Workplace violence in healthcare: 10 prevention steps that work

In 2018, healthcare workers accounted for 73% of all nonfatal workplace violence injuries and illnesses involving days away from work, according to the US Bureau of Labor Statistics (BLS). It is the latest BLS fact sheet titled for healthcare. A newer BLS fact sheet counts health care and social assistance as 72.8% of private industry workplace violence cases in 2021 and 2022, using a wider case definition that adds job restriction or transfer, so the picture has not changed.

This post gives a ward or department ten steps to start on. OSHA's Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA 3148) list five programme elements: management commitment and worker participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and programme evaluation. The ten steps are our own grouping of that guidance, not an OSHA list, and each one names the element it comes from. Every step has an owner and one way to train it.

The focus is the United States. OSHA lists working alone, poorly lit corridors and car parks, working when understaffed and high worker turnover among the risk factors, so most of the steps below are about those.

What OSHA does and does not require

Start with the legal picture, because it is easy to get wrong. OSHA's workplace violence page says there are currently no specific OSHA standards for workplace violence. OSHA 3148 is advisory: it says it is not a standard or a regulation. OSHA can still act under the General Duty Clause, which requires employers to provide a workplace free from recognised hazards that are causing or likely to cause death or serious physical harm. Its directive CPL 02-01-058, dated 10 January 2017, sets out enforcement procedures for occupational exposure to workplace violence.

Accredited hospitals have a second layer. The Joint Commission's R3 Report, Issue 30 says new and revised workplace violence prevention standards apply to all Joint Commission accredited hospitals and critical access hospitals from 1 January 2022. Check your own accreditation, and check your state, because several states have their own requirements.

Set 1: leadership and analysis, steps 1 to 5

The first set is about knowing where you stand. It covers elements 1 and 2.

1. Put leadership's commitment in writing. (Element 1.) OSHA 3148 says effective leadership starts by recognising that workplace violence is a safety and health hazard, and it lists assigning responsibility, allocating resources and a no-reprisal policy for reporting. Owner: the chief nurse or head of department. Training activity: brief every manager in 10 minutes on the policy and where to send a report.
2. Set up a worker participation group. (Element 1.) OSHA 3148 asks for a range of viewpoints, and says direct care workers in emergency departments or mental health may bring very different perspectives. Include frontline staff, not only managers. Owner: the safety lead. Training activity: have the group each pick one near miss from the last month and present it in two minutes.
3. Review your incident and injury records for patterns. (Element 2.) OSHA 3148 says to look at incident and near miss logs, the OSHA Form 300 where you keep one, and police reports, for patterns by place, shift and task. Owner: safety or quality officer. Training activity: show the team an anonymised pattern and ask what they would change first.
4. Walk the site and list the hazards. (Element 2.) Check lighting, entrances and exits, waiting areas, and places where one person works alone. Do it as a team, with a clinician and a security or facilities colleague. Owner: the safety lead. Training activity: each team member walks their own area with the checklist and reports one hazard back.
5. Ask staff which areas feel unsafe. (Element 2.) OSHA 3148 suggests periodic surveys, at least annually or whenever operations change or an incident occurs, with questions such as which daily activities expose you to the greatest risk. Keep it anonymous and share the results. Owner: the participation group. Training activity: run the survey live in a team meeting and discuss the top three answers.

Our pick: step 5. Staff know risks that the records miss, such as the corridor nobody reports because nothing has happened there yet.

Set 2: control, training and review, steps 6 to 10

The second set turns findings into change. It covers elements 3, 4 and 5.

6. Fix the physical hazards you found. (Element 3.) OSHA 3148 lists engineering controls such as door locks, panic buttons, better lighting and more accessible exits, and says measures should be site specific. Owner: facilities. Training activity: after each fix, show staff what changed and how to use it, for example where the panic buttons are and who responds.
7. Agree a rule for staffing and working alone. (Element 3.) OSHA 3148 suggests limiting working alone in emergency areas and walk-in clinics, particularly at night or when help is unavailable, and using a buddy system where personal safety may be threatened. Owner: the department manager. Training activity: ask each shift to say what they would do if a colleague were alone and a situation started to escalate.
8. Train every worker to spot escalation and respond. (Element 4.) OSHA 3148 says the programme should involve all workers, including contract workers, supervisors and managers, and lists topics such as early recognition of escalating behaviour, de-escalation, an emergency response plan and how to report. Owner: the education lead. Training activity: a short session on warning signs, followed by a reporting walk-through.
9. Run scenario drills by role. (Element 4.) OSHA 3148 says effective training involves role-playing, simulations and drills. Give a receptionist, a nurse and a security officer a different card each. Owner: the education lead with a clinical lead. Training activity: the drill in the next section.
10. Record every incident and review the programme on a schedule. (Element 5.) OSHA 3148 asks for accurate records of incidents, assaults, hazards, corrective actions and training, and for management to review the programme regularly and after each incident, protecting worker and patient confidentiality. Owner: the safety lead and top management. Training activity: close each review by telling staff what was found and what was done.

Our pick: step 9. Practising a scenario beats reading a policy, and a drill shows quickly whether people know where the alarm is and who comes.

A role-based scenario drill

A drill needs no equipment and takes about 20 minutes. Use a short scenario card, three decision points and a debrief.

1. Set the scene (2 minutes). Read one card to the group. Give each person a role, so a nurse, a receptionist and a security officer hear different details.
2. Run three decision points (12 minutes). Stop at each one and ask what each role does next: first sign, escalation, and the call for help.
3. Debrief (6 minutes). Ask what went well, which step was unclear and what to fix. Write the fixes down and give each an owner, which feeds step 10.

Two fictional scenarios to start with, both invented for this post:

• The long wait. A visitor has waited three hours in a crowded waiting room. They raise their voice at the receptionist and block the desk. Decision points: what the receptionist says, when they call for help, and what the next shift is told.
• The night corridor. A nurse on a night shift is alone in a dimly lit corridor when an agitated patient follows them and starts shouting. Decision points: what the nurse says and does, how they call for help, and how the incident is reported afterwards.

Keep real patient details out of drills, and say at the start that the scenarios are made up.

Ways to host this training with a group

A 20-minute live session turns the ten steps into practice. With AhaSlides you can build it from the scenarios above.

1. Pick Answer: "Spot the risk". Read out one scenario at a time, for example "a nurse is alone on a night corridor with poor lighting", and ask where the risk is. Show a team leaderboard and reveal which step covers it.
2. Word Cloud: "What warning signs do you notice first?" The biggest words show what your team already recognises and what it overlooks.
3. Rating Scale: "How safe do you feel on your ward?" Ask for 1 to 5 and look at the average by team. It points to the areas that need a walk-through (step 4).
4. Open Ended: report an unsafe area anonymously. People name the corridor or the car park when their name is hidden. For running it well, see our 9 tips for a successful Q&A session.

For more scenario ideas, our guide to scenario-based healthcare compliance training shows how to write them, and our workplace safety topics post has more to run in a short slot. The ready-made template below covers the same ground: Workplace violence prevention in healthcare.

Tips for managers

Go back to the number that opened this post. In 2018, the private healthcare and social assistance industry had a rate of 10.4 nonfatal injuries per 10,000 full-time workers from intentional injury by another person, against 2.1 for all workers. Both figures are for cases that involved days away from work.

Staff who report need to see something happen next. Three habits help:

• Answer every report. Tell the person who reported what was done, even if the answer is "we are still looking".
• Protect the person who speaks up. OSHA 3148 says reprisal against an employee for reporting a workplace violence incident related to the guidance would be a violation of Section 11(c) of the OSH Act.
• Start small. Pick one set, run one drill, and book the next review before you leave the room.

Frequently asked questions

Does OSHA have a workplace violence standard for healthcare?

No. OSHA says there are currently no specific OSHA standards for workplace violence. It enforces through the General Duty Clause and directive CPL 02-01-058, and its guidelines in OSHA 3148 are advisory.

What are the elements of a workplace violence prevention programme?

Five, according to OSHA 3148: management commitment and worker participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and programme evaluation.

How often should staff be trained?

OSHA 3148 recommends an initial orientation for new and reassigned workers before they start their duties and says all workers should receive required training annually, with refresher training perhaps monthly or quarterly in high-risk settings. This is guidance, not a legal requirement. For Joint Commission accredited hospitals, standard HR.01.05.03 EP 29 asks for training at the time of hire, annually and whenever the programme changes.

Do Joint Commission standards apply to my hospital?

They apply to Joint Commission accredited hospitals and critical access hospitals, from 1 January 2022, according to its R3 Report. Check your own accreditation to see whether they cover you.

What should a nurse do after an incident?

Get first aid or care if needed, then report it through your organisation's process. OSHA 3148 lists reporting as required as the first step of an incident investigation and says staff should receive prompt treatment and psychological evaluation after an assault. Ask your manager or safety lead how reports are made where you work.

Where to start

Pick one set, read the five steps aloud at your next team huddle, and name an owner for each. If you only run one session this quarter, make it step 9: a 20-minute drill shows you more about your ward than a policy review does.