What happens after violence and abuse from patients?

Abuse from patients is something that needs to be prevented, but if it does happen, the response from within the team is important. Dana Sammut, registered nurse and PhD student at the Research Centre for Healthcare and Community Transformation, Coventry University, gives her advice for how to respond, based on findings from her own research.

Healthcare workers often face violence and abuse from patients and their families. Unfortunately, many have come to see this as a normal part of the job, meaning staff are less likely to speak up, report and seek support. I am writing this article because I believe that what happens after incidents matters, both for individuals and at a wider system level. At a time when health services are under strain, the way we respond to incidents remains something within our control.

For decades, research and policies on workplace violence have largely focused on primary prevention, with less attention given to what happens in the aftermath (or the ‘post-violence period’).

Primary prevention is hugely important, and proactive risk management – for example, in the form of staff training, de-escalation and clinical risk assessment – remains essential for reducing clinicians’ exposure to avoidable harm. However, just as tertiary prevention is integral to public health, actions taken after violence can play an important role in reducing its ripple effects.

Why this matters

Within this article, the term ‘violence’ refers to any act of physical or non-physical aggression, including assault, verbal abuse, harassment and intimidation, regardless of intent and outcomes. While violence between colleagues – sometimes called lateral or horizontal violence – is also something many staff face, it will not be a focus here, but further reading on bullying and harassment among colleagues is provided in the resources list at the end of the article.

Patient and visitor violence is not unique to any particular professional group or clinical setting, but much of the existing evidence focuses on violence in emergency and psychiatric settings. While these areas do typically see higher levels of violence, staff working in primary care and community settings are by no means immune.

In the 2024 NHS Staff Survey, over 7% of community staff reported experiencing physical violence from patients, relatives or members of the public in the past year, while more than 18% reported facing non-physical abuse.¹ Primary care practitioners also face additional risks due to the nature of their work, which can involve a greater degree of lone working and isolation than hospital-based roles.

Beyond the physical and psychological injury caused to staff, evidence links violence to disruptions to patient care, including clinical errors and worse patient outcomes², and there are significant financial implications for organisations in the form of staff sickness and attrition, among others.³ These consequences are not limited to physical violence, with evidence suggesting that non-physical abuse (eg, verbal aggression or yelling) plays an even bigger role in driving clinicians’ intentions to leave the profession.⁴

Unfortunately, many of what are seen to be the key underlying causes of workplace violence – such as long waiting times, overwhelming pressures on services and understaffed nursing teams⁵ – are systemic issues that are beyond the power of any individual nurse, department or even trust to meaningfully solve. This is not to say we should not strive to prevent violence from happening in the first place, but instead, acknowledge that there is only so much within our ‘control’ when it comes to the behaviours of others.

This means making space for post-violence actions that do not solely look back to ask, ‘what went wrong?’ but also consider, in a forward-looking capacity, what can be done to support individuals and systems to continue functioning well in the aftermath. Indeed, clinicians are increasingly voicing concerns about the dangers of claiming to adopt a ‘zero tolerance’ approach, since this language sets unrealistic expectations and reinforces the conditions needed for blame culture.⁶

Staff often experience guilt and shame after facing violence at work, feeling as though they failed in their responsibility to keep themselves and those around them safe. This shame, together with expectations of a blame response from management, leads many to avoid reporting incidents altogether.⁷ This in turn limits opportunities for staff to be offered support, for proportionate investigations to take place, and for appropriate measures to be taken in relation to the person(s) who was violent.

Such measures do not always need to be punitive; in fact, another common reason for non-reporting is the perception that the behaviour was unintentional (for example, due to cognitive issues or illness).⁸ In such cases, staff often believe that reporting will be inconsequential, yet there is more to be done after incidents than attempting to punish or demand accountability.

Evidence from hospital settings

As part of my PhD research, I conducted a literature review to identify what post-violence interventions currently exist in global hospital settings. Once identified, the interventions were grouped across three levels: staff-focused measures (eg, debrief, psychological support, short-term duty modifications), patient-focused measures (eg, behaviour contracts, individual plans and alerts, accountability measures), and interventions focused on the wider physical and social environment (eg, protocols for incident investigation, structured feedback processes, and integrated monitoring systems).

A common thread among these interventions is visibility: staff and patients see a response which underscores that violence is not a normal part of the job, and organisations see (and make use of) the data they need to make responsive changes.

And yet, there is a paradox here: post-violence measures hinge on incidents being reported by staff who, in many cases, avoid reporting due to a belief that nothing will be done in response. This has led some organisations to introduce structured processes to feed back to staff involved in violent incidents, regardless of investigation outcomes.⁹ Similarly, one article in my review described introducing post-violence checklists for management, outlining a series of actions to be taken in the aftermath.¹⁰

Integrating resources like this into everyday workflow systems (whether digital or paper-based) could be particularly helpful for new managers or for teams that do not regularly encounter violence, for whom such pathways are not well-rehearsed.

While these measures can help to improve the visibility of post-violence activities, it is also important to consider how they are enacted, which is perhaps harder to prescribe. Within the NHS, prevailing attitudes and expectations of resilience may inadvertently reinforce the idea that violence is a normal part of the job. Resilience is important, of course, but it is possible for healthy coping to slide into quiet resignation, and for the burden of adaptation to fall disproportionately onto individual staff.

Repeated exposure to violence over a long clinical career may well cause some to become desensitised, whether consciously or not. However, when these same staff – who are also more likely to hold senior positions – model or demand a stiff upper lip from others, they risk minimising their colleagues’ trauma and passing on their own passive acceptance.

Practical steps for primary care nurses and managers

A key take-away message for all is that any violence from patients or visitors, no matter the severity or intent, should be reported using your organisation’s formal reporting channel.

While the reporting process can be time-consuming, these data are essential for recognising patterns, triggering appropriate follow-up actions, and, ultimately, reinforcing a culture that does not see violence as part and parcel of nursing.

In the aftermath of violence affecting colleagues, adopt a trauma-informed response. Recognise that it is normal for people to have different reactions and responses and take care not to minimise non-physical or non-intentional behaviours: these can be just as impactful.

Post-incident debriefs can provide a valuable space for reflection, but they are not the place to treat psychological traumas. Instead, consider what specialist referrals (if any) may be appropriate, and ensure that decisions are made in collaboration with the affected individual(s).

From a manager’s perspective, it is important to encourage reporting and follow up with the staff who reported (ie, ensure a visible management response, even if there is no ‘resolution’).

Familiarise yourself with your organisation’s violence response pathways, as well as other systems-level processes, such as involving the police, and take steps to make these transparent where possible.

Reflective prompts

• If a colleague were to face abuse from a patient tomorrow, how confident would you feel in taking them aside to debrief? What resources could you refer to?
• Do you know the support pathways available to staff within your organisation, and how to make a referral (whether for yourself or for a junior colleague)?
• How visible is the management response after reports of violence in your department? Is there a process to update staff on investigation outcomes, even when there is no clear ‘resolution’?

Conclusions

When it comes to patient violence, primary prevention is important, but a narrow focus on risk reduction risks placing responsibility on staff for circumstances that are not always within their control.

What we can reliably influence is what happens in the aftermath of these incidents. Responses in the aftermath can shape staff recovery and set the tone for what constitutes a normal part of the job.