Workplace Violence in Health Institutions


The 49th World Health Assembly in 1996 declared violence a major and growing public health problem across the world (Resolution WHA49.25). Privitera (2010, pg. 5), defines violence as the intentional use of physical force threatened or actual, against oneself, another person, or against a group or community, that either leads to or imposes a high likelihood of resulting in, psychological harm, injury, death, mal-development or deprivation. On the other hand WHO (2002) define violence as it relates to the health and wellbeing of individuals, allowing for cultural mores.

The International Labour Organization (2008) define workplace violence as “any action or incident, or behaviour that departs from reasonable conduct in which a person is assaulted, threatened, harmed, injured in the course of, or as a direct result of, his or her own work.” They have gone ahead and come up with four typologies under workplace violence, these they listed as, violence with criminal intent, customer/client violence, worker-on-worker and personal relationships affecting the employee at work.

Episodes of violence in the workplace are increasing in our society. Violence in the workplace has become a critical issue in the United States for a wide range of workers, including jitney and bus drivers, convenient stores clerks, nurses, teachers, and social workers. Although violence has always been inherent in certain occupations, such as law enforcement, correctional work in jails and prisons and security, it is now being reported in occupations traditionally assumed to be safe, such as nursing and social work.

According to Entwistle (2008, p.17; Cho, Orthmann, & Hess, 2010, pg.263-264) hospital’s emergency room employees seem particularly vulnerable to workplace violence, with 86 percent of emergency room nurses reporting being victims of workplace violence in the past three years and 20 percent reporting that they experience workplace violence frequently. According to OSHA statistics, healthcare facilities are the leading site of violence in the workplace. In 1998, OSHA updated their guidelines specifically to prevent injuries to employees of health care facilities. These guidelines include recommendations for recognizing risk factors, management commitment and employee involvement, work site analysis, hazard prevention and control, and safety and health training.

Violence against Health Workers                             

The levels of violence against healthcare staff have become a concern in recent years. More and more healthcare staffs face the prospect of violence and aggression in the workplace, not only from the people they care for, but from strangers and families. Although there is a high risk of work place violence across all healthcare occupations, most indicators suggest that it is the nursing profession that is most at risk, followed closely by ambulance and medical staff. (Linsley, 2006, pgs. 7-8) nurses are especially vulnerable to violence in high risk areas of practice such as the emergency department and psychatric settings (Dempski & Westrick, 2008, pg. 237)

This paper seeks to addreses the spectrum of violent behaviors in health care, including violence directed horizontally or vertically between healthcare providers or violence focused on nurses from patients, families, and visitors. In addition, it will give a brief explanation of the types of violence experienced by nurses at their place of work, the risk factors, the various ways through which workplace violence affects the workers as well as the steps and  measures which can be undertaken to reduce the impact and effects of workplace violence or minimize their chances of occurence and reoccurance.

Types of Violence in Healthcare Settings

Healthcare and social service workers for many years have confronted significant risks of job-related violence. Assaults in particular represent serious safety threats and health hazards for this field, and violence against their workers increasingly continues to manifest.

Healthcare settings are at risk for a variety of violent behaviours. Violence may be manifested as verbal abuse, sexual harassment, racial harassment, bullying, property damage, threats, murder, and physical assault. In 2000, almost half of all nonfatal injuries from violent acts against workers occurred in the healthcare sector. These injuries include, bruises, lacerations, broken bones, and head injuries (McPhaul & Lipscomb, 2004; Zuzelo, 2010, pg. 218)

There are also other forms of violence such as lateral and horizontal violence which frequently occur in healthcare agencies. Lateral violence is a form of bullying, nurse to nurse, and is usually directed toward nursing staff perceived as less powerful. This includes bullying which encompasses barrage behaviours which include being harassed, tormented, ignored, sabotaged, put down, and insulted among others. This form of violence is tolerated because many nurses experience it as a rite of passage and regard it as normal.

Risk Factors

Health care providers, especially so, nurses deal with a greater than before risk of work-related physical attack. A number of factors have been identified as causal factors, while they do not cause violence directly, they have an impact on it and can enhance its effects. Environmental factors such as poor lighting, poor security, and accessibility of objects can act as mediums that promote violence at the workplace.

Additionally, recently employed staffs have been found to be more at risk when compared with their more experienced colleagues, on the same note, inexperienced staffs and untrained staff can provide the opportunity for those that use violence and aggression as a coping strategy to engage in it.

Feelings of loss of control, feeling aggrieved due to unfair treatment, whether real or imaginary can also serve as a catalyst for violence, especially so, between the worker and the employer or between the worker and a fellow colleague.

Other risk factors include, the increased population of acute and chronically mentally disturbed patients who in recent times are being released from hospitals and medical institutions without follow-up care, the prevalence of handguns and other weapons, the availability and accessibility of drugs as well as money in medical institutions, clinics and pharmacies, therefore turning them into vulnerable robbery targets.

There are also situational and circumstantial factors such as the unrestricted and unobstructed movement of the general public into clinics and hospitals, the inflated presence of gang members, alcohol users and drug addicts, trauma patients, and or distressed family members. Other circumstantial factors include, long waits in emergency waiting or clinic areas, which bring about client irritation, frustration and aggravation which lead to a feeling of helplessness over an inability to obtain the sought after services promptly.

The staff can also become frustrated and strained; this could be as a result of the low levels of staffing especially in times of increased activities as during mealtimes, visiting hours, and when the staffs are moving patients. Other risk factors consist of isolated work episodes with patients in the course of examinations or treatment, solo work, which are often in secluded or isolated locations, predominantly in high-crime settings, where there is no backup or instrument of obtaining help such as devices of communication or alarm systems, lack of training of a mechanism where staff are familiarized with recognizing and managing hostility. All these factors serve to provide an environment which is accommodative to violence.

Effects of Violence and Aggresion on Staff

The consequences of violence and aggresion on the wellbeing of staff are increasingly well documented. Staffs who are victims of violence tend to distance themselves from patients. They may experience recurrent depression and anxiety, guilt  and self doubt, feelings of powerlessness and low self esteem.

Emotional reactions also arise and they take the form of rage, anxiety, a sense of helplessness, irritation, fear of returning to the location of the incidence, and feelings and thoughts that something should have been done to prevent what happened. (Linsley, 2006, pg. 9). Additionally, frequently assaulted staff have showed an increased risk to post-traumatic stress disorder (PTSD), psychological burnout or other stress reactions.

Exposure to physical violence has also associated with behavioral reactions and change, such as social withdrawal. This may affect social relationships at work, as well as relationships outside of work. Moreover, staff who are exposed to violent at work have higher rates of absenteeism and provide a lower standard of care than those who are not exposed.

Other costs which can be attributed to workplace violence in medical institutions include higher incidences of patient complaints, increased recruitment and retenton costs, reduced efficiency and productivity per worker, increased staff turnover, lowered reputation on the organization, reduced staff morale, and reduced staff numbers as well (Linsley, 2006, pg. 10). However, the worst impact that workplace violence can have is the death of an employee.

Instruments of Reducing Workplace Violence

Incidents of workplace cost employers and others several billion dollars each year. This off course does not reflect the human suffering caused by acts of violence. Although violence cannot be eliminated, some steps can help curb violent behaviour in the workplace. In order to reduce the recurrent occurrence and incidences of work place violence, there is a need to eliminate completely or minimize employee exposure to settings that may result to death or injury from violence by instigating effective security appliances and administrative work procedures, among other control measures.

There are four main components in any successful safety and health program which also apply to averting workplace violence; these are management commitment and employee involvement, work site analysis, hazard prevention and control and finally safety and health training

Additional  processes which can be made use of include; the use of hiring procedures that screen out unstable persons, this would include background checks and in-depth interviews, innitiating a strategy for responding to incidents prior to their occurence, that is, establishing policies that make it clear that workplace violence incidents will not be tolerated this will go a long way in minimizing worker-to-worker violence and finally, the provision of administrators and managers with training that will assist them thwart workplace violence and cope effectively with violence in the instance that it occurs. (Howie, Brandt, & Reece, 2010, pgs. 197-198)


The violent problem is serious and insidious and yet remains unregulated. Only a few states have enacted WPV laws, although 48 bills were introduced in state legislatures during 2006 (Trossman, 2006; Zuzelo, 2010, pg. 212). Moreover, the healthcare culture is resistant to recognizing that nurses are at risk and demonstrates complacency related to accepting the idea that violence is simply part of the job of nursing.

Health workers especially nurses play a very important and critical role at any health institution. Besides ensuring the smooth running  of any institution, they play the vital role of caring for the patient, work with the doctor to cure the patient, coordinate the care of the patient, protect the patient and teach the patient and family as well as advocate for the patient. Therefore, it is of great importance that their roles at the health institution are not hindered by violence or any other form of disruption that may harm them. Thus, it is indeed very critical that the management ensures that their personal security is guaranteed while at the work place.



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