This newsletter is distributed to chief executive officers and survey coordinators at Joint Commission accredited organizations

What is workplace violence?

The CDC National Institute for

Occupational Safety and Health

(NIOSH) defines workplace

violence as “violent acts (including

physical assaults and threats of

assaults) directed toward persons

at work or on duty.

The U.S.

Department of Labor defines

workplace violence as an action

(verbal, written, or physical

aggression) which is intended to

control or cause, or is capable of

causing, death or serious bodily

injury to oneself or others, or

damage to property. Workplace

violence includes abusive behavior

toward authority, intimidating or

harassing behavior, and threats.

A complimentary publication of The Joint Commission Issue 59, April 17, 2018

Revised: June 18, 2021 (in red)

Physical and verbal violence against health care workers

“I’ve been bitten, kicked, punched, pushed, pinched, shoved, scratched, and spat

upon,” says Lisa Tenney, RN, of the Maryland Emergency Nurses Association. “I

have been bullied and called very ugly names. I’ve had my life, the life of my unborn

child, and of my other family members threatened, requiring security escort to my

car.”

Situations such as these describe some of the types of violence directed toward

health care workers. Workplace violence is not merely the heinous, violent events

that make the news; it is also the everyday occurrences, such as verbal abuse, that

are often overlooked. While this Sentinel Event Alert focuses on physical and verbal

violence, there is a whole spectrum of overlapping behaviors that undermine a

culture of safety, addressed in Sentinel Event Alert issues 40 and 57;

2,3

those types

of behaviors will not be addressed in this alert. The focus of this alert is to help your

organization recognize and acknowledge workplace violence directed against health

care workers from patients and visitors, better prepare staff to handle violence, and

more effectively address the aftermath.

Each episode of violence or credible threat to

health care workers warrants notification to

leadership, to internal security and, as needed,

to law enforcement, as well as the creation of

an incident report, which can be used to

analyze what happened and to inform actions

that need to be taken to minimize risk in the

future. Under The Joint Commission’s Sentinel

Event policy, rape, assault (leading to death,

permanent harm, or severe temporary harm),

or homicide of a patient, staff member,

licensed independent practitioner, visitor, or

vendor while on site at an organization is a

sentinel event that warrants a comprehensive

systematic analysis. While the policy does not

include other forms of violence, it is up to every

organization to specifically define acceptable

and unacceptable behavior and the severity of

harm that will trigger an investigation. The

Centers for Disease Control and Prevention

(CDC) National Institute for Occupational Safety

and Health (NIOSH) defines workplace violence

as “violent acts (including physical assaults and threats of assaults) directed toward

persons at work or on duty.

The U.S. Department of Labor defines workplace

violence as an action (verbal, written, or physical aggression) which is intended to

control or cause, or is capable of causing, death or serious bodily injury to oneself or

others, or damage to property. Workplace violence includes abusive behavior

toward authority, intimidating or harassing behavior, and threats.

Published for Joint Commission

accredited organizations and

interested health care

professionals,

Sentinel Event

Alert

identifies specific types of

sentinel and adverse events and

high risk conditions, describes

their common underlying causes,

and recommends steps to

reduce risk and prevent future

occurrences.

Accredited organizations should

consider information in a

Sentinel Event Alert

when

designing or redesigning

processes and consider

implementing relevant

suggestions contained in the

alert or reasonable alternatives.

Please route this issue to

appropriate staff within your

organization.

Sentinel Event Alert

may be reproduced if credited to

The Joint Commission. To receive

by email, or to view past issues,

visit www.jointcommission.org.

Sentinel Event Alert, Issue 59

Page 2

Although most incidents of workplace violence in

health care are verbal in nature, other incidents

involve assault, battery, domestic violence, stalking,

and sexual harassment.

The most common type of

violence in health care is patient/visitor to worker.

7,8

A 2014 survey on hospital crime attributed 75

percent of aggravated assaults and 93 percent of

all assaults against health care workers to patients

or customers.

Prevalence of workplace violence in health care

According to the Occupational Safety and Health

Administration (OSHA), approximately 75 percent of

nearly 25,000 workplace assaults reported annually

occurred in health care and social service settings

and workers in health care settings are four times

more likely to be victimized than workers in private

industry.

The National Crime Victimization Survey

showed health care workers have a 20 percent

higher chance of being the victim of workplace

violence than other workers.

Bureau of Labor

Statistics (BLS) data show that violence-related

injuries are four times more likely to cause health

care workers to take time off from work than other

kinds of injuries.

The Joint Commission’s Sentinel

Event data show 68 incidents of homicide, rape, or

assault of hospital staff members over an eight-year

period.*

Alarmingly, the actual number of violent incidents

involving health care workers is likely much higher

because reporting is voluntary. Researchers at

Michigan State University estimated that the actual

number of reportable injuries caused by workplace

violence, according to Michigan state databases,

was as much as three times the number reported by

the BLS,

which does not record verbal incidents.

Episodes of workplace violence of all categories are

grossly underreported.

10,16

Health care workers are

sometimes uncertain what constitutes violence,

because they often believe that their assailants are

not responsible for their actions due to conditions

affecting their mental state.

Only 30 percent of

nurses report incidents of workplace violence;

among emergency department physicians, the

reporting rate is 26 percent.

Underreporting is due

in part to thinking that violence is “part of the job.”

In addition, worker-to-worker verbal abuse in health

care has been accepted too often, leading to

thinking that workers must accept verbal abuse

from patients, too.

_______________________________________

* The reporting of most sentinel events to The Joint Commission

is voluntary and represents only a small proportion of actual

events. Therefore, these data are not an epidemiologic data set

and no conclusions should be drawn about the actual relative

frequency of events or trends in events over time.

Adding to the problem are the many ways that

workplace injuries may be reported at health care

organizations. Information about health care

workers injured on the job — whether punched by a

patient or accidentally stuck by a needle — may be

reported into various databases rather than one

integrated database. This makes it difficult to

recognize the scope of a workplace violence

problem, or to track the effectiveness of efforts to

mitigate or prevent workplace violence.

To improve tracking efforts, OSHA launched

the Injury Tracking Application

, a secure website

where covered employers must submit their

workplace injury and illness information, including

acute injuries and illnesses, days away from work,

restricted work activity, or job transfer (also known

as Days Away, Restrictions and Transfers, or

DART).

21,22

In May 2016, OSHA published a rule

titled “Improve Tracking of Workplace Injuries and

Illnesses,” with an original effective date of Jan. 1,

2017 that was extended to Dec. 1, 2017.

OSHA is

considering whether or not to publish a new

standard to prevent workplace violence in health

care and social assistance settings. The agency

issued a public Request for Information on the

extent and nature of workplace violence in the

industry and the effectiveness and feasibility of

methods used to prevent such violence. The

comment period closed on April 6, 2017.

It is important to note that employers are required

to provide a place of employment that is “free from

recognized hazards that are causing or are likely to

cause death or serious harm,” under the

General

Duty Clause, Section 5(a)(1) of the Occupational

Safety and Health Act of 1970.

Contributing factors

Violence against health care workers occurs in

virtually all settings, with the emergency department

(ED) and inpatient psychiatric settings having the

most recorded incidents.

11,25

The home care setting

presents particular challenges because this

environment is less controlled than other health

care settings.

Sixty-one percent of home care

workers report workplace violence each year.

Long-term residential care facilities for the aged,

cognitively impaired and mentally ill patients

present special challenges.

There is very little

research about other settings.

Virtually all types of health care professionals have

been victims. Nurses and nurses’ aides, particularly

those in emergency settings

11,28

and in nursing

homes with dementia units,

have been victimized

at the highest rate.

11,15,20,30

An American Nurses

Sentinel Event Alert, Issue 59

Page 3

Association study found that over a three-year

period, 25 percent of surveyed registered nurses

and nursing students reported being physically

assaulted by a patient or a patient’s family member,

and about half reported being bullied.

Physicians,

particularly emergency medicine physicians,

11,20,29

and inpatient psychiatric workers

20,32

also are

frequently victimized.

The most common characteristic exhibited by

perpetrators of workplace violence is altered mental

status associated with dementia, delirium,

substance intoxication, or decompensated mental

illness.

10,33

Also, one study showed that patients in

police custody within a health care setting are

involved in 29 percent of shootings in emergency

departments, with 11 percent occurring during

escape attempts.

Increasingly, hospitals are

providing care for potentially violent individuals.

In addition to caring for patients with these

characteristics, other factors associated with

violence are:

• Stressful conditions, such as long wait times or

crowding in the clinical environment or being

given “bad news” related to a diagnosis or

prognosis.

10,35

• Lack of organizational policies and training for

security and staff to recognize and deescalate

hostile and assaultive behaviors from patients,

clients, visitors, or staff.

• Gang activity.

• Domestic disputes among patients or visitors.

• The presence of firearms or other weapons.

• Inadequate security and mental health

personnel on site.

• Understaffing, especially during mealtimes and

visiting hours.

• Staff working in isolation or in situations in

which they can be trapped without an escape

route.

• Poor lighting or other factors restricting vision in

corridors, rooms, parking lots and other

areas.

• No access to emergency communication, such

as a cell phone or call bell.

• Unrestricted public access to hospital rooms

and clinics.

• Lack of community mental health care.

Workplace violence results in low staff morale,

lawsuits, and high worker turnover.

High turnover

is associated with job burnout – defined as a

negative reaction to constant occupational

stressors.

There is no conclusive evidence linking workplace

violence with demographic groups

38,39

or with urban

versus suburban or rural emergency departments;

making these assumptions may lead to

discrimination against particular types of patients.

Although shootings in the health care environment

gain much media attention, they are quite rare

compared to other kinds of violence, such as

assaults not involving a firearm, and verbal abuse.

Recognizing verbal assault as a form of

workplace violence cannot be overlooked, since

verbal assault is a risk factor for battery.

According to the “broken windows” principle,

apathy toward assaults such as verbal abuse

creates an environment conducive to more

serious, physical crimes.

20,42

With leadership commitment and worker

participation, customized and evidence-based

approaches to reduce workplace violence can be

found and will vary from setting to setting. For

example, Aria-Jefferson Health implemented

Operation Safe Workplace

, a multidisciplinary

approach to hospital violence. After identifying a

baseline of 42 injuries related to workplace

violence in fiscal year 2012, the organization

gathered and analyzed data before designing

interventions to address the problem in five

ways: environment, policy and procedure,

technology and equipment, communication, and

people. By fiscal year 2015, Aria-Jefferson

reduced these injuries to 19, a 55 percent

decrease.

In addition, a cluster randomized

trial at Wayne State University reduced incidents

of workplace violence on intervention units

compared to control units by implementing

environmental, administrative and behavioral

strategies tailored to the needs of participating

units.

Actions suggested by The Joint Commission

Health care workers must be alert and ready to

act when they encounter verbal or physical

violence — or the potential for violence — from

patients or visitors who may be under stress or

who may be fragile, yet also volatile. Health care

organizations are encouraged to address this

growing problem by looking beyond solutions

that only increase security.

1. Clearly define workplace violence and put

systems into place across the organization that

enable staff to report workplace violence instances,

including verbal abuse.

• Leadership should establish a goal of zero harm

to patients and staff and, to that end, must

Sentinel Event Alert, Issue 59

Page 4

make clear that the health care organization is

responsible for identifying, addressing and

reducing instances of workplace violence; that

burden must not be placed upon victims of

violence.

• Emphasize the importance of reporting all

events involving physical and verbal violence

toward workers, as well as patients and visitors.

• Encourage conversations about workplace

violence during daily unit huddles, including

team leaders asking each day if any team

members have been victims of physical or

verbal abuse or if any patients or family

situations may be prone to violence.

• Develop systems or tools to help staff identify

the potential for violence, such as a checklist or

questionnaire that asks if a patient is irritable,

confused or threatening.

• Develop a protocol, guidance and training about

the reporting required by the hospital safety

team, OSHA, police, and state authorities. For

example,

Western Connecticut Health Network

developed a protocol to be used after incidents

of workplace violence against employees.

• Create simple, trusted, and secure reporting

systems that result in transparent outcomes,

and are fully supported by leadership,

management, and labor unions.

Protect

patient and worker confidentiality in all

reporting by presenting only aggregate data or

removing personal identifiers.

• Remove all impediments to staff reporting

incidents of violence toward workers – such as

retribution or disapproval of supervisors or co-

workers and a lack of follow-up or positive

recognition from leadership.

10,25

2. Recognizing that data come from several

sources, capture, track and trend all reports of

workplace violence – including verbal abuse and

attempted assaults when no harm occurred.

• Gather this information from all hospital

databases, including those used for OSHA,

insurance, security, human resources,

complaints, employee surveys, legal or risk

management purposes, and from change of

shift reports or huddles.

• Regularly distribute these workplace violence

reports throughout the organization, including

to the quality committee and up to the

executive and governance levels.

• Aggregate and report incidents to external

organizations that maintain a centralized

database. This can lead to identification of new

hazards, trends, and potential strategies for

solutions; these solutions can then be shared

broadly.

The

Centers for Disease and Control and Prevention

(CDC) Occupational Health Safety Network is a

useful resource to help to analyze and track worker

injury and exposure data, including data on

workplace violence. See Resources.

3. Provide appropriate follow-up and support to

victims, witnesses and others affected by workplace

violence, including psychological counseling and

trauma-informed care if necessary.

10,11,25

4. Review each case of workplace violence to

determine contributing factors. Analyze data related

to workplace violence, and worksite conditions, to

determine priority situations for intervention.

• According to OSHA, this process includes a

worksite analysis and hazard identification (for

example, risk assessment).

To determine

trends and “hot spots,” analyze where, when,

why and how violence has occurred and to

whom. This process can include a review of

workers’ compensation, insurance records,

OSHA logs and other data relating to workplace

violence, as well as an analysis of factors (such

as staffing levels) that can contribute to or

reduce the likelihood of violence occurring.

• Demonstrate the value and necessity of

reporting by communicating to staff the risk

assessment findings and the interventions

taken to immediately address the situation.

5. Develop quality improvement initiatives to reduce

incidents of workplace violence. Support the

implementation of cost-effective, evidence-based

solutions as they are discovered.

After a review of

all pertinent data relating to workplace violence,

develop evidence-based initiatives and

interventions (when possible) to prevent and control

workplace violence. Tailor specific interventions to

problems identified at the local level. Depending on

the data gathered, an initiative for the ED, inpatient

psychiatric unit, labor and delivery, or the intensive

care unit (ICU) may differ from an initiative in a unit

not generally associated with workplace violence.

According to OSHA, these initiatives generally focus

on eliminating hazards or substituting them with

safer work practices.

Some examples follow.

•

Changes to the physical environment:

Depending on the organization’s situation and

priorities (identified from the organization’s

data), physical or technological solutions may

include enhanced security or alarms, better exit

Sentinel Event Alert, Issue 59

Page 5

routes, regular security patrols/rounds, metal

detectors, panic buttons (including mobile panic

buttons), monitoring or surveillance technology

(such as cameras), barrier protection (for

example, keypad access doors and fencing),

environmental changes to facilitate de-

escalation and reduce hazards, and better

lighting.

As mentioned above, each

organization should use its own data to identify

the most effective use of these solutions. As

just one example, a hospital that has identified

a high incidence of confrontations occurring in

the parking lot and in waiting areas may want to

have more regular security patrols, or a more

visible security presence, in those areas.

•

Changes to work practices or administrative

procedures:

To create a calmer environment

less conductive to violence, assign sufficient

staff to units to reduce crowding and wait

times, both risk factors for workplace

violence.

Decreasing worker turnover and

providing adequate security and mental health

personnel on-site also are recommended.

10,47

Other administrative or work practice solutions

may include developing workplace violence

response teams and policies; reviewing entry

and identification procedures; and changing

work procedures to keep team members,

including those providing transportation, secure

and not isolated by having the means to call for

help.

6. Train all staff, including security, in de-escalation,

self-defense and response to emergency codes.

When threatening language and agitation are

identified, initiate de-escalation techniques

quickly.

Self-defense training may include topics

such as violence risk factors, de-escalation

techniques, alarms, security support, safe rooms,

escape plans, and emergency communication

procedures.

• Regarding de-escalation and self-defense,

experts suggest that hospitals prohibit firearms

from campus, except for firearms used by law

enforcement officers.

The Centers for

Medicare and Medicaid Services (CMS) does

not permit the use of weapons by any hospital

staff as a means of subduing a patient.

• Conduct practice drills that include response to

a full spectrum of violent situations, which

could range from a verbally abusive family

member to an active shooter. These practice

drills can be part of an ongoing safety program,

as indicated in The Joint Commission

Environment of Care (EC) standards; however, a

situation such as an active shooter require

more extensive coordination with community

responders, and can be addressed in exercises

as described in the Emergency Management

(EM) standards (see “Related Joint Commission

requirements” section).

7. Evaluate workplace violence reduction initiatives

by:

• Regularly reviewing reported incidents and

leadership’s responses to them.

• Analyzing trends in incidents, injuries and

fatalities relative to baseline rates and

measuring improvement.

• Surveying workers to determine effectiveness of

initiatives.

• Tracking if recommendations were completed.

• Keeping abreast of new strategies.

• Partnering with local law enforcement or having

a consultant review the worksite.

They can

provide advice and updates on possible risks

that are developing in the community, as well

as help with resource planning or security

audits. If local law enforcement response time

is known to be long due to distance or other

factors, consider internal resources or other

options to control a situation until law

enforcement arrives.

Related Joint Commission requirements

The Joint Commission has several standards that

relate directly or indirectly to workplace violence:

• Leadership (LD) and Rights and Responsibilities

of the Individual (RI) standards establish the

framework for safety and security of all persons

in the organization.

• Provision of Care, Treatment, and Services (PC)

standards provide guidance addressing patient

assessment and interventions.

• Environment of Care (EC) standards address

the physical environment and practices that

enhance safety.

• Emergency Management (EM) standards

address planning for more extreme risks of

workplace violence, such as active shooters,

community unrest, and terrorist attack.

Also, effective Jan. 1, 2022, new workplace violence

standards provide a framework to guide hospitals

and critical access hospitals in defining workplace

violence; developing strong workplace violence

prevention systems; and developing a leadership

structure, policies and procedures, reporting

systems, post-incident strategies, training, and

education to decrease workplace violence. The new

requirements are located at EC.02.01.01 EP 17;

Human Resources standard HR.01.05.03 EP 29;

Sentinel Event Alert, Issue 59

Page 6

and LD.03.01.01 EP 9. In addition, EC.04.01.01

EPs 1 and 6 have been revised.

See the content of these standards

on The Joint

Commission website, posted with this alert.

Resources

Occupational Safety and Health Administration

(OSHA)

• Guidelines for Preventing Workplace Violence

for Healthcare and Social Service Workers

• Preventing Workplace Violence in Healthcare

The Joint Commission

• Workplace Violence Prevention Resources

• Questions & Answers: Hospital Accreditation

Standards & Workplace Violence

• Improving Patient and Worker Safety (Pages 95-

108)

Centers for Disease Control and Prevention (CDC)

• Occupational Health Safety Network: A free,

web-based system to help health care facilities

analyze and track data they already collect on

workplace violence; sharps injuries; blood and

body fluid exposures; slips, trips and falls; and

patient-handling injuries.

• Workplace Violence Prevention for Nurses

• Home Healthcare Workers: How to Prevent

Violence on the Job

Centers for Medicare and Medicaid Services (CMS)

• Preparedness Requirements for Medicare and

Medicaid Participating Providers and Suppliers

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In: Ciottone G, ed. Ciottone’s disaster medicine. 2nd ed.

Philadelphia: Elsevier Health Sciences, 2015;424-30.

49. Centers for Medicare and Medicaid Services.

State

Operations Manual, Appendix A — Protocol, Regulations

and Interpretive Guidelines for Hospitals, Section

482.13(e), Baltimore, MD: CMS, 2015.

_____________________________________________

Patient Safety Advisory Group

The Patient Safety Advisory Group informs The Joint

Commission on patient safety issues and, with other

sources, advises on topics and content for Sentinel Event

Alert.