumatic consequences of their illnesses and their caregiving, only to be burdened further by the thoughtless and insensitive exercise of power. What can be done to ameliorate these harmful outcomes?

I have noted that violence in medicine can comprise necessary and intentional acts consciously designed to increase patient well-being as well as unnecessary and accidental consequences of structural, linguistic, and behavioral physician practices.. Both are problematic and require modification in terms of how we manage them. Regarding the former, not all violence in medicine can be avoided – physicians work with the tools they have. But there is something fundamentally dishonest about the way this sort of violence is not acknowledged by physicians. It is a kind of foundational lie that contaminates much of doctor-patient interactions. If physicians were better able to honestly witness suffering, and own the pain they must at times cause, they might be better able to speak more openly about necessary pain and risk as well as hoped-for outcomes. This point is especially relevant to the whole notion of informed consent and medical decision-making, whose purpose is to provide patients with a realistic and accurate understanding of risks and benefits, yet is sometimes honored more in the breach than in the observance [ 58 ]. Even as medicine works hard to minimize suffering, perhaps it also needs to accept when suffering is unavoidable, and help patients address this suffering with the strength of compassion rather than of violence.

Regarding the latter category of inadvertent harm, once we recognize that the inevitable violence of medicine should not be compounded by unnecessary violence, we should encourage physicians to seek out alternative ways of speaking, interacting, and being. We can work to change the acts, structures, and language that physicians currently often rely on. For example, we can consider the costs and benefits of medical acts within the context of patients’ values and lives. We can work to dismantle societal and institutional structures that benefit some while significantly harming others and change the way we educate future physicians to recognize how larger social forces negatively impinge on the possibilities of the health and wellbeing of so many [ 25 ]. We can change our metaphors and reject as unacceptable and unprofessional language that demeans or insults patients, or that bullies and intimidates subordinates. All of this involves changing the culture of medicine.

Ultimately, however, in order to effectively change actions, structures, and language, we must also reconsider underlying attitudes that contribute to the persistent endurance of these patterns. One place to start is to help physicians develop an awareness of the capacity for suffering they share with their patients; even as they help patients accept the limits of medicine. This means blurring some of the boundaries between physicians and patients, recognizing their common humanity and therefore their collective vulnerability, fragility, and woundedness. It means helping patients realize that doctors are always their witnesses, guides, advisors, partners and consolers, but not always their saviors. It means helping physicians come to terms with the suffering and death they have witnessed so that they can help contain their patients’ anxiety and dread, while at the same time honestly acknowledging the pain they must sometimes inflict and sometimes feel. Recognizing solidarity, as well as difference, with patients might also predispose physicians to being more receptive to the insights of structural analyses and working toward changing social systems in recognition of the injustices they impose on patients.

Drawing on the nursing literature, medicine might benefit from incorporating the theory of the wounded healer into training and practice. In this formulation, physicians, like nurses, must acknowledge both personal and professional traumas that over the years have turned them into “walking wounded” who attempt to cope with their own pain by depersonalizing and/or lashing out (often unconsciously) at others. Those who have theorized this concept offer the hope that, while perfection is not possible, healing can arise from the very woundedness of the healthcare provider [ 7 ]. Conti-O’Hare has posited a mechanism for transforming personal and professional pain into growth and development, thus moving healthcare providers from “walking wounded” to wounded healer [ 59 ]. Komisar and McFarland note that when resident-physicians are able to find meaning in traumatic patient care situations, it contributes to a positive transformation of their vicarious trauma [ 50 ].

When physicians are unable to honestly confront and acknowledge suffering; when out of fear they deny their privilege and the way in which healthcare systems often disenfranchise the patients they are trying to serve; when they inappropriately indulge in violent language out of self-protection and a desire to establish a heroic, invincible image – all these result in harm to patients, families, staff, and colleagues. Acknowledging the multifactorial nature of instances of structural, linguistic, and behavioral acts of violence in healthcare and then intervening to address societal and individual root causes represent first steps in mitigating their deleterious effects. Healing woundedness by cultivating attitudes of compassion, solidarity, humility, and social justice may provide the foundation for an alternative vision of medical practice.

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Acknowledgements

I would like to express my deep appreciation to Dr. Guy Micco for encouraging the development of this paper; and including it in the UCSF UC Berkeley Program for the Medical Humanities “Violence and Medicine Conference,” September 7-8, 2017, Berkeley, CA.

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Shapiro, J. “Violence” in medicine: necessary and unnecessary, intentional and unintentional. Philos Ethics Humanit Med 13 , 7 (2018). https://doi.org/10.1186/s13010-018-0059-y

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Preventing violence against health workers

Health workers are at high risk of violence all over the world. Between 8% and 38% of health workers suffer physical violence at some point in their careers. Many more are threatened or exposed to verbal aggression. Most violence is perpetrated by patients and visitors. Also in disaster and conflict situations, health workers may become the targets of collective or political violence. Categories of health workers most at risk include nurses and other staff directly involved in patient care, emergency room staff and paramedics.

Violence against health workers is unacceptable. It has not only a negative impact on the psychological and physical well-being of health-care staff, but also affects their job motivation. As a consequence, this violence compromises the quality of care and puts health-care provision at risk. It also leads to immense financial loss in the health sector.

Interventions to prevent violence against health workers in non-emergency settings focus on strategies to better manage violent patients and high-risk visitors. Interventions for emergency settings focus on ensuring the physical security of health-care facilities. More research is needed to evaluate the effectiveness of these programmes, in particular in low-resource settings.

WHO, ILO, ICN and PSI jointly developed  Framework guidelines for addressing workplace violence in the health sector  to support the development of violence prevention policies in non-emergency settings, as well as a questionnaire and study protocol to research the magnitude and consequences of violence in such settings. For emergency settings, WHO has also developed methods to systematically collect data on attacks on health facilities, health workers and patients.

of health workers

suffer physical violence at some point in their careers

Prevention and response to sexual misconduct: WHO stakeholder...

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Violence Against Healthcare Workers: A Rising Epidemic

As National Nurses' week comes to a close, more attention needs to be brought to increasing rates of violence against employees in the field of healthcare.

Studies show violence against healthcare employees is more common that most people realilze, and advocacy groups say it's time for policymakers to act on this growing but underreported problem. While 75% of nearly 25,000 workplace assaults occur annually in healthcare settings, only 30% of nurses and 26% of emergency department physicians have reported incidents of violence. 1 Those unfamiliar with daily events in healthcare institutions may be shocked to learn that violent altercations are so common that most employees in the field consider them to be simply part of the job.

“Workplace violence against nurses has been going on for decades,” said Michelle Mahon, RN, nursing practice representative for National Nurses United, in an interview with The American Journal of Managed Care ® ( AJMC ® ). “A physician heard a nurse being verbally abused by a patient. She walked up to the nurse, put her hand on her shoulder, and asked her if she was OK. The nurse shrugged it off and said that is happens all the time.”

The World Health Organization (WHO) defines workplace violence as, “Incidents where staff are abused, threatened, or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being, or health.” 2 WHO considers both physical and psychological harm, including attacks, verbal abuse, bullying, and both sexual and racial harassment, to be workplace violence. 2

According to the American College of Emergency Physicians (ACEP), nearly 7 out of 10 emergency physicians believe that emergency department violence is increasing. 3 About 80% of these physicians acknowledged that these events have also taken a toll on patients. Over 50% said that patients have been physically harmed. Also, 47% of physicians have said that they’d personally been physically assaulted at work.

The government has taken initiatives to help protect employees in the healthcare field, but advocacy groups have stressed that more meaningful changes are needed. In March, ACEP sent a letter of support for the Workplace Violence Prevention for Health Care and Social Service Workers Act, which asked Congress to consider how emergency departments (EDs) are staffed to ensure that the main provisions of the legislation could be appropriately implemented. 3 Near the beginning of April 2019, the Nevada Assembly’s Committee on Commerce and Labor passed a violence prevention bill that would make employers more accountable for the safety of their employees, according to a statement .

In an interview with AJMC ® , Leigh Vinocur MD, national spokesperson for ACEP, said more attention has been brought to the issue. “We’re bringing this up again because we want people to take notice. There are some bills in Congress about assaulting emergency medical services or healthcare workers. Maybe there needs to be some of that muscle behind it and people need to understand,” she said.

Types of Workplace Violence

According to a study in the New England Journal of Medicine , there are 4 types of violence that can occur in the workplace. 5 The first type is by perpetrators who have no association with the workplace or employee. In the second type, the assailant is a customer or a patient of the workplace or employee. A third type is when the attacker is a current or former employee of the workplace. The fourth type occurs when the perpetrator has a personal relationship with the employee but not with the workplace.

The second type of violence, usually committed by patient, their families, or their friends, is most prevalent against healthcare workers. However, acts of violence also occur between staff members. “I was previously assaulted by a physician,” Mahon mentioned.

Identifying the Causes

A hospital setting creates extreme levels or stress for patients, their families and friends, and employees of the institution. Fear and illness are major contributors of agitation and aggression from patients. While there are many causes act of violence, dire, emotional circumstances an addition to an overly stressful environmental are main contributors. “It makes sense because the healthcare setting and the ED specifically is a very emotionally volatile experience for people. Patients are at their worst, they’re feeling horrible, they’re ill, they’re frightened and vulnerable. Their family members are also frightened and stressed out, and people lash out. We see psychiatric issues because of lack of behavioral health, gang violence,and gun violence." Mahon said.

“It’s not always a criminal element that’s lashing out. These are frightened and scared sick people, frightened family members that are screaming,” Vinocur mentioned.

Previous measures taken by employers to reduce acts of violence have also been criticized by employees. “Safety interventions that hospitals have taken are failing. Acts of violence that occur are brought up the executive level daily, but that does nothing to prevent workplace violence. It’s a response not a prevention measure,” Mahon stressed.

“The violence that’s occurring is coming from sick people that are not in their right mind the majority of the time. It is not our patients. Many people are taking the approach of criminalizing our patients. It does not prevent violence to charge patients with a felony.” Mahon said. “It could be you. You can get your wisdom teeth pulled and be out of your head from that anesthesia drug and not in a good decision-making capacity. You could be confused, not understand what’s happening, and assault your nurse.”

Major design flaws in the current healthcare system have also been blamed for creating negative care settings. “Healthcare is not focused on wellness. The system creates a situation where there is so much stress, where people can’t get preventive care, where they’re worried about whether or not they’re going to have to file bankruptcy because their wife is sick and in bed, getting a surgery that they need. People suffer with food insecurity. There are no resources to take care of their family member or their loved one or themselves. This type of stress is leading to violence, and it all comes together in that hospital room. The system is broken. Our healthcare system has warped priorities.”

Frequency of Verbal and Physical Attacks

Whether the abuse suffered by healthcare employees may be verbal or physical, every single day employees in the healthcare field are assaulted in the United States.

In an interview with AJMC ® , Schipp Ames, vice president of Communications, Education and Member Services for the South Carolina Hospital Association noted the alarming reports of gun violence that occurred in South Carolina hospitals in April 2019. “Within 48 hours we had 2 hospital shootings in South Carolina. Something like that happens once and everybody’s antenna goes up. Something happens like that twice in that quick of a timeframe and people start to get very scared. To see that happen 2 times on back-to-back days like that when we’ve never had a hospital shooting, as far as I’m aware, in our history in 1 of our hospitals, it’s pretty hard to comprehend.”

Ames addressed the frequency of violent acts in healthcare settings. “I’ve been asked the question, ‘how often does this happen?’ and I think I shocked the reporter from South Carolina who asked. I said, 'This happens every day whether its physical or verbal assault. It just so happens that this time the gun was a weapon, but in the past it’s been a towel rack that was ripped off the wall and used to beat a nurse.' These were very deadly and very dangerous incidents that involved guns, so they got more attention, but I think a lot of folks don’t realize how much doctors and nurses jeopardize their own safety every day when they make that vow to go and serve patients,” Ames said.

Addressing the frequency of violent incidents, Vinocur said, “I would say that you can’t go through a shift without being sworn at or spit on. If you consider verbal abuse, it’s probably daily. Eighty percent of emergency room doctors have at some point been involved in workplace violence.

"If you look at labor and statistics after police and things like that, healthcare workers are on top of the list, from years back, being known as a dangerous profession. It isn’t just the ER, it’s all of healthcare. We put up with it but it’s a tragedy that we, as a nation, have to look at and assess," Vinocur said.

“It’s very prevalent, it’s a very big problem, It’s really common. I was also held at gunpoint in my workplace. The inpatient room, then the psychiatric unit, and the emergency department, in that order, is where most instances of violence occur,” Mahon pointed out.

The Effect on Moral and Burnout in the Field

Mahon addressed the effect that frequent acts of violence against employees can have on their morale over time. “Emergency care is one of the specialties that does have a high burnout rate. How many other places do you go to work, and it’s commonplace and almost accepted that people are going to swear and scream at you? Eighty percent of the emergency physicians say that patients threaten them or threaten to return to the emergency department to harm them. The cumulative effect of both kinds of violence does wear and it creates burnout. I think it’s contributing to nurses leaving the profession.”

She also recalled a devastating situation that she witnessed. “My coworker on my unit was shot in the head in the lobby of the hospital by their husband. It was at a world class institution, a place that you think these types of things wouldn’t happen. The response is that it can result in post-traumatic stress disorder (PTSD)."

“I think it definitely does affect morale,” Vinocur agreed. “That is probably 1 factor related to burnout in our profession of emergency medicine aside from the inundation of patients, lack of follow-up care, access to care, which is critical, and boarding psychiatric patients all night. It’s a piece of it and it contributes to it. It’s always a tragedy. It’s always something. I was there when there was a shooting within the hospital.”

Ames also cited the long-term effects of trauma, mentioning, “We’ve had a number of nurses that have come forward and said that they’ve been diagnosed with PTSD by their therapists.” He also noted that many hospital workers have moved on to outpatient care. “From a hospital perspective, you are seeing folks leave the traditional hospital bedside setting for different opportunities in outpatient settings, in clinics, in special surgery centers, and other facilities that don’t have these same types of hazards, that don’t have the same type of open-access to the public. I’m speaking as the husband of a nurse practicioner who worked in a hospital doing 12-hour shifts for several years. After several incidents, the quality of life is just different sometimes when you work in 1 of these outpatient facilities. It makes us question sometimes whether we have a nursing shortage or whether we’re just seeing more healthcare clinicians or nurses leave the bedside.”

Unreported Attacks

ACEP has stated that while 70% of emergency physicians have reported acts of violence against them, only 3% pressed charges. “I think it’s underreported because physicians and nurses go into healthcare to help people. We feel compassion for our patients. We understand if they’re acting out its because they’re ill or impaired and we have this ethical duty to do no harm. We don’t go into healthcare to police them or report them. It’s no excuse that you’re impaired or you’re ill but we understand it a little more and I think we tolerate it a lot longer than other professions might,” Vinocur said.

Beyond many healthcare workers believing that workplace violence is “just part of the job,” there is another driving force, a type of negative reinforcement, that has created barriers to reporting acts of violence. Many workers feel that they will suffer consequences if they speak out about what has happened to them. However, any act of retribution may not seem obvious. While retribution may not include written documentation of insubordination, supervisors have punished employees that have spoken out in other ways. For example, their hours may be cut or they may be forced to work schedules that they protest against. “I know a nurse that was hospitalized after being beaten and kicked with broken ribs from a psychiatric patient. She was made to care for that patient again when he returned, and when she objected, she was disciplined. It fundamentally goes back to the lack of respect that employers have for nurses and for their workforce,” Mahon stressed.

Ames suggested that a major societal flaw has contributed to rising acts of violence against healthcare employees. “We’ve recognized there’s a culture where clinicians believe that this is part of the job and there’s a culture among some of the patient community where it seems to be OK to treat clinicians subpar. Our communications campaign is a direct aim at that culture with signs that say ‘you report, we support’ with a picture of the CEO because 1 of the biggest challenges is how low reporting is. Any nurses’ group will tell you that so many of them go unreported because they feel like it’s just part of the job. They don’t want to stigmatize mental health patients. They’ve been taught to do no harm so much throughout their career that even when a patient could present a danger to them, they are still programmed to protect that patient. A lot of people don’t understand that we don’t have accurate data to know how big the problem is because so much goes unreported.”

Evaluating High-Risk Patients

Patients showing signs of agitation or aggression should be identified as “high-risk” to prevent an act of violence. Those who were given drugs that could cause impairment should be regarded as potentially dangerous. “One of our nurses who was injured very severely was attacked by a patient recovering from anesthesia from a simple procedure. In that scenario, the patient is not in their full faculties. This brings them confusion, agitation, and ultimately then violence. There was only 1 nurse there and the security staff were told that they were not permitted to touch the patient. Any type of illness or injury that creates confusion could exhibit temporary psychosis,” Mahon said.

Patients who have used illegal drugs could also pose a major threat. “During residency I was choked by a patient. That didn’t stop me from my residency,” Vinocur said. “It was somebody impaired, and it was a busy intercity hospital and he came in as an overdose. Normally you put on some light restraints when you’re reversing them with Narcan. He kind of popped up, didn’t have restraints. I was closest to him and he starts screaming that we ruined his ‘high’ and grabbed me by the throat. I don’t think he was cognoscente because he was still groggy. He ended up ripping my necklace off. Lucky we had security and I could feel him loosening, but I had scratch marks and little broken blood vessels in my eyes. That was the last time I wore jewelry to work because it cut into my throat too.”

Efforts to Reduce Acts Of Violence

WHO has stated, “An integrated approach should be actively pursued at all levels of intervention based on the combined and balanced consideration of prevention and treatment.” Therefore, WHO holds employers accountable for both ensuring the safety of their employees and acting to treat them after an act of violence has occurred. 2

A hospital employee was excited that the administration created a phone application with an alarm system. However, during a time of crisis, the usefulness of these technologies is questionable. “I’m a nurse that’s been personally attacked a number of times. First of all, many nurses are not permitted to carry their phone with them during work hours,” Mahon said. When the administrator said that they were changing that policy, Mahon responded by making a valid point. “If I were being choked by my patient and held at my throat, how would I open my phone to access this app and operate it? That’s an actual situation that I was in. It’s something that’s going on during an act of violence, not a preventive measure. The best type would be a device where you can simply press a panic button and get help. However, even the efficacy of the best safety intervention technology would come into question depending on the response time of security or other individuals who could help.”

While enhanced security measures have been taken by many major hospitals, the cost can be staggering. Ames noted, “It’s extremely difficult from a cost standpoint for a lot of hospitals if you consider rural hospitals. The cost of outfitting with metal detectors and adding a lot of these security measures is really not in the budget for a lot of smaller facilities. Some type of armed or unarmed security prevalence is becoming more common in hospitals, and that’s not cheap either.”

Ames said that remedying a complication situation before it leads to an act of violence is the most common intervention. Vinocur agreed, saying “Communication is the key. You need to learn to de-escalate. Create programs where you’re training the staff and everyone in the department to learn to recognize signs of agitation and potential violence. It’s a struggle because you’re dealing with so many different emergencies and critical issues all the time. Teaching, recognizing when people are getting agitated irritated and training in de-escalation and constant communication and all of those techniques need to be an important part of training for everyone that work in the health system."

Ames discussed an initiative that the South Carolina Hospital Association has taken to reduce violence against their employees. “We’ve launched an entire campaign called ‘Hospital Safe Zones.’ It is an operational communications campaign on how to implement different strategies to reduce violence. It is a way to centralize incidents of healthcare violence and analyze and treat them differently than other incidents in hospitals. We believe that by putting a focus on this issue, and bringing more awareness to it that we can increase reporting in our facilities and see a significant reduction in silent incidents by creating a culture of zero tolerance.”

Ensuring that healthcare settings have an ample amount of employees can also help reduce acts of violence. “Hospitals must provide safe staffing, which they do not in most cases. Most employers are failing to listen to direct input of the care staff, the people who are there who understand how violence is occurring. They understand what’s happening in their unit,” Mahon mentioned. "The surveillance and monitoring of the right amount of staff, and intervening before a patient becomes too agitated is the single best intervention to preventing violence in the workplace. Having the time to teach people, talk to them, educate them so that they don’t become anxious or upset, this is the best type of intervention. But nurses don’t have time for this type of care because they don’t have enough people around to provide that kind of care."

In discussing the design of a workplace violence prevention plan, Mahon explained, "First, there must be unit-specific plans that include meaningful input by direct-care staff. Two, those plans must be available and re-evaluated and see if they’re effective, or working, or need modification at least quarterly. There needs to be a guarantee that there will be no retaliation for reporting incidents of workplace violence, including from other workers in the healthcare facility. It must include transparency. When nurses aren’t safe, patients aren’t safe. When a work environment is not safe, the hospital is not safe. Workers and patients have the right to know what measures are being taken and if this facility is safe or not. It must include fines for the failure to comply. It must include mechanisms for remediation,” Mahon said.

“Healthcare is becoming more like factory work,” Mahon pointed out. “Work faster, patients are sicker, do more with less, deal with it. If you can’t, there is a culture that if you are unable to just roll through something like this happening and continue to be a fully productive worker, that you’re defective.”

1. Physical and verbal violence against healthcare workers. The Joint Commission. www.jointcommission.org/sea_issue_59/. Published April 17, 2018. Accessed May 3, 2019.

2. Framework guidelines for addressing workplace violence in the health sector. Geneva, Switzerland: International Labour Office (ILO), International Council of Nurses (ICN), World Health Organization (WHO), Public Services International (PSI); 2002. who.int/violence_injury_prevention/violence/activities/workplace/en/. Accessed May 3, 2019.

3. Violence in the emergency department: resources for a safer workplace. American College of Emergency Physicians (ACEP). acep.org/administration/violence-in-the-emergency-department-resources-for-a-safer-workplace/. Accessed May 2, 2019.

4. Nevada healthcare workplace violence bill passes committee, heads for floor vote [news release]. Nevada, Nation Nurses Organizing Committee; April 12, 2019. nationalnursesunited.org/press/nevada-healthcare-workplace-violence-bill-passes-committee-he ads-floor-vote. Accessed May 2, 2019.

5. Phillips J. Workplace violence against health care workers in the United States. N Engl J Med . 2016;374:1661-1669. doi: 10.1056/NEJMra1501998.

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Article Contents

Understand the threats and public health dimensions of violence against hcws, policy recommendations, acknowledgements.

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Violence against healthcare workers is a political problem and a public health issue: a call to action

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Ellen Kuhlmann, Monica Georgiana Brînzac, Katarzyna Czabanowska, Michelle Falkenbach, Marius-Ionut Ungureanu, George Valiotis, Tomas Zapata, Jose M Martin-Moreno, Violence against healthcare workers is a political problem and a public health issue: a call to action, European Journal of Public Health , Volume 33, Issue 1, February 2023, Pages 4–5, https://doi.org/10.1093/eurpub/ckac180

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Violence against healthcare workers (HCWs) strongly increased during the COVID-19 pandemic and this trend seems to continue. 1–3 The attacks have exacerbated occupational stress and the physical and mental health risks of individual HCWs while also creating new threats for healthcare and societies. The violence has spilled over to social media and the private sphere and created new forms of hate crimes and harassment. 4 Live-threatening physical aggression, primarily known from war and conflict settings, now occurs in ordinary workplace settings. 5 International estimations highlight that about every second HCW globally have been affected by violence once in their work lives 6 and up to 38% suffer physical violence at some point in their careers. 1 The frequency and patterns may vary between countries, but violence against HCWs is now also a problem in countries with developed healthcare systems and high levels of trust in institutions and professionals.

The COVID-19 pandemic emerged as a focal point for this violent trend and created new areas of confrontation. The reasons behind the violence are complex and the threats are not limited to HCWs and the workplace. Violence against HCWs is often aimed at the healthcare system and their political representatives and, finally, the democratic state and humanitarian values. Violence seeks to destroy trust in health policy and hamper the right to health for all. Furthermore, it is an attack on democratic states, humanitarian values and civil society.

Systematic monitoring and data are still poor, but the World Health Organization (WHO) and other international organizations and professional associations have taken action. 1 , 6–9 Recently, the ‘Framework guidelines for addressing workplace violence in the health sector’, developed jointly by WHO, International Labour Organization, International Council of Nurses and Public Services International to support the development of violence prevention policies in non-emergency settings and document and research violence in such settings, have become available. 1 However, no protective measures and prevention policies have been implemented so far. Most importantly, violence against HCWs is not adequately recognized as a political issue and public health crisis. 3 , 5 It is largely absent from health workforce policy and the European and national pandemic recovery plans and debates over health system resilience.

This Commentary seeks to address the complex political and public health dimensions of violence against HCWs and highlights the need for action. We argue that public health can, and should, play an important role to raise awareness and improve protection of HCWs, connect different stakeholder groups and establish coordination across sectors and policy areas. A transsectoral and multi-professional governance approach may help us to better understand the different forms of violence and the factors that worsen the attacks. Four major target groups of violence can be identified for non-conflict settings. The situation of HCWs in war and conflict regions is not considered in this work, but it should be mentioned that this group also needs greater public health attention and solidarity.

Frontline HCWs

During the pandemic, verbal and physical violence against frontline HCWs, especially physicians and nurses but also many others, have strongly increased. 2 , 3 Frontline HCWs were obliged to implement the COVID-19 lockdown and distancing policies in practice, oversee quarantines, check vaccination status and protective mask-wearing, and communicate service delays as well as severe illness and death to patients and family. The violence of patients and relatives towards individual HCWs was often a reaction to these conditions resulting in high levels of frustration, fear and emotionally difficult situations. The result, for many HCWs, was that violence became an everyday threat and part of their routine work. Some frontline HCWs even employed, and paid for, private security services to improve protection. In addition, the levels of stress, exhaustion and burn-out for HCWs dramatically increased, thereby worsening recruitment and retention and exacerbating workforce shortages.

HCWs in emergency care and highly politicized healthcare services

HCWs in emergency care are generally at higher risk for violent attacks. 1 , 2 However, new anti-democratic movements in the form of coronavirus denial and anti-vaccination as well as an increase in right-wing populism and neo-fascism in Europe worsened the situation. 10 A common denominator of these developments is their anti-democratic nature and rejection of scientific evidence, government institutions, equality, diversity and human rights, including the right to health. Within this context, HCWs in emergency care and those providing vaccination, abortion and reproductive health services, among others, as well as services for minority and vulnerable groups (e.g. asylum seekers, migrants, LGBTQ people) became the target and surrogate for attacks on the state and its institutions. A strong and coordinated political response to these attacks is therefore necessary.

HCWs affected by the gender-based and sexual violence dimension

Women account for the vast majority of the health workforce and violence is no gender-neutral threat. 8 Gender-based and sexual violence is widespread and most often affects women HCWs. Unfortunately, there is a severe lack of data, research and knowledge resulting in a scarcity of political will and policy-making. There is an urgent need to break the silence and improve protection and create more sensitivity, 8 also for sexual violence against minority women HCWs and some men.

HCWs affected by the racialized violence dimension

Healthcare systems increasingly rely on migrant HCWs. We can therefore assume that this group is also affected by growing violence. Specific protection may thus be necessary against the backdrop of anti-democratic political movements in some areas. Similar to gender-based violence, data in this area are scarce leading to a lack of political action in the realm of public health.

Prepare HCWs. Integrate violence prevention in education and training, e.g. training in self-protection against violent attacks; coping strategies for mental health and wellbeing; communication strategies to de-escalate violence; team-based multi-professional training models to improve coordinated action— micro-level, actor-centred .

Protect HCWs. Improve the scope and enforcement of existing laws and define violence prevention as a management task; implement zero tolerance guidelines, prevention and protection strategies; establish information, helplines and mental health support— organization and management level .

Establish monitoring and reporting systems, improve research evidence and funding programmes— health policy level .

Engage the public, media and communities, including the police. Improve sensitivity; launch a coordinated campaign— local public policy level .

Strengthen civil society and leadership of international public health organizations to respond with coordinated action— global/EU public health policy level .

Take action against violence on HCWs on all levels of governance, including addressing its gender-based and racialized forms.

We thank Sarada Das for very helpful comments and support.

Conflicts of interest : None declared.

World Health Organisation (WHO) . Preventing Violence Against Health Workers . Geneva: WHO, 2022 . Available at: https://www.who.int/activities/preventing-violence-against-health-workers (31 October 2022, date last accessed).

Brigo F , Zaboli A , Rella E , et al.  The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department . Health Policy 2022 ; 126 : 1110 – 6 .

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International Labour Organisation (ILO) . Joint Programme Launches New Initiative Against Workplace Violence in the Health Sector . Geneva: ILO, 2022 . Available at: https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_007817/lang–en/index.htm (4 November 2022, date last accessed).

International Council of Nurses, International Committee Red Cross, International Hospital Federation, World Medical Federation . Violence Against Health Care: Current Practices to Prevent, Reduce or Mitigate Violence Against Health Care . Geneva: ICN, ICRC. IHF, WMF, 2022 . Available at: https://www.icn.ch/system/files/2022-07/Violence%20against%20healthcare%20survey%20report.pdf (30 October 2022, date last accessed).

Women in Global Health (WGH) . #HealthToo. About Sexual Exploitation, Abuse and Harassment in Health, Read Women’s Stories . New York: WGH, 2022 . Available at: https://womeningh.org/read-womens-stories/ (1 November 2022, date last accessed).

European Medical Organisations . European Medical Organisations’ Joint Statement on Violence Against Doctors and Other Health Professionals. 2020 . Available at: https://www.cpme.eu/api/documents/adopted/2020/3/EMOs.Joint_.Statement.on_.Violence.FINAL_.12.03.2020.pdf (4 November 2022, date last accessed).

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• Published: 07 May 2021

Violence against healthcare in conflict: a systematic review of the literature and agenda for future research

• Rohini J. Haar   ORCID: orcid.org/0000-0002-9049-984X 1   na1 ,
• Róisín Read 2   na1 ,
• Larissa Fast 2 ,
• Karl Blanchet 3 ,
• Stephanie Rinaldi 2 ,
• Bertrand Taithe 2 ,
• Christina Wille 4 &
• Leonard S. Rubenstein 5  

Conflict and Health volume  15 , Article number:  37 ( 2021 ) Cite this article

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Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward.

Methods and findings

This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data.

Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.

Introduction

Attacks on healthcare in armed conflict violate central tenets of human rights and International Humanitarian Law (IHL) [ 1 ]. These attacks, comprising physical violence as well as threats, intimidation and interferences with healthcare, are a frequent but underreported facet of international and intra-national armed conflicts. Health facilities such as health centers, hospitals and private medical offices, and transports such as ambulances and supply trucks, have been bombed, looted, burned, blocked, or occupied across various contexts over decades. Healthcare personnel and patients have been physically assaulted as well as arrested and jailed, intimidated, threatened, or blocked from receiving or providing care. Resolutions from the World Health Assembly, the United Nations (UN) Security Council, and the UN General Assembly have reiterated the critical need to protect health during conflict and the need for the World Health Organization (WHO) to compile data on these violations [ 2 , 3 , 4 , 5 ]. Interest in rigorous and systematic documentation and reporting on these attacks is growing from the public health, medical and legal sectors. Better documentation is central to understanding the true scope of the attacks on healthcare across contexts, exploring their burden on health systems and populations already impacted by conflict and violence, and could assist in developing stronger protection, advocacy and accountability mechanisms.

Increased advocacy and attention in recent years has prompted calls to scale efforts to compile data on the nature and extent of attacks on healthcare and their sequalae. Non-governmental organizations and the ICRC and WHO in particular have met this call with efforts to improve documentation of incidents of attacks on health and the dissemination of research and investigations [ 6 , 7 ]. However, there has been significant variation in the objectives, types and geographic contexts of attacks as well as in the methods of data collection and the operational definitions used to investigate and describe them. Discrepancies in these elements may obscure important dynamics, such as why attacks occur and how they are counted, and limit comparison of datasets.

Interest in conflict data of all kinds and global programs to identify and document violence against civilians are growing alongside region-specific databases [ 8 , 9 , 10 , 11 ]. Initiatives focus on violence against civilians, airstrikes, terrorism events, security of humanitarian organizations and other facets of conflict [ 12 , 13 , 14 ]. The growth in conflict data initiatives has allowed quantitative, and increasingly disaggregated, analysis of conflict and conflict-related phenomena, albeit with limitations [ 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Within this broader conflict and human rights data landscape, research to document attacks on health and characterize their features can enable more timely and systematic monitoring of attacks.

Better understandings of attacks on healthcare can contribute to preventing attacks, mitigating their effects, bearing witness to the costs, and prosecuting the violations of IHL and international human rights law (IHRL) that they represent. Documentation of attacks can contribute to preventing attacks by identifying vulnerabilities, shaming perpetrators, and developing security strategies. Knowledge of the scope, scale and impact of attacks on health can help humanitarian actors target resources and programs towards those have been attacked and support recovery processes. The voices of survivors are powerful in condemning violence and deepening understanding of the social, psychological, physical and economic repercussions of attacks. Bearing witness and securing accountability for perpetrators and by exposing these attacks and their human toll is an important part of ensuring justice has been served.

There have already been several efforts to review some aspects of data on attacks on health in conflict. These include reviews focused on the impacts of attacks [ 22 ], reviews on the scope of attacks resulting from the Arab Spring, especially in Syria [ 23 , 24 ], and on incidents involving health workers [ 25 ]. One rapid review covering 2011 to 2017 criticized aspects of the documentation process and the limitations of standardization in the field [ 26 ]. The present study employs a systematic review methodology to build upon these inquiries. As part of the ongoing Researching the Impact of Attacks on Healthcare project, we ask: what is the state of evidence about attacks on health in conflict across the decades [ 27 ]? What research has been carried out? For what purpose? Using what methodologies? And what still remains to be done? We aim to provide insight into the current state of evidence about attacks on healthcare and identify next steps for data collection, data utilization and research.

Methodology

We conducted a systematic review of articles and reports that document attacks or analyze related risks, methods and/or impacts.

Data sources and search strategy

We utilized a methodology based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify peer-reviewed articles and reports pertinent to data collection and analysis around attacks on health in conflict settings. We reviewed multiple electronic databases for appropriateness and selected PubMed/Medline as it covered a broad range of topics on attacks on healthcare in armed conflict without overwhelming the search with irrelevant material. After empirically assessing relevant keywords, we identified pertinent articles that included the following terminology categories: (1) conflict or war, (2) attack (terms such as violence, bombing, arrest or torture) and (3) targeting health (including terms for facilities, transports, healthcare workers or patients). The full search strategy and MeSH terms can be found in Table  1 S (supplementary). We reviewed titles and abstracts of all papers retrieved from the systematic search to capture relevant articles, and then reviewed the full text of potentially suitable articles prior to inclusion. Aware that many articles and reports relevant to the research question are not available in traditional biomedical article searches, we rigorously reviewed article references and searched grey literature by browsing published reports by international organizations involved in the provision of healthcare and those that reported on human rights or humanitarian law violations in relation to health care. We also consulted professional networks to identify additional papers that fit the inclusion criteria.

Study selection

We framed a priori definitions of attacks, healthcare and conflict in the exploratory phase but remained open for additional input from the review. Initially, attacks were defined as violence, threatened or actual, as well as intimidation and interference with normal health functions and/or misuse or misrepresentation of the protected status of healthcare. We included non-physical and indirect violence in our definition to ensure we looked at these often overlooked but frequent types of incidents that nonetheless have serious impacts on the health system [ 28 ]. This broad definition of violence allows for a richer review of papers and aligns with the normative definitions of attacks on health by the WHO, ICRC and the Safeguarding Health in Conflict Coalition. We defined healthcare to include a diverse range of health services. Based on previous research, we included the domains of facilities, transports, patients (the wounded and sick), personnel and the protected status of healthcare as targets of attack [ 29 ]. The definition of conflict, for this study, was inclusive of the IHL definitions of international armed conflicts and non-international armed conflicts as well as other contexts that the authors of the article or the research team identified or referred to as conflict related [ 30 , 31 ].

To ensure we covered both historical and current trends and conflicts, we conducted an open search for documents published before January 1, 2020, but we limited articles to English based on the competencies of the research team. We did not formalize a start date in order to be inclusive of older reports but we did not identify any articles published prior to 1983.

We excluded articles that focused broadly on humanitarian settings without mentioning conflict, as their findings may fall outside the remit of IHL or may be more focused on interpersonal violence rather than conflict-related violence. Using the search terms defined earlier, we collected relevant articles, removed all duplicates and selected a final list for in-depth analysis.

The selection process was designed to identify articles with a robust research on violence against healthcare in the context of conflict research. Any article deemed by both reviewers to not substantively (1) conduct formal research or deep analysis of attacks (violence/interference or threats) and (2) focus on healthcare (broadly defined) (3) in the context of armed conflict (as defined by the article) was excluded during the title and abstract review.

For the included articles, the reviewers extracted descriptive data such as timeframe, context and region, source data and its availability, type of study or program, conceptual framing of the text, methods and outcome measures. We used a deductive approach to extract type(s) of attacks studied, geographical focus of the article or program, methods/study design, limitations and findings. Then, we used an inductive approach to identify additional categories emerging from the articles and to further dissect the concepts. The themes included: primary focus (armed conflict or attack on health or other), objective of paper, definitions of conflict and attacks on healthcare and take-aways. The process of extracting these themes was iterative, requiring continual comparison across papers.

We identified 45 articles for in-depth review. Our systematic search yielded 1479 discrete articles, of which we selected 23 articles (Fig.  1 ). An additional 22 articles were identified though references review and professional networks. The full list of papers appears in Table 1 : Study Summaries [ 22 , 23 , 24 , 26 , 29 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 ].

Search Strategy and Selection

Descriptive analysis of the literature

Objectives, focus and type of analysis in the literature.

Of the 45 included articles, 35 (78%) focused exclusively on attacks on healthcare while nine concentrated on armed conflict but incorporated substantial discussions of attacks on healthcare. The objectives of the papers were broadly categorized into four domains: 26 papers reviewed incidents of attacks and their features or the immediate aftermath; 15 papers explored the impact of the attacks: on the health system; on health workers; or on the population. Three papers addressed the legal and human rights facets and implications of attacks on health and one paper described methods for documenting attacks.

In evaluating the approaches to the subject matter, 28 papers (60%) broadly fell under research, six papers were best described as human rights investigations (informal methods that included visual inspection, interviews, forensics and/or document review), five papers were scoping or literature reviews, and another six papers analyzed law and/or policy. Among the 28 research articles, 15 reported primarily on quantitative analysis of incidents of attacks. Eight studies conducted secondary or retrospective data analysis using registry data from a hospital, health system, region, or country to document attacks ( n  = 3) or to analyze their impacts ( n  = 5). Three conducted retrospective cohort studies and four utilized publicly available data for secondary analysis. Thirteen articles were based on qualitative interviews, workshops or focus group discussions or a combination of these. While we did not formally assess the quality of the research studies, in general, studies adopted observational and retrospective methods with small sample sizes ranging from 20 semi-structured interviews [ 68 ] to a questionnaire with 700 respondents [ 64 ].

The six human rights investigation articles described violations in El Salvador during the civil war and the repressive regime that followed [ 35 , 48 , 59 ], in Nicaragua [ 56 ], Palestine (Gaza) [ 66 ] and South Sudan [ 44 ]. Four of the six were conducted or affiliated with human rights or advocacy organizations, one with Médecins Sans Frontières, and one with academic institutions. Methods for these papers included collection of witness testimonies and of physical and documentary evidence.

The six articles categorized as legal/policy analysis all conducted in-depth exploration of one or a handful of cases. Finally, five papers reviewed literature on attacks on healthcare since 2010. One study each focused solely on Syria and the Arab Spring, one on impacts of attacks on healthcare, and two on attacks on healthcare more generally. All reviews used scoping and qualitative methodologies and highlighted the lack of available and quality data. Information regarding the types, contexts, thematic domains and approaches of the articles are presented in Table 1 .

Source of data analyzed in the literature

Reporting on incidents of attacks on healthcare in the literature was retrospective and has taken the following forms: (1) field level monitoring and reporting on attacks, collated into incident reports; (2) open-source data collection based on social media, news media and other publicly available reports; (3) in-depth mixed-methods case studies of specific countries, conflicts or incidents using interviews, inspections and evidence collection; (4) post-hoc investigations; or (5) impact studies. Of the 34 studies that used data (research and human rights investigations, excluding the reviews and analysis papers), 13 conducted only secondary analysis of previously-collected data and 21 studies collected original data. Of these 21, three conducted interviews to augment secondary data and 14 studies conducted qualitative interviews as the primary data source. Only four studies independently collected quantitative data.

First authors were affiliated with 19 different countries: 19 were from the USA, three each from Canada and Switzerland, two each from Afghanistan, India, Lebanon, Sweden and the UK, and one each from Australia, Belgium, Denmark, France, Iraq, Israel, Mozambique, Norway, Pakistan and Turkey (Fig.  2 ). For authors with multiple affiliations, we scored the affiliation from the country with the highest ranking on the Fragile States Index [ 88 ].

Number of studies by conflict/country

Thematic analysis of the literature

Analysis of the reviewed literature includes synthesis of (1) the state of available data and (2) overarching themes. The state of the data section includes results on the geopolitical focus, temporal characteristics, terminology used, characteristics of documented attacks, and methodology. The overarching themes, inductively defined, include the impacts of the attacks and lessons on mitigation and resiliency.

State of the available data

Geopolitical focus.

Ten articles had no specific geopolitical focus. Of the remaining 35, one had a regional focus on Arabic speaking countries, while the other 34 focused on a single country and/or conflict (see Fig. 2 ). Several articles discuss sentinel events that could alter the nature of the discourse on attacks on health. For instance, the bombing of the MSF hospital in Kunduz, Afghanistan in October 2015, which brought widespread international attention to IHL and the culpability of the US military, is explicitly studied in four papers [ 34 , 62 , 80 , 82 ]. Similarly, six papers focus on attacks on health in Syria [ 24 , 49 , 53 , 60 , 75 , 85 ]. Other conflicts characterized by frequent attacks on health have been less well studied in the literature (i.e. four studies in Iraq [ 39 , 40 , 64 , 68 ], three studies in Palestine [ 66 , 77 , 79 ], two studies in Myanmar [ 29 , 53 ], 1 study each in South Sudan [ 44 ] and Yemen [ 70 ]).

Temporal characteristics

The attacks on health reported in these articles range from archival studies of historical conflicts [ 67 ] through the ongoing wars in Syria (2011-present) and Yemen (2014-present). Although attacks on health in conflict are not a recent phenomenon, the vast majority of the studies (40) were published between 2010 and 2019 (89%), and 2019 had the highest frequency of published studies (10), suggesting a growing interest in this problem.

Terminology

While ‘attack on health in conflict’ is the overarching framework as previously defined in the methods section, the terms “attack”, “health” and “conflict” are often undefined in the studies and, where they are, exhibit some variability in operational definitions.

Eighteen articles mention the legal landscape, using the Geneva Conventions’ approach to considering when violence reaches the threshold of an international or non-international armed conflict. Twenty-seven articles have no explicit conflict definition. Some articles [ 43 , 46 , 69 , 78 , 83 ] document attacks on health in contexts of violence or political volatility that may fall below the threshold of an armed conflict under IHL. For example, one study in Nicaragua [ 83 ], which was in the throes of the political crisis in the late 1980s, documented violence by police and paramilitary forces in protests that resulted in extra-judicial killing, disappearances and detentions of health workers.

Defining an ‘attack’ was often imprecise. Although 25 of 45 papers explicitly define the characteristics of attacks, there is significant heterogeneity in the types of attacks studied. These attacks range from airstrikes to delays at checkpoints, threats and harassment of health staff, kidnapping and violent deaths.

Nine of 45 articles [ 39 , 40 , 41 , 42 , 48 , 58 , 66 , 68 , 69 ] addressed impacts of conflict, human rights violations and indiscriminate violence on health professionals and services. The papers examined issues such as the impact of repression of women, including healthcare workers, by ISIS leaders on women’s ability to function freely [ 68 ], the effects of limitations on distribution of medical supplies and food [ 66 ], or how looting and pillaging of medicines and other resources can restrict health resources [ 41 ]. The literature contains examples of the impacts of chemical attacks on patients and health workers [ 53 ] and of delays of ambulances at checkpoints [ 66 ]. Many papers did not disentangle general disrespect for civilian lives and humanitarian law from attacks specifically on the health sector.

Research focus and findings

Attacks on personnel.

Twenty of the 45 articles focused on documenting or analyzing attacks against health personnel, including doctors, nurses, and other clinical staff; an additional nine articles discussed personnel without focusing exclusively on them. Attacks on personnel include beatings and shootings [ 44 , 50 ], as well as surveillance at work [ 68 ], arrest, intimidation or threats [ 29 ], obstruction of daily operations [ 48 ], or interference with obligations of impartial care [ 34 ]. While attacks on health workers occur in most places irrespective of ethnicity, a few articles point out how the experiences of health workers differ from those of the communities in which they work (‘local’), particularly when they are not from the specific geographic location or identity group. Those who are not ‘local’ may be at more risk of isolation from the host community and more vulnerable to attacks. In Burundi, attacks on health workers occurred ‘across ethnic lines’, and health workers “preferred to [work] in areas where they felt their safety and security was guaranteed, and that might be within their own community” [ 41 ]. Ethnicity or locality was found to be a factor in health worker vulnerability in the conflict in Myanmar as well [ 55 ], where ethnic groups fought the national government and the health workers provided care to targeted ethnic groups. There were anecdotal reports of similar vulnerabilities in South Sudan [ 44 ].

The gender dynamics of attacks on healthcare are not well-studied in general. Foghammar et al. [ 87 ] highlighted a knowledge gap around the ways that gender impacts on both the location and nature of attacks that health workers face. They observed that gender data may not be recorded or disclosed due to privacy concerns, or a lack of awareness of the importance of gender-sensitive data collection. One study of healthcare in Mosul under ISIS occupation noted that women were at risk of being forced to marry and not being allowed to travel or relocate, a practice also that also affected female health workers in particular [ 68 ]. Only one study focused solely on female health workers and considered the specific vulnerabilities of female community health workers in Pakistan [ 83 ]. It found that female community health workers were more likely to work in isolation in remote areas, with a risk of being targeted while doing preventative visits or vaccination campaigns. Additionally, attacks against them receive less attention and get reported less frequently. Only five papers [ 49 , 52 , 74 , 83 , 87 ] explicitly mentioned sexual violence as a form of attack that health workers may face, though three of these only noted that “it is very difficult to collect reliable data on sexual violence against health workers” because of stigma, and further violence from perpetrators, relatives and colleagues [ 87 ] and one remarked that no reports of sexual violence were recorded in their data collection [ 49 ]. None of the articles we included reported incidents or instances of sexual violence in either quantitative or qualitative data, though the paper on female health workers recorded threats of sexual violence [ 83 ].

Attacks on facilities

Attacks on facilities were the most commonly cited form of attack on healthcare in the papers reviewed. Facilities include clinics, hospitals, private offices and secondary health posts such as blood donation centers or medical education facilities. High profile hospital bombings in Syria, Yemen and Afghanistan have dominated the studies of attacks on facilities but incidents in other settings have highlighted the more insidious and chronic attacks [ 41 ]. For instance, a study in Mozambique highlighted that “196 peripheral health posts and health centers had been destroyed and another 288 had been looted and/or forced to close,” noting that this loss of health services has “hit people hardest in the rural areas where people are most in need of health care” [ 43 ]. In eastern Myanmar, qualitative interviews with health workers identified frequent attacks on clinics, which could not reopen because the military set up landmines around them [ 55 ]. Studies repeatedly noted the specificity of context and conflict. A study of hospital attacks in South Sudan in [ 44 ] illustrated variability in the nature of attacks that occur in different contexts within the same country, highlighting the importance of understanding conflict dynamics, historical context and perpetrators.

Attacks on transports

Only three papers specifically focused on attacks against ambulances and other medical transports [ 46 , 77 , 85 ] while 22 others included some information about attacks on transports. Chen and Wong used secondary analysis of literature to identify and characterize violent attacks on ambulances in Syria in 2016 and 2017 [ 85 ]. In other studies, delays at checkpoints, violence against mobile clinics and other transport-related violence featured more prominently than physical violence against ambulances [ 46 , 55 , 66 , 70 , 77 , 83 ]. Incidents such as looting of medical equipment [ 41 , 44 ], and disruption of medication cold chains [ 80 ] received little attention in the research literature on attacks on healthcare.

In a study of ambulances in Kashmir, the authors noted that police and paramilitary forces ‘did not allow them to use either the lights or the sirens. In fact, several drivers reported that they had been physically attacked by paramilitary forces for using a siren.’ [ 46 ]. Delays at checkpoints to inspect vehicles for weapons, refusal to allow ambulances to cross a thoroughfare and harassment and rerouting have most notably been documented in Palestine [ 66 , 77 , 79 ]. A study in Burundi and Northern Uganda identified few available ambulances and additional risks for travel at night, when ‘harassment, assault, or extortion by armed persons at roadblocks a common phenomenon” [ 41 ]. In Myanmar, two studies noted that destruction of mobile medical clinics, confiscation of supplies from mobile health workers and harassment of mobile health workers or patients while traveling. This limited their mobility in terms of the times of day they could travel and how much they could carry [ 29 , 55 ]. A health worker in Myanmar reported that “ [the patient] should have traveled immediately to another clinic, but because of government soldiers we had to stay and cross late at night, so the patient was very severely ill when we arrived and we had to give IV treatment. Because of the delay he was far sicker on arrival ” [ 55 ]. In Syria, interviews in the Ghouta region suggested that women would schedule daytime C-sections to avoid the risk of going into labor and requiring transport to hospitals overnight [ 42 ].

Attacks on the wounded and sick

No papers focused exclusively on documenting attacks against patients but several described the experience of and impacts on patients secondary to a variety of attacks. Chukwuma et al., for instance, studied the effect of the Boko Haram insurgency on maternal health care utilization [ 42 ] and Trelles et al. [ 82 ] measured the averted health burden at the Kunduz trauma hospital. Other papers address attacks on patients secondary to the main domain of attack, and include data on killing and injury of patients, harassment and intimidation, blocking or interfering with timely access to care, denial of medical assistance and discrimination, and interruption of medical care through disruptions to medical functions [ 22 , 24 , 29 , 41 , 42 , 44 , 49 , 55 , 57 , 58 , 60 , 66 , 77 , 82 , 87 ]. Several articles pointed to the challenges of identifying patients as victims of health attacks, especially if not yet treated, when they are confused with bystanders and other civilians [ 29 , 69 , 77 ].

Misuse of health facilities and ambulances for military purposes

Attacks on health may target not only physical structures and persons, but may also misuse the symbols and the protected status of healthcare and/or undermine the integrity healthcare, primarily through the deliberate misuse of health for military or other purposes, in violation of the Geneva Conventions. Several articles cite the US military’s ruse of a fake vaccination campaign in Pakistan to further intelligence gathering [ 83 ], the use of ambulances to carry militants across checkpoints [ 79 ] and hiding weapons inside a health facility [ 80 ].

Perpetrators and intent

Three articles [ 37 , 44 , 67 ] focus on identifying the perpetrator or considering the motivations of perpetrators. Many others generally comment on perpetrators of specific attack, battle, or conflict. In most studies, perpetrators were identified as either State or non-State armed groups but several articles noted that disentangling conflict-related violence from interpersonal violence is challenging in practice. Studies in Iraq [ 64 , 68 ] and Yemen [ 70 ] noted that interpersonal violence, including assaults on health workers by patients or families, did not disappear in conflict settings and may in reality reflect conditions of chronically insecure and underfunded health systems. They also noted that endemic violence may become more common in conflict settings where violence is more normalized in general [ 64 , 68 , 70 ]. An in-depth review of violence in South Sudan noted layers of complexity in circumstances of active conflict, particularly looting. Regarding an attack on a hospital in the town of Leer in 2014, the authors wrote, “Looting of the facility reportedly began in the last days when the staff were present and working, involving civilians and combatants alike in the panic and confusion created by the government’s offensive, including shelling the town. As one local witness recalled: ‘Light things like mats, medicines, items which can easily be picked up were taken by people from the community. Heavy machines were taken by the soldiers, both the rebels and the government soldiers and those who had joined the government” [ 44 ].

Identifying intent, or whether an attack was targeted or indiscriminate, is even more complicated than identifying perpetrators. As a result, intentionality is rarely addressed. The few discussions of intent focus on the challenges of understanding the motivations of attackers and note the complexities of any decision-making process [ 41 , 67 ]. Crombé and Kruper wrote that “the joint product of interactions between rival political elites, and between these elites and local groups, down to individuals with their own interests, violence defies the maximization logics of any given set of actors” [ 44 ].

Overarching themes from the literature review

Several cross-cutting themes threaded through published research papers. These included: (1) vulnerabilities to attack, particularly related to healthcare visibility and emblems, (2) efforts at mitigating attacks or their effects and (3) attempts to study the consequences of attacks on healthcare.

Do the emblem or other markers of the medical profession heighten vulnerability?

At least four articles discussed how emblems of healthcare can either protect from or expose health services to violence [ 24 , 60 , 67 , 80 ]. These emblems, most commonly the Red Cross or Red Crescent, are intended to designate protected services [ 67 ]. Studies in El Salvador, Iraq, Uganda, Afghanistan, Myanmar, Palestine, Syria, Yemen, Pakistan, and in the former Yugoslavia describe how the emblem has become a target and discuss strategies to avoid its use as a means of protection [ 24 , 50 , 55 , 64 , 67 , 69 , 79 ]. In South Sudan, signs of being a health worker, such as a white coat or possessing medical equipment, had to be hidden when security forces were present [ 44 ]. In Pakistan, emblems and identification as a health worker constituted a direct risk, particularly in remote areas in Swat Province [ 83 ]. In Kashmir, marked ambulances were at particularly high risk for targeted attack [ 46 ]. A study in Syria, where hospitals were systematically targeted, noted that only 14% of facilities and 31% of ambulances reported displaying a medical emblem in opposition-controlled Syria in 2016, and that “no significant difference ( p  = .208) in repeated attacks or probability of closure between hospitals with and without emblems in their limited dataset suggesting either that hospitals actively avoided being labeled and that the emblem did not protect from attack [ 60 ].

Prevention and mitigation

Many articles discussed prevention and mitigation efforts and included practical recommendations [ 24 , 34 , 44 , 46 , 53 , 64 , 67 , 68 , 69 , 70 , 74 , 79 ].

Protection and prevention

Concealment, in coordination with the local community, was discussed in several articles across continents. In Burma, Karen health workers hid in the forest and came out only when soldiers were asleep or moved away [ 55 ]. In South Sudan, health workers concealed their identify by removing medical paraphernalia and sleeping in the hospital among the patients, or frequently changing sleeping locations [ 44 ]. In Syria, hospitals removed medical insignia and moved to unmarked basements and caves to avoid being attacked [ 24 , 50 , 53 ]. Several articles note that concealment, however, does not mitigate risk from airstrikes, especially indiscriminate attacks [ 80 ].

Staff positionality and nationality. Use of expatriate staff was discussed both as protection and vulnerability. Attacks on expatriates are more likely to cause international outrage. On the other hand, international staff may raise the profile of a particular health facility or service, making it more visible for attack or more attractive for hostage takers. In some instances, the presence of international staff (and their higher standards of living) may cause resentment among the local population, leaving them less allied with the local community and therefore less protected [ 46 , 51 , 52 ].

Negotiating security. Literature on humanitarian negotiations exists but is beyond the scope of this review. Several papers, however, noted that negotiating directly with conflict parties and creating meaningful rapport was critical to protection. MSF had made significant progress in negotiating its neutrality with the Taliban and local government forces that may have protected from potential attacks ([ 34 , 76 ] though the protection is incomplete and staff continue to be targeted. In Colombia, the Red Cross directly communicated with guerilla forces and invoked their obligation to care for fighters on any side [ 80 ]. Terry noted that the ICRC’s neutral stance makes denunciation of perpetrators’ violence more challenging [ 80 ]. In El Salvador, negotiations produced myriad trades: providing medical assistance in exchange for free passage at a checkpoint and to “less deserving populations in return for permission to provide services to needier ones” and in negotiating aid for policy concessions with governments [ 35 ].

Mitigation of impacts

Task-shifting. Several articles mention task-shifting as a way of limiting the effects of lost health workers or lack of adequate training. Community health workers, cut off from the broader health care system, were trained in El Salvador to be primary healthcare workers and treat basic conditions [ 35 ]. In Uganda, nurses learned to perform C-sections and physicians shifted across specialties to the field of most urgent need [ 41 , 69 ].

Technology. Some articles suggested that using remote technology, such as surgeries with advice from abroad (telemedicine), may be helpful in managing complex illnesses when local staff are not available [ 24 ]. However, these strategies have limitations: high-tech communication is often unstable in conflict settings, and without strong security precautions, may identify the health workers’ locations or contacts to hackers and attackers. ‘Low’ technology solutions may also serve as a mitigating factor: some studies noted that local health workers might be able to utilize natural remedies or make homemade cleaning supplies or feeding solutions more efficiently [ 35 ], increasing the flexibility and cost-efficiency of limited health services in conflict settings.

Protecting from physical damage . Applying tempering film to the glass of buildings or ambulances to avoid glass shards, building hospitals inside bunkers and fortifying hospital (using sandbags, etc.) have been reported in various contexts to mitigate damage [ 80 ].

Impact of attacks

Fourteen of the papers touch on the wider, indirect, cumulative or long-term impacts of attacks on healthcare [ 22 , 39 , 40 , 41 , 42 , 43 , 48 , 56 , 57 , 62 , 68 , 69 , 77 , 79 ]. There are numerous dimensions of impact – including personal impact on health workers (death, injury, attrition, emotional distress), patients (death, injury, intimidation from seeking care, poor health outcomes), as well on facilities and the health system or the general population.

The studies have primarily used qualitative methods to assess impact. Two papers utilized heath worker interviews and surveys to understand the root causes of attrition, by interviewing refugee doctors in Jordan [ 40 ], and the experiences of health workers under ISIS, by interviewing 20 doctors in Mosul who lived and worked under the ISIS regime [ 68 ]. A third study reviewed personnel records to understand why doctors left tertiary care hospitals in Iraq between 2004 and 2007) [ 39 ]. Through participant interviews and observations in Palestine, Sousa and Hagopian found that, in addition to other sources of interference, checkpoints, road re-routing and regular sieges “were clearly a barrier to delivering critical, acute care” [ 79 ]. Namakula and Witter used a life-history approach to understand the longer-term experiences of health workers in northern Uganda, finding both a sense of disconnection as well as loss of morale [ 69 ].

Quantitative studies included two from Afghanistan that assessed the impacts of the aerial attack on the Kunduz trauma hospital by describing patient characteristics and services utilized before and after the bombing to calculate the untreated burden of disease [ 62 , 82 ]. In Palestine, Rytter et al. found that patients who experienced conflict-related delays (i.e. at checkpoints) were significantly more likely to be admitted to the hospital (32% vs. 13%, p  < 0001) [ 77 ]. A study of rebel-led attacks in the 1980s in Mozambique used national level registry data to assess how the attacks were used to destabilize the health system and weaken the perception that Mozambique was able to self-govern effectively [ 43 ].

This review illustrates a diversity of approaches to researching attacks on healthcare with the aim of understanding how the research is harnessed for advocacy, protection and accountability efforts. Much of the academic research on violence against healthcare is qualitative and focuses on analyses of secondary data (either surveillance data or medical charting, in 16 of 34 articles). Only four research papers (11%) collected new quantitative data, underscoring the challenges of data collection in conflict settings. Qualitative studies have primarily elucidated the experiences of health workers and illustrated the range of violent and non-violent attacks health workers have suffered as well as the impacts on their personal and professional lives. The studies use open-ended interviews, surveys, life-history, historical case study and participant observation methods. Quantitative studies, both secondary analysis and original data collection, have primarily focused on documenting attacks, their features, scope and scale with a range of sources including self-reports, the use of data collectors, online sources, and other methods. Quantitative research has also been employed to study the health systems level effects of attacks or to compare these attacks across conflict incidents and time. The research describes attack trends, links publicly available attack data to health indicators, surveys health worker experiences and compares hospital records to conflict data to identify trends. These data provide insights on what is known in select countries at a moment in time but represents a small sample of violence against healthcare in conflict.

When and where: When and where are attacks happening or being researched?

In nearly four decades since the first papers in this review (1983), there have been studies on 18 countries or conflicts. Over this period, the focus of research has shifted alongside global attention, from conflicts in Nicaragua in the 1980s, El Salvador and Yugoslavia in the 1990s, Iraq, Palestine and Kashmir in the 2000s, and Somalia, Syria, Nigeria, Uganda, Pakistan, Myanmar and Afghanistan in the 2010s. In the last decade, Syria has been the subject of 7 papers. However, many conflicts where violence against healthcare is significant and especially in Africa (the Democratic Republic of Congo, the Central African Republic, Mali, Sudan, and Libya), have not been subject to a single study.

Even within a country, the full geographic scope of the conflict is often not studied. For instance, attacks on healthcare have occurred for decades in Afghanistan but the three studies of attacks on healthcare in the country focused solely on the bombing of the Kunduz trauma hospital in 2015, likely because of global attention and U.S. responsibility. Even in the countries studied, only in Syria have there been assessments of methods of surveillance of attacks on healthcare.

As a result of the few studies conducted, and the absence of baseline data, no conclusions can be drawn on whether attacks on health are increasing over time. In sum, the research does not accurately portray where or when attacks on health are occurring but may give a perspective on the range and characteristics of attacks.

What: What types of attacks are being documented?

There is a concern that high-profile airstrikes targeting healthcare facilities, and the advocacy around them, could skew attention away from other conflicts or other attacks on civilians, or misrepresent the scale of attacks globally [ 86 ]. However, this systematic review finds that many articles study less dramatic attacks including threats and interferences with healthcare. Myriad types of health facility and transport attacks are cited in the literature, including studies in Uganda, Somalia, Myanmar, South Sudan, DRC, Nicaragua, Palestine and region-specific studies in Kashmir and the Swat valley. The attacks include pillaging, looting, occupation, confiscating supplies, blocking entrance, or checkpoint delays. Among attacks on health workers, the vast majority studied in the literature are committed against local or national health workers and include threats, beatings, arrests, restrictions on work, torture and killing. Among these health workers, most studies focus on physicians and nurses but some cover community health workers, medics and other ancillary staff, depending on the context [ 41 , 69 , 83 ]. Gender dimensions of attacks on health workers and the specific risks for women, who may be more likely to work in rural areas or as community health workers, and may suffer from distinct forms of attack, are rarely addressed, as has been noted elsewhere [ 89 ]. The papers that specifically consider attacks on patients research killing and injury, harassment and intimidation, blocking care or interfering with timely access, denial of medical assistance, discrimination and interruption of medical care through disruptions to medical functions. The paucity of research overall suggests that much remains unknown about the global scale and types of attacks that occur, the objects of attacks, and their impacts.

Why: Why are attacks on health occurring?

A key challenge in understanding attacks against healthcare is identifying perpetrators and their motivations [ 67 ]. In the studies in this review, circumstantial information such as the context, post-hoc legal evaluations and eyewitness accounts of surrounding events are used to attribute attacks. Rarely do these studies use direct evidence such as witness testimonies and self-identification [ 44 , 70 ]. Except by implication, few studies addressed whether the violence was specifically targeted at heathcare, or whether it was an element of generalized or indiscriminate violence against civilians. In several papers, inferences about possible strategic reasons of the attack exist, such as to weaken the perception “of the government’s concern for the welfare of the people,” intimidate the population, or destroy hope of rebuilding in that area [ 43 , 53 ]. As with other topics, much research remains undone in this realm.

Addressing challenges

Towards clarity in the definitions.

Synthesis of the literature has confirmed the need for more explicit discussion of the definitions and boundaries of this area of study. While some have suggested the need for consensus definitions to facilitate comparison across cases [ 22 , 29 , 49 ], the contexts of violence against health care are highly diverse and may require different approaches [ 41 , 60 , 86 ]. Instead, we argue researchers should endeavor to render explicit their definitions and discuss the implications of those decisions for their methodology.

The legal framework governing attacks on healthcare in conflict rests on the Geneva Conventions and its Additional Protocols, which apply during armed conflict. In some circumstances, international human rights law is more applicable [ 76 ]. However, some studies have looked beyond international and non-international armed conflict to address attacks within settings of political volatility and civil unrest [ 23 , 56 ],where violence against medics, ambulances and wounded protesters mimics many of the conditions of conflict. Because the meaning of conflict is variable, referring to international, non-international, as well as politically volatile contexts, explicit delineation of the terminology of “conflict” is more important than consistency in definitions. However, in broadly defining conflict and potentially including civil unrest, it will remain crucial to continue to distinguish this range of conflict settings from interpersonal violence and attacks that occur in peacetime situations. In settings not within the IHL definition of conflict, human rights law as well as criminal law will still apply [ 54 ].

Determining and classifying what counts as an attack on health in conflict was not always straightforward. Both violent and non-violent attacks constitute types of violence against healthcare. Non-violent interference included examples of intimidation, threats, and restrictions that profoundly harm health providers, patients and services. Beyond the attacks on facilities, transports, personnel and patients, misuse of health facilities and ambulances for military purposes, either violently or non-violently, also occurs frequently, and all may constitute violations of IHL. We conclude that it is critical to include physical and non-physical attacks, as well as direct and indirect attacks in any definition of violence against healthcare, as the impacts of the attacks are not always clearly correlated to the scale of the initial attack. While research should avoid equating airstrikes with threats of closure, for instance, both types of attacks can, in practice, halt service delivery for the local population.

Clarity is also needed to distinguish interpersonal violence in health care from conflict-related violence. Interpersonal violence persists in conflict and may even be exacerbated by the culture of aggression during armed conflict, but would not usually be understood as conflict-related violence per se. Furthermore, tensions among different communities and stress regarding sick family members, exacerbated by weak health systems with limited equipment and medical supplies (which may themselves be a result of attacks on health) may increase the frequency or scale of interpersonal attacks as respect for healthcare is eroded [ 40 , 64 ]. Recent reports on attacks on health in the setting of COVID-19 only serve to heighten this concern [ 90 , 91 ]. Moreover, it is difficult to distinguish interpersonal violence or criminal violence (e.g. robbery or gang violence), from politically-motivated violence. However, two critical factors in many papers distinguished interpersonal violence from the formal classification as “attacks on healthcare in conflict”: (1) the perpetration of violence against healthcare as politically motivated, whether specifically intended or as a result of indiscriminate violence and/or (2) when the perpetrator was an organized armed group or state actor. Attacks of this nature comprised the violence reported in these papers, which were framed around the obligations of ‘duty-bearers’ in armed conflict to ‘take precautions’ to protect civilian lives and medical care when engaging in hostilities.

Practical challenges to documenting attacks

Operationalizing any definition for those recording attacks adds another layer of complexity. Neuman addressed the potential differences between those doing the frontline documentation and those compiling data sets, and the organizational politics of recording insecurity:

‘At the project level for those whose responsibility it is to document incidents, there is no consensus on what exactly constitutes an incident. In a setting where violence and verbal threats are so prevalent, documenting insecurity represents a real challenge. Should the team only record events they consider to directly impact operations, such as shootings in the hospital, car jackings, etc., or should they try to document all incidents that occur, including minor threats, just to maintain a comprehensive record? The decision on whether to report an incident or not may be rooted in the fact that the person responsible for drafting the report wants to portray the reality in a specific light, whether that be to alert, alarm, or the opposite, reassure headquarters and the coordination team in Sanaa’ [ 70 ].

There are also challenges in characterizing or categorizing incidents. How do we account for multiple hits within a short, delineated timespan [ 49 ]? How do we account for attacks that span days or weeks such as the occupation of a facility or the kidnapping of a health worker [ 55 ]? How do we assign a classification of ‘healthcare attack’ for unclear situations? Additionally, naming protocols and language differences across contexts can make reporting consistency difficult. For instance, while post-British colonial countries may function under a centralized governorate➔ district➔subdistrict➔ community model, many countries, including the US, do not utilize this approach. Terms such as “medical point” or “mobile clinic” can imply different things. Even medical “transport” may refer to a fully functional ambulance in some settings and a motorcycle or boat in others. Health workers with the same titles may have vastly different responsibilities across settings [ 29 ]. In the US for instance, a receptionist may not have any clinical training and would not necessarily fall under an attack on a health worker while in Syria, a receptionist may be critical to clinical care, patient transport, vital sign measurement and other tasks. It is important, then, for researchers to consider not only how they understand and report attacks but also for stakeholders to explore the locally-held understandings of attacks and the victims. These challenges to standardization highlight a key challenge to producing globally aggregated data. Contextually specific, locally-held understandings of attacks may not be easily comparable. As with conflict definitions, we recommend clarity in definitions rather than a standardized attack definition which may miss these context-specific dynamics.

Fourteen of the articles address the indirect, cumulative or long-term impacts of attacks on health. There are numerous dimensions of impact – including those on health workers personally (attrition, emotional responses), patients (intimidation, health outcomes), as well on facilities and the health system as a whole or the population more broadly (population movements). None of the impact studies quantitatively link specific attacks to their impacts or probe the causal pathways in depth. There are also challenges in disentangling the impacts of attacks on health from the impacts of conflict and insecurity. Further research on the multiple wider, indirect and long term impacts of attacks on healthcare represents a promising opportunity to advance our understanding, and could draw upon impact studies in other fields.

Limitations of this review

This study is limited, despite its attempt to synthesize a large body of literature. The papers that we identified were dispersed among a variety of disciplines and formats, which made using any single search inadequate. We started with a systematic search to collect as many articles as possible but our final articles for inclusion emerged with nearly half of the papers identified through reference review and professional networks, highlighting the challenges of systematic review for interdisciplinary issues. We did not include the large body of human rights and other reports, or data-collection initiatives (for example, the ICRC’s Healthcare in Danger Initiative) that have addressed the problem of violence against healthcare. We chose to exclude these reports in this review as current search strategies were not successful in identifying all the key grey literature, especially for older reports before the internet was in wide use. Additionally, though grey literature publications have many useful insights, they usually consist of documentation of attacks or summaries of data. Many do not describe methods used. For the same reason, we excluded commentaries and perspective essays, though they often included important points. Reviewing these reports and initiatives would add significantly to the lessons learned on attacks on health [ 76 ] but were not within the scope of this review focused on peer-reviewed research.

Although we attempted to be comprehensive, we may not have captured all the papers written on this subject. We acknowledge the positionality of the authors, who wrote some of the reviewed papers and have engaged members of the civil society community working to advocate against attacks on healthcare. This positionality has informed the analysis but we have worked to utilize the depth and range of our collective experience to bring greater clarity and nuance to this paper. We only searched the English-language literature but further scoping of the Spanish, Arabic, Farsi, French, Hindi and other languages might reveal far more research. While we attempted to be thorough in our search terms, there may be some terms that yielded information about attacks on health that we excluded. The articles were heterogenous and hard to categorize, therefore, perhaps a defined taxonomy and engagement of dispersed researchers interested in this topic would be useful for future work.

Conclusions

This paper reviews 45 articles, of which 35 were research studies and 10 were analyses, over nearly 40 years to better understand how attacks on health in conflict are documented, studied and used for prevention, protection, and accountability. The studies provide insight into particular cases of violence against healthcare in armed conflict, but significant gaps exist regarding many contexts, characteristics of violence, and methods of documenting attacks and their implications. These underscore the need for future research. The studies offer lessons on the use of novel investigative methods as well as mitigation strategies in response to the violence. Cumulatively, these data underscore the context-specific nature of the purposes, means, and impacts of violence against healthcare. While there is much to be learned from collecting global data, measuring the scale of attacks, and standardizing reporting, the work must stay rooted in the context. Promisingly, the studies, written by physicians, researchers, legal experts, human rights investigators and others showcase the strengths of heterogenous and interdisciplinary approaches.

The literature has expanded in the past 10 years but it is unclear if the knowledge generated has helped to curb the frequency, scale or scope of incidents of attacks on health in conflict. Key questions remain: are states and armed groups modifying their behavior? Is there accountability for these crimes? The question of what actions are needed from states, armed groups, NGOs, UN agencies and civil society to prevent attacks is beyond the scope of this paper, but it is evident that further research, standardized monitoring and their use for reform, programming and accountability are critical. Further, stakeholders must ensure the relevance of research toward these ends. We also need a better understanding of the consequences of the attacks both in the short and long terms and on local, national and international impacts [ 92 ]. There is much at stake in ensuring we understand attacks on healthcare and this review has highlighted some of the key avenues for future research and policy action (Table  2 ).

In recent years there have been a number of initiatives apart from the research reviewed here to expand data collection on violence against healthcare, though many are under-resourced [ 6 , 21 , 95 ]. The WHO is beginning to take on a role in collecting and disseminating limited aggregated information in some countries based on a mandate from the World Health Assembly in 2012, but it is subject to political pressures and bureaucratic hurdles [ 5 , 96 ]. The WHO system has potential, though it needs to be methodologically strengthened, expanded in scope, better coordinated with country offices and external stakeholders, and have disaggregated and more detailed data available (including on details of an attack and on perpetrators) before it can become the global focal point for data on violence against healthcare. Further, neither the research nor data collection has resulted in state action to protect healthcare in conflict, as provided in UN Security Council Resolution 2286 (2016). Perpetrators of violations of IHL, including attacks on health, may be investigated but to date prosecutions have not been initiated. States and international organizations must make addressing attacks on healthcare a priority, in terms of supporting research, prevention and response. This, too, is unfinished business.

Availability of data and materials

Not applicable.

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Acknowledgements

The authors would particularly like to thank the health workers who work in conflict settings and manage to care for their patients under extraordinary circumstances. We thank Martin Gazimbi for initial work and Daniel Ellis for additional support on this project. We thank Monique Patil and Swetha Manne for assistance with data cleaning.

Funding for this project was provided by the UK Foreign, Commonwealth & Development Office.

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Rohini J. Haar and Róisín Read are co-first authors.

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Division of Epidemiology, University of California, Berkeley, School of Public Health, Berkeley, CA, USA

Rohini J. Haar

University of Manchester, School of Arts, Languages and Cultures, Humanitarian and Conflict Response Institute, Manchester, UK

Róisín Read, Larissa Fast, Stephanie Rinaldi & Bertrand Taithe

Geneva Centre of Humanitarian Studies, University of Geneva, The Graduate Institute of International and Development Studies, Geneva, Switzerland

Karl Blanchet

Insecurity Insight, Geneva, Switzerland

Christina Wille

Program on Human Rights, Health and Conflict, Center for Public Health and Human Rights, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA

Leonard S. Rubenstein

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RH designed the search strategy, carried out the review, extracted the data and co-wrote the paper. RR carried out the review, extracted the data and co-wrote the paper. LF conceived of the project and was a major contributor in writing the manuscript. KB advised on the analysis, and was a major contributor in writing the manuscript. SR assisted in managing the project and contributed to reviewing and revising the manuscript. CW provided guidance on the project and reviewed and revised the manuscript. BT advised on and revised the manuscript. LR supervised the project and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Rohini J. Haar .

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Additional file 1: supplementary table 1..

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Haar, R.J., Read, R., Fast, L. et al. Violence against healthcare in conflict: a systematic review of the literature and agenda for future research. Confl Health 15 , 37 (2021). https://doi.org/10.1186/s13031-021-00372-7

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Workplace Violence in Healthcare: Position Statement Essay

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Workplace violence refers to any physical assault, aggressive behavior, or any inappropriate use of words resulting in abuse in workstations. The workplace takes account of the external environment and the functional areas in an organization. Workplace violence instances include threats of intimidation, fights, suicides, shootings, rapes, harassment along other traumatizing actions. For instance, an individual may attempt to harm a colleague by pushing or striking him or her with the intention of causing bodily harm. Verbal harassment includes false accusations and the use of abusive language (Estes, Chapman, Dodd, Hollister, & Harrington, 2013). Strangers, co-workers, clients, or even personal relationships can instigate aggression. The economic effect of workplace violence in health care settings include lost wages, lost productivity, legal expenses, lost working hours, and damage to property.

Workplace violent behavior has become a compound and risky occupational danger in today’s health care setting. Consequently, the risk arises from exposure to aggressive people and due to lack of well-built violence deterrence programs in the health care environment. Domestic violence also spread out, and it results in the sphere of threat for other workers, visitors, as well as clients. Risk factors in health care violence consist of commonness of handguns and other weapons among patients or friends, increased use of hospitals by the criminal justice system to hold up criminals, lack of follow up for discharged mental patients, unrestricted movement along with pitiable lighting systems (Lipscomb & El Ghaziri, 2013). Vulnerability to violent threats in health care setting requires a detailed analysis and assessment aimed at determining actions needed to minimize the risk. This may involve trend analysis and incident monitoring. Victims and witnesses of workplace violence in the healthcare setting require immediate treatment and counseling to minimize trauma effects.

A stranger who has no legitimate relations with either the employees or organization may cause violence. The central aim is robbery and may be characterized by assaults, deaths, or sexual abuse. Patients who may be violent in nature or that are discontented with services offered may be behind violent acts in hospitals. These patients may be prison inmates or even suspects being pursued by police officers. A co-worker or a past employee may also be involved in workplace violence where he or she brings forth hostile behaviors that result to harm (Estes et al., 2013). Lastly, a person in close relationship may perpetrate workplace violence with the victim because of personal issues. Results of violence include psychological torture, injuries, death, and feelings of intimidation.

To prevent cases of workplace violence, employers should ensure the working environment is free from hazardous elements; this would involve worksite analysis, risk control, education, and training of employees on how to handle equipments along with effective evaluations. Management commitment, as well as employee involvement, should aim at curbing workplace violence. The management is responsible of ensuring reduced violence by seeking employees’ opinions and implementing safety programs. In that regard, employee emotional and physical safety should be guaranteed to promise quality client service. In addition, the management should outline a comprehensive plan to maintain workplace security, assign duties and authority to skilled personnel, and create a zero tolerance policy to workplace violence in the organization (Lipscomb & El Ghaziri, 2013). Employees should be encouraged to report cases of violence to ensure that prompt actions are taken. More so, employees should understand and comply with workplace violence prevention programs and adequately utilize available safety measures. Heath care environment installed with effective alarm systems, metal detectors, emergency rooms, secured nurses’ service counters and closed circuit video recorders guarantee maximum safety.

Estes, C., Chapman, S., Dodd, C., Hollister, B. & Harrington, C. (2013). Health Policy: Crisis and Reform . (6th ed.). Burlington, MA: Jones & Bartlett.

Lipscomb, J. A., & El Ghaziri, M. (2013). Workplace violence prevention: improving front-line healthcare worker and patient safety. New solutions: a journal of environmental and occupational health policy , 23 (2), 297-313.

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IvyPanda. (2022, April 23). Workplace Violence in Healthcare: Position Statement. https://ivypanda.com/essays/workplace-violence-in-healthcare-position-statement/

"Workplace Violence in Healthcare: Position Statement." IvyPanda , 23 Apr. 2022, ivypanda.com/essays/workplace-violence-in-healthcare-position-statement/.

IvyPanda . (2022) 'Workplace Violence in Healthcare: Position Statement'. 23 April.

IvyPanda . 2022. "Workplace Violence in Healthcare: Position Statement." April 23, 2022. https://ivypanda.com/essays/workplace-violence-in-healthcare-position-statement/.

1. IvyPanda . "Workplace Violence in Healthcare: Position Statement." April 23, 2022. https://ivypanda.com/essays/workplace-violence-in-healthcare-position-statement/.

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IvyPanda . "Workplace Violence in Healthcare: Position Statement." April 23, 2022. https://ivypanda.com/essays/workplace-violence-in-healthcare-position-statement/.

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News Sep | 11 | 2024

Research Spotlight: Public Health Solutions to Reduce the Impact of Pediatric Gun Violence

Eric Fleegler, MD, MPH, from the Department of Emergency Medicine at Massachusetts General Hospital and senior researcher at MGH Gun Violence Prevention Center , is the senior author of a viewpoint published in JAMA Surgery, The Updated Haddon Matrix for Pediatric Firearm Injuries .

How would you summarize your study for a lay audience?

Firearms are the number one cause of death among children and teenagers in the United States, overtaking motor vehicle collisions in 2017. The Haddon Matrix, a public health praxis, has been successfully utilized to reduce motor vehicle injuries, and this paper applies the same framework to propose how to reduce pediatric gun violence. 

What question were you investigating?

How can we reduce the effects of gun violence among youth including homicide, suicide and unintentional injuries and death?

What methods or approach did you use?

We used the Haddon Matrix, the most commonly used paradigm in the injury prevention field.

The matrix enables us to look at firearm injury prevention at three time periods: Pre-event, event, and post-event, and to examine these time periods across four domains:

• The host (the person hurt or killed)
• The agent (the gun)
• The physical environment (the home, neighborhood, medical system
• The social environment (legislative and regulatory policies, social culture)

What did you find?

There are multiple interventions that could decrease pediatric gun violence including regulations that would bring “smart” guns to market that only allow authorized individuals to fire, tightly regulate sale of military style weapons, create universal child access prevention laws that require secure storage, and establish resources for de-escalation training, among other changes.

What are the implications?

These interventions could reduce pediatric firearm injuries and deaths and likely have the same beneficial effects on adults as well.

What are the next steps? 

The authors recommend calling your representatives at the state and federal level to push for legislation and regulation that can improve gun safety.

Paper cited: 

Lee LK, Laraque-Arena D, Fleegler EW. The Updated Haddon Matrix for Pediatric Firearm Injuries. JAMA Surg. Published online September 11, 2024. doi:10.1001/jamasurg.2024.2753

Eric Fleegler, MD, MPH

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Justice Department Announces More Than $690 Million in Violence Against Women Act Funding

Today, the Justice Department announced the awards of over $690 million in grant funding administered by the Office on Violence Against Women (OVW). This funding will support services and justice responses for victims and survivors of domestic violence, dating violence, sexual assault, and stalking across all U.S. states and territories and in many Tribal nations.

The funding was announced as part of the Justice Department’s commemoration of the 30th anniversary of the passage of the Violence Against Women Act (VAWA), which was the first comprehensive federal law focused on preventing and addressing domestic violence, sexual assault, dating violence, and stalking.

“Thirty years ago, VAWA transformed our national response to domestic violence, sexual assault, dating violence, and stalking,” said Attorney General Merrick B. Garland. “Today, officers, prosecutors, judges, families, and society at large understand what should have always been clear: these crimes cannot be cast aside as somehow distinct or private. Instead, we recognize that they are among the most serious crimes that our society faces and that we must continue to improve access to justice, safety, and services for survivors.”

“I was privileged to work on the passage of the original Violence Against Women Act thirty years ago — landmark legislation that transformed how our nation responds to domestic violence and sexual assault,” said Deputy Attorney General Lisa Monaco. “Our country’s progress to prevent gender-based violence is not finished, but we have come a long way since 1994 thanks to the hard work of survivors, advocates, and members of law enforcement — including the women and men of the Justice Department — who work every day to hold perpetrators accountable and protect survivors. The grants we’re announcing today reaffirm our commitment to building safe communities for all, free from violence and fear.”

“Thanks to the changes in VAWA over the last 30 years, we've explored additional pathways to justice, acknowledging that justice looks different for each survivor,” Principal Deputy Associate Attorney General Benjamin C. Mizer said. “The right to live free from violence is fundamental, and our policies and resources must continue to evolve to protect this right fully. I commend OVW’s efforts to implement VAWA 2022’s expanded resources, including new funding to support and strengthen restorative practice programs addressing gender-based violence as well as to prevent and prosecute cybercrimes such as cyberstalking and the non-consensual distribution of intimate images.”

VAWA was first enacted in 1994 as part of the Violent Crime Control and Law Enforcement Act. It initially focused on providing resources and training to improve the responses and policies of law enforcement, prosecutors, and courts, to support victim services, and to address crimes historically treated as private matters. Recognizing that domestic violence, sexual assault, dating violence, and stalking require a coordinated community response that extends beyond the justice system, Congress subsequently reauthorized VAWA, enhancing its policies and expanding grant funding streams, in 2000, 2005, 2013, and 2022.

Each reauthorization of VAWA has broadened the law and expanded available resources, reflecting an evolving understanding of these crimes and underscoring the need for comprehensive, holistic approaches to improve victims’ access to justice, safety, and supportive services while also improving offender accountability. Over the years, VAWA has supported enhanced comprehensive services for survivors and increased equitable access to funding and legal protections across all communities, particularly those facing additional challenges to attaining the services and support they need.

“The power of VAWA is that it is centered on the lived realities and leadership of survivors. By identifying what works well that can be expanded and enhanced, and identifying gaps and barriers, we can continue to improve VAWA and ensure that we are supporting all survivors, including those from historically marginalized communities and underserved populations who often face multiple barriers to services and safety,” OVW Director Rosie Hidalgo said. “We remain committed to making progress toward ending domestic violence, sexual assault, dating violence, and stalking, and to ensuring that all survivors have multiple pathways to safety, services, healing, and justice.”  

Created in 1995 to implement the provisions of VAWA and its subsequent reauthorizations, OVW provides national leadership on domestic violence, sexual assault, dating violence, and stalking. The office is comprised of dedicated advocates, experts, and survivors, many of whom have extensive experience in the field of domestic and sexual violence. OVW has distributed over $11 billion in funding authorized by VAWA since its enactment. Through its grant programs and partnerships, OVW helps strengthen local responses to domestic violence, sexual assault, dating violence, and stalking and provides funding annually to all 50 states, six territories, and many Tribal nations. By funding essential services for survivors, OVW ensures that communities are better equipped to address these critical issues. Today’s announcement includes funding for numerous grant programs, including new programs launched in FY 2024 as a result of the most recent reauthorization of VAWA in 2022 and appropriations acts.

Funding announced today includes:

• STOP (Services, Training, Officers, and Prosecutors) Violence Against Women Formula Grants Program:  Grants totaling over $171 million will be distributed to all 50 states and six U.S. territories to support a coordinated community response among law enforcement, prosecution, courts, victim services organizations, and other community services to address domestic violence, sexual assault, dating violence, and stalking. The STOP program was one of VAWA’s first grant programs and was authorized in the original enactment in 1994.
• Sexual Assault Services Formula Program: Grants totaling over $52 million will be awarded in each state and territory to assist them in supporting rape crisis centers and nonprofit organizations, as well as Tribal programs that assist survivors of sexual assault.
• Transitional Housing Assistance Grants for Victims of Domestic Violence, Dating Violence, Sexual Assault, and Stalking Program: Grants totaling over $40 million will support programs that provide six to 24 months of transitional housing support for survivors who are homeless or in need of transitional housing and other housing assistance as a result of domestic violence, sexual assault, dating violence, or stalking.
• Grants to Improve the Criminal Justice Response (ICJR) Program: Grants totaling over $24 million will assist communities in improving their criminal justice response while seeking safety and autonomy for survivors. ICJR grantees are encouraged to develop, implement, or enhance a coordinated community response to bring together effective partners from the local government, law enforcement agencies, prosecutors’ offices and courts, nonprofit organizations, and population-specific organizations to address these crimes. This year for the first time, OVW is also awarding more than $14 million through a related initiative, the Enhancing Investigation and Prosecution of Domestic Violence, Dating Violence, Sexual Assault, and Stalking Initiative , to support effective policing and prosecution strategies by promoting and evaluating effective trauma-informed policing and prosecution responses to domestic violence, sexual assault, dating violence, and stalking.
• State and Territory Domestic Violence and Sexual Assault Coalitions Program : Grants totaling over $19 million will support the critical work of state and territory domestic violence and sexual assault coalitions, which includes coordinating victim services and collaborating with federal, state, and local entities.
• Indian Tribal Governments Program: Grants totaling over $45 million will support the development and enhancement of effective strategies by Tribal governments to address domestic violence, sexual assault, dating violence, and stalking in Tribal communities consistent with Tribal law and custom. Additionally, $7.5 million is awarded under the newly established Grants to Indian Tribal Governments Program: Strengthening Tribal Advocacy Responses Track to support Tribes who have not previously accessed the Tribal Government funding and seek additional support for capacity building.

In addition, funding for new grant programs that were launched this year, made possible by VAWA’s 2022 reauthorization and expansion includes:

• Demonstration Program on Trauma-Informed, Victim-Centered Training for Law Enforcement (Abby Honold Program): Grants totaling $3 million will support the development and evaluation of enhanced, trauma-informed training for law enforcement to improve the response to victims. This new grant program, recently authorized through the 2022 VAWA Reauthorization, was championed by a former college student whose own experience as a survivor of sexual assault led her to want to improve the law enforcement response.
• National Resource Center on Cybercrimes Against Individuals: New funding totaling $2.8 million will support the establishment of a national resource center to provide information, training, and technical assistance to improve the capacity of individuals, organizations, governmental entities, and communities to prevent, enforce, and prosecute cybercrimes against individuals. This includes addressing technology-facilitated abuse, such as the non-consensual distribution of intimate images, and cyber-stalking, among others.
• Local Law Enforcement Grants for Enforcement of Cybercrimes Program: Grants totaling $5.5 million will be distributed through this new grant program to support communities in preventing, enforcing, and prosecuting cybercrimes against individuals and providing training for law enforcement, prosecutors, judges, victim services providers, and judicial personnel to address such crimes. 
• Restorative Practices Pilot Sites Program : Grants totaling over $15 million will be provided through this new grant program authorized by the 2022 Reauthorization of VAWA to support, strengthen, and expand existing restorative practice programs that address domestic violence,  sexual assault, dating violence, and stalking through a trauma-informed and survivor-centered approach. Additionally, OVW will award $8 million to fund research and evaluation of restorative practices in collaboration with the pilot sites. Earlier this year, OVW awarded grants to three entities to serve as national training and technical assistance providers and to work with the pilot sites.
• Healing and Response Teams: For the first time, OVW is providing more than $2 million through its Healing and Response Teams Special Initiative to support the development of practices using a Tribal-based model of care to respond to Missing or Murdered Indigenous Persons cases related to domestic violence, sexual assault, dating violence, stalking, and sex trafficking. This initiative is in response to recommendations made by the Not Invisible Act Commission.

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Continuing Trends: Five Key Takeaways from 2023 CDC Provisional Gun Violence Data

The latest provisional data from the Centers for Disease Control and Prevention (CDC) for 2023 shows continuing trends of gun violence in the United States from the year prior. Soon after the Johns Hopkins Center for Gun Violence Solutions completed the analysis of 2022 gun violence data , the CDC released provisional data for 2023. While there are some signs of improvement, troubling trends persist, particularly among vulnerable demographic groups. Here are the five key takeaways from the CDC's 2023 provisional gun death data.  

1. Overall Gun Deaths Decreased, But the Toll Remains Near-Record High  

The CDC's data shows that gun violence claimed 46,728 lives in 2023, marking the third-highest number of gun-related deaths ever recorded in the United States. The overall gun death rate did see a 3% decline from 2022, resulting in 1,476 fewer deaths. However, this reduction, while encouraging, still shows the immense scale of the problem, with nearly 47,000 lives lost to gun violence in a single year.  

2. Gun Suicides Reach All-Time High  

A particularly concerning finding is the continued rise in gun suicides, which reached a record high in 2023. With a 1.5% increase from the previous year, 27,300 people died by suicide using a firearm. This trend is not new—since 2019, there has been a 12% increase in the gun suicide death rate. The rise in suicide by firearm is especially pronounced among certain demographic groups. For instance, gun suicide rates among Native Hawaiian/Other Pacific Islander Americans surged by 67%from 2022 to 2023 and by 86% since 2019. Similarly, significant increases were observed among Hispanic/Latino (34%), Asian American (30%), and Black female (68%) populations.  

3. Gun Homicides Decrease, But Youth and Minority Communities Remain Vulnerable  

The data revealed an 8.6% decrease in gun homicides in 2023, translating to 1,724 fewer homicides compared to the previous year. Despite this positive trend, certain groups remain disproportionately affected. Black people continue to face gun homicide rates that are 13 times higher than those of their white counterparts. Similarly, gun deaths remain the leading cause of death among children and teens ages 1-17, with 2,566 young lives lost in 2023—a 2% increase in the death rate compared to 2022. Notably, while the gun homicide rate among Black and Hispanic/Latino children and teens has decreased, it has still doubled over the past decade.  

4. Disparities in Gun Violence Persist Across Demographics  

The 2023 data underscores the persistent and growing disparities in gun violence across different racial and ethnic groups. Gun suicide rates among Asian Americans, Hispanic/Latino Americans, and Native Hawaiian/Other Pacific Islander Americans have all seen significant increases since 2019. The gun homicide rates among Asian Americans have also risen, with a 9% increase from 2022 to 2023 and a 19% increase since 2019. These disparities point to the need for targeted public health interventions that address the unique challenges faced by these communities.  

5. Youth Gun Violence Remains a Pressing Concern  

Gun violence among youth continues to be a major public health crisis. Guns have been the leading cause of death among children and teens ages 1-17 for four consecutive years. While the gun homicide rate among children and teens decreased by 3% in 2023, the overall gun death rate for this age group nearly doubled over the past decade. The increase in gun suicides among older teens and emerging adults ages 15-19 is particularly alarming. For instance, the gun suicide rate among Hispanic/Latino older teens and emerging adults increased by 18% in 2023 and doubled over the past decade. Similarly, the gun suicide rate among Black older teens and emerging adults has tripled in the last decade, surpassing the rate among their white counterparts.  

The 2023 CDC provisional data on gun violence highlights both progress and ongoing challenges in addressing this critical public health issue. While the overall decline in gun deaths and homicides is a step in the right direction, the rising rates of gun suicides and the persistent disparities among youth and minority populations demand urgent and targeted public health interventions. The data serves as a sobering reminder that more comprehensive strategies are needed to reduce gun violence and save lives.  

2022 CDC Data Analysis

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I’ve always been critical of my body. Then I saw what it was capable of

When I chose to freeze my eggs — something that took me two years to mull over and decide — I sought out the consult of women my age who had already done the same. A frequent warning I got was about a common physical side effect of the process: “Covering the bloat” was something I was repeatedly told I’d have to deal with. So naturally, when my timeline was set in stone, I put together a wardrobe for work and play that I hoped would do the trick. 

But then, once I was in the thick of the process, something surprising happened. I realized that I didn’t care how I looked. At all . 

Let me back up to one of my earliest memories — it’s relevant, I promise. It was August 1994, my third birthday party, and my parents graciously gifted me the presence of my favorite movie stars: Aladdin and Jasmine. I used to watch “Aladdin” every day, sometimes multiple times a day, so I’ve been told. I loved the fairy-tale aspect, and I idolized Jasmine — maybe because I hadn’t seen Middle Eastern beauty represented anywhere else.

When actors dressed as Aladdin and Jasmine showed up at our house, I froze. I remember thinking, “I can’t believe these people are in my home, and they’re here for me!” I could barely smile or speak — I just kept staring at them in awe, starstruck. After singing a couple of songs in front of my friends and me, it was time for cake (probably my favorite part). My mom set out the cake along with crudité and other bites for the parents, and while I was thinking, “I can’t wait to eat that cake,” I heard Jasmine behind me squeal in excitement. She must have been as eager for cake as I was! We have something in common , I thought excitedly. Then she said, “Ooh, cucumbers!” 

That moment has been ingrained in my psyche since I heard those two words. I remember thinking that if I want to look and be like Jasmine, well then I, too, need to prioritize the cucumbers over the cake.

And yes, I was only 3 years old, but we all have a first memory we can’t forget. 

My brain was wired around food and body image from a young age, hitting its peak distress in my late teens and early 20s. My insecurities around my body took up so much room in my brain. 

As an adult, I’ve done a lot of work to feel more comfortable in my body, and to stop being so hard on myself — but that seed of negativity never fully went away. I’m the type of person who asks to avoid seeing the number on the scale when I get weighed at doctor’s appointments, and if I accidentally see the number, mental havoc rules my week. I’m also the type of person to have an intense HIIT workout routine for both physical upkeep and mental release. So, I’ll be honest — when the time was approaching for my egg freezing cycle to begin, I was anxious about not what my body would feel, but how I would feel about how it looked.

What I never expected though was to completely embrace my body — mentally, physically and emotionally — throughout egg freezing, despite the fact that, yes, I was bloated and also had to limit physical activity. For two weeks I injected myself with hormones 2-3 times a day, combining the solutions on my own, feeling quick bouts of injection pain and periods of fatigue, and traveling to doctor’s appointments constantly. After each shot, ultrasound or blood draw, I’d await my body’s reaction. Would I feel run down? Stressed? Anxious about any expansion around my stomach? I waited, but that’s not what happened. I mostly felt … strong. I was surprised and delighted by what my body was capable of. The strength I felt made me feel immensely grateful for my body and what it could endure. I felt empowered. The experience also, frankly, made me angry at myself for all the times I criticized my body’s appearance in the past, and all the time and energy I wasted on that way of thinking.

I mostly felt … strong. I was surprised and delighted by what my body was capable of. The strength I felt made me feel immensely grateful for my body and what it could endure. I felt empowered.

Body image is a construct. It is an idea of what society deems to be subjectively appealing and has been supported by the media over decades and generations. I’m so glad society is evolving and becoming more welcoming of all shapes and sizes, but you can’t rely on internet culture and the news cycle for acceptance, especially since what is acceptable is constantly changing. It needs to come authentically and wholeheartedly from within.

I wanted to freeze my eggs in my 32nd year, and I did just that: My egg retrieval was on my last day of being 32. For my 33rd birthday — exactly three decades after that birthday party I remember as a girl — I started the year with a clean slate, freeing up that space in the back of my mind that used to be hyper-focused on what I looked like, for something new.

I vow to be less critical of how my body appears, and more in touch with how it feels. I vow to be mindful of the cucumbers and enjoy the cake, and maybe I can help other women be less critical of their bodies, too. Our bodies endure and are capable of so much. They hold so much power and strength. We should own the power of our bodies. We should be grateful for them. After this experience, I know I will be.

Donna Farizan is a contributor for TODAY's fourth hour with Hoda and Jenna.

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