Surgery centers can work to prevent workplace violence by following a strategy that includes culture changes, data collection, and conducting analyses.

There are no federal standards or regulations for workplace violence prevention; everything is advisory, but there are some key elements to prevention and actions healthcare organizations can take, according to Judy Arnetz, PhD, MPH, PT, with Michigan State University. She offers the following tips for ASCs:

Obtain management commitment and employee participation. “Management has to be committed to creating a culture in which efforts are made to mitigate or reduce and prevent violence as far as possible,” Arnetz says. “Management has to recognize that idea and recognize violence as an occupational hazard.”

Employees must shoulder responsibility, too. “They have to abide by policies, report incidents when they occur,” she says.

Guidelines from the Occupational Safety and Health Administration (OSHA) specifically address healthcare workers. ASC staff should be aware of fully aware of these guidelines.

Collect data about an organization’s incidents of violence. Each surgery center needs to know whether and how employees experience workplace violence. Incidents might involve violence from patients and their visitors, bullying from supervisors or managers, or worker-to-worker violence.

“There are many terms included in describing workplace violence,” Arnetz explains. “We talk about disruptive behavior, incivility, bullying, lateral violence, or horizontal violence.”

Horizontal violence is expressed in overt and covert hostility, and it can devastate healthcare staff, resulting in high turnover rates, decreased productivity, and more illnesses.1 A lot of what is considered a form of violence might include behavior that is not physical, which needs to be studied differently, according to Arnetz.

“There are different risk factors and interventions that are part of the worker violence spectrum,” Arnetz says. “The Joint Commission sees violence as a huge risk, not just for worker well-being and safety but also for overall health of the hospital or organization.”

As an accrediting body, The Joint Commission wants to see that healthcare organizations are taking proper steps to reduce and prevent violence. Collecting data is an important first step.

Conduct a worksite analysis. First: Know the site’s risks. “We usually talk about doing a worksite walkthrough,” Arnetz says. “Go through the unit to see if there are any physical things that could be done or things that pose risk.” For example, a room might lack a fire alarm or lack barriers between reception desk staff. The analysis should be based on data, too, Arnetz explains.

“Unless you know the types of incidents that occur and where they occurred, it’s difficult to do a workplace analysis,” she says. “Always begin with data.”

Enforce hazard prevention and control processes. “What we have looked at in our studies and what OSHA suggests is you look at environmental things, engineering controls,” Arnetz says. “Can you improve lighting in a certain area? Can you make more space? Can you make sure you have two exits instead of just one in the treatment room?” Healthcare organizations can create a way of flagging charts of patients known to be violent. They also can develop de-escalation training for every employee who interacts with patients and the public, Arnetz says.

Provide safety and health training. Among other regular training sessions, an ASC could include training to raise awareness about workplace violence prevention policies and de-escalation training.

The National Institute for Occupational Safety and Health offers a training module for nurses on workplace violence. The course teaches how to identify factors contributing to workplace violence, behavioral warning signs, communication and teamwork skills to prevent violence, and how to find resources for injured workers, as well as the steps to take to implement a comprehensive workplace violence prevention program.

Other training might involve active shooter skills. Many hospitals are implementing this type of training, Arnetz notes. “Regular training is the way to stay safe and healthy,” she adds.


  1. Bloom EM. Horizontal violence among nurses: Experiences, responses, and job performance. Nurs Forum 2018; Oct 17. doi: 10.1111/nuf.12300. [Epub ahead of print].

Risk Factors Checklist

OSHA has developed a checklist for healthcare sites that includes these potential risk factors:

  • Working with people who have a history of violence;
  • Transporting patients and clients;
  • Working alone in a facility or in patients’ homes;
  • Poor environmental design of the workplace that blocks workers’ vision or interferes with their escape from a violent incident;
  • Poorly lit corridors, rooms, and parking lots;
  • Absence of emergency communication;
  • Lack of staff training for de-escalating hostile behavior;
  • Understaffing;
  • High worker turnover;
  • Inadequate security and mental health personnel;
  • Long waits for patients and overcrowded waiting rooms;
  • Unrestricted movement of the public;
  • Perception that violence is tolerated and victims cannot report the incident to police;
  • Patients with firearms, knives, and other weapons;
  • Location in areas with high crime rates.