Overview and Summary: Patient and Visitor Violence: What Do We Know? What Can We Do?

  • Jonathan Rosen, MS CIH
    Jonathan Rosen, MS CIH

    Jonathan Rosen has more than 25 years of experience in the field of occupational safety and health. He served as Director of the Occupational Health & Safety Department for NYS Public Employees Federation (PEF) AFL-CIO, the labor union that represents New York State agency professional, scientific, and technical workers. Rosen has focused on workplace violence prevention for most of his career. He has worked with union and agency officials in conducting risk evaluations, developing workplace violence prevention programs and training. He has helped establish trauma response programs and provided direct assistance to injured nurses. He played a key role in establishing the New York State Public Employer Workplace Violence Prevention Law, and has been a co-investigator on several federal NIOSH violence prevention intervention research grants. Rosen has completed a Master's Degree in Industrial Health at the University of Michigan and is a Certified Industrial Hygienist.

In an instant, workplace violence can transform a nurse from being a healthcare provider to a healthcare patient. Broken bones, lacerations, contusions, and psychological trauma are among the injuries caused when patients or visitors attack. Violence destroys the therapeutic environment regardless of whether it is between patients, patient to staff, or visitor to staff.

We know that workplace violence is a serious problem across a broad spectrum of healthcare settings, but it is especially prevalent in behavioral health; emergency medicine; nursing homes and long term care; home care; and public institutions.

One outcome of deinstitutionalization is that formerly institutionalized patients are now frequently placed in group homes or living in supported housing. There have been a number of reports of homicides and assaults against staff in these locations throughout the country.

Many healthcare settings retain the notion that violence is part of the job, is unpredictable, and is therefore not preventable. This is a major impediment to addressing the problem.

Fatalities due to violence in healthcare are recorded by the U.S. Bureau of Labor Statistics’ Census of Fatal Occupational Injuries (CFOI) as well as the federal National Institute for Occupational Safety & Health's (NIOSH) Fatality Assessment and Control Evaluation (FACE) program. According to CFOI, there were 16 homicides among healthcare and social service workers in 2011, out of 113 total occupational fatalities in healthcare (U.S. Bureau of Labor, 2012). For the category "health diagnosing and treating practitioners" the homicides were 19% of the fatalities. Non-fatal injuries are more frequent, but also much harder to quantify. This is due to a number of factors including a) there is no national consensus definition of workplace violence, b) the collection of data on violence related injuries and threats suffers from chronic underreporting and different federal, state, and private entities use variant methodologies for recording and reporting workplace violence. These deficits are a deterrent to accurately evaluating trends on a national, state, and industry basis.

Twenty years of research has demonstrated that workplace violence is not just a criminal matter, but also a public health concern, and that the preventive framework within occupational safety and health can be effectively used to reduce workplace violence and limit its severity. This path was set with the publication of an alert by NIOSH (U.S. Department of Health & Human Services, 1993) followed by guidelines for healthcare and social services issued by the Occupational Safety and Health Administration (OSHA, 2004) in 1996, updated in 2004. The introductory articles in this OJIN topic provide some insight into recent research in the area of patient and visitor violence in several settings. The topic articles also address the status of violence prevention programs and advocacy for policy at all levels related to workplace violence.

A number of researchers have evaluated the implementation of the OSHA workplace violence program elements that are contained in the guidelines. In the first topic article, “Workplace Violence Prevention Policies in Home Health and Hospice Care Agencies,” authors Gross, Peek-Asa, Nocera, and Casteels review the extent that the OSHA elements have been implemented in home health and hospice care in California. The study revealed that, although California has a requirement for employers to have a workplace violence prevention program, only 55% of the study agencies had a formal program in place. Only 15% of the agencies provided training for all employees involved in patient care.

Gillespie, Gates, and Berry document the nature of physical violence in the emergency room in “Stressful Incidents of Physical Violence against Emergency Nurses.” They present a study to describe acts of physical aggression against emergency nurses using a mixed method design with a national sample of emergency nurses. Some of their key findings included the importance of factors such as workplace design; long wait times; delays in providing pain medication; timely transfer of mental health patients; weapons policies; and the existence and implementation of policies for prevention and control of violence.

A key to preventing assaultive behavior is recognizing and responding to aggression and agitation before it escalates to physical violence. In addition to training workers to recognize and respond, healthcare systems must have a robust approach to intervening when patients and clients become aggressive, assaultive, or self-injurious. Iennaco and colleagues discuss this problem in “Measurement and Monitoring of Healthcare Worker Aggression Exposure.” First, aggression must be accurately measured. This article provides an overview of aggression exposure in healthcare and reviews challenges of common measures of aggression. Discussion of a pilot study presents insights gained from using a novel measure of aggression, handheld counters.

McPhaul, London, and Lipscomb elucidate the translation of workplace violence intervention research into evidence based recommendations for preventive programs in today’s healthcare work environment. In “A Framework for Translating Workplace Violence Intervention Research into Evidence-Based Programs,” the authors conclude that to address violence in healthcare there must be very purposeful organizational processes conducted by very specific organizational structures. They also emphasize the importance of workplace violence committees and workplace safety ”champions” or advocates, as complements to effective regulation.

The research, as well as this author's experience, teaches that employers are often reluctant to act absent regulations or standards. Often the motivation to act is a tragedy, such as a violent death or serious injury to a nurse or patient. It is the old "canary in the coal mine" syndrome. When this occurs, it is important for advocates to push hard for meaningful improvements, as the window for change often does not remain open for long. A discussion about advocacy is laid out by Papa and Vanella in “Workplace Violence in Healthcare: Strategies for Advocacy.” The authors emphasize the importance of educating nurses and administrators about the impact of violence on the quality of care, as well as the fiscal health of the organization. This article provides a brief overview of workplace violence by discussing settings where aggression often occurs and direct and indirect financial impacts of violent acts. Advocacy strategies for nurses are offered to address workplace violence on several levels, such as legislative advocacy, workplace policy, and education.

Once a healthcare organization is engaged, another key is the balance between focusing on individual healthcare worker performance issues versus making improvements to organizational systems. Training, teamwork, clinical skills, and the ability to recognize and respond to patient agitation and behaviors are key individual skills. However, organizations must address such variables as unit design; security systems; emergency response protocols; patient assessment procedures; timely access to relevant patient information; building access control; and teamwork. All too often the focus is on individual healthcare workers and smacks of the "blame the victim" mentality. Similarly, zero tolerance policies have been criticized for being reflexive, inadequate, and potentially violating due process rights when they are applied without weighing facts or circumstances (Denenberg & Braverman, 2001). These policies also tend to ignore system-level risk factors and prevention strategies.

Violence against healthcare workers raises the need for employers to address related issues including criminal prosecution by building relationships with criminal justice authorities; providing support and assistance to injured healthcare workers in navigating the various state workers' compensation systems; and establishing peer-based trauma support systems that are available 24/7 to assist assaulted staff. These peer-based programs provide psychological first aid to traumatized staff members, affording a mechanism for organizational support and helping assaulted staff to recover, regain confidence necessary to return to work, and avoid development of post traumatic stress disorder. Unfortunately, many organizations continue to subscribe to the outdated critical incident management stress debriefing model. Use of group psychological debriefing may do more harm than good due to vicarious traumatization of some group participants (Fawzy & Gray, 2007).

As noted in several of the topic articles, a number of state laws have been passed and this may create the momentum necessary for a national standard. The bottom line is that effective development and implementation of workplace violence prevention programs is essential to the well being of patients, staff, and healthcare organizations. Let us all rise to address this key problem with the urgency it deserves. The journal editors invite you to share your response to this OJIN topic addressing Patient and Visitor Violence either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Jonathan Rosen, MS CIH
E-mail: JRosen396@gmail.com

© 2013 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2013


Denenberg, R., & Braverman, M. (2001). The violence prone workplace, new approaches to dealing with hostile, threatening, and uncivil behavior. Ithaca, NY: ILR Press, Cornell University.

Fawzy, T., & Gray, M. (2007). From CISD to CISM: Same song different verse? The Scientific Review of Mental Health Practice, 5(2), 31-43.

OSHA. (2004). Guidelines for preventing workplace violence for health care & social service workers. OSHA 3148-01R.

U.S. Bureau of Labor Statistics. (2012, September 20). National census of fatal occupational injuries in 2011(preliminary results). Retrieved from: www.bls.gov/news.release/pdf/cfoi.pdf

U.S. Department of Health & Human Services, Public Health Service, Centers for Disease Control & Prevention. (1993). NIOSH alert: Preventing homicide in the workplace. NIOSH, Publication 109-93.

Citation: Rosen, J., (January 31, 2013) "Overview and Summary: Patient and Visitor Violence: What Do We Know? What Can We Do?" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 1, Manuscript, Overview and Summary.