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New Workplace Violence Prevention Recommendations


By Barbara Braun, Associate Director, Health Services Research

While much of the recent focus on violence in the U.S. has centered around school environments, there’s been no reversal of the physical and verbal threats against healthcare workers.

In our continuing effort to contribute solutions, in addition to our Workplace Violence Prevention Resources for Health Care, The Joint Commission has now released Sentinel Event Alert 59: Physical and Verbal Violence Against Healthcare Workers to help organizations better prepare staff to handle violence and more effectively address the aftermath. 

As a reminder, 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.

Culture of Under-Reporting
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.  

The Joint Commission’s Sentinel Event data show 68 reported incidents of homicide, rape, or assault of hospital staff members over an eight-year period. However, the actual number of violent incidents involving health care workers is likely much higher because reporting is voluntary and that number doesn’t account for ambulatory, behavioral, nursing and all healthcare settings. In fact, researchers at Michigan State University estimated that the actual number of reportable injuries caused by workplace violence was as much as three times the number reported by the Bureau of Labor Statistics, which does not record verbal incidents.

All too often, healthcare workers just consider violence “part of the job”, regardless of whether the perpetrator is a patient or a colleague.

Another complication is that work-related injuries may be reported into various databases rather than one integrated database. OSHA is doing its part to improve the situation by launching the Injury Tracking Application, a secure website where covered employers submit their workplace injury and illness information, including:

  • acute injuries and illnesses

  • days away from work

  • restricted work activity 

  • job transfer

Contributing Factors
Though the issue is widespread, some disturbing trends are emerging. Emergency departments (ED) and inpatient psychiatric settings having the most recorded incidents with nurses and doctors in these specialties taking the brunt of the abuse. 

However, every health setting has unique challenges. Violence in home care can be quite serious because of the less controlled environment and long-term residential care facilities for the aged, cognitively impaired and mentally ill patients present special challenges.

Common characteristics exhibited by perpetrators of workplace violence are:

  • altered mental status associated with dementia, delirium, substance intoxication, or decompensated mental illness

  • placement in police custody

Other factors associated with violence are:

  • stressful conditions, such as long wait times or crowding in the clinical environment 

  • lack of organizational policies and training for security and staff to recognize and deescalate hostile and assaultive behaviors 

  • gang activity

  • domestic disputes 

  • 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

Actions Beyond Increasing Security

Simply adding more security staff or technology won’t reverse this tide. The Joint Commission recommends seven actions to combat workplace violence on all levels.

  1. Clearly define workplace violence and put systems into place across the organization that enable staff to report workplace violence instances, including verbal abuse
  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
  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
  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
  5. Develop quality improvement initiatives to reduce incidents of workplace violence
  6. Train all staff, including security, in de-escalation, self-defense and response to emergency codes
  7. Evaluate workplace violence reduction initiatives

Review and share the alert at your organization to address these recommendations.  We also encourage you to share your best practices, articles and resources with peers in the workplace violence prevention resource center.

Barbara Braun is currently Associate Director, Health Services Research, in the Division of Healthcare Quality Evaluation at The Joint Commission. She is a member of the CDC National Institute of Occupational Safety and Health (NIOSH) National Occupational Research Agenda Healthcare and Social Assistance Sector Council which is charged with developing an industry-specific research agenda for the nation, and is co-leader of The Joint Commission/JCR/OSHA Alliance activities. She has been involved in Joint Commission research, evaluation, and performance measurement activities for more than 20 years.  Prior to this position, she worked for the Veterans Administration health services research department in Hines IL on projects related to home care, long term care, and infectious diseases.

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