LEGAL CLINIC By Edie Brous, JD, MPH, MS, RN

Workplace Violence
How it affects health care, which providers are most affected,
and what management and staff can do about it.

RNs and employers across the health care Nurses and nursing assistants have higher rates
continuum, including academia, have an eth- of violent injuries than other providers.2 and higher
ical, moral, and legal responsibility to create a rates of workplace violence occur in emergency, geri-
healthy and safe work environment for RNs atric, and psychiatric settings.9, 10 Direct health care
and all members of the health care team, providers are substantially more likely to experience
health care consumers, families, and com- workplace injuries than are other industry workers.11, 12
munities. The CDC notes that “the unique culture and unpre-
—American Nurses Association position dictability of healthcare facilities increase the risk of
statement on Incivility, Bullying, and both physical and verbal abuse among workers,”6 and
Workplace Violence, 2015 Almendrala notes that “nursing and other careers in
the health industry are some of the most dangerous

C
iting Journal of Emergency Nursing and Cen- occupations in America.”13 Understaffing because of
ters for Disease Control and Prevention (CDC) workplace violence compromises patient care and
studies,1, 2 the Robert Wood Johnson Foun- staff safety while increasing expenses. Workplace vi-
dation notes that “violence against nurses is at epi- olence costs American industry more than $1.2 billion
demic levels.”3 Such violence can convert nurses into each year.14, 15
patients—or worse, lead to their permanent disabil- A vicious cycle is set up in which nurses leave the
ity or even death. Culture changes are necessary to workforce in response to workplace violence. The ex-
overcome the perception that workplace violence is odus of providers compromises staffing, and inade-
an acceptable part of the job. It is not. According quate staffing levels correlate with increased violence.
to National Nurses United, there was a 110% in- The violence then accelerates the rate at which nurses
crease in the rate of violent incidents against health leave the workforce, renewing the cycle. The Na-
care workers in private hospitals between 2005 and tional Institute for Occupational Safety and Health
2014.4 That increase shows that such violence must (NIOSH) notes, “Violence in the healthcare work-
not be normalized by elected officials, health care place is a major disruption to providing quality nurs-
organizations, employers, management, educators, ing care and has a negative impact on the therapeutic
or staff.5 setting. And it’s a prime reason why nurses are leav-
ing the profession.”16
NATURE AND PERVASIVENESS OF THE PROBLEM Inadequate staffing must be recognized as a safety
Workplace violence is a serious threat to nurses. issue not just for patients, but for nurses as well. As
Data from 2013 indicate that 9,200 nonfatal work- Whitman notes,12
place violence–related injuries were reported that
year among health care workers, accounting for The more patients that nurses and other pro-
more than 67% of nonfatal violence-related injuries viders must care for, the less time they can
across all industries.6 U.S. Department of Health spend with each. And the more overworked
and Human Services data indicate that the rate of they become, the harder it is for them to
nonfatal injuries among health care workers in pub- catch warning signs and stave off brewing
lic hospitals in 2014 was 154 per 10,000 workers.7 violence. . . . When frontline providers are
During that same time there were 228 violence-related stretched thin, there are also fewer of them
injuries per 10,000 nursing home workers. Similarly, to respond to violent incidents.
the Bureau of Labor Statistics notes that of 15,980
private industry workers who experienced trauma Phillips agrees, “Perhaps most important are rec-
from nonfatal workplace violence in 2014, 67% ommendations that health care organizations revise
were female and 69% worked in health care or so- their policies in order to improve staffing levels dur-
cial assistance.8 The health care industry experiences ing busy periods to reduce crowding and wait times,
almost as many violent injuries as all other indus- decrease worker turnover, and provide adequate se-
tries combined.5 curity and mental health personnel on site.”10

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 LEGAL CLINIC

Police sergeant Andy Matuszewski of the Lauderdale County, Mississippi, sheriff’s department leads a crisis intervention training
workshop for medical professionals and emergency responders, who learn how to recognize and deescalate potentially violent
incidents, including those aimed at the providers and paramedics themselves. Photo by Ryan Dorgan.

UNDERREPORTING patient is ill. Nurses, especially psychiatric nurses, can

Statistical analysis does not reflect the actual danger, view violent acts as nonviolent when they assume the
because much workplace violence is not reported. violence to be a manifestation of a patient’s disease.19
Health care settings measure violence poorly, with Also, nurses might not recognize patient violence as
fewer than half of incidents recorded, according to the violence it is because they focus on the patient’s
Whitman,12 and the Joint Commission states that intent, rather than the patient’s behavior. Most dis-
only 20% of disruptive and violent behavior incidents turbingly, some nurses do not report workplace vio-
are reported.17 Another recent study showed extremely lence because they believe it is part of the job.7, 12, 20, 21
low rates of reporting of workplace violence through
any mechanism—patient medical records (13% to WORKPLACE VIOLENCE PREVENTION PROGRAMS
26%, depending on the type of violence: verbal threat, Workplace violence prevention programs cannot be
physical threat, or physical abuse), an official hospital effective in the absence of accurate reporting. Unless
reporting system (7%), or calls to security for assis- incidents are reported, they cannot be analyzed to
tance (12% to 28%).18 Nurses fail to report such identify trends and develop effective preventive mea-
episodes for many reasons. Profit-driven corporate sures. The Occupational Safety and Health Adminis-
models and a management focus on patient satisfac- tration (OSHA) recommends that workplace violence
tion can deter reporting. Management structures can prevention programs contain the following elements22:
deter providers from holding patients responsible for • management commitment and employee partici-
inappropriate conduct, which can cause a learned pation
helplessness in which nurses become convinced that • worksite analysis
reporting does not effect change. Reporting mecha- • hazard prevention and control
nisms might be too complex or time consuming for • safety and health training
nurses who have many competing demands. In addi- • record keeping and program evaluation
tion, differing classifications for violent incidents cre- The Joint Commission encourages a “zero toler-
ate inconsistencies in data collection. ance” approach to workplace violence, which re-
Nurses might be reluctant to label their patients quires a nonpunitive culture.23 Writing for the Joint
as violent or might excuse violent behavior because a Commission, Blouin notes the importance of creating

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an easy way to report incidents of violence, and that 4. A multidisciplinary team, including patients
“increased incident reporting goes hand-in-hand and families, is required to address work-
with more effective prevention and better understand- place violence.
ing of risk areas.”23 She adds that once easy and non- 5. Everyone in the organization is accountable
punitive reporting systems are established, staff will for upholding foundational behavior stan-
know management is truly concerned about their dards, regardless of position or discipline.
safety. Joint Commission standard LD.03.01.01 6. When members of the health care team
states, “Leaders create and maintain a culture of identify an issue that contributes to violence
safety and quality throughout the hospital,” and in the workplace, they have an obligation
standard LD.04.04.05 states, “The hospital has an to address it.
organization-wide, integrated patient safety program 7. Intention, commitment, and collaboration
within its performance improvement activities.”24 of nurses with other health care profession-
These standards enable the reporting, tracking, and als at all levels are needed to create a cul-
analysis of incidents to inform proactive and reactive ture shift.
risk reduction. 8. Addressing workplace violence may in-
crease the effectiveness of nursing practice
ORGANIZATIONAL AND MANAGEMENT RESPONSIBILITIES and patient care.
Health care organizations are responsible for ad-
dressing acts of violence in the workplace and for OSHA states that management commitment is es-
taking effective steps to reduce them. Administra- sential and that effective management requires the
tors and supervisors must take all threats seriously recognition that workplace violence is a safety and
and engage in management practices that protect health hazard. The obligation to make this commit-
the nursing staff. ment comes from the General Duty Clause of the
Almendrala remarks,13 Occupational Safety and Health Act of 1970: “Each
employer shall furnish to each of his employees em-
It’s shocking to consider that the individuals ployment and a place of employment which are free
who are charged with caregiving during other from recognized hazards that are causing or are likely
people’s most vulnerable moments are uniquely to cause death or serious physical harm to his employ-
at risk of verbal and physical assault. But while ees.”26
the patients who lash out against nurses are Commenting on the clause, NIOSH notes,
certainly to blame, it is hospital administrators “Workplace violence is a recognized hazard within
who have the ability to gather data on the in- the healthcare industry and as such, employers have
cidents, enforce strict zero-tolerance policies the responsibility via the Act to abate the hazard.”27
against violence, and create environments Although OSHA does not provide specific workplace
that discourage assaults. Not doing so is a violence standards or directly enforce the act, it does
problem for nurses—many of whom fear for use the General Duty Clause to conduct inspections
their physical safety while at work—as well and issue citations.26
as the industry as a whole. Organizations must be proactive in protecting
their workforce and held accountable for failing to
Health care organizations must adopt a culture in do so. Nurses should not be discouraged from filing
which any form of violence is unacceptable and will police reports or threatened with disciplinary actions
be addressed.19 Multidisciplinary approaches are nec- if they do. Nor should they be told that filing a po-
essary to address the issue. Staff and management lice report violates a patient’s privacy rights under
must work together. The American Organization of the Health Insurance Portability and Accountability
Nurse Executives and the Emergency Nurses Associ- Act (HIPAA). HIPAA does not prohibit the disclo-
ation collaborated on a position paper that identifies sure of protected health information for law enforce-
a number of guiding principles for addressing work- ment purposes.28
place violence25: The Joint Commission lists three tips employers
should use to prevent workplace violence23:
1. [Organizations must recognize] that vio- • Provide deescalation training.
lence can and does happen anywhere. • Create a workplace violence prevention plan.
2. Healthy work environments promote posi- • Enforce a zero tolerance policy.
tive patient outcomes. Regarding such zero tolerance policies, the Joint Com-
3. All aspects of violence (patient, family, and mission states, “Do not allow violence in your facility.
lateral) must be addressed. Period. Staff should know implicitly that they don’t

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 LEGAL CLINIC

have to work in an unsafe environment, and should implemented to prevent and mitigate incivility,
feel empowered to report violence to leadership.”23 bullying, and workplace violence; to promote
the health, safety, and wellness of RNs; and
EMPLOYEE RESPONSIBILITIES to ensure optimal outcomes across the health
Employees have their own responsibilities, too. For care continuum.
nurses, NIOSH recommends that, at a minimum,
they should do the following29: Every incident of workplace violence must be docu-
mented and reported, regardless of whether an injury
• Familiarize themselves with their organiza- has occurred. Verbal aggression must be understood
tion’s workplace violence prevention pro- as a risk factor for physical violence and recognized
gram and policies. as a form of workplace violence. As Phillips notes,
• Attend personal safety training programs “When verbal abuse and low-level battery are toler-
offered by the organization. ated, more serious forms of violence are invited.”10
• Participate in safety and health commit- Workplace safety issues should be negotiated in
tees, as well as security committees. every collective bargaining agreement in unionized
• Alert supervisors to any concerns and report settings. Workplace violence prevention programs
all incidents as soon as possible through rec- must be in place, evaluated for effectiveness, and
ognized reporting procedures. consistently adhered to. Staff nurses with direct pa-
tient care responsibilities must be represented on all
Conflicts between policies, regulations, and safety related committees.
recommendations must be resolved. For example, Additional research is required to develop work-
an item on the OSHA fieldwork checklist—“Are place violence protections, and uniform metrics should
nametags required for workers in the field (omit- be developed so that data collection can be based on
ting personal information such as last name and so- standardized definitions and language. Lobbying ef-
cial security number)?”22—might conflict with a forts to strengthen workplace protections and promote
home care nurse’s nursing board requirement that greater penalization of patients who engage in violence
nurses wear name tags that display the nurse’s last against providers must continue. There must also be
name and status. New York, for example, defines further lobbying for federal safety standards and rules
as unprofessional conduct,30 mandating protection from violence in the workplace.
Organizations must be held accountable for failing to
failing to wear an identifying badge, which shall protect their employees.
be conspicuously displayed and legible, indi-
cating the practitioner’s name and professional CONCLUSION
title authorized pursuant to the Education Law, In a 2016 report to Congress called Workplace Safety
while practicing as an employee or operator of and Health: Additional Efforts Needed to Help Pro-
a hospital, clinic, group practice or multipro- tect Health Care Workers from Workplace Violence,
fessional facility, registered pharmacy, or at the Government Accountability Office noted,15
a commercial establishment offering health
services to the publ[ic] (emphasis added). Compared to workers overall, health care
workers face an increased risk of being as-
NURSING IMPLICATIONS saulted at work, often by the patients in their
Nurses should never accept workplace violence as care. Given the high rate of violence commit-
just part of the job. All health care providers should ted against health care workers, particularly
expect—and demand—safety in their employment in in-patient facilities, there is an increasing
settings. Violence is perpetuated when it is normal- need to help ensure that health care workers
ized. As the American Nurses Association (ANA) are safe as they perform their work duties.
states,31
Keeping nurses safe in the workplace is a shared
The nursing profession will no longer toler- responsibility. Elected officials must pass legislation at
ate violence of any kind from any source. the state and federal levels. Organizations must have
All RNs and employers in all settings, includ- workplace violence prevention programs in place that
ing practice, academia, and research, must are evaluated for effectiveness on an ongoing basis.
collaborate to create a culture of respect that Managers and administrators must create a culture in
is free of incivility, bullying, and workplace vi- which workplace violence at any level is not accept-
olence. Evidence-based best practices must be able and in which nurses are supported for reporting

54 AJN ▼ October 2018 ▼ Vol. 118, No. 10 ajnonline.com

incidents. Nurses must be vigilant in reporting all 14. Papa A, Venella J. Workplace violence in healthcare: strate-
gies for advocacy. Online J Issues Nurs 2013;18(1):5.
episodes and in guarding against the normalization
15. U.S. Government Accountability Office. Workplace safety and
of workplace violence. health: additional efforts needed to help protect health care
Provision 5 of the ANA’s Code of Ethics for Nurses workers from workplace violence. Washington, DC; 2016
Mar. GAO-16-11. Report to congressional requesters; https://
with Interpretive Statements states, “The nurse owes www.gao.gov/assets/680/675858.pdf.
the same duties to self as to others, including the re- 16. National Institute for Occupational Safety and Health (NIOSH).
sponsibility to promote health and safety, preserve Workplace violence prevention for nurses. Preface. Nurses
endure a range of incidents of verbal and physical assault,
wholeness of character and integrity, maintain com- or the fear of it, in their workplaces at a startling rate [on-
petence, and continue personal and professional line course https://wwwn.cdc.gov/wpvhc/Course.aspx/Slide/
growth.”32 This means nurses must understand and Intro_4]. 2013.
17. Wyatt RM. Work place violence update [powerpoint]. Oak-
consistently convey to others that being assaulted is brook Terrace, IL; 2016 May 13. https://www.jointcommission.
never just part of the job. ▼ org/assets/1/6/illinois_hospital_assoc_wpv_slides.pdf.
18. Pompeii LA, et al. Physical assault, physical threat, and ver-
Edie Brous is a nurse and attorney in New York City and Penn- bal abuse perpetrated against hospital workers by patients
sylvania, and the coordinator of Legal Clinic. Contact author: or visitors in six U.S. hospitals. Am J Ind Med 2015;58(11):
[email protected]. The author has disclosed no poten- 1194-204.
tial conflicts of interest, financial or otherwise. 19. Payne M. Perception and behavior for underreporting work-
place violence. Master’s Projects and Capstones 540 ed: Univer-
REFERENCES sity of San Francisco, Gleeson Library, Geschke Center 2017.
1. Speroni KG, et al. Incidence and cost of nurse workplace 20. Blando J, et al. Barriers to effective implementation of pro-
grams for the prevention of workplace violence in hospitals.
­violence perpetrated by hospital patients or patient visitors.
Online J Issues Nurs 2015;20(1).
J Emerg Nurs 2014;40(3):218-28.
21. Hogarth KM, et al. Nurses’ attitudes towards the reporting
2. Gomaa AE, et al. Occupational traumatic injuries among of violence in the emergency department. Australas Emerg
workers in health care facilities—United States, 2012-2014. Nurs J 2016;19(2):75-81.
MMWR Morb Mortal Wkly Rep 2015;64(15):405-10. 22. Occupational Safety and Health Administration. Guidelines for
3. Robert Wood Johnson Foundation. Nurses face epidemic preventing workplace violence for healthcare and social service
levels of violence at work. Washington, DC; 2015 Jul 16. workers. Washington, DC: U.S Department of Labor; 2016.
https://www.rwjf.org/en/library/articles-and-news/2015/07/ OSHA 3148-06R 2016. https://www.osha.gov/Publications/
nurses-face-epidemic-levels-of-violence-at-work.html. osha3148.pdf.
4. National Nurses United. National Nurses United petitions fed- 23. [no author.] Joint Commission: three tips on preventing work-
eral OSHA for workplace violence prevention standard [press place violence. Accreditation Insider 2017 May 9. http://www.
release]. 2016 Jul 11. https://www.nationalnursesunited.org/ hcpro.com/ACC-329390-4634/Joint-Commission-Three-tips-
press/national-nurses-united-petitions-federal-osha-workplace- on-preventing-workplace-violence.html.
violence-prevention-standard. 24. Occupational Safety and Health Administration (OSHA).
5. Campbell AF. Why violence against nurses has spiked in the Safety and health management systems and Joint Commission
last decade. The Atlantic 2016 Dec 1. https://www.theatlantic. standards: a comparison. Washington, DC; 2014. https://
com/business/archive/2016/12/violence-against-nurses/509309. www.osha.gov/dsg/hospitals/documents/2.2_SHMS-JCAHO_
comparison_508.pdf.
6. National Institute for Occupational Safety and Health (NIOSH).
25. American Organization of Nurse Executives and the Emer-
Occupational health safety network [brochure]. Atlanta: Cen-
gency Nurses Association. AONE/ENA guiding principles for
ters for Disease Control and Prevention; 2017 Mar. https:// mitigating violence in the workplace. Washington, DC; Des
www.cdc.gov/niosh/docs/2015-236/pdfs/ohsn_brochure_ Plaines, IL; 2015. http://www.aone.org/resources/mitigating-
2015-236_1.pdf?id=10.26616/NIOSHPUB2015236revised. workplace-violence.pdf.
7. Esposito L. Nurses face more violence from hospital pa- 26. National Council for Occupational Safety and Health (COSH).
tients. U.S. News and World Report 2017 Jan 18. https:// Using OSHA’s general duty clause. Somerville, MA; n.d.;
health.usnews.com/wellness/articles/2017-01-18/nurses-face- http://www.coshnetwork.org/node/353.
more-violence-from-hospital-patients. 27. National Institute for Occupational Safety and Health (NIOSH).
8. National Institute for Occupational Safety and Health (NIOSH). Workplace violence prevention for nurses. OSHA’s General
Occupational violence. Fast facts: injury data and fatality data. Duty Clause [online course https://wwwn.cdc.gov/wpvhc/
Centers for Disease Control and Prevention. 2016. https://www. Course.aspx/Slide/Unit5_4]. 2013.
cdc.gov/niosh/topics/violence/fastfacts.html. 28. U.S. Department of Health and Human Services. When does
9. Arnetz JE, et al. Underreporting of workplace violence: com- the Privacy Rule allow covered entities to disclose protected
parison of self-report and actual documentation of hospital health information to law enforcement officials? Washington,
incidents. Workplace Health Saf 2015;63(5):200-10. DC; 2004. HIPAA.
10. Phillips JP. Workplace violence against health care workers 29. National Institute for Occupational Safety and Health (NIOSH).
in the United States. N Engl J Med 2016;374(17):1661-9. Workplace violence prevention for nurses. Get involved [on-
11. Thayer K, Leone H. As hospital violence grows, nurses seek line course https://wwwn.cdc.gov/wpvhc/Course.aspx/Slide/
Unit6_4]. 2013.
reforms: ‘too many of us are being hurt.’ Chicago Tribune
30. New York State Education Department, Office of the Profes-
2017 Aug 11. http://www.chicagotribune.com/news/local/
sions. Rules of the Board of Regents. § 29.2(a)(9)—General
breaking/ct-hospital-violence-nurses-met-20170810-story. provisions for health professions: unprofessional conduct. Al-
html. bany, NY 2011. http://www.op.nysed.gov/title8/part29.htm.
12. Whitman E. Quelling a storm of violence in healthcare settings. 31. American Nurses Association. Position statement on incivility,
Mod Healthc 2017; Mar 11. http://www.modernhealthcare. bullying, and workplace violence. Silver Spring, MD; 2015
com/article/20170311/MAGAZINE/303119990. Jul 22. Position statements; https://www.nursingworld.org/
13. Almendrala A. Violence against nurses is a serious problem ~49baac/globalassets/practiceandpolicy/nursing-excellence/
but hospitals are basically policing themselves. Huffpost 2017 official-policy-statements/ana-wpv-position-statement-2015.pdf.
Sep 14. https://www.huffingtonpost.com/entry/violence-nurses- 32. American Nurses Association. Code of ethics for nurses with
hospital-responsibility_us_59bad5a3e4b02da0e1404e47. interpretive statements. 2nd ed. Silver Spring, MD; 2015.

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