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Workplace violence (WPV) in healthcare has steadily risen over the past decade, affecting medical staff across the United States.

In 2018, "healthcare and social service workers were five times more likely to experience workplace violence than all other workers," according to the U.S. Bureau of Labor Statistics (BLS).


These assaults increased in 2020 and 2021, yet experts suggest the numbers are vastly underreported and are possibly much higher than the statistics show. Consequently, it's critical to understand sources of violence, adopt measures to reduce violent incidents, and fully support staff.


As a public safety professional, you have the ability to influence change in your organization. Use this guide to explore the current state of violence in healthcare, including the types and contributing factors, while exploring how it may affect your staff. In addition, you’ll find workplace violence risk factors and warning signs along with various strategies for preventing workplace violence.


Healthcare Workplace Violence Overview


The Joint Commission developed a formal definition of workplace violence and implemented new and revised workplace violence prevention standards on January 1, 2022. WPV refers to "an act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors."


The new definition and standards aim to curb the endemic of healthcare workplace violence. And undoubtedly, changes are necessary. In September 2021, 31% of nurses told National Nurses United (NNU) that "workplace violence has increased recently," compared to 20% in November 2020 and 22% in March 2021. 


In addition, the American College of Emergency Physicians (ACEP) notes that "nearly seven in 10 emergency physicians say emergency department violence is increasing," and 47% “have been physically assaulted at work." These incidents affect staff,  operations, and your bottom line. The American Hospital Association (AHA) estimates post-incident violence costs $428.5 million nationally. This figure includes staff turnover, disability, compensation for lost wages, and absenteeism costs. 


Healthcare workplace violence statistics also show the impact on patients. The ACEP survey found that about 80% of physicians “say violence in the emergency department harmed patient care,” and “more than half say patients have been physically harmed.” Public safety professionals must take action to curb the violence and protect workplaces. However, to do so, you need to understand the root causes of various types of workplace violence and identify the contributing factors.


Types of Workplace Violence in Healthcare Setting

According to the American Journal of Managed Care (AJMC), "every single day, employees in the healthcare field are assaulted in the United States." These assaults vary in type and severity. 


The National Institute for Occupational Safety and Health (NIOSH) classifies workplace violence into four basic categories. 


Types II and III are most frequently found in the healthcare industry. The Emergency Care Research Institute (ECRI) says, "type 2 violence is the most common cause of physical violence in the healthcare setting, and type 3 violence is the most prevalent type of healthcare workplace violence." 


The four types of workplace violence are:

  • Type I, criminal intent: In this category, the perpetrator doesn't have a relationship with the healthcare facility or staff. It includes robberies, trespassing, and shoplifting. They may mug a staff member in the parking lot or brandish a weapon while demanding medication.
  • Type II, customer/client: This type refers to an incident involving patients or their families or visitors directing violence at healthcare staff. According to the Centers for Disease Control and Prevention (CDC), client-on-worker violence is the most common in healthcare settings, especially in waiting rooms and emergency, psychiatric or geriatric settings.
  • Type III, worker-on-worker: This grouping of violence includes workers who threaten or attack another employee. It includes bullying between staff members and violence by a present or former employee. Worker-on-worker violence often stems from a power imbalance, such as a charge nurse or doctor to another nurse.
  • Type IV, personal relationship: This type of violence refers to perpetrators who have a relationship with an employee but none with the healthcare organization. It includes acts of domestic violence by spouses or partners.

Impact of WPV on Healthcare Workers

Healthcare workplace violence results in less job satisfaction and more employee turnover and burnout. Furthermore, exposure to workplace violence leads to absenteeism, psychological distress, and higher costs while impairing effective patient care. The effects of violence can reduce morale and increase post-traumatic stress disorder (PTSD). 


The NNU finds that nurses and other healthcare workers experience fear, anxiety, or increased vigilance after an incident and have difficulty "working in an environment that reminds them of a past incident." Other impacts include depression, chest pain, helplessness, hypertension, and rage. 


Workplace violence also affects staffing levels, which is a contributing factor in some assaults. An NNU survey finds that 16% of nurses "changed or left a job because of workplace violence." And one in 10 respondents said that the "psychological impacts of workplace violence prevented them from working." The effects of violence are key reasons for addressing hostility against healthcare workers.


Workplace Violence Risk Factors


Workplace violence risk factors differ by healthcare setting, training, and organizational policies. However, cultural elements may play a more prominent role. Healthcare workers often express feeling like violence is "part of the job," as such, it's unavoidable or routine. Others put aside their own health and safety to help clients. Another common concept is that they don't want to blame perpetrators living with an impairment or illness.


Certain settings are more vulnerable to workplace violence, such as emergency departments (EDs), drug treatment clinics, long-term care facilities, and community health clinics. Additionally, employees working late night and early morning hours are more likely to encounter violence than daytime staff...


Unfortunately, NNU's 2021 Workplace Violence Survey found that only 35% of nurses and other healthcare workers "report that their employer provides a clear way to report incidents," and 42% said, "that their employer ignores nurses' reports of workplace violence incidents."


Contributing factors to workplace violence include:

  • Working with clients with a violent history or those under the influence of drugs
  • Extended wait times for care and congested waiting rooms
  • Unrestricted, 24/7 public access
  • Lack of policies and training for employees
  • Understaffing, particularly during visiting hours and meal times
  • Healthcare facility design, including poor lighting and visibility
  • Inadequate means of emergency communication
  • High staff turnover rates
  • Being located in areas with high crime rates
  • Insufficient security staff
  • Task-related factors, such as moving, lifting, or transporting patients
  • The perception that violence in healthcare is tolerated
  • Prevalence of firearms and other weapons among patients and their associates
  • Isolated work areas or departments that handle money

Warning Signs of Workplace Violence and Harassment


Many warning signs of workplace violence, including physical and behavioral, hint at potential problems. These red flags may be apparent in client-on-worker violence and worker-on-worker assaults. Staff members must understand the signs and reporting procedures. Although many may feel that one of these signs doesn't imply violence, the general theme should be to report it regardless of whether or not other signs exist. 


The list of physical and behavioral warning signs includes:

  • A history of violence or substance use
  • Sweating, flushing, or pallor
  • Extreme physical agitation, like hitting walls or pacing
  • Threatening or aggressive posture
  • Clenched muscles, such as making fists or arms held tight across their chest
  • Patients exhibiting poor impulse or anger control
  • Outbursts or frequent crying
  • A fixed stare or a terrified look
  • People with certain medical conditions, such as hypoxia, dementia, and head injuries
  • Loudly speaking, yelling, or swearing
  • Indicators of substance abuse or drunkenness

Strategies to Prevent Workplace Violence


All stakeholders should work together to reduce workplace violence by developing protocols, strategies, and a safety-focused culture. Your multi-layered approach should follow regulations and ensure active shooter training compliance. Your organization's actions and initiatives should stem from a moral imperative with the understanding that they can also reduce your bottom-line costs. 


Consider a well-rounded approach that consists of workplace programs, training, and consistent reevaluations. A comprehensive approach helps your organization mitigate workplace violence while reaching overarching business goals, such as employee retention and reputational improvements.


WPV Prevention Program

A WPV prevention strategy is part of your overall safety and health program and should adhere to local, state, federal, and industry standards.

Every organization needs a prevention program with clear goals suitable for its size and operation complexity. Your WPV program should also be flexible, so it's easy to adjust for specific facilities, departments, or situations.


The Joint Commission Standard LD.03.01.01 requires workplace violence prevention programs to:

Addressing each element of the framework ensures accountability, reduces program variation, makes data accessible and actionable, and increases transparency. In addition, OSHA provides five building blocks for creating effective workplace programs. These include management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation.


Employer and Employee Collaboration

Effective workplace violence prevention strategies require communication and collaboration by employees at all levels of your organization. After all, statistics suggest that underreporting is a significant barrier to fully understanding violence in healthcare settings. Yet, common causes for not reporting violent incidents are fear of retaliation and a belief that nothing will be done about it. 


Work culture improvements build better relationships between teams and leaders, place safety first, and improve the well-being of healthcare workers. Actions include encouraging workers to press charges when an assault occurs and providing ample support for victims and witnesses. Get your staff involved in your efforts and request regular feedback.


Risk Hazard Assessment and De-escalation

De-escalation models and assessment tools benefit patients and healthcare staff. They deter violent behavior and decrease client frustration and anger. De-escalation interventions enable patients to regain personal control and help them feel secure. 


Identify risks associated with different hospital settings, including residential treatment, hospital, non-residential treatment, community care, and fieldwork settings. Also, consider how threats differ by the type of healthcare or social service worker. Your employees must understand the importance of flexibility and use the method best for individual cases.


Assessment and de-escalation methods include:

  • Assessment tools like the Overt Aggression Scale (OAS) or STAMP — Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing
  • The Dix and Page or Safewards Model assesses the situation, communicates with the patient, and resolves the problem
  • Communicating verbally in a non-threatening manner and avoid using healthcare terms or abbreviations
  • Using non-confrontational body language when approaching and interacting with a patient while respecting personal space



Written Procedures and Policies

Your policies and processes make up the foundation of your workplace violence prevention program and should be easy to understand. Each procedure should have a clear and consistent reporting structure for documenting workplace violence and notifying public safety officers. Define what constitutes prohibited conduct, the risk reduction measures, and how your organization enforces policies.


WPV Employee Training and Education

Healthcare workplace violence prevention training is a necessary part of your WPV program and is covered under the Joint Commission's Standard HR.01.05.03. It should tailor educational methods to employees based on their roles and responsibilities. Also, training must be timely and consistent, consisting of new hires and ongoing education. 


The Joint Commission says healthcare organizations should provide training and resources that:

  • Define what constitutes workplace violence and describe the reporting process for violence incidents
  • Explain the roles and obligations of leadership, clinical personnel, safety professionals, and external public safety officers
  • Educate staff on physical intervention tactics, nonphysical intervention skills, de-escalation techniques, and emergency response

Recordkeeping and Evaluation

According to the Joint Commission's Environment of Care Standard EC.02.01.01, hospitals must perform a yearly worksite analysis on their WPV prevention program. This includes a review of the worksite and incidents. It should also determine if your training, policies, and procedures comply with applicable laws and regulations while reflecting best practices.

Likewise, Standard EC.04.01.01 discusses how organizations collect information to manage safety and security risks, including data types. Standard processes for ongoing data collection help find trends or gaps in your WPV prevention program and determine its overall effectiveness. For example, tools like the Patient Staff Conflict Checklist (PCC) reflect the number of actions that threaten safety and contaminants per shift.


Security Management Software Systems

Workplace security extends beyond your on-staff safety professionals. Indeed, alarms and emergency response tools can reduce incidences of workplace violence.

Security management software systems track, analyze, and retrieve data from virtually any location, on virtually any device. It also helps organizations comply with OSHA and Joint Commission Regulations.


End-to-end safety solutions enable organizations to:

  • Concentrate on patient care, manage visitors, and monitor high-risk areas
  • Create and integrate decision-making and de-escalation workflows
  • Improve response effectiveness and investigative response times after an incident
  • Classify WPV incidents for practical analysis and reporting
  • Integrate with your on-site patrols and security systems


Although violence in the workplace continues to rise, a purposeful, multi-layered approach can protect your organization and allow your staff to focus on patient care. Increase your program's success rate using data collection and analysis tools, so insights are accessible and actionable. Learn how Omnigo can help by requesting a demo today.

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