Now there is a common picture seen as police security in front of emergency and casualty department in government hospitals of Maharashtra. When ask the first reason is violence, assault cases of patient’s relatives on doctors etc. Statistics based on the Bureau of Labor Statistics (BLS) and National Crime Victimization Survey (NCVS)1data both reveal that workplace violence is a threat to those in the healthcare and social service settings. BLS data show that the majority of injuries from assaults at work that required days away from work occurred in the healthcare and social services settings. Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70 to 74% occurring in healthcare and social service settings. For healthcare workers, assaults comprise 10-11% of workplace injuries involving days away from work, as compared to 3% of injuries of all private sector employees. In 2013, a large number of the assaults involving days away from work occurred at healthcare and social assistance facilities (ranging from 13 to 36 per 10,000 workers). By comparison, the days away from work due to violence for the private sector as a whole in 2013 were only approximately 3 per 10,000 full-time workers. The workplace violence rates highlighted in BLS data are corroborated by the NCVS, which estimates that between 1993 and 2009 healthcare workers had a 20% (6.5 per 1,000) overall higher rate of workplace violence than all other workers (5.1 per 1,000).3 In addition, workplace violence in the medical occupations represented 10.2% of all workplace violence incidents. It should also be noted that research has found that workplace violence is underreported—suggesting that the actual rates may be much higher. In India some studies revealed that most of the assaults are taken place where there is less or no safety measures are available for health workers. Many doctors and Nurses become victim of mass verbal and physical abuse and violence. Rising violence against health care workers in India is mile stone article and great evidence to make strategies on.


“Violent acts, including physical assaults and threats of assault, di­rected toward persons at work or on duty.” Enforcement activities typically focus on physical assaults or threats that result or can result in serious physical harm. Howev­er, many people who study this issue and the workplace prevention programs highlighted here include verbal violence—threats, verbal abuse, hostility, harassment, and the like—which can cause significant psychological trauma and stress, even if no physical injury takes place. Verbal assaults can also escalate to physical violence. - The National Institute for Occupational Safety and Health.


How to identify /assess risk factors?


There are different types of risk factors. To assess those is also a challenge for health care sector for this we need to do lot of ground work in the form of research. Some o0f the following are the risk factors author had categorized based on available reviews and evidences.

Risk factors based on organization structure: Internal risk factors:

Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff;


  • Working when understaffed—especially during mealtimes and visiting hours;
  • High worker turnover;
  • Inadequate security and mental health personnel on site;
  • Long waits for patients or clients and overcrowded, uncomfortable waiting rooms;
  • Unrestricted movement of the public in clinics and hospitals; and
  • Perception that violence is tolerated and victims will not be able to report the incident to police and/or press charges.

External risk factors;


Risk of work-related assaults resulting primarily from violent behavior of their patients and/or residents. Epidemiological studies consistently demonstrate that inpatient and acute psychiatric services, geriatric long term care settings, high volume urban emergency departments and residential and day social services present the highest risks. Pain, devastating prognoses, unfamiliar surroundings, mind and mood altering medications and drugs, and disease progression can also cause agitation and violent behaviors. 

Patient, Client and Setting-Related Risk Factors


  • Working directly with people who have a history of violence, abuse drugs or alcohol, gang members, and relatives of patients or clients;
  • Transporting patients and clients;
  • Working alone in a facility or in patients’ homes;
  • Poor environmental design of the workplace that may block employees’ vision or interfere with their escape from a violent incident;
  • Poorly lit corridors, rooms, parking lots and other areas;4
  • Lack of means of emergency communication;
  • Prevalence of firearms, knives and other weapons among patients and their families and friends.
  • Working in neighborhoods with high crime rates.

Where does violence take place?

Violence exists in different settings and incorporates the latest and most effective ways to reduce the risk of violence in the workplace. Workplace setting determines not only the types of hazards that exist, but also the measures that will be available and appropriate to reduce or eliminate workplace violence hazards.


There are five different settings:


  • Hospital settings represent large institutional medical facilities.
  • Residential Treatment settings include institutional facilities such as nursing homes, and other long-term care facilities;
  • Non-residential Treatment/Service settings include small neighborhood clinics and mental health centers;
  • Community Care settings include community-based residential facilities and group homes; and Field work settings include home healthcare workers or social workers who make home visits.
  • These guidelines are intended to cover a broad spectrum of health workers right from administrators, doctors, registered Nurses, therapist, technicians, and home healthcare workers.

Diagnosis of health care violence:

Healthcare and social service workers face an increased risk of work-related assaults resulting primarily from violent behavior of their patients, clients and/or residents. While no specific diagnosis or type of patient predicts future violence. Employers should use these guidelines to develop appropriate workplace violence prevention programs, engaging workers to ensure their perspective is recognized and their needs are incorporated into the program.

Action plan:

Lets talk about safety. Safety but whose? As a part of health care system we need to think about every individual who is the part of this system. Client, patients, relatives attendance, residence, doctors, nurses, paramedics, administrators, pharmacist etc..Every health care institution must have definite protocol to practice safety for individuals. We have strategies for patient’s safety and our healthcare organizations are also planning and refining safety strategies based on global demands and needs.

Occupational Safety and Health Act of 1970


“To assure safe and healthful working conditions for working men and women; by authorizing enforcement of the standards developed under the Act; by assisting and encouraging the States in their efforts to assure safe and healthful working conditions; by providing for research, information, education, and training in the field of occupational safety and health...”

Violence Prevention Programs

A written program for workplace violence prevention, incorporated into an organization’s overall safety and health program, offers an effective approach to reduce or eliminate the risk of violence in the workplace. The building blocks for developing an effective workplace violence prevention program include:

(1) Management commitment and employee participation,

(2) Worksite analysis,

(3) Hazard prevention and control,

(4) Safety and health training, and

(5) Recordkeeping and program evaluation.

(Each of these components is included detailed explanation)


A violence prevention program focuses on developing processes and procedures appropriate for the workplace in question.

What is necessary before planning VPP?


  • Clear goals and objectives for preventing workplace violence must be set, it should be suitable for the size and complexity of operations and be adaptable to specific situations and specific facilities or units.
  • It require strategy of regular reassessment and adjustment to respond to changes occurring within an organization, such as expanding a facility or changes in managers, clients, or procedures.
  • Violence prevention program planning should be Parallel with work place legislation of that state or nation.

Safety and Health Management Systems: A Comprehensive Approach

A workplace violence prevention program can fit effectively within a broader safety and health management system, also known as an injury and illness prevention program. Under this type of program, employers and employees continually monitor the workplace for hazards and then cooperate to find and implement solutions. All of this happens within a Plan-Do-Study-Act management system framework that should be familiar to healthcare administrators. A comprehensive safety and health management system can effectively manage a wide range of worker safety risks in healthcare, including workplace violence; patient handling (e.g., lifting); bloodborne pathogens; slips, trips, and falls; and more. This approach can go hand-in-hand with HRO principles and practices.

Almost all successful safety and health management systems include six core elements that are very similar to the elements of a workplace violence prevention program:

Safety and Health Management System Element


Workplace Violence Prevention Program Element


Management leadership

Managers demonstrate their commitment to improved safety and health, communicate this commitment, and document safety and health performance. They make safety and health a top priority, es­tablish goals and objectives, provide adequate resources and support, and set a good example.

Management commitment and worker participation

Employee participation

Employees, with their distinct knowledge of the workplace, ideally are involved in all aspects of the program. They are encouraged to communicate openly with management and report safety and health concerns.

Hazard identification and assessment

Processes and procedures are in place to continually identify work­place hazards and evaluate risks. There is an initial assessment of hazards and controls and regular reassessments.

Worksite analysis and hazard identification

Hazard prevention and control

Processes, procedures, and programs are implemented to eliminate or control workplace hazards and achieve safety and health goals and objectives. Progress in implementing controls is tracked.

Hazard prevention and control

Education and training

All employees have education or training on hazard recognition and control and their responsibilities under the program.

Safety and health training

System evaluation and improvement

Processes are established to monitor the system’s performance, verify its implementation, identify deficiencies and opportunities for improvement, and take actions needed to improve the system and overall safety and health performance.

Recordkeeping and program evaluation

Workers’ Rights

Workers have the right to:


  • Working conditions that do not pose a risk of serious harm.
  • Receive information and training (in a language and vocabulary the worker understands) about workplace hazards, methods to prevent them, and the OSHA standards that apply to their workplace. Review records of work-related injuries and illnesses.
  • File a complaint asking OSHA to inspect their workplace if they believe there is a serious hazard or that their employer is not following OSHA’s rules. OSHA will keep all identities confidential.
  • Exercise their rights under the law without retaliation, including reporting an injury or raising health and safety concerns with their employer or OSHA. If a worker has been retaliated against for using their rights, they must file a complaint with OSHA as soon as possible, but no later than 30 days. 


 Center for Disease Control. (2002). Violence: Occupational Hazards in Hospitals. Cincinnati: National Institute of Occupational Safety and Health.

Chapman, R., Perry, L., Styles, I., & Combs, S. (2009). Predicting patient agression against nurses in all hospital areas. British Journal of Nursing, 476-483.

Dillon, B. L. (2012). Workplace violence: Impact, causes, and prevention. Work, 15-20.

Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 469-478. 

Minnesota Department of Health Preventing Violence in Healthcare: Gap Analysis

Worksheet designed to help healthcare facilities identify risks and implement best practices to prevent patient-on-worker violence.



OSHA: Worker Safety in Hospitals (www.osha.gov/dsg/hospitals)—a suite of informational products and tools to help hospitals assess workplace safety needs, implement safety and health management systems, implement workplace violence prevention programs, and enhance their safe patient handling programs. In particular, see Preventing Workplace Violence: A Road Map for Healthcare Facilities for a detailed discussion of the core elements of a workplace violence prevention program. 

OSHA: Workplace Violence (www.osha.gov/SLTC/workplaceviolence)—resources related to workplace violence, including OSHA’s Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 

The Joint Commission: Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation(www.jointcommission.org/improving_Patient_Worker_Safety). 

The Joint Commission: Patient Safety Systems (www.jointcommission.org/patient_safety_systems_chapter_for_the_hospital_program). 

The Joint Commission: Quick Safety, Issue 5, “Preventing Violent and Criminal Events” (www.jointcommission.org/assets/1/23/Quick_Safety_Issue_Five_Aug_2014_FINAL.pdf). 

OSHA: Injury and Illness Prevention Programs (www.osha.gov/dsg/topics/safetyhealth). 

ECRI Institue. (2011). Healthcare Risk Control: Violence in Healthcare Facilities. Plymouth Meeting: ECRI Institute.

Erdmann, S. L. (2008-2009). Eat the Carrot and Use the Stick: the Prevalence of Workplace Violence Demands ProFarkas, G. M., & Tsukayama, J. K. (2012). An integrative approach to threat assessment and management: Security and mental health response to a threatening client. Work, 9-14.

Ferns, T., & Cork, A. (2008). Managing alcohol related aggression in the emergency department (Part I). International Emergency Nursing, 43-47.

Foley, M. (2012). Evaluating progress in reducing workplace violence: Trends in Washington State workers’ compensation claims rates, 1997-2007. Work, 67-81.

Forster, J. A., Petty, M. T., Schleiger, C., & Walters, H. C. (2005). kNOw workplace violence: developing programs for managing the risk of aggression in the health care setting. Medical Journal of Australia, 357-361.

Gallant-Roman, M. A. (2008). Strategies and Tools to Reduce Workplace Violence. American Association of Occupational Health Nurses , 449-454.

Gates, D., Fitzwater, E., Telintelo, S., Succop, P., & Sommers, M. (2004). Preventing Assaults by Nursing Home Residents: Nursing Assistants’ Knowledge and Confidence--A Pilot Study. Journal of American Medical Directors Association, S16-S21.

Geiger-Brown, J., Muntaner, C., McPhaul, K., Libscomb, J., & Trinkoff, A. http://laborcenter.berkeley.edu/homecare/pdf/geiger.pdf. Retrieved September 14, 2012, from http://laborcenter.berkeley.edu.

Gerson, R. R., Pogorzelska, M., Qureshi, K. A., Stone, P. W., Canton, A. N., Samar, S. M., et al. http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Gershon_88.pdf. Retrieved September 14, 2012, from www.ahrq.gov.

Gillespie, G. L., Gates, D. M., Miller, M., & Howard, P. K. (2010). Workplace Violence in Healthcare Settings: Risk Factors and Protective Strategies. Rehabilitation Nursing, 177-184.active Federal Regulation of Employers. Valparaiso University Law Review, 725-770.

Author: Mrs. Jessica N. Waghmare.
MSc(N) Asso. Prof. HOD Community Health Nursing
Wanless Hospital Miraj.