Reluctant victims: healthcare workers and workplace violence

Workplace violence may be defined as “violent acts, including physical assaults and threats of assaults, directed toward persons at work or on duty”.¹ Violence may pose an implicit or explicit challenge to a person’s safety, wellbeing or health.² In the healthcare sector, violence can have significant physical, psychological and emotional consequences, and delayed and longer-term impacts on functioning.³ Globally, pressure on healthcare services and increased demand for services is exacerbated by difficulties in recruiting and retaining staff. This rings particularly true for mental health, addiction and intellectual disability services,⁴ but we refrain from focussing on the specialty of psychiatry as an increasing number and variety of healthcare staff experience occupational violence.⁵ The rates of non-physical violence are reported to be between two- to ten-fold higher than physical violence. However, the prevalence of physical violence is reported to be as high as 65% and has risen significantly in the past three decades relative to the change in non-physical violence.⁶

The most at-risk services for violence are emergency departments, mental health units, drug and alcohol clinics, ambulance services and remote health locations.⁷ Factors underlying violence include delay in receiving care, frustration with long waits leading to emotional escalation, understaffing, emotional or mental stress of patients or visitors, insufficient security and lack of preventative measures.⁸

We are a registered nurse, a victims advocate and a psychiatrist. We care and advocate for people who are both victims and perpetrators of violence, and have helped many withstand the conflicting and incomprehensible nature of violence. Together, we have taught healthcare professionals about victim-survivors’ perspectives. Victim-survivor is the preferred term; in this article, we use the term “victim”, the technical term used in Aotearoa New Zealand legislation.

Violent acts can occur suddenly and unexpectedly to anyone, and cause trauma to victims. The neurobiology of trauma—connecting mind, body and trauma—goes some way to explaining the actions and behaviours of victims.^9,10 In this viewpoint, we focus on healthcare workers as a category of victims who experience workplace violence. We describe two of the authors’ experiences within a healthcare context as case studies to demonstrate the challenges in navigating recovery after violence. This has several aims: to introduce the concept of the victim landscape; to reflect on the psychic shifts and disruptions to a healthcare worker’s life after experiencing violence; to explore the relationship between workplace violence and negative consequences such as post-traumatic stress; and to provoke dialogue on optimal care practices for people who experience workplace violence. Workplace violence is not an isolated, individual problem; it is a structural, strategic problem involving relational, environmental, organisational and cultural factors.¹¹ Therefore, we take a broad, integrative view, emphasising the systematic role of organisations to support and protect healthcare workers who experience workplace violence.

Living experiences of violence

Nils Christie, writing on factors that shape our understanding of victimisation,¹² often invites people to scribble down a few words from their own personal histories as a victim, noting that memories prove valuable in prompting discussion. He posed the following questions: Have you ever been a victim? When was that? Where was it? What characterised the situation? How did you react? How did your surroundings react? We use some of these prompts to present our lived experience of violence.

Case 1—surviving attempted murder while on duty as a health professional: While working as a registered nurse in the community I visited a patient in respite care. I was attacked and held captive for 30 minutes before I managed to escape. I survived because I was fit and used the skills I learned in calming and restraint training. I sustained severe physical injuries that included facial fractures, severe bruising, nerve damage, stab wounds to my face, neck and back, and burns to 30% of my body. The assailant threatened to kill me. Unfortunately, this was just the beginning of my trauma experience.

Case 2—physical assault while assessing a psychiatric patient: I assessed a young woman in the intensive care unit at a women’s prison, in an interview room, with my nurse, a student and three corrections officers present. The patient walked calmly into the room and sat across a desk opposite us. Suddenly she lunged across the desk. Her fist contacted my head before she was restrained by the custodial staff. I did not lose consciousness nor was I severely injured. This was my first and only incident of violence.

The descriptions above demonstrate a spectrum of experienced violence. Violence is antisocial and confronting. It can be difficult to predict and breathtaking in the intensity and speed at which it can occur. It may be a split-second decision that separates survival from disaster and minor injury from serious disability. We should not normalise nor minimise a violent act, yet it may be tolerated or expected by healthcare staff when working with disturbed or distressed patients.

Navigating the victim landscape

The concept of the victim landscape is relevant as the healthcare worker who survives any form of violence navigates the immediate aftermath and beyond. They may report the incident and complete necessary documentation. They may or may not attend to personal injuries or take time off work to recover. They may recount and repeat events to different agencies such as police, occupational health and rehabilitation providers and they may enter the criminal justice system.

Case 1: Alongside personal and professional challenges, navigating the criminal justice system added another layer of distress. Conflicting protocols and practices between the Ministry of Justice and the Ministry of Health left me in a no man’s land of uncertainty, without clear rights or protections. I completed a victim impact statement with special permission—not as a right. The lack of procedural clarity and recognition compounded my sense of invisibility and disempowerment. Regular counselling could not keep pace with the evolving traumas. In order to access deeper psychological intervention, I was obliged to accept a diagnosis of post-traumatic stress disorder/response (PTSD/PTSR). The unintended consequence was discrimination: because of my mental (ill) health diagnosis I was not able to access certain work options, income protection insurance or travel insurance.

Case 2: Immediately after the incident I continued working. Shortly after, the patient was transferred to a medium-secure psychiatric unit. They subsequently assaulted multiple staff members in separate incidents. No charges were laid by the police. Weeks later, I took advice from the occupational safety advisor for a work-related injury (personal communication in: email, 4 December 2025). I eventually made an insurance claim for latent symptoms of a concussion.

The term “victim” can be considered an unwanted technical descriptor; for what healthcare professional wants to be termed a victim? Societal narratives and unconscious biases shape the response to victims.¹² The interfaces of “justice” and “health” do not intersect well, and victims often discover a clunky process that consumes time and energy and generates a significant amount of paperwork. The needs and rights of victims are fundamental: to be informed about access to services that address their needs, to utilise these services, to get help to understand reactions to their experience of a crime committed against them and the need for safety, which can only be held by well-constructed processes.

Disruptions to a healthcare worker’s life after experiencing violence

Individuals bear direct and indirect costs of workplace violence: physical illness, psychological repercussions, stigma, financial loss and time-consuming efforts to process and recover from the incident. They may find they have little control over the unfolding process. The imprint of violence returns in unconscious and unexpected ways, in memory and in body.¹⁰ They may experience latent and extended trauma, emergent on return to the workplace and other post-traumatic phenomena such as avoidance or hypervigilance.

Case 1: Before the attack, I worked full time, I loved my role and was regarded as competent and innovative. The aftermath of the attempt on my life was catastrophic. Ten weeks after the incident, I returned to part-time work despite still recovering from burns and experiencing pain. The trauma extended far beyond the obvious physical injuries—it dismantled the very fabric of my life. It contributed to the breakdown of my 25-year marriage, the loss of my job and my home, and—most painfully—my sense of self. That sense of self was deeply shaken but not destroyed. I went from being a respected colleague and clinician to being defined as a victim. The ripple effect was devastating and widespread; it deeply affected my friends, colleagues and whānau, especially my sons. My husband, also a registered nurse in mental health, never recovered from the secondary trauma.

Case 2: In retrospect, my initial reluctance to take action was to minimise the incident; after all, I wasn’t severely injured and the patient received treatment. I did not wish to waste my or anyone else’s time or energy and I did not view myself as a victim. I found the incident very disturbing, especially as I learned that several colleagues had sustained serious injuries from violent patients at work, requiring substantial periods of time off. I also learned that the patient had struck multiple staff previously under the care of adolescent health services.

Victims’ lives are disrupted by violence. It is a criminal act, and victims may endure crime as an extended process along a continuum of pain and discomfort.^9,10

The relationship between workplace violence, post-traumatic stress and moral injury

Often the onus is on the healthcare worker to be proactive and follow-up. Any violent incident is a salient reminder of the paramount importance of self-care. Recovery from workplace violence may involve a long period of rehabilitation. Staff require support during the entire period of rehabilitation and to be allowed necessary time to recover and supported to return to work.²

Case 1: My wellbeing was not always prioritised. Basic safety measures to monitor staff movements and implement staff alarms took many months. I was invited by my managers to share my thoughts about what contributed to the attack. I emailed my feedback but I received no reply. Many colleagues were supportive while others responded with avoidance (unconscious bias) and judgement (secondary trauma). Finally, deciding a highly stressful workplace environment was not worth the toll on my health, I resigned. This resulted in a loss of thousands of dollars in wages, as non-government roles pay significantly less. Over the next few years, I rebuilt my life and career and was employed as a mental health promoter for a non-government organisation dedicated to improving community and workplace mental health and wellbeing. My rebuild was shaken and significantly affected by the return of the assailant (who tried to kill me) to the vicinity as a patient. I became seriously concerned for my safety and wellbeing and that of secondary victims. My request for a restorative justice meeting was never progressed, and my concerns were often met with platitudes—“no system is perfect”—exemplifying systemic complacency and inflicting moral injury. I was eventually released from the stress and harm of the assailant’s return when he passed away in care.

Case 2: Being assaulted at work led to reflection—in retrospect, I should have left the workplace immediately and sent my affected team members home. My questions: How do we model self-care? How many of my colleagues had sustained injuries and not sought care for themselves? Who took time off work to recover? How many consulted their general practitioner to complete an insurance claim? What environmental protections are in place to protect workers? The interview room had a blind corner, observed on previous occasions as a place to be entrapped. After the incident, our team ceased using this room to see patients and, soon after, construction for a new interview room was approved. We got lucky that day: no one was severely injured.

It is unfortunate when a serious incident prompts action on ensuring a secure working space to assess patients. Workplace context is important,⁴ as violence is associated with understaffing, burnout, restructuring, insufficient resources and a culture that is tolerant of violence.² There can be longer-term disruptions to interpersonal relationships and development of a deeper type of distress. There may be a more enduring disruption in one’s sense of self and in team cohesion.¹³ Moral distress or injury may be amplified when managerial decision making disregards the impact on staff already affected, undermining trust in the organisation.¹⁴

Optimal care practices for employees who experience workplace violence

Victims often need medical care, emotional support and financial help for serious injuries. From an organisational perspective, there are extra considerations in protecting healthcare staff from workplace violence and its impacts.

Case 1: I considered my return to work and managing 32 hours per week only 6 months after a near fatal attack to be a major achievement. However, my rehabilitation case manager told me reduced hours “can’t go on forever”. She admitted she had not taken the time to read my notes and understand what had happened to me, citing workload pressures. Support from the acting manager of my workplace was limited, which compounded the sense of not being heard, invisibility and disempowerment during an already traumatic time as I was working through the legal process as a victim. Six months after my return to work my usual manager resumed her role. The difference was stark, resulting in real support and action, including a transfer to another (safer) unit. My lived experiences have shaped both my values and my voice, enabling me to be truly authentic within my mental health promotion role. They have taught me that wellbeing is not theoretical—it’s personal, lived and deeply connected to how we treat one another. It is therefore deeply concerning that workplace assaults remain widespread and, for many, are still part of daily working life in New Zealand. I have rebuilt my life, found a new career path, mana and purpose, and I am grateful for the unwavering support from whānau, friends and colleagues, both present and past.

Case 2: I learned much about optimal responses to being assaulted at work and the process after a work-related injury. I especially valued cultural support, reflecting on the head as tapu (sacred) and the disruption to wairua (spirit) when the head is struck. Support from occupational safety and health was not forthcoming, which meant I delayed seeking help. When I did, I received a comprehensive rehabilitation package due in part to self-advocacy. Stoic colleagues may not seek or get help, instead suffering consequences by minimising the impacts of violence.

Institutions have an obligation to ensure employees are aware of their right to receive support for recovery and return to meaningful employment.¹⁵ Healthcare organisations can do much to avoid compounding trauma through an active desire to understand, non-judgemental enquiry and putting in place positive, sustainable measures to prevent violence.

Discussion

These experiences illustrate gaps in system care of staff after violence in a healthcare setting. The scaling back of New Zealand Police involvement in mental health–related emergencies places health staff at an increased risk of harm when they are exposed to violence at work. We suggest there is a need to more accurately capture the incidence, extent and consequences of violence directed towards healthcare professionals at work. It is important that incidents of violence are reported in a timely manner and actions taken to proactively educate and care for staff. We recommend written information be provided by occupational health and safety services to all staff in orientation about work-related injuries and rehabilitation policies, and this information should also be readily available following an incident of workplace violence. This would operationalise Health New Zealand – Te Whatu Ora’s values in “recognising, supporting and valuing our people”.¹⁵ A compassionate healthcare system must work together with victims and other systems to intervene with support, solutions and justice. Including victims in redressing omissions or integrating recommendations for measures may protect workers from future harm.

The Health and Safety at Work Act 2015¹⁶ requires New Zealand employers and employees to actively identify and manage risks, with the aims of decreasing serious workplace injuries and deaths. One proposed amendment to this legislation would focus regulatory attention on critical risks associated with a hazard of any kind that is likely to result in a death, a notifiable injury, illness or incident. At Health New Zealand – Te Whatu Ora, the organisational values that emphasise safety and wellbeing are described under Te Mauri o Rongo – The New Zealand Health Charter. This emphasises caring for people who care for people¹⁵ under Te Korowai Āhuru, the cloak that seeks to provide safety and comfort to the workforce. The principle of do no harm applies to patient care and the health workforce, yet reports suggest hundreds of health workers in New Zealand experience occupational harm, including serious physical and verbal assault.⁵ If employees are injured or take time from work, they are more likely to formally report a violent event.¹⁷ Understanding the magnitude of under-reporting and characteristics of healthcare workers who are less likely to report may assist healthcare organisations to determine where to focus efforts in violence education and prevention.

When violence occurs we may ask what lessons have been learned and what sustained actions have been taken. Despite legislative frameworks and organisational values that emphasise safety and wellbeing, harm persists. Under-reporting of incidents aids no one—neither the victim nor the perpetrator. When violence towards staff is not reported, interventions that otherwise may prevent violence are not put in place. This may result in worse harm and more serious outcomes down the track.

The principle of “cause no harm” applies not only to patient care but also to the health workforce. Health New Zealand – Te Whatu Ora includes “caring for people who care for people”¹⁵ in its values and principles. The first case demonstrates missed opportunities to learn from and mitigate harm and the harmful impacts on staff, whānau, colleagues, patients and the wider community. The second case highlights delayed consequences of violence and the need for holistic, high-quality care to process a work-related injury. Victims become experts in contributing to preventing violence within the healthcare system. This knowledge can be harnessed, as each of us has a duty to identify what can be improved and to advocate for change. Victims need to know they and their experiences are valued and that their suggestions are considered and integrated in the healthcare system. This includes practical care of victims. Currently, there is limited provision to reimburse Health New Zealand – Te Whatu Ora employees when they pay a surcharge to a treatment provider to make an initial insurance claim (not reimbursed) or lose a percentage of their salary during their recovery (personal communication in: email, 4 December 2025). Documents outlining the process to support employees with investigations and rehabilitation should be made readily available (personal communication in: email, 4 December 2025). Staff may defer seeking help due to cost, contributing to inequitable access to care, and not be compensated adequately for recovery from work-related injuries. These disadvantages affect junior colleagues, health assistants, casual staff and those with other pressing family and financial commitments.

We encourage and recommend research that examines workplace violence and its associations with burnout, patient safety and adverse events.¹⁸ Impacts of workplace violence are feelings of anger, reduced work enthusiasm and the intention to quit work. An important longer-term consequence is poor job satisfaction contributing to staff turnover.¹⁹ Detrimental organisational effects include reduced work effectiveness, burnout and decreased wellbeing.²⁰ Special attention should be paid where there is high absence due to sickness or staff leaving, and recurring violence. Notably, the effects of workplace violence can remain active for up to 8 years, and arguably longer, after an incident.²⁰ An engaged, effective and culturally safe workforce contributes to a health system that learns, is responsive and equitable.²¹ A just culture is open to suggestions that improve safety.¹⁸ The onus is on healthcare organisations to proactively work to educate and support staff and develop policies and systemic improvements where violence is a recurring phenomenon in the workplace. Care practices that support staff recovery and reflection after work-related harm include timely debriefing and follow-up to build team capacity to manage violence and minimise harm.²² Organisations can carefully consider safety precautions,²³ security of the built environment, security presence, restricted areas, cameras, panic buttons and regular, compulsory Safe Practice Effective Communication (SPEC) training that needs to be passed as a core requirement. Innovative ideas to develop health workforce safety could be drawn together in a summit that includes WorkSafe, Health Quality & Safety Commission – Te Tāhū Hauroa,²⁴ Health New Zealand – Te Whatu Ora, Māori health and other health providers and people with lived experience. There must be a clear expectation that violence and mistreatment of staff will not be tolerated and will be reported.²² Healthcare organisations are obligated to flag risk(s) and injustice, and advocate for timely improvements. Workplace violence must never be accepted and simply attributed to the system.

Conclusion

Health professionals are key responders to victims of violence but also need sensitive and expert assistance and aftercare when they become victims. Workplace violence is consequential and effects may be delayed. Organisations can proactively promote optimal care for healthcare workers who survive violence by responding to incidents promptly, strongly encouraging staff to seek post-incident support as early as possible and providing practical support, initially and in the long term. There is an obligation to genuinely assess and re-assess the risks posed to staff. Staff should expect a safe return home from work. We emphasise protection of staff, with ongoing review and sharing of policies and practices that promote safety and wellbeing within the healthcare system.

Summary of recommendations

• A nationwide unified approach to collecting, analysing and reporting data on workplace violence across the health sector would assist with sharing information on findings.
• Commissioning research on the consequences of workplace violence, particularly psychosocial impacts, would enable further understanding on productivity, retention, burnout and organisational culture.
• Strengthening health and safety legislation would assist with clarifying responsibilities of individuals and organisations in identifying and managing risks and monitoring violence.