Violence against Healthcare Staff: How Leaders in Ambulatory Care Can Keep Providers and Staff Safe

According to the U.S. Bureau of Labor Statistics, healthcare workers suffer from higher rates of workplace violence (i.e., verbal abuse such as threats, harassment, or intimidation, or physical abuse such as hitting, biting, kicking, sexual assault, or shooting) than almost every other profession. Further, according to the World Health Organization, between 8% and 38% of healthcare workers are estimated to experience physical violence during their careers. In some extreme cases, the violence may escalate, resulting in the serious injury or death of the healthcare worker.   

Violence directed toward healthcare staff may come from other staff members or from patients or family members and can undermine the organization’s culture of safety. Workers can suffer from both physical and emotional trauma that could result in time away from work, burnout, job dissatisfaction, decreased productivity, or leaving the organization or profession entirely. Organizations also suffer consequences as a result of workplace violence, including liability risks, higher staff turnover, and damaged reputation. 

Workplace violence has been extensively studied in hospitals and nursing homes, yet it has only recently begun to be studied in outpatient physician clinics. The workloads and the work environment (e.g., standalone facilities without security personnel) of these organizations expose staff to an increased risk of violence. 

The Occupational Safety and Health Act's General Duty Clause requires employers to provide a workplace free from recognized hazards that are causing or likely to cause death or serious physical harm.​ In addition, Joint Commission accreditation standards require leadership to develop and enforce a workplace violence prevention program.  

Leaders of ambulatory care organizations have a duty to provide a safe environment for patients, visitors, providers, and employees, which is why ECRI highlighted this growing concern in its Top 10 Patient Safety Concerns for 2023. The following are strategies leaders of ambulatory care organizations can implement to keep their providers and staff safe from harm: 

• Assess the risk of workplace violence in the organization and local community by conducting an all-hazard risk assessment. Leadership should form and lead a team composed of clinical and nonclinical staff, security personnel, and local law enforcement to carry out this assessment. 
• Develop a written workplace violence prevention program plan outlining strategies to reduce identified risk factors that can foster violent events. Many aspects of violent events can be mitigated by understanding and anticipating the root causes of these behaviors, since warning signs often precede violent acts. Common factors may include: 
  • Stressful conditions for patients such as long wait times, high noise levels, or a crowded environment.  
  • Stressful conditions for staff such as understaffing, feeling unprepared due to lack of training for violent situations, the misperception that disruptive behavior or violence is part of the job, working in isolation, or having limited or no security staff. 
  • Environmental conditions such as poor lighting in the office or parking lot, open floor plans that do not have barriers between the waiting room and exam rooms, lack of panic buttons or other alarms, unrestricted public access to the facility, or the potential for staff and patients to bring in firearms in open-carry or concealed-carry jurisdictions. 
• Set an organizational tone that any violence against healthcare workers is unacceptable by establishing a zero-tolerance policy that extends to staff, patients, and visitors. Enforce the policy with a strong, consistent response.
• Offer staff training for prevention, early recognition of warning signs, response, de-escalation, self-defense, and reporting of violent situations through simulation drills involving scenarios that incorporate organization-specific risks and strategies.
  • Training should cover detailed information from the organization’s workplace violence prevention plan and any related policies and procedures. Information on reporting incidents should also be addressed. Training should also cover information regarding safety devices such as panic buttons and other alarms including their locations, operation, and maintenance schedules and procedures. 
  • Managers and other organizational leaders should receive additional training focused on responding to reports of suspicious behavior and threats, enforcing the workplace violence prevention plan, and fostering a culture of safety.  
  • Conduct workplace violence training drills (e.g., active shooter drills). Develop a policy that addresses what to do if a patient arrives for an appointment with a weapon. 
• Create and maintain a culture where providers and staff trust each other and feel that they can report issues without repercussions.
• Encourage reporting of physical and/or verbal abuse, including suspicious behavior. 

Want to learn more about additional strategies to prevent workplace violence and other top patient safety concerns? Download ECRI's Top 10 Patient Safety Concerns 2023 Special Report or reach out to an ECRI expert for further assistance.