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Workplace Violence: a Primer for Health Centers

Sunday, February 10, 2013   (0 Comments)
Posted by: Joy Ingram
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by Mollie Melbourne, Director of Emergency Management,  National Association of Community Health Centers

Far too frequently, news headlines feature stories of workplace violence – store clerks shot during robberies, disgruntled employees attacking former bosses, and domestic violence spilling over into the workplace, catching in the crosshairs those unlucky enough to be in the wrong place at the wrong time.  The grisly details are recited, pictures of the victims or alleged assailant are shown, and those left behind are mentioned.  And then the news moves onto the next big story.  But what have we learned from these events and how can we use this information to help make our workplace a little safer?

Workplace violence is defined by the National Institute for Occupational Safety and Health (NIOSH) as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”[1]  It can range from threats of aggression to physical attack to even homicide and covers the actions by and against employees, patients, visitors, vendors, and anyone else who enters your health center.  This is a pretty broad definition and covers a lot of undesirable behavior in the workplace.  In the paragraphs to follow, we will dig a little deeper into workplace violence to better understand the types, offer guidance on preventing and responding to incidents, and provide resources to learn more.

To understand violence in the workplace and identify various ways to implement solutions, it is helpful to understand the categories of workplace violence.  Most events fall into one of four categories[2]:

Criminal Intent (Type I):  In this type of workplace violence, the violence is tied to a crime being committed.  The perpetrator of this type of violence may not have an existing relationship with the health center – they are there to commit a crime and someone gets hurt in the process.  An example of this is a staff member or patient being hurt by someone committing a robbery. 

Disgruntled Patient/Client/Customer (Type II):  In this case, the perpetrator has a relationship with the health center and commits violence that is related to an interaction at the health center.  The classic example with this type of violence is a patient threatening or assaulting a health center staff member because they are unhappy with wait time, didn’t get the care they thought they should, or were denied a prescription or service they wanted.  This would also include a patients’ family member threatening or hurting a staff member because they were unhappy with services provided to the patient.

Worker on Worker Violence (Type III):  As the name implies, this is threats or acts of violence committed by one staff member against another employee.  Examples include retaliation against a supervisor or health center leadership for disciplinary action or violence in response to a grudge against another employee.

Personal Relationship / Domestic Violence (Type IV):  This category covers violence against a staff member or patient while they are at the health center by someone who has a personal relationship with that person.  This includes incidents of intimate partner/domestic violence that occur at the workplace.   

According to Bureau of Labor Statistics[3], between 2003 and 2007, nearly 60% of the 81,600 reported nonfatal assaults and violent acts in the workplace occurred in the health care and social service industry.  Furthermore, almost three-quarters of the assaults in the healthcare industry were perpetrated by health care patients or residents of a health care facility.    

There are a number of risk factors that increase the likelihood of workplace violence[4].  The risk factors may differ based on geographical location, size of organization, and the type of care delivered but common risks include:

  • Working directly with volatile people, especially those who are under the influence of drugs or alcohol or have a history of violence
  • Being short staffed
  • Providing patient transport
  • Long wait times for services
  • Overcrowded, uncomfortable waiting rooms
  • Working alone or in isolated locations
  • Poor environmental design
  • Inadequate or non-existent security
  • Lack of staff training and policies for preventing and responding to potential volatile situations
  • Drug and alcohol abuse among people receiving services for your organization
  • Access to weapons
  • Unrestricted movement of public through facilities
  • Poorly lit hallways, exam rooms, offices, parking lots, and other areas
  • Being located in an area with a high crime rate

Understanding the types of workplace violence, the prevalence of incidents, and the risk factors are critical in developing strategies to prevent violence when possible and respond to situations when prevention isn’t feasible.   Clearly, not every risk factor can be eliminated so it is essential that every health center develop and maintain a comprehensive workplace violence prevention and response plan.  This plan synthesizes all of the strategies and provides structure for ongoing assessment, review, training, and staff engagement.  There are three main components that should be taken into consideration when an organization is addressing the issues of workplace violence: administrative processes, policies, and procedures, informed and empowered workforce, and facilities management.

Start by setting the stage with a zero-tolerance policy for weapons and violence.  Let it be known among patients, staff, and visitors that violence, or threats of violence, and weapons of any kind will not be allowed in your facility.  This should be posted in patient and staff areas within the health center, staff need to be aware of this and clearly understand what it covers, and all incidents must be managed according to policy without exception.

A zero-tolerance policy is strengthened when coupled with a procedure to facilitate incident reports or concerns without fear of reprisals.  This is critical in helping to identify staff, patients, or visitors who may become violent or threatening as well as highlighting any activities that may provide an opportunity for violence.

Lastly, policies around hiring, disciplinary action, and dismissal should be reviewed from a workplace violence perspective.  Ensure that background checks are conducted as appropriate and make the process for disciplinary action transparent and well known to all staff.  This helps to avoid an employee feeling targeted should action be necessary based on performance. Finally, be sure that dismissal policies foster respectful interactions and include procedures should the interaction turn violent.

The second component of the workplace violence prevention and response plan is your staff.  They are a crucial part of preventing and responding to violent incidents.  Begin by establishing a multi-disciplinary committee of staff to develop strategies, review policies, identify training topics, review past incidents for trends, and oversee prevention activities.  Be sure to include front line staff who interact regularly with patients and visitors, those who work in areas of the health center prone to violent outbreaks, such as the waiting room and billing office, and have representatives from all locations within your health center organization.

While violent situations can occur with little or no warning, there can also be red flags that point to the possibility of a violent outcome.  For these reasons, employees need to know what to do should an event unfold in front of them and be trained to identify the warning signs that may signal an escalation of aggression.  In addition, staff must be empowered to take appropriate action in either case.  Provide your staff the tools they need to prevent and respond to incidents through training on your health center’s workplace violence policies, de-escalation techniques, lock down procedures, and other topics specific to your health centers’ risks.   Back the training up with drills and exercises that give staff a chance to put their training to the test by responding to a simulated event.

The final piece of a comprehensive workplace violence prevention and response strategy focuses on the facility and environmental controls.  To address this aspect, it is very useful to conduct a thorough assessment of each facility to identify any structures that may contribute to incidents or inhibit effective response, including:

  • Poor lighting in the parking lot
  • Trees, shrubs, or other items that could conceal a person
  • Door locks that don’t work properly
  • Outside doors that are frequently propped open for ease
  • Items that could be used as weapons, such as chairs that aren’t bolted down, desk lamps, or wall hangings that aren’t securely affixed to the wall
  • Exam room and office layout that place patients and visitors between the staff person and the exit
  • Reception areas that don’t provide any barrier between the staff and patients and visitors

Some of these issues are fixed pretty easily; others require more time and more dollars.  Prioritize quick fixes and develop a plan to addresses the issues that require more time or capital.  Security measures currently in place should be reviewed for adequacy once a facility assessment and review of incidents is completed.  Local law enforcement may be able to assist in this process and offer suggestions to make your facility safer for your staff, patients, and visitors.  In addition, they may be able to guide evacuation planning in response to violence and identify an area to be used as a ‘safe room’ for staff to shelter from a violent incident.

By designing and implementing workplace violence prevention and response strategies that are based on an understanding of the types of violence, risk factors, and organization specific concerns, health centers can create a safer, more nurturing environment for their staff, patients, and visitors.  This is an ongoing journey but one that can be most effectively accomplished with a comprehensive and inclusive approach.  To learn more, here are a number of sources for additional information:

Occupational Safety and Health Administration:  With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.  You can find standards, tools, and guidance specific to healthcare organizations here:  http://www.osha.gov/SLTC/workplaceviolence/standards.html

The National Institute for Occupational Safety and Health - NIOSH provides national and world leadership to prevent work-related illness, injury, disability, and death by gathering information, conducting scientific research, and translating the knowledge gained into products and services, including scientific information products, training videos, and recommendations for improving safety and health in the workplace.   You can access their website and resources here:  http://www.cdc.gov/niosh/

ECRI Institute - For 45 years, ECRI Institute, a nonprofit organization, has been dedicated to bringing the discipline of applied scientific research to discover which medical procedures, devices, drugs, and processes are best, all to enable you to improve patient care.  Health centers have free access to the ECRI clinical risk management program through HRSA but must be registered users.  This resource includes a number of tools, templates, and articles specific to workplace violence, including a comprehensive assessment.  Here is the website and information about becoming a registered user if you are not already one:  https://www.ecri.org/clinical_rm_program/Pages/default.aspx

The National Association of Community Health Centers – NACHC partnered with the Colorado Community Health Network to present a two part webinar series on workplace violence and health centers.  You can access the recordings of this free webinar series here:  http://www.nachc.com/EM%20Webinars.cfm  



[1] CDC/NIOSH. Violence. Occupational Hazards in Hospitals. 2002.

[2] University of Iowa. Injury Prevention Research Center. A Report to the Nation.  2001

[3] Workplace Safety and Health in the Health Care and Social Assistance Industry, 2003-07

[4] Texas Department of Insurance.  Health Care Facilities and Workplace Violence Prevention. 

NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.


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