Today more than 5 million U.S. hospital workers from many occupations
perform a wide variety of duties. They are exposed to many safety and
health hazards, including violence. Recent data indicate that hospital
workers are at high risk for experiencing violence in the workplace.
According to estimates of the Bureau of Labor Statistics (BLS), 2,637
nonfatal assaults on hospital workers occurred in 1999-a rate of 8.3
assaults per 10,000 workers. This rate is much higher than the rate of
nonfatal assaults for all private-sector industries, which is 2 per
Several studies indicate that violence often takes place during times
high activity and interaction with patients, such as at meal times and
during visiting hours and patient transportation. Assaults may occur
when service is denied, when a patient is involuntarily admitted, or
when a health care worker attempts to set limits on eating, drinking,
tobacco or alcohol use.
The purpose of this brochure is to increase worker and employer
awareness of the risk factors for violence in hospitals and to provide
strategies for reducing exposure to these factors.
Who is at risk?
Although anyone working in a hospital may become a victim of violence,
nurses and aides who have the most direct contact with patients are at
higher risk. Other hospital personnel at increased risk of violence
include emergency response personnel, hospital safety officers, and all
health care providers.
Where may violence occur?
Violence may occur anywhere in the hospital, but it is most frequent in
the following areas:
· Psychiatric wards
· Emergency rooms
· Waiting rooms
· Geriatric units
What are the effects of violence?
The effects of violence can range in intensity and include the
· Minor physical injuries
· Serious physical injuries
· Temporary and permanent physical disability
· Psychological trauma
Violence may also have negative organizational outcomes such as low
worker morale, increased job stress, increased worker turnover, reduced
trust of management and coworkers, and a hostile working environment.
What are the risk factors for violence?
The risk factors for violence vary from hospital to hospital depending
on location, size, and type of care. Common risk factors for hospital
violence include the following:
· Working directly with volatile people, especially, if they are under
the influence of drugs or alcohol or have a history of violence or
certain psychotic diagnoses
· Working when understaffed-especially during meal times and visiting
· Transporting patients
· Long waits for service
· Overcrowded, uncomfortable waiting rooms
· Working alone
· Poor environmental design
· Inadequate security
· Lack of staff training and policies for preventing and managing
with potentially volatile patients
· Drug and alcohol abuse
· Access to firearms
· Unrestricted movement of the public
· Poorly lit corridors, rooms, parking lots, and other areas
Prevention Strategies for Employers
To prevent violence in hospitals, employers should develop a safety and
health program that includes management commitment, employee
participation, hazard identification, safety and health training, and
hazard prevention, control, and reporting. Employers should evaluate
this program periodically. Although risk factors for violence are
specific for each hospital and its work scenarios, employers can follow
general prevention strategies.
· Develop emergency signaling, alarms, and monitoring systems.
· Install security devices such as metal detectors to prevent armed
persons from entering the hospital.
· Install other security devices such as cameras and good lighting in
· Provide security escorts to the parking lots at night.
· Design waiting areas to accommodate and assist visitors and patients
who may have a delay in service.
· Design the triage area and other public areas to minimize the risk of
Provide staff restrooms and emergency exits.
Install enclosed nurses' stations.
Install deep service counters or bullet-resistant and shatterproof
enclosures in reception areas.
Arrange furniture and other objects to minimize their use as weapons.
Design staffing patterns to prevent personnel from working alone and to
minimize patient waiting time.
Restrict the movement of the public in hospitals by card-controlled
Develop a system for alerting security personnel when violence is
Provide all workers with training in recognizing and managing assaults,
resolving conflicts, and maintaining hazard awareness.
Dealing With the Consequences of Violence
Violence may occur in the workplace in spite of preventive measures.
Employers should be prepared to deal with the consequences of this
violence by providing an environment that promotes open communication
and by developing written procedures for reporting and responding to
violence. Employers should offer and encourage counseling whenever a
worker is threatened or assaulted.
Safety Tips for Hospital Workers
Watch for signals that may be associated with impending violence:
Verbally expressed anger and frustration
Body language such as threatening gestures
Signs of drug or alcohol use
Presence of a weapon
Maintain behavior that helps diffuse anger:
Present a calm, caring attitude.
Don't match the threats.
Don't give orders.
Acknowledge the person's feelings (for example, "I know you are
Avoid any behavior that may be interpreted as aggressive (for example,
moving rapidly, getting too close, touching, or speaking loudly).
Evaluate each situation for potential violence when you enter a room or
begin to relate to a patient or visitor.
Be vigilant throughout the encounter.
Don't isolate yourself with a potentially violent person.
Always keep an open path for exiting-don't let the potentially violent
person stand between you and the door.
Take these steps if you can't defuse the situation quickly:
Remove yourself from the situation.
Call security for help.
Report any violent incidents to your management.
Case Reports: Prevention Strategies That Have Worked
A security screening system in a Detroit hospital included stationary
metal detectors supplemented by hand-held units. The system prevented
the entry of 33 handguns, 1,324 knives, and 97 mace-type sprays during
A violence reporting program in the Portland, Oregon, VA Medical Center
identified patients with a history of violence in a computerized
database.* The program helped reduce the number of all violent attacks
by 91.6% by alerting staff to take additional safety measures when
serving these patients.
A system restricting movement of visitors in a New York City hospital
used identification badges and color-coded passes to limit each visitor
to a spe cific floor. The hospital also enforced the limit of two
visitors at a time per patient. Over 18 months, these actions reduced
the number of reported violent crimes by 65%.
*Health information and the electronic recording of this information
must comply with appliscable Federal standards on privacy under Titles
42 and 45 of the U.S. Code.
All hospitals should develop a comprehensive violence prevention
program. No universal strategy exists to prevent violence. The risk
factors vary from hospital to hospital and from unit to unit. Hospitals
should form multidisciplinary committees that include direct-care staff
as well as union representatives (if available) to identify risk
in specific work scenarios and to develop strategies for reducing them.
All hospital workers should be alert and cautious when interacting with
patients and visitors. They should actively participate in safety
training programs and be familiar with their employers' policies,
procedures, and materials on violence prevention.
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