By Gary Evans, Medical Writer

There are signs that the historical complacency and “part-of-the-job” acceptance of healthcare violence is ending.

The horrific accounts of attacks on healthcare workers have humanized the problem, the opioid epidemic has highlighted the dangers in EDs, and a recent study found that overall violence appears to be increasing in hospitals.1

The issue may be reaching a tipping point, translating to political momentum at the state and federal level. While more states are adopting laws on violence prevention in healthcare, long-sought federal action has been stalled out time and again. The latest proposal for a national law comes with the recently introduced “Workplace Violence Prevention for Health Care and Social Service Workers Act.”2

Introduced by Rep. Joe Courtney, D-CT, and 20 congressional co-sponsors, the bill would require healthcare employers to develop, at a minimum, workplace violence prevention plans based on 2016 guidelines from the Occupational Safety and Health Administration (OSHA).3

“This [OSHA] guidance is not enforceable,” according to the bill. “Absent an enforceable standard, employers lack mandatory requirements to implement a violence prevention program, and workers lack sufficient protection from workplace violence.”

After opening a request for information in 2016, OSHA announced on Jan. 10, 2017, that it would promulgate a federal regulation to protect healthcare workers from violence.4 However, the action was a nonstarter with a new administration coming in to power.

“OSHA’s efforts to move forward with rulemaking have been halting and inconsistent,” the proposed bill states. “Therefore, legislation is necessary to ensure the timely development of a standard to protect workers in healthcare and social service settings.”

The OSHA guidelines that the bill would codify into law cover key aspects of a violence prevention program, including management commitment, worker involvement, training, reporting, and assessing the risk of violence to employees. The risk assessment poses such questions as:

  • Do the employees work alone?
  • Do they work late at night or during early morning hours?
  • Is the workplace often understaffed?
  • Is the workplace located in a high-crime area?

The Joint Commission May Cite

While the federal bill comes amid shifting political power that could favor its passage, some hospitals are moving ahead to establish comprehensive programs. In April 2018, The Joint Commission (TJC) issued a Sentinel Event Alert5 on violence, reminding healthcare facilities that several current standards can be cited if hospitals refuse to act to protect workers. Key provisions in the alert include that accreditation surveyors will be looking at reported violent incidents, leadership response, and trends in violence and injuries. TJC also may survey workers to assess the effectiveness of interventions to prevent violence.

Although various iterations of these standards, guidelines, state laws, and proposed bills are similar in substance and recommendations, federal regulation has been seen by many as the best long-term solution. That said, there are familiar concerns that federal legislation may be counterproductive if it contains “unfunded mandates” and limited local flexibility once implemented.

“As with anything in government, it’s hard to enact and it’s hard to change,” says Scott Cormier, CHEP, NRP, vice president of emergency management, environment of care, and safety at Medxcel, a healthcare facilities management company in Indianapolis. “Our workplace violence programs need to be very fluid, so as we gather more information and see better results from best practices, we can implement those.”

There is a problem that must be addressed through federal and state regulations or a call to voluntary action at the local level, he says.

“According to OSHA, there is four times more workplace violence in healthcare than any other industry,” Cormier adds. “Workplace violence can be as simple as somebody reaching to grab your arm, to people being assaulted with weapons.”

Any federal regulation should recognize the difficulty of preventing violence, which can be unpredictable, an occupational health nurse says. JoAnn Shea, ARNP, MS, COHN-S, director of employee health and wellness at Tampa General Hospital, says she could support a regulation if it recognized such caveats and did not penalize hospitals acting in good faith.

“Yes, as long as it is reasonable for healthcare organizations,” Shea says. “With workplace violence, there are so many variables and unknowns. You don’t want OSHA to come in and ding a hospital that is trying to put a good program together. Things happen, but I think a lot of hospitals are really trying hard to address this issue now.”

Comprehensive Upgrade

Shea and colleagues responded to the Joint Commission alert by taking a hard look at their violence prevention program and implementing a comprehensive and ongoing upgrade. The hospital formed an antiviolence committee that incudes members from nursing, employee health, psychiatric nursing, security, management, and compliance.

“My work comp manager and I are both on the committee,” Shea says. “We are taking a very proactive approach to this, and the goal is zero harm to patients and staff.”

The program still is something of a work in progress, but data are emerging that will inform future violence prevention efforts.

“We’ve had 31 injuries related to patient violence in 2018,” Shea says. “They actually came to employee health and reported an injury. Some are minor, sometimes they get hit in the nose or they fracture a finger as a patient pulls at them. Most of these patients are very confused.”

Injured healthcare workers also are given psychiatric care and counseling as needed after a violent incident.

“This can be very emotionally difficult for the healthcare worker,” Shea says. “People have really gotten hurt, and then they are afraid to come back to work, so we provide them a lot of counseling.”

Even verbal abuse, which often is not reported, can be very difficult to deal with, she adds.

“When I was a [staff] nurse people verbally abused you, and you were supposed to just shake it off,” she says. “I think nowadays patients are even less respectful to healthcare workers. It is difficult to come into a work environment where patients are verbally abusing you.”

Being a large teaching hospital and a Level 1 trauma center with a psychiatric unit, Shea sees a steady inflow of patients at risk of committing violence.

Communication Breakdown

“We are really taking this seriously,” she says. “The main thing is collecting all the data and looking at how many verbal assaults, physical assaults, and near-misses we are having. We want our staff to feel safe.”

An initial finding was that reports of violent incidents were logged in unconnected databases, with employee health, security, risk management, and other departments collecting siloed information that was not necessarily shared.

“We realized with violence, that if someone is injured at work, they come to employee health [and] we are collecting that data,” Shea says. “But one of the missing pieces we identified is a central repository. Nobody was really talking to each other.”

Realizing the data from violent injuries and codes were not being pooled, Shea and fellow committee members are developing a central repository to collect and aggregate all incident data.

Hospital security collects data on codes called for a violent incident or an escalating situation. The hospital calls a Code Gray for patient violence and a Code Bert to summon security for a tense situation that threatens escalation. “Security tries to defuse the situation, and that has been very successful,” Shea says.

Near-misses include patients attempting to hit healthcare workers, lashing out, or acting like they have the potential for violence. These incidents often are not reported, but Shea and colleagues are trying to raise awareness about all aspects of violence.

“We are centralizing all of this so we can do aggregate reports by department,” Shea says. “We need to get a better feel for how common these situations are. It’s all over the place right now, but we are moving in the right direction.”

Risk assessments are an important part of the program and are conducted regularly.

“We have psychiatric nurses that make rounds,” she says. “They assess all the psychiatric patients and identify risks and see if we need to intervene. We also have a lot of severely disabled patients, and they might kick a nurse or something.”

In some cases, given the patient’s condition, healthcare workers are reluctant to report these incidents.

“They feel bad, but we tell them they are not getting the patient in trouble — we just need to know,” she says.

To overcome reluctance to report, Shea is setting up an anonymous reporting system so that workers can report threats and violent incidents without identifying themselves.

“People don’t always want to report patients — they feel like [violence] is part of their job,” she says.

All violent incidents that result in an occupational injury are subject to root cause analysis, with the central question: How could this injury have been prevented?

Shea’s committee meets once a month, but more frequent huddles are used to identify patients who are potentially violent. Education and training increase awareness of the problem and emphasize the need to report all incidents. This training begins with orientation sessions for new employees but also is available for those already on staff. A link on the employee computer portal prompts workers to take the training.

“We also have two or three off-duty police we hire, including one in the ER,” Shea says. “We have armed some of our security guards, too. They have tasers, but we also armed them with weapons recently. They are trained.”

The hospital also teaches self-defense classes for workers and conducts active shooter drills.

Run, Hide, Fight

Cormier co-chairs a federal committee that publishes guidance on preventing, responding to, and recovering from active shooter incidents in healthcare.

“We update that guidance every two years,” he says. That means an update will be coming this year, with the most recent report issued in 2017.

The “run, hide, fight” approach is recommended, meaning evacuate the target area if possible, find a secure place to hide or deny access, and as a last resort, “make the personal decision to try to attack and incapacitate the shooter to survive.”6

The report also addresses the complex ethical decisions that arise during an active shooter situation in a hospital.

“Some ethical decisions may need to be made to ensure the least loss of life possible,” Cormier and colleagues report. “Every reasonable attempt to continue caring for patients must be made, but in the event this becomes impossible without putting others at risk for loss of life, certain decisions must be made.”

Open discussion and preparation before an incident occurs certainly is preferable to dealing with these questions in the moment. Cormier and the panel recommend allocating “resources fairly, with special consideration given to those most vulnerable.” Although urging healthcare workers to “limit harm to the extent possible,” the report acknowledges that “with limited resources, healthcare professionals may not be able to meet the needs of all involved.”

Remove as many barriers as possible to reporting incidents, as healthcare workers concerned for their patients’ welfare may be reluctant to be drawn into a prolonged process, he urges.

“In one of our inner-city hospitals, if a healthcare worker is assaulted but doesn’t require hospitalization, the local police department refuses to come take a report,” he says. “If they want to report it, they have to take time to drive down to the police department and stand in line. The employees don’t want to be taken away from caring for their patients.”

Reluctance to report violence is a deeply rooted problem, but basic improvements in the process may increase worker participation.

“Primarily, you have to have a reporting system that the employees are willing to use and is easy to access,” Cormier says. “If your reporting process is filling out a form that takes 30 minutes, they are not going to do it. They want to spend that 30 minutes caring for their patients. That is how dedicated healthcare workers are.”

In addition, the reporting process should be available at all hours on all shifts.

“If you are working nights on weekends, you should have the same accessibility to it as somebody that works daytime during the week,” he says.

Be aware that employees will likely become skeptical of the benefits of reporting if they see no action is being taken to address violence problems, he adds. Cormier recommends forming a crisis management team much like the one Shea describes, which should open a line of communication with local law enforcement before an incident occurs.

“They need to understand your processes because if they don’t, they are going to come in to it blindly,” he says.

The violence prevention committee should look at the big picture, including addressing the full continuum of care and educating nonclinical staff such as environmental service workers.

“We need to be inclusive with these partners so they are part of our threat assessment team,” he says. “Counselors in hospitals need to be part of the team, especially when it comes to the point of response. We need to have the resources in place to support our employees both physically and emotionally.”


  1. Groenewold MR, Sarmiento RFR, Vanoli K, et al. Workplace violence injury in 106 US hospitals participating in the Occupational Health Safety Network (OHSN), 2012-2015. Am J Ind Med 2018;61:157–166.
  2. U.S. Congress. Workplace Violence Prevention for Health Care and Social Service Workers Act. Nov. 14, 2018. Available at:
  3. OSHA. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 3148-06R 2016. Available at:
  4. OSHA. Prevention of Workplace Violence in Healthcare and Social Assistance. Fed Reg 2016-29197, Dec. 7, 2016. Available at:
  5. The Joint Commission. Physical and verbal violence against health care workers. Sentinel Event Alert 59: April 16, 2018. Available at:
  6. Healthcare and Public Health Sector Coordinating Council. Active Shooter Planning and Response: Learn How to Survive a Shooting in a Healthcare Setting. 2017. Available at: