Preventing Workplace Violence in Healthcare Settings: An Overview
Most of us tend to think of inherently risky professions like police work or armed security when we hear about workplace violence. Or, we recall tragic incidents that have made headlines in the past involving disgruntled workers taking the lives of employers or coworkers.
It may come as a surprise, then, that healthcare and social service workers are among the most common victims of workplace violence.
From 2002 to 2013, workers in hospitals, nursing homes, psychiatric care centers, and other healthcare facilities faced four times the rate of serious incidents of workplace violence requiring days off to recuperate than did workers in private industry settings, according to the Occupational Safety and Health Administration (OSHA).1 And, since many threats and assaults against healthcare workers go unreported, the true number is likely much higher.
Why is the risk of violence in the workplace so high for healthcare workers?
There are many factors-chief among them is that healthcare workers interact with and care for people who may have a history of violent behavior, who may be under the influence of drugs, or who may be delirious from medications, narcotics, or a medical condition.
Instances of workplace violence against healthcare workers can be significantly reduced with a comprehensive violence prevention program. Ahead, we'll explore just how common workplace violence is in healthcare settings, we'll outline common risk factors for violence, and we'll cover the basics elements of a violence prevention program. We'll also explore the importance of training nurses and other healthcare workers about recognizing and managing aggressive behavior (nurse education videos on the topic of workplace violence and security). First, it's necessary to define what workplace violence is.
What Defines Workplace Violence?
What constitutes workplace violence varies from one authority to the next.
The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as "the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty." 2
The OSHA defines it as "any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site."3
Yet other organizations extend the definition of workplace violence to acts of aggression, physical assault, or threatening behavior in a work setting that causes physical or emotional harm to customers, coworkers, or managers.
Despite variations in the definition from one organization to another, there are common themes among all of them. Ultimately, workplace violence in healthcare settings constitutes a range of violent acts by patients, visitors, and employees/workers that result in actual physical harm or concern for personal safety.
This can include things like:
Verbal threats or physical attacks by patients or their family members
A distraught family member who becomes verbally abusive or violent
A domestic dispute that carries over in the workplace
Coworker bullying or "hazing"
Gang violence (e.g., in the emergency department)
It's critical to include verbal abuse (e.g., hostility, harassment, bullying, verbal attacks, and other stressors) in the definition of workplace violence; verbal abuse can cause significant stress and psychological trauma on its own, and it can be a precursor to physical violence.
While healthcare workers may dismiss physical or verbal abuse by patients and others as "part of the job," this thinking can perpetuate the problem by preventing staff from taking necessary measures to prevent instances of violence and abuse.
Statistics on Violence in Healthcare Settings
Examining the statistics on workplace violence in healthcare settings emphasizes the need for prevention. According to OSHA's "Workplace Violence in Healthcare" report:4
In 2013, there were 7.8 cases of serious workplace violence per 10,000 full-time employees in the healthcare and social assistance sector, versus fewer than 2 cases per 10,000 full-time employees in the other large sectors, including construction, manufacturing, and retail.
Patients are the largest source (80%) of violence in healthcare settings.
Other clients or customers account for 12% of violence in healthcare settings.
Students, co-workers, other (unidentified persons), and assailants/suspects/inmates make up the remaining 8%.
1 of every 5 (21%) registered nurses and nursing students reported being physically assaulted in a 12-month period; more than half reported being verbally abused.
In a survey of 7,169 nurses, 12% of emergency department nurses reported experiencing physical violence, and 59% reported experiencing verbal abuse in just a 7-day period.
In a survey of more than 72,000 workers at 142 facilities, 13% of employees in Veterans Health Administration hospitals reported being assaulted in a 12-month period.
Some professions and healthcare settings present more risk. In 2013, psychiatric aides experienced the highest rate of violent injuries resulting in days away from work, at nearly 600 injuries per 10,000 full-time employees, according to the same OSHA report.
Nursing assistants, by contrast, experienced about 55 injuries per 10,000 full-time employees-a rate that is 10 times lower than that of psychiatric aides, yet is still significantly higher than the 4.2 injuries per 10,000 full-time employees reported in the private sector as a whole for that year, per the OSHA report.
It's also important to note that women are disproportionately affected by workplace violence in the healthcare industry (and in general). Of the nearly 16,000 workers in the private sector who experienced trauma from workplace violence in 2014 (incidents that required days away from work to recover):5
69% worked in the healthcare and social assistance industry.
2 of every 3 (67%) were female.
The Problem of Underreporting
Survey data helps illuminate the problem of underreporting of violent incidents in healthcare settings, even in facilities that have formal reporting systems in place. A survey of more than 4,700 Minnesota nurses, for example, found that only around two-thirds of physical assaults (69%) and non-physical assaults (71%) were reported to a manager.4
Incidents of bullying and verbal abuse are more underreported than physical assaults.
Reasons for underreporting include lack of faith in the reporting system, fear of retaliation, and lack of a formal reporting policy, among others. The problem of underreporting highlights the need for healthcare facilities to maintain comprehensive violence prevention and reporting programs and, importantly, to actively encourage healthcare workers to report incidents without fear of negative repercussions.
Workplace Violence Is Costly
Worker's compensation typically must pick up the tab for medical treatment or missed work when an employee is injured from violence in the workplace.
Caregiver fatigue, stress, and injury as a result of workplace violence can also lead to medication errors and patient infections, which not only negatively impacts patients but can lead to increased legal costs for the facility.
Injuries and stress are common reasons healthcare workers leave the industry-and it's expensive to replace those workers, ranging anywhere between $27,000 and $103,000.
Identifying Risk Factors
OSHA identifies two main sources of risk for workplace violence in healthcare settings:
Patient-, Client-, and Setting-Related Risk Factors : These can include working with people who have a history of violence and/or drug abuse, working alone in clients' homes (e.g., home health aides), lifting, moving, and transporting patients/clients, working in high-crime neighborhoods, dealing with hostile family members who may be carrying weapons, poorly lit corridors and buildings without adequate escape routes in case of a violent incident, lack of means for emergency communication, etc.
Organizational Risk Factors : These can include lack of violence prevention policies, lack of staff training for recognizing and managing hostile behaviors, understaffing, high employee turnover, inadequate on-site security personnel, long waits for patients and/or overcrowded conditions, which can create tension and anger, etc.
The Challenge of the "Do No Harm" Mantra
The cultural ethos of health care is (and should be) to "do no harm" to patients. Yet, this philosophy often leads healthcare workers to put their own safety and health at risk to help patients.
Many healthcare workers simply see violence and abuse as "part of the job."
Caregivers are in a challenging position-some are not comfortable holding patients who commit violence accountable, especially if those patients have an illness or impairment that prevents them from making sound judgments. Yet, everyone deserves a safe workplace, and tense situations that can escalate to violence can be prevented with the right measures.
Prevention is where we turn our attention now.
Developing a Comprehensive Workplace Violence Prevention Program
As of August 2015, nine states have requirements in place requiring certain healthcare facilities to have some type of workplace prevention program. California became the first state to require such a program in healthcare facilities in 1993. Facility administrators must take state requirements into account when developing a violence prevention program. Links to the programs for each state can be found in this report published by OSHA.
Healthcare facilities in the majority of states must create violence prevention programs on their own; thankfully, guidelines exist to help. OSHA recommends creating a program that contains the following five core elements:
1: Management Commitment and Employee Participation
Acknowledging that violence in the workplace is a safety and health hazard is a key first step in effective management leadership. Healthcare facility managers can demonstrate their commitment to preventing workplace violence by:
Establishing violence prevention programs with clearly outlined goals and objectives
Devoting adequate resources to the program
Appointing leaders who are properly trained to facilitate the program
Providing ongoing support to ensure the program's effectiveness
Employees (who have first-hand knowledge of issues that take place in their work environment) should be involved in all aspects of the program; employees should be encouraged to report problems and provide feedback without fear of reprisal.
2. Workplace Analysis and Hazard Identification
Management should conduct an initial workplace analysis to identify risks and hazards, after which they should establish procedures and processes for the continual identification of workplace hazards and risks and conduct periodic reassessments and evaluations.
3: Hazard Prevention and Control
Management should implement procedures to eliminate workplace hazards and work toward the goals and objectives outlined in their violence prevention program.
4: Safety and Health Training
Employees should be trained on recognizing hazards and on properly responding to aggressive behavior from patients/clients, visitors, coworkers, and others. They should know what to do in case of emergencies (e.g., active shooter, natural disaster, etc.) and where and how to report problems/hazards.
5: Recordkeeping and Program Evaluation
Accurate and complete recordkeeping is a vital part of any workplace violence prevention program. Facility managers should keep records of hazards, assaults, injuries and illnesses, corrective actions taken, and training provided to employees, all of which can help employers identify patterns and trends and develop solutions to ongoing problems.
Violence prevention programs should be periodically evaluated to identify deficiencies and areas for improvement. Read OSHA's report for more in-depth guidelines on creating an effective violence prevention program.
Everyone Wins with a Comprehensive Violence Prevention Program
Reducing workplace violence keeps patients and caregivers safer, improves patient outcomes, creates a more comfortable work environment, reduces employee turnover, and curbs unnecessary costs to healthcare facilities and, by extension, taxpayers.
Healthcare facilities can ensure their staff members are properly trained on workplace safety and violence prevention by holding periodic training sessions and using medical videos designed specifically for healthcare workers, like those offered by Medcom.