Healthcare Workplace Violence Prevention: A Practical Program Guide

Healthcare workplace violence prevention is a written, continuously managed program that reduces assaults and threats against staff by patients, visitors, coworkers and outsiders. It rests on leadership commitment, a worksite analysis, practical hazard controls, staff training, easy reporting and regular review. Hospitals accredited by The Joint Commission have specific requirements, and some states, including California, add their own.

Why is healthcare workplace violence different from violence elsewhere?

Federal injury data has consistently shown that healthcare and social assistance workers suffer a disproportionate share of nonfatal workplace violence injuries. The reasons for healthcare workplace violence are built into the work: caring for people who are in pain, frightened, intoxicated, confused or in mental health crisis, often around the clock and with open public access.

Security experts commonly sort workplace violence into four types: criminal intent by a stranger, violence by a customer or patient, worker on worker violence, and violence spilling over from a personal relationship. In hospitals and clinics, healthcare workplace violence is dominated by the second type. That means many controls a bank or office would use, such as refusing entry, do not apply. You cannot turn away a patient in crisis, so the program has to manage risk while care continues.

What are the core elements of a healthcare workplace violence program?

OSHA’s Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (publication 3148) describe five building blocks. They are voluntary guidance, but they remain the most practical way to organize a healthcare workplace violence program.

1. Management commitment and worker participation. Leaders assign responsibility, fund the program and involve frontline staff, who know where the risks are.
2. Worksite analysis. Review incident records, survey staff, and walk each unit to find where and when violence happens.
3. Hazard prevention and control. Fix what the analysis finds with physical changes and work practices.
4. Safety and health training. Teach staff to recognize escalation, de-escalate, call for help and protect themselves.
5. Recordkeeping and program evaluation. Track incidents, near misses and corrective actions, then review the program regularly.

What do The Joint Commission and state rules require?

Since January 2022, The Joint Commission has applied workplace violence prevention requirements to accredited hospitals and critical access hospitals. In broad terms, they call for a defined program overseen by a designated leader and a multidisciplinary team, an annual worksite analysis, processes for reporting and investigating incidents, and training at orientation and on an ongoing basis that includes de-escalation and response to incidents. Check the current standards manual for exact wording.

California has a healthcare specific workplace violence standard in Title 8, Section 3342, which covers hospitals and certain other healthcare settings. Employers covered by that standard are generally excluded from the state’s newer general requirement under SB 553, which is explained in our article on the workplace violence prevention plan. Other states have their own laws for hospitals or healthcare workers, and federal legislation has been proposed in Congress more than once, so confirm what applies to each of your facilities.

Where does healthcare workplace violence happen, and what controls work?

A worksite analysis usually points to the same hot spots: emergency departments, behavioral health and psychiatric units, waiting rooms, intake and registration, long term care, pharmacies, parking areas, and home and community visits. Each needs controls matched to how care is delivered there.

Physical design matters as much as policy in reducing healthcare workplace violence. Principles of CPTED, such as natural surveillance and natural access control, can be built into renovations so staff can see and be seen without making spaces feel like a jail.

How should staff be trained?

Healthcare workplace violence training should match the risk a person actually faces. A registrar, a behavioral health nurse and a security officer need different skills.

Everyone

• How to recognize early signs of escalation and when to call for help
• Verbal de-escalation basics and positioning (keeping an exit, not turning your back)
• How and why to report every incident, including verbal threats
• What the facility’s emergency codes mean and what to do when one is called

High risk units and response teams

Staff in emergency, behavioral health and security roles need deeper de-escalation, safe physical intervention techniques consistent with your restraint and seclusion policies, and practice working as a team. Many hospitals train internal instructors so refreshers can happen on every shift. See trainers in our security training directory, and budget using the workplace violence prevention cost guide.

How do you fix underreporting?

Many clinicians have long viewed being hit, grabbed or threatened as part of the job. When staff believe nothing will happen, they stop reporting healthcare workplace violence, and leadership sees a falsely calm picture. To change that:

• Make reporting fast, ideally a short form that takes a couple of minutes from any workstation or phone.
• Count verbal threats and near misses, not just injuries.
• Close the loop: tell staff what changed because of their reports.
• Offer post incident support, including time off the floor and access to counseling.
• Make clear that reporting will never be held against the employee.

Concerning behavior that points to planned violence, such as threats from a family member or a former employee, should go to a behavioral threat assessment team rather than sitting in an incident log.

When should you bring in a consultant?

Internal teams know the facility, but an outside healthcare workplace violence expert brings fresh eyes and a benchmark from other organizations. A consultant is especially useful when you are preparing for an accreditation survey, after a serious incident, when opening or renovating a unit, or when staff surveys suggest people feel unsafe. Look for direct healthcare experience; credentials from the International Association for Healthcare Security and Safety (IAHSS), such as the CHPA, or ASIS certifications like the CPP and PSP are useful signals.

You can compare specialists in our healthcare security consultant directory. OSHA’s workplace violence resources are a good free starting point before you engage anyone.