Don’t Get Caught Off Guard: Understanding the Components of a Workplace-Violence Program

Jenny Schmitz, MA, MEP, Co-CEM, HEM

PICTURE THIS: It’s an average day in your organization. The Emergency Department is busy, and an experienced nurse is caring for a patient in an exam room. As she turns her back to make a note in the patient’s record, the patient jumps from the bed and kicks her in the back. She cries out, falls to the floor, and hits her head. She starts bleeding from her wound.


  • If this were your employee, what would you do?
  • What type of workplace violence is this?
  • What policy covers this event?

Unfortunately, this is not an uncommon scenario in health care. The Bureau of Labor Statistics (BLS) reports that between 2011 and 2013, health-care and social-service settings accounted for 74% of workplace assaults.1 74%! And these types of violent events are thought to be significantly underreported. In a 2011 survey, the Emergency Nurses Association found that nurses who experienced a physically violent event only filed a formal report 35% of the time.2 Reports filed for verbal abuse dropped to 14%.3

The financial impact can be staggering. Employees who are hurt on the job will typically be covered by worker’s compensation insurance at a cost. For example, one hospital system had 30 nurses in one year who required treatment for violent injuries—at a cost to the hospital of $94,156.4 Some costs are less obvious. Caregiver fatigue and stress, for example, can be tied to errors and patient infections.5 Employees often leave an organization forUnfortunately, this is not an uncommon scenario in health care. The Bureau of Labor Statistics (BLS) reports that between 2011 and 2013, health-care and social-service settings accounted for these reasons, and the estimated cost of replacing one registered nurse is $27,000–$103,000.6


To begin, let’s define workplace violence. The Occupational Safety and Health Administration (OSHA) defines “workplace violence” as any physical assault, threatening behavior, or verbal abuse occurring in the workplace, which can include physical harm to a person, threats with a weapon, sexual assault, verbal threats, obscene phone calls, and intimidation.7 “The workplace” is any location where an employee performs work-related duties, including buildings and their surrounding perimeters, field locations, and anywhere on the way to and from work assignments. As you begin to think about workplace violence and a strategy for preventing it, think about all the places where your employees do their work. 

Remember: each employee can be at risk for workplace violence, as risk factors abound in health-care facilities. Health-care employees often work in isolation with patients in an exam room or procedure room, which leaves them with minimal ways to protect themselves if a patient becomes violent. The public can access most health care facilities freely, which makes for a pleasant patient experience—but facility openness can also lead to a significant compromise in employee safety. Additional risk factors include the availability of pharmaceuticals and money in health-care facilities; the presence of trauma victims and distraught families; patients/clients who have a history of violence or drug use; and poor environmental design and lighting that limits the field of view.


There are four types of workplace violence in health care, as defined by OSHA:

TYPE 1: Violence by Strangers

Violence by strangers is most likely to occur in organizations that have contact with the public and that have (or may be assumed to have) items high in value on-premises. In health care, strangers can target facilities and employees alike, with robbery, vandalism, and car theft topping the list of types of violence in this category. Often, violence by strangers increases in high-crime neighborhoods and within the community around healthcare facilities.

TYPE 2: Violence by a Patient, Family Member, or Visitor

This is the largest source of violence in the health-care setting. In 2013, the BLS found that 80% of serious violent incidents reported in health care were caused by interactions with patients.8 There is also a perception that there is no repercussion for this type of violence and that it is “part of the job,” with many health-care employees understanding that some of the injuries caused by patients are unintentional, and being willing to accept them as unavoidable. According to the same 2013 BLS survey, the most common injuries in this category were from hitting, kicking, beating, and shoving. 

Although most injuries in this category are inflicted by patients on employees, there are a few other considerations to be taken into account. Family members and visitors can also be the source of violent acts toward employees. Especially in times of stress and angst, emotions can run of the workplace. Although female employees are at the highest risk of violence in this area, a violent personal relationship can impact the ability of any employee to perform his or her work duties. Relationship violence goes beyond physical abuse, and can include financial abuse (controlling financial assets or spending habits), sexual abuse, child abuse, and stalking. Employees who experience a difficult divorce or custody battle can also be considered to be suffering from violence from a personal relationship.


The best way to address workplace violence is to create a comprehensive program to review policies, monitor events, and support employees. The program should include strategies to prevent or mitigate the impact of violent events, prepare employees for violent events, respond to violent events when they happen, and help employees recover from each event.


Conduct a hazard assessment of the workplace to understand the existing risk factors that your employees face. More than one assessment may be needed if there are a variety of locations, or in certain other circumstances. Look at environmental design, lighting, lines of sight in vulnerable areas, security-sensitive areas that may be more prone to violent events, and security systems (alarms, panic buttons, cameras, etc.), and ask for your employees’ perceptions of workplace safety. This assessment process will help you identify where your employees are vulnerable to violent events. 

Collecting data on violent events from all parts of the organization is crucial. Data is often held in silos, so reach out to other departments to develop a full picture of the organization. Look at security reports, the OSHA 300 log or occupational health injuries, reports of violent patients or patients with a history of violent acts, and crime statistics from the neighborhood in which your facility is located. These data points will help paint a picture of the kinds of workplace violence that are already occurring in your organization. 

Implement strong workplace-violence policies that your employees can understand and follow. Develop a human resource policy that defines “violent acts,” provides a clear process for reporting events, describes the investigation process, and outlines disciplinary actions for those employees who don’t follow the policy. In addition, have another policy in place to define the process employees should follow in dealing with a violent patient or visitor. Define “violent acts,” determine the reporting process, and outline the consequences for the patient or visitor. In both policies, be strong with your words and enforce the policies. They are in place to protect your employees, and to show them that their organization supports them.

In addition, understand your state legislation. There are many states that have specific legislation in place to define workplace violence and give you a legal ground for your policies. Many states also have legislation in place specifically to protect health-care workers from acts of violence or assaults that happen in the workplace. (See page 14 to understand your state’s legislation.)


Preparedness for workplace violence is largely a matter of employee training. All employees are vulnerable, so all employees need training in their organization’s policies, risk factors, methods to prevent or de-escalate violent events, workspace safety devices and their use, and employee-support programs. That said, there may be areas in your workplace that are more susceptible to violent events, and employees who work in these areas may need to be given special training, in addition to base-level training, in order to work safely in their environment. Finally,provide specialized training for managers and supervisors that explains what to dowhen employees come to them for help, what support is available to employees, and conflict-resolution techniques.


Despite assessments and mitigation strategies, violent events will still happen. Create standard checklists for employees to use after such an event that delineate whom they should call, how to report the event, what to do for an injury, and what support and other resources are available. A best practice is to have separate checklists for the victim, the supervisor, and the manager, as each will play a different role in the response. 

Another best practice is to form a Response Team, to provide a quick response to an employee who experiences any kind of violence. The Response Team can also conduct an investigation (with police, if needed), taking a statement from the victim, interviewing witnesses, and ensuring policies are followed. Typically, members of this team include personnel from security, human resources, risk management, and administration.


Ensure support for employees after a violent event. The victim, witnesses, and co-workers may each be impacted in different ways, so offer the employee assistance program to all of them. Consider leaves of absence, time off, modified schedules, or changes in work location. Because each violent event is different, it’s important that you conduct a review or debrief of each event, in which you review policies and suggest revisions, and recommend and enforce consequences for perpetrators. Each event will provide you with an opportunity to learn, make your procedures stronger, and make your employees safer.


Health care is an evolving and changing industry. As the push for patient satisfaction turns up new ways to make facilities more open and inviting, the safety risks for employees are increasing, due to more violence in communities, less access to specialized mental-health services, and understaffing at facilities themselves. A proactive organization will not lose focus on employee safety; after all, studies have correlated higher patient-satisfaction scores and health-care facilities where there are fewer dissatisfied and burned-out employees.9

Work for a safe environment. Collect and analyze the data that will help you create and enforce policies to support your employees. Teach them the skills they need to recognize and de-escalate a potentially violent situation, and give them the tools they need to respond. Support employees after a violent event, and develop a workplace-violence program to better protect them, prevent large workplace-injury claims, lower the risk of medication errors, and increase patient satisfaction scores.

Jenny Schmitz is the Director of Healthcare Preparedness at All Clear Emergency Management Group, where she is working diligently to advance the preparedness level in all facets of the health-care industry. She is a FEMA Master Exercise Practitioner (MEP), Colorado Certified Emergency Manager (CO-CEM) through the Colorado Emergency Management Association, and a Healthcare Environmental Manager (HEM). She is also the Safety Officer on the Colorado-3 Disaster Medical Assistance Team (DMAT).


1 “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.” OSHA 3148-04R,2015.

2 “Emergency Department Violence Surveillance Study.” Emergency Nurses Association. November 2011. Accessed April 14, 2016. P. 27.…

3 Ibid., p. 27.

4 Speroni, K.G., Fitch, T., Dawson, E., Dugan, L., and Atherton, M. “Incidence and Cost of Nurse Workplace Violence Perpetrated by Hospital Patients or Patient

Visitors.” Journal of Emergency Nursing, 2014. 40(3):218–228.

5 Rogers, A.E., Hwang, W.T., and Scott, L.D. “The Effects of Work Breaks on Staff Nurse Performance." Journal of Nursing Administration, 2004. 34(11): 512–519.

6 Li, Y., and Jones, C.B. “A Literature Review of Nursing Turnover Costs.” Journal of Nursing Management, 2012. 21(3): 405–418. (This cost includes separation, recruiting, hiring, orientation, and training. Dollar amounts presented here are adjusted to 2013 prices.)

7 “OSHA Factsheet: Workplace Violence.” 2002. Accessed April 11, 2106.…

8 “Preventing Violence in Healthcare.” OSHA. Accessed April 11, 2016.

9 McHugh, M.D., Kutney-Lee, A., Cimiotti, J.P., Sloane, D.M., and Aiken, L.H. “Nurses’ Widespread Job Dissatisfaction, Burnout, and Frustration with Health Benefits Signal Problems for Patient Care.” Health Affairs, 2011. 30(2): 202–210. 32