Workplace Violence and Safety
Prevention and Solution Strategies

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have increased your knowledge in order to prevent, identify, and respond to workplace violence. Specific learning objectives to address potential knowledge gaps include:

• Describe the various types of workplace violence.
• Discuss the impact of workplace violence.
• Identify risk factors for workplace violence.
• Summarize how to respond to workplace violence.
• Describe employer responsibilities in responding to violence in the workplace.
• Identify essential components of a workplace violence program and barriers to its implementation.

WHAT CONSTITUTES WORKPLACE VIOLENCE?

Reliance on violence to address any perceived threat is a characteristic of many individuals in American society. It is, therefore, no surprise that violence occurs in the workplace. Such violence is a public health issue that requires identifying precipitating factors and developing strategies to keep employees safe.

Workplace violence has been federally recognized as an organizational, community, and societal issue. The Occupational Safety and Health Administration (OSHA, n.d.) defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at any work site.” It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers, and visitors.

The National Institute for Occupational Safety and Health (NIOSH, 2020a) defines workplace violence as “any physical assault, threatening behavior, or verbal abuse occurring in the work setting.” Violence can occur in any workplace and among any type of worker.

Workplace violence ranges broadly from offensive or threatening language to homicide. Elements of workplace violence include physical assaults, swearing, verbal abuse, harassment, pranks, vandalism, property damage, sabotage, pushing, theft, rape, arson, and murder (CCOHS, 2023).

The Centers for Disease Control and Prevention (CDC, 2020b) has identified four types of workplace violence. These include:

• Type 1: Violence by a stranger with criminal intent
• Type 2: Violence by a customer or client
• Type 3: Violence by a coworker (worker on worker)
• Type 4: Violence by someone in a personal relationship

Type 1: Violence by a Stranger with Criminal Intent

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, robbery, and homicide (CDC, 2020b).

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 (Society Insurance, 2021).

Nurses may also be at particular risk for robbery since many of them work at night and/or work in facilities that have a variety of drugs that may be targets for theft. In the healthcare professions, personnel known or perceived to have items of value in their possession or in their workplace may also be at increased risk for targeting (Matheson & Horowitz, 2021). Examples include:

• Home health providers (nurses, OTs, PTs, and aides)
• Clinic personnel working alone or in an isolated area of a facility
• Any personnel going to/from vehicles alone and/or at times or in places when few others are around

Type 2: Violence by a Customer or Client

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 organization 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 (CDC, 2020b).

Violence by a customer or client is the most common type in healthcare settings. In such settings, the customer/client relationship includes patients, families, and visitors. Violence by a customer or client most often occurs in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings (CDC, 2020b). These attacks may be perpetrated by “unwilling” clients who are brought into emergency departments or mental health facilities by law enforcement for assessment and/or treatment.

There may also be situations with people not known to be violent who can become violent in response to something present in the situation. Provoking situations may be those that are frustrating to the individual, such as the denial of needed or desired services or delays in receiving such services.

Type 3: Coworker (Worker-to-Worker) Violence

Coworker violence occurs when an employee or past employee attacks or threatens coworkers. This category includes violence by employees, supervisors, managers, and owners. Examples may be violence committed by supervisors against subordinates, physicians against nurses, subordinates against supervisors, and workers against other workers who are on the same level of the organizational hierarchy (CDC, 2020b).

Worker-to-worker violence includes:

• Overt verbal and/or physical abuse
• Refusing to help a coworker who needs assistance
• Spreading malicious gossip about a coworker
• Embarrassing a coworker in front of clients and/or other workers
  (TJC, 2021a; Vidal-Alves et al., 2021)

VERTICAL VIOLENCE

Vertical violence is defined as any act of violence that occurs between two or more persons on different levels of the hierarchical system and that prohibits professional performance and satisfaction in the workplace.

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 physicians and nurses and can be 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 (Dellasega, 2020; Sadler, 2020; Vidal-Alves, 2021).

HORIZONTAL (LATERAL) VIOLENCE

Horizontal violence (HV) is defined as “nonphysical intergroup conflict expressed in overt and covert behaviors of hostility.” Also referred to as lateral violence, HV is workplace conflict in which confrontational behavior is targeted at one person by another employed at the same level of responsibility across time in repeated instances of emotional, psychological, physical, or sexual abuse. It is meant to create a power relationship in which the victim is controlled emotionally by the abuser. The practitioners of lateral violence characteristically demonstrate impatience, condescension, anger, threatening posturing, and even physical aggression.

Horizontal violence permeates the healthcare professions. In nursing, research shows that HV contributes to high nurse turnover rates, increased illness, decreased productivity, and a decrease in the quality of care that patients receive. Additionally, research has found that:

• HV is evident during nursing education.
• HV occurs early in nursing careers.
• Manager and staff support and workplace education were the most helpful in reducing HV.
  (Bloom, 2019)

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 theories of oppression, the oppressed group internalizes the values, norms, and behaviors of the dominant group as the most appropriate, while the characteristics of their own group become negatively valued and suppressed (Freire, 1999; Roberts, 1983).

WORKPLACE BULLYING

Workplace bullying is defined as frequent or repeated personal attacks that are emotionally hurtful or professionally harmful. Bullying is a deliberate attempt to undermine a coworker’s ability to carry out work, to injure the person’s reputation, to undermine the person’s self-esteem and self-confidence, or to remove personal power from that coworker.

Bullying can be both obvious and subtle. The following are examples of bullying:

• Spreading malicious rumors, gossip, or innuendo
• Excluding or isolating someone socially
• Intimidating a person
• Undermining or deliberately impeding a person’s work
• Physically abusing or threatening abuse
• Removing areas of responsibilities without cause
• Constantly changing work guidelines
• Establishing impossible deadlines that will set the person up to fail
• Withholding necessary information or purposefully giving the wrong information
• Making jokes that are obviously offensive by spoken word or email
• Intruding on a person’s privacy by pestering, spying, or stalking
• Assigning unreasonable duties or workload that are unfavorable to one person in a way that creates unnecessary pressure
• Assigning too little work (underwork), creating a feeling of uselessness
• Yelling or using profanity
• Criticizing a person persistently or constantly
• Belittling a person’s opinions
• Unwarranted or undeserved punishment
• Blocking applications for training, leave, or promotion
• Tampering with a person’s personal belongings or work equipment
  (CCOHS, 2020)

Type 4: Violence by Someone in a Personal Relationship

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 (CDC, 2020b).

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 (CDC, 2020b; OSHA, n.d.).

IMPACT OF WORKPLACE VIOLENCE

The Bureau of Justice Statistics (BJS) is the primary source of information on criminal victimization in the United States, including workplace violence. In 2022, the BJS, in cooperation with the Bureau of Labor Statistics (BLS) and the National Institute for Occupational Safety and Health (NIOSH) analyzed incidents of fatal and nonfatal violence that took place against persons at work or on duty over a 27-year period (1992–2019). Key findings include:

• 17,865 persons were killed in a workplace homicide.
• From 2014 to 2019, workplace homicides increased 11%.
• 82% of victims of workplace homicide were male.
• 46% of workplace homicide victims were White; 25% were Black; and 16% were Hispanic.
• 66% of workplace homicide victims were ages 25–54.
• 23% of victims of workplace homicide were self-employed.
• 79% of workplace homicides were shootings.
• In 2019, the rate of nonfatal workplace violence was 9.2 violent crimes per 1,000 workers ages 16 or older.
• The average annual rate of nonfatal workplace violence was 8.0 nonfatal violent crimes per 1,000 workers ages 16 or older.
• Males committed 64% of nonfatal workplace violence occurrences.
• The perpetrator was armed in 16% of nonfatal workplace violence occurrences.
• 12% of nonfatal workplace violence involved injury to the victim.
• Nearly 25% of nonfatal workplace violence against workers in medical occupations resulted in injury to the victim.
• 15% of victims of nonfatal workplace violence reported severe emotional distress due to the violence.
• An estimated 39% of all nonfatal workplace violence were reported to law enforcement.
  (BJS, 2022; CDC, 2022)

The National Safety Council (2022) reports that assaults are the fifth leading cause of work-related deaths. For the first time since 2011 (when recording keeping was established), nonfatal work-related assault injures decreased in 2020. Assaults in the workplace resulted in 20,050 injuries and illnesses involving days away from work in 2020 and 481 fatalities in 2021.

The National Safety Council (2022) categorizes assaults as “intentional injury inflicted by another person.” Assaults include several types of events, including:

• Intentional shooting by another person
• Stabbing, cutting, slashing, or piercing
• Hitting, kicking, beating, and shoving
• Strangulation
• Bombing and arson
• Rape and sexual assault
• Threats and verbal assault

Incidence of Workplace Violence in the Healthcare Setting

Violence against healthcare workers is an increasing epidemic. Data taken from various research projects show that:

• In a survey of 15,000 registered nurses, 20% reported increased workplace violence.
• The Joint Commission noted that healthcare workers are four times more likely to be assaulted compared to workers in private industry.
• OSHA reports that about 75% of an estimated 25,000 workplace assaults are reported every year in healthcare and social service settings.
• The U.S. Bureau of Labor Statistics reported that healthcare workers and people who work in social assistance are five times more likely to experience workplace violence than other workers.
• A National Crime Victimization Survey showed healthcare workers are 20% more likely to be the victim of workplace violence than other workers.
• The American College of Emergency Physicians reported that 70% of emergency department physicians have reported experiencing acts of work-related violence. However only three percent of these physicians pressed charges.
  (Nurse.org, 2022)

Consequences of Workplace Violence

Workplace violence extracts a significant toll on everyone involved. This includes physical, emotional, and mental effects on the individual, such as:

• Physical injury (minor to severe disability)
• Psychological trauma (short- and long-term)
• Emotional distress/anxiety
• Lowered self-esteem
• Posttraumatic stress disorder
• Death by suicide
• Chronic stress-related illness
• Intent to leave the job
• Feelings of incompetence, guilt, powerlessness
• Fear of returning to work
• Fear of criticism by supervisors
• Loss of confidence in ability
• Changes in relationships with coworkers
• Secondary impact on personal life (daily activities, emotional issues, economic issues)
  (AAETS, 2020; USDOL, n.d.)

Negative consequences for institutions can include:

• Decreased employee productivity
• Low employee morale
• Increased job stress
• Increased absenteeism and lost work days
• Restricted or modified duty (secondary to injury)
• Increased employee turnover
• Difficulties retaining employees
• Recruitment challenges
• Distrust of management
• Financial loss resulting from insurance claims
• Legal expenses due to consequences of workplace violence
• Property damage
• Need for increased security measures
• Compromised patient care and safety
• Diminished public image
  (Excel Medical, 2022; USDOL, n.d.)

RECOGNIZING AND RESPONDING TO WORKPLACE RISK FACTORS

A number of actions can be taken to minimize the risk of violence in the workplace. These precautions acknowledge that violence should be expected but can be avoided or mitigated through preparation, which includes:

• Paying attention to physical surroundings
• Trusting personal instincts
• Presenting a strong, confident image by posture, stride, and eye contact (however, it is important to be aware of different cultures’ perceptions regarding eye contact)
• Leaving an uncomfortable situation, if possible
• Avoiding locations that are poorly lit or have poor visibility, if possible
• Carrying and using a flashlight if the surroundings are poorly lit or when traveling at night
• Working with a partner or having an effective means of communication, such as a cell phone or pager
• Using the locks and security systems that are available
• Reporting security hazards promptly to a supervisor
• Not using a cell phone or personal music system while on route to or from the workplace
• Taking a self-defense class or requesting that the facility offer one
• Dressing for safety
  • Removing anything that can be used as a weapon or grabbed by someone
  • Tucking long hair away
  • Not wearing earrings or necklaces that can be pulled
  • Avoiding overly tight clothing that can restrict movement
  • Avoiding overly loose clothing or scarves that can be grabbed
  • Using breakaway safety cords or lanyards for glasses, keys, or name tags
  (Columbia University, 2023; Vaughn, 2022)

Identifying Risk Factors

Nothing can guarantee that an employee will not become a victim of workplace violence. However, every employee can be aware of the risk factors that contribute to workplace violence and what can be done to avoid it.

RISK FACTORS IN THE HEALTHCARE ENVIRONMENT

Healthcare and social service workers face an increased risk of work-related assaults stemming from several risk factors. These include:

• Altered mental status of clients due to dementia, delirium, substance intoxication, or decompensated mental illness
• Lack of community mental health care and increasing numbers of mental health clients discharged without adequate follow-up care
• Stressful patient conditions, such as long wait times, crowding in the clinical environment, being given upsetting news related to a diagnosis or prognosis
• Lack of training for security and staff to recognize and de-escalate hostile and assaultive behaviors
• Unrestricted public access to hospital rooms and clinics
• Easy movements by clients and visitors in healthcare facilities
• Providing care for clients in police custody or gang members
• Domestic disputes among clients or visitors
• The presence of firearms or other types of weapons
• Inadequate security and mental health personnel on site
• Understaffing, especially during times when clients have visitors
• Staff working in isolation or in situations in which they can be trapped without an escape route
• Isolated work environments with clients, patients, and families
• Poor lighting or other factors restricting vision in corridors, rooms, parking lots, and other areas
• No access to emergency communication, such as a cell phone or call bell
• Belief that violence is “part of the job”
• Lack of managerial and/or administrative support
  (CDC, 2020a; TJC, 2021b; Wells, 2022)

RISK FACTORS IN THE PHYSICAL ENVIRONMENT

Early recognition of risk factors calls for enhanced awareness of the security hazards in the physical environment that isolate employees, allow others easy access to buildings and work sites, or place potential weapons within reach.

General workplace security hazards include:

• Isolated location or job activities
• Numerous points of entry and exit and uncontrolled access to the building
• No locks on doors or between work areas
• Lighting problems, such as dark hallways and parking lots
• Lack of phones or means of communication between employees
• Lack of adequate security systems
• Early-morning or night-time hours of employment
• Unknown person(s) loitering outside workplace
• Easy access to potential weapons, such as knives or scissors
  (CDC, 2020a; NIOSH, 2020b)

RISK FACTORS IN THE BEHAVIOR OF OTHERS

No one can predict human behavior, and there is no specific profile of a potentially dangerous individual. There are, however, “red flags” that can alert others to a potentially threatening and violent person in the workplace. There are three levels of warning signs, which include:

Level One (early warning signs). The person is:

• Intimidating/bullying
• Discourteous/disrespectful
• Uncooperative
• Verbally abusive

Level Two (escalation). The person:

• Argues with customers, vendors, coworkers, and management
• Refuses to obey facility policies and procedures
• Sabotages equipment and steals property for revenge
• Sends threatening note(s) to coworker(s) and/or management
• Sees self as victimized by management

Level Three (emergency response usually required). The person displays intense anger resulting in:

• Suicide threats
• Physical aggression
• Destruction of property
• Extreme rage
• Utilization of weapons to harm others
  (USDOL, n.d.)

(See also “Recognizing and Responding to Workplace Violence” later in this course.)

RISK FACTORS FOR HOME CARE EMPLOYEES

For persons who work in home care, patient’s homes are often in unfamiliar and/or unsafe neighborhoods. Community-based employees must rely on their own resources to deal with abuse and violence, evaluating each situation for possible violence by being alert and watching for signs of impending violent assault. Risk factors for violence against home care workers include:

• Typically working alone in communities that have varying degrees of violence
• Decreased control of the work environment
• Lack of policies and procedures related to workplace violence in the home care setting
• Insufficient training in ways to deal with workplace violence in the home care setting

Working in any community setting outside a traditional office building increases the risk of coming in contact with potentially violent situations. An estimated 18%–65% of home healthcare workers have experienced verbal abuse from patients, 41% reported sexual harassment, and 25%–44% reported being physically assaulted. These workers may also have to deal with aggressive pets, neighborhoods in violent crime areas, the presence of firearms in the home, and racial/ethnic discrimination. Prevention measures for home care workers include consideration of the following:

• Participating in training regarding environmental awareness and how to prevent and/or respond to workplace violence
• Trusting one’s instincts; if circumstances do not feel “right,” seeking a safe location
• Reporting to supervisory staff when observing or hearing something that is unsafe
• Preparing a daily work plan/itinerary, including both locations and estimated times of arrival and departure
• Conducting post-visit assessments, recordkeeping, and evaluations
• Including an itinerary of anticipated public transport routes if such transport will be used and sharing that itinerary with a supervisor
• Avoiding traveling alone into unfamiliar locations or situations and/or traveling with another employee or security escort whenever possible
• Varying travel routes (both in and out of a vehicle) when making repeat visits to a location
• Maintaining periodic contact with others throughout the day
• Carrying a fully charged cell phone
• Using telecommunication devices such as access buttons or voice activation tools on ID badges
• Carrying minimal money and payment cards and carrying them in a variety of places in clothing and equipment
• Carrying required identification, also in varied places
• Recognizing potentially dangerous situations ahead of time and initiating backup
  (Small et al., 2021; Stanlay & Oliveri, 2021)

RECOGNIZING AND RESPONDING TO WORKPLACE VIOLENCE

Although it is important to be able to identify risk factors for workplace violence, it is equally important to know how to respond to the three levels of violence should they occur (see “Risk Factors in the Behavior of Others” earlier in this course).

Responses to Level One (early warning signs) include:

• Observe the behavior.
• Report concerns to the supervisor to seek help in the assessment and response to the situation.
• If the offending person is the reporting employee’s immediate supervisor, notify the next level of supervision.
• If the offending person is not an employee, report it to the supervisor, who should provide the initial response.
• Document the observed behavior.

Responses when a situation has escalated to Level Two (escalation) include:

• Secure one’s own safety and the safety of others, including contacting people who are in danger.
• Immediately contact the supervisor and, if necessary, the supervisor will contact other appropriate officials.
• Document the observed behavior.

Responses when a situation is a Level Three emergency (emergency response required) include:

• Secure personal safety first.
• Call 911 and other appropriate emergency contacts.
• Remain calm and contact the supervisor.
• Cooperate with law enforcement personnel when they have responded to the situation.
• Document the observed behavior.
• Prepare to provide a description of the violent or threatening individual.
  (USDOL, n.d.)

Managing the Aggressive Person

When confronted with an aggressive person in any setting, it is important to utilize de-escalation techniques in an attempt to prevent harm to the person or to others. The objectives of such techniques are to ensure the safety of the staff, the aggressive persons, and others in the environment; assist the aggressive persons to regain control of their behaviors; and avoid escalating the situation. De-escalation includes using techniques to manage conflict and resolve the crisis (CPI, 2022; TJC, 2019).

GENERAL RECOMMENDATIONS

General recommendations include:

• Avoid showing fear and/or anxiety, which may escalate the aggression.
• Remain calm and behave rationally and professionally.
• Avoid gestures such as pointing or shaking fingers at the aggressive person.
• Do not be defensive; even if the comments or insults are directed at you, they are not about you.
• Do not touch or attempt to touch the person.
• Know your organization’s crisis response procedures and how to summon assistance.
• Be very respectful even when firmly setting limits or calling for help.
• Be empathetic and avoid judging aggressive persons or dismissing their feelings and concerns.
  (CISA, n.d.; CPI, 2022)

BODY LANGUAGE AND PHYSICAL STANCE

Recommendations for body language and physical stance include:

• Never turn your back to the person for any reason.
• Stand between the exit and the person; never allow the person to block your exit.
• Respect others’ personal space. The amount of personal space people require to feel comfortable may vary greatly, and anxiety rises when that space is entered by others. Maintaining personal space protects your safety, shows respect, and tends to decrease the aggressive person’s anxiety.
• Be aware of body position. Stand at an angle to an aggressive person and off to one side so you can sidestep away if needed.
• Always maintain the same eye level, stay alert, and display a relaxed posture.
• Use slow, deliberate movements.
• Display a neutral and attentive facial expression.
• Do not stand rigidly or directly in front of the person, point your finger, gesture excessively, pace, or display a fake smile (which could be perceived as mockery).
  (CPI, n.d.).

DE-ESCALATION COMMUNICATION

Recommendations for de-escalation communication include:

• Do not raise your voice or shout.
• Do not try to convince or argue with the person.
• Speak slowly and calmly.
• Avoid emphasizing words that can be perceived as aggression or mockery.
• Use phrases such as “I want to help” or “I understand that you are upset.”
• Do not use phrases such as “calm down,” “I know how you feel,” or “I can’t help you.”
• Listen actively. Give your full attention, nod, ask questions as appropriate, avoid changing the subject or interrupting.
• Do not criticize, act impatient, belittle, or make an aggressive person feel foolish.
• Ignore challenging questions. Bring the focus back to how you can work together to solve the problem.
• Set limits respectively and reasonably. Offer respectful choices and speak clearly and simply.
• Allow silence for the purpose of reflection.
• Allow the person time to make decisions. Stress rises when feeling rushed. Allowing time helps to calm the person.
  (CSI, n.d.; CPI, 2022)

EMPLOYER RESPONSIBILITIES

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 (OSH Act) of 1970 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 (USDOL, 1970).

The OSH Act also prohibits employers from retaliating against employees for exercising their rights under the law, including the right to raise a health and safety concern or report an injury. Employers can be cited and fined when incidents of worker illness or injury are attributed to the workplace (USDOL, 1970).

OSHA Workplace Safety Standards

The Occupational Safety and Health Administration (OSHA) publishes Safety and Health Program Management Guidelines. OSHA standards are mandatory, enforceable rules that must be followed. OSHA guidelines, however, are voluntary recommendations for compliance with general workplace safety and training initiatives. The guidelines are intended for use by employers that are seeking to provide a safe and healthful workplace through effective workplace violence prevention programs (McKay, n.d.).

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.

OSHA mandates the following employer responsibilities:

• Provide a workplace free from serious recognized hazards and comply with standards, rules, and regulations.
• Examine workplace conditions to make sure they conform to applicable OSHA standards.
• Use codes, posters, labels, or signs to warn employees of potential hazards.
• Provide safety training in a language and vocabulary that employees can understand.
• Establish or update operating procedures and communicate them to employees.
• Employers with hazardous chemicals in the workplace must develop and implement a written hazard communication program and train employees on the hazards they are exposed to and proper precautions.
• Provide medical examinations and training when required by OSHA standards.
• Post, at a prominent location within the workplace, the OSHA poster (or the state-plan equivalent) informing employees of their rights and responsibilities.
• Report to the nearest OSHA office all work-related fatalities within eight hours, and all work-related inpatient hospitalizations, all amputations, and all losses of an eye within 24 hours.
• Keep records of work-related injuries and illnesses.
• Provide employees, former employees, and their representatives access to the Log of Work-Related Injuries and Illnesses.
• Provide access to employee medical records and exposure records to employees or their authorized representatives.
• Not discriminate against employees who exercise their rights under the Act.
• Post OSHA citations at or near the work area involved.
• Correct cited violations by the deadline set in the OSHA citation.
  (OSHA, 2023)

Workplace Violence Prevention Programs

A workplace violence prevention program demonstrates an organization’s concern for employee emotional and physical safety and health. The OSHA recommended guidelines present a step-by-step approach to implementing a safety and health program. The building blocks for developing an effective workplace violence prevention program include:

• Management commitment
• Employee participation
• Worksite analysis
• Hazard prevention and control
• Safety and health training
• Record-keeping and program evaluation
  (OSHA, 2016)

The 2016 guidelines place great emphasis on worker participation and collaboration between managers and workers to find, fix, and prevent incidents.

MANAGEMENT COMMITMENT

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 is to establish that all reports of incidents will be taken seriously and dealt with appropriately. Management commitment should include:

• Acknowledging the value of a safe and healthful, violence-free workplace and equal commitment to the safety and health of workers and patients/clients
• Allocating appropriate authority and resources to all responsible parties
• Assigning responsibility and authority for the various aspects of the workplace violence prevention program
• Maintaining a system of accountability for involved managers, supervisors, and health committees
• 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
• Establishing policies that ensure the reporting, recording, and monitoring of incidents and near misses and that no reprisals are made against anyone who does so in good faith
  (OSHA, 2016)

EMPLOYEE INVOLVEMENT

Employee involvement enables workers to develop and express their commitment to safety and health. Employee involvement should include:

• 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, make facility inspections, and respond to recommendations for corrective strategies
• Providing input on additions to or redesigns of facilities
• Identifying the daily activities that employees believe put them most at risk for workplace violence
• Participating in discussions and assessments to improve policies and procedures, including complaint and suggestion programs designed to improve safety and security
• Being aware of and following employer policies on reporting incidents and near misses
• Taking proactive approaches to ensure incidents are addressed
• Actively participating in employee training and continuing education programs
  (OSHA, 2016)

WORKSITE ANALYSIS

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 to establish prevention strategies. An effective team will:

• Assess the organization’s vulnerability to workplace violence
• Ensure communication between workers and employers
• Make recommendations for preventive actions
• Develop employee training programs in violence prevention
• Establish a plan for responding to acts of violence
• Evaluate the overall workplace violence prevention program on a regular basis
  (OSHA, 2016)

Barriers to Implementation of Workplace Violence Prevention Programs

A 2021 qualitative study identified the following barriers to implementation of workplace violence prevention programs.

• High tolerance of workplace violence among staff
• High frequency of violent events, resulting in staff failing to report violent incidents
• A lack of support from law enforcement
• Lack of information about a history of violent behavior by patients
• In the emergency department, patients/families who become aggressive to achieve goals, such as avoiding long waits in the waiting room
• Lack of follow-up
• Lack of managerial support
  (Thomas et al., 2021)

Post-Event Response

An institution’s response to incidents of workplace violence should reflect an organizational commitment to overall employee health and safety. After the immediate danger has passed post-incident actions should include:

• Examining power dynamics from the perspective of the healthcare professionals and the patient
• Discussing what de-escalation tactics and crisis intervention strategies were used
• Examining the role of hospital management and security in the event
• Reviewing the healthcare professional’s perception of administrative support and follow-up care
• Determining what the healthcare team can learn from the event about prevention and how the event was handled
  (NIOSH, 2020c)

Institutional Initiatives

Although there are no federal standards requiring workplace violence protection, the prevalence of workplace violence in the healthcare sector has prompted studies and organizational initiatives aimed at addressing the problem. Nursing and other healthcare professional organizations and unions are advocating for federal standards and regulations that require healthcare institutions to practice effective violence prevention and response.

The International Association for Healthcare Security and Safety Industry Guidelines and Design Guidelines are intended to assist healthcare administrators in providing a safe and secure environment and support national, state, county, and local requirements. They are also intended to be in agreement with all regulatory, accreditation, and other healthcare professional association requirements (IAHSS, 2022).

In 2015, the American Nurses Association released a position statement calling on healthcare employers to implement violence prevention programs. The statement declared that the nursing profession “will no longer tolerate violence of any kind from any source. Taking this clear and strong position is critical to ensure the safety of patients, nurses, and other healthcare workers.” The statement called on RNs and employers to share responsibility to create a culture of respect and to implement evidence-based strategies (ANA, n.d.).

Effective January 1, 2022, the Joint Commission released new workplace violence standards that provide a framework to guide hospitals and critical access hospitals in defining workplace violence; developing strong workplace violence prevention systems; and developing a leadership structure, policies and procedures, reporting systems, post-incident strategies, training, and education to decrease workplace violence (TJC, 2022).

CONCLUSION

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 risks 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.

Healthcare professionals must become educated in the recognition of and response to workplace violence, including effective de-escalation communication techniques and appropriate ways to manage an aggressive individual. Employees must also make a commitment to safety and health by making themselves accountable for modeling appropriate behaviors among coworkers.