How common is physical violence in healthcare work? Workplace violence occurs in health care work considerably more often than in other industries. Workers in long-term care units and nursing homes, in particular, are frequently exposed to assaults. In fact, according to national injury reports, the nurse aide working in a nursing home is the most assaulted worker in the U.S. Of all workplace attacks across the country, every fourth one occurs in a nursing home. Staff surveillance studies show that as many as two out of three nursing home workers are assaulted at least once a month. Workplace violence rates have been increasing over the past years, not only in the U.S. but all over the world, so that the public health officials globally have begun to talk about an epidemic of violence against healthcare workers. What are the types of physical assaults and who are the assaulters? The perpetrator of physical violence is often an elderly nursing home resident with dementia or other organic brain disease that has caused a severe cognitive impairment. Dementia patients frequently experience agitation that may manifest itself in a form of physical violence towards the nursing personnel. The danger in this type of violence lies in suddenness of the assault, without any preceding provoking incident or verbal offense by the patient. A sense of hurry during close staff-resident contact may be enough to agitate the dementia patient, and the agitation may be expressed in various forms, e.g., grabbing, pinching, hair pulling, scratching, biting, pushing, hitting with or without an object, throwing objects at staff, kicking, or spitting. It should be, however, noted that the resident is not the only possible source of workplace violence; other potential perpetrators include the resident's family member or other visitor, or a co-worker or supervisor. Most violence is unreported in the workplace. The exact frequency of physical assaults is not known. National statistics (OSHA logs) underestimate the true rates, since assaults are often unreported by the worker. (Assaults that do not produce physical injury are not reportable by OSHA criteria, even if there are psychological consequences.) Some studies have shown that almost half of the assaulted nurses do not report physical violence, and overall 55-80% of violent episodes are not officially reported. There are many reasons for underreporting: the workplace may lack reporting policies, or the process may be viewed as too time-consuming. The workers may also have doubts about the benefits of reporting assaults or concerns that assaults are viewed as a result of poor job performance or worker negligence. Surveys have revealed a surprising and somewhat worrying phenomenon: many health care workers consider violence to be "part of the job," meaning that violence is often just accepted and not seen as a considerable safety and health hazard. What are the consequences of physical violence? The consequences of violence are various, and often serious, the worst of course being a homicide. As many as 69 homicides occurred in the U.S. health services sector between 1996 and 2000. Most assaults, however, cause relatively minor physical injuries, such as bruises, contusions, temporary skin discolorations, slap marks, cuts, scratches, bites and punctures. Headache, fatigue and sleep problems often arise as a result of violence. Even if the physical symptoms are minor, the emotional effects from being assaulted are often considerable. Frequently experienced psychological reactions. Even post-traumatic stress disorder has been diagnosed among assaulted workers. Sickness absenteeism and costs related to security, counselling, litigation and workers' compensation all tend to increase in workplaces in which violence is common, as do recruitment difficulties and turnover rates. Violence is likely to affect workplace spirit and staff morale and inevitably affects productivity. Therefore, workplace violence is worth preventing. What can be done to reduce violence in health care settings? Although it may be impossible to achieve zero assaults in health care work, many could be prevented. OSHA's violence prevention guidelines summarize policy recommendations and practical methods to help prevent workplace violence. Most importantly, management should commit to building a worker-supportive environment in which as much importance is placed on employee safety and health as on serving and nursing the patient. Employees' views and opinions should be taken into account when designing, implementing and evaluating of the workplace violence prevention program. Employees should also commit to following these programs, including reporting assaults accurately. Workers' behavioral management skills training reduces physical assaults considerably. Also, a supportive atmosphere between the nursing team members as well as good supervisor support, reasonable job demands and less hurry at work provide conditions that reduce the likelihood of violence. The number of residents per nursing staff member should be kept manageable and ideally each resident would have a regular assigned caregiver. The physical work space layout and lighting should be designed and modified to eliminate or reduce security hazards - e.g., a violent patient should not be able to lock the doors and prevent exit from the room. It is essential that all physical assaults and threats are officially reported in a uniform manner to achieve an accurate and comparable estimation of violent assaults at workplaces. These reports should be reviewed regularly and appropriate actions should be taken immediately. Workplace violence should never be tolerated and all workers should be allowed to perform their profession in a safe environment.