Violence: Not in My Job Description

Laura A. Stokowski, RN, MS


August 23, 2010

In This Article

Violence Prevention and Intervention Programs

If you have been so lucky as to avoid being a victim of violence at work, don't make the mistake of thinking it can't happen to you. The odds are not favorable, but the good news is that awareness of the problem is increasing. This awareness prompted the US Department of Labor and OSHA to produce Guidelines for Preventing Workplace Violence for Health Care and Social Workers.[1] A summary of recommendations includes:

  1. Adopt a written violence-prevention program and communicate it to all employees.

  2. Advise all patients and visitors that violence, verbal and nonverbal threats, and related behavior will not be tolerated.

  3. Set up a trained response team to respond to emergencies.

  4. Encourage employees to promptly report incidents and to suggest ways to reduce or eliminate risks.

  5. Review the workplace layout to find existing or potential hazards, and install and maintain alarm systems and other security devices, such as panic buttons and other alarms. Arrange for a reliable response system when an alarm is triggered.

  6. Use metal detectors to screen patients and visitors for guns, knives, or other weapons.

  7. Establish a liaison with local police and state prosecutors, report all incidents of violence, and provide police with floor plans of facilities to expedite emergency response or investigations.

  8. Ensure adequate staff coverage at all times.

  9. Use chart tags, logbooks, or other means to identify patients and clients with assaultive behavior problems.

  10. Institute a sign-in procedure with passes for visitors and compile a list of "restricted visitors" for patients with a history of violence.

  11. Control access to facilities other than waiting rooms, particularly drug-storage or pharmacy areas.

  12. Provide medical care and psychological counseling and debriefing for employees who experience or witness assaults and other violent incidents.

OSHA emphasizes that if a violence prevention program is to be successful, it must have the following elements: management commitment and employee involvement, hazard prevention and control, safety and health training, and recordkeeping and program evaluation.[1] The effectiveness of violence prevention programs in healthcare, however, has not been well studied.[5]

The Joint Commission recommends that hospitals begin with a risk assessment (assessment tools are available for this purpose).[3] Controlling access is at the top of the list for prevention of violence in the workplace. Security precautions in the ED must be especially tight. All staff should undergo training in responding to visitors who are agitated and potentially violent. Some training programs teach the STAMP assessment tool (Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling, and Pacing) to help nurses identify potential violent behavior.[26]

Healthcare organizations should adopt a zero-tolerance policy with respect to violence. Employees must be encouraged to report incidents of violence or threats of violence, including offensive and violent gestures and language. Supervisors must take these reports seriously and, when appropriate, also report them to law enforcement. Accurate statistics on incidents of violence will lead to more effective prevention. Counseling should be offered to victims of workplace violence.

Both OSHA and the Joint Commission recommend violence prevention training for staff members at risk for violence in the workplace, but little empirical evidence exists to support this strategy.[27]Even when nurses have been trained about workplace violence, surveys about experiences with workplace violence show little evidence of the protective effect of such training.[7] Similarly, although healthcare institutions are urged to develop policies related to workplace violence, it is unclear whether having policies in place does anything to protect nurses from violence.[28] These areas are sorely in need of more research.[29]


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