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Workplace Violence in Healthcare

Feb 23, 2018 11:39PM ● By MED Magazine

By Lori Berdahl

According to the 2011 to 2013 Bureau of Labor Statistics data, US healthcare workers suffered  15,000 to 20,000 injuries each year related to workplace violence that required time away from work for treatment and recovery. 1 Between 70% and 74% of all workplace violence injuries occurred in healthcare, on average this is four times greater than in private industry.2

And, the problem is likely much greater than these statistics suggest, considering they do not account for the assaults or threats that don’t lead to time away from work. Studies have also shown that violence in healthcare is remarkably underreported. 1    

Contributing to these trends are caregivers’ perceptions that they have a professional and ethical duty to “do no harm” to patients, often putting their own safety and health at risk to help a patient.

In their Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, OSHA outlines 5 key components to a comprehensive workplace violence prevention program.2

First, demonstrated commitment from management and active inclusion of front-line employees are equally critical for success during each phase of the prevention program.2 

Second, a thorough worksite analysis is needed to identify hazards and risk factors for violence. It is important to remember that the violent acts are perpetrated not only by patients, but also by distraught family members, visitors, and fellow workers.2

Common risk factors include long wait times, overcrowded or uncomfortable waiting rooms, understaffed areas, patients with a history for violence, lack of ability to easily communicate emergency needs, working in isolated areas, and a department or unit perception that violence is simply tolerated.

The Emergency Care Research Institute (ECRI) identifies the following clinical areas as particularly vulnerable to violence: labor and delivery, emergency department, intensive care unit, neonatal or pediatric ICU, and home care. The ECRI provides a helpful list of items to assess and address in all departments during worksite analysis walk-throughs.3 

Employee surveys can also be helpful to identify the types of problems workers face on a daily basis. Questions could include: “What work activities make you feel unprepared to respond to a violent act?” “What daily activities expose you to the greatest risk of violence?” “Are you ever out of hearing or sight of other workers?”

OSHA’s third key component for violence prevention involves design and implementation of control measures to respond to the identified risk factors. These may include engineering or administrative changes such as protecting nurses’ stations with enclosures or deep counters, improving lighting, controlling public access to high-risk areas, ensuring adequate staffing, or installing panic buttons, which can quickly notify security of threats.2

The fourth key is thorough and repeated training so staff can recognize warning signs and can respond effectively and confidently. Staff should be taught to watch for early signs of rising anxiety levels including speaking quickly in a high pitched or quavering voice, rapid heart rate or perspiration, and nervous habits such as foot tapping or palm rubbing.2

A few common warning signs for imminent violence include rapid eye movements or a wide-open focused stare, heavy breathing, clenching of jaws and fists, constant questioning, and verbal threats of aggression.

The words and actions of staff can either fuel or defuse tensions. With training and practice, de-escalation procedures can become more natural. Examples include allowing the stressed person to express their concerns verbally, demonstrating supportive body language, setting firm limits without using threats, and using a shared problem solving approach to give the person a better sense of control.

The National Institute for Occupational Safety and Health (NIOSH) has an interactive and multimedia training module available on its website called Workplace Violence Prevention for Nurses. It defines the types of workplace violence, outlines risk factors, and reviews prevention strategies. The site also offers supplemental resources for creating a violence prevention program.4

OSHA’s final key component for violence prevention is recordkeeping and program evaluation. Healthcare providers need to feel empowered to report any and all threatening incidents. These should not be overlooked as simply “part of the job.” Supervisors need to listen to these reports empathetically and ask follow up questions that help to identify system vulnerabilities. A uniform violence reporting system should be established with regular review of reports.2


1Occupational Safety and Health Administration. (2015). Preventing workplace violence: A road map for healthcare facilities. Occupational Safety and Health Administration Publication No. 3827. Retrieved from

2Occupational Safety and Health Administration. (2016). Guidelines for preventing workplace violence for healthcare and social service workers. Occupational Safety and Health Administration Publication No. 3148-06R 2016. Retrieved from

3ECRI Institute. (2017). Violence in healthcare facilities. Retrieved from

4Centers for Disease Control. (2013). Workplace violence prevention for nurses.  The National Institute for Occupational Safety and Health (NIOSH) Publication No. 2013-155. Retrieved from


Lori Berdahl, OTR/L, CEES, is an Ergonomics and Loss Control Specialist with RAS.