Skip to main content

Workplace Violence

Online Continuing Education Course

Course Description

Continuing education course discussing types of workplace violence, risk factors in the healthcare industry, safety hazards, prevention, measures for dealing with aggressive persons. Applicable for nursing, occupational and physical therapy, and EMS personnel.

Course Price: $22.00

Contact Hours: 2.5

Start Course Now

Choose a profession below:

Workplace Violence

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:

  • Define the types of workplace violence.
  • Summarize the risk factors for workplace violence, including those specific to the healthcare industry.
  • Identify safety hazards that put workers at risk for becoming victims of workplace violence.
  • Recognize measures for dealing with aggressive persons in the workplace.
  • Describe the elements of a workplace violence prevention program.

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:

  • In 2011 at a California mental hospital, a psychiatric technician was strangled to death by a mentally ill patient.
  • In 2012 a woman working at a Kentucky home health services company was shot at work by her estranged husband.
  • In 2013 a nurse was stabbed to death and four other people were wounded by a visitor at a hospital in Longview, Texas.

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.

Workplace Violence in the Healthcare Setting

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).
Medical 393,200 6.5
Nurse 150,300 8.1
Technician 87,800 11.1
Physician 42,100 10.1
Other medical 113,000 3.7
Mental health 152,300 20.5
Professional 55,900 17.0
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:

  • A lack of institutional reporting policies
  • Employee beliefs that reporting will not benefit them
  • Employee fears that employers may deem assaults the result of employee negligence or poor job performance

All of these factors underscore the need for effective policies that are communicated to all workers and supported by employer actions.

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
  • Post-traumatic stress disorder (PTSD)
  • Death
  • 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)

Negative consequences for institutions can include:

  • Decreased productivity
  • Low employee morale
  • Increased job stress
  • Absenteeism and lost work days
  • Restricted or modified duty (secondary to injury)
  • Increased employee turnover with retention issues
  • Recruitment challenges
  • Distrust of management
  • Financial loss resulting from insurance claims
  • Legal expenses
  • Property damage
  • Increased security measures
  • Diminished public image

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.

  • Verbal threats to inflict bodily harm, including vague or covert threats
  • Attempting to cause physical harm: striking, pushing, and other aggressive physical acts against another person
  • Disorderly conduct, such as shouting, throwing or pushing objects, punching walls, and slamming doors
  • Verbal harassment; abusive or offensive language, gestures, or other discourteous conduct toward supervisors or fellow employees
  • False, malicious, or unfounded statements against coworkers, supervisors, or subordinates that tend to damage their reputations or undermine their authority

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:

  • Type 1: Violence by a stranger with criminal intent
  • Type 2: Violence by a customer or client
  • Type 3: Violence by a coworker
  • 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, 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.

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 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:

  • Physical layout of the emergency department and location of the assessment rooms used for the program
  • Supplies and equipment available in the assessment rooms and how they are stored
  • Security provided at the entrance and within the department
  • Staffing levels
  • Training initially provided to the staff at the start of the program
  • Program policies and procedures
  • Training provided to all hospital staff members on the topic of workplace violence

The committee proposed that a better response to the situation might have included:

  • A police officer present during the intake process to explain to the patient what to expect and how long he would be there, and to help determine what kind of security or restraining measures would be necessary
  • A second staff member in the room during the assessment process or called in right away when the patient began to show signs of anger
  • The nurse acknowledging that the patient had questions about why he needed to be there, calmly stating that she will check how things are going, leaving the room quickly to get help, and not attempting to restrain the patient
  • Telling Eric about the circumstances surrounding the case prior to his entering the room and checking with the nurse before going into the room to perform the blood draw

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 assessment room used for this program will be closer to the main desk whenever possible.
  • A second staff member will be present for the initial assessment process.
  • Employees are to use the emergency call button located in each assessment room immediately at the first signs of an agitated patient. This will summon additional personnel and security.
  • Supplies in the assessment rooms are to be stored inside cupboards rather than in loose containers on the countertops.
  • Personnel are to be trained on how to recognize signs of possible violence and how to respond when faced with a variety of potentially dangerous situations.
  • Training will include role-playing and a review of the program policies and procedures. Since there are a low number of admissions to the program, the training is to be provided at least twice per year to help remind staff members of program policies and reinforce how to respond to escalating situations.
  • A debriefing conference will be held after any incident of workplace violence to review what happened, to offer support to the staff members involved, and to determine what can be learned from the incident.

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.

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. 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):

  • Aggressive or mocking body language such as raising eyebrows or making faces
  • Verbal retorts, abrupt responses, vulgar language, sarcastic comments or retorts
  • Belittling gestures (e.g., deliberate rolling of eyes, folding arms, staring into space when communication being attempted); body language designed to discomfort the other
  • Undermining behavior, such as constantly ignoring questions, devaluing comments
  • Criticizing or excluding individuals from discussion (freezing out) or controlling behaviors
  • Withholding needed information or advice
  • Sabotage, such as setting up a new hire for failure or turning others against a person
  • Constantly confronting with negativity
  • Infighting and bickering
  • Scapegoating
  • Blaming and gossiping behind a colleague’s back
  • Humiliation and confrontations in public
  • Failure to respect privacy, broken confidences
  • Shouting, yelling, or other intimidating behavior
  • Judging others on age, gender, sexual orientation, ethnicity, or size
  • Fault finding (nitpicking) beyond those situations where professional and clinical development is required
  • Behaviors which seek to control or dominate (power “over” rather than power “with”)
  • Elitist attitudes regarding work area, education, experience
  • Punishing activities by management (e.g., repeatedly sending someone out of area; bad schedules; chronic under-staffing; lack of concern with mental, emotional, spiritual, and physical health of employees)
  • Physical violence

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:

  • Bullying
  • Yelling
  • Snide comments
  • Withholding pertinent information
  • Physical, sexual, and emotional abuse
  • Rude, ignoring, and humiliating behaviors
    (Cantey, 2013)

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:

  • Nonverbal negative innuendo (raising eyebrows, face-making)
  • Covert or overt verbal affront (snide remarks, withholding information, abrupt responses)
  • Undermining clinical activities (not available to help, turning away when asked for help)
  • Sabotage (deliberately setting up a negative situation)
  • Bickering among peers
  • Gossiping among peers and management
  • Scapegoating (always assigning blame to one person when things go wrong)
  • Failure to respect privacy (gossip/talking about others without permission)
  • Broken commitments and/or broken confidences (repeating something meant to be kept confidential)
    (Bartholomew, 2013)

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: Violence by Someone in a Personal Relationship

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:

  • Learning how to recognize, avoid, or diffuse potentially violent situations by attending employee personal safety training programs
  • Alerting supervisors immediately and in writing to any concerns about safety or security and reporting all incidents
  • Being familiar with laws and regulations regarding workplace violence and the facility’s violence prevention program

Identifying Risk Factors

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

  • The increasing use of hospitals by police and the criminal justice system for criminal holds, and the care of acutely disturbed, violent individuals
  • The increasing number of acute and chronically mentally ill patients being released from hospitals without follow-up care (these patients have the right to refuse medicine and can no longer be hospitalized involuntarily unless they pose an immediate threat to themselves or others)
  • The unrestricted movement of the public in clinics and hospitals
  • Long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly
  • The increasing presence of gang members, drug or alcohol abusers, trauma patients, or distraught family members
  • Low staffing levels during times of increased activity, such as mealtimes, visiting times, and when staff are transporting patients
  • Isolated work with clients during examinations or treatment
  • Working alone in remote locations, with no backup or way to get assistance (i.e., communication devices or alarm systems); this is particularly true in high-crime settings

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).

Recognizing and Reducing Security Hazards

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:

  • Isolated location or job activities
  • 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
  • Early-morning or night-time hours of employment
  • Unknown person(s) loitering outside workplace
  • Easy access to potential weapons, such as knives or scissors

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.

  • Emergency department
  • Pharmacy
  • Patient accounts/accounting
  • OB/nursery/pediatrics
  • Cash handling areas
  • Central stores
  • Parking areas
  • Shipping/receiving

The unique characteristics of hospitals, clinics, and other healthcare settings add to the potential of environmental security hazards. These may include:

  • The availability of drugs or money in the pharmacy or medication area, making them likely robbery targets
  • Open visiting hours
  • The presence of large numbers of persons who may or may not be connected to a patient (e.g., other patients’ family or friends, volunteers, repair persons, outside vendors, outpatients, students, persons making financial inquiries, and other members of the public)
  • Lack of security personnel in open clinics and hospitals
  • Unfamiliar and potentially dangerous locations such as when personnel are delivering services in home or community settings
  • Treatment areas not prepared for violent patients (e.g., moveable furniture that could be used as weapons or to entrap employees, possible items on countertops that could be thrown at workers)

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:

  • Paying attention to physical surroundings
  • Trusting personal instincts
  • Presenting a strong, confident image by posture, stride, and 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 cellphone or pager
  • Using the locks and security systems that are available
  • Reporting security hazards promptly to a supervisor
  • Not using a cellphone or personal music system while en route to or from the workplace
  • Taking a self-defense class or requesting that the facility offer one

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:

  • Frequent aggressive outbursts or excessive displays of temper
  • History of threats or violent acts
  • Unusual fascination with weapons and/or references to weapons, violent media content, or violent events
  • Verbal abuse of coworkers and customers
  • Harassment through phone calls or emails
  • Bizarre comments or behavior, including sexual or violent content
  • Holding grudges, inability to handle criticism, making excuses, and blaming others
  • Chronic hypersensitive complaints about persecution
  • Making jokes or offensive comments about violent acts
  • Deteriorating work habits, frequent absenteeism
  • Depression or withdrawal, noticeable decrease in appearance and hygiene
  • Escalation of domestic problems

Prevention Measures for Community-Based Employees

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:

  • Preparing a daily work plan/itinerary, including both locations and estimated times of arrival and departure
  • 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 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
  • Using a buddy system
  • Using telecommunication devices
  • Carrying minimal money
  • Carrying required identification
  • Recognizing potentially dangerous situations ahead of time and initiating backup

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.

  • She shares a copy of her scheduled home visits with her supervisor, including the client’s name, phone number, and street address.
  • She takes a few minutes prior to leaving for the first client visit to familiarize herself with the locations she will be visiting and determine if there are known high-risk areas in the vicinity; she plans the routes she will use to travel from one client home to the next, avoiding any potentially dangerous areas.
  • She makes sure her car is in good repair and the gas tank is full. She carries a spare key in her supply bag.
  • She travels with her car doors locked and windows rolled up.
  • She parks in the client’s driveway or in well-lighted areas located as close to the client’s home as possible.
  • She locks her home care supplies and equipment and personal belongings out of sight in the trunk of the car.
  • She carries a cellphone and makes sure the batteries are fully charged at the beginning of each shift.
  • She is familiar with the emergency notification system at work and the number to call to request back-up.
  • She arranges to use the buddy system put in place by the agency whenever her instincts tell her it would be a good idea. She has done this for her coworkers and does not hesitate to ask for help for herself.
  • She confirms with her clients ahead of time by telephone so she is expected.
  • Before getting out of the car, she checks the surrounding area and does not leave the car if she feels uneasy.
  • She calls one of her roommates at the end of her last home visit to report where she is and when she will be home.

By following these steps, Janice feels comfortable that she is taking the necessary precautions to avoid finding herself in a potentially dangerous situation.

Managing the Aggressive Person

In any setting it is essential that employees be familiar with measures to defuse and respond to aggression.

  • Respect others’ personal space. The amount of personal space people require to feel comfortable may vary greatly, and anxiety rises when that space is invaded. Maintain at least an arm’s length distance from a person whose behavior is escalating.
  • Be polite and avoid becoming defensive or showing anger. Show confidence, not fear.
  • Do not criticize, act impatient, belittle, or make an aggressive person feel foolish.
  • Be aware of body position. Avoid eye-to-eye and toe-to-toe positions, as they may be considered challenging. Stand at an angle to an aggressive person and off to one side.
  • Use active listening. Empathize with the person’s feelings. Try not to judge or patronize the person. Using silence and being supportive can be more important than what is said.
  • Be aware of body language. Nonverbal communication (gestures, facial expressions, tone of voice, and movements) is extremely important in exhibiting a calm and respectful attitude.
  • Stay with the issue at hand when a person is challenging. Ignore the challenge and redirect.
  • Set and enforce reasonable limits with persons who become defensive, disruptive, or belligerent. Offer simple and clear choices and consequences to the person, ensuring that they are reasonable and enforceable.
  • Do not attempt to bargain with a threatening person.
  • Do not make promises that can’t be kept.
  • Never lie to the person.
  • Have an escape route.
  • If the person has a weapon, do not try to disarm him/her. Evacuate the area and call 911.

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:

  • Avoid situations that don’t “feel right.” Trust personal instincts and judgment.
  • Sit or stand close to the door.
  • Keep a cellphone in a pocket or attached to clothing.
  • Use diversional tactics to help the person calm down (offer something to drink, for example).
  • Keep shoes on. If asked to remove them, explain it is a safety and health policy that they be worn.
  • When threatened and unable to gain control of the situation, leave as quickly as possible and go to a safe place.
  • Call police if necessary.
  • Always document and report the incident.
    (CDC, 2012)

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.

Workplace Safety Standards

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:

  • Any hazards that may exist
  • Whether the hazard is causing or likely to cause serious physical harm or death
  • Which effective methods to control the hazard are available
  • What control methods are feasible

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).

Workplace Violence Prevention Programs

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:

  • Management commitment and a system of accountability
  • Employee involvement
  • Worksite analysis
  • Hazard prevention and control
  • Training and education
  • Recordkeeping and evaluation of the program

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:

  • The emotional as well as physical health of the employee
  • Appropriate allocation of authority and resources to responsible parties
  • Equal commitment to worker safety and health and patient/client safety
  • A system of accountability for involved managers and employees
  • A comprehensive program of medical and psychological counseling for employees experiencing or witnessing violent incidents
  • No employee reprisals for reporting incidents
  • Consideration of a “zero-tolerance” policy for intimidating and/or disruptive behaviors

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

  • Understanding and complying with the workplace violence prevention program and other safety and security measures
  • Participating in employee complaint or suggestion procedures covering safety and security concerns
  • Reporting violent incidents promptly and accurately
  • Participating in safety and health committees or teams that receive reports of violent incidents or security problems
  • Making facility inspections and responding with recommendations for corrective strategies
  • Taking part in a continuing education program that covers techniques to recognize escalating agitation, high-risk behavior, or criminal intent and discusses appropriate responses

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:

  • Assess the organization’s vulnerability to workplace violence
  • 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

Employee Assistance Programs (EAPs)

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:

  • Strict confidentiality
  • Availability to employees and their immediate families
  • Recognition and commitment by management and employees that an EAP is needed
  • Policies and procedures supported by top management and employees
  • Establishment of both formal and informal referral procedures
  • Promotion of the EAP and encouragement to use the service
  • Education of managers and employees in the workings of the EAP
  • Periodic evaluation of the EAP to ensure it meets the needs of both the employee and the employer
    (EAPA, 2010)

Post-Event Response

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:

  • Providing medical care to the victim
  • Debriefing the victim
  • Providing counseling
  • Reporting the incident
  • Assisting with injury claims
  • Prosecuting perpetrators when indicated

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:

  • OSHA 300 logs
  • Incident reports dealing with assault or near-assault incidents
  • Insurance records
  • Police reports
  • Accident investigations
  • Training records
  • Filed grievances

She finds the following:

  • Several incidents involving verbal threats to receptionists from clinic patrons
  • Ten incidents involving pushing/shoving in the parking lot in which police were called to intervene
  • No staff training records
  • Twenty insurance claims for damages to cars in the parking lot

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:

  • Access through the main entrance to the clinic is not controlled. The door is unlocked for all hours of operation.
  • There is no lock on the door between the reception area and the treatment area.
  • The parking lot is not well lit, and unidentified persons often loiter there.
  • There is no method of communication between the reception desk and the treatment area of the clinic.

Concerned with the hazards from the inspection, she further reviews the tasks of the receptionists and identifies the following concerns:

  • Money is kept behind the main reception desk in an unlocked drawer.
  • One receptionist works alone during the early-morning and late-night hours.
  • The clinic is in a high-crime area.

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:

  • Improve lighting in the parking lot and main entrance to the clinic.
  • Hire a security guard—minimally for the early-morning and evening hours.
  • Lock the main entrance during early-morning and evening hours.
  • Install a buzzer for patients to use when the door is locked.
  • Secure the door between the reception area and the clinic.
  • Install communication between the clinic area and reception desk.
  • Limit the amount of cash kept in the reception area and remove excess cash on a varying schedule.
  • Review staffing and hours of operation for the reception area and revise as needed.
  • Develop policy, procedures, and training for:
    • Use of security equipment
    • Diffusing hostile or threatening situations
    • Summoning assistance in an emergency
    • Medical follow-up
    • Availability of counseling and referral
    • Incident reporting and investigation
    • Incident recordkeeping

Institutional Initiatives

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).

  • A program utilizing a green-yellow-red light, color-coded alert system was put in place in the University of Wisconsin Hospitals and Clinics emergency department. Each color represents a current security status, with lights placed strategically throughout the department. During red light status, the ED restricts visitor access and goes into lockdown while security members cover all department entrances. Following institution of the system, there has been only one reported staff member injury and no injury-related staff absences (Childers, 2013).
  • In the five years since Overlook Medical Center in Summit, New Jersey, implemented its Nurse Safe program, its two emergency departments have experienced a 36% decrease in employee injuries from violent patients, a 35% decrease in codes for a violent patient incident, and a 59% decrease in work-days lost due to injuries. The program involves training nurses and clinical staff how to identify the warning signs of aggressive behavior; how to verbally defuse situations; and how to escape from physical attack, move to safety, and help colleagues under attack. The facility also introduced an electronic health record system that flags anyone with a past history of violence at the facility (Wood, 2013).
  • John T. Mather Memorial Hospital in New York adopted a zero-tolerance policy for violence, added security upgrades, improved communication with local law enforcement, created shooter and weapons policies, and added a requirement for managers and supervisors to receive a one-day training in assessing for violence potential. These measures have reduced violence and improved safety (Wood, 2013).
  • A nonviolent crisis-intervention training program delivered at a South Dakota vocational services organization resulted in a 50% decrease in the number of peer-to-peer incidents. Staff members were better able to identify people’s signs of anxiety and defensiveness and implement supportive approaches prior to people becoming violent toward themselves, staff, and others served (CPI, 2010).


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.


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

Bartholomew K. (2013). Break the spell and end lateral violence in nursing. Retrieved from

Bullen D. (2013). Bosses, bullying & burnout in nursing. Retrieved from

Bureau of Labor Statistics (BLS). (2013a). Economic news release: census of fatal occupation injuries summary, 2012. Retrieved from

Bureau of Labor Statistics (BLS). (2013b). Workplace homicides. Retrieved from

Bureau of Labor Statistics (BLS). (2013c) Fact sheet: workplace homicides from shootings. (2013b). Retrieved from

Business and Legal Resources (BLR). (2011). Compliance tools for HR professionals. HR and Employment Law News. Retrieved from

Campbell J. (2011). Workplace violence: prevalence and risk factors in the Safe at Work study. Journal of Occupational & Environmental Medicine, 53(1), 82–9.

Cantey SW. (2013). Recognizing and stopping the destruction of vertical violence. Am Nurs Today, 8(2). Retrieved from

Centers for Disease Control and Prevention (CDC). (2013). Workplace violence: prevention for nurses. Retrieved from

Centers for Disease Control and Prevention (CDC). (2012). NIOSH fast facts: home healthcare workers: how to prevent violence on the job. National Institute for Occupational Safety and Health. DHHS (NIOSH) Publication No. 2012-118. Retrieved from

Childers L. (2013). Danger on the job: nurses speak out against hospital violence. Retrieved from

Crisis Prevention Institute (CPI). (2010). Success stories and testimonials. Retrieved from

Employee Assistance Professionals Association (EAPA). (2010). EAPA standards and professional guidelines for employee assistance programs. Retrieved from

Encyclopedia of Small Business. (2011). Workplace violence. Retrieved from

Harrell E. (2011). National crime victimization survey, U.S. Department of Justice special report: workplace violence, 1993–2009. Retrieved from

Haynes M. (2013). Workplace violence: why every state must adopt a comprehensive workplace violence prevention law. Cornell HR Review. Retrieved from

Iyer P. (2012). Bullying among doctors and nurses: an alarming patient safety issue. Retrieved from

Monson M, Scaglione B, Allen D, Wilkes K. (2011). Health care: violence in the workplace. Retrieved from

New York State Senate (NYS Senate). (2010). Senate acts to protect nurses from violence. Retrieved from

Occupational Safety and Health Administration (OSHA), United States Department of Labor. (2011). Workplace violence. Retrieved from

Office of Personnel Management (OPM). (2012). Employee assistant programs: overview. Retrieved from

Restrepo T & Shuford H. (2012). Violence in the workplace. NCCI research brief. National Council on Compensation, Inc. Retrieved from

Stanley K, Martin M, Michel Y, Welton M, & Nemeth S. (2007). Examining lateral violence in the nursing workplace. Issues in Mental Health Nursing 28, 1247–65.

The Joint Commission (TJC). (2010). Preventing violence in the health care setting. Sentinel Event Alert, 45(June 3). Retrieved from

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

Wood DE. (2013). ED nurses work to curb violence. Retrieved from

Table of Contents Back to Top