Workplace Violence in Healthcare

Executive Summary

Workplace violence is actual violence or the threat of violence against workers. It can take place at the workplace or outside of the job site and can range from threats and verbal abuse to physical assaults. Increasingly, there has been heightened attention to the issue of violence among healthcare workers who represent one of the most at-risk groups (along with teachers, social servants, correctional officers, retail and public works employees). Estimates are as high as 80% of healthcare employees reporting having experienced violence within their work setting. Moreover, incidents are generally under-reported. It is suggested that the incidence of workplace violence is attributed to a lack of employee training programs, deficiencies in violence management protocols, and delays in response times. Strategies to reduce workplace violence include:

  • Identify Types of Violent Interactions
  • Conduct a Risk Assessment
  • Develop Prevention Strategies to Address:
  • Workplace design
  • Administrative policies & procedures
  • Work practices


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Types of Violent Interactions

Workplace violence is a complex issue that can involve not only healthcare providers but also patients and their families. Types of violent interactions can take place between other healthcare providers (e.g., provider-to-provider interactions), or between patients (e.g., patient-to-staff interactions, staff-to-patient interactions, patient-to-patient interactions), or other interactions involving family or members of the general public.


There are a number of ways to determine the extent and prevalence of violence in the healthcare workplace. Asking employees to discuss their experiences and whether or not they feel safe in their place of employment can be one method (anonymous surveys may be a good place to start). Assessing the risk factors previously cited in addition to reviewing documentation such as incident reports and undertaking a visual inspection of the workplace are also worthwhile (e.g., identify any isolated areas). Consulting or partnering with other similar organizations to assess and address the issue of workplace violence can be useful (e.g., professional associations, union groups). Reviewing relevant legislation to better understand the roles and responsibilities at an organization and employee level is also warranted. The collected information can be used to begin developing a workplace violence prevention program for an organization.

Identification of Risk Factors

Health care workers are one of the most at-risk employee groups to experience violence in the workplace for a number of reasons:

  • Working in direct contact with the public in a service-provision capacity puts them in potentially violent situations;
  • Working with unstable individuals (e.g., aggressive mental health patients);
  • Having a mobile workplace (such as a car in the case of homecare personnel);
  • Working late at night or during the early morning hours;
  • Working long hours/shifts; working alone or in small numbers;
  • Working in an environment with valuable property (e.g., pharmaceuticals);
  • Working during periods of organizational change (e.g., strikes, restructuring, downsizing);
  • Working in specific healthcare departments (e.g., emergency, psychiatric);
  • Organizations with hierarchical management structures;
  • Geographic location of the workplace (e.g., areas that are isolated from other buildings or in places with known crime); and
  • The extent to which employees are overworked (e.g., burnout).


Recent evidence suggests that nurses may be at increased risk over other professions, as well as those who are younger. Males tend to more often be at risk of physical violence while females tend to be at increased risk of verbal abuse. Mental health nurses have a three-fold risk of being the victims of violence as compared with nurses working in other healthcare sectors. The risk of violence may be greater at certain times of the day, night or year; for example:

  • Late hours of the night or early hours of the morning
  • During holidays
  • Pay days
  • Performance appraisals


Prevention Strategies

It is critical that all personnel and associated organizations (e.g., unions, staff associations, professional groups) within the healthcare workplace be committed to, and involved in developing a workplace violence prevention program. Senior leadership support is a key factor in ensuring that the program is successful. Written policies are important, but must be supported by a culture that encourages open dialogue and incident reporting with zero tolerance for abusive behaviour. Preventive strategies fall into three major categories:

Workplace Design: includes the consideration of factors such as building layout, use of signs, locks, physical barriers, lighting, security, electronic surveillance, the positioning of furniture, use of access key cards, minimizing the number of workplace entrances, designated safe zones for emergency situations, panic buttons, alarms, etc.

Administrative: organizational decisions regarding workplace procedures (e.g., use of secure dispensing carts for pharmaceutical access, using a locked safe for cash register funds, having emergency contact numbers, development of employee training programs, etc).

Work practices: include all activities performed by employees while on the job. Adopting specific practices can help reduce risk (e.g., having a documented daily work plan so that you and others know where and when you are expected somewhere; having a designated contact and back-up person; using “buddy systems” particularly in situations where personal safety may be an issue such as dealing with difficult patient situations or staff encounters; documented procedures for informing workers of potentially dangerous situations and how to access assistance if needed).

Developing written workplace violence policies should be undertaken by senior leadership in consultation with employee representatives after identifying risks and collecting relevant information. These policies should:

  • Be applicable to everyone, including all those who have an indirect relationship with the organization (e.g. suppliers);
  • Define in plain language what is meant by workplace violence;
  • Provide clear examples of unacceptable behaviour;
  • State in clear terms your organization's stance on workplace violence and its commitment to prevention;
  • Identify the consequences of engaging in such behaviour;
  • Encourage reporting of all incidents of violence;
  • Outline the confidential process by which employees can report incidents, with assurances that no retribution will occur against those who make reports;
  • Include details about support services offered to victims of violence and also those struggling with personal problems (e.g., Employee Assistance Programs);
  • Include a commitment to regularly review the policy; and
  • Outline any applicable legislation.


Employee Training Programs

Numerous international jurisdictions have recognized that educating employees about workplace violence prevention is a critical step in decreasing the incidence of violence among healthcare workers. While some programs have been shown to be effective in preventing violence, they remain challenging to implement in healthcare settings. Barriers include a lack of action on the part of leadership despite increased employee reporting; varying perceptions of what constitutes violence; profit-driven management models; lack of management accountability; a focus on customer service rather than employee protection; and weak legal and social service infrastructure for mentally ill patients. Undertaking an appropriate risk assessment in which different types and sources of violence are identified can help support the development of prevention programs.