Addressing Workplace Violence in Healthcare

How professionals and students in patient-facing positions can stay safe at work and school.

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Phil-La-Duke
Phil La Duke

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Phil La Duke is the author of Lone Gunman: Rewriting the Handbook on Workplace Violence Prevention. Prior to his current position as a global business consultant, Phil was a talent development manager for Trinity Health, one of the U.S.’s largest healthcare systems. There he was a certified Just Culture professional and trained many of the healthcare systems’ top executives.

Violence can occur in any workplace, but 75 percent of all workplace assaults happen to healthcare professionals. These incidents of violence, which can range from verbal assaults to attacks with weapons, have many healthcare workers on alert as they navigate their day-to-day responsibilities. Understanding violence in healthcare settings can help workers and students better equip themselves to stay safe and reduce the chances of an encounter. This guide discusses what violence looks like in healthcare settings, why it happens, and what workers and employers can do to mitigate risk. You can also find resources and get advice from an expert in workplace violence reduction.

Forms of Violence Against Healthcare Workers

Identifying workplace violence in healthcare can be surprisingly tricky. Understanding what workplace violence is and how it happens can help you maintain a safe workplace and know how to address it when it occurs.

What is Workplace Violence?

The CDC provides a very succinct explanation, defining workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.” Violence is abusive or harassing behavior, and threats can be written, verbal, or physical. The World Health Organization adds that these violent acts may be explicit or implicit and can involve any circumstance related to a person’s work, including commuting. Workplace violence includes both physical and psychological threats and harm.

What Does Violence in the Healthcare Workplace Look Like?

Workplace violence takes many forms and ranges in severity. Biting, kicking, hitting, and spitting are all common forms of violence healthcare professionals can face. Being yelled at, swatted at, or otherwise deliberately intimidated through aggressive gestures and personal space violations also should not be ignored. Here are a few violent acts that can happen in healthcare settings, according to the Joint Commission:

  • Biting
  • Kicking
  • Punching
  • Pushing
  • Pinching
  • Shoving
  • Scratching
  • Spitting
  • Name calling
  • Intimidating
  • Threatening
  • Yelling
  • Harassing
  • Stalking
  • Beating
  • Choking
  • Stabbing
  • Killing

Even though many of these things take place multiple times a day in healthcare settings, it’s important to remember that dealing with violence is not just part of the job. Any violence should be reported regardless of its perceived severity.

What Triggers Violence in Healthcare settings?

A study published in the New England Journal of Medicine found that workplace violence in healthcare settings can be divided into four categories:

Type I

Violence committed by perpetrators who have no association with the workplace or the employee.

Type II

Violence committed by someone who is a customer or patient of the workplace.

Type III

Violence committed by someone who is a current or former employee of the workplace.

Type IV

Violence committed by a perpetrator who has a personal relationship with the employee but not the workplace

Violence committed by patients, their families, or their friends (type II violence) is the most common in healthcare settings. Often, these situations are caused by distress. Healthcare workers regularly have to deliver unpleasant news to patients and their loved ones. This can be upsetting, and people may lash out as a result.

It’s also common for patients to act out when they have no control of their actions, like when coming out of anesthesia. Healthcare workers may feel that this does not count as violence, and that their patients should be protected since they are not directly at fault. However, this is still violence and should be reported. If instances of violence, whether intentional or not, go unreported, healthcare facilities can’t get an accurate picture of safety and can’t, therefore, take necessary measures to improve safety for staff, patients and visitors.

Contributing Factors

There isn’t a singular cause of violence in healthcare settings. Hospitals and other healthcare facilities are as dynamic and varied as the people who visit them. Altered mental states of patients and other visitors, mental illness, police custody, upsetting news, gang activity, and domestic disputes can all contribute to violence in healthcare environments.

It’s also important to remember that healthcare facilities can be highly stressful environments for workers, patients, and visitors. Being in a hospital or other healthcare facility can be extremely emotional, and people usually don’t have a lot of time to effectively process those emotions. They may be having to make significant decisions about their health or the health of a loved one. Some may receive devastating or unexpected news. Many people who act violently in healthcare settings do so in part because they are physically unwell. Plus, medical expenses can contribute to people’s stress and irritation, as can the confusing industry terminology. Healthcare facilities can also be noisy and overcrowded, which only exacerbates these factors. Generally speaking, people in healthcare facilities are not at their best, and violence can occur more easily as a result of various stressors coming together in one place.

Protecting Yourself Against Workplace Violence

Avoiding violent situations at work is ideal, but in healthcare settings, this isn’t always easy. Not all instances of violence are preventable, so students and employees should take steps to protect themselves and minimize damage in advance.

As a Healthcare Student

Before starting your internship or clinical hours, ask what protocols and policies are in place to address workplace violence, and make sure you know what to do and who to talk to in case of violence. If the facility doesn’t have any solid protocols in place, you may consider interning elsewhere. As a student, you want to be able to focus on honing your skills, not wondering whether you will get the support you need if faced with violence. Students can also ask their teachers for advice. Chances are good that they’ve dealt with this before and can offer valuable insights.

When Applying for Healthcare Jobs

When interviewing for healthcare jobs, be sure to ask questions directly related to workplace violence. Find out whether the facility offers violence prevention and de-escalation training. It may be worthwhile to ask whether those trainings are mandatory or how well-attended they are. Knowing whether or not your coworkers are well-versed in de-escalation and violence prevention may help you decide if a particular workplace is a good fit.

It’s also important to ask if a violence prevention plan is in place. This can help you see how seriously the facility takes violence, as can asking to see their incident reporting figures. It may be encouraging to see low figures, but it may also mean that workers under-report instances of workplace violence. Ask for details about their incident reporting procedures. If they are complicated and take a lot of time, this may point to under-reporting. In any case, follow up by asking how the workplace responds to reported incidents of violence. Their answers to all of these questions should give you a fairly good picture of the workplace’s attitude toward violence. If it seems questionable, protect yourself by seeking employment at a different facility.

If possible, it may be a good idea to ask current staff how they feel about the way violence is handled at their workplace. They likely have firsthand experience and can provide honest answers.

When on the Job

Participate in violence prevention and de-escalation training sessions. If your workplace does not offer this type of training, insist that it be made available. While this training won’t prevent everyone from acting violently, they can help healthcare workers minimize damage and keep many conflicts from getting out of hand. When violence does occur at work, report it. Even if you are trying to protect patients, not reporting violence can harm staff and other patients in the long run. Leaving violence unaddressed can increase patients’ exposure to potentially violent situations and reduce the efficacy of care when healthcare workers’ emotional well-being diminishes. While many healthcare workers are resilient and accustomed to workplace violence, their patients are not, so reporting violent incidents can help protect everyone.

It’s also important to talk to a counselor. Workplace violence can take a toll on healthcare workers’ mental health and often leads to burnout. Getting mental health support and checking in regularly can help you protect yourself before a severe psychological condition, like PTSD, develops.

Healthcare workers can also leverage their skills as a way to protect themselves from workplace violence. Healthcare workers are in extremely high demand, so you may opt to tell your employer that if they do not take violence and safety seriously, you will look for work at a facility that does.

What if it Happens to You? A Checklist

Workplace violence may be prevalent in healthcare careers, but workers do not have to let it go unaddressed. Preparing for incidents of violence at work can help you handle potentially dangerous situations. How you react will depend on the type and severity of violence, but these tips can give a general idea of things to do if you face workplace violence.

While it’s happening

Reacting to violence while it’s happening can be extremely stressful and scary. Every situation will be different, but being aware of your surroundings and knowing what tools and techniques you can use may help you respond to violence safely and appropriately.

  • Prioritize your own safety.
  • Identify an exit route.
  • Call for help.
  • Employ active listening and other de-escalation techniques.
  • Maintain appropriate body language. Show you are open and listening.
  • Intervene with medication if necessary and appropriate.

Immediately after/once you’re safe

After getting out of a violent situation, take steps to make sure that you, patients and other staff are safe. You should provide information about the situation and involve appropriate authorities, like hospital administration or law enforcement, depending on the situation. This can help resolve the issue and keep everyone informed.

  • Get a physical examination to make sure you are unharmed.
  • Attend a debriefing with all staff involved in the incident.
  • Report the incident.
  • Call law enforcement if necessary.

Follow up

Victims of workplace violence should follow up in the days, weeks or months following the incident. This may be to ensure their health is in check and that the incident is being handled properly.

  • Get another physical exam to monitor health.
  • Get a mental health screening and/or see a counselor.
  • Press charges if necessary.
  • Make sure the incident report has been processed properly.
  • Discuss prevention tactics with your employer to help mitigate similar incidents in the future.

What Should Your Employer Be Doing About Workplace Violence?

Workplace violence is a reality for most healthcare workers, but as this epidemic gets more exposure, healthcare facilities are working to minimize violence and its damage. Prevention strategies can vary to meet the specific needs and limitations of different facilities, but these are some things to look for in a healthcare workplace. If your workplace is lacking in safety features and violence prevention systems, remember that they may be open to making changes based on accepted violence-reducing protocols in the healthcare workplace.

Environmental

Environmental factors like entries, exits, hazards and building layout can greatly affect healthcare workplace safety. A safe workplace should have multiple exits and escape routes. Ideally, doors and waiting rooms should be designed to prevent unauthorized entry. To that end, exit doors may be lockable from the inside only, and reception areas should be located in front of work areas and have a clear view of the waiting room. While not feasible for all facilities, security guards and metal detectors can reduce violent occurrences, too. Workers can see if furniture and other objects in waiting areas and patient rooms can be used as weapons. Securing these objects and making sure they don’t obstruct exit paths can improve safety. Things like security cameras, facility visibility, noise levels, the ability to be heard when calling for help, working alarms and panic buttons and lockable employee-only areas can also be taken under consideration.

Administrative

Safe healthcare workplaces should have clear policies related to workplace violence. These policies should include things like a zero-tolerance attitude toward workplace violence that is communicated to employees, patients and visitors. Violence prevention programs with designated coordinators, emergency procedures, incident reporting policies and meaningful consequences for employees who engage in violent behaviors should be established and clearly communicated. Making sure there are enough staff members on hand to prevent people from working alone or being put into vulnerable positions and having trained security personnel available can protect workers from violence, too.

Behavioral

Workplaces should ensure that staff are trained in violence prevention and response, de-escalation and self-defense. Staff should also receive training in incident reporting and be familiar with an established emergency response plan. Safe healthcare facilities should support staff by making sure they are informed about violence in their units, legal issues and updates to violence-related policies. Employers should also promote respect between employees and provide trained mediators to aid in conflict resolution between coworkers.

Healthcare Violence in the Workplace Resources

Hazardous to Your Health: Violence in the Health-Care Workplace

This article from the American Hematology Association offers a deeper look at causes of violence in healthcare and the current state of healthcare violence in general.

Nurses and Bullying: How to Protect Yourself and Your Co-workers

Not all workplace violence is committed by outsiders. This page offers insights and advice to nurses dealing with bullying from other nurses.

Occupational Violence: Training and Education: Workplace Violence Prevention for Nurses

This CDC course provides nurses with workplace violence prevention training.

Preventing Workplace Violence: A Road Map for Healthcare Facilities

OSHA provides an extensive handbook on violence prevention training and workplace hazards that can contribute to violence.

Worker Safety in Hospitals

OSHA provides an array of resources to help address workplace violence in healthcare, like questionnaires to help you determine how safe your workplace is.

Sentinel Event Alert 59: Physical and verbal violence against health care workers

The Joint Commission released a sentinel event alert in 2018 that includes webinar replays, informative presentation slides, infographics and workplace violence prevention tips.

6 Steps to Manage Violence Against Hospital Healthcare Workers

This article published by HealthLeaders magazine offers hospital leaders tips for reducing violence in healthcare settings.

Workplace Violence: Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers

These OSHA guidelines can help healthcare facilities and workers establish policies and procedures related to workplace violence.

Workplace Violence Prevention

The Joint Commission offers different resources related to violence in healthcare facilities, including research, blog posts, presentations and newsletters.

Healthcare Workplace Violence: Expert Q&A

Phil-La-Duke

Phil La Duke is the author of Lone Gunman: Rewriting the Handbook on Workplace Violence Prevention. Prior to his current position as a global business consultant, Phil was a talent development manager for Trinity Health, one of the U.S.’s largest healthcare systems. There he was a certified Just Culture professional and trained many of the healthcare systems’ top executives.

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How important is incident reporting when it comes to workplace violence? Does it even make a difference?

It is extremely important because violence left unreported diminishes the scope and breadth of the problem. One could argue that the difference between ten attacks or twenty is statistically insignificant and that workplace violence isn’t a problem worth addressing, but accurate reporting reveals the enormity of the problem. It’s important because people don’t want to think or talk about this issue.

What are your top tips for healthcare workers who are subjected to violence in the workplace that they might not think of?

Practice de-escalation and empathy. There is typically a lead-up to and increasing escalation prior to the attack. The natural tendency of the threatened is to try to assert dominance and authority, which causes attackers to demonstrate their dominance and control. When demonstrating empathy, be sure to use assertive language but avoid aggressive language.

Take action early. Too often, healthcare workers take too long to summon help. Instead of waiting until an attack is all but certain, healthcare workers need to sound the alarm if they suspect a situation could be developing. If the situation is defused, then it’s no harm no foul, but if the situation escalates, help is already on the way when seconds count.

There is strength in numbers. Alert those around you of the potential attack. Tell everyone. Visitors, clinicians and patients can all be powerful allies. Make sure bystanders back you up. Ask for their help and be specific. Point at individuals and give them directions. Screaming “somebody help me” is not going to save you, but pointing at an individual and saying, “You, call the police,” is far more likely to elicit a desired result and may even panic the attacker into fleeing the scene.

How can employees talk to their employers about addressing violence in their workplace? What tips do you have to start that discussion?

Be frank. Employees and employers can’t beat around the bush when it comes to workplace violence. They have to clearly articulate the dangers and the warning signs. Pretending that it “won’t happen here” just makes the issue worse. Also reinforce the gravity of the situation. Workplace violence is an everyday threat to healthcare workers and should be at the forefront of everyone’s minds to keep them vigilant without creating chronic unease.