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COURSE OBJECTIVE: The purpose of this course is to prepare healthcare practitioners to identify and react appropriately to workplace violence situations and to identify individual and organizational preventive measures.
Upon completion of this course, you will be able to:
Workplace violence came into public awareness in 1986 following the media attention given to the shooting of 14 postal workers by a coworker. This homicidal phenomenon gave rise to the term going postal. But the postal service setting is not the only workplace to experience such violence. For instance, in the healthcare setting:
Homicides such as these make the news almost every day. However, the majority of workplace violence is not homicide, but rather threats, assaults, bullying, intimidation, stalking, sexual and other forms of harassment, and emotional abuse. Workplace violence has been ascribed to the combination of violence-prone individuals and incident-prone environments. It is an important health and safety issue in today’s workplace and requires identifying risk factors and strategic actions to keep employees safe.
The Occupational Safety and Health Administration (OSHA, 2011) states that nearly 2 million workers report being victims of workplace violence each year. The 2011 Liberty Mutual Safety Index lists workplace violence as the tenth-leading cause of nonfatal occupational injuries. Workplace violence is the fourth-leading cause of death in the workplace and the leading cause of death among women in the workplace (Monson et al., 2011).
The Bureau of Labor Statistics (2013a) reports there were 4,383 fatal work injuries in 2012, and violence accounted for about 17% of them. Of those killed by violence, 463 were homicides and 225 were suicides. Of the fatal work injuries involving female workers, 29% were homicides, and of the fatal work injuries involving males, 9% were homicides. In 2012, 375 workers were killed in shootings while on the job. Shootings connected with robberies accounted for 33% percent of homicides, while coworkers accounted for 13% (BLS, 2013b).
Efforts have been made to collect specific data regarding workplace violence by the National Institute for Occupational Safety and Health (NIOSH), which records reported workplace injuries and fatalities, including assaults, violent acts, and homicides. The Consumer Product Safety Commission (CPSC), using the National Electronic Injury Surveillance System (NEISS) and the National Crime Victimization Survey, records only reported work-related injuries requiring treatment in emergency rooms. This demonstrates that many assaults go unreported due to the lack of treatment required, giving only a narrow vision of the actual scope of workplace violence.
Healthcare and social assistance is the largest industry sector in the United States, with an estimated 18.9 million workers. In the last decade healthcare workers represented two thirds of nonfatal workplace violence injuries. These workers have a five-times greater risk for requiring time off due to assault (CDC, 2013).
The majority of workplace assaults within the healthcare sector occur in nursing-related facilities and are committed by patients or residents of a healthcare facility (Restrepo & Shuford, 2012).
The U.S. Department of Justice published a special report in 2011, providing statistics regarding healthcare workers who were victims of workplace violence between 2005 and 2009 (see table).
|Occupation||Number||Rate per 1,000 Employed Persons Age 16 or Older|
|Source: National Crime Victimization Survey data (Harrell, 2011).|
|Custodial care||27,200||37.6 (based on 10 or fewer sample cases)|
|Other mental health||69,200||20.3|
The actual number of incidents is probably much higher, since incidents of violence are likely to be underreported, perhaps due in part to the persistent perception within the healthcare industry that assaults are “part of the job.” Underreporting may reflect:
All of these factors underscore the need for effective policies that are communicated to all workers and supported by employer actions.
Workplace violence extracts a significant toll on everyone involved. This includes physical, emotional, and mental effects on the individual, such as:
Negative consequences for institutions can include:
The aggregate cost of workplace violence to U.S. employers is estimated to be more than $36 billion as a result of such impacts (Encyclopedia of Small Business, 2011).
NIOSH defines workplace violence as violent acts directed toward persons at work or on duty. Workplace violence is any physical assault, threatening behavior, or verbal abuse occurring in the work setting. A work setting is defined as any location, either permanent or temporary, where an employee performs work-related duties. This comprises, but is not limited to, the buildings and surrounding perimeters, including the parking lots, field locations, clients’ homes, and traveling to and from work assignments.
Workplace violence ranges broadly from offensive or threatening language to homicide. Elements of workplace violence include beatings, stabbings, suicides, shootings, rapes, psychological traumas, threats or obscene phone calls, intimidation, harassment of any kind, as well as being sworn at, shouted at, or followed.
In the mid-1990s, as more researchers were becoming engaged in the study of occupational violence, the California Occupational Safety and Health Administration developed a model that describes three distinct types of workplace violence based on the perpetrator’s (person committing the violence) relationship to the victim and/or the place of employment. Later, the typology was modified to define four types of workplace violence, creating the system that remains in wide use today.
The four types of workplace violence are:
In this type of workplace violence the perpetrator is a stranger without a legitimate relationship to the organization or its employees. Typically, a crime is being committed in conjunction with the violence. The primary motive is usually robbery, but it could also be shoplifting or criminal trespassing. A deadly weapon is often involved, increasing the risk of fatal injury. Crimes of violence in this category include assault, sexual assault, robbery, homicide, and acts of terrorism.
The vast majority of workplace homicides (85%) are violence by a stranger (BLR, 2011). Workers who are at higher risk for violence by a stranger with criminal intent are those who exchange cash with customers as part of the job, work late-night hours, and/or work alone. Convenience store clerks, taxi drivers, and security guards are all examples of the kinds of workers who are at increased risk for criminal violence.
In type 2 incidents, the perpetrator has a legitimate relationship with the organization by being a recipient of its services. This category includes customers, clients, patients, students, inmates, and any other group for which the business provides services. The violence can be committed in the workplace or, as with home healthcare providers, outside the workplace but while the worker is performing a job-related function.
Only about 3% of all workplace homicides result from this type of violence, but it accounts for a majority of nonfatal workplace violence incidents (BLR, 2011). Service providers, including healthcare workers, schoolteachers, social workers, and bus and train operators, are among the most common targets of customer/client violence (Haynes, 2013). A large proportion of customer/client incidents in the healthcare industry occur in settings such as nursing homes, hospitals, and psychiatric facilities.
One category of type 2 violence involves inherently violent situations or settings, such as prisons or mental-health facilities. Attacks from “unwilling” clients (those who have not chosen to be a recipient of services), such as prison inmates on guards or crime suspects on police officers, are examples of this type of workplace violence. The risk of violence to some workers in this category may be constant or even routine.
Eric is a college student who works part-time on the night shift as a lab technician at Memorial Medical Center, a mid-sized hospital in a suburb of a large metropolitan area. The hospital emergency department (ED) has eight beds and is relatively quiet unless they are treating overflow patients from the trauma unit downtown. Recently, the hospital agreed to allocate space in the ED for the local police department to admit suspected drunk drivers for assessment and short-term intervention. To date there have been only a handful of such cases.
Eric was on duty when an intoxicated 28-year-old male patient was admitted for assessment after hitting a parked car while leaving a party. The patient, who was initially cooperative while the police officer was present, was taken to one of the assessment rooms at the end of the hall by a nurse. The patient began to get agitated, denied he had done anything wrong, jumped up, and demanded to be released.
Eric entered the room to take a blood sample just as the nurse was responding to the patient’s angry request by grabbing onto his arm and telling him that he was not allowed to leave yet. The patient picked up a small metal canister off the counter, threw it at Eric, and ran out of the room toward the entrance, where he was subdued by the hospital security guard and two additional staff members. The canister hit Eric in the face, injuring his left eye.
The hospital’s safety committee was asked to review the incident and make recommendations for preventing future occurrences. The committee evaluated the specific incident as well as the:
The committee proposed that a better response to the situation might have included:
It was determined that the hospital had overlooked some of the risks involved with the new program, and they responded quickly to the committee’s suggestions by implementing the following improvements:
The other category of type 2 violence involves people who are not known to be inherently violent but are situationally violent. Something in the situation induces an otherwise nonviolent client or customer to become violent. Provoking situations may be those that are frustrating to the client or customer, such as denial of needed or desired services or delays in receiving such services.
Alice Adams is a 70-year-old resident at Hillcrest Manor, a skilled nursing and long-term care facility. She was admitted six months ago after she was found wandering a few blocks away from her long-time family home. She was recently diagnosed with second-stage Alzheimer’s disease. Prior to her admission she lived alone with daily help from her two sons, their wives, and several grandchildren. Her husband died eighteen months ago after a fall from a ladder while cleaning leaves out of the gutters.
The older son, Jack, still feels guilty for not helping his father with the gutter clean-up and blames himself for his father’s death. He was not in favor of the decision to admit his mother to Hillcrest but reluctantly agreed when the other family members and Alice’s physician decided it was the best option. Jack has been a frequent caller to the facility administrator’s office with complaints about his mother’s care. He thinks that she is not checked often enough, that she needs more help with meals, and that she should be taken for walks more frequently. He believes that his mother’s health is worse and blames the facility for a decline in her mental capacity.
Today Jack arrives to find Alice dozing in her recliner chair with her supper tray sitting untouched on the table next to her. He storms out of her room into the hallway and shouts that he needs help right away. The evening shift nurse is just down the hall making rounds and responds immediately, as does the occupational therapist helping a resident in the next room. Jack grasps the therapist’s shoulders and pushes her into his mother’s room, asking why his mother has not been helped yet with her meal. He curses and states that this is the last time he is going to ask nicely.
The therapist recognizes Jack and is familiar with his frequent complaints about his mother’s care. She steps aside and exits the room. Standing in the doorway, she calls him by name, calmly stating, “Mr. Adams, I can see that you are upset. I was just finishing up next door and was going to help Mrs. Adams next. It sounds like you would like to talk with someone about your concerns. I will get the supervisor, who will be glad to meet with you.” Jack visibly relaxes and sits down.
The evening shift nurse arrives in time to see the incident and steps into the room. She helps Jack set up his mother’s dinner tray and calls a nursing assistant to help Alice with her meal. She then suggests that Jack meet with her in a nearby conference room.
She asks Jack to describe what happened, and as he does, he acknowledges that his behavior was out of line. He apologizes for his outburst and shares how frustrated he is with his mother’s health decline and not being able to do anything to prevent it. The nurse acknowledges his feelings and how difficult it must be for him to deal with the kind of changes he has been faced with. She states that his behavior was inappropriate and will be reported to the facility’s security manager. She tells Jack that any additional incidents like she witnessed that evening will result in further action to ensure the safety of the residents and the employees. She reminds him that he can communicate any concerns about his mother’s care to the administrator or to her if it is the evening shift.
She then suggests that Jack may benefit from talking with the facility’s social worker, who also runs the local caregivers support group, and provides him with the phone number. Jack agrees that the suggestion sounds like a good idea and returns to his mother’s room to resume his visit.
Coworker violence occurs when an employee or past employee attacks or threatens coworkers. This category includes violence by employees, supervisors, managers, and owners. In some cases, these incidents can take place after a series of increasingly hostile behaviors from the perpetrator. The motivating factor is often one, or a series of, interpersonal or work-related disputes. The perpetrator may be seeking revenge for what is perceived as unfair treatment.
Worker-to-worker violence accounts for approximately 7% of all workplace homicides (BLS, 2013b). Because some of these incidents appear to be motivated by disputes, managers and others who supervise workers may be at greater risk of being victimized.
Workplace violence and harassment experts identify the following behaviors that constitute coworker violence in the workplace (Hawaii Nurses Association, 2008):
The American Psychiatric Nurses Association (APNA) characterizes worker-to-worker violence as either vertical or horizontal.
Vertical violence is defined as any act of violence that occurs between two or more persons on different levels of the hierarchical system and prohibits professional performance and satisfaction in the workplace. Such acts can include:
Vertical violence may be directed downward (e.g., superior to subordinate) or upward (e.g., subordinate to superior). Vertical violence can reflect either an abuse of legitimate authority or abuse of informal power. Abuse of informal power by individuals or cliques of coworkers are behaviors that undermine the work of a manager or leader.
Vertical violence is prevalent among nurses and between doctors and nurses and can be further connected to medical errors and preventable negative outcomes for patients. For example, a nurse may be reluctant to call a physician about a patient’s worsening condition because of physician bullying, incivility, or overt or covert abuse; or a medication order may not be questioned in order to avoid the threat of intimidation.
Roland is a nurse working in the emergency department of a local hospital in a midsize town. Among the physician staff there, Dr. Johnson is known to be difficult to deal with. He is an angry man ever since his daughter was killed in a car accident caused by a drunk driver ten years ago. He is rude and obnoxious both to staff and patients.
This evening, Roland is working in trauma room 1 and needs to obtain a piece of equipment from trauma room 3. The door to room 3 is closed, as Dr. Johnson is suturing a patient there. Roland knocks on the door and opens it slowly, excuses himself, and announces his need to obtain equipment from the room. Abruptly, Dr. Johnson gets up, walks to the door, and slams it shut, hitting Roland in the face and crushing his wire-rim glasses. As a result, Roland must delay treatment for the patient he was caring for in room 1.
No action has ever been taken in regard to Dr. Johnson’s violent behavior despite Roland and the other nurses in the emergency department having reported such behavior many times before. The department manager has told the nurses that Dr. Johnson is dealing with grief and that they should understand what he is going through. After all, it is hard to find doctors to staff the ED, and dealing with such situations is just “part of the job.” As a result, the nurses have become resigned to this physician’s behavior and try to avoid any interaction that might cause him to abuse them. After this latest incident, Roland complains to his coworkers but does not report it.
Seeing too many such scenarios go unreported and get swept under the rug, another nurse decides to contact the new medical director, Dr. Bachhuber. The next day, Dr. Bachhuber calls Roland into her office and asks about the recent incident with Dr. Johnson. Roland is asked to complete an incident report describing what happened. The medical director tells him there will be an investigation carried out to determine the extent of the problem, offers to have Roland evaluated medically, and assures him that his glasses will be replaced at the hospital’s cost if necessary.
Horizontal, or lateral, violence is an act of aggression among peers characterized by the presence of a series of undermining incidents over time that creates a toxic environment. Horizontal hostility and aggression is designed to control, diminish, or devalue a peer. Such acts may include:
Horizontal violence is prevalent in the nursing profession. Estimates of horizontal violence in the nursing workplace range from 46% to 100% (Stanley et al., 2007). When such behaviors are tolerated, they create a toxic work environment that harms nurses and eventually harms patients. Because of lateral violence, up to 60% of new nurses leave their first professional position within six months and 20% leave forever (Iyer, 2012).
A negative work environment affects a hospital financially when it must replace each nurse experiencing burnout. Within three years, 27% of novice nurses leave their original facility, with one third of those departures being directly caused by bullying behaviors. Nurse leaders and staff nurses cause the greatest number of bullying incidents (Bullen, 2013).
Attempts to explain the high incidence of horizontal violence in the nursing profession are traced to the history of nursing, where oppression was once the norm between the male medical profession and female nurses. Members of the nursing profession have been described as an oppressed group, and according to the theory of oppression, powerlessness, lack of control over the working environment, and subsequent low self-esteem have contributed to negative role socialization and the development of horizontal violence among nurses.
Additionally, administrators can add to the oppression when nurses are treated as employees first and individuals with rights second. Nurses have not always been provided with education in conflict resolution, assertion of their rights, or access to resources to help develop professionalism (Bartholomew, 2013).
Elizabeth, a physical therapist, moved from Chicago to a small town in Montana and now works at the local hospital there. This is her second job since graduating two years ago. Elizabeth has not been having good experiences with her coworker Margaret. Margaret often makes snide remarks about Elizabeth being “a big city girl with little experience” and belittles her when she speaks up at staff meetings.
Several times over the past month, Elizabeth asked for assistance from Margaret and was told she needed to “learn to set priorities better.” At times when she asked for information about a patient or situation, Margaret rolled her eyes, ignored her, and walked away.
Elizabeth recognized she was being bullied and needed to take steps to stop it. She began keeping a journal, objectively recording specific behaviors, including date, time, who else was present, and any other details surrounding each incident. When she felt she had enough documentation, Elizabeth sought out another coworker who was very supportive and asked if she would accompany her when she decided to talk to Margaret about her concerns. The coworker agreed.
Elizabeth made an appointment with Margaret. At their meeting, Margaret asked the coworker to leave, but Elizabeth said she had a right to have someone with her because she wanted to feel safe discussing how Margaret was treating her. During the meeting Elizabeth presented her journal to Margaret, told her she was being bullied, and said she wanted it to stop. She also handed Margaret a memo stating that Margaret’s behavior was unacceptable, distracts from her work, and that if the behavior continued, she would need to go to the next level of authority. Elizabeth left the meeting, thanked the other coworker, and documented the meeting in her journal.
Over the next few days, Margaret never mentioned Elizabeth’s complaint, but her behavior changed and the bullying stopped. Elizabeth’s confidence returned and she began to enjoy her work.
Type 4 workplace violence is often the greatest threat to female employees and is most likely to occur in organizations with large female populations where there is easy access by outsiders (Grayson, 2010). In this type of workplace violence, the perpetrator usually has or has had a personal relationship with the intended victim and does not have a legitimate relationship with the workplace. The incident may involve a current or former spouse, lover, relative, friend, or acquaintance. The perpetrator is motivated by perceived difficulties in the relationship or by psychosocial factors that are specific to the situation and enters the workplace to harass, threaten, injure, or even kill.
Type 4 violence is often the spillover of domestic violence into the workplace. In some cases, a domestic violence situation can arise between individuals in the same workplace. These situations can have a substantial effect on the work environment. They can manifest as high absenteeism and low productivity on the part of a worker who is enduring abuse or threats, or the sudden, prolonged absence of an employee fleeing abuse.
In 2010, the Bureau of Labor Statistics reported a total of 518 workplace homicides. Of the total number of women killed in the workplace, 39% were killed by a relative or personal acquaintance, whereas this type of assailant accounted for only 3% of men killed in the workplace. Four percent of these workplace homicides occurred in the areas of education and health services (BLS, 2013c).
Jenny is a certified nursing assistant working in a 120-bed nursing home. She has always worked the evening shift, which ends at 11 p.m., and is on her way home by 11:30. Jenny has confided in coworkers that she is in an abusive relationship with her husband of five years. She has often come to work with bruises and occasionally has been hospitalized for injuries inflicted by her husband. Currently, she has a restraining order against him.
This evening the supervising nurse noticed that Jenny was not keeping up with the scheduled routine and that she seemed unusually nervous and distracted. The nurse approached Jenny and asked her if something was troubling her. Jenny reported that she had received a threatening phone call from her husband earlier that day and that she was afraid of him. Jenny asked the nurse if she would walk with her out to her car at the end of her shift, and the nurse agreed. At the end of the shift, they both left the facility and walked out the employee entrance to the parking lot. The door of a car parked near the entrance opened; a man got out, aimed a rifle at Jenny, shot her, and quickly drove away. The supervisor used her cellphone to call 911 and stayed with Jenny until help arrived; however, Jenny died on the way to the hospital.
The supervisor gave a statement to the police and later was subpoenaed as a witness during the trial. Jenny’s husband was found guilty and convicted of first-degree murder.
As part of the post-incident response, counseling was offered for employees traumatized by the incident, and a critical-incident stress debriefing was carried out. Additional training and education were provided for early recognition of warning signs, and a standard response action plan for violent situations was included. Facility security was analyzed, and a security guard was assigned to monitor the parking lot at every change of shift. In addition, training was provided in domestic violence and the steps to be taken when a restraining order has been violated.
In this instance, the nursing supervisor would have been advised to have Jenny contact the police department about the phone call received earlier in the day and would counsel her to wait for police to arrive before leaving the facility.
Nothing can guarantee that an employee will not become a victim of workplace violence. However, several steps can help individuals reduce the risk:
Healthcare and social service workers face an increased risk of work-related assaults stemming from several factors. These include:
Workplace location—particularly emergency departments and psychiatric units—elevates the risk for workplace violence. Facilities for older adults were found to generate particularly high levels of verbal abuse. Further, male nurses run a greater risk for violence than female nurses, which may result from the assignment of male nurses to more risky, potentially abusive patients and environments. One fourth of physical violence and almost one third of psychological violence were directed at nurses by patients’ relatives (Campbell, 2011).
As described above, security hazards are circumstances present in the physical surroundings of the workplace and in the behavior of others that increase the risk of violence. Early recognition of security hazards calls for enhanced awareness of the physical environment and the behavior of coworkers and self.
Security hazards in the physical environment are factors that isolate employees, allow others easy access to buildings and work sites, or place potential weapons within reach. General workplace security hazards include:
Security-sensitive areas in healthcare organizations are areas that require a higher level of security than others and are identified as such because of either the types of materials used or stored in the area or the level of security or confidentiality needed for patient care.
The unique characteristics of hospitals, clinics, and other healthcare settings add to the potential of environmental security hazards. These may include:
There are a number of actions that can be taken to minimize the risks associated with security hazards in the work environment. “Universal precautions” for violence acknowledge that violence should be expected but can be avoided or mitigated through preparation. The first and most important step is to be aware of what is going on in the workplace. Every work environment has a routine amount of activity, noise, and energy. The employee thus needs to be aware of any changes, unfamiliar noises, or unfamiliar sounds that could signal a safety issue.
Universal precautions for violence include:
Healthcare personnel have an increased risk of encountering potentially violent behavior because clients may be disoriented by drugs, alcohol, stress, or physical trauma.
No one can predict human behavior, and there is no specific profile of a potentially dangerous individual. There are, however, “red flags” that are characteristic behaviors of potentially threatening and violent persons in the workplace. The following may alert employees and supervisors to potential problems:
Home care workers are at risk for violence in the home by patients or family members. Workers can be victims of violence themselves, or they can experience vicarious trauma after witnessing domestic abuse or violence among family members. Verbal abuse is the most common form of violence, with abuse by patients more common than by relatives.
When the workplace is a private home, employer safety policies and programs are not in place, and home care workers must rely on their own resources to deal with abuse and violence. Home healthcare workers should evaluate each situation for possible violence by being alert and watching for signals of impending violent assault, such as verbally expressed anger and frustration, threatening gestures, signs of drug or alcohol abuse, or the presence of weapons. Any unsecured weapon observed in a client’s home should be reported to the employer.
Working in any community setting outside a traditional office building increases the risk of coming in contact with potentially violent situations. Prevention measures for field workers include consideration of the following:
Janice is working part-time as a home health aide two evenings per week and on weekends. She shares an apartment with two housemates and commutes 30 minutes to the Visiting Nurse Care home health agency for work. She is required to check in at the main office before her shift starts to pick up her assignments, attend occasional staff meetings and training sessions, and restock her patient care supplies. She is not required to return to the office at the end of her shift. Rather, she can go home after she finishes with her last client.
Janice attended hazard assessment and safety training when she was hired for the job as a home health aide. The training is repeated on an annual basis for each home care worker at the agency. Janice remembers hearing about a case in a nearby city where a home health aide was assaulted by an angry family member, and the story has stuck with her. The injured employee was the same age as Janice. She does not need to be talked into attending the training sessions when they are offered.
Janice readily follows the safety protocols that have been established by the home care agency and has added a few of her own.
By following these steps, Janice feels comfortable that she is taking the necessary precautions to avoid finding herself in a potentially dangerous situation.
In any setting it is essential that employees be familiar with measures to defuse and respond to aggression.
The home healthcare worker should follow the same measures as described for those working in a healthcare facility. In addition, home healthcare workers should be instructed to:
Zoe is a home health aide working for a private home care agency. She has been assigned 6-hour shifts providing care for Eleanor, an elderly woman who experienced a stroke and requires assistance with daily activities. A care plan describes Zoe’s duties, which include bathing, dressing, feeding, toileting, changing bed linens, and straightening Eleanor’s bedroom.
Eleanor’s daughter Kathy has agreed to come to the house regularly to do the laundry and cleaning. She also is going to do Eleanor’s grocery shopping. When Zoe meets Kathy, she quickly becomes aware that Kathy is angry and resentful over having to take care of these things for her mother. As time passes, Kathy begins to complain that she is tired of doing these tasks for her mother and that Zoe is “lazy” and not “worth the money.”
Soon, Kathy tells Zoe she wants her to clean the house and do the laundry. Zoe politely informs Kathy that these duties are not her role in Eleanor’s care plan and that she will not be able to do them. Kathy immediately becomes angry, shouting, “We’ll see about that!” She begins picking up things and throwing them about, yelling that she has had enough of caring for that “old bat.”
With the situation seeming to spiral out of control, Zoe begins moving toward the door. She sees Kathy reach for a knife from the kitchen counter. Zoe quickly runs out the door toward her car, pulling her cellphone from her pocket. Once safely in her car, she calls 911.
When the police arrive, they subdue Kathy and ensure that Eleanor is safe. Kathy is arrested for assault. Zoe calls her supervisor to report what has happened and is told a replacement will be sent right away. Zoe informs the police officer that she is willing to go to the police station to make a statement as soon as her replacement arrives. While waiting, she returns to the home and reassures Eleanor that they are both safe and that she is there to assist her.
Federal and state job safety laws require employers to make reasonable efforts to provide a safe workplace. Employers may be liable for negligence if they fail to exercise ordinary care to avoid potential violence. No federal law explicitly establishes an employer’s duty to prevent or remedy workplace violence against employees. However, the Occupational Safety and Health Act of 1970 (OSH Act) states that employers have a “general duty” to provide a place of employment that is free from recognized hazards causing, or likely to cause, death or serious physical harm, including the prevention and control of workplace violence. Employers can be cited and fined when incidents of worker illness or injury are attributed to the workplace.
In 1989, OSHA published the Safety and Health Program Management Guidelines. These guidelines, while not mandatory, are intended for use by employers who are seeking to provide a safe and healthful workplace through effective workplace violence prevention programs.
The OSHA guidelines provide the agency’s recommendations for reducing workplace violence, developed following a careful review of workplace violence studies, public and private violence prevention programs, and input from stakeholders. OSHA encourages employers to establish violence prevention programs and to track their progress in reducing work-related assaults. Although not every incident can be prevented, many can, and the severity of injuries sustained by employees can be reduced.
The OSH Act, however, often fails to provide protection to employees subjected to workplace violence because it is not well-enforced. OSHA has yet to issue a specific standard that regulates workplace violence, and it does not provide comprehensive enforcement of the OSH Act due to lack of adequate staffing. As a result, OSHA only manages to inspect about a quarter of worksites with a reported workplace fatality (Haynes, 2013).
When inspecting a worksite, OSHA surveyors evaluate the following:
Since the OSH Act has not provided adequate protection for employees, some states have responded by enacting workplace violence legislation. California’s 1994 Workplace Violence Safety Act gives employers the ability to seek temporary restraining orders against perpetrators of violence on behalf of their employees. Illinois’ 2005 Health Care Workplace Violence Prevention Act targets the health industry (Haynes, 2013). In 2010, the New York Senate passed a law that strengthens penalties for persons who attempt to injure nurses in the workplace by making an assault on registered and licensed practical nurses a felony (NYS Senate, 2010).
A workplace violence prevention program demonstrates an organization’s concern for employee emotional and physical safety and health. Such a program typically encompasses the following elements:
The first two elements—management commitment and employee involvement—are complementary and essential to a successful workplace violence prevention program.
Management commitment provides the motivating force for dealing effectively with workplace violence. Policies should be established to clearly communicate that violence, threats, harassment, intimidations, and other disruptive behavior in the workplace will not be tolerated. Another key element of organizational policy should establish that all reports of incidents will be taken seriously and will be dealt with appropriately. Management should to be committed to:
Employee involvement enables workers to develop and express their commitment to safety and health. Employee involvement should include:
A key element of a workplace violence prevention program is the threat assessment team, or safety committee. The primary function of the team is to provide a thorough workplace security/hazard analysis and establish prevention strategies. An effective team will:
Employee assistance programs first started in the 1940s to help employees with alcohol addiction. An EAP is a voluntary, work-based program offering free and confidential assessments, short-term counseling, referrals, and follow-up services to employees with personal and/or work-related problems. EAPs address a wide range of issues affecting mental and emotional well-being. Many EAPs are active in helping organizations prevent and cope with workplace violence, trauma, and other emergency response situations (OPM, 2012).
EAP plans are usually paid for by the employer and can include a wide array of other services such as nurse lines, basic legal assistance, and referrals. Services may be provided on-site or contracted through outside providers. Several factors make up a successful EAP, including:
An institution’s response to incidents of workplace violence should reflect an organizational commitment to overall employee health and safety. Post-incident actions should include:
Downtown Free Clinic is located in the center of the city and is slated for renovation. This clinic has been a staple walk-in medical care facility for inner-city residents. Downtown Clinic is open six days a week from 6 a.m. to 10 p.m. The clinic sees an average of 120 patients per day. The clinic has just been acquired by a large hospital system.
Cynthia works as a nurse manager and has been selected to represent the clinic as a member of the hospital’s safety committee. As part of the threat assessment team, her assignment for the upcoming meeting is to lead a workplace violence hazard assessment for the clinic. She has worked at the facility for six years and has never felt threatened, nor has she had any complaints from her staff. She anticipates a quick assessment.
To prepare for the assignment, Cynthia decides to review the hospital’s existing workplace violence prevention plan. The policy statement includes a commitment to zero tolerance for violence in the workplace and further commits all managers and supervisors to implement all aspects of the program, thus ensuring a safe environment for all employees.
Cynthia has been charged with analyzing and reviewing existing records related to assault incidents, inspecting the workplace, and evaluating all work tasks to determine the presence of hazards or situations that may place workers at risk for violent acts. She begins by reviewing the following records for the last three years:
She finds the following:
Cynthia also interviews managers and staff of the clinic, asking about all instances of violence that they may have witnessed over the past six months but which were not reported. Surprised by the number of unreported incidents, Cynthia proceeds to conduct an inspection of the workplace areas assigned to her. She discovers that:
Concerned with the hazards from the inspection, she further reviews the tasks of the receptionists and identifies the following concerns:
After careful consideration, Cynthia decides that the building, work area design, and staffing will need to change and that written policies and procedures must be instituted to address the security hazards she has identified. Her initial recommendations to the hospital safety committee include:
Although there are no federal standards requiring workplace violence protections, the prevalence of workplace violence in the healthcare sector has prompted studies and organizational initiatives aimed at addressing the problem.
In January 2007, the International Association for Healthcare Security and Safety issued its first set of “Healthcare Security Basic Industry Guidelines,” a resource for healthcare institutions in developing and managing a security management plan, addressing security training, conducting investigations, identifying areas of high risk, and more (TJC, 2010).
The Joint Commission introduced a new leadership standard (EC.02.01.01, EP 1) that addresses workplace violence by coworkers. The standard covers several suggested actions aimed at reducing intimidating and disruptive behaviors between coworkers. Hospitals, nursing homes, home health agencies, laboratories, ambulatory care facilities, and behavioral healthcare facilities must have a code of conduct in place that determines which behaviors are tolerated and which are not and that creates a formal procedure for managing any unacceptable behavior (TJC, 2010).
Likewise, NIOSH conducts research and makes recommendations to prevent work-related illness and injury. NIOSH works with industries, labor organizations, and universities to understand and improve worker safety and health. NIOSH also outlines prevention strategies for reducing exposure to violence risk factors in healthcare facilities, including safe workplace environmental design development, administrative controls, adequate security measures, and training workers to recognize and manage potential assaults (DHHS, 2012).
In 2012 the American Nurses Association House of Delegates put forth a resolution to petition OSHA to disseminate code language requiring healthcare and social services employers to develop comprehensive workplace violence prevention programs that include management commitment and employee involvement; risk assessment and surveillance; hazard controls (to include environmental, architectural and security controls); training and education; post assault programs; and recordkeeping (ANA, 2012).
Violence in the workplace is prevalent in the United States, and workplace violence has become one of the most serious occupational hazards facing personnel working in today’s healthcare environment. Healthcare workers should not be expected to accept violence as “part of the job,” and employers must take appropriate steps to ensure that the chances for violence are minimized. It is necessary for employers to create an environment in which employees are safe, secure, and productive. Systems must be put in place that address violence and promote risk-assessment and prevention.
Workplace Violence (OSHA)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
American Nurses Association (ANA). (2012). 2012 House of Delegates resolution: workplace violence. Retrieved from http://www.nursingworld.org
Bartholomew K. (2013). Break the spell and end lateral violence in nursing. Retrieved from http://www.nursetogether.com
Bullen D. (2013). Bosses, bullying & burnout in nursing. Retrieved from http://nursing.advanceweb.com
Bureau of Labor Statistics (BLS). (2013a). Economic news release: census of fatal occupation injuries summary, 2012. Retrieved from http://www.bls.gov
Bureau of Labor Statistics (BLS). (2013b). Workplace homicides. Retrieved from http://www.bls.gov
Bureau of Labor Statistics (BLS). (2013c) Fact sheet: workplace homicides from shootings. (2013b). Retrieved from http://www.bls.gov
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Campbell J. (2011). Workplace violence: prevalence and risk factors in the Safe at Work study. Journal of Occupational & Environmental Medicine, 53(1), 82–9.
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Childers L. (2013). Danger on the job: nurses speak out against hospital violence. Retrieved from http://www.minoritynurse.com
Crisis Prevention Institute (CPI). (2010). Success stories and testimonials. Retrieved from http://www.crisisprevention.com
Employee Assistance Professionals Association (EAPA). (2010). EAPA standards and professional guidelines for employee assistance programs. Retrieved from http://www.eapassn.org
Encyclopedia of Small Business. (2011). Workplace violence. Retrieved from http://www.enotes.com
Harrell E. (2011). National crime victimization survey, U.S. Department of Justice special report: workplace violence, 1993–2009. Retrieved from http://www.bjs.gov
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Iyer P. (2012). Bullying among doctors and nurses: an alarming patient safety issue. Retrieved from http://www.medleague.com
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New York State Senate (NYS Senate). (2010). Senate acts to protect nurses from violence. Retrieved from http://www.nysenate.gov
Occupational Safety and Health Administration (OSHA), United States Department of Labor. (2011). Workplace violence. Retrieved from https://www.osha.gov
Office of Personnel Management (OPM). (2012). Employee assistant programs: overview. Retrieved from https://www.opm.gov
Restrepo T & Shuford H. (2012). Violence in the workplace. NCCI research brief. National Council on Compensation, Inc. Retrieved from http://www.ncci.com
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The Joint Commission (TJC). (2010). Preventing violence in the health care setting. Sentinel Event Alert, 45(June 3). Retrieved from http://www.jointcommission.org
U.S. Department of Health and Human Services (DHHS). (2012). Workplace violence. National Institute for Occupational Safety and Health (NIOSH) Publication No. 2012-118. Retrieved from https://www.osha.gov
Wood DE. (2013). ED nurses work to curb violence. Retrieved from http://news.nurse.com