Workplace violence in trauma centers is a serious problem: an AAST Disaster Committee survey on assaults on trauma teams

Abstract

Objective

Violence against healthcare workers (HCWs), especially in emergency departments and trauma centers (TCs), is a significant and growing problem. HCWs have the highest numbers and annual rates of workplace violence (WPV) compared with any other private industry sector. There is less information about the rates of violence and stalking against trauma providers in TCs. We hypothesized that a majority of trauma surgeons and team members have experienced deliberate assaults in their TCs. Our secondary hypothesis was that a majority of trauma providers consider WPV a significant issue in their workplace.

Methods

The American Association for Surgery of Trauma Disaster Committee invited 2,100 members to participate in an online survey in May and July 2024. Questions evaluated practice type, TC characteristics, training, experience with WPV, beliefs about WPV prevention, and potential WPV prevention strategies interventions.

Results

The survey response rate was 10.9%, yet the prevalence of WPV in TCs was reported to be high. 63.9% of respondents were aware of a deliberate assault on an HCW in their TC or system. 42.5% had been assaulted personally, and 7.5% suffered injury as a result of a deliberate assault. Respondents generally agreed on the need for WPV prevention measures such as prevention education, metal detectors, armed police, or security, and were aware of deaths and disabilities among HCWs after assaults. However, they did not personally see WPV as a significant issue in their TCs.

Conclusions

There is a high prevalence of WPV with significant effects on the entire trauma workforce, including elevated levels of emotional distress, burnout, post-traumatic stress disorder, and long-term irreversible physical injuries and deaths. Respondents agreed on the need for preventive measures but did not view WPV as a major issue in their own TCs. Research into this discrepancy, as well as effective strategies to reduce WPV in TCs, would support advocacy for improved legislation and policies aimed at preventing WPV in healthcare.

Level of Evidence

V – Survey of expert opinion

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Workplace violence (WPV) against healthcare workers (HCWs), including physical assaults on physicians, nurses, and staff in emergency departments and trauma centers (TCs), has been a significant concern in the USA. Studies show high rates of physical and verbal violence. Little is known specifically about the incidence of WPV against trauma team members.

WHAT THIS STUDY ADDS

• This limited survey of American Association for Surgery of Trauma members indicates that WPV in TCs is common among respondents, with most (63.9%) respondents aware of an intentional assault on an HCW in the TC or system, 42.5% having experienced an assault personally, and 7.5% sustaining injuries from a deliberate attack. Respondents generally support preventive measures such as WPV prevention education, metal/weapon detectors, armed police or security, and weapons searches of emergency medical service patients. They were also aware of deaths and disabilities resulting from assaults, however, most did not report personally perceiving WPV as a major issue in their TCs. This suggests that there is a lack of awareness of the systemic nature of this problem. WPV in healthcare may have become “just part of the job,” assuming each incident is a “one-off”, and perhaps lends to the perception that “bad things won’t happen here.”

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY.

• This study will raise awareness to the prevalence and experience of violence in healthcare workplaces affecting trauma team members. Formal education in workplace violence (WPV) prevention should be a requirement for all trauma surgeons and team members as part of American College of Surgeons or state trauma center (TC) verification. This study will provide data to support advocacy efforts for state and federal legislation requiring hospital violence prevention programs and to improve reporting and penalties for deliberate attacks of WPV on TC HCWs.

Introduction

Violence against healthcare workers (HCWs) is a significant and growing concern, particularly in emergency medical settings. HCWs experienced the highest numbers and annualized incidence rates of workplace violence (WPV) compared with any other private industry sector.¹ A 2018 report from the Centers for Disease Control and Prevention found that 73% of those injured due to WPV were HCWs.² The number of assaults on HCWs, including physicians, increased during the SARS-CoV-2 pandemic.³ 44% of nurses reported experiencing physical violence, and 68% reported verbal abuse.⁴ A majority of orthopedic surgeons in a 2022 survey reported WPV experiences.⁵ Violence against HCWs can cause death, physical injuries, psychological trauma (including anxiety, depression, post-traumatic stress disorder (PTSD)), and burnout.6,8 Exposure to violence can lead to reduced job satisfaction, increased absenteeism, and higher HCW attrition.⁹

In a 2021 survey, 23% of responding physicians reported being personally attacked on social media.¹⁰ Stalking on social media can escalate into extreme physical violence, as when a patient fatally shot two doctors, a receptionist, and a visitor in Tulsa, Oklahoma.¹¹ In trauma centers (TCs) there is limited literature and a significant gap in HCW knowledge on the rates and types of violence against HCWs. Under-reporting of incidents is common. This is due to unsupportive cultures for reporting, failure to collect verbal assault data, concerns about a lack of effective changes after reporting, and the absence of meaningful penalties for perpetrators.12,14

The objectives of this survey are to obtain a sample of the experiences of American Association for Surgery of Trauma (AAST) members and associate members regarding violence against team members in the TC, including the occurrence of incidents, the nature of attacks, and protective measures in place. Our primary hypothesis is that a majority of trauma providers have knowledge of deliberate assaults or other categories of targeted WPV committed against team members working in their TCs. Our secondary hypothesis is that a majority of trauma providers consider hospital violence (deliberate assaults, stalking) to be a significant issue in their workplace.

Methods

Survey

In April 2024, the Disaster Committee of the AAST developed a cross-sectional survey tool to assess respondent demographics, the frequency and characteristics of violence, including assaults and stalking of healthcare providers in TCs, and opinions on hospital preparedness and support for violence prevention. The survey also explored how medical professional organizations can better assist with WPV prevention. No personally identifiable information was collected. Members of the AAST Disaster Committee working group developed the survey. Eight members of the committee pretested the survey for usability.

All members and associate members of the AAST were invited by email to participate in an online, cross-sectional survey on May 1, 2024, and again in July 2024. Data was securely collected via SurveyMonkey with IP address tracking to prevent duplicate responses; data collection ended on September 1, 2024. Survey questions and responses are included in tables 1–5 and also in the online supplemental file S-2. The survey methodology and questionnaires are detailed in the online supplemental file S-3. Data is available on reasonable request by investigators.

Table 1. What was the most severe degree of injury that you think the healthcare worker(s) sustained in the assault?

(Multiple responses allowed, totals greater than 100%)	n=131
Physical contact with the perpetrator but no visible injuries	53 (40.5 %)
Moderate disability: needed one or more days off work	34 (26.0 %)
Mild disability: no time or less than 1 day off work	28 (21.4 %)
No physical contact with the perpetrator	28 (21.4 %)
Death: died from injuries from the attack	13 (9.9 %)
Severe disability: hospitalized, prolonged absence from work or unable to return to work	7 (5.3 %)
Suicide: died from later suicide after the attack	1 (0.8 %)
Unsure/decline to state	8 (6.1 %)

Definitions

For survey purposes, deliberate HCW-directed violence included intentional assault, battery causing injury, verbal threats, written threats, or electronic threats. Stalking refers to persistent harassing or threatening behavior that an individual engages in repeatedly and may or may not be precursors to an assault or murder but places the subject in fear of death or physical injury. Under federal law, a person is guilty of stalking when they travel across state lines or into federal jurisdiction, including maritime boundaries or Indian territory, with the intent to kill, injure, harass, intimidate, or place another person in fear of death or physical injury.¹⁵

Data analysis

A sample size calculation for a 95% confidence level and a population of 2,100 members, with an estimate of 20% positive reported exposure to violence and a 5% margin of error, resulted in a required sample size of 221 respondents. SPSS V.30 (IBM, Armonk, New York, USA) was used for statistical analysis. Likert scale means were compared using t-tests. Missing responses were excluded from the analysis. Data reporting adhered to the CROSS checklist requirements (see the online supplemental files – S1)

Results

In 2024, 2,100 surgeons were either full or associate members of the AAST. 228 responded, resulting in a response rate of 10.9% achieving the required sample size. All 228 (100%) completed the main survey. Of these, 165 (72.4%) indicated knowledge of HCW assault or stalking events and completed additional survey questions on these topics. The median age group was 40–49 years. Among respondents, 110 (50%) were male, 101 (49.1%) were female, and 2 (0.9%) declined to specify their gender. The majority of respondents (192, 87.3%) identified as acute care surgeons (including trauma surgery, emergency general surgery, or surgical critical care). Additionally, 181 (83.0%) worked in an Adult Level 1 TC, 31 (14.2%) in an Adult Level II TC, and 10 (4.6%) in an Adult Level III TC. 56 (24.6%) worked in designated Pediatric TCs. The median penetrating trauma rate in those centers was 10–25%.

Regarding current preventive measures at their centers, 130 (61.6%) respondents have firearm-armed security agents or police readily available. 97 (45.5%) have metal detectors or weapons detectors at their entrances. A further 19 (9.0%) responded as “Other”: 16 indicated that metal detectors were only at a limited number of entrances, such as the emergency department (ED), and 3 noted that “wanding” (handheld metal detector) or other measures were used.

77 (36.0%) reported having an institutional policy to routinely search trauma admissions for weapons at their center or system (with emergency medical service, police, security, or hospital staff searchers). 39 (17.1%) responded “No” or “Unsure/don’t know” to any of these preventive measures, and 39 (17.1%) responded “Yes” to all three measures.

97 (45.3%) answered “Yes” to “I have been assaulted (physical or verbal threat or contact) while on duty in the TC.” Six respondents provided additional details—one incident occurred during training, two by patients with altered mental status, one by nursing staff, one was a verbal assault only, and two occurred at other centers or during residency. 43 (44.3%) of those 97 respondents who experienced assault were women, and 64 (66%) were men. 16 respondents (7.5%) reported being deliberately injured by a patient while on duty in the TC, with 10 (62.5%) of these being women, and one respondent reported being “grabbed by a patient” while in the third trimester of pregnancy. The difference in assault rates (males 47/106 (44.3%), females 42/104 (40.4%), p=0.13) and deliberate injuries (males 7/106 (6.6%), females 9/103 (8.7%), p=0.59) between males and females was not significant. 25 (11.7%) reported being personally attacked through phone calls, messages, emails, or social media, with 12 (48%) of those targeted being women.

Regarding awareness of deliberate HCW-directed violence within their TC/trauma system during the past 10 years, 136 (63.9%) respondents reported being aware of an incident. Among these targeted incidents, 95 (73.1%) of the assaulted workers were female. Perpetrators were a patient or former patient in 101 (77.1%) cases, a family member or friend of a patient in 70 (53.44%) cases, a coworker within the TC or system in 15 (11.5%) cases, a stranger or unknown person in 9 (6.9%) cases, and a spouse or intimate partner of the HCW in 11 (8.4%) cases, with 6 (4.6%) cases categorized as “Other.” The “Other” category included roles such as “Medical Student,” “Coworker’s husband,” “Law enforcement,” “Correction officer in the Sheriff’s department,” “Prisoner inmates,” “Several of the above,” or “Political Extremists.” There were no significant differences in personal assault rates between adult and pediatric TC levels or between adult and pediatric TCs.

38 (18.7%) respondents were aware of a stalking incident involving an HCW at the TC or trauma system in the past 10 years. 10 (4.7%) respondents experienced stalking directly as a result of their employment at the TC, of whom 6 (60%) were women. Eight (80%) of those stalked also reported suffering an assault while on duty at the TC, with 4 (50%) of these being women. Perpetrators were patients or former patients in 23 (60.5%) cases, a family member or friend of the patient in 9 (23.68%) cases, a coworker at the TC or system in 9 (23.7%) cases, a spouse or intimate partner of the HCW in 4 (10.5%) cases, and a stranger or unknown person in 1 (2.6%) case. Women accounted for 30 (79.0%) of those to be stalked by respondents. Escalation of stalking to physical injury or death of the HCW occurred in six reported cases. Two cases involved assault only by the stalker, one case resulted in physical injury (2.6%), and in three cases (7.9%) the HCW was murdered. Of those murdered by their stalker, two were women. Intimate partner violence was responsible for 8.4% of assaults and 10.1% of stalking incidents.

Figure 1 shows the distribution of HCW occupations who were assaulted or stalked. Figure 2 provides responses to the multiple-choice question: “Please describe the most significant event of assault or threats you are aware of at your TC/system in the last ten years - What method or weapons were used in the assault?”

Figure 1. Please describe the most significant event of assault/threats you are aware of at your trauma center/system in the last 10 years using the choices below: who was the healthcare worker(s) who was assaulted/threatened? (check all that apply) (n=131). Other: “Corrections officer”, “city police officer badly assaulted by her prisoner”, “all”, “active shooter subdued by police outside”, “entire "surgical" team”, “Janitor staff”.

Figure 2. Please describe the most significant event of assault/threats you are aware of at your trauma center/system in the last 10 years using the choices below: what method/weapons were used in the assault?.(check all that apply) (n=131).Other: “Physical contact/attempting to force”.

Table 1 shows responses to the multiple-choice question: “What was the most severe degree of injury do you think the healthcare worker(s) sustained?” Table 2 provides responses to the multiple-choice question: “What do you think were the consequences of this deliberate violence event (assault or stalking) that you know?”

Table 2. What do you think were the consequences of this deliberate violence event on the healthcare worker?

(Multiple responses allowed, totals greater than 100%)	Assault (n=131)	Stalking (n=38)
Emotional distress, burnout, PTSD, depression of the assaulted healthcare worker(s).	84 (64.1%)	26 (68.4%)
Increased emotional distress, burnout, PTSD, depression of coworkers.	59 (45.0%)	15 (39.5%)
Impaired performance of the assaulted healthcare worker(s).	44 (33.6%)	20 (52.6%)
Resignation, early retirement, job change of assaulted healthcare worker(s).	24 (18.3%)	17 (44.7%)
Prolonged absence of the assaulted healthcare worker(s) from their job.	32 (24.4%)	7 (18.4%)
Changes in physical security of trauma unit, hospital.	39 (29.8%)	11 (29.0%)
Event was not reported to law enforcement.	30 (22.9%)	19 (50%)
Event reported to law enforcement—no prosecution of assailant.	18 (13.7%)	5 (13.2%)
Event reported to law enforcement—prosecution of assailant occurred.	17 (13.0%)	14 (36.8%)
Clear policy or method to report possible or witnessed hospital violence to administration.	25 (19.1%)	N/A
Adoption of metal detectors/weapons detectors at trauma center entrances.	27 (20.6%)	N/A
Improved internal hospital violence prevention training program.	23 (17.6%)	2 (5.3%)
Increased numbers of hospital security agents.	20 (15.3%)	5 (13.2%)
Increased attrition, resignations, early retirements, job changes in coworkers.	17 (13.0%)	3 (7.9%)
New policy to adopt firearms-armed police or security agents in trauma center.	11 (8.4%)	N/A
Policy to routinely search trauma admissions for weapons.	11 (8.4%)	N/A
Unsure/decline to state.	13 (9.9%)	3 (7.9%)
Other* (please specify)	7 (5.3%)	2 (13.2%)

^*Other free text responses:

N/A, not applicable; PTSD, post-traumatic stress disorder.

Table 3 presents agreement and Likert-scale ratings for 12 statements about TC assaults, stalking, and potential advocacy and policy interventions. The statement with the least agreement was “I think that deliberate healthcare worker-directed violence and stalking is a significant issue in my TC/trauma system,” with a weighted average Likert score of 2.79 and a median (IQR) of 2 (2-4). Similar lower agreement responses included “I am concerned that I may be deliberately assaulted in my job at the TC” (weighted average 3.1, median (IQR) of 3 (2–4)) and “I am concerned that I may be stalked due to my job at the TC” (weighted average 2.9, median (IQR) of 3 (2–4)).

Table 3. Please rate your agreement with the following statements on trauma center assaults and stalking: (n=165).

Likert scale: 1—Strongly Disagree, 2—Somewhat Disagree, 3—Neither Agree nor Disagree, 4—Somewhat Agree, 5—Strongly Agree	Weighted average	Median (IQR)
Deliberate assaults on healthcare workers performing their duties in a trauma center should be punishable by a felony (2+ years in prison) in my state/province.	4.27	4 (4-5)
Education on preventing and mitigating deliberate assaults and stalking should be provided to all trauma team members.	4.15	4 (4-5)
Stalking of healthcare workers after performing their duties in a trauma center should be punishable by a felony (2+ years in prison) in my state/province.	4.13	4 (3-5)
The law in my state should mandate workplace violence prevention programs in trauma centers/systems like the one I work in.	3.99	4 (3-5)
Trauma centers should have metal detectors or similar devices to detect weapons at their entrances.	3.98	4 (3-5)
Federal law should mandate workplace violence prevention programs in trauma centers/systems like the one I work in.	3.91	4 (3-5)
Trauma centers should have armed security and/or police present at all times.	3.91	4 (3-5)
Trauma center verification guidelines should mandate workplace violence prevention programs in trauma centers/systems like the one I work in.	3.7	4 (3-5)
Emergency medical services agencies should have policies to search trauma patients for weapons prior to entering the trauma center.	3.68	4 (3-5)
I am interested in receiving education on how to prevent or mitigate deliberate violence or stalking in my trauma center.	3.6	4 (3-4)
It is clear how to report possible or witnessed violence in my workplace to the responsible leadership.	3.44	4 (2-4)
I am concerned that I may be deliberately assaulted in my job at the trauma center.	3.08	3 (2-4)
I am concerned that I may be stalked due to my job at the trauma center.	2.9	3 (2-4)
I think that deliberate healthcare worker-directed violence and stalking is a significant issue in my trauma center/trauma system.	2.85	3 (2-4)

Complete survey results, including free-text responses and comments, are available in the online supplemental materials S3.

38/199 (19.1%) of respondents reported experiencing stalking. Online supplemental Table S1 includes a table detailing how the HCW was stalked. Online supplemental Table S2 presents a table of agreement and Likert-scale responses to four statements about stalking events.

Discussion

This survey is the first to evaluate nationwide trauma team experiences with WPV. A majority of respondents (63.9%) were aware of deliberate assaults on HCW staff; 42.5% had experienced assault, and 7.5% had been injured. These findings support our hypothesis that most trauma providers are aware of deliberate assaults or targeted WPV in TCs.

Most respondents were physicians or trauma surgeons, and their assault rates mirror those reported in the emergency medicine literature. A 2008 study found that 47% of emergency physicians experienced physical assault and 71% verbal assault.¹⁴ A 2016 survey showed 78% of ED physicians faced WPV.⁶ In 2022, 77.3% of American Academy of Orthopaedic Surgeons (AAOS) surgeons reported WPV, with 71.8% experiencing verbal assaults and 14.6% physical assaults—lower than in our cohort.⁵ Although trauma surgeons spend limited time in the ED, their WPV exposure resembles that of ED physicians, reflecting risks from this selected patient population.

Our secondary hypothesis—that most trauma providers see hospital violence as a major workplace issue—was not supported. Many respondents disagreed that violence was a significant concern, possibly due to cognitive bias, coping mechanisms, or denial (“violence happens to patients, not to me”). Acceptance of patient risk behaviors may also divert attention from team safety. Some may feel resigned that little can be done or believe emphasizing WPV is a distraction. Such attitudes may persist until a serious event affects them personally or their immediate colleagues.

64% reported emotional distress, burnout, PTSD, or depression as common outcomes of WPV. Surgeon burnout is already high—74% in one survey—although not specific to trauma care.⁸ Continuous workload and stress may reduce awareness of WPV as a systemic threat to well-being.

Desensitization to frequent violence, well documented in ED studies,¹⁶ can also normalize aggression. Trauma surgery is already a high-stress, high-stakes endeavor - adding the cognitive load of personal threat assessment may not be something that can be contemplated in the environment. A 2025 review found ED staff often accept violence as “part of the job,” prioritizing patient care over safety.¹⁷ Themes included desensitization, hopelessness, identity-targeted WPV, and moral injury. Pandemic-era increases in WPV correlated with burnout and staffing pressures.^{18 19} Other reasons for low concern may include overconfidence in prevention efforts or underestimation of risk.²⁰

Stalking was reported by 18.7% of respondents, consistent with literature rates of 2–25%.²¹ Stalking often precedes assault (in 80% of cases) and has resulted in at least three known and documented homicides. High-risk specialties include psychiatry, surgery, and OB/Gyn.²² Because stalking can cause severe disruption and increase the risk of assault, 16 states classify first-offense stalking as a felony. Limited institutional understanding may lead to victim-blaming and poor protection. Leadership involvement is crucial to prevent physical harm, staff attrition, and morale issues.

Few studies address WPV prevention in TCs; most focus on EDs. De-escalation training—focusing on communication and recognizing aggression—is common, but its effectiveness remains uncertain. A recent ED survey found no universally effective de-escalation strategy.²³ Few residency programs teach such skills. Early identification of high-risk patients, possibly aided by artificial intelligence, shows promise.²⁴ Respondents supported measures like metal detectors or armed guards, though these can be costly or reactive. Currently, no states require hospital metal detectors.²⁵

Surgeon-led health policy advocacy is essential to protect the surgical workforce. The American College of Surgeons (ACS) supports the “Workplace Violence Prevention for Health Care and Social Service Workers Act” (H.R.2531/S.1232). Several states, such as California, New York, Illinois, Massachusetts, New Jersey, Pennsylvania, and Washington, mandate hospital WPV programs including de-escalation training, zero-tolerance policies, environmental adjustments, and mandated reporting. Survey respondents favored such laws, and should be encouraged to speak on their behalf, that of their coworkers and patients. Developing WPV-specific legislation for TCs should be an initiative for ACS Committee on Trauma (ACSCOT).

Respondents also supported more severe legal penalties for assaults on HCWs. 37 states already enhance penalties for attacks on ED staff. In 2024, California’s AB977—sponsored by and advocated for ACS trauma surgeons and allies—raised assaults in EDs or trauma bays to significant misdemeanors, although not yet a felony as in some states. The main effect hoped for in surgeon advocacy for AB977 is to encourage reporting and prosecution.^{26 27}

Significant limitations of the survey include a modest sample size and low response rate. The sample size was just statistically sufficient, which raises the risk of bias. The study presents the largest trauma-center WPV experience cohort to date. Low participation may reflect survey fatigue in heavily surveyed AAST membership or avoidance of distressing topics. Other surgeon surveys report similar low response rates,^{19 28} and the AAOS WPV survey had only a 5% response rate. Respondents may over-represent those with personal WPV experiences due to positive response bias for a significant life event. Most respondents were younger Level I trauma surgeons, which limits generalizability since most trauma care occurs in Level II and III TCs. Self-reported data and lack of response rationale also constrain further analysis.

Further research on effective measures to prevent WPV would be valuable, but existing literature provides guidance for planning and assessing compliance with WPV prevention standards in TCs. Guidelines and key elements have already been established by The Joint Commission, and resources are available from the Occupational Safety and Health Administration and others.^{29 30} ACSCOT can develop TC verification requirements based on these evidence-based strategies to ensure education and prevention of WPV, a suggestion that respondents widely supported. Tailored WPV education for individuals and centers could be feasible, such as a pioneer by AAOS and American College of Emergency Physicians initiatives. Increasing awareness of WPV could also be integrated into trauma-informed care education, such as in advanced trauma life support courses.³¹ WPV research and prevention efforts would also benefit from surgeon health policy advocacy to promote legislation, improve reporting, and implement WPV prevention measures. A summary of recommendations is included in online supplemental Table S3 in the supplementary material.

Conclusions

This survey by the AAST Disaster Committee on WPV against trauma providers, despite a low, response rate, reveals a high rate of assaults and stalking directed at TC HCWs, with risks of emotional distress, burnout, PTSD, injury, disability, and death. Stalking of trauma surgeons and their allies is especially dangerous as it is associated with increased subsequent risk of assault and death. Most respondents recognize the importance of preventive measures like armed security and metal detectors, but many do not view WPV as a serious issue in their own TCs. We think trauma surgeons, their teams, and associations should advocate for improved training, policies, and legislation to enhance hospital safety and reporting. Increased leadership and advocacy are needed to advance effective strategies for reducing violence in trauma settings and to develop evidence-based WPV safety guidelines. These guidelines could be multidisciplinary, endorsed by trauma organizations, and ultimately incorporated into TC verification programs.

Data availability statement

Data are available upon reasonable request.