Patients with dementia or Alzheimer’s and patients on drugs were the most likely to hurt nurses, according to one research study published last year in the Journal of Emergency Nursing. The study surveyed more than 700 registered nurses at a private hospital system in Virginia, and 76 percent said they had experienced physical or verbal abuse from patients and visitors in the previous 12 months. About 30 percent said they had been physically assaulted.

Working directly with patients in emotional and physical pain has always put health-care workers at risk of violence. The intensifying abuse has a lot to do with money: During the Great Recession, public and private hospitals began slashing budgets at the same time people were losing jobs—and their health insurance. That meant fewer nurses and security guards available to help when patients got out of control, and more people turning to hospitals instead of private practice for medical care since they couldn’t be turned away due to lack of insurance. States also cut billions of dollars in funding for preventative mental-health services, which likely had a significant effect on the frequency of violence against doctors and nurses. Psychiatric patients are increasingly seeking treatment in hospital emergency rooms, where staff are often unprepared to deal with violent outbursts. “This is creating volatile, unpredictable situations,” says Bonnie Castillo, a registered nurse and director of health and safety for National Nurses United, a labor group representing more than 160,000 nurses across the country. Her organization has been pushing states to pass laws to protect workers in the health-care industry.

There’s also a pervasive notion that dealing with unruly patients is just part of a nurse’s job. “We always feel discouraged from reporting it,” says Castillo. She said she was punished by a past employer for calling 9-1-1 after a patient attacked her. It’s not surprising then, that only 29 percent of the surveyed nurses who were physically attacked actually reported it to their supervisors. About 18 percent said they feared retaliation if they reported violence, and 20 percent said they didn’t report it because of the widespread perception that violence is a normal part of the job. A spokeswoman for the Inova Health System hospitals, where the nurses were surveyed, did not respond to a request to comment for this story, though it’s hardly a problem unique to one hospital.

Rose Parma, a registered nurse in California’s Central Valley, says nursing school did not prepare her for the brutality she would face in her career. Patients have spit on her, slapped her, and even threatened her life during the five years she has worked as a hospital nurse. But it reached an intolerable level about a year into her career, when a delirious patient kicked her so hard in the pelvis that she slammed into a glass wall and fell to the ground. She was two months pregnant. The pain was not as shocking as her supervisor’s response when she reported the incident. “The manager seemed so surprised and said ‘Has this never happened to you? Is this really the first time?’ As if it weren’t a big deal,” Parma says. The manager then told Parma she would see her the next day at work. “I literally thought I was going to die [during the attack], and they didn’t even offer me counseling.” (Her baby survived.)