Violence is a Common Ailment in Hospital Settings

May 7, 2002
Hospital workers have four times the chance of being the victim of a violent act than the average worker. A new brochure from NIOSH can help reduce that number.

If you or someone you knows works in a hospital, then you have four times the chance of being the victim of a violent act than the average worker.

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 two per 10,000 workers.

When you consider that the National Institute for Occupational Safety and Health (NIOSH) reports that there are more than 5 million workers in many occupations performing a wide variety of duties in hospitals today, the number of assaults could be as high as 4,100 using BLS's rate from 1999.

Several studies indicate that violence often takes place during times of 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 or tobacco or alcohol use.

To increase worker and employer awareness of the risk factors for violence in hospitals and to provide strategies for reducing exposure to these factors, NIOSH has released a new brochure, "Violence: Occupational Hazards in Hospitals" (DHHS (NIOSH) Publication No. 2002-101).

According to NIOSH, workplace violence ranges from offensive or threatening language to homicide. NIOSH defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. Examples of violence include the following:

  • Threats: Expressions of intent to cause harm, including verbal threats, threatening body language and written threats.
  • Physical assaults: Attacks ranging from slapping and beating to rape, homicide, and the use of weapons such as firearms, bombs or knives.
  • Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob.

The brochure offers several examples of violence, including an elderly patient who verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night, and an agitated psychiatric patient who attacked a nurse, broke her arm, and scratched and bruised her.

Patients are not the only problem, notes NIOSH. In once case, a disturbed family member, whose father had died in surgery at the community hospital, walked into the emergency department and fired a small-caliber handgun, killing a nurse and an emergency medical technician and wounding the emergency physician.

These circumstances of hospital violence differ from the circumstances of workplace violence in general. In other workplaces such as convenience stores and taxicabs, violence most often relates to robbery. Violence in hospitals usually results from patients and occasionally from their family members who feel frustrated, vulnerable and out of control, says NIOSH.

The brochure includes such topics as: What is workplace violence? Who is at risk? Where may violence occur? What are the effects of violence? What are the risk factors for violence? It includes prevention strategies for employers, environmental designs, administrative controls, behavior modifications, and dealing with the consequences of violence.

Although violent acts can occur anywhere in the hospital, NIOSH notes that they are most frequent in psychiatric wards, emergency rooms, waiting rooms and geriatric units. Risk factors for 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 hours
  • 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 crises with potentially volatile patients
  • Drug and alcohol abuse
  • Access to firearms
  • Poorly lit corridors, rooms, parking lots and other areas

The NIOSH report offers a number of safety tips for hospital employees, such as:

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 frustrated.").
  • Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching or speaking loudly).

Be alert:

  • 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.

Although the situation is grim, the news isn't all bad, says NIOSH. The agency includes examples of violence prevention strategies that have worked, such as a security screening system in a Detroit hospital that 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 6-month period.

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 percent by alerting staff to take additional safety measures when serving those 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 specific 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 percent.

To find out more about the report, visit

by Sandy Smith ([email protected])

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