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Trends, Policies, and Protocols Related to Healthcare
Workplace Violence
Corina Solé Brito, M.A., ICF’s ASPR TRACIE Technical Resources Lead and Communications Manager, and Anne
Hasselmann, MPH, Public Health and Healthcare Emergency Management Consultant
The headlines speak volumes, and they all lead to the same conclusion: violence in healthcare facilities presents a
significant challenge to patients, providers, support staff, and visitors. The Occupational Safety and Health Administration
(OSHA) estimates that nearly 75% of about 25,000 workplace assaults reported annually happen in healthcare settings.
In addition to violent incidents happening more often, victimized healthcare workers are increasingly more likely to report
them, rather than dismissing maltreatment as “part of the job.”
Security varies significantly in healthcare facilities—some do not have a formal force, some larger systems employ their
own departments, others may contract the service out, and in some areas, local law enforcement departments may set
up substations within the emergency department (ED).
This article provides an overview of workplace violence, highlights risk factors that contribute to healthcare workplace
violence, and summarizes related legislation and policies. It also highlights strategies and guidance healthcare staff and
security partners can incorporate into their coordinated healthcare workplace violence plans.
The Prevalence of Workplace Violence in Healthcare Facilities
Healthcare workplace violence is traditionally underreported (Stephens,
2019). Many feel as though it is “part of the job” and there is a culture of
silence associated with this type of victimization. The U.S. Bureau of
Labor Statistics (2020) reports:
“In 2018, the private ownership all-worker incidence rate for nonfatal
occupational injuries and illnesses involving days away from work
resulting from intentional injury by other person in the private
healthcare and social assistance industry was 10.4 per 10,000 full-
time workers, compared to the all-worker incidence rate of 2.1. The
health care and social service industries experience the highest
rates of injuries caused by workplace violence and are 5 times as
likely to suffer a workplace violence injury than workers overall”
(emphasis added).
In 2020, staff from Cox Medical
Center (Branson, MO) reported
more than 120 assaults on staff,
three times the number reported
in 2019. Assaults leading to
injuries also increased by 21%
(Gerber, 2021).
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Omar et. al (2018) compared the results of two surveys to determine how
rates of violence against emergency physicians have changed between
2005 and 2018. Despite the relatively low response rate and small sample
size, their ndings were helpful and can contribute to an understanding of
the problem:
• More than 80% said a patient had threatened to return and harm them
or their emergency department staff
• 71% personally witnessed others being assaulted during their shifts
• Nearly 22% frequently felt afraid of becoming a victim of violence
• There was a signicant increase in the number of respondents
reporting that their hospitals had security personnel that performed
rounds throughout the facility and armed security ofcers
A study of violent incidents tracked in 106 hospitals between 2012 and
2015 found that nursing assistants and nurses had the highest injury rate
per 1,000 full-time equivalent employees. A review of home care aides who
reported verbal abuse in the past year found that they were 11 times more
likely to also report physical abuse (Gerberich, 2019). Violence committed
against healthcare workers is not limited to hospitals; it occurs in outpatient
clinics, during patient transport, and in pharmacies.
Workplace violence is expensive—in addition to treating physical
injuries (e.g., concussions and lacerations), there are costs associated
with the negative mental health effects survivors may experience (e.g.,
missing work, taking time off to seek behavioral health care). Incidents
can also lead to staff turnover in a eld that is already strapped for
human resources; one study found 30% of healthcare workers who had
experienced workplace violence had thoughts about leaving their job
or career.
Patients and visitors often bring weapons to healthcare facilities, presenting
another daily challenge. In an interview, Dr. Tom Mihaljevic, President and
CEO of Cleveland Clinic, indicated that in 2018, the system—which has
been using metal detectors since 2016—“conscated a staggering 30,000
weapons from patients and visitors in its system in the Northeast Ohio
region” (Coutré, 2019).
Active Shooter Incidents
The Federal Bureau of Investigation (FBI) reports that there were a total of
277 active shooter incidents in the U.S. between 2000 and 2018, resulting
in 884 deaths and 1,546 wounded. Twelve of these incidents took place in
healthcare facilities (two in 2018), resulting in 25 fatalities (including three
law enforcement ofcers) and 30 wounded (including 8 ofcers).
Kelen et al. (2012) identied 154 hospital-related (i.e., inside the hospital
and on the grounds) shootings between 2000-2011. Reasons for the
shooting ranged from settling a “grudge” (27%), attempting suicide (21%),
“euthanizing an ill relative” (14%), and prisoner escape (11%). Almost
one third of these shootings took place in the ED area, followed by the
parking lot and patient rooms. A subsequent study (Gao and Adashi, 2015)
highlighted a generally consistent rise in active shooter incidents and
emphasized the need for more research.
Workplace Violence: Denitions
The Joint Commission (2021), which
evaluates and accredits healthcare
organizations and programs in the
U.S., denes workplace violence
as “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.”
OHSA denes workplace violence as
“any act or threat of physical violence,
harassment, intimidation, or other
threatening disruptive behavior that
occurs at the work site. It ranges from
threats and verbal abuse to physical
assaults and even homicide. It can
affect and involve employees, clients,
customers and visitors.” OSHA
denes “serious workplace violence”
as an incident in which the victim
needs time off to recover.
Related ASPR TRACIE
Resources
Workplace Violence Topic Collection
Active Shooter and Explosives
Topic Collection
Workplace Violence and
Active Shooter Technical
Assistance Responses
The FBI defines an active shooter
as one or more individuals actively
engaged in killing or attempting to
kill people in a populated area.
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COVID-19 and Violence Against Healthcare Workers
The vast majority of people appreciate and support healthcare workers,
particularly since the COVID-19 pandemic began. More recently, however,
healthcare workers have been targeted in person and online for a variety of
reasons, including:
• Frustration with visitation policies that keep people from their sick
loved ones
• Longer wait times contributing to irritated, ill patients
• Disbelief in the virus, vaccination, and treatment protocols
• Frustration with/refusal to comply with isolation protocols
• Anger at having alternate care/treatment/vaccination sites set up
in communities
• The belief that healthcare workers are somehow spreading the virus
• Being perceived as pro-mask and pro-vaccine by those who do not support either strategy
Since 2020, healthcare workers have been under an inordinate amount of stress. In some circumstances, colleagues
may face off at work; what may have been a simple disagreement before COVID-19 may now devolve into a physical
altercation. Or, for some who work in healthcare, simply attending a school board meeting on mask mandates—as a
parent, not an employee—can lead to a high-stress encounter, or worse. While the data accumulates, videos, social
media, and anecdotal evidence demonstrate that “pandemic fatigue” is taking its toll on this country, and healthcare
workers are often treated as scapegoats.
Risk Factors Associated with Violence
What risk factors are associated with violent encounters in a healthcare
setting? In a recent Joint Commission “Sentinel Event Alert” on physical
and verbal violence against healthcare workers, the authors reviewed
the literature and lessons learned from past incidents, creating this list of
risk factors:
• Patients with altered mental status associated with dementia, delirium,
substance intoxication, or various forms of mental illness
• Patients in police custody (they cited a study that found these
patients were involved in 29 % of ED shootings; 11 % occurred during
escape attempts).
• Stressful conditions (e.g., long wait times, crowding, being given bad
health-related news)
• Lack of policies and training related to de-escalation
• Gang activity
• Domestic disputes among patients or visitors
• The presence of weapons
• Inadequate on-site security and/or mental health personnel
• Understafng (in general and during visiting hours)
• Staff working in isolation or in physical locations that do not have an
escape route
• Poor environmental design (e.g., lighting and factors that affect visibility in hallways, rooms, parking lots and
other areas)
Bullying (e.g., physical aggression,
making offensive comments,
and spreading rumors) is also
considered a form of workplace
violence (Kumari et al. 2020); risk
is heightened in a competitive
work environment with a relatively
unsupportive administration.
Risk factors may vary by location.
One study that examined violence
against healthcare workers in the
ED found that risk increased when
there were no areas where people
could go to de-escalate, no alarm
systems, no workplace violence
task forces, and when staff worked
alone. Risk factors reported by
home care aides include working
with clients with dementia and
working in homes with limited
physical space. In skilled nursing
facilities, patients with cognitive
challenges and residents’
“emotionally charged” visitors
were more likely to be involved
in incidents.
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• No access to emergency communication, such as a cell phone or
call bell
• Unrestricted public access to hospital rooms and clinics
• Lack of access to community mental health care
Kumari et al (2020) added several factors to this list, categorizing them as:
• Patient related factors (e.g., unexpected/high cost of services, poor
previous experience, and complex family relationship)
• Doctor related factors (e.g., being female, having less experience,
being unable to deescalate)
• Organizational factors (e.g., psychiatric and ED, lack of security, lack of
guidelines and protocol, discouragement in reporting)
• Societal factors (language/cultural barriers, lack of respect for authority,
patient distrust, negative media image, and lack of policies).
Federal and State Legislation to Help Prevent and
Respond to Workplace Violence
As of 2021, there were no OSHA standards specic to workplace
violence. OSHA does highlight, however, the General Duty Clause of the
Occupational Safety and Health Act of 1970 that requires employers to
provide staff “a place of employment that is ‘free from recognized hazards
that are causing or are likely to cause death or serious physical harm’”
(OSHA, n.d.).
The Workplace Violence Prevention for Health Care and Social Service
Workers Act (H.R. 1195, 117th Congress) was passed by the House of
Representatives in April 2021 and referred to the Senate Committee on
Health, Education, Labor, and Pensions, where it awaits additional action.
This bill was originally introduced in 2019 as H.R. 1309 but failed to
become law before the last congressional term ended.
If enacted, H.R. 1195 will require the U.S. Department of Labor to
promulgate an occupational safety and health standard that requires
covered entities to “develop and implement a comprehensive workplace
violence prevention plan and carry out other activities or requirements…
to protect health care workers, social service workers, and other personnel
from workplace violence.” An interim nal standard would need to be
issued “not later than 1 year” after enactment and be based on the 2015 OSHA Guidelines for Preventing Workplace
Violence for Healthcare and Social Service Workers, at minimum. The nal standard must be issued “not later than
42 months” after enactment and provide enforceable protections that are “no less” than any State workplace violence
prevention standards. Covered entities would be required “to develop, implement, and maintain” a workplace violence
prevention plan “not later than 6 months after the promulgation of the interim nal rule.” Annual employee training and
reporting to the Secretary of Labor would also be mandated. The list of covered entities/services in H.R. 1195 is broad
and includes:
• Any hospital, including any specialty hospital, in-patient or outpatient setting, or clinic operating within a hospital
license, or any setting that provides outpatient services.
• Any residential treatment facility, including any nursing home, skilled nursing facility, hospice facility, and long-term
care facility.
• Any non-residential treatment or service setting (e.g., home health care, home-based hospice, and home-based
social work).
Related Legal Resources
American Nurses Association (2021).
Workplace Violence.
Gonzalez, G. and Childers, A. (2019).
States Lead the Way on Mitigating
Workplace Violence in Health Care
Settings. Business Insurance.
U.S. Congress. (2021.) H.R.1195
- Workplace Violence Prevention
for Health Care and Social Service
Workers Act.
U.S. Congress. (2019). H.R. 1309
- Workplace Violence Prevention
for Health Care and Social Service
Workers Act.
U.S. Department of Labor,
Occupational Safety and Health
Agency. (2015). Guidelines for
Preventing Workplace Violence
for Healthcare and Social
Service Workers.
U.S. Department of Labor,
Occupational Safety and Health
Agency. (n.d.). OSH Act of 1970.
U.S. Department of Labor,
Occupational Safety and Health
Agency. (2015). Workplace Violence
Prevention and Related Goals.
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• Any medical treatment or social service setting or clinic at a correctional or detention facility.
• Any community care setting, including a community-based residential facility, group home, and mental health clinic.
• Any psychiatric treatment facility.
• Any drug abuse or substance use disorder treatment center.
• Any independent freestanding emergency centers.
• Any emergency services and transport, including such services provided by reghters and emergency responders.
According to an analysis by the American Nurses Association, many states have established penalties for assaulting
healthcare workers, though some only apply to certain settings or types of healthcare workers. As of 2021, only a small
subset of states (n=9) across the U.S. have enacted legislation requiring employers to develop formal programs to prevent
and/or report workplace violence in healthcare facilities. Eight of 9 states require the program to be based on a risk
assessment, and for staff to receive training on the Workplace Violence Prevention plan/program. State requirements vary
widely, and the laws do not include the same level of specicity and detail against which compliance may be assessed.
Where specic standards for workplace hazards are lacking, the Occupational Safety and Health Act’s General Duty
Clause is often used to cite employers for violations (Gonzalez and Childers, 2019). Although only a few states have
legislation requiring Workplace Violence Prevention plans/programs, 26 states, Puerto Rico, and the U.S. Virgin Islands
had OSHA-approved State Plans as of 2015. Such plans must be “at least as effective” as Section 18(c) of the OSH Act
of 1970.
Policies and Protocols to Help Prevent and Respond to Workplace Violence
The Joint Commission
The Joint Commission is updating and adding new workplace violence
requirements (which all accredited hospitals and critical access hospitals
must comply with) in January 2022. They recently published the Workplace
Violence Prevention Compendium, which includes links to resources
(authored by federal agencies and medical organizations) designed to help
healthcare organizations create/update related policies and programs to
ensure they are in compliance with these requirements.
Select Policies and Protocols
In the 2019 article 6 Steps to Manage Violence Against Hospital Healthcare Workers, the author described strategies for
protecting staff and patients and encouraging the reporting of violent incidents:
1. Know your jurisdiction/applicable laws in the state; many have specic laws that call for enhanced criminal penalties
when a healthcare worker is assaulted (similar to assaults on rst responders).
2. Set policies and protocols—make them consistent and include policy for investigating incidents. Focus on de-
escalation. Disseminate widely.
3. Require employees to report workplace violence and assure them that they will not face retaliation for doing so.
4. Investigate violent incidents. Create emergency response teams (which would include representatives from human
resources, legal, and security) to respond to these types of issues and decide next steps (e.g., press charges).
5. Enforce your policies.
6. Press charges. Sarah Swank of the American Health Lawyers Association was quoted in the article as saying, “A
hospital can support its employees. For example, if there has been an assault and an employee has pressed charges,
the hospital can provide information as part of the charges, or the employee can be given time off from work to testify
in the criminal case.”
In 2020, the Healthcare in Danger team from the International Committee of the Red Cross published a checklist that
aligns these steps with a hospital’s COVID-19 response. Their specic recommendations include:
• Support healthcare workers with high exposure to stress and violence.
This Joint Commission webpage
shares how ve healthcare
organizations address
workplace violence.
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• Assess the risks and implement preparedness measures.
• Understand and promote the rights and responsibilities of staff to provide respectful and ethical care.
• Engage, listen, and communicate with the public.
• Coordinate with security forces and other services.
• Document and monitor violent incidents.
Threat Assessment Teams and Protocols
Threat assessment teams (comprised of healthcare security, hospitalists, social workers, risk management, and nursing
administration) can meet regularly to create/update “threat assessment protocols” (TAPs). These forms (e.g., the Violence
Reduction Protocol Treatment Plan and the Brøset Violence Checklist) allow healthcare and security staff to track patients
who may become violent, potentially “scoring” them based on variables such as negative behavior observed by staff,
criminal background, medical history, and previous history with the healthcare facility.
Strategies for Reducing Risk
While preventing workplace violence incidents is ideal, a supportive
leadership team and respectful environment combined with training staff
how to recognize threats and respond appropriately is equally important.
Healthcare facilities have implemented several strategies to minimize
the threat, including remote access control technology (allowing staff
to remotely activate locks, alarms, and sensors); panic buttons close to
where ED staff conduct initial check in; badge access for staff; limiting
visitor hours; using metal detectors/ wands on patients and visitors; placing
security cameras in key areas; and offering training in de-escalation, self-
defense, and other related topics.
Apps and Panic Buttons
Coutré (2019) describes an app created with support of leadership at University Hospitals (Ohio)—it includes a mobile
panic button; a system for reporting suspicious behavior; and a feature that allows users to set a timer that measures
the time it takes to walk to the car (or home or next mode of transportation)—if the user does not enter a PIN into the
app within that set time, the app will ask the user for conrmation and if none is received, the app will alert a designated
person/security. One hospital is planning to issue staff personal panic buttons after assaults by patients increased by 21%
in 2020.
De-escalation and Self-Defense Training
De-escalation training is also gaining in popularity, as ED staff nd themselves having to manage patients and visitors
who may be aggressive, violent, and/or experiencing severe stress. In this short video, Dr. Scott Zeller demonstrates how
to speak with an agitated patient to reassure and comfort him. He also compares the level of time and other resources
needed to de-escalate versus restrain (and sedate) a patient, highlighting that many assaults could be avoided by using
de-escalation techniques. The Joint Commission (2021) encourages leadership to ensure that all staff be trained in
escalation and self-defense, citing OSHA’s 2015 guidance that training include a hands-on component.
Crime Prevention through Environmental Design
Another strategy being implemented in hospitals around the country is
rethinking the design of EDs and reception areas. Jon Huddy, an architect
who has helped design EDs for years lists the following considerations
for “walk-in/public areas, [emergency medical systems] EMS entry
points, forensic patients, general emergency department care areas, and
behavioral health patients” (Huddy, 2016):
• Ensure security staff are both visible and active.
• Use metal detectors (x-ray machines or wands, which are smaller and efcient), and make room for related equipment
and more in-depth searches. Try to reduce lines/improve visibility.
Check out the ASPR TRACIE 2021
article based on an
interview with
John Huddy for more information.
Social media has increasingly
been used as a platform for
personal attacks on healthcare
workers. The IMPACT social media
harassment toolkit was created
by a health advocacy group and
includes links to related resources
on recognizing, preventing, and
reacting to online abuse.
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• Harden reception desks or build new ones with increased security features (e.g., slope them so they are difcult to
climb over, place staggered glass panes between visitors and staff that are impossible to climb between). No “islands”
in this area—no one should be able to walk behind desk.
• Add security to EMS entrance as volume dictates. Consider having a substation in the ED.
• Consider separate, secure entrance for “forensic patients” (dened as “prisoners and jail inmates who are brought to
the emergency department for evidence collection”) and those in custody requiring care.
• Ensure multiple ingress and egress options and staff awareness of options.
• Considerations for patients with behavioral health issues/areas where they are treated: if doors that lead to patient
rooms swing, make sure they swing in both directions. Consider placing a de-escalation room near entrances. Ensure
related equipment is available and visual supervision is possible.
Active Shooter Challenges and Strategies Specic to Healthcare Facilities
In 2017, the International Association of Emergency Medical Services Chiefs published the report Active Shooter Planning
and Response in a Healthcare Setting. In this report, they list specic challenges active shooter incidents pose in a
healthcare setting:
• A possibly large, vulnerable patient population that may be unable to ee
• The presence of hazardous materials (e.g., patients with infectious disease, heavy/sharp instruments
• Powerful magnets used in magnetic resonance imaging machines, which could remove rearms from the hands of
law enforcement
Though healthcare providers are encouraged to follow the “Run, Hide, Fight” directive whenever possible, Inaba et al.
presented the “Secure, Preserve, Fight” strategy in their 2018 article, taking into account the need for facilities to continue
providing care for those patients who cannot be moved or for whom discontinuing care could have dire health effects.
As part of this strategy, the authors emphasize the need for a hospital-based active shooter plan that identies and
secures “essential patient care areas where lifesaving treatment is provided.” They also describe methods for securing
doors that lead into these areas and the need to stock the areas with “kits containing essential supplies for hemorrhage
control.” Inaba et al. refer to bleeding control as a “high-yield target for educational initiatives,” and encourage healthcare
facilities to train medical and support staff. The three steps are:
• Secure. Immediately safeguard the aforementioned areas and barricade entrances. Dim or switch off nonessential
lights and silence communication devices.
• Preserve (the life of the patient and the provider). In this instance, the focus is on preserving patient lives, to include
moving them to a sheltered area while continuing to provide just the most essential care. Healthcare workers should
also preserve their own safety by eeing or hiding when they are under immediate threat.
• Fight (last resort, only if necessary).
The authors also discuss the importance of having communication signals (that announce the threat and when it has been
neutralized); a method for notifying patients’ loved ones of their status; and a plan for “attending to the psychological rst
aid needs of the patients, family, visitors, and health care workers that were present.”
Collaborating with Security to Prevent Workplace Violence
Whether security is provided by a private rm or local law enforcement, having a collaborative relationship is key to
preventing, and identifying, responding, and recovering from workplace violence incidents. The Minnesota Hospital
Association, Department of Health, and Sheriff’s Association developed the Health Care and Law Enforcement
Collaboration Roadmap that stresses the benet of interdisciplinary safety teams and communications and security plans.
Laid out like a checklist, this resource includes links to related resources that can help healthcare facilities create and
follow their own maps.
As previously mentioned, creating a multidisciplinary threat assessment team can ensure a more coordinated approach.
Staff who specialize in behavioral health, facility security personnel, front-line supervisors, and legal and labor union
representatives can work “to create a culture of reporting in order to best detect threats” (Henkel, 2020). Together, they
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can assess the threat and determine next steps (management and mitigation), done by level of threat (low, moderate, and
high), concluding with ongoing case management (ibid).
The response to active shooter incidents changed after the Columbine High School shooting in 1999 and rescue task
forces—where law enforcement immediately pursue and establish contact with and neutralize the shooter instead
of waiting for a special weapons and tactics team to arrive—has become the preferred response strategy for many
(Iselin, 2009).
Hospitals must have a plan for an active shooter incident that addresses expectations of on-site security (engage vs.
track/conne) based upon their capabilities. The plan must also address questions related to the role of responding law
enforcement, such as, would on-site security escort the teams and help them navigate to the affected area? How would
law enforcement gain access to camera feeds? Maps can help, but in the moment, responding ofcers will likely need an
escort to help them navigate as they are unlikely to know the facility layout very well. Planning and exercising together
may help address these and other issues in advance.
Patient care units should have their own response plans that address actions to take to protect the unit, patients, and staff.
“Safe” rooms should have a visual (but nonspecic) indicator on the door to assist staff in nding a lockable room. Exit
routes should be easily recognized and staff should know the next closest unit that has controlled access.
The threat of workplace violence in its many forms is all too real. There are many mitigation and preparedness strategies
that can reduce the chances of an incident and its impact. The information, education, and infrastructure/systems for
notication and staff protection strategies highlighted in this article can help staff be safer at work.