Although an assault may last only a matter of moments, workplace violence often has lingering effects. "I still have little flashes," said Susan Schultheis, MSN, RN, a staff nurse in the medical intensive care unit at Portland VA Medical Center in Oregon.

Although most recent media stories of workplace violence depict assaults by patients or visitors against nurses, occasionally the violence occurs between health care professionals. Two years ago, after Schultheis had a rancorous disagreement with a physician about patient care, the physician erupted in anger, pinned Schultheis against a wall and dragged her down the hall by her arm.

Although Schultheis was able to break free fairly quickly, she’s still dealing with the psychological scars. "When someone explodes in anger, I have more of a fear-and-flight response," she said. "But I recognize and control it."

She was able to regain control by taking some time off, seeking counseling, using some antidepressants and receiving "amazing" support from her co-workers. "If my co-workers had not been so supportive, I probably would have left nursing," Schultheis said.

No two people respond exactly the same way in the aftermath of violence. But experts agree that organizations need programs to help victims and witnesses recuperate. Employee assistance programs, on-site counseling and psychological and situational debriefings aid in successful recovery, said Jane Lipscomb, Ph.D., RN, FAAN, associate professor of nursing at the University of Maryland in Baltimore.

Psychological debriefings allow survivors to talk with mental health experts about what happened, and to discuss possible aftereffects, such as sleeplessness, flashbacks or mind wandering, said Glenda Walker, DSN, RN, director of nursing at Stephen F. Austin State University in Nacogdoches, Texas.

Situational debriefings focus on what could have been done differently to prevent the incident without pointing fingers. Instead, participants make suggestions to change policies or the environment.

Most important, recovering nurses need to understand that even though they couldn’t control that one violent event, they still can be in control in the future "by taking a proactive approach, always being aware of your surroundings," said Deborah DiBenedetto, MBA, RN, president of the American Association of Occupational Health Nurses.

A routine end to a routine day was all Cathleen Shultz, Ph.D., RN, FAAN, anticipated after finishing her shift at a metropolitan hospital late one afternoon. Her goal was to beat the Atlanta traffic home. But within a few moments, Shultz, dean of nursing at Harding University in Searcy, Ark., was running for her life.

As she started her solitary walk to her car, she quickly noticed the staccato beat of unfamiliar footsteps keeping pace with her own, no matter how she varied her gait. In a fear-induced rush of adrenaline, she fled. Not until she was well within the security of the guarded parking lot did she feel safe enough to turn around. By then, the sound of soles on the asphalt had been replaced by the metallic scrape of a 10-inch knife blade against the chain-link fence. A man clad in a trench coat yelled to her as he flashed his weapon, "It’s a good thing you got inside the gate, because look what I had for you!"

Unfortunately, Shultz’s day was more routine than many may think. Violence in general is becoming commonplace in health care settings, and nurses are particularly vulnerable. Almost two-thirds of hospitals are in areas that have above average or average violent crime risk, reported a study last year by the International Association for Healthcare Security and Safety.

But the inside of hospitals can be just as dangerous. Increased stress due to lower staffing ratios and decreased insurance coverage, as well as rampant drug and alcohol abuse, often translate into assaults, beatings, stabbings, shootings or rapes in the facility.

The perpetrator may be a stranger, a patient, a visitor or a co-worker. Although traditionally emergency rooms and psychiatric settings have been the most dangerous, no department is immune to violence.

"Now it’s across the board, in every clinical area in the hospital, clinics, any health care setting," said Cheryl Anderson, Ph.D., MN, RN, an assistant professor in the school of nursing at the University of Texas at Arlington.

Of the estimated 1,000 murders and 1.5 million assaults in the workplace every year, about two-thirds occur in health care settings, said Anderson, who has written magazine articles on workplace violence.

"Fifty percent of the nursing population is affected by violence in the workplace," DiBendetto said.

Reasons vary, but "across the board, there’s more rage in America," said Tim Dimoff, president of SACS Consulting and Investigative Services Inc., in Akron, Ohio. He has trained health professionals on violence reduction and defusing techniques.

"Frustrations are taken out against the primary caregiver," DiBenedetto said. Nurses in particular are vulnerable, she said, because "we tend to close our eyes to potential danger. We make exceptions or allowances for behavior that would be intolerable in any other environment."

Other violent incidents could happen anywhere to anyone, but when a nurse nearly is attacked, solutions are not far behind. But individuals alone can’t control the problem. Organizations need to do their part as well.

"You can prevent a great amount of rage and violence by having a system and policies and procedures in place to let people know they can’t get away with it," Dimoff said. Visible security personnel, immediate response to threats, well-lit walkways and the buddy system go a long way toward deterring trouble.

Within the last few years, Harrison Memorial Hospital in Bremerton, Wash., has taken extra security precautions to control increasing violence, said Kathleen Sanford, RN, the organization’s vice president for nursing. New hospital features include bulletproof glass, rebuilt entrances to the ER to restrict access if necessary, and lock-down features between the ER and the rest of the facility.

Security policies include "Code 28," which summons a specialized team 24/7 to de-escalate violence at the first sign of trouble. All employees receive safety training, updated annually, and assistance in filing charges against instigators.

Although no amount of preparation or precautions can make a setting immune to violence, they can help minimize harm to staff and patients. Nurses should not accept violence as an inevitable part of their jobs, said Phil Burns, president of SyTech Research in Tulsa, Okla. His company studies workplace violence in all arenas.

"Violence is never acceptable. Period," he said.

Shultz knows that firsthand. Unfortunately, her would-be assailant was never caught, although she reported the incident immediately. Through sheer nerve, she was able to go back to the parking lot, but she never received any formal counseling to deal with the incident.

"The world is not as naive a place after something like that," she said. But she retells her story frequently to teach violence prevention and awareness to the next generation of nurses to make sure they can avert a violent encounter.