Workplace Violence and Safety
Prevention and Solution Strategies
CONTACT HOURS: 3
Copyright © 2023 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this course, you will have increased your knowledge in order to prevent, identify, and respond to workplace violence. Specific learning objectives to address potential knowledge gaps include:
- Describe the various types of workplace violence.
- Discuss the impact of workplace violence.
- Identify risk factors for workplace violence.
- Summarize how to respond to workplace violence.
- Describe employer responsibilities in responding to violence in the workplace.
- Identify essential components of a workplace violence program and barriers to its implementation.
TABLE OF CONTENTS
- What Constitutes Workplace Violence?
- Impact of Workplace Violence
- Recognizing and Responding to Workplace Risk Factors
- Recognizing and Responding to Workplace Violence
- Employer Responsibilities
- Conclusion
- Resources
- References
WHAT CONSTITUTES WORKPLACE VIOLENCE?
Reliance on violence to address any perceived threat is a characteristic of many individuals in American society. It is, therefore, no surprise that violence occurs in the workplace. Such violence is a public health issue that requires identifying precipitating factors and developing strategies to keep employees safe.
Workplace violence has been federally recognized as an organizational, community, and societal issue. The Occupational Safety and Health Administration (OSHA, n.d.) defines workplace violence as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at any work site.” It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers, and visitors.
The National Institute for Occupational Safety and Health (NIOSH, 2020a) defines workplace violence as “any physical assault, threatening behavior, or verbal abuse occurring in the work setting.” Violence can occur in any workplace and among any type of worker.
Workplace violence ranges broadly from offensive or threatening language to homicide. Elements of workplace violence include physical assaults, swearing, verbal abuse, harassment, pranks, vandalism, property damage, sabotage, pushing, theft, rape, arson, and murder (CCOHS, 2023).
The Centers for Disease Control and Prevention (CDC, 2020b) has identified four types of workplace violence. These include:
- Type 1: Violence by a stranger with criminal intent
- Type 2: Violence by a customer or client
- Type 3: Violence by a coworker (worker on worker)
- Type 4: Violence by someone in a personal relationship
Type 1: Violence by a Stranger with Criminal Intent
In this type of workplace violence, the perpetrator is a stranger without a legitimate relationship to the organization or its employees. Typically, a crime is being committed in conjunction with the violence. The primary motive is usually robbery, but it could also be shoplifting or criminal trespassing. A deadly weapon is often involved, increasing the risk of fatal injury. Crimes of violence in this category include assault, robbery, and homicide (CDC, 2020b).
Workers who are at higher risk for violence by a stranger with criminal intent are those who exchange cash with customers as part of the job, work late-night hours, and/or work alone. Convenience store clerks, taxi drivers, and security guards are all examples of the kinds of workers who are at increased risk for criminal violence (Society Insurance, 2021).
Nurses may also be at particular risk for robbery since many of them work at night and/or work in facilities that have a variety of drugs that may be targets for theft. In the healthcare professions, personnel known or perceived to have items of value in their possession or in their workplace may also be at increased risk for targeting (Matheson & Horowitz, 2021). Examples include:
- Home health providers (nurses, OTs, PTs, and aides)
- Clinic personnel working alone or in an isolated area of a facility
- Any personnel going to/from vehicles alone and/or at times or in places when few others are around
Type 2: Violence by a Customer or Client
In type 2 incidents, the perpetrator has a legitimate relationship with the organization by being a recipient of its services. This category includes customers, clients, patients, students, inmates, and any other group for which the organization provides services. The violence can be committed in the workplace or, as with home healthcare providers, outside the workplace but while the worker is performing a job-related function (CDC, 2020b).
Violence by a customer or client is the most common type in healthcare settings. In such settings, the customer/client relationship includes patients, families, and visitors. Violence by a customer or client most often occurs in emergency and psychiatric treatment settings, waiting rooms, and geriatric settings (CDC, 2020b). These attacks may be perpetrated by “unwilling” clients who are brought into emergency departments or mental health facilities by law enforcement for assessment and/or treatment.
There may also be situations with people not known to be violent who can become violent in response to something present in the situation. Provoking situations may be those that are frustrating to the individual, such as the denial of needed or desired services or delays in receiving such services.
CASE
Violence by a Patient
Eric is a college student who works part-time on the night shift as a lab technician at Memorial Medical Center, a mid-sized hospital in a suburb of a large metropolitan area. The hospital emergency department (ED) has eight beds and is relatively quiet unless they are treating overflow patients from the trauma unit downtown. Recently, the hospital agreed to allocate space in the ED for a program in which the local police department admits suspected drunk drivers for assessment and short-term intervention. To date there have been only a handful of such cases.
Eric was on duty when an intoxicated 28-year-old male patient was admitted for assessment after hitting a parked car while leaving a party. The patient, who was initially cooperative while the police officer was present, was taken to one of the assessment rooms at the end of the hall by a nurse. The patient began to get agitated, denied he had done anything wrong, jumped up, and demanded to be released.
Eric entered the room to take a blood sample just as the nurse was responding to the patient’s angry request by grabbing onto his arm and telling him that he was not allowed to leave yet. The patient picked up a small metal canister off the counter, threw it at Eric, and ran out of the room toward the hospital exit, where he was subdued by the hospital security guard and two additional staff members. The canister hit Eric in the face, injuring his left eye.
(continues below under “Institutional Initiatives”)
CASE
Violence by a Visitor
Alice Adams is a 70-year-old resident at Hillcrest Manor, a skilled nursing and long-term care facility. She was admitted six months ago after she was found wandering a few blocks away from her long-time family home. She was recently diagnosed with second-stage Alzheimer’s disease. Prior to her admission she lived alone with daily help from her two sons, their wives, and several grandchildren. Her husband died eighteen months ago after a fall from a ladder while cleaning leaves out of the gutters.
The older son, Jack, still feels guilty for not helping his father with the gutter clean-up and blames himself for his father’s death. He was not in favor of the decision to admit his mother to Hillcrest but reluctantly agreed because the other family members and Alice’s physician determined it was the best option. Jack has been a frequent caller to the facility administrator’s office with complaints about his mother’s care. He thinks that she is not checked often enough, that she needs more help with meals, and that she should be taken for walks more frequently. He believes that his mother’s health is worse and blames the facility for a decline in her mental capacity.
Today Jack arrives to find Alice dozing in her recliner chair with her supper tray sitting untouched on the table next to her. He storms out of her room into the hallway and shouts that he needs help right away. The evening shift nurse is just down the hall making rounds and responds immediately, as does the occupational therapist, who is helping a patient in the next room to use eating aids as part of his stroke rehabilitation process. Jack angrily grasps the therapist’s shoulders and pushes her into his mother’s room, asking why his mother has not been helped yet with her meal. He curses and states that this is the last time he is going to ask nicely.
The therapist recognizes Jack and is familiar with his frequent complaints about his mother’s care. She steps aside and exits the room. Standing in the doorway, she calls him by name, calmly stating, “Mr. Adams, I can see that you are upset. I was just finishing up next door and was going to help Mrs. Adams next. It sounds like you would like to talk with someone about your concerns. I will get the supervisor, who will be glad to meet with you.” Jack visibly relaxes and sits down.
The evening shift nurse arrives in time to see the incident and steps into the room. She helps Jack set up his mother’s dinner tray and calls a nursing assistant to help Alice with her meal. She then suggests that Jack meet with her in a nearby conference room.
She asks Jack to describe what happened, and as he does, he acknowledges that his behavior was out of line. He apologizes for his outburst and shares how frustrated he is with his mother’s health decline and not being able to do anything to prevent it. The nurse acknowledges his feelings and how difficult it must be for him to deal with the kind of changes he has been faced with.
The nurse also states that Jack’s behavior was inappropriate and will be reported to the facility’s security manager. She tells Jack that any additional incidents like she witnessed that evening will result in further action to ensure the safety of the residents and the employees. She reminds him that he can communicate any concerns about his mother’s care to the administrator or to her if it is the evening shift. She then suggests that Jack may benefit from talking with the facility’s social worker, who also runs the local caregivers support group, and provides him with the phone number. Jack agrees that the suggestion sounds like a good idea and returns to his mother’s room to resume his visit.
Type 3: Coworker (Worker-to-Worker) Violence
Coworker violence occurs when an employee or past employee attacks or threatens coworkers. This category includes violence by employees, supervisors, managers, and owners. Examples may be violence committed by supervisors against subordinates, physicians against nurses, subordinates against supervisors, and workers against other workers who are on the same level of the organizational hierarchy (CDC, 2020b).
Worker-to-worker violence includes:
- Overt verbal and/or physical abuse
- Refusing to help a coworker who needs assistance
- Spreading malicious gossip about a coworker
- Embarrassing a coworker in front of clients and/or other workers
(TJC, 2021a; Vidal-Alves et al., 2021)
EXAMPLES OF COWORKER VIOLENCE
Examples of the most frequently encountered situations among coworkers are:
- Concealing or using a weapon
- Physical assault
- Actions which damage, destroy, or sabotage property
- Intimidating or frightening others
- Harassing, stalking, or showing undue focus on another person
- Physically aggressive acts, such as shaking fists at another person, kicking, pounding on desks, punching a wall, angrily jumping up and down, screaming at others
- Verbal abuse, including offensive, profane, and vulgar language
- Threats (direct or indirect), whether made in person or through letters, phone calls, or electronic communications
(USDOL, n.d.)
VERTICAL VIOLENCE
Vertical violence is defined as any act of violence that occurs between two or more persons on different levels of the hierarchical system and that prohibits professional performance and satisfaction in the workplace.
Vertical violence may be directed downward (e.g., superior to subordinate) or upward (e.g., subordinate to superior). Vertical violence can reflect either an abuse of legitimate authority or abuse of informal power. Abuse of informal power by individuals or cliques of coworkers are behaviors that undermine the work of a manager or leader.
Vertical violence is prevalent among nurses and between physicians and nurses and can be connected to medical errors and preventable negative outcomes for patients. For example, a nurse may be reluctant to call a physician about a patient’s worsening condition because of physician bullying, incivility, or overt or covert abuse; or a medication order may not be questioned in order to avoid the threat of intimidation (Dellasega, 2020; Sadler, 2020; Vidal-Alves, 2021).
CASE
Worker-to-Worker Violence
Roland is a nurse working in the emergency department of a local hospital in a midsize town. Among the physician staff there, Dr. Johnson is known to be difficult to work with. He has been an angry man ever since his daughter was killed in a car accident caused by a drunk driver 10 years ago. He is rude and condescending to staff and patients.
This evening, Roland is working in trauma room 1 and needs to obtain a piece of equipment from trauma room 3. The door to room 3 is closed, since Dr. Johnson is suturing a patient there. Roland knocks on the door and opens it slowly, excuses himself, and announces his need to obtain equipment from the room. Abruptly, Dr. Johnson gets up, walks to the door, and slams it shut, hitting Roland in the face and crushing his wire-rim glasses. As a result, Roland must delay treatment for the patient he was caring for in room 1 until he gets his extra pair of glasses from his locker and finds the necessary equipment from another room. Since he has no apparent injury or change in vision, Roland elects to continue to work.
As soon as the patient in room 1 has been discharged, Roland informs his supervisor of the incident. He follows policy and completes and submits an incident report before he leaves. When he gets home, he writes down the sequence of events.
No action has ever been taken in regard to Dr. Johnson’s violent behavior despite Roland and the other nurses in the emergency department having reported such behavior many times before. The department manager has told the nurses that Dr. Johnson is dealing with grief and that they should understand what he is going through. After all, it is hard to find doctors to staff the ED, and dealing with such situations is just “part of the job.” As a result, the nurses have become resigned to this physician’s behavior and try to avoid any interaction that might cause him to abuse them.
After this latest incident, Roland complains to his coworkers, who have also experienced similar situations. Roland and his colleagues review organizational policies and procedures pertaining to workplace violence. Policy states that if the immediate supervisor (in this case the departmental manager) does not resolve the issue satisfactorily according to policy, the complaint should be presented to the next person of authority on the hierarchical ladder.
Roland and his colleagues hesitate to do this for fear of retaliation, but after much discussion, all but one out of the five persons involved agree to file a complaint with the departmental manager’s immediate supervisor, the Vice President (VP) for Critical Care Services. The VP has 10 days to investigate the complaint. While waiting, Roland and his colleagues experience their manager’s resentment. The manager has limited her interaction with them and speaks to them only when absolutely necessary. Clinical assignments have remained equitably distributed.
Roland and the others are worried about whether their complaint will be taken seriously. Near the end of the 10-day response timeframe, rumors begin to surface. Gossip is that Dr. Johnson will be put on administrative leave for an indefinite period of time. The VP meets with Roland and the other complainants to confirm that Dr. Johnson is now on leave. She further explains that employee privacy requires her to maintain confidentiality regarding other details of any disciplinary action against Dr. Johnson and emphasizes that “no information does not mean there has been no action.” Roland and his colleagues are relieved that their complaint has been taken seriously.
HORIZONTAL (LATERAL) VIOLENCE
Horizontal violence (HV) is defined as “nonphysical intergroup conflict expressed in overt and covert behaviors of hostility.” Also referred to as lateral violence, HV is workplace conflict in which confrontational behavior is targeted at one person by another employed at the same level of responsibility across time in repeated instances of emotional, psychological, physical, or sexual abuse. It is meant to create a power relationship in which the victim is controlled emotionally by the abuser. The practitioners of lateral violence characteristically demonstrate impatience, condescension, anger, threatening posturing, and even physical aggression.
Horizontal violence permeates the healthcare professions. In nursing, research shows that HV contributes to high nurse turnover rates, increased illness, decreased productivity, and a decrease in the quality of care that patients receive. Additionally, research has found that:
- HV is evident during nursing education.
- HV occurs early in nursing careers.
- Manager and staff support and workplace education were the most helpful in reducing HV.
(Bloom, 2019)
Attempts to explain the high incidence of horizontal violence in the nursing profession are traced to the history of nursing, where oppression was once the norm between the male medical profession and female nurses. Members of the nursing profession have been described as an oppressed group, and according to theories of oppression, the oppressed group internalizes the values, norms, and behaviors of the dominant group as the most appropriate, while the characteristics of their own group become negatively valued and suppressed (Freire, 1999; Roberts, 1983).
WORKPLACE BULLYING
Workplace bullying is defined as frequent or repeated personal attacks that are emotionally hurtful or professionally harmful. Bullying is a deliberate attempt to undermine a coworker’s ability to carry out work, to injure the person’s reputation, to undermine the person’s self-esteem and self-confidence, or to remove personal power from that coworker.
Bullying can be both obvious and subtle. The following are examples of bullying:
- Spreading malicious rumors, gossip, or innuendo
- Excluding or isolating someone socially
- Intimidating a person
- Undermining or deliberately impeding a person’s work
- Physically abusing or threatening abuse
- Removing areas of responsibilities without cause
- Constantly changing work guidelines
- Establishing impossible deadlines that will set the person up to fail
- Withholding necessary information or purposefully giving the wrong information
- Making jokes that are obviously offensive by spoken word or email
- Intruding on a person’s privacy by pestering, spying, or stalking
- Assigning unreasonable duties or workload that are unfavorable to one person in a way that creates unnecessary pressure
- Assigning too little work (underwork), creating a feeling of uselessness
- Yelling or using profanity
- Criticizing a person persistently or constantly
- Belittling a person’s opinions
- Unwarranted or undeserved punishment
- Blocking applications for training, leave, or promotion
- Tampering with a person’s personal belongings or work equipment
(CCOHS, 2020)
CASE
Bullying
Elizabeth, a physical therapist, moved from Chicago to a small town in Montana and now works at the local hospital there. This is her second job since graduating two years ago. Elizabeth has not been having good experiences with her coworker Margaret. Margaret often makes snide remarks about Elizabeth being “a big city girl with little experience” and belittles her when she speaks up at staff meetings.
Several times over the past month, Elizabeth asked for assistance from Margaret and was told she needed to “learn to set priorities better.” At times when she asked for information about a patient or situation, Margaret rolled her eyes, ignored her, and walked away.
Elizabeth recognized she was being bullied and needed to take steps to stop it. She began keeping a journal, objectively recording specific behaviors, including date, time, who else was present, and any other details surrounding each incident. When she felt she had enough documentation, Elizabeth sought out another coworker who was very supportive and asked if she would accompany her when she decided to talk to Margaret about her concerns. The coworker agreed.
Elizabeth made an appointment with Margaret. At their meeting, Margaret asked the coworker to leave, but Elizabeth said she had a right to have someone with her because she wanted to feel safe discussing how Margaret was treating her. During the meeting Elizabeth presented her journal to Margaret, told her she was being bullied, and said she wanted it to stop. She also handed Margaret a memo stating that Margaret’s behavior was unacceptable, distracts from her work, and that if the behavior continued, she would need to go to the next level of authority. Elizabeth left the meeting, thanked the other coworker, and documented the meeting in her journal.
Over the next few days, Margaret never mentioned Elizabeth’s complaint, but her behavior changed and the bullying stopped. Elizabeth’s confidence returned and she began to enjoy her work again.
Type 4: Violence by Someone in a Personal Relationship
In this type of workplace violence, the perpetrator usually has or has had a personal relationship with the intended victim and does not have a legitimate relationship with the workplace. The incident may involve a current or former spouse, lover, relative, friend, or acquaintance. The perpetrator is motivated by perceived difficulties in the relationship or by psychosocial factors that are specific to the situation and enters the workplace to harass, threaten, injure, or even kill (CDC, 2020b).
Type 4 violence is often the spillover of domestic violence into the workplace. In some cases, a domestic violence situation can arise between individuals in the same workplace. These situations can have a substantial effect on the work environment. They can manifest as high absenteeism and low productivity on the part of a worker who is enduring abuse or threats, or the sudden, prolonged absence of an employee fleeing abuse (CDC, 2020b; OSHA, n.d.).
CASE
Domestic Violence and the Workplace
Jenny is a certified nursing assistant working in a 120-bed nursing home. She has always worked the evening shift, which ends at 11 p.m., and is on her way home by 11:30. Jenny has confided in coworkers that she is in an abusive relationship with her husband of five years. She has often come to work with bruises and occasionally has been hospitalized for injuries inflicted by her husband. Currently, she is separated from her husband and has a restraining order against him.
This evening the supervising nurse notices that Jenny is not keeping up with the scheduled routine and that she seems unusually nervous and distracted. The supervisor approaches Jenny and asks her if something is troubling her. Jenny reports that she had received a threatening phone call from her husband earlier that day and that she is afraid of him. Jenny asks the supervisor if she would walk with her out to her car at the end of her shift, and the nurse agrees.
At the end of the shift, they both leave the facility and walk out the employee entrance to the parking lot. The door of a car parked near the entrance opens; a man gets out, aims a rifle at Jenny, shoots her, and quickly drives away. The supervisor uses her cell phone to call 911 and stays with Jenny until help arrives; however, Jenny dies on the way to the hospital. The supervisor gives a statement to the police and is later subpoenaed as a witness during the trial. Jenny’s husband is found guilty and convicted of first-degree murder.
As part of the post-incident response, counseling is offered for employees traumatized by the incident, and a critical-incident stress debriefing is carried out. Additional training and education are provided for early recognition of warning signs, and a standard response action plan for violent situations is included. Facility security is analyzed, and a security guard is assigned to monitor the parking lot at every change of shift. In addition, training is provided in domestic violence and the steps to be taken when a restraining order has been violated.
In this instance, it is determined that it would have been more appropriate for the nursing supervisor to have advised Jenny to contact the police department about the phone call received earlier in the day and to have counseled her to wait for police to arrive before leaving the facility.