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Inside Medical Liability

First Quarter 2020



Mitigating Healthcare Workplace Violence Risks

With workplace violence on the rise, healthcare workers find themselves in the cross hairs among the most likely victims. Nearly three-quarters of all workplace violence occurs in healthcare settings while overall workplace violence has increased by 12% during the past seven years.1,2



U.S. healthcare workers aren’t alone in their experience of workplace violence. In fact, 45% of healthcare professionals across the globe report an encounter with workplace violence. 3

Medical workplace violence is a complex topic because it so often involves people at their lowest moments harming a professional who is only trying to help. The most common offense is verbal harassment, but the nature of workplace violence can vary drastically and include sexual harassment, stalking, kidnapping, domestic violence, assault, battery, and homicide.

A goal of eliminating medical workplace violence is laudable, but difficult to accomplish. However, there are steps that organizations can take to reduce medical workplace violence and to create an atmosphere where violence is less likely and reporting and remediating is encouraged. Establishing protocols and policies around workplace safety and reporting is critical from both the risk and compliance standpoints.

Current climate

The healthcare sector in the United States employs 18 million—more than 10% of the workforce—and is the fastest growing industry in the country.5,6 Despite these factors, there’s no doubt that a disproportionate amount of workplace violence occurs in the healthcare sector.

Medical workplace violence is not simply a geographical or cultural anomaly unique to the United States. In 2002, the World Health Organization reported survey results that showed in countries across the world healthcare workers were victims of violence at rates exceeding 45% and many exceeding 60%.7 This means that at least one out of every two healthcare personnel in the world has experienced workplace violence.

Medical workplace violence affects workers at every level, from home care aides to physicians. One survey of emergency department physicians found that nearly 50% reported being the victim of workplace violence, but only 3% pressed charges demonstrating that despite the high levels of violence, it’s a messy issue since providers often don’t want to seek retribution.8 It’s easy to see why many understand the problem of workplace violence to be endemic to healthcare, or, “just part of the job.”

Rising tide of violence?

The numbers paint a grim picture about the future of work in healthcare and social service settings, but they also offer an opportunity for greater understanding of trends underlying workplace violence. The most optimistic interpretation is to contextualize the increase in voluntary reporting and consider that such reporting may account for much of the growth in number of reported incidents, rather than an actual rise in the number of incidents of healthcare workplace violence.

The confluence of factors behind the rise in reporting includes shifting attitudes toward what constitutes acceptable workplace behavior, greater public awareness of workplace violence and improved organizational and governmental standards for reporting and preventing violence. More robust legal measures to allow justice for victims have also contributed.

Regulatory landscape

As awareness rises regarding healthcare workplace violence, more states are passing legislation to address this issue. States including NewYork, Minnesota, California, and Nevada have all attempted to address the problem with varying levels of success.9 Legislation between states can vary drastically, with some states creating clear regulations requiring workplace violence prevention programs and protocols, while others feature general or vague language and/or increases in mandatory sentencing requirements for those found guilty of assaulting a healthcare worker.10

There has been a push in recent years to enact legislation at the federal level, which has yet to bear fruit. While the U.S. House of Representatives passed legislation designed to address medical workplace violence, that legislation languished in the Senate at the end of 2019.11

In certain states there are laws mandating medical workplace violence training programs in both public and private employers; in others only public employers are forced to provide such training. Only one state, Washington, has mandatory reporting of incidents.12 The Occupational Safety and Health Act contains important provisions about mandatory record keeping of workplace injury, nondiscrimination against reporters of workplace injury, and anonymization of personal data in reporting of incidents.13

A major drawback of an increased legislative and regulatory focus on medical workplace violence is the risk it incurs to organizations in dealing with these incidents. Laws and regulations vary a large amount across each jurisdiction, so the only true way to assess compliance is through assessments from legal experts.

The Joint Commission, a nonprofit health organization accreditation agency, released a guidebook for de-escalation of violence in healthcare settings in 2019. Its techniques focus on giving healthcare workers strategies to avoid increasing conflict in the moment.14 The Occupational Safety and Health Administration (OSHA) also provides guidelines for preventing healthcare workplace violence that offer strategies on identifying and assessing risk factors, designing training, and performing recommended record keeping and evaluation.15

Strategies for reducing workplace violence

In an environment where the potential for employee and patient injury, institutional liability, and reputational damage all contribute to increased risk, healthcare facility administrators and board members need to either create or update protocols and procedures for preventing and responding to medical workplace violence. Policies and procedures that are clear, actionable, and incorporated into mandatory staff training are the most likely to succeed.

Comprehensive planning to prevent and address workplace violence in the healthcare sector involves addressing the specific needs of each organization and its employees. OSHA recommends a comprehensive five-step program that involves:
1. Management commitment and employee participation
2. Workplace analysis and hazard identification
3. Risk prevention and control
4. Safety and health training
5. Record keeping and evaluation.

Within the broad categories, organizations must define terms, understand the scope of the problem, declare violence and aggression unacceptable, emphasize preventive measures, and identify the parties responsible for implementing and monitoring those measures. Employees also need clear direction and training for a wide variety of eventualities and possibilities, including instances of physical and non-physical aggression, situations involving weapons, how to intervene physically if necessary, what organizational follow-up must occur, how to report incidents and what must be reported, where to receive support in the aftermath of a violent incident, and how to file complaints.16

Procedures should always involve employee training, and there are readily available resources that can provide useful templates, such as the National Institute for Occupational Safety and Health course for nurses on occupational violence.17 The policies implemented to solve the problem of medical workplace violence will only be as good as the accounting an organization does regarding these incidents.

In Caring for the Caregiver, OSHA notes why recordkeeping is so important.According to the report,“Accurate records of incidents, assaults, hazards, corrective actions, patient histories, and training can help employers to: Determine the severity of their workplace violence problems, identify any trends or patterns in particular locations, job categories, or departments, evaluate methods of hazard control, determine whether programs are working, [and] identify training needs.” Investigations of incidents goes hand in hand with reporting, and should involve a team of professionals from legal, human resources, and administrative departments that can perform a root-cause analysis.18

Leverage resources to combat challenges

Workers and employers across the world are only beginning to contend with the reality of medical workplace violence as an epidemic. It has an outsized effect on the healthcare and social services sector, and appears to be only getting worse, but it is an incredibly complex topic to address.

Thankfully, the number and types of resources available in planning to prevent and deal with instances of violence are only increasing, and the code of silence among healthcare practitioners appears to be on the wane. In the coming years better personnel training and reporting of incidents will eventually lead to new solutions. Although it has taken a long time and the particulars are up for debate, legislation may be passed on the federal level to it appears that legislation to guide the healthcare sector in becoming a safer and more enjoyable environment to work in.


1. U.S. Occupational Safety and Health Administration.Workplaceviolenceinhealthcare.
2. Society for Human Resource Management. Workplace violence: A growing threat, or growing in awareness? March 2019. today/trends-and-forecasting/research-and-sur- veys/Documents/SHRM%20Workplace%20Violence %202019.pdf.
3. PaolaFerrietal.Workplaceviolenceindifferent settings and among various health professionals in an Italian general hospital: A cross-sectional study. J Psych Res and Beh Man, Sept. 2016. 2196/#!po=1.19048.
4. American College of Emergency Physicians. Violence in the emergency department: Resources for a safer workplace. 2018. resources-for-a-safer-workplace.
5. The Pew Research Center. 10 facts about American workers. Aug. 29, 2019. https://www.pewresearch. org/fact-tank/2019/08/29/facts-about-american- workers/.
6. U.S. Centers for Disease Control and Prevention. Healthcare workers. topics/healthcare/default.html.
7.WorldHealthOrganization.Workplaceviolencein the health sector: Country case studies. 2008. https:// ctivities/workplace/WVsynthesisreport.pdf?ua=1.
8. Wallace Stephens. Violence against healthcare workers: A rising epidemic. Am J of Man Care, May 12, 2019. week/violence-against-healthcare-workers-a-rising- epidemic.
9. Gloria Gonzalez and Angela Childers. States lead the way on mitigating workplace violence in health- care settings., June 26, 2019. cle/00010101/NEWS08/912329252/States-lead-the- way-on-mitigating-workplace-violence-in-health- care-settings.
10. Justin Steiner. Protecting healthcare workers: A summary of laws in our members’ states. Physicians Insurance Company. zine/protecting-health-care-workers-summary-laws- our-members-states.
11. US Congress. H.R. 1309—Workplace Violence Prevention for Health Care and Social Service Workers Act., Nov. 21, 2019. bill/1309.
12. American Association of Nurses. Workplace vio- lence.
13. U.S. Occupational Safety and Health Administration. OSHA injury and illness recordkeep- ing and reporting requirements. https://www.
14. The Joint Commission. Quick safety issue 47: De-escalation in healthcare. Jan. 28, 2019. and-multimedia/newsletters/newsletters/quick-safe- ty/quick-safety-47-deescalation-in-health-care.
15. U.S. Occupation and Safety Administration. Guidelines for preventing workplace violence for healthcare and social service workers. 2016.
16. Ireland Health Service Executive. Linking service and safety. December 2008. staff/safetywellbeing/healthsafetyand%20wellbeing/li nking%20service%20safety%20summary.pdf.
17. U.S. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Workplace violence prevention for nurses. ing_nurses.html.
18. HealthLeaders. 6 steps to manage violence against hospital healthcare workers. March 27, 2019. steps-manage-violence-against-hospital-healthcare-workers.



Amy Buttell is the editor of Inside Medical Liability.