Approved by the Board of Governors Dec. 5, 2023
Statement of the Issue
Incidents of violence are confronting healthcare executives with a major public health and safety concern. Healthcare executives are in the position of responding to violence inflicted upon members of their workforce often by perpetrators entering their facilities. According to the U.S. Bureau of Labor Statistics, healthcare workers are five times more likely to experience workplace violence than employees in all other industries. Further, a 2022 analysis by Press Ganey revealed that more than two nurses were assaulted every hour in the second quarter of that year.
Workplace violence includes not only events involving active assailants or other sensational acts of physical violence, but also everyday occurrences such as verbal abuse that often are overlooked. Workplace violence has negative implications for patient safety, employee burnout and turnover, and healthcare organization finances. Caregiver fatigue, stress and burnout of employees contribute to a higher risk of patient infections and medical errors. Other costs to the healthcare organization include reduced employee engagement, a degraded patient experience, worker compensation claims, absenteeism, property damage, increased building security needs and insurance costs.
The psychological impact of violence on employees is harder to quantify but can lead to missed work, deterioration of health, burnout and, in some cases, post-traumatic stress disorder and secondary trauma. These factors contribute to increased employee turnover, which can be costly. The true cost of violence in the workplace is unknown, because in addition to these factors, many incidents go unreported.
Treating and preventing violence does not end with workers inside healthcare facilities. Victims and perpetrators of harmful acts who enter healthcare facilities are 44% more likely to return as patients with a new injury within five years, and 20% will die by homicide, according to the Health Alliance for Violence Intervention Keys to Collaboration between Hospital-based Violence Intervention and Cure Violence Programs. Medical care alone is not the answer but presents leaders with an opportunity to intervene in the cycle of violence.
Policy Position
The American College of Healthcare Executives believes that healthcare executives have a professional responsibility to treat and take steps to mitigate violence and to advocate for cultures of safety. Hospitals and healthcare facilities serve as community anchors, so actions implemented to reduce violence are likely to have a ripple effect on the health and safety of national and local communities.
Violence can be defined broadly to encompass the full spectrum of harmful acts, including those committed by staff that physically or mentally threaten co-workers as well as the harm inflicted upon staff by patients and/or perpetrators who come inside the facility. Examples of workplace violence include, but are not limited to, physical acts, psychological and verbal abuse, intimidation and threats of physical harm to an individual or object. Patients come to healthcare facilities to be treated for inflicted wounds due to acts of violence committed outside of the facility, including gun violence, abuse, sexual assault, human trafficking and many other criminal acts. These warrant post-violence, patient-centered and post-trauma-informed care for patients and healthcare workers, which can be influenced directly by healthcare leaders.
Violence manifests in many ways, and mitigating it is a complex issue requiring a multifaceted and multidisciplinary approach, which may require the infusion of new competencies to existing teams. Healthcare executives should lead efforts to ensure comprehensive violence prevention plans are in place for their facilities. In developing these plans, ACHE encourages healthcare executives to undertake the following actions within their organizations:
- Clearly Define Workplace Violence: Evaluate the landscape, listen to and learn about what is happening in the facility. This will determine the scope of behaviors and actions to be included in the definition. Identify, name and encourage reporting of every type and incident of workplace violence, including verbal abuse. Establish organizational systems that enable staff to report and provide ongoing feedback on incidents of workplace violence.
- Establish Governance for Addressing Workplace Violence: Establish an organizational structure that focuses on workplace violence prevention with the goal of reducing incidents, injuries and the severity of injuries that occur. Such a structure can help the organization align policies and approaches while providing guidance, tools and resources. Identify an executive champion who has a line of sight to the board.
- Assess the Scope and Prevalence of Violence Within the Facility: Seek cross-functional input making sure to include administrators and clinical staff along with perspectives from impacted patients and families. Collect baseline incident and injury data, including details on the nature, severity and cost of injuries. Recognize the likelihood of under-reporting. Many types of behaviors such as bullying, verbal abuse and incidents of physical violence are unreported because front-line staff accept the behaviors as “part of the job.”
- Raise Awareness That Workplace Violence is a Public Health Issue:Highlight the facts and data surrounding workplace violence and communicate regularly about the organization’s commitment to preventing it. Establish a zero-tolerance policy that specifies actions to be taken against the aggressor, whether it be a staff member, patient or visitor, to assure stakeholders that violence and safety are being taken seriously. Focus on facilitating the changes in culture necessary to prevent violence, promote nonviolence and respond to and support staff when violence occurs. Commit to ongoing conversations and dialogues about the issue.
- Identify and Remediate Risk Factors: Take steps to secure the physical premises of the facility by incorporating security measures such as access restrictions, visitor screening and security officers. Consider integrating behavioral threat assessment and management principles into an organization’s workplace violence prevention programs.
- Provide Training on How to Recognize and Mitigate Workplace Violence: Educate providers and caregivers in mitigation and intervention efforts to identify and treat victims of violence, crime and abuse. Training may include de-escalation techniques, avoiding and preventing assaults, self-defense and emergency preparedness. Train all stakeholders who work near patients on how to screen for and de-escalate dangerous behaviors, situations and triggers, including how to assess patients at risk of violent behavior and identify them so staff are aware of the risk. Focus also on how to intervene early before situations escalate and on how to promote resiliency in the workforce. Measure training compliance to ensure it is ongoing and current.
- Evaluate, Measure and Report Progress: Conduct regular and ongoing evaluation and improvement cycles to ensure the prevention action plan is effective and meets the needs of the organization. Include metrics on post-incident response, follow-up and implementation processes. Conduct ongoing, periodic audits to identify risk and gaps in current policies and practices. Involve staff in the determination of root cause and to ensure data on near misses are included. Incorporate improvements to the physical environment in construction and renovation design.
- Engage with Community Partners to Address Patterns and Cycles of Violence: Form coalitions with security professionals, law enforcement, government and community agencies, nonprofits and grassroots organizations to improve safety in the community. Establish guidelines for collaborating with law enforcement on practical steps and scenario-based examples to maximize safety for patients and staff. Review the latest community health needs assessment, which may highlight violence as a health priority based on social determinants of health and other factors.
As anchors in their communities, healthcare organizations must ensure proper planning for all the hazards they face. Healthcare executives should lead and champion the planning and development of systems, processes and policies to intervene and mitigate incidents of violence within their workplaces and communities.
Policy created: November 2018
Policy updated: December 2023