What will your staff members do when violence erupts in your workplace?

Recent incident, state actions raise awareness: You need policies

(Editor's note: This is the first part of a two-part series on workplace violence. This month, we tell you about a recent activity and how you should manage this problem. We also give you a checklist, sample policies, and advice on how to handle layoffs. Next month, we'll give you warning signs, advice on when to call the police, and an extensive list of resources.)

It's an incident every outpatient surgery manager prays they'll never have to face. An unemployed anesthesiologist in Florida has been arrested after police report he threatened former co-workers at a hospital and broke windows at two other medical facilities, according to a media report.1 The hospital had an injunction that prohibited his presence at the facility, according to the report. He faces two charges of criminal mischief, one charge of aggravated stalking, and one charge of resisting arrest without violence, it said. Another newspaper reported the men's restroom at the hospital was vandalized in a manner similar to vandalism against the anesthesiologist's former co-workers.2 He was being held without bail, the media reported.1

"This was a situation that was clearly escalating; and, in these situations, it is important to take the situation very seriously and bring in resources as needed," says Corinne Peek-Asa, PhD, professor of occupational and environmental health and director of the Injury Prevention Research Center, University of Iowa, Iowa City. "The action of the hospital may have helped this situation from becoming worse over time," Peek-Asa says.

This situation serves as a reminder of the importance of thoroughly researching a potential employee's history, says W. Barry Nixon, SPHR, executive director of the National Institute for the Prevention of Workplace Violence, Lake Forest, CA. Such scenarios potentially can be avoided "with a really good background check," he says.

The bottom line? You must expect and be prepared for violence, experts say. Nixon points out that there was a 13% increase in workplace violence homicides from 2006 to 2007, according to the Department of Labor/Bureau of Labor Statistics. While violent events in health care often go unreported, states are moving to change that tradition. Oregon's hospitals and surgery centers are implementing violence tracking programs. The Workplace Violence Prevention Law for Healthcare requires periodic security and safety assessments, regular training, and an assault prevention program. Since January 2009, hospitals and surgery centers have been required to report their workplace violence data on all assaults. (Editor's note: See workplace violence checklist from the federal government below. This checklist is part of U.S. OSHA's Guideline for Preventing Workplace Violence in Healthcare, which can be found at www.osha.gov/SLTC.)

Since January 2008, New Jersey has had a Violence Prevention in Healthcare Facilities Act, which requires hospitals and surgery centers to take steps to reduce the hazard of workplace violence. New Jersey is the third state, after California and Washington, to enact a law that specifically addresses workplace violence in hospitals. The law requires facilities to set up a committee of managers and frontline workers to conduct an "annual comprehensive risk assessment" and to develop a violence prevention plan. NJ facilities also are required to conduct annual training, including techniques to de-escalate violent behavior, to respond to violence, and to report violent incidents.

Workplace ViolenceAt some facilities, such as Providence Health and Services facilities in Portland, OR, every employee completes an annual module on workplace violence with their environment of care training. The initial course lasts eight hours, and the annual refresher is a four-hour course. Employees learn how to recognize warning signs, calm agitated persons, and de-escalate potentially violent behavior. If they are unable to diffuse the situation, employees learn how to protect themselves and the violent person with physical intervention. They then work with the person to respectfully diffuse the event.

The key pieces of an effective workplace violence prevention program include administrative policies and procedures, training, and environmental control, Peek-Asa says.

"Effective workplace violence prevention programs include policies and procedures that clearly state what the expectations for good conduct are, and what the consequences for violent actions or threats of violent actions — physical or psychological — are," she says.

Clearly define every employee's role, disseminate these policies to all employees, and provide training, Peek-Asa says. "The business should have grievance procedures so that problems are identified early and dealt with in a fair manner," she says. Develop and practice a protocol for threat assessment, Peek-Asa says.

Have a zero-tolerance policy for violence at work, and make it prominent in your handbook, suggests Sandy Seay, PhD, president of Seay Management Consultants, a human resources management consulting firm in Orlando, FL. (See sample workplace violence policy, left.) Seay is scheduled to speak on "Lateral Violence, Problem Employees & Other Challenging Staffing Issues" at this month's ASC Association meeting.

"Also ban weapons at work, and define what you mean by 'weapon,'" he says. "You don't want people coming to work with guns or long knives." However, keep in mind that some states, such as Florida and Georgia, allow employees to bring guns to a work location if they have a license and if the guns are kept locked in a personal vehicle, Seay adds.

Environmental control issues include good entrance and exit control, lighting, and visibility, Peek-Asa says. "Identify areas that might be vulnerable, and consider remediation such as access control or surveillance," she says.

The key to handling violence is to realize that it is not a rare situation, Seay says. "We have to expect it and prepare for it," he says.

Dawn Q. McLane, RN, MSA, CASC, CNOR, chief development officer of the Nikitis Resource Group, a Broomfield, CO-based company that specializes in surgery center development, management, and consulting, adds, "We take for granted that our workplaces are safe, and we take precautions to attempt to ensure that they are; however, we are living in extraordinary times."


  1. Abel J. Threats, violence, and vandalism. Tampa doctor accused of damaging medical centers. St. Petersburg Times, Feb. 3, 2009. Accessed at www.tampabay.com/news.
  2. Southmayd C. Anesthesiologist jailed on multiple charges. Belleair Bee, Feb. 4, 2009. Accessed at www.tbnweekly.com/pubs.

Workplace Violence Checklist

(Editor's note: This checklist is part of U.S. OSHA's Guideline for Preventing Workplace Violence in Healthcare, which can be found at www.osha.gov/SLTC.)

Designated competent and responsible observers can readily make periodic inspections to identify and evaluate workplace security hazards and threats of workplace violence. These inspections should be scheduled on a regular basis; when new, previously unidentified security hazards are recognized; when occupational deaths, injuries, or threats of injury occur; when a safety, health, and security program is established; and whenever workplace security conditions warrant an inspection.

Periodic inspections for security hazards include identifying and evaluating potential workplace security hazards and changes in employee work practices that may lead to compromising security. Please use the following checklist to identify and evaluate workplace security hazards. Every "true" answer indicates a potential risk for serious hazards:

True or False?

__ This industry frequently confronts violent behavior and assaults of staff.

__Violence has occurred on the premises or in conducting business.

__ Customers, clients, or co-workers assault, threaten, yell, push, or verbally abuse employees or use racial or sexual remarks.

__ Employees are NOT required to report incidents or threats of violence, regardless of injury or severity, to employer.

__ Employees have NOT been trained by the employer to recognize and handle threatening, aggressive, or violent behavior.

__ Violence is accepted as "part of the job" by some managers, supervisors, and/or employees.

__ Access and freedom of movement within the workplace are NOT restricted to those persons who have a legitimate reason for being there.

__ The workplace security system is inadequate — i.e., door locks malfunction, windows are not secure, and there are no physical barriers or containment systems.

__ Employees or staff members have been assaulted, threatened, or verbally abused by clients and patients.

__ Medical and counseling services have NOT been offered to employees who have been assaulted.

__ Alarm systems such as panic alarm buttons, silent alarms, or personal electronic alarm systems are NOT being used for prompt security assistance.

__ There is no regular training provided on correct response to alarm sounding.

__ Alarm systems are NOT tested on a monthly basis to assure correct function.

__ Security guards are NOT employed at the workplace.

__ Closed-circuit cameras and mirrors are NOT used to monitor dangerous areas.

__ Metal detectors are NOT available or NOT used in the facility.

__ Employees have NOT been trained to recognize and control hostile and escalating aggressive behaviors, and to manage assaultive behavior.

__ Employees CANNOT adjust work schedules to use the "Buddy System" for visits to clients in areas where they feel threatened.

__ Cellular phones or other communication devices are NOT made available to field staff to enable them to request aid.

__ Vehicles are NOT maintained on a regular basis to ensure reliability and safety.

__ Employees work where assistance is NOT quickly available.

Advice on how to handle layoffs

In these tough economic times, when people are losing their jobs, communication is the key to prevent worker-on-worker violence, says Corinne Peek-Asa, PhD, professor of occupational and environmental health and director, Injury Prevention Research Center, at the University of Iowa, Iowa City.

"Businesses with a good work culture, open communication, fair policies and procedures, and workplace violence policies will likely be ready to handle downsizing and layoffs," she says.

Keep employees informed of changes, the program's current financial position and, if there will be downsizing, who will be affected and how the decisions will be made, she suggests. "With good communication, perceptions of unfairness will be diminished," Peek-Asa says.

With the current scarcity of jobs, people might feel more anxious about finding another position, says Dawn Q. McLane, RN, MSA, CASC, CNOR, chief development officer of the Nikitis Resource Group, a Broomfield, CO-based company that specializes in surgery center development, management, and consulting. "This added stress has the potential to create a heightened emotional response, which, in some people, may result in a more violent reaction than it ordinarily would," McLane says.

Weapons at WorkHave a written layoff policy to ensure there is consistent guidance to managers and those leading the layoff process, says W. Barry Nixon, SPHR, executive director of the National Institute for the Prevention of Workplace Violence in Lake Forest, CA. Ensure that all people who will address terminated employees are trained in recognizing the early warning signs of potential workplace violence, appropriate ways to respond to upset or agitated employees (those who arrive angry), and that policies and practices have been tuned to treat employees in a respectful manner, Nixon says. "There are numerous examples of disgruntled employees being triggered toward violence by a sharp-tongued disability clerk or payroll reps," he says.

"Consistent practices are a critical element of the layoff process, Nixon says. "People will never be happy with getting laid off," he says. "However, what sets off the perception of injustice is where there are inconsistent applications of the policy and/or unfair decisions."

It's best to handle a termination at the end of the day, says Sandy Seay, PhD, president of Seay Management Consultants, a human resources management consulting firm in Orlando, FL. "That gives employees prone to violence less opportunity at the location to engage in violence," he says.

While some experts suggest terminating employees on a Friday, Nixon suggests you avoid that day. "This is convenient for the organization because it most likely parallels the pay period and is the end of the week; however, it is the worse time to terminate an employee because they have no avenues available to them to refocus on the future, but instead have the whole weekend to brew over 'how awful it is that you terminated them' and to conjure up all kinds of things," he says.

Midweek terminations are better because the employee can immediately apply for unemployment, start putting in applications at other firms, talk to counselors, handle other business matters, and take other positive steps, he says. "The key is to shape your termination/layoff policy from the viewpoint of the impacted person, not from the viewpoint of what is easy for the organization," Nixon says.

All aspects of the termination process should be tuned to treat people with dignity and respect, he says. It also is a good idea to offer terminated employees some type of assistance package that can include severance, job counseling and placement services, and extended benefits such as EAP, Nixon says. "It helps to soothe the pain," he says.

Always alert security staff that you are terminating or laying off an employee, Seay advises. "It's always better to escort employees off the premise rather than just let them go," he says. Otherwise, they might destroy property on their way out, warns Seay, who knows of one employee who destroyed thousands of dollars of computer equipment after being terminated.

Always have a witness in the room with you when you're delivering layoff or dismissal news, Seay advises. The conversations should be short, he says. "There's an old saying, 'The more you say, the more you pay.'"

Have a prearranged sentence or paragraph that you'll use to deliver the news, Seay says. Resist the temptation to explain, he says.

Clearly communicate what the expectations are, and explain that these are policy-based and not just for the single individual, Peek-Asa says. For example, is the employee expected to remain off of the business property? Usually this step is advised as a policy, Peek-Asa says. When is the employee expected to have his or her personal items removed? Usually right away, she says.

"It is also important to communicate what is available to the employee, such as any training opportunities, if a reference letter be provided, and information about employment resources within the business and in the community," Peek-Asa says.