Addressing Workplace Violence and Creating a Safer Workplace
While violence in the workplace can occur across many industries and professions, this issue disproportionately impacts the healthcare workforce. Healthcare workers are five times more likely to sustain a workplace violence injury than other professions. In 2018, 73% of all nonfatal workplace violence-related injuries involved healthcare workers.1 Even with such a high reported prevalence, the incidence of workplace violence is likely even higher due to underreporting.2 Workplace violence in healthcare settings has become an increasing problem in recent years, particularly during the COVID-19 pandemic, which presented unique challenges for both patients and providers.
The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as violent acts, including physical assaults and verbal threats, directed toward persons at work or on duty.3 Acts of violence against healthcare workers can range from verbal abuse to violent physical assaults. Risk factors for workplace violence in healthcare settings can include (1) unpredictable behaviors of patients and families who are often under emotional stress, as well as (2) organizational and systemic factors such as high-stress work environments, staff shortages, lack of organizational policies and staff training, overcrowding, long wait times, inflexible visiting hours, and lack of information.4
In addition to violence that healthcare workers may experience from patients, families, or visitors, horizontal violence is also prevalent in healthcare. Horizontal violence can be defined as hostile, aggressive, and harmful behaviors toward coworkers via attitudes, actions, words, or other behaviors such as bullying, incivility, or hazing.13 While this can occur across all healthcare professions, nurses are especially impacted, with one study estimating that 22% to 44% of nurses experience bullying at some point in their professional careers.14
Workplace violence can jeopardize the safety of patients and staff. To highlight the importance of addressing this problem, the Joint Commission released a sentinel event alert in 2018 calling attention to the prevalence of violence in the healthcare workplace. The alert noted contributing factors and suggested actions for mitigating violence.5 The Joint Commission released new workplace violence prevention standards in 2022 to guide hospitals in defining workplace violence and implementing organization-wide strategies to address the issue.6 Interventions at the systemic, organizational, and individual levels are crucial to prevent workplace violence and better understand incidents when they do occur.
Types of Workplace Violence
The traditional press most often covers workplace violence incidents that yield devastating results, such as gun violence or homicide in healthcare settings. However, it is important to understand that workplace violence can take many forms, ranging from commonplace occurrences of verbal abuse to more serious acts of physical violence. Most incidents of workplace violence are verbal in nature; however, other types of incidents can include assault, battery, stalking, and sexual harassment.5
Perpetrators of workplace violence can vary, and violence can occur from patients toward healthcare staff or between coworkers. The most common type of violence in healthcare settings is violence from patients, families, or visitors toward healthcare staff.7 According to a 2019 survey on healthcare crime, about 78% of aggravated assaults and 88% of all assaults that occurred in hospitals were from patients and families toward healthcare workers.8 Horizontal violence that occurs between coworkers may include personal bullying, job-related bullying, and intimidation.15 Factors that lead to bullying among staff may include lack of experience or role conflicts, work overload, and insufficient support from management.14
In addition to varying by type and perpetrator, workplace violence can vary across care settings. For example, emergency departments and psychiatric units are more likely to experience workplace violence than other care settings.5 While some units or departments may experience a higher incidence of violence than others, workplace violence can impact all healthcare settings and is not limited to one particular area of care.
Trends and Impact
Workplace violence is not a new problem in healthcare. However, the incidence of violence has increased in recent years, particularly during the COVID-19 pandemic. According to the International Association for Healthcare Security and Safety’s 2019 Healthcare Crime Survey, physical assault against healthcare workers in hospitals increased from 7.8 incidents per 100 beds in 2014 to 11.7 incidents per 100 beds in 2018.8 One study found that violent incidents in emergency departments rose from 1.13 incidents per 1,000 visits in the 3 months preceding the pandemicto 2.53 incidents per 1000 visits during the pandemic.9 Another study conducted in Italy found that the monthly average of attacks against hospital workers increased from 13.5 events per 1,000 emergency department accesses per month in the pre-COVID-19 era to 27.2 in the pandemic months.10 This rise in violence during the pandemic has been attributed to increased stress, anxiety, and isolation for patients and providers, as well as ongoing staffing issues and burnout.9
While it is evident that workplace violence is an ongoing problem, it is also widely underreported. One study conducted at the University of Michigan estimated that the incidence of workplace violence could be up to three times higher than reported rates due to underreporting.2 Another survey found that over the course of a year, 39% of healthcare workers experienced violence from patients and families (including physical assaults, physical threats, and verbal abuse), but only 19% of events were reported.12
Underreporting of workplace violence incidents makes it difficult to estimate its true scope and impact. However, it is clear that workplace violence has broad-reaching and long-lasting implications for the healthcare workforce and subsequent effects on patient safety. Exposure to, or fear of, violence in the workplace can lead to negative psychological consequences for healthcare workers such as anxiety, depression, loss of self-esteem, and post-traumatic stress disorder.4 Horizontal violence among staff can also have negative psychological consequences, such reduced self-esteem and increased risk for stress, anxiety, and depression.15 These psychological effects can lead to higher rates of absenteeism and burnout, which can have negative downstream effects on quality of care and patient safety.11 Workforce stress and burnout negatively impact patient safety culture, leading to consequent safety issues including increased errors and potential patient harm.
In addition to implications for patients and healthcare workers, workplace violence of all types negatively impacts healthcare organizations as a whole. Workplace violence is a leading cause of job dissatisfaction among providers, particularly nurses. Annual nurse turnover rates due to workplace violence are estimated to be between 15% and 36%.11 Workplace violence incidents can lead to increased costs due to staff turnover, costs for treating injuries, and staff time away from work.11
Strategies to Address Workplace Violence
To effectively address workplace violence to create a safer healthcare environment for patients, families, and providers, it is imperative to implement interventions at both the organizational and individual levels. When reviewing the effectiveness of violence prevention training for nurses, research has found that these trainings lead to increased confidence and improved communication skills. However, the trainings are ineffective as standalone methods to reduce workplace violence without additional organizational interventions.11
At the organizational level, leaders should take steps to address barriers to reporting workplace violence incidents in order to better understand, address, and prevent problems. Underreporting of workplace violence incidents may be due to healthcare workers’ beliefs that violence is an expected part of the job, beliefs that no action will be taken against perpetrators of violence, fear of negative consequences from reporting, or a lack of easily accessible reporting systems.3 Implementation of straightforward and easy-to-use reporting systems combined with support and action from leaders can help address these barriers, reduce the burden of reporting for healthcare staff, and prevent further burnout.7
The Joint Commission recommends that, in addition to addressing barriers to reporting, healthcare leaders should make it clear that it is the organization, rather than the victims of violence, that is responsible for addressing workplace violence. At the organizational level, leaders should cultivate safer work environments by developing clear workplace violence protocols and taking steps to address issues such as staffing shortages and turnover.5 The Joint Commission also recommends that healthcare organizations capture and track workplace violence incidences from all available sources, including databases used for insurance, security, human resources, and employee surveys, and use this data to inform quality improvement initiatives to reduce incidences of workplace violence.5 These initiatives may involve changes to the physical work environment, such as enhanced security and better exit routes, as well as changes to work practices or administrative procedures, such as developing workplace violence response teams and providing adequate mental health support on-site.5
Effective January 2022, the Joint Commission released new and revised standards for the prevention of workplace violence in hospitals. These standards require that hospitals manage safety and security risks by establishing processes for continually monitoring, reporting, and investigating incidents related to workplace violence. They also require that staff participate in ongoing education and training, and that leaders create and maintain a culture of safety and quality throughout the hospital.6
Creating a culture of safety within organizations is also crucial to addressing horizontal violence and bullying in the healthcare workplace. It is critical for organizations to establish and enforce a zero-tolerance policy towards bullying, as tolerance of bullying at the organizational level is closely related to bullying prevalence.16 By implementing anti-bullying interventions, such as manager training, teambuilding exercises, and clear reporting systems, organizations can enhance allyship, communication, empowerment, and trust among healthcare staff, thus creating a safer work environment for patients and staff alike.16
Workplace violence is a complex issue that affects more than the workers who experience it. Safety leaders recognize workplace violence as a significant patient safety issue; workforce safety is one of four foundational areas in the National Action Plan to Advance Patient Safety. This document, which is focused on improving patient safety at the national level, was created by the National Steering Committee for Patient Safety, an interdisciplinary workgroup of leading healthcare organizations, associations, patient and family advocates, and federal agencies, including AHRQ.
To achieve improved workforce safety, organizations should start with a systems approach, which includes a comprehensive safety program overseen by senior leaders and clinical leader oversight for accountability for physical and psychological safety at the clinical and unit level. Development of programs to prevent and address workplace violence should be complemented by programs that support psychological safety and joy at work. The Implementation Resource Guide of the National Action Plan provides specific tactics and resources that organizations can use as they assess the status of their current initiatives to address workplace violence and develop programs to prevent violence and create safer spaces. By establishing policies and procedures to prevent and address workplace violence incidents on multiple levels, healthcare organizations can take steps toward creating a safer environment for both patients and providers.
- U.S. Bureau of Labor Statistics. Workplace Violence in healthcare, 2018. Accessed August 23, 2023. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm
- Rosenman KD, Kalush A, Reilly MJ, Gardiner JC, Reeves M, Luo, Z. How much work-related injury and illness is missed by the current national surveillance system? J Occup Environ Med. 2006;48(4):357-365.
- The National Institute for Occupational Safety and Health (NIOSH). Violence: Occupational Hazards in Hospitals. Centers for Disease Control and Prevention; 2002. Accessed October 3, 2023. https://www.cdc.gov/niosh/docs/2002-101/default.html#print
- Lim MC, Jeffree MS, Saupin SS, Giloi N, Lukman KA. Workplace violence in healthcare settings: the risk factors, implications and collaborative preventive measures. Ann Med Surg. 2022;78(78):103727. doi:https://doi.org/10.1016/j.amsu.2022.103727
- The Joint Commission. Physical and Verbal Violence Against Health Care Workers. Issue 59. Sentinel Event Alert. 2018. Accessed August 23, 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-59-workplace-violence-final2.pdf
- The Joint Commission. Workplace Violence Prevention Standards. R3 Report: Requirement, Rationale, Reference. 2021. Accessed August 23, 2023. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3_20210618.pdf
- Kim S, Lynn MR, Baernholdt M, et al. How does workplace violence-reporting culture affect Workplace violence, nurse burnout, and patient safety? J Nurs Care Qual. 2023;38(1):11-18. 10.1097/ncq.0000000000000641
- Vellani KH. The 2019 IAHSSF Healthcare Crime Survey. IAHSS Foundation; 2019. Accessed October 3, 2023. https://iahssf.org/assets/2019-Healthcare-Crime-Survey-IAHSS-Foundation.pdf
- McGuire SS, Gazley B, Majerus AC, Mullan AF, Clements CM. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med. Published online September 2021. doi:https://doi.org/10.1016/j.ajem.2021.09.045
- Brigo F, Zaboli A, Rella E, et al. The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department. Health Policy. 2022;126(11):1110-1116. doi:https://doi.org/10.1016/j.healthpol.2022.09.010
- Somani R, Muntaner C, Hillan E, Velonis AJ, Smith P. A systematic review: effectiveness of interventions to de-escalate workplace violence against nurses in healthcare settings. Saf Health Work. 2021;12(3):289-295. doi:https://doi.org/10.1016/j.shaw.2021.04.004
- Pompeii LA, Schoenfisch AL, Lipscomb HJ, Dement JM, Smith CD, Upadhyaya M. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med. 2015;58(11):1194-1204. doi:10.1002/ajim.22489
- Jaber H, Abu M, Mahmoud Al Kalaldeh, et al. Perceived Relationship Between Horizontal Violence and Patient Safety Culture Among Nurses. Risk Management and Healthcare Policy. 2023;Volume 16:1545-1553. doi:https://doi.org/10.2147/rmhp.s419309
- Shen Hsiao ST, Ma SC, Guo SL, et al. The role of workplace bullying in the relationship between occupational burnout and turnover intentions of clinical nurses. Applied Nursing Research. Published online August 2021:151483. doi:https://doi.org/10.1016/j.apnr.2021.151483
- Kim Y, Lee E, Lee H. Association between workplace bullying and burnout, professional quality of life, and turnover intention among clinical nurses. Heslop L, ed. PLOS ONE. 2019;14(12):e0226506. doi:https://doi.org/10.1371/journal.pone.0226506
- Jang SJ, Son Y, Lee H. Intervention types and their effects on workplace bullying among nurses: A systematic review. Journal of Nursing Management. 2022;30(6). doi:https://doi.org/10.1111/jonm.13655