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Workplace Violence Prevention

Workplace Violence Prevention: Why Hospitals Should Give Doctors Time to Rehearse

A grieving relative wants answers after a death, and the anger is turning toward the doctor in front of them. The doctor has to respond to real concerns while recognizing when the discussion is no longer safe. These are high-stakes decisions for the family, for the doctor and for the care that follows. Hospitals can give doctors a place to rehearse them, review the conversation with an educator, and connect practice to local procedures for getting help and reporting threats.

Discuss a Focused Proof RunExplore the Station

Hospitals begin with a paid, bounded proof run. Pricing is shared after a scoping conversation.

Medical college or another eligible institution? Request a scoped free trial.

By the Lingua CoPilot Medical team. Evidence reviewed .

Three takeaways

  1. 1

    The stakes are real. Violence and threats from patients and families affect doctors across health systems, and the consequences reach staff, patient care and the hospital.

  2. 2

    Check that preparation reaches doctors. Training requirements have not always applied to physicians as consistently as to nursing staff, and feeling confident is not the same as performing well under pressure. Rehearsal with educator review shows what a doctor actually said.

  3. 3

    Rehearsal is one layer, not the whole answer. Evidence on whether training reduces incidents is mixed. Rehearsal sits inside the hospital's own program of security, staffing, reporting and staff support.

What doctors practice, and what educators review

Illustrative case from the station. A man has died in casualty after a heart attack. His son is convinced his father lay unattended, and he confronts the casualty doctor, first about the timeline and then personally.

In the Workplace Violence Prevention - Threat Recognition and Safe Response station, the doctor practices out loud with a responsive AI relative:

  • acknowledging the loss and the concern the son has raised;
  • offering a concrete, legitimate route for each concern, such as a records request, a review of care or the hospital's grievance process, without admitting what has not been established;
  • recognizing when anger becomes a direct personal threat, and pausing the discussion to call for support instead of arguing on.

Afterward, your hospital's educator can review the conversation evidence with the doctor. The assessment engine works from verbatim quotes of what the learner said, and missed steps are marked not observed. The evidence helps them choose what to rehearse next, and the doctor can repeat the case and try a different approach. The review arrangement is agreed during scoping.

For patients whose fear or pain presents as hostility, the Crisis De-escalation station offers related practice.

Why these conversations are high stakes

Violence can happen however well a doctor communicates, and keeping staff safe is an organizational responsibility. The evidence below explains why the conversations around a death, a deterioration or a delay still deserve preparation.

Doctors face violence and threats across health systems.

The figures below use different measures, samples and years. They show that the problem is widespread, not how countries compare.

  • United States (physician survey, 2020 to 2021): in a national survey of US physicians, 14.8% of respondents to the physical-harm question had been physically harmed by a patient, a family member or a visitor in the year before the survey. [1]
  • England (NHS Staff Survey 2025): 14.47% of NHS staff experienced at least one incident of physical violence from patients, their relatives or other members of the public in the last 12 months, and 31.82% of medical and dental staff experienced harassment, bullying or abuse from the same groups. [2]
  • India (online survey, 2019 to 2020): in a self-selected survey of doctors across India, relatives were identified as the main perpetrators in 82.2% of reported incidents. [3]
  • Australia and New Zealand (member surveys, 2016 and 2019): the Australasian College for Emergency Medicine's 2024 policy, citing its member surveys of 2016 and 2019, reports that nine in ten members reported feeling threatened by a patient and four in ten reported physical assault. [4]
  • Global research (2019 meta-analysis): Across 138 studies, the pooled estimate of health workers experiencing physical violence during the 12 months preceding their survey was 24.4%. [5]

The moments that deserve preparation.

Doctors in the Indian survey most often linked violence to a deterioration or lack of improvement (40.0%), a perception of wrong treatment (37.3%), a death (34.4%) or a delay in treatment (28.5%). The survey's authors recommend strengthening doctors' communication skills, including explaining prognosis, treatment outcomes and costs in the patient's own language. [3] In a survey of 520 relatives at one emergency department in Turkey, the most commonly perceived driver of violence was that patients or relatives had not been adequately informed about the patient's condition. [6] These are perceptions, not proof of cause. They point to the conversations worth rehearsing: explaining a death, a deterioration or a delay to a family in distress. Not every incident starts this way. In a 2022 poll, US emergency physicians attributed most assaults to psychiatric patients or to people seeking drugs or under the influence. [7]

The consequences reach staff, care and the hospital.

  • Staff. Among US physicians, reported mistreatment by patients, families and visitors was associated with higher odds of burnout: 2.2 times the odds in the highest score category, compared with no reported mistreatment. [1] In a four-year study of Finnish physicians, exposure to physical violence was associated with greater later intention to leave, and Australian doctors exposed to aggression were more likely to intend to leave patient care within five years. [8][9]
  • Patient care. Experiments suggest that hostility competes with clinical thinking. Using written clinical vignettes, residents diagnosed less accurately when the patient was described as disruptive (0.41 against 0.51). [10] In a neonatal intensive care simulation, rude comments from a patient's mother lowered teams' treatment and teamwork scores. [11] In the Indian survey, among the 477 respondents who had experienced workplace violence, 62.9% reported handling fewer emergency or critical cases, and 60.0% reported increased referrals or consultation liaison, calculated from Table 5. [3]
  • The hospital. The American Hospital Association estimated $541.3 million a year (2023) in absenteeism, lost productivity and turnover in US hospitals linked to workplace violence. [12]

Check that preparation reaches doctors.

In a 2022 survey of Texas hospitals, workplace-violence training was required in all units for clinical nursing staff at 79.7% of responding hospitals, against 64.8% for other clinical staff, a group that includes physicians and allied health professionals. This compares hospital requirements, not attendance. [13] A 2017 paper in the Journal of Graduate Medical Education reported that "all staff" training was not reaching resident physicians in appreciable numbers at the time, and recommended conflict-management and de-escalation training for all resident physicians in direct patient care. [14] Earlier surveys found similar gaps (see study notes). Hospitals can review whether their doctors have opportunities to rehearse, beyond completing required training.

Confidence is not the same as performance.

In a small randomized trial, psychiatry residents who practiced with a simulated agitated patient improved their observed performance more than a control group given a different simulation, while the change in their confidence did not differ between the groups. [15] In another program, medical students' confidence in verbal de-escalation rose, but an objective structured clinical examination found no difference in skill. [16] Acute stress can impair attention, working memory and decision making. [17] For hospitals, the lesson is to look at observed conversations under realistic pressure, not only at completion records or self-rated confidence.

What the research supports, and what remains uncertain

What it supports

  • Practice can improve communication skills. A Cochrane review of studies in medical students found that communication skills training may improve overall communication skills (low-quality evidence), and that personalized, specific feedback probably improves them to a small degree compared with generic or no feedback (moderate-quality evidence). [18]
  • Effective training for physicians is practice-based. An overview of systematic reviews found that effective communication programs for physicians focused on practicing skills, through role-play, feedback and small-group discussion. [19]
  • De-escalation training can improve knowledge, confidence and performance in simulated scenarios. A systematic review of training for mental health staff found its strongest apparent effects there, while noting limits in the evidence. [20]
  • Simulation suits rare, high-risk moments. It lets learners "gain experience recognizing and responding to uncommon, high-risk, situations that might not otherwise occur over the course of their training". [21]

What remains uncertain

  • Whether training reduces incidents. Evidence is mixed and depends on the setting and the intervention. A 2020 Cochrane review found that education and training may not reduce workplace aggression toward healthcare workers, based on low- and very-low-certainty evidence. [22] A 2022 cluster randomized study in Slovenian acute psychiatric wards reported lower rates of aggression and restraint after staff de-escalation training. [23] Neither study evaluated brief AI rehearsal or conversations with relatives after a death.
  • How long gains last. Communication skills can fade without practice, follow-up may help skills transfer to clinical work, and some gains have lasted a year. [24][25][26] The studies reviewed here do not establish an optimal interval for this kind of rehearsal.
  • How AI practice compares. Early studies are small and mostly use self-rated outcomes. In a UK crossover study of medical students, practice with an AI virtual patient improved self-rated communication skills slightly less than practice with actors. [27] That study did not evaluate Lingua CoPilot Medical or threat response.

What has not been tested for this station

The station has not been evaluated for its effect on incidents, injuries or return on investment. Its scores are formative evidence for educators, not certification that a doctor is safe.

So the case for rehearsal rests on preparation and oversight, not on a promise of fewer incidents. Doctors get to practice consequential decisions before they meet them with a real family, and educators see what was actually said.

For hospital programs in India, the US, the UK and Australia

Cases can be configured for hospital programs in India, the US, the UK and Australia, using context-specific English and supported Indian regional languages: Hindi, Punjabi, Bengali, Malayalam, Telugu, Tamil, Kannada, Gujarati and Marathi. Not every country and language combination is available for every case today. Configuration brings in the terminology, family conversations and local review and escalation routes your doctors encounter.

How a hospital can begin

  1. Choose a doctor cohort, such as emergency department residents, casualty medical officers, or doctors who speak with families after a death.

  2. Pair the cases with your procedures: escalation contacts, reporting process and security response.

  3. Doctors practice in a browser and can repeat a case.

  4. Educators review the conversation evidence with each doctor.

  5. Choose the next rehearsal based on what the evidence shows.

A proof run shows participation and observed conversational actions. It is not designed to show incident reduction or return on investment. Security, staffing, the physical environment, reporting routes and support for staff after an incident remain part of the hospital's own program.

Hospital accreditors, national guidance and professional bodies expect workplace-violence training to reach doctors as well as other staff, appropriate to their role (see the policy context below).

Discuss a Focused Proof RunExplore the Station

Hospitals begin with a paid, bounded proof run. Pricing is shared after a scoping conversation.

Medical college or another eligible institution? Request a scoped free trial.

Policy context

Selected policy and professional expectations (context only; none of these bodies endorses Lingua CoPilot Medical, and using the station does not by itself meet any requirement):

  • United States, accredited hospitals. The Joint Commission's National Performance Goals, effective January 2026, require training, education and resources "at time of hire, annually, and whenever changes occur" for "leaders, staff, and licensed practitioners", including de-escalation, with the hospital deciding what is appropriate for each role. [28]
  • England. The NHS staff standards published in July 2026 expect employers to "ensure that all staff receive training appropriate to their role" as part of violence prevention and reduction. [29]
  • Australia and New Zealand, emergency departments. The Australasian College for Emergency Medicine recommends that all emergency department staff receive "regular and ongoing violence prevention training that includes verbal de-escalation strategies". This is professional guidance, not law. [4]

FAQ

Who is the station for?
Doctors: residents and junior doctors, casualty and emergency physicians, and treating doctors who speak with families after a death.
What do educators review?
The conversation evidence for each attempt. The assessment engine works from verbatim quotes of what the learner said, and missed steps are marked not observed. If no direct threat occurs, the threat response is shown as not assessed.
How does it fit with our existing workplace-violence training?
It adds spoken conversation practice. It does not cover physical intervention, restraint or security procedures, which stay with your hospital's own program. Pair the cases with your escalation contacts and reporting process.
Does rehearsal reduce violence?
The evidence on training and incident reduction is mixed and depends on the setting. This station has not been evaluated for incident reduction. What it offers is repeatable practice and reviewable evidence of what doctors said.
Which contexts and languages are supported?
Cases can be configured for hospital programs in India, the US, the UK and Australia, with context-specific English and supported Indian regional languages. Not every combination is available for every case today.
How does a hospital begin?
With a paid, bounded proof run for one doctor cohort. We agree the cohort, cases, educator review process and local safety boundaries with you, and share pricing after a scoping conversation.
Can a medical college use the station?
Yes. Medical colleges and other eligible institutions can request a scoped free trial, subject to review. Use the same inquiry form and choose your institution type.

Study notes

  • Survey dates and samples. US physicians: national survey fielded November 2020 to March 2021 with 6,512 physicians; 930 of those who answered the physical-harm question reported harm (14.8%). India: online snowball survey, November 2019 to April 2020; 617 doctors responded, 477 reported violence, and the 82.2% figure is a share of reported incidents. England: 766,285 staff responded; 14.47% (all staff) and 31.82% (medical and dental staff, occupation chart) are on page 27 of the national results briefing. The ACEM policy links the threatened figure to its 2016 member survey report and the assault figure to its 2019 report; the recall period was not checked, so the page gives none. The global meta-analysis included 253 studies found in searches to October 2018; 138 of them contributed to the physical-violence estimate (Table 1).
  • Earlier training-gap surveys. Only 16% of US emergency medicine residency programs offered violence workshops (published 2011) [32]; 16.8% of emergency medicine residents in New York City had prior training in violence prevention or de-escalation (2015 data, published 2016) [33]; six of 151 doctors in a Delhi hospital had received any such training (published 2016) [34]; 71% of US pediatric residents had no teaching on workplace violence and 74% wanted more training in managing angry patients and families (2007 data) [35].
  • US injury data. Health care and social assistance accounted for 72.8% of private-industry workplace-violence cases involving days away from work, job restriction or transfer in 2021 to 2022. [30]
  • Incident records. In one US hospital system, of respondents who reported a violent event in the past year, 88% had not documented an incident in the electronic system; many had reported informally. [31] In England, among NHS staff who experienced physical violence and gave a yes/no answer to the reporting question, 75.36% said that they or a colleague reported their last incident, from any source (national results briefing, page 29). [2]
  • Unit-level programs. In a cluster randomized trial in seven US hospitals, units that built action plans from their own violence data had approximately half the violent-event rate of control units at six months (incident rate ratio 0.48); this difference was not statistically significant at later follow-ups. [36]
  • The feedback finding comes from medical students, and the physician-training overview describes programs lasting at least one day. The practical features on this page are informed by the research; they are not a validated curriculum.

References

  1. Dyrbye LN, West CP, Sinsky CA, et al. Physicians' experiences with mistreatment and discrimination by patients, families, and visitors and association with burnout. JAMA Network Open. 2022;5(5):e2213080. Burnout analysis: Table 4. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792386
  2. NHS Staff Survey Coordination Centre. 2025 NHS Staff Survey (England): national results briefing, pages 27 and 29. March 2026. https://www.nhsstaffsurveys.com/results/national-results/ (Technical Guide, section 4, page 15: the reporting figure excludes 'Don't know' and 'Not applicable' answers https://www.nhsstaffsurveys.com/static/0e6b1554117a6a032f16a6cba7b4cc2d/NHS-Staff-Survey-2025-Technical-Guide-V2.pdf#page=16)
  3. Kaur A, Ahamed F, Sengupta P, et al. Pattern of workplace violence against doctors practising modern medicine and the subsequent impact on patient care, in India. PLOS ONE. 2020;15(9):e0239193. https://pmc.ncbi.nlm.nih.gov/articles/PMC7500628/
  4. Australasian College for Emergency Medicine. P32 Violence in emergency departments, version 5. August 2024. https://policy.acem.org.au/index.php/policies-menu/p32-violence-in-emergency-departments
  5. Liu J, Gan Y, Jiang H, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occupational and Environmental Medicine. 2019;76(12):927-937. https://oem.bmj.com/content/76/12/927 (Open-access manuscript, Table 1, page 5: https://ueaeprints.uea.ac.uk/id/eprint/72807/1/Published_Manuscript.pdf#page=5)
  6. Bingöl S, İnce S. Factors influencing violence at emergency departments: patients' relatives' perspectives. International Emergency Nursing. 2021;54:100942. https://pubmed.ncbi.nlm.nih.gov/33302240/
  7. American College of Emergency Physicians. Emergency department violence poll results. 2022. https://www.emergencyphysicians.org/siteassets/emphysicians/all-pdfs/acep-emergency-department-violence-report-2022-abridged.pdf
  8. Heponiemi T, Kouvonen A, Virtanen M, Vänskä J, Elovainio M. The prospective effects of workplace violence on physicians' job satisfaction and turnover intentions: the buffering effect of job control. BMC Health Services Research. 2014;14:19. https://pmc.ncbi.nlm.nih.gov/articles/PMC3898009/
  9. Hills DJ. Associations between Australian clinical medical practitioner exposure to workplace aggression and workforce participation intentions. Australian Health Review. 2016;40(1):36-42. https://doi.org/10.1071/AH14246
  10. Mamede S, Van Gog T, Schuit SCE, et al. Why patients' disruptive behaviours impair diagnostic reasoning: a randomised experiment. BMJ Quality & Safety. 2017;26(1):13-18. https://doi.org/10.1136/bmjqs-2015-005065
  11. Riskin A, Erez A, Foulk TA, et al. Rudeness and medical team performance. Pediatrics. 2017;139(2):e20162305. https://doi.org/10.1542/peds.2016-2305
  12. American Hospital Association. The burden of violence to U.S. hospitals: a comprehensive assessment of financial costs and other impacts of workplace and community violence. 2025. https://www.aha.org/system/files/media/file/2025/05/The-Burden-of-Violence-to-US-Hospitals.pdf
  13. Texas Center for Nursing Workforce Studies. 2022 Employer Nurse Staffing Study: Workplace Violence Against Nurses. Texas Department of State Health Services; December 2022. https://dshs.texas.gov/sites/default/files/chs/cnws/Workplace%20Violence/2022_WPVAN_Report.pdf
  14. Rosenman ED, Vrablik MC, Charlton PW, et al. Promoting workplace safety: teaching conflict management and de-escalation skills in graduate medical education. Journal of Graduate Medical Education. 2017;9(5):562-566. https://doi.org/10.4300/JGME-D-17-00006.1
  15. Vestal HS, Sowden G, Nejad S, et al. Simulation-based training for residents in the management of acute agitation: a cluster randomized controlled trial. Academic Psychiatry. 2017;41(1):62-67. https://doi.org/10.1007/s40596-016-0559-2
  16. See J, Van Deusen R, Claxton R, et al. CALMER Conflict: a novel curriculum for graduating medical students to manage and defuse patient-provider conflict. Journal of General Internal Medicine. 2025;40(1):253-257. https://doi.org/10.1007/s11606-024-08975-5
  17. LeBlanc VR. The effects of acute stress on performance: implications for health professions education. Academic Medicine. 2009;84(10 Suppl):S25-S33. https://doi.org/10.1097/ACM.0b013e3181b37b8f
  18. Gilligan C, Powell M, Lynagh MC, et al. Interventions for improving medical students' interpersonal communication in medical consultations. Cochrane Database of Systematic Reviews. 2021;(2):CD012418. https://doi.org/10.1002/14651858.CD012418.pub2
  19. Berkhof M, van Rijssen HJ, Schellart AJ, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews. Patient Education and Counseling. 2011;84(2):152-162. https://doi.org/10.1016/j.pec.2010.06.010
  20. Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. British Journal of Psychiatry. 2015;206(6):447-455. https://doi.org/10.1192/bjp.bp.114.144576
  21. Agency for Healthcare Research and Quality, PSNet. Simulation training (patient safety primer). Updated 2023. https://psnet.ahrq.gov/primer/simulation-training
  22. Geoffrion S, Hills DJ, Ross HM, et al. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database of Systematic Reviews. 2020;(9):CD011860. https://doi.org/10.1002/14651858.CD011860.pub2
  23. Celofiga A, Kores Plesnicar B, Koprivsek J, et al. Effectiveness of de-escalation in reducing aggression and coercion in acute psychiatric units: a cluster randomized study. Frontiers in Psychiatry. 2022;13:856153. https://doi.org/10.3389/fpsyt.2022.856153
  24. Aspegren K. BEME Guide No. 2: Teaching and learning communication skills in medicine, a review with quality grading of articles. Medical Teacher. 1999;21(6):563-570. https://doi.org/10.1080/01421599978979
  25. Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Patient Education and Counseling. 2006;60(3):313-325. https://doi.org/10.1016/j.pec.2005.08.008
  26. Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I. Enduring impact of communication skills training: results of a 12-month follow-up. British Journal of Cancer. 2003;89(8):1445-1449. https://doi.org/10.1038/sj.bjc.6601309
  27. Tyrrell EG, Sandhu SK, Berry K, et al. Web-based AI-driven virtual patient simulator versus actor-based simulation for teaching consultation skills: multicenter randomized crossover study. JMIR Formative Research. 2025;9:e71667. https://doi.org/10.2196/71667
  28. The Joint Commission. National Performance Goals, effective January 2026 for the Hospital Program: NPG.02.04.01, EP 2. https://www.jointcommission.org/en-us/knowledge-library/workforce-safety-and-well-being-resource-center/workplace-violence-prevention/workplace-violence-prevention-program (standard text read from https://digitalassets.jointcommission.org/api/public/content/9ca80055182b4274842a5780a94f2c82)
  29. Department of Health and Social Care. NHS staff standards: detailed requirements for employers, violence prevention and reduction. 6 July 2026. https://www.gov.uk/government/publications/nhs-staff-standards/nhs-staff-standards-detailed-requirements-for-employers#violence-prevention-and-reduction
  30. US Bureau of Labor Statistics. Workplace violence in healthcare and social assistance, 2021-2022. 2024. https://www.bls.gov/iif/factsheets/workplace-violence-2021-2022.htm
  31. Arnetz JE, Hamblin L, Ager J, et al. Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents. Workplace Health & Safety. 2015;63(5):200-210. https://pubmed.ncbi.nlm.nih.gov/26002854/
  32. Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. Journal of Emergency Medicine. 2011;40(5):565-579. https://doi.org/10.1016/j.jemermed.2009.11.007
  33. Schnapp BH, Slovis BH, Shah AD, et al. Workplace violence and harassment against emergency medicine residents. Western Journal of Emergency Medicine. 2016;17(5):567-573. https://pmc.ncbi.nlm.nih.gov/articles/PMC5017841/
  34. Kumar M, Verma M, Das T, et al. A study of workplace violence experienced by doctors and associated risk factors in a tertiary care hospital of South Delhi, India. Journal of Clinical and Diagnostic Research. 2016;10(11):LC06-LC10. https://pmc.ncbi.nlm.nih.gov/articles/PMC5198359/
  35. Judy K, Veselik J. Workplace violence: a survey of paediatric residents. Occupational Medicine. 2009;59(7):472-475. https://doi.org/10.1093/occmed/kqp068
  36. Arnetz JE, Hamblin L, Russell J, et al. Preventing patient-to-worker violence in hospitals: outcome of a randomized controlled intervention. Journal of Occupational and Environmental Medicine. 2017;59(1):18-27. https://doi.org/10.1097/JOM.0000000000000909 (Free full text (author manuscript), Table 2, page 21: https://pmc.ncbi.nlm.nih.gov/articles/PMC5214512/pdf/nihms-822608.pdf#page=21)