The prevention of workplace violence (WPV) has emerged as an important safety issue in and around hospitals and healthcare facilities. Workplace violence, such as physical assaults or threatening behavior, is a growing problem in the workplace and, in particular, in healthcare.
Emotionally-charged situations where patients and family members are fearful and lack control may increase the potential for violence perpetrated against hospital staff. In addition, the event that brought the patient to the hospital could involve crimes, weapons, drugs and alcohol, or violence. These external factors could put staff at an increased risk of workplace violence. Although anyone working in a hospital may become a victim of violence, staff who have direct contact with patients are at higher risk.
The effects of violence can range in intensity and include minor or serious physical injuries, temporary or permanent physical disability, psychological trauma, and even death.
The individual risk factors for violence vary from hospital to hospital depending on factors such as location, size, and type of care provided. Some common risk factors for hospital violence include the following:
- Working directly with patients or visitors who have a history of violence, abuse drugs or alcohol, and/or have access to firearms, knives, or other weapons;
- Working when understaffed;
- Long waits for service;
- Overcrowded, uncomfortable waiting rooms;
- Working alone;
- Poor environmental design;
- Inadequate security;
- Lack of staff training and policies for preventing and managing crises with potentially volatile patients;
- Unrestricted movement of the public; and
- Poorly lit corridors, rooms, parking lots, and other areas.
Select a common safety and health topic or hazard from the list on the left to view information related to the topic/hazard.
A written program for workplace violence prevention, incorporated into an organization's overall safety and health program, offers an effective approach to reduce the risk of violence. Like any other safety and health program, workplace violence prevention programs require continual assessment and possible modifications. Several states have passed legislation and developed requirements that address workplace violence. OSHA's Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. OSHA Publication 3148, (2016) and other documents referenced below can be used in conjunction with state requirements.
Establish and maintain a workplace violence prevention program, as part of your facility's safety and health management program that is suitable to the size and complexity of the facility.
An Effective Workplace Violence Prevention Written Program:
- Creates and disseminates a clear policy that violence, verbal and nonverbal threats, and related actions, will not be tolerated.
- Provides for the continual assessment of hazards and improvements to the program.
- Ensures that no reprisals are taken against employees who report or experience workplace violence.
- Encourages prompt reporting of all violent incidents.
- Requires recordkeeping of incidents to assess risk and to measure progress.
- Establishes a plan for maintaining security in the workplace, which includes law enforcement officials and other specialists.
- Is available to all employees and contractors, including managers and supervisors, who receive specific training concerning the program's content and implementation.
- Provides assistance and support to staff who report being assaulted.
- Management Commitment to the Workplace Violence Prevention Program
- Employee Involvement
- Worksite Analysis
- Hazard Prevention and Control
- Safety and Health Training
- Recordkeeping and Program Evaluation
In this eTool, OSHA briefly summarizes the components of a successful workplace violence prevention program. For a full discussion, please see Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers.
Management Commitment and Employee Involvement
Management commitment provides the motivation and resources to deal effectively with workplace violence and includes:
- Establishing a policy that does not tolerate violence, threats of violence, and other disruptive behavior in the workplace;
- Ensuring that all reports of incidents will be taken seriously and will be dealt with appropriately;
- Allocating appropriate authority and resources to all responsible parties. Resource needs often go beyond financial needs to include access to information, personnel, time, training, tools, or equipment;
- Assigning responsibility and authority for the various aspects of the workplace violence prevention program to ensure that all managers and supervisors understand their obligations;
- Maintaining a system of accountability for involved managers, supervisors and workers;
- Supporting and implementing appropriate recommendations from safety and health committees;
- Establishing a comprehensive program of medical and psychological counseling and debriefing for workers who have experienced or witnessed assaults and other violent incidents and ensuring that trauma-informed care is available; and
- Establishing policies that ensure the reporting, recording and monitoring of incidents and close calls, and that no reprisals are taken against anyone who does so in good faith.
Employee involvement and feedback enable workers to provide useful information to employers to design, implement and evaluate the program. This involvement includes:
- Participating in the development, implementation, evaluation and modification of the workplace violence prevention program;
- Participating in safety and health committees that receive reports of violent incidents or security problems;
- Partaking in facility inspections and making recommendations for corrective strategies;
- Providing feedback on policies and procedures—including complaint and suggestion programs designed to improve safety and security;
- Ensuring that there is a way to report and record incidents and close calls, and that issues are addressed appropriately; and
- Participating in employee training and continuing education programs.
Worksite Analysis, Hazard Prevention and Control
A worksite analysis involves a step-by-step assessment of the workplace to find existing or potential hazards that may lead to incidents of workplace violence.
Once the systematic analysis is complete, the employer should take the following steps to prevent or control the hazards that were identified:
- Identify the types of hazard prevention and control measures needed to reduce or eliminate the possibility of a workplace violence incident occurring;
- Select effective and feasible controls to eliminate or reduce hazards;
- Implement those controls in the workplace;
- Follow up to confirm that these controls are being used and maintained properly;
- Evaluate the effectiveness of controls and improve, expand, or update them as needed; and
- Assist in the identification or development of appropriate training.
NOTE: Conduct a worksite analysis annually or after an incident that identifies weaknesses in the program.
Recognized Controls and Work Practices
It is important that employers and workers determine the most effective method for ensuring the safety of workers without making working conditions worse. Implement prevention and control measures, including, as appropriate, the following engineering and administrative controls and work practices:
- Using appropriate engineering controls to provide security such as:
- Designing of waiting rooms to reduce tension from overcrowding
- Bolting down furniture.
- Securing other items that could be used as weapons, such as phones, fire extinguishers, lamps, etc.
- Installing concealed panic buttons in hospital areas, on staff, and at the check-in area, that can be pushed for emergency help. These buttons could notify hospital security as well as directly reach the local Police Department.
- Installing and maintaining improved lighting and video surveillance.
- Installing and using metal detectors.
- Providing secure rooms that have the following characteristics:
- Video camera surveillance;
- Visual surveillance (e.g., through a window);
- Door locks;
- Locked cabinets;
- Furniture arranged to prevent entrapment of staff (e.g., ensure that furniture is minimal, lightweight, without sharp corners, and/or affixed to the floor);
- Room layout that ensures to easy exit for workers;
- Free from clutter; and
- Secondary door for escape in case main door is blocked.
- Establish a Workplace Violence Prevention program that addresses the elements discussed in this section of the eTool.
- Train staff to recognize and de-escalate potentially violent situations, to be alert for potential violence and suspicious behavior and report it, and to provide intervention measures including verbal, social, physical, and pharmacological interventions where feasible.
- Provide adequate staffing levels, with experienced clinicians on each shift.
- Increase worker safety during arrival and departure by providing security escorts and shuttle service to and from parking lots and public transportation.
- Ensure accurate reporting of all violent behavior, including possible triggers.
- Make patients aware of the zero tolerance policy for violence.
- Include local law enforcement authorities in overall security plan as appropriate.
- Obtain records of patients to learn of any past violent behaviors.
- Establish a system of charting or tracking, and evaluating, possible assaultive behaviors and patients with a history of violence that includes procedures to pass on information from one shift to another.
OSHA emphasizes that the controls discussed here do not represent the full array of controls that would comprise an effective Violence Prevention Program. For more information, please see Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers.
Safety and Health Training
Provide Safety and Health Training to make all staff aware of security hazards and how to protect themselves through established policies and procedures.
- Training is a critical component of any prevention strategy for staff, supervisors and other employees.
- Training could be conducted by a team of individuals, police representatives, or others who have expertise in workplace violence.
- Involve employees responsible for the workplace violence prevention program. Personally knowing these individuals will encourage employees and supervisors to seek assistance from them at a much earlier stage of a potential workplace violence incident.
An effective training program provides the following:
- An understanding of the facility's workplace violence policy and program.
- Procedures for and encouragement to report incidents.
- How to recognize and deal with hostile, aggressive persons.
- Methods for preventing or diffusing volatile situations or aggressive behavior, such as conflict resolution.
- Information on the causal dynamics of violence (such as patient behavior, patient care events, and the outside environment).
- Techniques and skills on managing anger and resolving conflicts.
- Stress management and relaxation techniques.
- Security procedures.
- Personal security measures and self-defense.
- Techniques for supporting victims.
For additional information, see Workplace Violence, OSHA Training and Reference Materials, and other materials referenced below.
Provide a program of support for workers involved in violent incidents and workers who observed violent incidents. Employers usually set up trained teams to respond to emergencies, and provide post-incident response assistance to the workers. The assistance comprises prompt medical treatment and psychological evaluation. The follow-up program in place can also offer counseling, support groups, stress debriefing, trauma-crisis counseling, and other employee assistance programs.
OSHA provides non-mandatory forms to help employers develop their post-incident response policies and procedures.
Program Evaluation and Recordkeeping
Recordkeeping and evaluation of the violence prevention program are necessary to determine its overall effectiveness and to identify any deficiencies or changes that should be made.
Good records on injuries, illnesses, incidents, assaults, hazards, corrective actions, patient histories and training are important to the success of a workplace violence prevention program and can:
- Help employers determine the severity of the problem;
- Identify any developing trends or patterns in particular locations, jobs or departments;
- Evaluate methods of hazard control;
- Identify training needs; and
- Develop solutions for an effective program.
Records can be especially useful to large organizations and for members of a trade association that "pool" data.
Important records include:
- OSHA Log of Work-related Injuries and Illnesses (OSHA Form 300).
- Medical reports of work injury, workers’ compensation reports and supervisors' reports for each recorded assault.
- Near miss reports of verbal attacks or aggressive behavior.
- Records of incidents of abuse.
- Security incident reports.
- Information on patients with a history of past violence, drug abuse or criminal activity
- Minutes of safety meetings, records of hazard analyses, and corrective actions recommended and taken.
- Records of all training programs, attendees and qualifications of trainers.
Employers must comply with OSHA’s Recordkeeping Rule, 29 CFR Part 1904. OSHA's updated recordkeeping rule, which took effect January 1, 2015, expands the list of severe injuries that all employers must report to OSHA. According to the updated Recordkeeping rule, employers have to report the following to OSHA:
- All work-related fatalities, within 8 hours of finding out about them;
- All work-related inpatient hospitalizations, within 24 hours of finding out about them;
- All work-related amputations, within 24 hours of finding out about them; and
- All work-related losses of an eye, within 24 hours of finding out about them.
In addition to records required by the Recordkeeping Rule, it is important that other records covering the following be maintained:
- Medical reports of workplace violence-related injuries.
- Incidents of abuse (either physical or verbal abuse, or other acts of aggression, even when they do not result in injuries).
- Information on patients with a history of past violence. Record this information on the patient's chart, and make staff aware of the potential for aggression.
- Workplace violence training.
- Reviews assessing the workplace violence-related risks in the procedures and operations of different jobs and tasks.
- Employee surveys on workplace violence.
- Patient/client surveys on workplace violence.
- Workplace security analyses.
Elements of program evaluation
Ongoing evaluation of a facility's violence prevention program helps determine its effectiveness. The evaluation:
- Helps identify any problems or deficiencies that can then be corrected;
- Allows management to review program effectiveness, and re-evaluate policies and procedures on a regular basis; and
- Helps management analyze trends, measure improvements, and keep well-informed about new trends to reduce workplace violence.
As part of your overall program, evaluate your safety and security measures. It is important that top management reviews the program and regularly evaluates its success, and that responsible parties (including managers, supervisors and employees) reevaluate policies and procedures on a regular basis to identify deficiencies and take corrective action.
It is also important that management shares workplace violence prevention evaluation reports with all workers. Discuss any changes in the program with the safety committee, union representatives or other employee groups.
Ensure that all reports protect worker and patient confidentiality either by presenting only aggregate data or by removing personal identifiers, if individual data are used.
Processes involved in an evaluation include:
- Establishing a uniform violence reporting system and regular review of reports;
- Reviewing reports and minutes from staff meetings on safety and security issues;
- Analyzing trends and rates of illnesses, injuries or fatalities caused by violence relative to initial or baseline rates;
- Measuring improvement based on lowering the frequency and severity of workplace violence;
- Keeping up-to-date records of administrative and work practice changes to prevent workplace violence, and evaluating how well the changes work;
- Surveying workers before and after making job or worksite changes or after installing security measures or new systems to determine their effectiveness;
- Tracking recommendations through to completion;
- Keeping abreast of new strategies available to prevent and respond to violence in the healthcare and social service fields;
- Surveying workers periodically to learn if they experience hostile situations in performing their jobs;
- Complying with OSHA and state requirements for recording and reporting, injuries, illnesses and fatalities; and
- Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving worker safety.
- Guidelines for Preventing Workplace Violence for Healthcare & Social Service Workers. OSHA Publication 3148, (2016).
- Worker Safety in Hospitals: Caring for our Caregivers, Preventing Workplace Violence in Healthcare. OSHA.
- Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence. OSHA Directive CPL 02-01-058 [CPL 02-01-052], (January 10, 2017).
- Inspection Guidance for Inpatient Healthcare Settings. (June 25, 2015). OSHA memorandum establishing guidance for inspections conducted in inpatient healthcare settings.
- Violence Occupational Hazards in Hospitals. U.S. Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication 2002-101, (April 2002).
- Workplace Violence. OSHA Safety and Health Topics Page.
- Sample Confidential Incident Report Form. Reprinted on CDC website with permission of permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm of Abbott, Nicholson, Quilter, Esshaki & Youngblood, P. C., Detroit, MI. An example of what might be used or modified by employers in hospitals to help prevent workplace violence.
- Arnetz, J.E. et al., (2015). Understanding patient-to-worker violence in hospitals: a qualitative analysis of documented incident reports. J Adv Nurs, 71(2): 338–348.
OSHA Recordkeeping Requirements
- 29 CFR Part 1904, Recording and reporting occupational injuries and illnesses. OSHA Regulations.
- OSHA Injury and Illness Recordkeeping and Reporting Requirements, OSHA Recordkeeping Rule page
- Updates to OSHA’s Recordkeeping Rule: Reporting Fatalities and Severe Injuries. OSHA Fact Sheet, (2014)
- Recordkeeping Policies and Procedures Manual. OSHA Directive CPL 02-00-135, (December 30, 2004).