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6 Steps to Manage Violence Against Hospital Healthcare Workers

Analysis  |  By Christopher Cheney  
   March 27, 2019

Hospitals have an obligation to address assaultive behavior in the workplace, employment and labor attorneys say.

This article appears in the May/June 2019 edition of the magazine. 

Workplace violence against healthcare workers by patients and patients' family members has reached epidemic proportions at hospitals, but there are strategies hospital leaders can implement to cope with the problem.

Hospitals carry a heavy workplace violence burden, with about three-quarters of U.S. workplace assaults occurring in healthcare settings, according to a report by the Occupational Safety and Health Administration. Workplace violence is prevalent in emergency departments—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.

The scope of the peril for healthcare workers is so immense that hospitals have an obligation to address assaultive behavior in the workplace, says Laura Monaco, JD, an associate in the Employment, Labor, and Workforce Management practice at Epstein Becker Green in New York.

"We're not just talking about punching or hitting—it's also things like spitting, biting, and shoving. Employers have to be mindful this is an urgent situation that they need to be on top of and have a laser-focus on because it is such a large threat," she says.

There are six steps hospital leaders can take to manage workplace violence against healthcare workers.

1. Know your jurisdiction

The first step for hospital leaders is knowing the applicable laws in their state, Monaco says. "The first thing to consider is where are you—what is your jurisdiction? Many states have specific laws that provide for enhanced criminal penalties when a healthcare worker is assaulted similar to assaults on police officers or firefighters."

In New York, perpetrators face stiff penalties for assaults on healthcare workers, she says. "The New York penal code provides that it is a Class D felony to assault not just RNs and LPNs but also non-nurse healthcare providers. If the assault is proven, the perpetrator can face up to a seven-year term of imprisonment."

2. Set policies and protocols

It is essential for hospitals to have policies and protocols established to deal with violent episodes at their facilities, Monaco says.

"The employer should have a policy and protocol for investigating incidents—especially when you are dealing with patients. They should develop standard questions: Was the patient on medication? What medication were they on? Was there a normal or adverse reaction to medication?"

Consistency is crucial, she says. "There need to be procedures in place where—on a standardized basis—the employer can investigate and ask questions because these are case-by-case decisions."

Policies and protocols should promote peaceful resolutions to violent situations, says Sarah Swank, vice chair, Educational Programs, In-House Counsel Practice Group, at the American Health Lawyers Association in Washington, D.C.

"The policies should be based on de-escalation because violence in the workplace can come from different sources. It can come in different levels of intensity. Training and policies based on de-escalation can be very successful," Swank says.

To be effective, policies and protocols for workplace violence should be widely disseminated throughout a hospital's staff, she says. "Training and policies should not just be focused on the hospital security team but also on clinicians and other frontline employees because they can be part of the de-escalation process."

3. Mandate assault reporting

Hospital employees should be required to report workplace violence incidents, Monaco says.

"Anything an employer can do to encourage reporting of these assaults is important—having clear procedures, explaining how employees can make these reports and who they can go to, having steps for managers and supervisors to take once they receive a report of an assault, and knowing how to contact law enforcement authorities. These things should be planned out in advance and streamlined."

Hospital leaders must assure healthcare workers that they will not face retaliation for reporting workplace violence, Monaco says.

"Policies should make it clear that there will be no retaliation against an employee who reports an assault. Nurses and other healthcare workers have a concern that they will be retaliated against—either by patients' family members or other staff who may not agree with the assault reporting. If you mandate reporting and there is no retaliation, then you are encouraging people to come forward when they are assaulted."

Some states require employers to report assaults on healthcare workers to law enforcement, Monaco says. "For example, Connecticut has a law that requires assaults to be reported within 24 hours whether or not charges are pressed."

4. Investigate violent incidents

Hospital-led investigations of workplace violence episodes are opportunities to reduce future assaults on healthcare workers, Swank says. "After a violent incident, The Joint Commission recommends doing a root-cause analysis, which can be helpful in process improvement and improving policies."

To promote effective investigations, hospitals can create dedicated teams to probe workplace violence incidents, Monaco says. "One approach is having an emergency response team—people who respond when these types of issues come up. There can be representatives from the legal department, from HR, and from administration who make decisions in a uniform way about whether to press charges and how to proceed."

5. Enforce policies

Having an emergency response team can boost enforcement of workplace violence policies, Monaco says.

"When you formalize procedures, it's easier to follow through. If there is an emergency response team, and the task of the team is to address workplace assaults, it becomes more difficult to sweep these situations under the rug. There is accountability, which is one way to make sure these kinds of policies are enforced."

Adherence to policies is fundamental to successfully addressing workplace violence, Swank says. "Once a hospital sets a policy, it's important for the hospital to follow the policy. A policy should not be aspirational—it should be easy to follow, easy to understand, and reflective of the hospital's culture."

6. Press charges

For hospital leaders, deciding whether to press charges against patients or their family members who have assaulted healthcare workers can be a daunting challenge, Swank says.

"Oftentimes, it is not the hospital that presses charges against family members or patients who have had a violent incident. The hospital needs to balance supporting its employees without creating a chilling effect on those who want to seek care at the hospital. Achieving this balance is especially difficult when patient violence is part of a patient's medical condition."

If hospital officials decide not to press charges, they can still help staff members who have been assaulted, Swank says. "A hospital can support its employees. For example, if there has been an assault and an employee has pressed charges, the hospital can provide information as part of the charges or the employee can be given time off from work to testify in the criminal case."

Assistance should not be limited to legal aid, she says. "It should be addressed with compassion and sympathy for the people who were injured or were part of the incident."

It is important for hospital leaders to participate broadly in what happens after a workplace assault, Monaco says. "Policies should not forget about the employee once the decision is made whether to press charges. If an employee has been assaulted, they are going to need support and they could need counseling."

Leaders who raise awareness at their hospitals about the potential for pressing charges against patients who have assaulted healthcare workers can have a significant impact, Monaco says.

"Sometimes, the deterrent affect can be achieved even if you don't press charges. It can help to have administrative action ready to go. If a patient commits an assault but it's in a gray area, you can flag the file not only as a warning for other staff members but also as a record that the patient is assaultive. It can be made clear to the patient and family members that if it happens again the hospital will press charges," she says.

Christopher Cheney is the CMO editor at HealthLeaders.


About three-quarters of U.S. workplace assaults occur in healthcare settings, according to federal statistics.

For healthcare facility leaders, the first step to address workplace violence is knowing the provisions of state law.

Unless hospitals have policies and protocols in place for workplace violence, pressing charges against patients and family members can be daunting.

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