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September 13, 2016

Workplace Violence in Health Care: A Critical Issue With a Promising Solution

Author Affiliations
  • 1Office of Quality and Patient Safety, The Joint Commission, Oakbrook Terrace, Illinois
  • 2Workplace Violence Prevention Program, Veterans Health Administration, Oregon Health and Science University, Portland
JAMA. 2016;316(10):1037-1038. doi:10.1001/jama.2016.10384

Workplace safety is a critical issue in health care. The National Institute for Occupational Safety and Health defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed towards persons at work or on duty.”1 This Viewpoint discusses the scope and characteristics of workplace violence in health care settings, relevant government regulations, the responsibility of health care leaders in addressing workplace violence, a model program for violence prevention in health care settings, and a comprehensive environmental risk analysis.

Extent and Characteristics of Workplace Violence in Health Care

Approximately 24 000 workplace assaults occurred in health care settings between 2010 and 2013, resulting in major and minor physical injury, psychological harm, temporary or permanent physical disability, and death.2 The Joint Commission analyzed 33 homicides, 38 assaults, and 74 rapes in health care workplaces from 2013 to 2015. Health care workers identified in these events included 10 nurses, 2 physicians, 3 security employees, and 7 other health care workers.3 These sentinel events resulted in death, permanent harm, or severe temporary harm. The most common root causes of these events were failures in communication, inadequate patient observation, lack of or noncompliance with policies addressing workplace violence prevention, and lack of or inadequate behavioral health assessment to identify aggressive tendencies in patients.3 Comprehensive behavioral health assessments may be able to identify biopsychosocial factors known to increase the risk of violent behavior.

In US hospitals, there has been an increase in violent crime, from 2.0 events per 100 beds in 2012 to 2.8 events per 100 beds in 2015.3 A disproportionate number of aggravated assaults (44%) and other assaults (46%) occurred in emergency departments compared with the entire hospital.4 Bureau of Labor statistics data document that while less than 20% of workplace injuries involve health care workers, 50% of workplace-related assaults involve health care workers. In 2013, 27 of 100 health care worker or patient fatalities in health care settings were attributable to assaults and violence.2

Workplace violence in health care includes verbal, sexual, and physical assaults; threats; stalking; intimate partner violence; and homicide. In addition to emergency departments, workplace violence most frequently occurs in behavioral health settings, extended-care facilities, and inpatient units.6 Female nursing staff and psychiatric assistants most frequently experience assaults.5 Approximately 60% of reported threats and assaults occur between noon and midnight.5

Government Regulations Addressing Health Care Workplace Violence

The Occupational Safety and Health Act of 1970, 26 states, and 2 US territories now require elements of comprehensive health care violence prevention programs. A 2016 Government Accountability Office report made recommendations for how violence prevention in health care settings is addressed in the United States.7 The office recommended that the Occupational Safety and Health Administration develop, implement, and enforce standards addressing the unique attributes of violence prevention in health care workplaces, including penalizing employers for exposing employees to potential workplace violence. A specific example is exposing employees to the hazard of violent behavior and being physically assaulted by patients with known histories of violence or the identified potential for violence.

Leadership Responsibility

Leadership commitment is manifested by establishing a violence prevention program, encouraging reporting of violent and behavioral safety events, reassuring employees that appropriate actions will be taken, engaging personnel and patients in safety plans, and measuring performance of violence prevention programs.

Although zero-tolerance policies for workplace violence have been suggested, such language may create barriers to program success by inhibiting reporting of safety issues and concerns. Rather, leaders have a duty to their employees to institute programs and ensure adherence to policies requiring all reported events be taken seriously, assessed appropriately, and managed individually and ethically.

Health Care Violence Prevention Program: Model and Process

Workplace violence prevention should be part of new-employee training and ongoing training of existing employees. Programs aimed at prevention of workplace violence should include employee training and awareness, reporting, threat assessment, management plans, and a communication strategy. All employees should have training relevant to the risk for violence that may exist in their respective workplaces.

Reporting is an essential element of a successful workplace violence prevention program. Without efficient and fully utilized event reporting systems, employees have a limited ability to communicate their safety and risk issues to leadership. Reporting helps leadership develop relevant violence prevention programs. However, personnel underreport violent events because they believe these experiences are part of the job, reporting is either cumbersome or unlikely to result in action from leadership, or they fear retaliation for reporting.6 For these reasons, reporting systems should be simple, trusted, secure, and with optional anonymity; result in transparent outcomes and delivery of a report confirmation; and be fully supported by leadership, labor unions, and management.

Every report of alleged workplace violence should be assessed and managed individually, using evidence-based, data-driven assessment of violence risk and management best practices, and involve a multidisciplinary team trained in the fundamentals of violence risk and threat management. Multidisciplinary threat assessment teams usually operate under the authority of a facility’s chief medical officer and are chaired by senior clinicians trained in threat assessment practice (most commonly, behavioral science professionals). Team members should include representatives from the behavioral sciences, security/law enforcement, labor union(s), known high-risk workplaces, employee education (eg, trainers), patient advocates, and legal counsel.

If the reported behavior is determined by the multidisciplinary threat assessment team to pose an ongoing safety or security risk, then a treatment and safety management plan should be developed and implemented to reduce the likelihood of safety risk exposure. Such plans augment relevant protective factors and reduce identified risk factors. Management plans may include noninvasive interventions (eg, conversation with the individual or individuals; written letters expressing behavioral expectations) to more restrictive approaches (eg, limiting the time, place, or manner in which safe and effective health care may be delivered). The safety management plan should not permanently bar an individual from care.

Informing employees of the management plan should enable the ongoing cycle of effective violence prevention programming: employees are educated and trained regarding the management plan and have the skills necessary to implement it; they report the outcome of implementing the plan; information regarding the management plan’s effectiveness is assessed (or reassessed) and modified according to risk; and such modifications are then communicated back to employees.

Environmental Analysis and Interventions

Organizations should assess risk factors for violence in the internal environment and the surrounding community. Internal environmental assessment focuses on dynamic factors (eg, staffing levels, census, weather, and traffic) and static factors (eg, floor plans, alarms, surveillance equipment, entry points, and reception areas). The surrounding community should be assessed by examining the type and severity of crime and violence, including the frequency with which the health care organization provides care for victims of violence. Physical security measures should align with known risks of community-based violence migrating into the health care setting. Recurrent comprehensive environmental risk analysis identifies emerging vulnerabilities, allowing for relevant employee training, proactive modification of existing processes, and the development of new risk management measures.


Workplace violence prevention should be addressed aggressively and comprehensively in health care. Safety in health care workplaces relies on leadership enacting appropriate policies; trained employees intervening and reporting; multidisciplinary teams using evidence-based threat assessment and management practices, communicating safety plans, and analyzing the environmental context; and ongoing evaluation of program effectiveness. A workplace violence prevention program should be a required component of the patient safety system of all health care organizations. Comprehensive patient safety systems can effectively manage a broad range of worker safety risks in health care, including workplace violence.

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Article Information

Corresponding Author: Ron Wyatt, MD, MHA, DMS (HON), Office of Quality and Patient Safety, The Joint Commission, One Renaissance Blvd, Oakbrook Terrace, IL 60181 (

Published Online: July 18, 2016. doi:10.1001/jama.2016.10384.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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