International Labour Office ILO International Council of Nurses ICN

World Health Organization WHO Public Services International PSI

Joint Programme on Workplace Violence in the Health Sector
Geneva
2002

Copyright International Labour Organization, International Council of Nurses,

World Health Organization and Public Services International 2002
First published 2002
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International Labour Office/International Council of Nurses/
World Health Organization/Public Services International
Framework Guidelines for Addressing Workplace Violence in the Health Sector.
Geneva, International Labour Office, 2002
ISBN 92-2-113446-6
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These Framework Guidelines have been developed as an integral part of the work done within the ILO/ICN/WHO/PSI Joint
Programme on Workplace Violence in the Health Sector (2000 2002). Several country case studies and cross-cutting theme
studies have been conducted in the frame of this programme to fill major information gaps by obtaining baseline and in depth information. Based on this evidence, the present Framework Guidelines were developed. The Guidelines have an informal status at this
stage and are meant to stimulate and guide initiatives at international, national and local levels. This current version is a pilot version, to be tested in practice. Feedback and comments are welcome.
The first version of the Framework Guidelines had been drafted by Vittorio Di Martino and was discussed in April 2002 in
Geneva at an informal technical consultation of the ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health
Sector. The Joint Programme wishes to thank him and all persons involved in the development of these Framework Guidelines for
their valuable contributions.

Contents
1 Background, scope and definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Extent of workplace violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 GENERAL RIGHTS AND RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.1 Governments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.2 Employers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.3 Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.4 Professional bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.5 Enlarged community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3 APPROACH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.1 Preventive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.2 Participative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.3 Culture/gender-sensitive and non-discriminatory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.4 Systematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4 VIOLENCE RECOGNITION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4. 1 Organisations at risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.2 Potential perpetrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4.3 Potential victim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
5 VIOLENCE ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5. 1 Analysing available information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5.2 Identifying situations at special risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
6 WORKPLACE INTERVENTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
6.1 Pre-conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
6.2 Organisational interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
6.3 Environmental interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
6.4 Individual-focussed interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
6. 5 After-the-event interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
7 EVALUATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
8 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1. BACKGROUND, SCOPE AND DEFINITION

1.1 BACKGROUND
Workplace violence be it physical or psychological has become a global problem crossing
borders, work settings and occupational groups. For long a forgotten issue, violence at work
has dramatically gained momentum in recent years and is now a priority concern in both industrialised and developing countries.
Workplace violence affects the dignity of millions of people worldwide. It is a major source of
inequality, discrimination, stigmatisation and conflict at the workplace. Increasingly it is
becoming a central human rights issue. At the same time, workplace violence is increasingly
appearing as a serious, sometimes lethal threat to the efficiency and success of organisations.
Violence causes immediate and often long-term disruption to interpersonal relationships, the
organization of work and the overall working environment.
While workplace violence affects practically all sectors and all categories of workers, the health
sector is at major risk. Violence in this sector may constitute almost a quarter of all violence at
work. (Nordin, H., 1995)
Under the strain of reforms, growing work pressure and stress, social instability and the deterioration of personal interrelationships, workplace violence is rapidly spreading in the health sector. Increasingly, domestic violence and violence in the streets are spilling over into the health
institutions. Recent studies confirm that workplace violence in the health sector is universal,
although local characteristics may vary, and that it affects the health of both women and men,
though some are more at risk than others. Altogether it may affect more than half of health care
workers. (Di Martino, V., 2002, forthcoming)
The negative consequences of such widespread violence impact heavily on the delivery of health
care services, which could include deterioration in the quality of care provided and the decision
by health workers to leave the health care professions. This in turn can result in a reduction in
health services available to the general population, and an increase in health costs. In develop-

Framework Guidelines for Addressing Workplace Violence in the Health Sector

ing countries particularly, equal access to primary health care will be threatened if health workers, already a scarce resource, abandon their profession because of the threat of violence.
It has been estimated by a number of reliable studies that stress and violence together possibly
account for approximately 30% of the overall costs of ill-health and accidents. Based on the
above figures it has been suggested that stress/violence may account for approximately 0.5
3.5% of GDP per year. (Hoel, H.; Sparks, K.; Cooper, C., 2000)
This evidence clearly indicates that workplace violence is far too high and that interventions are
urgently needed. Further, more specific evidence is available in each country which should be used
to increase awareness of the importance of the problem of workplace violence and to make it a priority target for all people operating in or concerned with the development of the health sector.

1.2 SCOPE

Objective
The objective of these Framework Guidelines (from now on referred to as Guidelines) is to provide
general guidance in addressing workplace violence in the health sector. Far from being in any
way prescriptive, the Guidelines should be considered a basic reference tool for stimulating the
autonomous development of similar instruments specifically targeted at and adapted to different
cultures, situations and needs.
The Guidelines cover the following key areas of action:

prevention of workplace violence

dealing with workplace violence
management and mitigation of the impact of workplace violence
care and support of workers affected by workplace violence
sustainability of initiatives undertaken

Use
These Guidelines should be used to:

develop concrete responses at the enterprise, sectorial, national and international levels
promote processes of dialogue, consultation, negotiation and all forms of cooperation among
governments, employers and workers, trade unions and other professional bodies, specialists
in workplace violence, and all relevant stakeholders (such as consumer/patient advocacy
groups and non-governmental organizations (NGOs) active in the areas of workplace violence, health and safety, human rights and gender promotion)

Background, scope and definition

give effect to its contents in consultation with the interested parties: in national laws, policies
and programmes of action; in workplace/enterprise/sectorial agreements; and in workplace
policies and plans of action.

Field of application
These Guidelines apply:

to all employers and workers

in the public, private and voluntary sectors
to all aspects of work, formal and informal.

1.3 DEFINITION
Within a general common understanding of the significance of workplace violence, specific
understanding and terminology may vary from country to country and from situation to situation. It is therefore important that definitions and terms as given below are assessed in relation
to such situations and adapted accordingly so that their significance is clear to and shared by
those who will be using the guidelines.

General definition of workplace violence

Incidents where staff are abused, threatened or assaulted in circumstances related to their work,
including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health. (Adapted from European Commission)

Physical violence and psychological violence

While the existence of personal physical violence at the workplace has always been recognized,
the existence of psychological violence has been long under-estimated and only now receives due
attention. Psychological violence is currently emerging as a priority concern at the workplace.
It is also increasingly recognized that personal psychological violence is often perpetrated
through repeated behaviour, of a type which by itself may be relatively minor but which cumulatively can become a very serious form of violence. Although a single incident can suffice, psychological violence often consists of repeated, unwelcome, unreciprocated and imposed upon action
which may have a devastating effect on the victim.

Physical violence
The use of physical force against another person or group, that results in physical, sexual or psychological harm. It includes among others, beating, kicking, slapping, stabbing, shooting,
pushing, biting and pinching. (Adapted from WHO definition of violence)

Framework Guidelines for Addressing Workplace Violence in the Health Sector

Psychological violence
Intentional use of power, including threat of physical force, against another person or group, that
can result in harm to physical, mental, spiritual, moral or social development. It includes verbal
abuse, bullying/mobbing, harassment and threats. (Adapted from WHO definition of violence)

Terms frequently used

Physical and psychological violence often overlap in practice making any attempt to categorize
different forms of violence very difficult. Some of the most frequently used terms relating to violence are presented in the following list.

Assault/attack
Intentional behaviour that harms another person physically, including sexual assault.

Abuse
Behaviour that humiliates, degrades or otherwise indicates a lack of respect for the dignity and
worth of an individual. (Alberta Association of Registered Nurses)

Bullying/mobbing
Repeated and over time offensive behaviour through vindictive, cruel or malicious attempts to
humiliate or undermine an individual or groups of employees. (Adapted from ILO Violence at
Work)

Harassment
Any conduct based on age, disability, HIV status, domestic circumstances, sex, sexual orientation, gender reassignment, race, colour, language, religion, political, trade union or other opinion or belief, national or social origin, association with a minority, property, birth or other
status that is unreciprocated or unwanted and which affects the dignity of men and women at
work. (Human Rights Act, UK)

Sexual harassment
Any unwanted, unreciprocated and unwelcome behaviour of a sexual nature that is offensive to
the person involved, and causes that person to feel threatened, humiliated or embarrassed. (Irish
Nurses Organisation)

Racial harassment
Any threatening conduct that is based on race, colour, language, national origin, religion, association with a minority, birth or other status that is unreciprocated or unwanted and which
affects the dignity of women and men at work. (Adapted from Human Rights Act, UK)

Background, scope and definition

Threat
Promised use of physical force or power (i.e. psychological force) resulting in fear of physical,
sexual, psychological harm or other negative consequences to the targeted individuals or groups.

Victim
Any person who is the object of act(s) of violence or violent behaviour(s) as described above.

Perpetrator
Any person who commits act(s) of violence or engages in violent behaviour(s) as described above.

Workplace
Any health care facility, whatever the size, location (urban or rural) and the type of service(s)
provided, including major referral hospitals of large cities, regional and district hospitals,
health care centres, clinics, community health posts, rehabilitation centres, long-term care facilities, general practitioners offices, other independent health care professionals. In the case of
services performed outside the health care facility, such as ambulance services or home care, any
place where such services are performed will be considered a workplace.

2. GENERAL RIGHTS AND RESPONSIBILITIES

2.1 GOVERNMENTS
Governments and their competent authorities should provide the necessary framework for the
reduction and elimination of such violence. This includes:

making the reduction/elimination of workplace violence in the health sector an essential part
of national/regional/local policies and plans on occupational health and safety, human
rights protection, economic sustainability, enterprise development and gender equality
promoting the participation of all parties concerned with such policies and plans
revising labour law and other legislation and introducing special legislation, where necessary
ensuring the enforcement of such legislation
encouraging the inclusion in national, sectorial and workplace/enterprise agreements of provisions to reduce and eliminate workplace violence
encouraging the development of policies and plans at the workplace to combat workplace violence
launching awareness campaigns on the risks of workplace violence
requesting the collection of information and statistical data on the spread, causes and consequences of workplace violence
coordinating the efforts of the various parties concerned

2.2 EMPLOYERS
Employers and their organisations should provide and promote a violence-free workplace.
This would include:

recognizing overall responsibility for ensuring the health, safety and wellbeing of workers
including the elimination of the predictable risk of workplace violence, according to national
legislation and practice
creating a climate of rejection of violence in their organisations
the routine assessment of the incidence of workplace violence and the factors that support or
generate workplace violence
developing policies and plans at the workplace to combat workplace violence and establishing
the required monitoring mechanisms and range of sanctions

General rights and responsibilities

consulting with representatives of the workers on the development of such policies and plans
and how to implement them
the introduction of all necessary preventive and protective measures and procedures to reduce
and eliminate the risks of workplace violence
giving managers at all levels responsibility for implementing policies and procedures relating
to workplace violence
the provision of adequate information, instruction and training concerning workplace violence
the provision of short, medium and long-term assistance to all those affected by workplace violence, including legal aid, as required
giving special consideration to the specific risks faced by particular categories of health care
workers as well as to risks in certain working environments in the health sector
endeavouring to have included provisions to reduce and eliminate workplace violence in
national, sectorial, and workplace/enterprise agreements
actively promoting awareness of the risks and destructive impact of workplace violence
the provision of adequate reporting systems
setting up of mechanisms for collecting data and information in the area of workplace violence

2.3 WORKERS
Workers should take all reasonable care to reduce and eliminate the risks associated with workplace violence. This would include:

following workplace policies and procedures

cooperating with the employer to reduce and eliminate the risks of workplace violence
attending relevant educational and training programmes
reporting incidents, including minor ones
actively contributing to promoting awareness of the risks, impact of and sanctions associated
with workplace violence
seeking guidance and counselling if involved in situations that may lead to workplace violence

2.4 PROFESSIONAL BODIES

Trade unions, professional councils and associations should launch, participate in and contribute to initiatives and mechanisms to reduce and eliminate the risks associated with workplace violence. This would include:

promoting training of health care personnel concerning the risks of workplace violence and
the mechanisms to prevent, identify and cope with such violence
elaborating on data collecting procedures for incidents of violence in the health sector and
promoting the collection of such data
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Framework Guidelines for Addressing Workplace Violence in the Health Sector

incorporating in their codes of practice and codes of ethics, clauses concerning the inadmissibility of any incident of violence at the workplace
promoting the incorporation in the accreditation procedures for health care institutions and
facilities, of a requirement of measures aimed at the prevention of violence at the workplace
endeavouring to have included provisions to reduce and eliminate workplace violence in
national, sectorial and workplace/enterprise agreements
encouraging the development of policies and plans at the workplace to combat workplace violence
actively contributing to promoting awareness of the risks of workplace violence
providing support for victims of workplace violence, including legal aid if required

2.5 ENLARGED COMMUNITY

The media, research and educational institutions, specialists in workplace violence, consumer/patient advocacy groups, the police and other criminal justice professionals, NGOs active in
the area of workplace violence, health and safety, human rights and gender promotion, should
actively support and participate in the initiatives to combat workplace violence. This would
entail:

contributing to the creation of a network of information and expertise in this area

contributing to promoting awareness of the risks of workplace violence
contributing to the development of coordinated policies and plans to combat workplace violence
contributing to continuing training and education, as required
contributing with support structures for the prevention of workplace violence and the management of incidents as well as post-incident management.

3. APPROACH
Workplace violence is not an isolated, individual problem but a structural, strategic problem
rooted in social, economic, organisational and cultural factors. An approach should consequently be developed and promoted which would attack the problem at its roots, involve all parties concerned and take into account the special cultural and gender-dimension of the problem.
It is also essential that any intervention adopted is developed from its inception, in a systematic
way to maximise the effective use of often limited resources in this sector. Such an approach
should therefore be an integrated, participative, cultural/gender sensitive, non-discriminatory and
systematic one.

3.1 INTEGRATED
An integrated approach should be actively pursued at all levels of intervention based on the combined and balanced consideration of prevention and treatment. Treatment should cover all necessary interventions to cure and rehabilitate those affected by workplace violence for as long as is
necessary. Prevention consists of a pro-active response to workplace violence with emphasis on
the elimination of the causes and a long-term evaluation of each intervention. Preventive measures to improve the work environment, work organisation and interpersonal relationships at
the workplace, have proved particularly effective. It is important that preventive measures are
immediately introduced when risks of workplace violence are identified without waiting for
workplace violence to manifest itself at the workplace.

3.2 PARTICIPATIVE
A participatory approach, whereby all parties concerned consider it worthwhile to work together
to reduce workplace violence and where such parties have an active role in designing and implementing anti-violence initiatives, should be actively promoted. A participatory approach should:

create the trust necessary for open communication with all staff. It is particularly important
for the management to clarify that workers who openly share their feelings regarding workplace violence, and their ideas for changes in the work environment, are not only protected
from reprisals but valued for their positive contribution
involve all parties concerned. The involvement of trade unions and other professional bodies,
governments, employers and workers, specialists in workplace violence, the police and all relevant stakeholders (such as consumer/patient advocacy groups and non-governmental organ9

Framework Guidelines for Addressing Workplace Violence in the Health Sector

izations (NGOs) can greatly contribute to generate awareness and sensitivity on the issue of
workplace violence
activate safety and health committees or teams that receive reports of violent incidents, make
inquiries into and conduct surveys on workplace violence and respond with recommendations
for corrective strategies
encourage workers participation in such teams

3.3 CULTURE/GENDER SENSITIVE AND NON-DISCRIMINATORY

Culture
While workplace violence has an universal significance, the perception and understanding of it
may vary among different cultures. This cultural difference should be taken into account and
properly addressed by:

the use of appropriate terminology that reflects the commonly used language in a specific culture
special emphasis on forms of workplace violence that have a particular relevance in a specific
culture
a special effort to identify and unveil situations of workplace violence that are difficult to detect
and accept as a reality because of specific cultural backgrounds

Gender
The gender dimension should be recognised. Women and men are both affected although in different ways, by workplace violence with women particularly exposed to certain types of violence,
such as sexual offences. (D. Chappell and V. Di Martino 2000). In the health sector, where violence is so pervasive that it is often seen as part of the job, a large number of women are employed.
The continued concentration of women in low-paid and low status jobs in this sector, further
exacerbates the problem making women a real or perceived vulnerable target. More equal gender
relations and the empowerment of women are vital to successfully prevent violence in the health
sector. Action in this area should take into due account the specificity of the concrete situations to
be addressed.

Discrimination
Workplace violence is closely linked to and generates discrimination. Discrimination includes
any distinction, exclusion or preference which has the effect of nullifying or impairing equality
of opportunity or treatment in employment or occupation such as those made on the basis of
race, colour, sex, religion, political opinion, national extraction or social origin. Any policy or
action against workplace violence should be also directed at combating any form of discrimination linked to or originated by such violence.

10

Approach

3.4 SYSTEMATIC
In order to develop the above approaches effectively, it is essential that anti-violence action be carried out in a systematic way.
Short, medium and long term objectives and strategies should be identified at the earliest stages
so as to organize action towards realistically achievable targets within agreed time frames.
Action should also be articulated in a series of fundamental steps that include:

violence recognition
risk assessment
intervention
monitoring and evaluation.

11

4. WORKPLACE VIOLENCE RECOGNITION

Early recognition of risks of violence allows for intervention before violence manifests itself.
Even though each pre-condition and signal may be due to other factors, their combined simultaneous occurrence may require the need to take anti-violence action. It should be borne in mind
however, that workplace violence is always difficult to predict and that it is important to avoid
stereotyping or labelling, which can lead to discrimination, especially when considering risk
factors at individual level.
The following should be considered.

4.1 ORGANISATIONS AT RISK

While all kinds of health facilities are potentially exposed to workplace violence, some are at
higher risk than others. Such risk should be assessed having regard to the specific situation and
conditions in which each health care facility operates with special attention paid to those health
facilities that are:

located in suburban, highly populated and high crime areas

small and isolated
understaffed
under the strain of reform and downsizing
working with insufficient resources, including inappropriate equipment
functioning in a culture of tolerance or acceptance of violence
working with a style of management based on intimidation
noted for poor communication and interpersonal relationships

In this respect, attention should also be paid to abnormally high levels of absence on grounds of
sickness, high levels of staff turnover and previous records of violent incidents.

12

Workplace violence recognition

4.2 POTENTIAL PERPETRATORS

A number of factors of risk have been identified which may help in preventing workplace violence, particularly physical violence.
However, in dealing with such factors every attention should be paid to avoid any labelling of
individuals as potential or alleged perpetrator. The potential perpetrator can be a member of the
public, of the organisation or other organisation in the health sector or a patient or client of the
service. Consideration should be also given to the fact that, in a number of cases, perpetrators
are themselves victims of violence.

Background
Can include:

a history of violent behaviour

a difficult childhood
problems of psychotropic substance abuse, especially problematic being alcohol use
severe mental illness, the symptoms of which are not being adequately identified or controlled
through therapeutic regimes
access to firearms or objects that can be used as weapons

Warning signals
Can include:

aggressive/hostile postures and attitudes

repeated manifestations of discontent, irritation or frustration
alterations in tone of voice, size of the pupils of the eyes, muscle tension, sweating
the escalation of signals and the building up of tense situations

4.3 POTENTIAL VICTIM

A number of factors of risk have been identified which may help in preventing workplace violence.
As in the case of a perpetrator, every attention should be paid to avoid any labelling of the victim.

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

Profession
Although all professions in the health sector are potentially at risk of workplace violence, some
appear to be at special risk:

nursing and ambulance staff: at extremely high risk

doctors, support and technical staff: at high risk
all other allied professionals: at risk

Real or perceived vulnerability

Can apply to:

members of minorities
people in training or on placement
workers in precarious job situations
young people
women

Experience/attitudes/appearance
Can include:

being inexperienced
the display of unpleasant, irritating attitudes
absence of coping skills
wearing uniforms or name tags

Uniforms or name tags have proved to act both as a deterrent to and a trigger of workplace violence depending on the circumstances. Consequently, recourse to them and the way uniforms or
name tags are used, is a matter that should be carefully assessed and decided upon according to
the specific situation under consideration.

14

5. WORKPLACE RISK ASSESSMENT

One of the first steps to be taken when considering the prevention of work-related violence, is an
assessment or diagnosis of the relevant hazards and situations at risk as an integral part of the
occupational safety and health management system and of the overall organisational management of heath institutions. This should include:

5.1 ANALYSING AVAILABLE INFORMATION

A great deal of information is usually available that should be properly exploited. To this purpose:

official records concerning incidents, absenteeism, turnover should be carefully analysed

information on the management style should be obtained and considered
workplace inspections should be carried out regularly
periodical general and situation-specific surveys should be carried out among the staff
discussions with workers and their representatives should be developed
an on-going relationship with occupational health services should be maintained
contacts with other employers, employers organisations, relevant governmental organisations, customer/patient advocacy groups and insurance companies should be maintained.

5.2 IDENTIFYING SITUATIONS AT SPECIAL RISK

There are a number of work situations that have been identified as being at special risk of workplace violence. Health care workers are exposed to the entire range of such situations of risk and
this makes this category of workers unique in terms of the importance and spread of workplace
violence.

Situations at special risk

Working alone
Workers working alone are at special risk of suffering physical and sexual attacks. Many workers in the health sector such as night and home care nursing staff, do work alone or in relative
isolation and are therefore subject to greater risk of violence.

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

Working in contact with the public

A wide variety of occupations, including many in the health sector, involve contact with the public. Increasingly, exposure to the public generates higher risks of violence.

Working with objects of value

Wherever valuables (e.g. cash, drugs, syringes/needles, expensive equipment) are, or seem to be
within easy reach, there is a risk that crime, and increasingly violent crime, may be committed. Workers in the health sector, such as cashiers and those dealing with the dispensing and
storage of drugs, are exposed to such a risk.

Working with people in distress

Frustration and anger arising out of illness and pain, psychiatric disorders, alcohol and substance abuse, can affect behaviour and make people verbally or physically violent. The incidence
of violence faced by workers in contact with people in distress is so common that it is often considered an inevitable part of the job. Health care workers are at the forefront of this situation.

Working in an environment increasingly open to violence

Violence in health care settings which was traditionally concentrated in a few areas such as
emergency services, is now progressively spreading to all areas of work.

Working in conditions of special vulnerability

Extended processes of reform and down-sizing in the health sector lead to an increasing number
of workers becoming involved in occasional and precarious employment, exposed to the risk of
poor working conditions and job loss as well as associated risks of violence.
In order to fully assess the specific relevance of situations at special risk in different workplaces,
an analysis should be conducted of the presence of such situations within each workplace and
each category of workers employed there. This is an essential pre-condition for a targeted and
effective intervention and should be satisfied before any intervention takes place.

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6. WORKPLACE INTERVENTIONS
Once the potential existence of violence has been recognised and the situations at risk identified,
action to deal with violence should be taken.

6.1 PRE-CONDITIONS

Developing a human-centred workplace culture

Priority should be given to the development of a human-centred workplace culture based on safety and dignity, non-discrimination, tolerance, equal opportunity and cooperation. This requires
actively promoting the development of socialisation processes, new, participative management
styles and the establishment of a new type of organisation where:

social dialogue and communication are extensively utilised

the organisation and staff share a common vision and goals
the manager is committed to combating workplace violence
services and responsibilities are decentralised so that managers, supervisors and workers
become more aware of local issues and are better able to respond to the needs of the patients
the organisation encourages problem-sharing and group problem solving
the organisation provides an environment where the efforts of the staff are recognized, feedback given and opportunities created for personal and professional development
there is a strong and supportive social environment

Issuing a clear policy statement

A clear policy statement of intent should be issued from the top management in consultation
with all stakeholders recognizing the importance of the fight against workplace violence.
The statement should contain at least the following:
a definition of violence so that people know exactly what is being referred to
a declaration indicating a real commitment to make the issue of violence a high priority in the
organisation
a caution stating that no violent behaviour or behaviour intentionally generating violence will
be tolerated
a readiness to engage in support of any action targeted at creating a violence-free environment;

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

a directive stating that supervisors and managers have a positive duty to implement the policy
and to demonstrate leadership by example
an engagement to provide managers with the ability and the means necessary to carry out the
policy at all levels within the organisation
an assignment of responsibility to individuals or teams with appropriate training and skills
for the implementation of the policy
the provision of an independent and free- from -retaliation complaint system
raising awareness

It is essential that the policy statement be accompanied by initiatives to raise awareness among
the management, supervisors and staff, patients, clients, suppliers and local communities, of the
deleterious effects of workplace violence and of the advantages of undertaking immediate action
to eliminate or reduce violence at the workplace. The following implications of violence should
be clearly highlighted:

For the individual:

The suffering and humiliation resulting from violence usually lead to a lack of motivation, loss
of confidence and reduced self-esteem and, if the situation persists, consequences such as physical illness, psychological disorders or tabacco, alcohol and drug abuse are often observed.

At the workplace:
Workplace violence causes immediate, and often long-term disruption to interpersonal relationships, the organisation of work and the overall working environment, usually leading to deterioration in the quality of service provided. Employers bear the direct cost of legal liabilities, lost
work and more expensive security measures. They are also likely to bear the indirect cost of
reduced efficiency and productivity, deterioration in the quality of service provided, difficulty in
recruiting or retaining qualified personnel, loss in company image and a reduction in the number of clients.

In the community:
Workplace violence may eventually result in unemployment, psychological and physical problems that adversely influence an individuals social position. The costs of violence include health
care and long-term rehabilitation costs for the reintegration of victims, unemployment and
retraining costs for victims who lose or leave their jobs as a result of such violence, and disability
and invalidity costs where the working capacities of the victims are impaired by violence at work.
Access for the public to quality health services is also threatened.

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Workplace interventions

6.2 ORGANISATIONAL INTERVENTIONS

High priority should be given to organizational intervention. Sorting out the organizational
problem at the source usually proves much more effective and less costly than increasing the coping capacity through intervention at the individual level or intervening on the effects of violence
on the individual worker. Organisational interventions should be developed and adapted in the
light of specific situations, and priorities for intervention should be identified in consultation
with the local stakeholders. Organisational intervention may include:

Staffing
The adequate presence of staff, in terms of numbers and qualification, should be ensured, especially:

at peak periods, during patient transfers, emergency responses, meal times, and at night.
in admission units and crisis or acute care units
for patients with a history of violent behaviour or gang activity

Available staff should be used in the most effective way and arrangements should be made in this
respect with the staff concerned, including:

arranging staff rotation for particularly demanding jobs and for those who are new to the job
detailing how staff move between different working areas
arranging rosters to help staff to be as alert as possible and have assistance in case violent situations
arranging assignments so that workers in dangerous situations do not work alone.

Management style
Management is a natural point of reference within organisations. When the management exemplifies positive attitudes and behaviour at the workplace, the entire organisation is likely to follow suit. A management style based on openness, communication and dialogue, in which caring
attitudes and respect for the dignity of individuals are priorities, can greatly contribute to the diffusion and elimination of workplace violence.

Information and communication

Among the staff and working units
Circulation of information and open communication can greatly reduce the risk of workplace
violence by defusing tension and frustration among workers. They are of particular importance
in removing the taboo of silence which often surrounds cases of sexual harassment, mobbing
and bullying.

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

The following should be promoted:

information sessions
personnel meetings
office meetings
group discussions
team working
group training

With the patients and the public

The provision of timely information to patients and their friends and relatives, is crucial in lessening the risk of assault and verbal abuse. This is particularly the case in situations involving distress
and long waiting periods, as often occurs in accident and emergency departments. In particular:

protocols or codes of conduct, explaining the obligations as well as the rights of patients, relatives and friends, should be compiled, distributed, displayed and applied
sanctions in response to violence against personnel, should be made known

For workers at special risk

Information on the risks involved in specific situations and effective communication channels
should be provided to workers at special risk, such as community and home care workers or
ambulance staff. This includes:

providing protocols for informing staff that a colleague is away from base, where he/she has
gone and the approximate or expected time of return. Procedures for reacting to failed protocols should also be in place.
providing emergency codes so that staff can request help without having to explain the situation and, therefore, without alerting an assailant
providing information on the possible risks involved in future contacts and their location
maintaining links with the local police to acquire up-to-date information on problem locations or known violent patients
providing alarm systems as indicated below under workplace design

Work practices
Changing and improving work practices is a most effective, inexpensive way of diffusing workplace violence. Since every working situation is unique, a combination of different measures
should be used which can best respond to each situation.

client flow and the scheduling of appointments should be tailored to suit needs and resources
crowding should be avoided
waiting times should be kept to a minimum
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Workplace interventions

workers should be given margins of flexibility so that rules and policies are not interpreted by
patients as intolerable constraints
workers making home visits should, wherever possible, telephone or write to make appointments for visits; schedule visits to problem areas for particular times of the day, such as the
morning when drug activity and drunkenness should be minimal
night workers, especially women and those moving from building to building or working in
isolated areas of a building, should, if at all possible, work together or in close proximity to
each other
transportation should be provided, if at all possible, to night workers

Job design
Job design is an essential factor in respect of violence at the workplace. An efficient design should
ensure that:

tasks performed are identifiable as whole units of a job rather than fragments
jobs make a significant contribution to the total operations of the organisation which can be
understood by the worker
jobs provide an appropriate degree of autonomy
jobs are not excessively repetitive and monotonous
sufficient feedback on task performance and opportunities for the development of staff skills
are provided
jobs are enriched with a wider variety of tasks
job planning is improved
work overload should be avoided
pace of work is not excessive
access to support workers or team members is facilitated
time is available for dialogue, sharing information and problem solving

Working time
To prevent or diffuse workplace violence, working time management should avoid excessive work
pressure by:

arranging, as far as possible, working time in consultation with the workers concerned
avoiding too long hours of work
avoiding a massive recourse to work overtime
providing adequate rest periods
creating autonomous or semi-autonomous teams dealing with their own working time
arrangements
keeping working time schedules regular and predictable
keeping, as far as possible, consecutive night shifts to a minimum
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Framework Guidelines for Addressing Workplace Violence in the Health Sector

6.3 ENVIRONMENTAL INTERVENTIONS

Action should be undertaken to identify and address problems within the working environment
with a view to preventing workplace violence. Environmental interventions should be developed
and adapted having regard to the specific situations, and priorities among the various types of
intervention available should be established in consultation with the local stakeholders.
Environmental interventions may include:

Physical environment
The physical features of a workplace are key factors in either defusing or acting as a potential trigger of violence. Special attention should be therefore paid to the level and ways in which workers,
patients and visitors are exposed to such factors and to the adoption of adequate solutions, in line
with existing law and practice, to reduce or eliminate any negative impact. In particular:

levels of noise should be kept to a minimum to avoid irritation and tension among workers,
visitors and patients
colours should be relaxing and attractive
bad odours should be eliminated
good illumination should be maintained to improve visibility in all areas, particularly access,
parking and store areas especially at night
measures should be taken to provide adequate temperature/humidity/ventilation especially in
crowded areas and in hot climates
all physical structures and fixtures should be well maintained

Workplace design
In the specific context of possible violence and aggression in the workplace, especially in those
areas open to the public, the design of workplaces requires special attention and involves the following additional factors:

Access

safe access should be provided to and from the workplace

multiple areas of public access to health care facilities should be minimized
security services should be placed at the main entrance, near visitors transit route and emergency departments
checking for weapons should be considered with great caution and implemented if necessary,
according to local law and practice with the priority aim of avoiding any unnecessary risk
the reception area should be easily identifiable by patients/visitors, easily accessible and visible to other staff
public access to the main health care facility should be regulated according to agreed protocols
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Workplace interventions

access to staff areas (e.g. changing rooms, rest areas) must be restricted and limited to personnel of the facility
staff parking areas should be located within close proximity to the workplace

Space

there should be sufficient space among visitors and patients to reduce personal interference
and the build up of tension
adequate work space should be provided to facilitate provision of services
adequate place should be provided for health care personnel to relax
spacious and quiet reception areas with sufficient space for personnel, should be provided
protective barriers should be used for workers at special risk and to separate dangerous
patients from other patients and the public

Waiting areas

there should be comfortable seats especially where long waiting is involved

boredom should be reduced by providing activities (e.g. reading materials, television, toys for
children)

Fixtures and fittings

furniture should be arranged in such way as to prevent entrapment of staff

in interview rooms or crisis treatment areas, furniture should be minimal, lightweight, without sharp corners or edges, and where appropriate, be affixed to the floor

Premises

treatment rooms should have two exits or where this is not possible, they should be so
arranged as to allow easy means of exit
treatment rooms in emergency services should be separated from public areas
the possibility of providing a separate room for emotionally disturbed patients, intoxicated
patients, confronting gangs and similar cases, should be given special consideration bearing
in mind however, that in certain circumstances, recourse to such a facility may be perceived as
discrimination and thus further exacerbate the situation
toilets, areas providing food, drink and public telephones should be signposted, easily accessible and properly maintained
non-smoking and smoking areas should be clearly identified
privacy should be respected as much as possible.

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

Alarm systems and surveillance cameras

surveillance cameras should be installed in potentially dangerous areas

alarm systems e.g. telephone, beeper, short-wave radio, should be provided to workers where
risk is apparent or may be anticipated to alert or notify other colleagues in the event of a problem
the use of silent systems is advised in order to avoid the reaction of the assailant. If silent systems are not available the victim should avoid using the systems before the assailant has left in
order to avoid angry reactions from him/her
a reliable response system when an alarm is triggered should be arranged
the type of alarm system should depend on the risk assessment for the particular area.

6.4 INDIVIDUAL-FOCUSSED INTERVENTIONS

Interventions should be developed to reinforce the capacity of individuals to contribute to the prevention of workplace violence. Individual-focused interventions should be developed and adapted having regard to the specific situations, and priorities among the various types of
interventions available should be established in consultation with the local stakeholders.
This would include:

Training
Training to cope with workplace violence should be based on a set of policies and provided on a
continuous or periodical basis depending on the specific needs, to all workers and their representatives, supervisors and managers.
Training should include:

orientation to the workplace environment, management policies and grievance procedures

information on the different types of workplace violence, physical and psychological, and best
practices for its reduction
information on gender, multicultural diversity and discrimination to develop sensitivity to
such issues
improving the ability to identify potentially violent situations
instilling interpersonal and communication skills which could prevent and defuse a situation
of potential workplace violence
developing competence in the particular functions to be performed
preparing a core group of mature and specially competent staff and workers representatives
who can take responsibility for more complicated interactions
assertiveness training or empowerment, especially for women
self-defence, as required according to risk assessment
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Workplace interventions
Guidelines for specific occupations should further identify the special training needs and skills
required for preventing or coping with workplace violence under particular circumstances.

Assistance and counselling

Assistance and counselling to help individuals recognize the danger in their present behaviour
and assistance to change their conduct/attitude, e.g. domestic violence, substance abuse, or that
resulting from stress, depression, insomnia, should be made available.

Well-being promotion
Maintaining physical fitness and emotionally stable psychic conditions is an effective way to
cope with workplace violence. Special attention and encouragement should be given to the development of the habit of regular physical exercise, proper eating and sleeping habits, relaxation
techniques and leisure activities particularly those involving socialisation among staff members.
Dealing with the often overlapping and conflicting demands of the workplace and the family can
be very stressful and generate tension and dissatisfaction. The provision of the means to reconcile work and family responsibilities such as flexible working time arrangements, the creation of
crches at the workplace or special assistance given to single parents, can effectively contribute to
the prevention of workplace violence.

6.5 AFTER-THE-EVENT INTERVENTIONS

After the- event- interventions should be directed to minimise the impact of workplace violence
and to ensure that such violence will not be repeated in future. They should be targeted not only
at the victim but also at the perpetrator, the witnesses and all other staff directly or indirectly concerned by a violent incident/behaviour.

Response plans
Management plans for handling situations of workplace violence and for helping all those
affected by workplace violence to deal with the distressing and often disabling after-effects of a
violent incident/behaviour as well as to prevent severe psychological problems from developing
later, should be made available and tested in advance.

Reporting and recording

Reporting and recording systems are essential for identifying places and work activities where
violence can be a problem. All incidents, involving both physical and psychological violence, as
well as minor and potential incidents where no actual harm has resulted, should be reported and
recorded.

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

The manager should establish procedures to register all cases of workplace violence and mechanisms to respond to such cases should be available. Periodic review of such reports of incidents as
an indicator for improving workplace safety measures, should be carried out.
All workers should know how and where to report, without fear of reprisal or criticism.
A report form should be designed to elicit the following information:

where the incident occurred, including the physical environment

the date and time of day
activity at the time of the incident
details of the victim
details of the alleged perpetrator
relationship between victim and alleged perpetrator
account of what happened
witnesses
outcome
measures undertaken after the incident
effectiveness of such measures
recommendations to prevent a similar incident happening in the future

Workers should also be encouraged to report on conditions or situations where they are subjected to excessive or unnecessary risk of workplace violence; and to make suggestions for reducing
the risk of violence or improving working conditions.

Medical treatment
Immediate medical treatment should be available, and its existence known to all those affected by
workplace violence. Special care should be exercised when dealing with victims of sexual offences
since the medical examination can be reminiscent of the offence itself and therefore particularly
distressing.

De-briefing
Debriefing as required should be made available to all those affected by workplace violence It
would include:

sharing personal experience with others to diffuse the impact of violence

helping those who have been affected by workplace violence to understand and come to terms
with what has happened
offering re-assurance and support
26

Workplace interventions

getting people to focus on the facts and give information

explaining the subsequent help available.

Counselling
Counselling by specialist or peer groups should be also made available as required. Specialist counselling should be provided directly by the health care institution as part of occupational health or
its own clinical psychology service, or, if these are not available, by referral to external services.

Management support
The management should provide immediate and protracted support to all those affected by workplace violence.
In particular, the management should:

deal with the immediate aftermath of violence

minimise the impact of workplace violence by taking care of or advising on provision of leave,
costs and legal issues
provide information and support to the families of those affected
initiate a timely internal investigation
follow-up the case for as long as is necessary

Representation and legal aid

Trade unions, professional organisations, and if necessary colleagues, should be involved in
providing representation and legal aid, as required. This would involve:

assistance and support with police procedures

consulting with sources of legal aid in regard to options
attending meetings, investigations and hearings
stewards having access to training in workplace violence
a member from an ethnic or other minority community/group being represented by a steward
from a similar background

Grievance procedures
Procedures should be available which may help solve problems before a situation, particularly
among workers, supervisors or managers, further deteriorates. These may consist of informal
meetings between the complainant and an appropriate line manager or a facilitator. Meetings to
clarify matters with the alleged perpetrator or any other relevant person, with the assistance of a
workers representative or the ombudsperson or a colleague, may also be arranged. They can offer
opportunities for conciliation and prevent violence or further violent incidents. Nonetheless, if a

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Framework Guidelines for Addressing Workplace Violence in the Health Sector

solution is not possible on the basis of such a procedure, a route for a complaint to be lodged
according to law and practice to formal jurisdictional bodies, should be offered to the complainant.
The complainant and the perpetrator should be:

seen privately
informed that the organization will take the complaint seriously and that every endeavour will
be made to sort the case out quickly
advised on what is likely to happen next
assured of confidentiality
protected from further violence and the spreading of rumours

Rehabilitation
Recovery from workplace violence may involve a long period of rehabilitation. Workers
should be supported during the entire period of rehabilitation, allowed all necessary time
to recover but also encouraged to return to work. The sooner the victim can return to work,
the easier it would be for him/her to rejoin the group and the worker will have missed out on less
of the current information needed for effective job performance. However, workers should not be
subjected to too much stress at first and flexibility such as in the form of part time work, a different assignment or support of a co-worker can allow the victim to recover self-confidence. For victims of workplace violence it is important that, when they return to work, they feel safe in their
environment both from physical and psychological violence.

28

7. EVALUATION
Evaluation of the effectiveness of anti-violence plans and measures should include:

monitoring, on a continuous basis, and regular dissemination of the results of measures

introduced
involving the workers in developing the criteria for evaluation and receiving regular feedback
from them to check how well they are working and to make modifications as necessary
organising periodical joint meetings of management and workers to discuss the measures put
in place
reviewing the management plan on a regular basis including the assessment of policy implementation.
re-assessing the workplace culture, work organisation and the quality of the environment to
effectively respond to workplace violence
activating a risk management cycle to make the combat of workplace violence an ongoing
process within organisations

29

8. REFERENCES
Chappell, D.; Di Martino, V. (2000). Violence at Work, second edition, Geneva: International
Labour Office
Di Martino, V. (2002). Workplace Violence in the Health Sector - Country Case Studies Brazil,
Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian Study: Synthesis
Report; Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health
Sector, forthcoming working paper
Hoel, H.; Sparks, K.; Cooper, C. (2000). The cost of violence and stress at work and the benefits of
a violence and stress- free working environment, University of Manchester Institute of Science and
Technology, http://www.ilo.org/public/english/protection/safework/whpwb/econo/costs.pdf
Krug, E. et al., eds. (2002). World Report on Violence and Health. Geneva: World Health
Organization.
Nordin, H. (1995). Fakta om vaold och hot I arbetet, Solna, Occupational Injury Information
System, Swedish Board of Occupational Safety and Health

ILO/ICN/WHO/PSI Joint Programme on

Workplace Violence in the Health Sector

Study reports and working papers

ILO/ICN/WHO/PSI (2002). Framework Guidelines for Addressing Workplace Violence in the Health
Sector. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector
Di Martino, V. (2002). Workplace Violence in the Health Sector - Country Case Studies Brazil,
Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian Study: Synthesis
Report. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health
Sector, forthcoming working paper

Country case studies

Palcios, M.; Loureiro dos Santos, M.; Barros do Val, M.; Medina, M.I.; de Abreu, M.; Soares
Cardoso, L.; Bragana Pereira, B. Workplace Violence in the Health Sector Country Case Study
30

References
Brazil. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health
Sector, forthcoming working paper
Tomev, L.; Daskalova, N.; Ivanova, V. Workplace Violence in the Health Sector Country Case
Study Bulgaria. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the
Health Sector, forthcoming working paper
Deeb, M. Workplace Violence in the Health Sector Lebanon Country Case Study. Geneva:
ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper
Ferrinho, P.; Antunes, A.R.; Biscaia, A.; Conceio, C.; Fronteira, I.; Craveiro, I.; Flores, I.;
Santos, O. Workplace Violence in the Health Sector Portuguese Case Studies. Geneva:
ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper
Steinman, S. Workplace Violence in the Health Sector Country Case Study: South Africa. Geneva:
ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper
Sripichyakan, K.; Thungpunkum, P. ; Supavititpatana, B. Workplace Violence in the Health
Sector - A Case Study in Thailand. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace
Violence in the Health Sector, forthcoming working paper

Theme studies
Cooper, C.; Swanson, N. (2002).Workplace violence in the health sector State of the Art.
Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector
Di Martino, V. Relationship of Work Stress and Workplace Violence in the Health Sector. Geneva:
ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming
working paper
Richards, J. Management of Workplace Violence Victims. Geneva: ILO/ICN/WHO/PSI Joint
Programme on Workplace Violence in the Health Sector, forthcoming working paper
Wiskow, C. Guidelines on Workplace Violence in the Health Sector Comparison of major known national guidelines and strategies: United Kingdom, Australia, Sweden, USA. Geneva: ILO/ICN/WHO/PSI
Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper
31