Two veteran occupational health nurses described their experiences with workplace violence over the years, emphasizing this chronic situation can be stopped if individual hospital leaders set a tone that enough is enough. If they are to succeed, they must address all facets of a comprehensive violence prevention program, the nurses said at a Caring for Healthcare Professionals podcast by the Association for Occupational Health Professionals in Healthcare (AOHP).1

Donna Zankowski, MPH, RN, FAAOHN, an occupational health nurse consultant in Maryland, started focusing on workplace violence in 2014.

“I was a graduate nurse intern at OSHA in the office of Occupational Medicine and Nursing,” she said. “I did a research project for them looking at the contents of these commercially available workplace violence prevention programs that hospitals were buying to train their employees with. And that project really encouraged me to want to get more involved from an advocacy perspective.”

It has been delayed and blocked for years, but OSHA proposed a violence prevention as the Obama administration came to an end in 2016. Such regulations were a nonstarter in the succeeding Trump administration.

“There is federal legislation right now on workplace violence prevention that would basically mandate OSHA to hurry up and issue that workplace violence standard,” Zankowski said. “That particular legislation is the Workplace Violence Prevention for Health Care and Social Service Workers Act. It has passed the House.”

A career nurse, Zankowski said violence against healthcare workers has always been more the rule than the exception in the facilities she has worked at over 35 years.

“I’ve seen workplace violence in every single facility I’ve ever worked at,” she said. “I was an ICU nurse, a case manager, a discharge planner, and I did home care — and, of course, then, occupational health. But I’ve seen it in every possible setting. A lot of the workplace violence is coming from patients; it’s patients on staff. But as you know, we have the other types as well.”

The violence appears in myriad forms, from someone coming in to commit a crime (often with a weapon) to domestic situations that have spilled over into the workplace.

“You’ve got violence between co-workers — I’ve seen that as well. Sometimes, it’s physical; sometimes, it’s verbal abuse and bullying,” Zankowski noted.

Mental Health in Teens

Amy Straight, RN, MBA, interim director for occupational health and safety at Seattle Children’s Hospital, said she is seeing a mental health crisis in youth that results in violence in the ED and psychiatric units.

“These behaviors are really aggressive in terms of what we’ve seen in the past,” Straight noted. “More biting, more hitting, more punching and kicking vs. the verbal types of assaults we’re normally used to seeing. Sadly, through the pandemic, we’ve also noticed an increase in racial violence and discrimination and microaggressions in the workplace that are starting to play out as people are experiencing racism in the community.”

Zankowski stressed the importance of violence prevention programs requiring reporting of all incidents.

“We all know that workplace violence is really underreported — severely underreported,” she said. “I’ve seen a lot of nurses don’t want to report when they get hit, bit, or punched. They make excuses: ‘Well, the person was just upset, in pain, [or] a little confused because the room was dark.’ To my mind, none of those things actually matter in terms of creating your workplace violence prevention program. [You must] account for the numbers and report the workplace violence. Because regardless of why it’s happening, we still need to have an accurate picture of how much it’s happening.”

Even if initially reported, breakdowns in the communication chain leave islands of data here and there, unknown to all the principals in the program.

“Many times, people will report [violence] to their direct supervisor, but they don’t report that to employee health,” Zankowski said. “It’s a major issue because sometimes reports go to security, and then it ‘lives’ there. Then, sometimes it goes to employee health if the worker is injured. Facilities that find a way to integrate all the reporting do much better with their workplace violence prevention.”

Leadership or Leaderless?

A fully functioning program that expects and receives compliance from workers requires leadership that sets the tone of the institutional culture.

“I think the facilities that have really involved leaders that care deeply about the workplace violence program do better, because management is completely on board with making sure that the program is successful and the numbers go down,” Zankowski said.

More leadership involvement should be forthcoming, as The Joint Commission’s new violence prevention requirements become effective Jan. 1, 2022.

“It has it has to start with culture,” Straight emphasized. “You have to have a culture of safety for any policy or program to be effective when implemented. You can have all the technologies, tools, and resources and everything at your disposal, but if you don’t have a culture that is committed to it, you’re not going to be [successful].”

Violence prevention is not a program to set up and walk away from, intending to check the data occasionally but perhaps getting lost in the day-to-day crises in healthcare.

“This program that really requires constant eyes on it, constant auditing of your strategies,” Straight said. “[Use] metrics to start looking at where you’re making those positive changes, then you can start to use that data to drive forward other strategic initiatives with workplace violence.”

Look for the root cause of incidents, which will help prevent recurrence. “It’s not just saying, ‘Well, the nurse didn’t do this or we were short-staffed.’ I mean, that’s not good enough,” Zankowski said. “We really need to get down to the root causes so we can make things better.”

Another longstanding problem is the policy and legal inconsistencies between some states and individual hospitals. In some states, attacking a healthcare worker is a felony. Similarly, in some hospitals, management encourages workers not to file charges against the patient who attacked them. Sometimes, employees are afraid to file criminal charges for their reasons of their own.

“Even if you do file criminal charges, or you try to, if your local state attorneys are not inclined to prosecute it, it really doesn’t matter,” Zankowski lamented. “We have found in Maryland that you really need to do education with your state’s attorneys to have them understand the nature of the violence, that this is not part of our job, and that, yes, these really are crimes when they escalate to that level. They should be prosecuted to the fullest extent of the law.”

Patients should understand healthcare workers are valued and protected when they enter the hospital.

“When they walk through your doors, is there an exception that’s made for them to act that way?” Straight asked. “If so, we should not be accepting that as normal behavior. There should never be allowance for any of that.”

One facility reinforced this by requiring patients to sign a behavior contract, explaining that if they become violent or disruptive, they could be discharged from care.

“They would still be allowed to be admitted to the facility for an emergency,” Zankowski explained. “If they came to the ER, they’d be accepted, but they couldn’t come back for elective procedures if they weren’t willing to abide by the behavioral expectations.”

On the other hand, hospitals are a business that need high patient satisfaction scores for marketing and to secure return customers.

“The staff is feeling like, ‘We can’t win here,’” Zankowski said. “Because if we get bad satisfaction scores, then they come down hard on us for not making the patients happier. But we also have to make patients be accountable for their behavior.”


  1. Association for Occupational Health Professionals in Healthcare. AOHP Caring for Healthcare Professionals podcast, episode 14: Workplace violence prevention in healthcare. July 22, 2021.