Preventing Workplace Violence in Healthcare

The possibility of workplace violence exists in nearly every work environment, but no where is it more prevalent than in healthcare settings. Understanding the potential dangers and specific issues that are unique to the healthcare industry and then taking action to implement programs that will minimize risk are key to keeping employees in medical practices and clinics safe.

According to the Bureau of Labor Statistics, workers in healthcare settings are four times more likely than other professionals to experience a violent act. This is primarily due to the unique nature of their occupational environment.

“There are a combination of factors in health care environments that put workers there at greater risk,” said Gene Rugala, a former profiler/supervisory special agent with the Federal Bureau of Investigation's (FBI) Critical Incident Response Group (CIRG), at the National Center for the Analysis of Violent Crime (NCAVC), FBI Academy, in Quantico, Virginia. “Many times, facilities are open at times of day when violent crimes are most likely to occur; most medical clinics/hospitals are accessible to any member of the public; and these are high stress environments – both for patients and families dealing with the stress of illness, and for the healthcare professionals themselves who work long hours in high pressure environments.”

Characteristics intrinsic to a typical healthcare environment put workers at higher risk for violence, as does a lack of understanding of what constitutes violence, and a workplace culture where certain types of violent behaviors are accepted.

It’s Not Just ‘Going Postal’: Knowing Risks and Types of Violence Are Keys to Prevention

Workplace violence is defined by the legal system as, “an act of aggression, physical assault, or threatening behavior that occurs in a work setting and causes physical or emotional harm to customers, coworkers, or managers”.

“Most people think of disgruntled employees seeking revenge when they think about acts of violence in a workplace setting,” said Rugala. “But the sensationalistic incidents that garner high profile media attention are actually quite rare. More commonly, workplace violence involves: criminal acts such as robbery, domestic violence that carries over into the workplace, coworker-on-coworker acts such as bullying or threatening behavior, or incidents where a customer or client lashes out at a worker.”

It is these broader based definitions of workplace violence that represent the largest portion of incidents in all settings. According to the Centers for Disease Control, less than one percent of the total 1.7 million incidents each year are homicides. In healthcare lower-profile events are vastly underreported because many times they are seen as “part of the job” or deemed to be minor incidents. Examples might include bullying from a supervisor, verbal abuse of a residential care nurse by a patient, or an orderly that is assaulted during regular rounds.

But why would health care workers – who themselves are trained as professional caregivers – cultivate an unhealthy workplace setting?

“It’s complex, but many times healthcare employees exhibit violent behavior toward one another because there may not be appropriate reporting channels or policies in place, and violence is viewed as an acceptable and tolerated part of the workplace culture” said Rugala.

For instance, much has been written lately about bullying behavior in the nursing world, and incivility in healthcare has been identified as such as problem that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) passed a Leadership Standard to require a code of conduct and processes to manage disruptive behaviors by physicians or other clinicians.

It is difficult to put a price tag on the human and financial costs of these types of behaviors. For these reasons and more it is important to have appropriate measures in place and create a solid prevention program that will inhibit violence in the workplace as much as possible.

"Medical practices and facilities that have a workplace violence prevention and education program are much better prepared to catch and prevent an unhealthy or dangerous situation before it occurs,” said Rugala.

Creating a Program That Works

There are several different factors to address when creating a plan that is ideal for your work environment. Barry Nixon, executive director for the National Institute for the Prevention of Workplace Violence, Inc., recommends seven steps that will help your practice or office feel assured about prevention tactics (See Chart 1).

“Talking about the problem or potential for one is the first step,” said Nixon. “By creating an atmosphere where employees know that management takes the threat seriously they will feel more confident in the program.”

Following that, a well-rounded assessment of the organization needs to take place to determine the current threat level and address areas that are vulnerable. Then specific measures can be put in place for security, hiring and education of staff.

“One of the biggest things your practice can do is to build a rapport with police and other first responders,” said Nixon. “In doing so you could improve response rates and include the appropriate personnel to call should an incident occur.”

Looking Out for Danger

“Being aware of the early warning signs and potential risks is also an important factor in preventing an incident in the workplace,” said Nixon. “Having employees take a class on potential behaviors, identifying internal and external threats and continually being aware and reporting unusual activity can help them avoid harmful situations.”

Early warning signs may include an employee acting irresponsibly or unreasonably. If you have someone that is constantly blaming others for their pitfalls or oversights, or they become continually upset with the current state of how the organization runs, management should be alerted. This also applies to more obvious behaviors such as open threats or a combative nature. It is important to be aware of the warning signs and fellow co-workers' attitudes and behaviors so the proper channels can be alerted prior to something happening. (See Chart 2)

Making It Work Before It Is Too Late

“Violence in the workplace isn’t always 100 percent avoidable, but there are steps that you can take and implement into your practice or office to protect yourself and staff members,” said Rugala.

Please check out the additional sources we have supplied to get you started in creating a plan that is well-suited for your office and listen to our October podcast featuring Gene Rugala, “Preventing Workplace Violence in Healthcare Settings”.

Also, for more information on how you can create a plan that works, visit the award winning website for the National Institute for the Prevention of Workplace Violence, Inc.,


Step 1 - Workplace Violence Prevention Program Development

  • Make Workplace Violence a priority for the organization
  • Form a cross functional Threat Management strategy team
  • Develop an overall program and process to address workplace violence prevention

Step 2 - Needs Assessment and Identification of Vulnerabilities/Risk

  • Implement 360 Violence Assessment Process:
    • Organizational Violence Assessment
    • Facility Risk Assessment
    • Individual Threat Assessment
  • Implement plan to address deficiencies

Step 3 - Implementation of Effective Security Measures and Processes

  1. Enhance Physical Security measures
  2. Establish Workplace Violence Audit teams
  3. Conduct on-going assessments & effectiveness of security efforts

Step 4 - Implement Effective Law Enforcement and First Responder Response Process

  1. Develop a positive relationship with local law enforcement and other appropriate First Responders
  2. Develop effective and rapid response processes
  3. Define process to use law enforcement and First Responder procedures to prevent and address occurrences

Step 5 - Implement Effective Human Resources Measures and Processes

  1. Enhance selection & hiring processes, e.g. background screening, drug testing, reference checks, etc
  2. Establish workplace violence zero incident policy
  3. Strengthen EAP program as preventive tool
  4. Establish Anger Management Coaching program
  5. Implement Forensic Psychiatric Review process (Fitness for Duty)
  6. Implement Individual Threat Assessment process

Step 6 - Create an Effective Crisis Response Plan

  • Develop crisis response procedures to respond to a Workplace Violence incident
  • Implement a crisis communication plan before it is needed

Step 7 - Design and Deliver Effective training in Workplace Violence Prevention

  1. Provide education & training to managers, supervisors and employees in preventative steps
  2. How to foster regular communication to create partnership with employees to combat violence in the workplace and create violence free workplace environment
  3. How to effectively intervene and address potential hostile situations and actual incidents

(Source: Barry Nixon for the National Institute for the Prevention of Workplace Violence, Inc.)


Warning Signs

Potential Behavior


Person makes direct, veiled or conditional threats of harm.


Person constantly makes slighting references to others. He is never happy with what is going on. He is consistently unreasonable and over reacts to feedback or criticism. He blows everything out of proportion. He is unable to accept criticism of job performance, has a tendency to take comments personally and turns it into a grudge.

Intimidation and Control Oriented

Person feels a need to constantly force their opinion on others. He has a compulsive need to control others. He uses intimidation of others to get his way (can be physical or verbal intimidation).e.g., fear tactics, threats, harassing behaviors including phone calls, stalking, etc.


Person thinks other employees are out to get them. She thinks there is a conspiracy to all functions of society. She feels persecuted, or victim of injustice.


Person doesn’t take responsibility for any of their behaviors or faults or mistakes, it's always someone else's fault. Employee does not accept responsibility for own actions, makes excuses, blames others, the company, the system for problems, errors and disruptive behaviors, etc.

Angry, Argumentative & Confrontational

Person has many hate and anger issues on and off the job with co-workers, family, friends, or the government. He is frequently involved in confrontations, belligerent and arguments with others including supervisors, co-workers, neighbors, etc. He has low impulse control, frequently involved in arguments and altercations, physically slams things, doors, etc., pounds fist or verbally demonstrative, uses inappropriate language.

Violence Fascination and Acceptance

Person applauds certain violent acts portrayed in the media such as racial incidences, domestic violence, shooting sprees, executions etc. He may have had trouble with the law, even just a minor incident. He is fascinated with the killing power of weapons and their destructive effect on people coupled with extreme interest in guns, particularly semi-automatic or automatic weapons.


Person makes statements like "he will get his" or "what comes around goes around" or "one of these days I'll have my say". She often verbalizes hope for something to happen to the person against whom the employee has a grudge.

Bizarre Behavior

Person is quirky, strange; considered weird and behaves in unusual manner; their presence makes others feel uneasy and uncomfortable


Person expresses extreme desperation over recent family, financial or personal problems.


Person has obsessive involvement with the job, particularly when no apparent outside interests exist. He has a romantic obsession with co-worker who has no interest in him. He suffers from other forms of obsessions.

Substance Abuse

Person has signs of alcohol and/or drug abuse.

Chronic Depression

Person displays chronic signs of depression, loss of interest and confident in life or work, is lethargic, lacks energy, particularly when this is a significant change in behavior.

(Source: Barry Nixon for the National Institute for the Prevention of Workplace Violence, Inc.)

Jennifer McDuffee's picture

Jennifer McDuffee

Marketing & Communications

Jennifer has been a marketing and communications professional with more than 15 years experience in corporate, agency and non-profit sectors.  She has expertise with both business-to-business and business-to-consumer marketing and public relations, and her specialties include branding/brand management, media relations/public relations, copywriting/editing/AP style, and product marketing.

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