Stop the violence: Assault risk high for health care workers

Hospitals assess threats, set zero tolerance’

"You killed my mother!" the man shouted as he began shooting in the corridors near where patients awaited surgery at West Anaheim (CA) Medical Center. Less than an hour before, his 72-year-old diabetic mother had died at the hospital. He returned with a .357 Magnum, apparently targeting those who had cared for her. By the time he was subdued, three employees had died — a nursing assistant, the pharmacy director, and the director of environmental services.

That is every hospital’s nightmare, come to life last January. Such homicides are rare, but the incidents of verbal abuse or physical assault are shockingly commonplace. More nonfatal assaults occur in nursing homes and hospitals combined than in any other workplace.1 Nurses and other health care workers report being punched, slapped, choked, and even thrown across the room. A survey of 475 surgical residents nationwide found that 60% had witnessed a physical attack and more than a third had been attacked.2

While overall the rate of occupational injuries has declined in the past five years, workplace violence has shown no consistently downward trend. Some 7,800 cases were reported in hospitals in 1998, and patients were the main source of injury. Hospitals in England have set "zero-tolerance" policies for assaultive behavior, but many U.S. hospitals are just beginning to recognize the problem of workplace violence.3

The potential for violence exists in every facility and in every community, notes an official with the U.S. Occupational Safety and Health Administration (OSHA) who specializes in workplace violence issues. "If you haven’t typically had a reporting mechanism in place [for assaultive incidents], you may not think you have a problem," she says. "Most of the time there is a problem, and people haven’t been encouraged to report it."

Emotions are at their peak when the stakes are high. Emergency department (ED) staff are well aware of the potential for explosive situations, and many EDs have implemented security measures to limit access. But a locked door, metal detector, and security guards aren’t the ultimate answer to workplace violence, experts say. Hospitals need a comprehensive approach that includes a risk assessment, staff training, and supportive policies. "It’s our recommendation that everyone look at the issue of violence and have a program in place," says the OSHA official.

In 1998, OSHA published Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, outlining components of a violence prevention program. (See "Elements of a violence prevention program," in this issue.) While some elements were later incorporated in the security standard of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, OSHA’s guidelines are voluntary and not regulatory.

States with their own occupational safety and health regulations may have additional requirements. For example, the hazard analysis conducted as a part of California’s required injury and illness prevention program must include violent injury.

Last year, the Atlanta-based American Association of Occupational Health Nurses (AAOHN) in Atlanta issued a position statement urging occupational health nurses to take an active role in violence prevention activities. "Many times, occupational health nurses are the only health professionals dealing with worker behavior and worker health. We felt that was an untapped resource," says Deborah V. DiBenedetto, MBA, RN, COHN-S/CM, ABDA, an occupational health consultant based in Yonkers, NY, and president of AAOHN.

A violence prevention program may fit into a broader context of creating a workplace free of sexual or physical harassment, as it does for Allina Health System in Minnesota. In a survey of about 3,300 Allina employees, 29% reported that they had witnessed violence in the workplace in the past 12 months. While physical threats or actions are most likely to come from patients or their family members, incidents of emotional abuse often come from peers, physicians, or managers, says Marlene Jezierski, RN, Allina violence prevention educator. "I’m a nurse; I’m from the [ED]. I had a good idea what’s out there. I wasn’t surprised [by the survey results]. But some people were quite surprised."

That is why OSHA recommends that hospitals conduct a hazard analysis for violence prevention. Many incidents may go unreported, and therefore hospital management may not realize the extent of the problem. "In the health care setting, people haven’t tended to think of it as workplace violence until the government and others started describing it that way," says the OSHA official. "[For example,] for years, psychiatric workers and nurses have endured attacks from patients. They just looked at it as part of the job."

The first step toward stopping verbal and physical abuse is simply to refuse to accept it. At Allina, a brochure urges employees to "stand up against workplace violence." Managers are trained to "reflect a zero tolerance for any workplace violence such as disrespectful language; aggressive, threatening behaviors; or immediate threat to personal safety." Even job interviews include questions designed to gauge a propensity for violent or aggressive behavior.

"I think one of the things that helps is telling people that they have a right to not be treated [in an abusive] way," says Jezierski. "I think that’s a very important message we give employees." At the same time, Allina stresses that employees must respond to other people "respectfully, objectively, and without making assumptions — even when the other individuals are being offensive and disrespectful," she notes.

Mercy and Unity hospitals, members of the Allina system, post the following statement:

"The administration and employees of Mercy and Unity hospitals are committed to providing a therapeutic environment, free from violence in any form, to promote health within our community. We believe that each person, including patients and visitors, has a responsibility to maintain respectful, safe behavior in all their interactions while at Mercy and Unity hospitals. We will hold all individuals responsible for the effect their behavior has on our community."

Perhaps the ultimate example of a zero-tolerance policy comes from Great Britain, where the health secretary announced that hospitals could refuse to treat patients who threatened or attacked health care workers. After a first incident, patients would receive a written warning. If violent or threatening behavior continued, the hospitals could refuse treatment. The policy would not apply to patients suffering from severe mental illness or life-threatening conditions.

Another way hospitals can show that they do not tolerate violence is by prosecuting those who assault employees, notes Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto. "The proper decorum hasn’t traditionally been enforced [in hospitals] as it has in other parts of life," Lantos contends. "It’s a place where they feel it’s safe to let loose. Rarely are there repercussions. There’s a tendency for the workplace to become more and more violent because it’s tolerated."

While making employees aware of their right to a violence-free workplace, hospitals also need to educate them about how to identify and defuse aggressive behavior. John Byrnes, DHum, president of the Center for Aggression Management in Winter Park, FL, identifies the stages of behavior that lead to aggression, which he calls "the trigger phase, the escalation phase, and the crisis phase."

The trigger phase can comprise a series of anxiety-producing events, such as when a person oversleeps, rushes to get to work, then encounters an unexpected traffic jam. "When a person stops coping with their anxiety and stress, they enter into the escalation phase and they have mounting anxiety," says Byrnes. "It changes our behavior, our body language, and how we communicate. We can identify these changes. We teach people how to identify the emergence of aggression so they can foresee the possibility of conflict. That foreseeability is essential," he says. "Imbedded in that foreseeability is the imperative to do something now."

When health care workers encounter an agitated patient or family member, they should try to engage the person and connect with them, Byrnes advises. As an example, he relates a story of a man in his mid-50s who went to a hospital to visit his sister, a woman in her 70s who was suffering from advanced dementia. He found her in a corner of the room completely naked, covered in feces. He exploded and strode to the nurses’ station. The nurses pointed him to the head nurse’s office, where he barged through the door. She immediately told him, "If I ever found myself in the circumstances your sister is in, I pray I have someone like you as an advocate." The man fell to his knees in tears. "It’s very difficult for an aggressor to become aggressive with someone they perceive as genuinely trying to help," Byrnes comments.

Spot trends to lower potential for violence

The triggers for aggression don’t lie solely in individual circumstances. By examining trends, a hospital may be able to make changes to reduce the potential for violence, says Steve Kaufer, CPP, co-founder of the Workplace Violence Research Institute in Palm Springs, CA. "If you’re always having conflict in the waiting area in the emergency department, why is that?" he says. "Is it that there aren’t enough staff people? We don’t explain well enough how the process works? People are more reasonable if they know what’s going to happen."

Allina uses a "Threat Assessment Tool" to analyze incidents and determine what steps could be taken to prevent future problems. (To see a sample copy, click here.)

Sometimes hospital policy needs to be flexible to allow staff to diffuse the anxiety of family members. For example, Jezierski recalls a time when, as an ED nurse, the brother of a critically ill patient grabbed her arm and demanded to know what was happening with his brother. "Please let go of my arm," she said in even tones. "I can appreciate your fear about your brother. You must be very concerned about your brother." She explained that she needed to bring some supplies into the room, but would bring someone back to talk to him. She was able to bring him back into the ED to see his brother, then she escorted him back to the waiting area.

Jezierski says she is a proponent of the family presence, whenever possible. "What a difference it makes for someone to see family members," she says. "There’s such a need for people to be with their loved ones before they die."

While patients and their family members are often sources of violence-related injuries in health care facilities, they aren’t the only ones. A comprehensive prevention program addresses violence that could come from co-workers, managers, physicians, or domestic violence. Problems that exist in the community at large are likely to spill over into a diverse and large staff. In the Allina system, primary prevention involves creating policies and training for a respectful workplace. In secondary prevention, staff and managers learn how to detect the signs that a co-worker may be suffering from domestic violence. They also learn to identify and respond to behaviors that may be escalating toward violence.

The emphasis on respect is also designed to address verbally or even physically abusive behavior that may come from an authority figure. Nurses have tales to tell of physicians who spoke in a demeaning way or threw charts or instruments at them. But with the support of top administrators, hospitals can set clear boundaries that do not allow that behavior, says Jezierski. "A lot of people say, What kind of support am I going to get if I say this is not OK? Who’s going to support me?’" she says.

"You need a strong human resources component in this, as well as administrative support," she says. "We have very strong support for a respect-for-work environment. Getting there is not always easy, but [you can do it if] there’s strong support from the top down."

(Editor’s note: For more information on the Center for Aggression Management, see the web site: For more information on the Workplace Violence Research Institute, see the web site:


1. National Institute for Occupational Safety and Health. Violence in the Workplace Fact Sheet. NIOSH Doc. 705022. Washington, DC; 1997.

2. Barlow CB, Rizzo AG. Violence against surgical residents. West J Med 1997; 167:74-78.

3. National Health Service Zero Tolerance Zone. Web site: