Workplace Violence Prevention in Healthcare

Understanding Workplace Violence

NIOSH defines workplace violence as violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty. It includes a range of behaviors, from verbal abuse, threats, and harassment to physical assault and, rarely, homicide.

NIOSH and OSHA describe four commonly used types:

• Type 1, criminal intent: the perpetrator has no legitimate relationship to the business, such as during a robbery.
• Type 2, customer/client: the perpetrator is a patient, family member, visitor, or other person receiving services. This is the most common type in healthcare.
• Type 3, worker-on-worker: violence between current or former employees, including bullying and threats.
• Type 4, personal relationship: the perpetrator has a personal relationship with the worker, such as intimate partner violence that spills into the workplace.

OSHA notes that healthcare and social service workers face an increased risk of workplace violence compared with many other occupations. Violence is never simply 'part of the job.'

Risk Factors

OSHA's Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA 3148) identify risk factors, including:

• Working directly with people who have a history of violence, who are under the influence of drugs or alcohol, or who have certain medical or psychiatric conditions that can cause agitation or delirium.
• Long waits and crowded, uncomfortable waiting areas.
• Working alone, including home visits and community settings.
• Poor environmental design that limits escape routes or visibility.
• Poorly lit corridors, rooms, and parking areas.
• Inadequate security and lack of staff training.
• Understaffing, especially during meal times and at night.
• Unrestricted public access and transporting patients.

Elements of a Prevention Program

There is no specific federal OSHA standard for workplace violence in healthcare, but employers have obligations under the General Duty Clause of the Occupational Safety and Health Act, Section 5(a)(1), to provide a workplace free from recognized hazards likely to cause death or serious physical harm. Some states have their own requirements, and The Joint Commission established workplace violence prevention standards for accredited hospitals effective in 2022.

OSHA's guidelines describe five core program elements:

• Management commitment and worker participation.
• Worksite analysis, including reviewing incident records and surveying staff to identify hazards.
• Hazard prevention and control, such as alarm systems, panic buttons, adequate lighting, controlled access, furniture arrangement that keeps exit paths clear, adequate staffing, and policies for flagging patients with a history of violence.
• Safety and health training for all workers, supervisors, and managers.
• Recordkeeping and program evaluation.

Recognizing Escalation

Violence is often preceded by warning signs. Watch for:

• Raised voice, shouting, or swearing.
• Pacing, clenched fists, or a rigid posture.
• Staring or, conversely, avoiding eye contact.
• Verbal threats or threatening gestures.
• Throwing or striking objects.
• Signs of intoxication, confusion, or acute distress.

Remember that agitation can result from medical causes such as pain, hypoglycemia, hypoxia, delirium, withdrawal, or medication effects. Clinical assessment of the underlying cause is part of a safe response.

Verbal De-escalation

De-escalation aims to calm a situation and reduce the likelihood of physical harm. Commonly taught techniques include:

• Maintain safety first: keep a clear exit path for yourself, keep at least an arm's length or more of space, and avoid standing directly in front of the person.
• Stay calm: use a quiet, steady voice and relaxed, open body language.
• Listen actively: acknowledge feelings, for example, 'I can see you are frustrated about the wait.'
• Use simple, clear language and avoid arguing, sarcasm, or commands that sound like ultimatums.
• Offer choices when possible to restore a sense of control.
• Set respectful limits on unacceptable behavior.
• Know when to stop: if de-escalation is not working, leave and summon help.

Remove items that could be used as weapons, such as lanyards or stethoscopes worn around the neck, when entering a potentially volatile situation, consistent with facility policy.

Responding and Reporting

If a situation becomes dangerous:

• Get to a safe location and call for help using your facility's emergency code, panic button, or 911.
• Follow your facility's emergency response plan, including procedures for an active threat.
• Do not attempt to physically intervene unless trained and it is part of your role.

After an incident:

• Report all incidents, including verbal threats and near misses, according to facility policy. Underreporting prevents organizations from identifying hazards and improving controls.
• Seek medical care for any injury and document it.
• Use support resources, such as an employee assistance program, since psychological effects can be significant.
• Participate in debriefing to help prevent recurrence.

Employers may not retaliate against workers who report injuries or safety concerns. NIOSH offers a free online course, Workplace Violence Prevention for Nurses, with additional information applicable to many healthcare roles.

Special Settings: Home Health and Community Care

Workers who provide care in homes and community settings face unique risks because they often work alone and have less control over the environment. Practices described in OSHA and NIOSH guidance include:

• Reviewing available information about the visit location and any history of violence before the visit.
• Sharing your schedule and checking in with your office according to policy.
• Keeping a charged phone and car keys readily available.
• Parking in well-lit areas where you will not be blocked in.
• Leaving immediately if you feel unsafe, and rescheduling with an escort when appropriate.
• Reporting threatening animals, weapons in the home, or hostile individuals present during visits.

Employers should establish procedures that allow staff to refuse or postpone a visit when they believe it is unsafe, without penalty.