Published 5/24/2017
https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1
Executive Summary
Violence is much more common in healthcare than in other industries, and although many
violent events in healthcare are perpetrated by patients, a notable percentage are not.
Individuals other than patients who may cause violence in healthcare settings include
family members of patients and other visitors, employees, and criminals. Many factors
contribute to violence in healthcare: patients and their loved ones are often vulnerable
and, at times, distraught; healthcare workers must function in typically stressful
environments; there is 24-hour access to the hospital setting; and the presence of drugs
can make healthcare settings attractive targets.
Violence in healthcare may take a variety of forms, ranging from verbal aggression to
physical assault, including the use of deadly weapons against physicians, other workers,
and patients. It is therefore associated with a variety of risks for patient and worker safety
as well as organizational liability. In addition to physical harm, individuals who experience
or witness violence in the healthcare workplace are at risk for emotional consequences
that can lead to time away from work, burnout, job dissatisfaction, and decreased
productivity. These and other consequences compromise both worker and patient safety.
Healthcare employers are obligated to provide a safe working environment free from
recognized hazards, and failure to effectively abate the risk of violence can result in losses
including fines, claims, litigation, and reputational damage. However, employers'
prevention efforts may be stymied by failure of victims to report violent incidents, because
many healthcare workers consider violence "part of the job."
Violent events can and do happen, and being unprepared is unacceptable. Although it is
difficult to completely eliminate violence in healthcare settings, and although there is no
"one-size-fits-all" approach for prevention, there are many ways to reduce the potential
for violent occurrences and to minimize the impact if violence does occur. Risk managers
committed to decreasing risk of violence in their organizations will need to convene
stakeholders from various disciplines and collaborate to implement strategies,
individualized according to identified risks, across the organization.
1
Action Recommendations
1. Develop and enforce comprehensive policies and procedures against workplace
violence.
2. Evaluate objective measures of violence to identify risks and risk levels.
3. Train staff to recognize the warning signs of violent behavior and respond
proactively.
4. Establish a comprehensive workplace violence prevention program.
5. Encourage all employees and other staff to report incidents of violence or any
perceived threats of violence.
6. Ensure appropriate follow-up to violent events, including communication,
postincident support, and investigation.
7. Ensure that the violence prevention program addresses the possibility of gun
violence, including active shooters.
==================== =
Many violent events in healthcare, particularly assaults on staff members, are caused by
patients; however, this guidance article focuses on violence committed by visitors,
employees, and trespassers (e.g., robbery, stalking of a patient or employee, intimate
partner violence). For more information on violence caused by patients, see Patient
Violence.
The National Institute for Occupational Safety and Health defines workplace violence as
"violent acts, including physical assaults and threats of assault, directed toward personnel
at work or on duty." Many other sources include verbal aggression (e.g., threats, verbal
abuse, hostility, harassment) in the definition of workplace violence. Not only can verbal
aggression cause significant psychological trauma and stress, it can also escalate to
physical violence. (OSHA "Caring")
INCIDENCE
The Occupational Safety and Health Administration (OSHA) reports that in each year from
2011 to 2013, U.S. healthcare workers suffered 15,000 to 20,000 serious workplace-
2
violence-related injuries; serious injuries are those that require time away from work for
treatment and recovery (OSHA "Caring").
Violence is significantly more common in healthcare than in other industries, such that
violence-related injuries to healthcare workers account for almost as many similar injuries
sustained by workers in all other industries combined. In 2013, healthcare and social
assistance workers experienced 7.8 cases of serious workplace violence injuries per
10,000 full-time equivalents (FTEs), while other larges sectors such as construction,
manufacturing, and retail all had fewer than two cases per 10,000 FTEs. (OSHA "Caring")
3
ORGANIZATIONAL PERSPECTIVE
In a violence reduction project conducted at a large American hospital that examined
employee event reports involving workplace violence, an overall rate of 3.03 incidents per
100 FTEs per year was identified (Arnetz et al. "Application").
RISK FACTORS
Healthcare workers face serious risks. As Kevin Tuohey, president-elect of the
International Association for Healthcare Security and Safety, stated in a 2017 publication,
"While hospitals have always been looked at as places of refuge, as places that were
really safe, I think in the last 10 years that's changed, and I think that they are no longer
exempt." (HCPro)
The following risk factors for violence are inherent to the provision of healthcare (Joint
Commission "OSHA"; Papa and Venella):
1. Setting-specific vulnerabilities of acute care hospitals, emergency departments
(EDs), community health clinics, drug treatment clinics, long-term care facilities, and
private homes
2. Isolated work—conducted alone or in small groups, in remote areas, or in areas with
high crime rates
3. Late night or early morning work hours
4. The "economic realities of healthcare," such as reduction in staff, increased
productivity pressure, patients and visitors who are experiencing difficult personal or
financial circumstances
5. Exchange of money with the public
6. Transport and delivery of passengers, goods, or services
HIGH-RISK AREAS
Certain clinical areas are particularly vulnerable to violence perpetrated by a family
member or visitor.
Emergency department. Several factors predispose the ED to violence. As the main route
of public access into the facility, EDs are often understaffed and overcrowded. The
American College of Emergency Physicians posits that an overall increase in violence
throughout society has, in turn, increased violence in hospitals and EDs. The organization
cites the following factors that increase the risk of violence in EDs (ACEP "Emergency"):
Presence of gangs
4
Long wait times for care, sometimes in undesirable environments
Influence of drugs and alcohol
Private citizens arming themselves
Presence of individuals requiring "medical clearance" after an arrest by law
enforcement
Presence of individuals requiring psychiatric support in absence of sufficient
dedicated mental health facilities
In one survey, more than 75% of emergency physicians reported experiencing at least
one incident of workplace violence per year; nearly as many emergency nurses reported
verbal or physical assault by patients or visitors. (ACEP "Emergency")
Perhaps not surprisingly, nearly a quarter of the residents surveyed reported feeling safe
at work "occasionally," "seldom," or "never." (Schnapp et al.)
Intensive care unit (ICU). Because the ICU cares for the most seriously ill patients, visitors
to this area may be extremely distraught, stressed, and demanding of staff attention,
which may—or may appear to be—in short supply. This combination can lead to verbal
aggression toward staff and can escalate into physical assault, especially if staff are not
properly trained in responding to distraught visitors.
Neonatal or pediatric ICU. Concerned parents may become violent while waiting to talk
to a physician, while waiting for test results, or after finding out that their child has an
serious disease. Divorced or estranged parents may come into conflict over their child's
care in nurseries or on pediatric floors; custody disputes may spill over into the hospital.
Policies on how to deal with estranged parents should be in place, as well as procedures
for proving that abuse-protection and custody orders are valid. For more information on
security measures used to prevent babies from being improperly removed from the
hospital, see Preventing Infant Abductions.
Parking lots and other exterior areas. Several factors can contribute to a parking area
becoming the scene of violence. Parking areas may be dark, may offer many hiding
places, and may be deserted at certain hours.
5
Home care. Home care workers, who often must enter patients' homes alone, are
particularly vulnerable to violence. Home care workers may be exposed to unsafe
conditions and have reported feeling threatened when they know that loaded weapons
are present in a patient's home, or that drive-by shootings or gang violence have occurred
in the neighborhood. Rats, other vermin, or hostile animals may be present, or housing
may be in a deteriorated condition, or other situations may exist that suggest the potential
for physical violence, verbal abuse, or sexual harassment by patients, family members,
or visitors (Gershon et al.). For more information on risks and strategies for home care
workers, see the guidance articles Home Care: An Overview and Home Care: Staff-
Related Risks, and the self-assessment questionnaires Home Care: Management and
Operations and Home Care: Staff-Related Risks.
Types of Workplace Violence
Type 1 : Violence perpetrated by criminals who have no connection with the workplace
(e.g., thieves)
Type 2 : Violence perpetrated by those whom an organization serves (e.g., patients,
families, visitors)
Type 3 : Violence perpetrated against coworkers, supervisors, or managers by a
present or former employee
Type 4 : Violence perpetrated by someone who has a personal relationship with an
employee (e.g., an abusive spouse)
Type 1 violence accounts for only a small number of healthcare workplace violence
incidents. Type 2 violence is the most common cause of physical violence in the
healthcare setting, and type 3 violence is the most prevalent type of healthcare workplace
violence. (Wax et al.)
A violence reduction project conducted at a large American hospital found that 64% of
incidents against healthcare workers were perpetrated by patients or their visitors (type
2), while 35% were perpetrated by coworkers (type 3). Additionally, researchers identified
surgery as the sole clinical area in which incidents perpetrated by coworkers (type 3)
outnumbered incidents perpetrated by patients (type 2) (Arnetz et al. "Application").
6
Healthcare workers may experience a range of violent acts. To understand the
experiences of hospital nurses who responded to a validated electronic survey regarding
violence perpetrated by visitors, see Table 1. Type of Violence Perpetrated by Visitors.
WORKER SAFETY
The potential impact of workplace violence on healthcare workers—both victims and
witnesses—is significant in both the short and long term. In addition to the most immediate
consequences of psychological trauma, physical injury, or even death, affected
healthcare workers report feelings of anger, shock, hurt, frustration, embarrassment,
humiliation, and depression. (Wax et al.) A literature review on workplace violence in
healthcare identified the following responses, likely to impact quality of care, for affected
workers (Phillips):
PATIENT SAFETY
Violence in the healthcare workplace, by its very nature, can put both patients and
healthcare workers at risk. This may happen overtly, such as when a patient and a nurse's
aide "were shot and killed for no apparent reason" by an armed man at a Florida hospital
in 2016 (HCPro).
Impact on patients can also be more subtle; violence in healthcare settings has many
potential downstream effects. For example, a negative relationship has been reported
between violence experienced by healthcare workers and patient-perceived quality of
care (Arnetz and Arnetz). Additionally, worker-to-worker incivility in the operating
7
department has been linked to a poorer safety climate and decreased compliance with
recommended practices in the surgical environment (Hamblin et al. "Catalysts").
COSTS
Loss of life, injury, and suffering by patients and healthcare workers alike are obvious
costs of violence in healthcare—and the financial implications are significant. OSHA
reports that just one serious injury can result in workers' compensation losses of
thousands of dollars, in addition to thousands more for overtime, temporary staffing, or
recruiting and training a replacement. (OSHA "Prevention") The overall cost associated
with workplace violence to all American businesses—not exclusively healthcare—is an
estimated $120 billion a year (Papa and Venella).
Potential hidden costs that organizations may incur include those for counseling affected
individuals, the time required for managers and administrators to handle the issue and
participate in the investigation, and increased medical claims for stress-related conditions.
The publicity that follows a violent act in a healthcare setting can also do long-term
damage to an organization's reputation. (Papa and Venella) Other hidden costs include
increased worker turnover and decreased productivity and morale (OSHA "Prevention").
WORKERS' COMPENSATION
In a retrospective database review of violence perpetrated against nurses by patients or
visitors in a U.S. urban and community hospital system, annual costs for the 2.1% of
nurses reporting workplace violence injuries were $94,156, including $78,924 for
treatment and $15,232 for indemnity (Speroni et al.).
LAWSUITS
Litigation that follows acts of workplace violence is a "major direct cost." The average jury
award in workplace violence cases in which an employer failed to take proactive,
preventive measures has been reported as $3.1 million per person per incident. (Papa
and Venella)
Three police officers employed by a Michigan hospital sued the owner of the parent
medical system for $1 million each in 2016, alleging that they faced retaliation in response
to filing complaints about crime and violence on the hospital campus. One of the officers
reportedly questioned, "Hospitals are supposed to be safe havens. If we, as the first line
of defense, aren't safe, how are we going to keep patients and their visitors safe?" (Kurth)
8
Federal law
The general-duty clause of the Occupational Safety and Health Act (OSH Act) broadly
addresses a multitude of workplace safety issues by requiring employers to furnish
employees with employment and with a place of employment free from recognized
hazards that cause or are likely to cause death or serious physical harm (29 USC §
654[a][1-2]).
Courts have interpreted the general-duty clause to mean that an employer has a legal
obligation to provide a workplace free of conditions or activities—for example, workplace
violence—that either the employer or industry recognizes as hazardous and that cause,
or are likely to cause, death or serious physical harm to employees when there is a
feasible method to abate the hazard. OSHA can cite and fine employers who fail to take
reasonable steps to prevent or abate a recognized violence hazard in the workplace.
(OSHA "Fact Sheet")
Osha guidance
In 2016, OSHA released updated guidance on preventing violence in healthcare and
social service settings. The guidance is advisory in nature; it is not a standard or
regulation, and it does not create new legal obligations or alter existing obligations created
by OSHA standards or the OSH Act. (OSHA "Guidelines") However, it does provide a
wealth of practical strategies for violence prevention.
There have been signals that OSHA's protection of the healthcare workforce may become
increasingly robust. For example, in a 2016 report, GAO recommended that OSHA
increase its education and enforcement efforts; OSHA agreed and stated that it would
take action to address the following steps (GAO) :
1. Provision of additional information for inspectors on developing citations
2. Follow-up on hazard alert letters
3. Assessment of efforts to address workplace violence in healthcare settings to
determine whether additional action is needed
Furthermore, OSHA is also considering the need for a specific standard to protect
healthcare workers from workplace violence. In 2016, the agency published a request for
information in the Federal Register, seeking public comments on the extent and nature of
workplace violence in the healthcare industry as well as the nature and effectiveness of
interventions and controls for violence prevention. (OSHA "Prevention") The American
Hospital Association has argued against the need for such a standard (American Hospital
Association).
9
Violent events that result in worker or staff injuries requiring treatment beyond first aid or
requiring days away from work must be reported to OSHA, per agency standard (29 CFR
§ 1904). Employers must record these injuries in the OSHA Form 300 Log of Work-
Related Injuries and Illnesses. Employers must report all work-related fatalities within 8
hours of learning of them, and must report the following occurrences within 24 hours of
learning of them (OSHA "Updates"):
For more information on OSHA's record-keeping standard and injury reporting forms, see
OSHA Illness and Injury Record-Keeping Standard.
Osha inspections
OSHA may conduct an inspection in response to complaints or reports of workplace
violence. According to Joint Commission, the agency typically evaluates the need for an
inspection according to the following factors (Joint Commission "OSHA"):
For example, OSHA is more likely to inspect following a violent incident involving a known
risk factor if previous incidents have occurred and potential methods existed to alleviate
the risk factors (e.g., an attack on a nurse by a patient's family member who has a history
of violence toward staff), as opposed to following a random act of violence. (Joint
Commission "OSHA")
Federal fines
Healthcare organizations that fail to properly protect employees from the dangers of
workplace violence face the threat of being fined by OSHA. For example, a Pennsylvania
home care provider in 2016 was fined nearly $100,000 after a home care worker was
sexually assaulted. The agency found that the organization failed to provide an effective
workplace violence prevention program even in the face of numerous reports of verbal,
physical, and sexual assaults on employees. (OSHA "Federal Inspectors")
In 2014, OSHA fined a New York hospital $70,000 for willful failure to protect employees
from assaults by patients and visitors, substantiated by 40 incidents of violence by
patients and visitors in a three-month period. Given that many employees were unaware
of its existence or purpose, OSHA found the organization's workplace violence prevention
program ineffective. (OSHA "Brookdale")
10
State law
State law may provide additional protection for healthcare workers. Some states—
including Maine, Connecticut, New York, New Jersey, Maryland, Illinois, Washington,
Oregon, and California—have enacted laws that require employers to establish
comprehensive workplace violence prevention programs for healthcare employees.
Others have increased penalties for those convicted of assaulting a nurse or, in some
cases, other healthcare workers. The laws vary in scope and groups of individuals
protected. (OSHA "Workplace Violence Prevention")
Such laws have proven effective in lowering injury rates and workers' compensation
costs. For example, in Washington State, a 28% decrease in the rate of workers'
compensation claims in the healthcare and social assistance industry occurred after a
state rule took effect requiring hazard assessments, training, and incident tracking for
workplace violence. (OSHA "Workplace Violence Prevention")
State fines
State regulators may levy fines for failure to protect employees from workplace violence.
For example, in 2016, investigators identified 116 injuries related to patient and visitor
violence at a Detroit hospital between 2012 and 2015 (Kurth). The Michigan Occupational
Safety and Health Administration imposed a $5,000 fine and required implementation of
a plan to address routine exposure of healthcare and security employees to violent
behavior by patients and visitors (Rege).
Joint commission
The following Joint Commission standards address workplace violence in accredited
healthcare settings (Joint Commission "Comprehensive"):
Standard LD.03.01.01 requires leaders to create and maintain a culture of safety and
quality throughout the organization, which impacts both patient and worker safety
Standard LD.04.04.05 requires an organization-wide safety program, and requires
systems for blame-free incident reporting
Standard EC.02.01.01 requires organizations to manage safety and security risks
Standard EM.02.02.05 requires organizations to maintain emergency operations
plans describing how the facility will coordinate security activities with community
security agencies
DNV
Det Norske Veritas Germanischer Lloyd (DNV-GL) quality management standards
require accredited hospitals to "maintain safe and secure facilities that are designed and
maintained in accordance with national and local laws, hospital policy, regulations and
guidelines." Standards further specify that "the Security Management System shall
11
address issues related to abduction, elopement, visitors, workplace violence, and
investigation of property losses and [shall] be proportional to the risk." (DNV-GL, PE 4,
SR 3)
Professional associations
Professional associations including the American College of Emergency Physicians, the
American Nurses Association, and the Emergency Nurses Association have issued
policies, position statements, and resources regarding workplace violence. See Resource
List for more information.
ACTION PLAN
Organizations should develop and enforce comprehensive policies and procedures, such
as the following, against violence perpetrated by visitors, staff, patients, or other
individuals. All policies concerning violent events should be applied consistently to all
individuals.
Zero tolerance. A zero-tolerance policy, which states that any form of violence is not
acceptable, applies to all employees, patients, and visitors (ACEP "Protection"). Although
zero tolerance does not mean that violence will not happen, it sets the expectation that
violence will not be tolerated and will be dealt with according to policy. Such a policy
should explicitly acknowledge verbal assault as a form of violence, because tolerance of
verbal abuse and low-level battery invites more serious forms of violence (Phillips). The
policy should also specify actions that are grounds for termination or discipline (e.g.,
committing an act of violence, failing to report an act of violence) (Hamer).
Mandatory reporting. A mandatory reporting policy requires all staff to report any actual
or threatened physical or verbal assault without delay (ACEP "Protection").
12
To determine a healthcare facility's risk of violence and develop prevention strategies,
risk managers should partner with the security department to conduct a review of facility
and community records and statistical crime rates. An internal or external event reporting
system can be instrumental in this assessment. By looking for patterns and determining
root causes, risk managers can glean insights into vulnerabilities. See Violent Events
Reported for a sampling of violent events reported to the ECRI Institute Patient Safety
Organization (PSO).
Risk managers should not only review documentation of previous violent acts within the
facility but also collect statistics on violent gang activity, drug abuse, and other such
issues in the community. Records for review include existing documentation, such as the
OSHA log, union information, incident reports, workers' compensation or other insurance
reports, minutes from safety and risk management meetings, security reports, and
suggestions from employees. (OSHA "Caring") Risk managers can ask the local police
department and emergency management services to provide a community crime profile,
which should include the number and types of criminal offenses committed in the vicinity
of the facility and the times of day when incidence of violent crime is the highest. (Wax et
al.) Risk managers can also consult local businesses and other area healthcare facilities
about the amount of violence in and around their establishments, read national news for
trends in violent crime, or research U.S. Bureau of Labor Statistics data to identify trends
in comparable locations with similar populations.
To get a more complete list of possible risks, risk managers may conduct a survey asking
workers, volunteers, and contractors to identify specific violence risks or concerns. For
example, while there may be no history of assaults in the parking lots, employees may be
afraid to walk there after dark. Once analyzed, data should be used to inform an
appropriate action plan and communicated accordingly. For example, it would be helpful
for staff to know whether threats have been made against physicians or that the
organization serves a high number of patients from correctional institutions. (HCPro)
However, such information would likely be alarming in the absence of an appropriate
organizational response. Risk managers can also use the self-assessment questionnaire
Violence Prevention to identify strengths and weaknesses and improve the organization's
violence prevention program.
13
Violence may also be committed by distraught family members of patients who have died
or who have been discharged from the hospital. In a widely publicized 2015 incident, the
son of a former patient shot and killed his deceased mother's cardiologist in an exam
room at a Boston hospital. According to published reports, the man arrived at the
cardiologist's office without an appointment, demanding to meet with the physician. The
cardiologist agreed, and for more than half an hour he answered the man's questions
about a drug that had been prescribed to his mother before her death. After 15 minutes,
the cardiologist dismissed his physician's assistant, requesting that she check on other
patients. Twenty minutes later, shots were heard from behind the door of the exam room.
The cardiologist emerged injured and collapsed. The patient's son killed himself. After
eight hours of emergency surgery, the physician died. (Sweeney)
Although cases of family violence may be difficult to prevent, healthcare staff can look for
warning signs that may indicate an increased risk of family violence and take steps to de-
escalate a family member's behavior. For example, family members who are excessively
stressed may exhibit early warning signs such as rapid pacing, excessive fidgeting,
shouting, or depression (Barthel; Barboza and Zarembo).
In some cases, taking family members to a safe, quiet area to help calm their emotions
or arranging a meeting with a supervisor to help answer the family members' clinical
questions can help defuse emotions (Barthel). In addition, a family member who spends
most of his or her time at the facility, who visits the facility at odd hours, or who attempts
to access restricted areas of the facility may be more prone to violence (Barboza and
Zarembo; Kaldy). For more information on recognizing potentially violent behavior, and
use of de-escalation techniques, see Patient Violence.
14
3. Behavioral changes (e.g., the employee appears nervous, complains of chronic
ailments, or has an obvious change in appearance or personality)
4. Decreased productivity and difficulty concentrating and performing normal duties
Patients or healthcare workers may also become victims of stalking. Patients are
particularly vulnerable while in a hospital bed. Patients should be encouraged to report
threats against them during the intake process (e.g., show protection orders). Patients
who report being threatened or stalked should be placed in a room that can be easily and
constantly monitored. Of course, this type of information must be treated as confidential.
Only with assurance of confidentiality will patients or healthcare workers come forward
with this information.
1. "Pharmacy technician was in the medication room completing 'cart exchange.' During
her duties, she was approached by a nurse who grabbed her hands/wrists, stopped
her from completing her duties, while she questioned her about her activity.
Technician explained her duties and nurse finally let go."
2. "Security officer entered the unit and was in the process of restraining a patient when
it was noted that he had his weapon still on. When asked to leave the unit, he
responded 'It's not loaded'; when asked to leave again he became angry and threw a
watch across the nursing desk, pulled off his gloves and threw them, hitting one of
our nurses in the head."
A study of violent incident reports from a large hospital system's human resources
database revealed perpetrator characteristics of worker-to-worker (i.e., type 3) violence,
defined as physical assault, verbal aggression, sexual harassment, intimidation, bullying,
15
and threats. Researchers found that perpetrators of type 3 violence in healthcare were
typically female, full-time workers and were more likely to be nurses or patient care
associates. The following were identified as the five most common perpetrator-target
dyads (Hamblin et al. "Worker"):
1. Nurse to nurse
2. Patient care associate to nurse
3. Allied health professional to nurse
4. Medical resident to nurse
5. Nurse to patient care associate
Healthcare organizations must take precautions to minimize the risk of violent behavior
from staff members. The stressful healthcare environment can increase the chance that
individuals who usually do not demonstrate violent tendencies will act violently.
Drug and alcohol abuse (to which many healthcare workers may be vulnerable owing to
the stressful nature of their occupation) exacerbates the risk. See Substance Use
Disorders in Nurses and Substance Use Disorders in Physicians for more information.
However, employees generally do not just "snap"—red flags usually appear first.
Supervisors and employees should be advised of signs that an individual may become
violent. See Table 2. Signs That an Individual May Become Violent for behavioral and
physical signs as described by the Canadian Centre for Occupational Health and Safety
(CCOHS).
Staff should be educated about warning signs of potential violence and instructed to
inform their supervisor if an employee exhibits any of these indicators of potentially violent
tendencies. The supervisor should maintain confidentiality by first talking to human
16
resources staff or a representative from the EAP about the staff concerns and behaviors
that have been reported. However, if the healthcare worker is creating a hostile work
environment—or if the reported behavior poses an immediate threat to patient or staff
safety—the behavior must be addressed immediately.
Supervisors should refer employees who exhibit warning signs of potential violence to the
facility's EAP for assistance when appropriate. As discussed above, healthcare workers
and staff members not normally prone to violence may unpredictably lash out due to
workplace or personal stressors. EAPs can contribute to minimizing the risk of this type
of violence and may offer individual counseling or family counseling.
Healthcare organizations may consider providing job counseling through the EAP for
terminated or laid-off workers. This shows that the organization cares, and it may reduce
hostility levels. When potentially violent or highly disgruntled employees must be
terminated, staff may prevent a violent response by making eye contact, by allowing the
employee to communicate his or her feelings, by listening attentively and paraphrasing
what is being said, by empathizing but not apologizing, and by always asking if the
employee has further questions before closing the meeting (Johnson et al.). After the
employee's termination, a security officer or member of management should be available
to escort the employee back to his or her desk and then to the door of the building.
Identification cards and badges should be returned, computer identification passwords
should be deleted from the system, and methods for access to the building or campus
should be changed as necessary. The facility may also wish to organize a meeting with
staff members to inform them of the termination (without providing confidential or
unnecessary information) and remind them of which procedures to take if they notice a
terminated employee near the facility or campus.
17
their procedures took place as well as the hospital's chief executive officer and vice
president/risk manager, alleged that the hospital had sufficient information to act against
the anesthesiologist years before his eventual arrest. In total, 19 women, including
patients and hospital staff, alleged abuse by the physician. ("Claims Against Hospital")
The plaintiffs received $700,000, $800,000, and $900,000 respectively; two other women
reached confidential settlements with the hospital; and other cases were pending at the
time of the report. The physician pled guilty to 11 counts of sexual abuse and one count
of rape; he was sentenced to 23 years in prison. ("Claims Against Hospital")
Enforcing stringent background check procedures is key to preventing patient harm. One
of the most accurate predictors of harmful or violent behavior is a history of violence or
implication in a suspicious patient injury or death. If an event involving employee violence
does occur, it is important, from a liability standpoint, for the healthcare facility to be able
to show that it did everything in its power to screen out employees with a violent past. For
a more detailed discussion on conducting background checks, refer to Criminal
Background Checks. Healthcare employers whose workforce includes healthcare
providers and practitioners obtained through temporary staffing agencies may have a duty
to ensure that the temporary employment agencies they use have obtained criminal
background records. For more on this topic, refer to Employing Temporary and Agency
Staff. However, background checks are not foolproof safeguards against hiring
employees who may become violent. Risk managers must work with supervisors to
ensure they treat employee reports of suspicious behavior seriously, investigate reports
thoroughly, and never react negatively toward the reporting employee. In alarming cases,
workers continued to maliciously harm patients because warning signs went unnoticed or
were ignored by other employees, supervisors, and healthcare facility administration.
Despite the prevalence of violence in healthcare, research on prevention has not yielded
universally applicable strategies for risk reduction (Phillips). However, OSHA has
identified the following five core elements of a comprehensive workplace violence
prevention program that can form the basis for organization-specific prevention strategies
(OSHA "Caring") :
Management commitment and employee participation
Worksite analysis and hazard identification
Hazard prevention and control
Safety and health training
Record keeping and program evaluation
18
Leaders. According to OSHA, leaders should begin the development of a workplace
violence prevention program by convening a planning group or task force to collect
baseline data, plan, implement strategies, and monitor the program. Whoever leads the
group should have the appropriate knowledge base and the appropriate authority to effect
the necessary changes. (OSHA "Caring")
Leaders should also build a multidisciplinary threat assessment team, which often
includes representatives from the behavioral sciences, security or law enforcement, labor
union(s), high-risk areas, staff education, patient advocates, and legal counsel. Typically,
an organization's chief medical officer leads such a team with support from senior
clinicians (e.g., behavioral science professionals) who are trained in threat assessment.
(Wyatt et al.)
Supervisors and staff. OSHA also cites the importance of a "participatory approach [in
which] employees and management work together on worksite assessment and solution
implementation." Suggested areas for representation on workplace violence prevention
committees include direct care staff; human resources, safety, security, and legal
departments; unions; and local law enforcement. (OSHA "Caring") As the individuals on
the front lines of care and interaction with visitors, family members, and coworkers, direct
care workers have valuable input on the problem of workplace violence.
When supervisors engage staff to review incidents of violence, they should discuss how
situations fall outside of established norms and strategize to prevent future incidents. The
benefit of this collaboration is twofold: First, supervisors will promote a culture of civility
and empowerment in the workplace; in so doing, supervisors will also help to prevent
future harassment or violence. (Hamblin et al. "Worker;" Phillips)
19
A workplace security analysis, or "walk-through," should cover all internal and external
areas, with a special focus on areas identified as high risk. The assessment team should
include frontline healthcare workers with nurse representatives from each unit and safety
and security professionals. Any deficiencies documented during the walk-through should
be addressed immediately to avoid liability in the event of violence. During the walk-
through, employees may be questioned about relevant details. The team should try to
assess issues such as prevailing style of management, areas of excess stress, and ways
in which individuals organize their duties.
Staff should be surveyed during all shifts and situations (e.g., holidays, emergencies). On
holidays and third shifts, staff shortages may make organizations more vulnerable to
violence. During emergencies, people are usually so involved with response efforts that
20
they may forget procedures that protect against violence. The self-assessment
questionnaire Violence Prevention and sample policy Workplace Violence Prevention
Plan can be used to further identify and document the strengths and weaknesses of the
facility's violence prevention program. Additionally, OSHA's "Guidelines for Preventing
Workplace Violence for Healthcare and Social Service Workers" contains program
assessment checklists; see Resource List for details.
Examples of administrative and work practice controls—changes to the way staff perform
their jobs—include the following (OSHA "Caring") :
Conducting threat assessments—and periodic reassessments—to evaluate the
potential for violence
Ensuring adequate staffing at all times
Conducting training in de-escalation techniques and related skills
Enforcing policies and procedures that are designed to minimize stress for patients
and visitors
Although the importance of training the workforce in policies and prevention strategies
may seem obvious, these steps cannot be taken for granted. For example, in one survey
of ED resident physicians, only 16% of subjects reported prior training in violence
prevention or de-escalation techniques. Researchers found this result to be in
concurrence with other reports on training of ED physicians (Schnapp et al.)
21
training employees in factors predicting violence and aggression; fewer trained workers
on de-escalation or self-defense, and only 15% provided training for all employees
participating in patient care. (Gross et al.)
Although all staff, affiliated physicians, and contract workers should be trained in
prevention and response to workplace violence, training should also be tailored according
to duties and work locations. OSHA recommends customizing training to the particular
needs of nurses and other direct caregivers, ED staff, support staff, security personnel,
and supervisors and managers. (OSHA "Caring")
For example, supervisors and managers, who have higher levels of responsibility as
agents of the employer, should be trained separately from staff; they should be informed
that all reports of suspicious behavior or threats must be treated seriously and thoroughly
investigated. Areas for emphasis include the following (Hamer):
1. Recognizing potential violence in the early stages
2. Enforcing policy adequately
3. Fostering a culture in which reporting is encouraged and retaliation is unacceptable
Security personnel are critical responders in violent or potentially violent situations. They
should receive specialized training to address "the psychological components of handling
aggressive and abusive clients" and instruction in techniques for managing aggressive
individuals and defusing hostile situations. (OSHA "Guidelines")
Some training topics suggested by OSHA for all staff, affiliated physicians, and contract
workers include the following (OSHA "Caring") :
1. Information regarding safety devices such as alarm systems
2. Warning signs of situations that may lead to assaults (e.g., escalating behavior)
3. Use of de-escalation techniques, self-defense strategies, and other approaches to
address volatile situations or aggressive behavior (for more information on de-
escalation techniques, see Patient Violence)
4. Approaches for responding to aggressive behavior in individuals other than patients
5. The importance of seeking assistance promptly
6. Strategies for self-protection, including working in teams and accessing areas that
can provide shelter from violence
7. An action plan for responding to violent incidents
8. Policies and procedures for reporting, record keeping, and seeking support (e.g.,
medical care, counseling, workers' compensation, legal assistance) after a violent
event
The most successful training programs for workplace violence prevention utilize a variety
of formats including classroom training, hands-on instruction, real-time (i.e., "just-in-time")
coaching, and periodic refresher training. Although OSHA acknowledges several
advantages of web-based training, the agency recommends blending any remote training
format with live instruction and practice opportunities—essential elements for skill
building. (OSHA "Caring") Such in-person training provides critical opportunities for
employees to practice individual roles and responsibilities as delineated by organizational
22
policy for violence prevention and response. Because violence management training is
learned, not innate, practice and refresher training are critical to maintain learned skills.
See Encourage Reporting for more information. Violent events that result in worker or
staff injuries requiring treatment beyond first aid or requiring days away from work must
be reported to OSHA, per the agency's standard for reporting and recording work-related
illness and injury (29 CFR § 1904). See OSHA Illness and Injury Record-Keeping
Standard for more information.
Encourage Reporting
Action Recommendation: Encourage all employees and other staff to report
incidents of violence or any perceived threats of violence.
At a large academic level I trauma center in the Midwest, a quality improvement project
identified the organization's "cumbersome online reporting process," which takes 15 to 20
minutes to complete, as a barrier to reporting workplace violence. The project team
created an "informal reporting tool" that takes 1 to 2 minutes to complete, and provided a
comprehensive educational program addressing workplace violence and how to report it.
Reporting increased from zero reported workplace violence events in 2012 to more than
50 reports filed the following year. Furthermore, and considered the project's "greatest
23
success" by the project team, the percentage of staff who considered workplace violence
to be part of the job decreased from nearly 56% to just over 24%. (Stene et al.)
Respond Appropriately
Action Recommendation: Ensure appropriate follow-up to violent events,
including communication, postincident support, and investigation.
Despite a healthcare organization's best efforts, violent events are bound to occur.
Appropriate postincident support for employees who are victims of violence includes first
aid, prompt medical treatment, debriefing, counseling, and employee assistance (ACEP
"Protection"). Most importantly, organizations need to be cognizant of the impact of
workplace violence on the individual healthcare worker, and provide appropriate support
and ongoing resources (Papa and Venella).
First aid and medical care. First, victims must be attended as required by their physical
condition, whether with first aid or more comprehensive medical evaluation and treatment.
The area should then be cleaned (e.g., blood, broken glass, and sharp objects removed).
The facility may also refer employees to outside specialists for this need. Some
employees may prefer peer counseling or employee support groups. Employees may fear
returning to work or even suffer posttraumatic stress disorder; it may be beneficial to allow
24
victims to transfer to a different work area if desired. It is imperative that employees
involved in violent events, whether as victims or tangentially, feel supported and never
feel that they are being blamed. Victims of violence should be encouraged to use the EAP
even if they are not certain that it is necessary. (OSHA "Guidelines")
Investigation. Once the safety of all involved has been ensured, an investigation should
be conducted. Important steps include notifying appropriate individuals within and outside
the organization, involving workers from the affected area, identifying root causes,
reviewing related records (e.g., prior incident reports), and investigating near misses.
(OSHA "Guidelines") See Getting the Most out of Root-Cause Analyses for more
information.
Thorough documentation and investigation of the violent episode can provide a silver
lining to an otherwise negative situation. By identifying contributing factors—inadequate
security, failure to investigate complaints of suspicious behavior, physical features of the
facility—the organization can develop controls to prevent a recurrence.
Hospital-based shootings are relatively rare in comparison with other violent events in
healthcare settings, yet they have obvious potential for grave consequences. In a study
conducted to identify U.S. acute care hospital shooting events between 2000 and 2011,
researchers identified 154 incidents. Approximately 60% of shootings occurred within the
hospital; the remainder took place on hospital grounds. The most common sites were the
ED (29%), the parking lot (23%), and patient rooms (19%). Researchers found that the
majority of events involved a "determined shooter with a strong motive," such as a grudge
(27%), suicide (21%), mercy killing (14%), and prisoner escape (11%). (Kelen et al.) Not
all of the shootings in this study fit within federal law enforcement's definition of "active
shooter" incidents.
FBI has created a repository of active shooter incidents in the United States occurring
between 2001 and 2016; six of these incidents occurred in healthcare settings. Although
none occurred before 2009, since then an active shooter incident has occurred in a
healthcare setting almost every year. See Table 3. Active Shooter Incidents in Healthcare
Facilities for more information.
25
Additionally, in 2016, a patient and a nurse's aide "were shot and killed for no apparent
reason by an armed man" who entered a Florida hospital. According to published reports,
the hospital's active shooter plan, which had been in place for eight years, was
instrumental in avoiding further loss of life. Furthermore, the hospital has reportedly taken
additional security measures since the shooting, including the following (HCPro) :
1. Maintaining law enforcement presence with enhanced security at public entrances
2. Requiring identification before granting access at the main entrance and ED
3. Conducting random checks of bags
4. Arming security officers with additional protective equipment and gear
5. Providing security officers with additional training
In 2014, the U.S. Department of Health and Human Services, in collaboration with several
other federal agencies, released a guide on how to incorporate planning for an active
shooter incident into healthcare facility emergency-operations plans. Although such an
event is "still an anomaly in the healthcare setting," this training is an important part of a
comprehensive workplace violence prevention program (Hartley). See Resource List for
additional information.
26
event. Personnel are required to monitor machines, and entrances without machines
would need to be closed. Given the relative rarity of this type of violence, and citing a lack
of concrete evidence to support the expectation that metal detectors decrease violence
in healthcare settings, researchers have acknowledged that "metal detectors may not be
the best use of safety resources" (Phillips). For more information on physical security
solutions, see Hospital Security.
27