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

INTRODUCTION

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 Bureau of Justice Statistics National Crime Victimization Survey (NCVS) is the primary source of information on criminal victimization in the United States, and workplace violence is an integral part of this survey. Findings from the NCVS include:

• In 2015 homicide accounted for about 9% of all fatal workplace injuries, and firearm-related workplace homicides accounted for almost 85% of all workplace homicides.
• In 2015, 61 women and 356 men were victims of homicide in the workplace. Of these women, 43% were killed by a relative or a domestic partner, compared to 2% of the men.
• In 2015, 20% of the women who were killed in the workplace were killed by a person committing a robbery, compared to 33% of the men.
• White victims reported 78% of known workplace violence victimization and 66% of non-workplace violence victimization.
• Black or African-American workers experienced 9% of violent victimization.
• Hispanic/Latino workers experienced 8% of violent workplace victimization and 15% of non-workplace violent victimization.
  (BJS, 2019)

The National Safety Council (2020) reports that in 2017, workplace assaults led to 18,400 injuries and 458 fatalities. The Council notes that workers in specific industries, including healthcare, are more likely to have violent incidents than others.

In 2019, the Bureau of Labor Statistics (2019) published a news release that contained information about fatal occupational injuries in 2018. Violence and other injuries by persons or animals increased 3% in 2018 due to an 11% increase in work-related suicides from 275 to 304.

WHAT CONSTITUTES WORKPLACE VIOLENCE?

The Occupational Safety and Health Administration (OSHA, 2019) 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, 2020) 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 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 (OSHA, 2019).

The Centers for Disease Control and Prevention (CDC, 2016) 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, 2016).

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, 2019). 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. 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, 2016).

Violence by a customer or client is the most common 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, 2016). 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 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.

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
  (Bartholomew, 2014)

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 (Bartholomew, 2014; Falletta, 2017; Lippincott Solutions, 2016; Rainford et al., 2015).

Contributing factors to vertical violence in healthcare between physicians and nurses include:

• Physicians are revenue generators and decision makers.
• Often, disruptive physicians are the most clinically talented and valued by hospital administration.
• Administration may give in to physician demands.
  (Burkhardt, 2015)

HORIZONTAL (LATERAL) VIOLENCE

Horizontal, or lateral, violence refers to 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 is prevalent in the nursing profession, for example, and studies have arrived at the conclusion that lateral violence in the healthcare workplace is a nearly universal experience for nurses. Lateral violence by nurses is estimated to cost more than $4 billion dollars each year due to lost time, lost productivity, and turnover of trained staff (Bartholomew, 2014; Falletta, 2017; Rainford et al., 2015).

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 Feier’s theory of oppression (1970), 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.

Contributing factors to horizontal or lateral violence in the nursing profession include:

• The field of nursing is predominantly female (studies document that male nurses feel more valued than female nurses do).
• Nurses are under the dominance of a patriarchal system.
• Nursing managers are marginalized.
• Displaced frustration from perceived oppression is played out toward coworkers.
  (Bartholomew, 2014; Falletta, 2017; Burkhardt, 2015)

By extension, other healthcare professions or professional specialties may face similar issues if they practice under a patriarchal system and with a high proportion of women.

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, 2016).

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, 2016; OSHA, 2019).

IMPACT OF WORKPLACE VIOLENCE

General Workplace Violence Data

Specific data related to workplace violence is collected by the National Institute for Occupational Safety and Health (NIOSH), which records reported workplace injuries and fatalities, including assaults, violent acts, and homicides. According to NIOSH (2018), 2017 data on nonfatal workplace violence include:

• 18,400 workers in private industry experienced trauma from nonfatal workplace violence.
• 70% of these workers were female.
• 67% were aged 25 to 54.
• 71% worked in the healthcare and social assistance industry.
• 18% required 31 or more days away from work to recover, and 25% involved three to five days away from work.

In 2017, 458 U.S. workers were workplace homicide victims. Of these victims:

• 82% were male.
• 48% were white.
• 64% were aged 25 to 54.
• 21% were working in sales and related occupations.
• 19% were performing protective service activities.
  (NIOSH, 2018)

In 2019, OSHA reported that:

• Workplace violence is the third leading cause of fatal occupational injuries in the United States.
• Of the 5,147 fatal workplace injuries that occurred in the U.S. in 2017, 458 were cases of intentional injury by another person.

Incidence of Workplace Violence in the Healthcare Setting

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

• About 75% of workplace assaults reported annually occur in healthcare and social service settings.
• Healthcare workers have a 20% higher chance of being a victim of workplace violence than other workers.
• 76% of registered nurses report experiencing workplace violence.
• 54.2% of nurses experienced verbal abuse from patients and 29.9% experienced physical abuse.
• Nearly 33% of nurses reported verbal abuse by visitors and 3.5% reported physical abuse by visitors.
• The most common acts of violence against nurses were shouting/yelling, swearing, and groping.
• On average, nurses report only 20% to 60% of workplace violence incidents.
• 13% of nurses’ missed work days are due to workplace violence.
• 70% of emergency department physicians have reported acts of violence against them, but only 3% pressed charges.
• 80% of serious violent incidents reported in healthcare settings involved patients.
  (Masson, 2019; Nelson, 2019)

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; Sheely, 2019)

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
  (ECRI Institute, 2017; Sheely, 2019)

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
• 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 en 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, 2020; Next Avenue, n.d.; Office on Violence Against Women, 2019)

Identifying Risk Factors

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

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 deescalate 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
  (TJC, 2018)

Cultural factors unique to the healthcare setting include:

• Putting oneself at risk to help a patient because of a professional and ethical duty to “do no harm”
• The belief that violence is just “part of the job,” routine, and unavoidable
• The unintentional nature of patient violence and unwillingness to stigmatize patients due to their illness or impairment
• Increased use of emergency departments rather than specialized facilities for treatment of severely ill patients with violent tendencies due to lack of funding for mental health services
  (CDC, 2016)

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
  (NIOSH, 2016)

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. These include:

• Verbally expressed anger and frustration
• Threatening gestures
• Signs of drug or alcohol abuse
• Presence of weapons
  (Lynch, 2020)

Working in any community setting outside a traditional office building increases the risk of coming in contact with potentially violent situations. Research indicates that perhaps as many as 61% of home care nurses have experienced some type of workplace violence. Prevention measures for “field” 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
• 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
  (Lynch, 2020)

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 person, the staff, and others in the area
• Assist the person to manage emotions and regain control of behavior
• Avoid coercive interventions that could increase agitation

Verbal de-escalation techniques involve three things: self-control, physical stance, and de-escalation communication.

SELF-CONTROL

Recommendations for self-control include:

• Appear calm and do not show fear. Relax facial muscles and look confident. Anxiety can make the aggressive person feel anxious and unsafe, which can escalate aggression.
• Speak in a modulated, low, monotonous tone of voice. A high-pitched, tight voice conveys fear.
• 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.
• Do not be defensive. Even if the comments or insults are directed at you, they are not about you. Do not defend yourself or anyone else from insults, curses, or misconceptions about their roles.
• Do not point or shake your finger at the person.
• Do not touch or attempt to touch the person, even if some touching is otherwise generally appropriate in the setting; touching may be misinterpreted to be hostile or threatening.
• Be aware of the back-up assistance that is available and crisis response procedures.
• Be very respectful even when firmly setting limits or calling for help; an agitated individual is typically very sensitive to feeling shamed and disrespected.
  (Daud, 2015; NASW, 2017)

PHYSICAL STANCE

Recommendations for physical stance include:

• Never turn your back to the person for any reason.
• 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. Maintain extra physical space at about four times the usual.
• Be aware of body position. Avoid toe-to-toe positions, as they may be considered challenging. Stand at an angle to an aggressive person and off to one side so you can sidestep away if needed.
• Have an escape route. Stand between the door and the individual.
• Always maintain the same eye level. Encourage the person to be seated, but if the person needs to stand, you stand up also.
• Do not smile. This could be interpreted as mockery or anxiety.
• Keep hands out of your pockets, up, and available to protect yourself.
  (Daud, 2015; NASW, 2017)

DE-ESCALATION COMMUNICATION

Recommendations for de-escalation communication include:

• Do not get loud or try to yell over a person who is screaming. Wait until the person takes a breath and then talk.
• Do not try to convince or argue with the person.
• Respond selectively. Answer all informational questions no matter how rudely asked; do not answer abusive questions.
• Do not criticize, act impatient, belittle, or make an aggressive person feel foolish.
• Use active listening. Empathize with the person’s feelings but not with the behavior. Try not to judge or patronize the person. Using silence and being supportive can be more important than what is said.
• Do not solicit how a person is feeling or interpret feelings in an analytic way.
• Explain 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.
• Never lie to the person and do not make promises that cannot be kept.
• If possible, try to tap into the person’s cognition by stating, “Help me to understand what it is you’re saying (or wanting).” This may distract them from attacking in order to teach you what you want to know.
• If the person has a weapon, do not try to disarm him/her. Evacuate the area and call 911.
  (Daud, 2015; NASW, 2017)

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 (U.S. DoL, 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 (U.S. DoL, 1970).

OSHA Workplace Safety Standards

In 1989, OSHA published the Safety and Health Program Management Guidelines, and in 2016 these guidelines were updated to reflect changes in the economy, workplaces, and evolving safety and health issues. 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, 2020).

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.

Workplace Violence Prevention Programs

A workplace violence prevention program demonstrates an organization’s concern for employee emotional and physical safety and health. The updated 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 (OSHA, 2016).

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 will be 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 recent qualitative study was conducted to determine the effectiveness of workplace violence prevention programs in healthcare settings. The study indicated seven primary themes, some of which are both problems within the program itself and/or are related to broader healthcare industry and societal issues. These barriers were found to be:

• Lack of action resulting from reporting
• Varying perceptions of what constitutes violence
• Bullying
• Impact of money- and profit-driven management models
• Lack of management accountability
• Intense focus of healthcare organizations on customer service
• Weak social service and law enforcement approaches to mentally ill patients
  (Blando et al., 2015)

Employee Assistance Programs

An employee assistance program (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.

Employee assistance programs first started in the 1940s to help employees with alcohol addiction. Today EAPs address a wide range of issues affecting mental and emotional well-being. EAPs offer confidential, behavioral counseling as well as help in a personal/family crisis or something that affects the workplace or a person’s effectiveness in the workplace.

Employee assistance programs are evolving and adapting to changing technology and to the needs of younger workers. Services are becoming more accessible. Online interactive assessment may be available. Webinars or other online information for employees, online training for supervisors, and the use of text messaging and emails to facilitate communication and support are now being utilized (APA, 2016).

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:

• Providing medical care to the victim
• Debriefing victims and witnesses
• Evaluating the impact on the victim(s) and witnesses
• Helping employees process events by using, for example, counseling, emotional support, referral to mental health professionals
• Communicating with employees to alleviate feelings of fear and uncertainty
• Taking control of incident communication to ensure that accurate, objective information is disseminated
• Conducting a thorough review of workplace violence policies and procedures
  (Employer Flexible, 2019)

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, 2018).

The American Organization of Nurse Executives and the Emergency Nurses Association in 2015 jointly released Guiding Principles on Mitigating Violence in the Workplace. These principles provide a framework to systematically reduce lateral and patient and family violence in hospital settings (AONE & ENA, 2015).

Recommendations from NIOSH are that a written workplace violence policy should clearly indicate a zero-tolerance of violence at work, whether the violence originates inside or outside the workplace. Workplaces must develop threat assessment teams to which threats and violent incidents can be reported. The team is to assess threats of violence and to determine what steps are necessary to prevent the threat from being carried out (NIOSH, 2014).

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 health care 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.).

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.