By Don Sadler
Violence in the workplace has become an all-too-common occurrence in our nation. Unfortunately, the healthcare setting, including the operating room, is not immune to workplace violence.
Healthcare workers are five times more likely to experience violence in the workplace than employees in other industries and account for 73% of all nonfatal workplace injuries caused by violence, according to the U.S. Bureau of Labor Statistics.
Meanwhile, eight out of 10 nurses reported experiencing workplace violence in 2023 while nearly half said that violence is on the rise. And one in four nurses responding to an ANA survey report being physically assaulted.
“Workplace violence is pervasive and increasing across healthcare, with hospital workers facing much higher rates of physical assault, threats and verbal abuse than workers in other industries,” says ECRI Lead Safety Consultant Chris Barfield, MHIT, RN, CPPS. “This is particularly true in parts of healthcare with high-stress conditions, close teamwork and power hierarchies, such as operating rooms.”
ASCA board member David Shapiro, MD agrees: “Workplace violence in the form of bullying occurs far too frequently among surgical staff. This has been known to happen in all perioperative areas including pre-op, post-op, sterile supply and in the OR itself.
“Because perioperative professionals almost always work as part of a team, the presence of even a single individual exhibiting this type of behavior can filter down to affect the entire team,” says Shapiro.
A Common OR Problem
Erin Kyle, DNP, RN, CNOR, NEA-BC, EBP-C, Editor-in-Chief, Guidelines for Perioperative Practice with the Association of periOperative Registered Nurses (AORN), believes that bullying, incivility and violence in the perioperative setting are more common than many people realize.
“And it’s certainly more common than most organizations would like to acknowledge,” says Kyle. “What makes this difficult is that these behaviors often exist on a spectrum. Some are overt and unmistakable while others are subtle, normalized or dismissed as ‘just part of the OR culture.’ ”
“When these behaviors go unaddressed, they become embedded in the work environment and a threat to safety at every level,” says Kyle, who distinguishes between internal (staff) and external (patients and visitors) threats of OR violence.
“Internal threats are not an inevitable feature of perioperative work, high-stress environments or surgical urgency. They are fully preventable,” says Kyle. “But when organizations fail to set clear expectations, intervene early and apply accountability consistently, these behaviors persist. And over time, they teach staff to self-silence.”
Healthcare Sterile Processing Association (HSPA) Education Director Natalie Lind says her eyes were opened to the prevalence of violence and bullying in the OR when she gave a presentation on the topic a few years ago.
“Like many people, I knew workplace bullying and violence existed, but I didn’t realize the prevalence until I gave a presentation on bullying,” she says. “The program hit a nerve.”
Afterward, several attendees shared their personal experiences with Lind. “Some were in tears and the stories they shared were eye opening,” she says.
Bullying and violence are now Lind’s most requested presentation topic.
Forms of Bullying and Violence
Bullying and violence in the OR can take many different forms other than physical attacks. These include intimidating colleagues, abusive and offensive language, insults, unreasonable criticism, and spreading rumors and gossip.
Kayla Gough, RN, BSN, a charge nurse at OAM Surgery Center at MidTowne in Grand Rapids, Michigan, lists belittling comments and assumptions about a knowledge deficit as forms of bullying. “Additionally, teasing or sarcastic banter within the team can sometimes be taken personally or interpreted more negatively than intended,” she says.
Staff who feel bullied or undervalued may become hesitant to speak up about important safety concerns, adds Brittany Vondra, RN, BSN, a charge nurse at OAM Surgery Center at MidTowne.
“If staff do not feel respected or supported, they may avoid raising questions or correcting practices, even when patient safety could be at risk,” she says.
According to Barfield, the most common forms of bullying or violence within perioperative teams are intimidation, blame and exclusion.
“Known as Type III, or worker-to-worker violence, these create unsafe and uncomfortable working conditions,” he says.
Meanwhile, common forms of external violence initiated by patients and visitors may include verbal or physical aggression, threats, disrespectful behavior and even assault.
In an analysis of healthcare workplace violence-related events submitted by ECRI members between January 2021 and September 2022, 33% of incidents involved physical violence, 23% involved verbal violence and 31% involved both physical and verbal violence. While most of these were external violence, over 20% resulted in direct harm to the healthcare provider.
“This is unacceptable, regardless of the offender,” says Barfield. “When a healthcare worker experiences violence of any kind, it can affect their mental health by creating anxiety, fear and emotional exhaustion.”
Mental & Emotional Stress
While physical harm and injury are obvious risks of bullying and violence in the OR, the damage is often more mental and emotional.
“The perioperative environment is already stressful enough without adding more negativity, which makes everything more difficult,” says Lind. “The added stress from bullying and violence can lead to burnout.”
“When perioperative professionals work in environments where they feel disrespected, unsafe or unsupported, the stress is constant,” says Kyle. “Over time, this can lead to emotional exhaustion, moral distress and burnout. Many nurses will tell you that what wears them down is not the complexity of the work, but the emotional labor of navigating unsafe interpersonal dynamics while trying to keep patients safe.”
Beyond staff well-being, OR violence must be addressed to ensure positive patient safety outcomes. Says Barfield: “Violence disrupts communication, concentration and necessary collaborative teamwork, weakening the culture of safety that is the foundation of clinical quality.”
Barfield urges healthcare organizations to develop and rely on comprehensive violence prevention frameworks that include the following:
- Multidisciplinary workplace violence prevention teams to plan and oversee initiatives.
- Staff training on violence deescalation, early warning signs and reporting procedures.
- Behavioral Rapid Response Teams (BRRTs) to manage escalating situations.
- Environmental and administrative controls such as access limits, surveillance and clear behavioral expectations.
- Data analysis of reports to identify trends and evaluate interventions.
Lind says that addressing bullying requires modification of behaviors and a change in culture. “Change is difficult, but the more people understand how their words and behaviors can be hurtful and stressful, the better the transition will be,” she says.
Preventable Safety Issues
Kyle calls OR bullying and violence preventable safety issues. “Prevention has to be intentional, systemic and sustained,” she says. “It’s not a one-time training or poster on the wall.”
She recommends the following steps to help prevent bullying and violence in the OR:
Set clear expectations and enforce them consistently. Healthcare organizations need clear codes of conduct, well-defined unacceptable behaviors and consistent accountability, regardless of the team member’s role or status. “When behavior standards are applied unevenly, the culture learns that safety is negotiable,” says Kyle.
Build and protect a just culture. A just culture supports reporting and learning, distinguishes human error from reckless behavior and keeps the focus on systems while still addressing harmful conduct.
Equip teams with skills and shared tools. Simulation can be especially powerful for preparing teams to respond to higher-risk situations, whether these involve internal conflict or patient-related aggression.
Strengthen preoperative screening and planning, especially in ambulatory care. Kyle believes this is a major opportunity area. “Validated violence tendency or agitation risk screening tools are underused in the preoperative visit,” she says. Examples include asking about prior episodes of severe agitation in recovery, identifying significant anxiety or PTSD risk and noting substance use or withdrawal risk.
Address anesthesia-related triggers with compassion and preparedness. These include emergence delirium and emergence agitation, transient conditions that can lead to confusion and thrashing. “These behaviors are not intentional and do not reflect a patient’s character,” says Kyle.
Preventing bullying and violence in the OR starts during the hiring process.
“We clearly communicate our expectation of a positive and respectful culture, setting the tone for new team members from the start,” says Grace Patton, RN, MBA, BSN, CNOR, the OR manager at OAM Surgery Center at MidTowne.
However, you can never fully know how a new hire will fit in with the rest of the team. “So, it’s important not to rush the hiring process, especially when you already have a strong team,” says Patton. “Trust your instincts and listen to team feedback if a candidate doesn’t seem like the right fit.”
Barriers to Implementation
Unfortunately, there may be obstacles and barriers to implementing violence prevention steps. These may include resource limitations (especially in rural or smaller organizations), cultural acceptance of violence as “part of the job” and underreporting due to fear of reprisal or skepticism that reports lead to action.
“To overcome these barriers, executive-level support with consistent escalation protocols is paramount,” says Barfield. “When resources are low, explore community collaboration with law enforcement or behavioral health partners, lower-cost education and peer support models.”
Kyle lists a few more potential obstacles: hierarchy and fear of retaliation, inconsistent enforcement, financial and productivity pressures, and acceptance of bullying and incivility as being ‘just how it is in the OR.’ “Normalization of these behaviors is one of the most persistent barriers to violence prevention,” she says.
“These obstacles are real and they are often rooted less in lack of awareness than in competing pressures and long-standing norms,” Kyle adds. “Addressing them requires clarity, consistency and intentional use of time and resources.”
Lind says that bullying behaviors are sometimes unintentional. “Bullying may have been prevalent at a former job, or something that staff saw and accepted in their younger years,” she says. “Too often, we assume staff knows their behavior is bullying, but they may not. So, start by defining bullying and workplace violence and then begin to educate staff about prevention.”
Kyle stresses the importance of strong leadership when it comes to violence prevention in the perioperative setting. “Leadership matters – not in an abstract sense, but in practical, everyday ways,” she says.
“The tone leaders set, the behaviors they tolerate and the actions they take after concerns are raised all shape whether perioperative teams feel safe enough to speak up and supported enough to stay,” says Kyle.
“Even the best perioperative team can be impacted by bullying and the threat of violence,” says Lind. “It isn’t some other facility’s problem. Therefore, be proactive in addressing current issues and establishing a plan to prevent incidents from happening.”
New Wearable Technology Helps Combat OR Violence
When violence escalates in the operating room, it can do so quickly and without warning or visibility to the broader healthcare team. So even if safety protocols and security teams are in place, they’re not always immediately accessible to perioperative team members.
“These systems are only effective if they can be activated in the moment they’re needed,” says Kenny Kelley, the founder and CEO of Silent Beacon, a workplace safety company that provides real-time emergency communication solutions. “In many real-world scenarios, they can’t.”
Silent Beacon is a wearable panic button worn by perioperative personnel that triggers an immediate alert notifying 911 and internal security if violence occurs in the OR. It shares real-time location data so responders know exactly where to go.
“The key difference is that the ability to call for help is no longer tied to the operating room, the equipment or someone else recognizing the situation,” says Kelley. “A wearable panic button removes this delay – and in these moments, this determines whether a crisis stays controlled or escalates.”
Silent Beacon shortens the window between when an event happens and a response begins. “This window is where incidents escalate, injuries worsen and liability exposure grows,” says Kelley. “Closing the window changes outcomes.”
There’s also an operational benefit. Kelley explains: “Staff who work in high-acuity, unpredictable environments and know they have a reliable way to call for help work differently. This confidence has a measurable effect on staff retention, which is a real cost pressure for most OR and ASC administrators right now.”
