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Published on

31/7/2025

Violence in healthcare among caregivers

An alarming reality is emerging: the deterioration of working relationships due to violence and oppressive behavior among caregivers.

Violence in healthcare among caregivers: a scourge with devastating consequences for patients and teams

The healthcare sector, by its very nature, is a high-pressure environment where many professional categories work together to care for patients. However, under this pressure, an alarming reality emerges: the deterioration of working relationships due to violence and oppressive behavior among caregivers. This phenomenon, far from being anecdotal, has devastating consequences not only on individuals and teams, but also, and critically, on the quality of care and patient safety. Professional organizations recognize the urgency of this issue and are actively committed to combating it, emphasizing the imperative for better communication, enhanced cooperation, and unwavering team cohesion.

Prevalence and alarming observation of violence in healthcare settings

Violence and oppressive behaviors in healthcare settings are persistent and widespread problems, documented by numerous studies and surveys. Their figures reveal a concerning situation that affects all levels of medical and dental professions.

According to the NHS (National Health Service) Staff Survey for England 2021, almost 19% of all NHS staff reported experiencing at least one incident of harassment, bullying or abuse from colleagues in the previous twelve months. This means that around a fifth of all NHS staff report experiencing harassment, bullying and belittling from colleagues each year.

Studies in the United States have shown a direct link between disruptive behavior and adverse events, particularly in the perioperative area. These studies attributed 67% of adverse events, 71% of medical errors and 27% of perioperative deaths to disruptive behavior.

The problem of bullying within the medical and dental professions is not new. As early as 2002, a survey by the British Medical Association (BMA) of young doctors revealed that nearly 50% of the sample reported being bullied in the previous year. Although the sample size (594 doctors) was small, these figures already suggested that bullying was a significant problem.

In 2014, the General Medical Council (GMC) national training survey in the United Kingdom explored the issue of bullying among trainees. 8% of junior doctors reported experiencing some form of bullying or belittling, and surgery was ranked as the second most affected specialty in this area, just behind obstetrics and gynecology.

In 2015, the President of the Royal Australasian College of Surgeons (RACS) publicly apologized for the extent of bullying behaviors found in surgical settings in Australia and New Zealand, where up to 50% of surgeons had been subjected to bullying. This situation led to the launch of their "Let's Operate with Respect" campaign.

The Royal College of Obstetricians and Gynaecologists (RCOG) published the results of its survey on bullying among consultants in 2016. Up to 44% of respondents described persistent bullying, and a third of these rated it as severe. In response to these results and the GMC survey, the RCOG has put in place initiatives for its members, including an online toolkit and regional "anti-bullying tutors" outside the training hierarchy.

The Royal College of Surgeons of Edinburgh (RCSEd) also conducted its own survey of its members in 2014. This survey revealed that 60% of surgical trainees reported having been bullied in the workplace, and almost all described witnessing it. In addition, this survey highlighted that the problem was not limited to trainees, as 34% of all Members and Fellows who responded reported having been bullied.

In France, the Health Commission of the Anesthesiologist-Resuscitator at Work (SMART) of the French College of Anesthesiologists-Resuscitators (CFAR) conducted a survey in 2018 on working relationships in technical settings. The results are equally alarming: more than 90% of healthcare professionals have experienced a conflict between professionals. More specifically, 63% have been victims of violence from another healthcare professional, while 30% have been perpetrators of violence towards another healthcare professional. The survey also revealed that 97% of reported violence was verbal, 14% physical against people, and 12% physical against property. This observation is accompanied by a general feeling of helplessness, since 75% of caregivers feel helpless in the face of conflict, and only 16% of hospitals have a formalized procedure for reporting conflicts. Caregivers are an at-risk group who often feel helpless in the face of their own physical and psychological suffering at work.

These data confirm that violence among caregivers is a global problem, affecting various specialties and career levels, with profound implications for staff well-being and quality of care.

The multiple forms of oppressive behaviors

Oppressive behaviors in healthcare settings are not limited to blatant and easily identifiable acts; they encompass a wide range of actions, some subtle, others obvious, but all detrimental to the work environment and the quality of care. Sources identify several categories of these behaviors.

In broad terms, the terms used to describe these actions include bullying, undermining, harassment, and abuse. These behaviors are contrary to the professional practices described by regulatory bodies such as the General Medical Council and the Nursing and Midwifery Council.

More specifically, the CFAR campaign aims to prevent so-called "acute" conflicts within teams, such as incivility, verbal, or even physical violence. Verbal violence is particularly prevalent, representing 97% of reported acts of violence between caregivers according to the SMART 2018 survey. The ONVS 2018 Report details this verbal violence perpetrated by doctors, men or women, between themselves or towards other staff. It manifests itself through incessant criticism and reproaches about the professional incompetence, real or supposed, of peers or collaborators. It can also take the form of a hostile attitude, crude remarks, or permanent denigration of the work carried out, whether in private or in public. These behaviors can escalate to moral harassment.

In addition to verbal violence, physical violence can also occur, although less frequently, with 14% of cases reported as physical violence against people and 12% against property. A concrete example mentioned in the sources is that of an incident where a surgeon threw the soiled contents of a syringe in the face of an operating room nurse, leading the Order of Nurses to file a civil action to condemn the perpetrator.

Disruptive behaviors can be more subtle and insidious, making them difficult to recognize. These may include hostile or aggressive behaviors that are not necessarily physically violent, but which create a toxic atmosphere. The article on voices of reason points out that there remains work to be done to combat other forms of violence, sometimes very subtle and invisible, but just as detrimental to the physical and mental health of professionals. Recognizing these signs, whether you are experiencing them or witnessing them, is a crucial step in addressing them.

Finally, denigration - undermining a colleague's authority or competence - is also a form of oppression. The fact that the RCSEd survey showed that 60% of surgical trainees had experienced bullying, and that almost 100% had observed it, suggests that these behaviors are deeply rooted in the culture of certain work environments.

These different manifestations of oppressive behaviors, whether blatant or subtle, contribute to an unhealthy work environment that has repercussions far beyond the individuals directly involved.

Devastating impacts on individuals, teams, and patient safety

The consequences of violence and oppressive behavior in healthcare extend far beyond immediate conflicts, profoundly affecting the health and well-being of professionals, team dynamics, and ultimately, the safety and quality of care provided to patients.

Impact on individuals and teams: Bullying, belittling, and abusive behaviors have a devastating impact on individuals and teams. They not only impair the morale and mental health of caregivers but also the overall work environment. Affected healthcare professionals may experience stress, dissatisfaction, and exhaustion, potentially leading to burnout. A survey of French physicians specifically studied burnout among anesthesiologists. The negative impact also translates into direct and indirect costs for the healthcare system. In the United Kingdom, it is estimated that bullying, belittling, and abuse cost the NHS in England at least £2.3 billion per year due to absenteeism, staff turnover, decreased productivity, and professional relationship issues. Verbal violence can cut deeper than a scalpel, with lasting effects on working conditions.

Impact on patient safety and quality: Beyond the human and financial impact, the most critical and alarming effect is the serious consequence on patient care. Bullying and belittling have a proven and detrimental impact on patient outcomes, diverting resources and attention from necessary care. The Royal College of Surgeons of Edinburgh (RCSEd) emphasizes that the degradation of relationships is not just a matter of "being nice": bullying directly affects patients.

Investigations into deaths in establishments such as Mid Staffordshire and Morecombe Bay NHS Trusts have identified a breakdown in teamwork as one of the causes. There is a mountain of evidence showing the detrimental effect of bullying and denigration on team performance. The CFAR SMART survey found that 97% of respondents said that conflict compromises the quality of care. Conflict-related problems increase the risk of errors and jeopardize patient safety. Analyses of adverse events associated with care (AEIAS) showed that around 27% of these AEIAS in hospitalization were due to inadequate communication between professionals. Fluid communication and cooperation are essential to limit preparation or material defects, and avoid last-minute cancellations, which are sources of stress and lost opportunity for the patient. An oppressive work environment can compromise patient care.

In summary, cordial understanding, a smile, respect, and self-control in daily practice are essential to the quality of care. The concept of a cohesive team, focused on the patient and their needs, can only improve patient adherence and understanding. The strength of the links between interprofessional tensions and the occurrence of adverse events associated with care, or even morbidity and mortality, should collectively encourage efforts to improve working relationships.

Root causes of conflict and violence in the hospital setting

Conflicts and violence between caregivers are not isolated or random phenomena; they are often a symptom of deeper problems rooted in the work environment, organizational structures, and interpersonal dynamics. Analyzing these causes is essential to developing effective solutions.

The working environment of healthcare professionals is inherently prone to tension. Technical platforms – operating rooms, intensive care units, emergency rooms, and other interventional platforms – are high-pressure environments. These environments are often complex and confined, involving numerous professional categories with interdependent tasks focused on patient care. The stress inherent in surgical activity, combined with this confinement, can be a source of conflict.

According to CFAR's SMART Commission, most conflicts can only be seen as symptoms of an ailing system. The underlying causes of conflict situations are often organizational or communication-related. Caregivers do not always have the opportunity to reflect as a team on the determinants of these situations.

The 2018 SMART survey identified the main causes of conflict:

Poor communication and a lack of understanding of each other's priorities are cited by more than 90% of healthcare professionals as major factors.
Workload, fatigue, and staff shortages also contribute significantly.
Poor organization of care, as well as deficient management and supervision, are frequently identified organizational causes.
Finally, interpersonal factors such as personality, abuse, or power rivalries play a role. These rivalries, combined with personality conflicts, can exacerbate violence.

The operating room, in particular, is a place prone to conflicts due to its complexity, production pressure, and the involvement of numerous occupations, each with distinct professional objectives and a different perception of care and risk management. The traditional hierarchy, dominated by the surgeon, is gradually giving way to a patient-centered, interprofessional, interdisciplinary system that allows everyone to express themselves. However, this transition can also generate tension.

Differences in occupations, age, experience, and objectives among caregivers complicate relationships and are sources of conflict that can significantly impact staff health. Unresolved disagreements can cause tension, blockages in communication, and ultimately open conflict.

By understanding these multifactorial causes, it becomes clear that resolving conflicts requires a comprehensive approach that goes beyond immediate reactions to address structural and cultural problems.

Initiatives and commitments of organizations to combat violence

Faced with the scale and devastating consequences of violence between caregivers, many professional organizations have mobilized to implement campaigns and initiatives to eradicate these behaviors and promote a healthy and respectful work environment.

The Royal College of Surgeons of Edinburgh (RCSEd) is strongly committed to this fight. The College has a zero-tolerance approach to intimidation, denigration, and harassment, and categorically condemns them in all circumstances. This commitment is the result of work that began in 2014, following its investigation that identified a significant problem at all stages and grades of surgery.

The RCSEd strives to:

Produce a series of Professional Standards for the prevention of bullying and denigration in the healthcare service. These standards define the expectations of Members and Fellows to promote respectful and inclusive workplaces and ensure patient safety.
Provide free access to its anti-bullying toolkit, an online learning module (e-module), and other materials offered by partner organizations.
Collaborate with partners from all health professions, such as the Anti-Bullying Alliance, to organize events, offer advice, and develop practical solutions.
Conducting the debate on this issue in the press and on social media.
Develop key performance indicators to assess the effectiveness of interventions and collaborations aimed at combating bullying and denigration.
Apply a Code of Conduct that reflects the values of the College and sets out the ethical and behavioral standards expected of its members. Each new member, past or present, is invited to adhere to it automatically. The College is committed to using its educational, evaluation and audit activities to improve workplace behavior and culture, and to promote systemic change in partnership with other organizations.

On the other hand, in France, the Health of the Anesthesiologist-Resuscitator at Work (SMART) commission of the French College of Anesthesiologists-Resuscitators (CFAR) initiated the "1 Patient 1 Team" campaign. Launched following an alarming observation of the deterioration of working relationships, this campaign aims to raise awareness among all healthcare professionals working on technical platforms. It is aimed at multi-professional teams, including young people in training, and is not limited to technical platforms but extends to related care services, as well as managers.

The objectives of the "1 Patient 1 Team" campaign are clear:

Prevent so-called "acute" conflicts (incivility, verbal and physical violence) and offer tools for their management and analysis.
Reduce the occurrence of conflict situations by seeking to resolve disagreements immediately, from the first manifestation, in order to prevent them from escalating into open conflicts.
Promoting communication, cooperation and team cohesion. The central message is that all professionals belong to the same team, working towards a common goal: the patient. Cordial understanding, respect and self-control contribute to the quality of care and well-being at work.
The "1 Patient 1 Team" campaign has brought together nearly 40 institutional partners, all of whom have committed to disseminating the message and tools free of charge through their own media and social networks. These partners include major players such as the National Academy of Surgery, the National Association of Occupational Medicine and Ergonomics for Hospital Staff (ANMTEPH), the National Council of the Order of Midwives, the National Council of Young Surgeons, the Federation of Visceral and Digestive Surgery, the Haute Autorité de Santé (HAS), the National Observatory of Violence in Healthcare Settings (ONVS), the French Society of Anesthesia and Resuscitation (SFAR), the French Society of Orthopedic Surgery and Traumatology (SOFCOT), the French-Speaking Society of Simulation in Healthcare (SoFraSimS), and the National Union of Associations of State-Certified Operating Room Nurses (UNAIBODE). Each partner expresses its support by emphasizing the importance of cooperation and mutual respect for patient safety and quality of life at work.

These initiatives demonstrate a collective awareness and a strong commitment from professional organizations to transform work cultures and make benevolence a pillar of healthcare.

Tools and strategies for preventing and managing acute conflicts

To move from awareness to action, organizations have developed a range of practical tools and strategies designed to help healthcare professionals prevent conflicts and manage them effectively when they occur. These resources aim to equip healthcare providers with the necessary skills to navigate complex and emotionally charged environments.

The Royal College of Surgeons of Edinburgh (RCSEd) offers a comprehensive anti-bullying resource hub for surgical and dental professionals. These resources include:

Standards for the Prevention of Bullying and Undermining in the Health Service: Guidelines on expected behaviors to create respectful workplaces and ensure patient safety.
The Facts and the Law: Information on the legal protection of healthcare professionals against intimidation, harassment, and discrimination, as well as the steps to take.
The Literature and the Specialities: A synthesis of studies and surveys on the prevalence of bullying and its impact, including the RCSEd's response.
How Oppressive Behaviour Affects the Team and Patient Care: Real case studies illustrating the impact of oppressive behavior on team morale, mental health, and patient safety.
Are You Being Bullied?: Tools to recognize the signs of bullying and disruptive behavior, whether you are experiencing it or witnessing it, and steps to protect yourself and ensure patient safety.
Is My Behaviour Affecting the Team?: A personal reflection guide with a checklist to assess one's own behavior and its impact on colleagues and patient care.
How to be Assertive Without Being a Bully: Practical advice for trainers on how to lead effectively, set clear expectations, and provide constructive feedback without belittling or intimidating.
Protecting Yourself, Protecting Your Colleagues: Support and advice on how to protect yourself from bullying or criticism, maintain your well-being and support your colleagues.
Negotiation: Negotiation strategies for surgeons to reduce workplace conflicts and support patient care, with tips for building confidence in communication and resolving tensions.
Resources to Help Change the Culture: Posters, presentations, accredited training, and events to transform surgical culture and promote a healthier work environment.

The "1 Patient 1 Team" campaign by CFAR/SFAR also offers a comprehensive "toolkit" for conflict prevention and management. These tools are available for free download.

To prevent conflicts, the campaign proposes:

Campaign visuals to disseminate to promote cooperation and team spirit.
A "savoir-être" charter to be signed by the entire team, encouraging respect and professional behavior.
The Hippocratic Oath and the Physician's Oath (Declaration of Geneva) to disseminate, recalling the ethical commitments of professionals.
Documentation including a reminder of the legal framework, a bibliography, and the report of the National Observatory of Violence in Healthcare Settings (ONVS).

For managing acute conflicts, the tools are focused on immediate action and analysis:

Interactive training videos on conflict management in the operating room. For example, the video "Dealing with a conflict situation in the operating room: How to respond to hostile or aggressive behavior?" offers different responses: aggressive, passive, passive-aggressive, and assertive. The assertive response involves the use of active listening and communication focused on the feelings and needs of both parties in order to find a compromise solution. Another series of videos addresses "How to express disagreement?" with passive, confrontational, and factual and open responses.
Immediate reaction sheets to know how to react to hostile behavior or intervene in the event of an acute conflict between professionals.
An analysis sheet called REACT (Réunion d'Equipe d'Analyse des Conflits au Travail - Workplace Conflict Analysis Team Meeting) for cold conflict management and the search for corrective measures in work organization.
Simulation trainings for conflict management. The French-Speaking Society for Simulation in Healthcare (SoFraSimS) supports this approach to help professionals understand their role within the group, the needs and skills of others, and to regain well-being at work.
Guidelines for managing disruptive behavior, including a memorandum of understanding between the Ministries of Justice, Labor and the Interior on security in healthcare facilities.

These tools and strategies, whether offered by the RCSEd or the CFAR/SFAR, demonstrate a concerted effort to equip healthcare professionals with the relational and conflict management skills essential for effective teamwork and patient safety.

Improving team cohesion and work culture

The fight against violence between caregivers is not limited to conflict management; it also, and above all, involves building a positive work culture and strengthening team cohesion. It is in this spirit that several initiatives are being developed.

The "1 Patient 1 Team" campaign emphasizes that cordial understanding, a smile, respect, and self-control in daily life contribute to the quality of care, recognition of professional value, and «well-being» at work. The fundamental idea is that we belong to the same team around a common goal: the patient. It is essential to play collectively on the healthcare field.

To sustainably improve team cohesion, the sources suggest several approaches:

Involvement of administration: Conflict management and improved cohesion can only be achieved as a team, and it is important to involve the hospital's administration in this process.
Continuous improvement programs: The Haute Autorité de Santé (HAS) offers specific programs, such as the "Continuous Improvement of Teamwork Program (PACTE)" and the "Medical Team Accreditation Program". Team accreditation is seen as the sum of individual skills that creates a collective competence, with common objectives and a sharing of responsibilities to improve the quality and safety of care. Another program is the "Solution for Patient Safety: Cooperation between Anesthesiologists and Surgeons". The Fédération de Chirurgie Viscérale et Digestive (FCVD) emphasizes that teamwork among operating room staff, combined with a perfect definition of tasks, is essential to improving the safety and quality of care.
Participatory Approach: The Observatory for Quality of Life at Work (QVT) for Healthcare and Medico-Social Professionals supports this campaign, the results of which will be promoted and shared as part of a participatory approach.
Understanding the differences to better cooperate: Conflicts often reflect a lack of understanding of the issues of different specialties called upon to work together. The campaign emphasizes the importance of interdisciplinarity, which draws on everyone's skills, and highlights the determining role played by each professional. The effectiveness of the operating room depends on the efficiency of this interdisciplinarity.
The culture of professionalism and respect: Prevention involves a better understanding of the problems, better control of our own reactions and emotions, and participation in conflict management workshops. These efforts must be reinforced at the institutional level by a culture of professionalism, teamwork, and interdisciplinary respect.
The power of collective commitment: A concrete example is given where the collective commitment of the 45 people present in an operating room (orderlies, scrub nurses, nurse anesthetists, surgeons, anesthesiologists intensivists) made it possible to put an end to verbal violence. The proposal that "anyone who uses verbal violence will be considered unfit to carry out their activity on the same day" was adopted unanimously and had an immediate and lasting effect. This collective "contract" seems to have been very effective.
Develop interpersonal skills: For physicians, it is essential to acquire skills in human resource management, such as supporting change, defusing conflicts, and facilitating the coordination of "teammates."

Ultimately, teamwork is essential to the quality of care. Teams must be healthy, with constructive and effective internal processes, to fully contribute to the health of the population. This implies that all team members adopt optimal teamwork practices.

The role of the various stakeholders and collective commitment

The fight against violence and the promotion of a positive culture in the healthcare sector require a collective commitment and the active participation of all stakeholders, from students to managers, including all professional categories.

Awareness campaigns, such as the RCSEd's "Let's Remove It" and the CFAR/SFAR's "1 Patient 1 Team", are aimed at a very broad audience. The RCSEd targets all surgical and dental professions, as well as its Members and Fellows. The "1 Patient 1 Team" campaign is aimed at multi-professional teams on technical platforms, including:

Anesthesiologists-intensivists
Surgeons
Radiologists
Gastroenterologists
Gynecologists-Obstetricians
Cardiologists
Resuscitators
Emergency physicians
Perfusionists
Midwives
Nurse Anesthetists
Operating Room Nurses
Nurses
Radiology Technologists
Healthcare assistants
Orderlies
Cleaning staff

It also extends to the care services with which these platforms are related and is aimed at managers, inviting them to reflect on the organizations and levers for corrective measures.

Responsibility is shared by all. The RCSEd survey showed that the problem of bullying is not just a matter for trainees, but also affects Members and Fellows. The "1 Patient 1 Team" campaign insists that it is the business of all members of care teams.

Collective engagement is a cornerstone of the proposed solutions. The "1 Patient 1 Team" initiative brings together nearly 40 institutional partners, including the National Academy of Surgery, which emphasizes that the patient is cared for by an entire team and that all links must work in harmony. The Association for Hospital Practitioners & Assimilated (APPA) emphasizes the importance of promoting team cohesion, conflict prevention, and management as essential in the hospital. The ANMTEPH, as occupational medicine, emphasizes the importance of working relationships for staff health. The National Council of the Order of Midwives is committed to this campaign, which carries the fundamental values of cooperation and respect, essential to the quality of care.

Unions such as the Fédération des Médecins de France (FMF) or the Syndicat National des Infirmiers-Anesthésistes (SNIA) also support the campaign, recognizing that quality of work life and safety in the operating room depend on a united and cooperative team. The Syndicat National des Praticiens Hospitaliers Anesthésistes-Réanimateurs Élargi (SNPHARe) points out that the concept of teamwork is being undermined by current challenges, but that it is essential to "resynchronize medical time" and value the concept of teamwork to restore meaning to the profession and ensure the best care.

The National Council of Nurses, strongly involved in addressing workplace suffering and psychosocial risks, emphasizes the importance of unity to recall the meaning of teamwork and mutual respect, both for patients and for caregivers themselves.

In conclusion, the eradication of interprofessional violence and the improvement of quality of life at work and patient safety require a concerted, constant, and inclusive effort from the entire healthcare community. Every professional, every organization, every hierarchical level has a crucial role to play in building an environment where respect, communication, and cooperation are the foundations of quality patient care. The initiatives of the RCSEd and CFAR/SFAR are eloquent examples of this collective commitment, emphasizing that "To care, let's play collectively!". This is a long-term commitment, because prevention is essential and the crisis is always dramatic.