www.osha.gov

Guidelines for 

Preventing Workplace Violence for Health Care &

Social Service Workers

OSHA 3148-01R 2004
This informational booklet provides a 

general overview of a particular topic 

related to OSHA standards. It does not alter

or determine compliance responsibilities in

OSHA standards or the Occupational Safety

and Health Act of 1970. Because interpretations and enforcement policy may change

over time, you should consult current OSHA

administrative interpretations and decisions

by the Occupational Safety and Health

Review Commission and the Courts for 

additional guidance on OSHA compliance

requirements.

This publication is in the public domain 

and may be reproduced, fully or partially,

without permission. Source credit is 

requested but not required.

This information is available to sensory

impaired individuals upon request.

Voice phone: (202) 693-1999; teletypewriter

(TTY) number: (877) 889-5627.
U.S. Department of Labor

Occupational Safety and Health Administration

OSHA 3148-01R

2004

Guidelines for 

Preventing Workplace 

Violence for Health Care &

Social Service Workers
2

Contents

Notice...3

Acknowledgments...4

Introduction...4

Overview of Guidelines...7

Violence Prevention Programs...8

Management Commitment and Employee Involvement...10

Worksite Analysis...11

Hazard Prevention and Control...14

Safety and Health Training...19

Recordkeeping and Program Evaluation...21

Conclusion...24

References...25

OSHA assistance...25

Safety and Health Program Management Guidelines...25

State Programs...26

Consultation Services...26

Voluntary Protection Programs (VPP)...27

Strategic Partnership Program...27

Alliance Programs...28

OSHA Training and Education...28

Information Available Electronically...29

OSHA Publications...29

Contacting OSHA...30

OSHA Regional Offices...30

Appendices

Appendix A: Workplace Violence Program Checklists...32

Appendix B: Violence Incident Report Forms...40

Appendix C: Suggested Readings...42
Notice

These guidelines are not a new standard or regulation. They 

are advisory in nature, informational in content and intended to

help employers establish effective workplace violence prevention

programs adapted to their specific worksites. The guidelines do 

not address issues related to patient care. They are performanceoriented, and how employers implement them will vary based on

the site’s hazard analysis. 

Violence inflicted on employees may come from many sources—

external parties such as robbers or muggers and internal parties

such as coworkers and patients. These guidelines address only the

violence inflicted by patients or clients against staff. However, OSHA

suggests that workplace violence policies indicate a zero-tolerance

for all forms of violence from all sources.

The Occupational Safety and Health Act of 1970 (OSH Act)1

mandates that, in addition to compliance with hazard-specific

standards, all employers have a general duty to provide their

employees with a workplace free from recognized hazards likely to

cause death or serious physical harm. OSHA will rely on Section

5(a)(1) of the OSH Act, the “General Duty Clause,”2 for enforcement

authority. Failure to implement these guidelines is not in itself a

violation of the General Duty Clause. However, employers can be

cited for violating the General Duty Clause if there is a recognized

hazard of workplace violence in their establishments and they do

nothing to prevent or abate it. 

When Congress passed the OSH Act, it recognized that workers’

compensation systems provided state-specific remedies for jobrelated injuries and illnesses. Determining what constitutes a

compensable claim and the rate of compensation were left to the

states, their legislatures and their courts. Congress acknowledged this

point in Section 4(b)(4) of the OSH Act, when it stated categorically:

“Nothing in this chapter shall be construed to supersede or in any

manner affect any workmen’s compensation law. . ..”3 Therefore,

3

1 Public Law 91-596, December 29, 1970; and as amended by P.L. 101-552, Section

3101, November 5, 1990.

2 “Each employer shall furnish to each of his employees employment and a place of

employment which are free from recognized hazards that are causing or are likely

to cause death or serious physical harm to his employees.”

3 29 U.S.C. 653(b)(4).
these non-mandatory guidelines should not be viewed as enlarging

or diminishing the scope of work-related injuries. The guidelines are

intended for use in any state and without regard to whether any

injuries or fatalities are later determined to be compensable.

Acknowledgments

Many people have contributed to these guidelines. They include

health care, social service and employee assistance experts;

researchers; educators; unions and other stakeholders; OSHA 

professionals; and the National Institute for Occupational Safety

and Health (NIOSH).

Also, several states have developed relevant standards or 

recommendations, such as California OSHA’s CAL/OSHA Guidelines

for Workplace Security and Guidelines for Security and Safety of

Health Care and Community Service Workers; New Jersey Public

Employees Occupational Safety and Health’s Guidelines on

Measures and Safeguards in Dealing with Violent or Aggressive

Behavior in Public Sector Health Care Facilities; and the State of

Washington Department of Labor and Industries’ Violence in

Washington Workplaces and Study of Assaults on Staff in

Washington State Psychiatric Hospitals. Other organizations with

relevant recommendations include the Joint Commission on

Accreditation of Health Care Organizations’ Comprehensive

Accreditation Manuals for Hospitals, the Metropolitan Chicago

Healthcare Council’s Guidelines for Dealing with Violence in Health

Care, and the American Nurses Association’s Promoting Safe Work

Environments for Nurses. These and other agencies have

information available to assist employers.

Introduction

Workplace violence affects health care and 

social service workers.

The National Institute for Occupational Safety and Health

(NIOSH) defines workplace violence as “violent acts (including

physical assaults and threats of assaults) directed toward persons

at work or on duty.”4 This includes terrorism as illustrated by the

4

4

CDC/NIOSH. Violence. Occupational Hazards in Hospitals. 2002.
terrorist acts of September 11, 2001 that resulted in the deaths of

2,886 workers in New York, Virginia and Pennsylvania. Although

these guidelines do not address terrorism specifically, this type of

violence remains a threat to U.S. workplaces.

For many years, health care and social service workers have

faced a significant risk of job-related violence. Assaults represent a

serious safety and health hazard within these industries. OSHA’s

violence prevention guidelines provide the agency’s recommendations for reducing workplace violence, developed following a

careful review of workplace violence studies, public and private

violence prevention programs and input from stakeholders. OSHA

encourages employers to establish violence prevention programs

and to track their progress in reducing work-related assaults.

Although not every incident can be prevented, many can, and the

severity of injuries sustained by employees can be reduced.

Adopting practical measures such as those outlined here can 

significantly reduce this serious threat to worker safety.

Extent of the problem

The Bureau of Labor Statistics (BLS) reports that there were 

69 homicides in the health services from 1996 to 2000. Although

workplace homicides may attract more attention, the vast majority

of workplace violence consists of non-fatal assaults. BLS data shows

that in 2000, 48 percent of all non-fatal injuries from occupational

assaults and violent acts occurred in health care and social services.

Most of these occurred in hospitals, nursing and personal care

facilities, and residential care services. Nurses, aides, orderlies and

attendants suffered the most non-fatal assaults resulting in injury. 

Injury rates also reveal that health care and social service

workers are at high risk of violent assault at work. BLS rates

measure the number of events per 10,000 full-time workers—in this

case, assaults resulting in injury. In 2000, health service workers

overall had an incidence rate of 9.3 for injuries resulting from

assaults and violent acts. The rate for social service workers was

15, and for nursing and personal care facility workers, 25. This

compares to an overall private sector injury rate of 2. 

The Department of Justice’s (DOJ) National Crime Victimization

Survey for 1993 to 1999 lists average annual rates of non-fatal

violent crime by occupation. The average annual rate for non-fatal

5
violent crime for all occupations is 12.6 per 1,000 workers.

The average annual rate for

physicians is 16.2; for nurses,

21.9; for mental health professionals, 68.2; and for mental

health custodial workers, 69.

(Note: These data do not

compare directly to the BLS

figures because DOJ presents

violent incidents per 1,000

workers and BLS displays

injuries involving days away

from work per 10,000

workers. Both sources,

however, reveal the same

high risk for health care and

social service workers.)

As significant as these

numbers are, the actual

number of incidents is probably much higher. Incidents of violence are likely to be underreported,

perhaps due in part to the persistent perception within the health

care industry that assaults are part of the job. Underreporting may

reflect a lack of institutional reporting policies, employee beliefs that

reporting will not benefit them or employee fears that employers

may deem assaults the result of employee negligence or poor job

performance.

The risk factors

Health care and social service workers face an increased risk 

of work-related assaults stemming from several factors. These

include:

■ The prevalence of handguns and other weapons among

patients, their families or friends; 

■ The increasing use of hospitals by police and the criminal justice

system for criminal holds and the care of acutely disturbed,

violent individuals;

■ The increasing number of acute and chronic mentally ill patients

being released from hospitals without follow-up care (these

6

30

25

20

15

10

5

0

Private

Sector

Overall

Health

Services

Overall

Social

Services Nursing &

Personal

Care

Facilities

Incidence rates for nonfatal assaults

and violent acts by industry, 2000

Incidence rate per 10,000 full-time workers

Source: U.S. Department of Labor, Bureau of

Labor Statistics. (2001). Survey of Occupational

Injuries and Illnesses, 2000.
patients have the right to refuse medicine and can no longer be

hospitalized involuntarily unless they pose an immediate threat

to themselves or others); 

■ The availability of drugs or money at hospitals, clinics and

pharmacies, making them likely robbery targets; 

■ Factors such as the unrestricted movement of the public in

clinics and hospitals and long waits in emergency or clinic areas

that lead to client frustration over an inability to obtain needed

services promptly;

■ The increasing presence of gang members, drug or alcohol

abusers, trauma patients or distraught family members; 

■ Low staffing levels during times of increased activity such as

mealtimes, visiting times and when staff are transporting

patients;

■ Isolated work with clients during examinations or treatment;

■ Solo work, often in remote locations with no backup or way 

to get assistance, such as communication devices or alarm

systems (this is particularly true in high-crime settings);

■ Lack of staff training in recognizing and managing escalating

hostile and assaultive behavior; and

■ Poorly lit parking areas.

Overview of Guidelines

In January 1989, OSHA published voluntary, generic safety and

health program management guidelines for all employers to use 

as a foundation for their safety and health programs, which can

include workplace violence prevention programs.5 OSHA’s violence

prevention guidelines build on these generic guidelines by

identifying common risk factors and describing some feasible

solutions. Although not exhaustive, the workplace violence

guidelines include policy recommendations and practical corrective

methods to help prevent and mitigate the effects of workplace

violence.

7

5

OSHA’s Safety and Health Program Management Guidelines (54 Federal Register

(16):3904–3916, January 26, 1989).
The goal is to eliminate or reduce worker exposure to conditions

that lead to death or injury from violence by implementing effective

security devices and administrative work practices, among other

control measures.

The guidelines cover a broad spectrum of workers who provide

health care and social services in psychiatric facilities, hospital

emergency departments, community mental health clinics, drug

abuse treatment clinics, pharmacies, community-care facilities and

long-term care facilities. They include physicians, registered nurses,

pharmacists, nurse practitioners, physicians’ assistants, nurses’

aides, therapists, technicians, public health nurses, home health

care workers, social workers, welfare workers and emergency

medical care personnel. The guidelines may also be useful in

reducing risks for ancillary personnel such as maintenance, dietary,

clerical and security staff in the health care and social service

industries.

Violence Prevention Programs

A written program for job safety and security, incorporated into

the organization’s overall safety and health program, offers an

effective approach for larger organizations. In smaller establishments, the program does not need to be written or heavily

documented to be satisfactory.

What is needed are clear goals and objectives to prevent

workplace violence suitable for the size and complexity of the

workplace operation and adaptable to specific situations in each

establishment. Employers should communicate information about

the prevention program and startup date to all employees. 

At a minimum, workplace violence prevention programs should:

■ Create and disseminate a clear policy of zero tolerance for

workplace violence, verbal and nonverbal threats and related

actions. Ensure that managers, supervisors, coworkers, clients,

patients and visitors know about this policy.

8
■ Ensure that no employee who reports or experiences workplace

violence faces reprisals.6

■ Encourage employees to promptly report incidents and suggest

ways to reduce or eliminate risks. Require records of incidents to

assess risk and measure progress.

■ Outline a comprehensive plan for maintaining security in 

the workplace. This includes establishing a liaison with law

enforcement representatives and others who can help identify

ways to prevent and mitigate workplace violence.

■ Assign responsibility and authority for the program to individuals or teams with appropriate training and skills. Ensure that

adequate resources are available for this effort and that the team

or responsible individuals develop expertise on workplace

violence prevention in health care and social services.

■ Affirm management commitment to a worker-supportive

environment that places as much importance on employee

safety and health as on serving the patient or client.

■ Set up a company briefing as part of the initial effort to address

issues such as preserving safety, supporting affected employees

and facilitating recovery.

Elements of an effective violence prevention program

The five main components of any effective safety and health

program also apply to the prevention of workplace violence:

■ Management commitment and employee involvement;

■ Worksite analysis;

■ Hazard prevention and control; 

■ Safety and health training; and

■ Recordkeeping and program evaluation.

9

6

Section 11 (c)(1) of the OSH Act applies to protected activity involving the hazard of

workplace violence as it does for other health and safety matters:

“No person shall discharge or in any manner discriminate against any employee

because such employee has filed any complaint or instituted or caused to be

instituted any proceeding under or related to this Act or has testified or is about to

testify in any such proceeding or because of the exercise by such employee on

behalf of himself or others of any right afforded by this Act.”
Management Commitment and 

Employee Involvement

Management commitment and employee involvement are 

complementary and essential elements of an effective safety and

health program. To ensure an effective program, management and

frontline employees must work together, perhaps through a team or

committee approach. If employers opt for this strategy, they must

be careful to comply with the applicable provisions of the National

Labor Relations Act.

7

Management commitment, including the endorsement and

visible involvement of top management, provides the motivation

and resources to deal effectively with workplace violence. This

commitment should include:

■ Demonstrating organizational concern for employee emotional

and physical safety and health;

■ Exhibiting equal commitment to the safety and health of workers

and patients/clients; 

■ Assigning responsibility for the various aspects of the workplace violence prevention program to ensure that all managers,

supervisors and employees understand their obligations;

■ Allocating appropriate authority and resources to all responsible

parties;

■ Maintaining a system of accountability for involved managers,

supervisors and employees;

■ Establishing a comprehensive program of medical and psychological counseling and debriefing for employees experiencing or

witnessing assaults and other violent incidents; and

■ Supporting and implementing appropriate recommendations

from safety and health committees.

Employee involvement and feedback enable workers to develop

and express their own commitment to safety and health and provide

useful information to design, implement and evaluate the program.

10

7

29 U.S.C. 158(a)(2).
Employee involvement should include:

■ Understanding and complying with the workplace violence

prevention program and other safety and security measures;

■ Participating in employee complaint or suggestion procedures

covering safety and security concerns;

■ Reporting violent incidents promptly and accurately;

■ Participating in safety and health committees or teams that

receive reports of violent incidents or security problems, make

facility inspections and respond with recommendations for

corrective strategies; and

■ Taking part in a continuing education program that covers

techniques to recognize escalating agitation, assaultive behavior

or criminal intent and discusses appropriate responses.

Worksite Analysis

Value of a worksite analysis

A worksite analysis involves a step-by-step, commonsense look

at the workplace to find existing or potential hazards for workplace

violence. This entails reviewing specific procedures or operations

that contribute to hazards and specific areas where hazards may

develop. A threat assessment team, patient assault team, similar

task force or coordinator may assess the vulnerability to workplace

violence and determine the appropriate preventive actions to be

taken. This group may also be responsible for implementing the

workplace violence prevention program. The team should include

representatives from senior management, operations, employee

assistance, security, occupational safety and health, legal and

human resources staff.

The team or coordinator can review injury and illness records

and workers’ compensation claims to identify patterns of assaults

that could be prevented by workplace adaptation, procedural

changes or employee training. As the team or coordinator identifies

appropriate controls, they should be instituted.

11
Focus of a worksite analysis 

The recommended program for worksite analysis includes, but

is not limited to:

■ Analyzing and tracking records;

■ Screening surveys; and 

■ Analyzing workplace security.

Records analysis and tracking

This activity should include reviewing medical, safety, workers’

compensation and insurance records—including the OSHA Log of

Work-Related Injury and Illness (OSHA Form 300), if the employer 

is required to maintain one—to pinpoint instances of workplace

violence. Scan unit logs and employee and police reports of

incidents or near-incidents of assaultive behavior to identify and

analyze trends in assaults relative to particular:

■ Departments;

■ Units; 

■ Job titles;

■ Unit activities;

■ Workstations; and

■ Time of day.

Tabulate these data to target the frequency and severity of

incidents to establish a baseline for measuring improvement.

Monitor trends and analyze incidents. Contacting similar local

businesses, trade associations and community and civic groups is

one way to learn about their experiences with workplace violence

and to help identify trends. Use several years of data, if possible, 

to trace trends of injuries and incidents of actual or potential workplace violence.

Value of screening surveys

One important screening tool is an employee questionnaire or

survey to get employees’ ideas on the potential for violent incidents

and to identify or confirm the need for improved security measures.

Detailed baseline screening surveys can help pinpoint tasks that put

12
employees at risk. Periodic surveys—conducted at least annually or

whenever operations change or incidents of workplace violence

occur—help identify new or previously unnoticed risk factors and

deficiencies or failures in work practices, procedures or controls.

Also, the surveys help assess the effects of changes in the work

processes. The periodic review process should also include feedback and follow-up.

Independent reviewers, such as safety and health professionals,

law enforcement or security specialists and insurance safety

auditors, may offer advice to strengthen programs. These experts

can also provide fresh perspectives to improve a violence prevention program.

Conducting a workplace security analysis

The team or coordinator should periodically inspect the workplace and evaluate employee tasks to identify hazards, conditions,

operations and situations that could lead to violence.

To find areas requiring further evaluation, the team or coordinator should:

■ Analyze incidents, including the characteristics of assailants 

and victims, an account of what happened before and during 

the incident, and the relevant details of the situation and its

outcome. When possible, obtain police reports and recommendations.

■ Identify jobs or locations with the greatest risk of violence as

well as processes and procedures that put employees at risk of

assault, including how often and when.

■ Note high-risk factors such as types of clients or patients 

(for example, those with psychiatric conditions or who are disoriented by drugs, alcohol or stress); physical risk factors related

to building layout or design; isolated locations and job activities;

lighting problems; lack of phones and other communication

devices; areas of easy, unsecured access; and areas with

previous security problems. 

■ Evaluate the effectiveness of existing security measures,

including engineering controls. Determine if risk factors have

been reduced or eliminated and take appropriate action.

13
14

Hazard Prevention and Control

After hazards are identified through the systematic worksite

analysis, the next step is to design measures through engineering

or administrative and work practices to prevent or control these

hazards. If violence does occur, post-incident response can be an

important tool in preventing future incidents.

Engineering controls and workplace adaptations 

to minimize risk

Engineering controls remove the hazard from the workplace or

create a barrier between the worker and the hazard. There are

several measures that can effectively prevent or control workplace

hazards, such as those described in the following paragraphs. The

selection of any measure, of course, should be based on the hazards identified in the workplace security analysis of each facility.

Among other options, employers may choose to:

■ Assess any plans for new construction or physical changes to

the facility or workplace to eliminate or reduce security hazards.

■ Install and regularly maintain alarm systems and other security

devices, panic buttons, hand-held alarms or noise devices,

cellular phones and private channel radios where risk is

apparent or may be anticipated. Arrange for a reliable response

system when an alarm is triggered.

■ Provide metal detectors—installed or hand-held, where

appropriate—to detect guns, knives or other weapons,

according to the recommendations of security consultants.

■ Use a closed-circuit video recording for high-risk areas on a 

24-hour basis. Public safety is a greater concern than privacy in

these situations.

■ Place curved mirrors at hallway intersections or concealed

areas.

■ Enclose nurses’ stations and install deep service counters or

bullet-resistant, shatter-proof glass in reception, triage and

admitting areas or client service rooms.

■ Provide employee “safe rooms” for use during emergencies.

■ Establish “time-out” or seclusion areas with high ceilings with-
out grids for patients who “act out” and establish separate

rooms for criminal patients.

■ Provide comfortable client or patient waiting rooms designed to

minimize stress.

■ Ensure that counseling or patient care rooms have two exits.

■ Lock doors to staff counseling rooms and treatment rooms to

limit access.

■ Arrange furniture to prevent entrapment of staff. 

■ Use minimal furniture in interview rooms or crisis treatment

areas and ensure that it is lightweight, without sharp corners 

or edges and affixed to the floor, if possible. Limit the number 

of pictures, vases, ashtrays or other items that can be used 

as weapons.

■ Provide lockable and secure bathrooms for staff members

separate from patient/client and visitor facilities.

■ Lock all unused doors to limit access, in accordance with local

fire codes.

■ Install bright, effective lighting, both indoors and outdoors.

■ Replace burned-out lights and broken windows and locks.

■ Keep automobiles well maintained if they are used in the field.

■ Lock automobiles at all times.

Administrative and work practice controls to minimize risk

Administrative and work practice controls affect the way staff

perform jobs or tasks. Changes in work practices and administrative

procedures can help prevent violent incidents. Some options for

employers are to:

■ State clearly to patients, clients and employees that violence is

not permitted or tolerated.

■ Establish liaison with local police and state prosecutors. Report

all incidents of violence. Give police physical layouts of facilities

to expedite investigations.

■ Require employees to report all assaults or threats to a

supervisor or manager (for example, through a confidential

interview). Keep log books and reports of such incidents to help

determine any necessary actions to prevent recurrences.

15
■ Advise employees of company procedures for requesting police

assistance or filing charges when assaulted and help them do

so, if necessary.

■ Provide management support during emergencies. Respond

promptly to all complaints.

■ Set up a trained response team to respond to emergencies.

■ Use properly trained security officers to deal with aggressive

behavior. Follow written security procedures.

■ Ensure that adequate and properly trained staff are available to

restrain patients or clients, if necessary.

■ Provide sensitive and timely information to people waiting in

line or in waiting rooms. Adopt measures to decrease waiting

time.

■ Ensure that adequate and qualified staff are available at all

times. The times of greatest risk occur during patient transfers,

emergency responses, mealtimes and at night. Areas with 

the greatest risk include admission units and crisis or acute 

care units. 

■ Institute a sign-in procedure with passes for visitors, especially

in a newborn nursery or pediatric department. Enforce visitor

hours and procedures.

■ Establish a list of “restricted visitors” for patients with a history

of violence or gang activity. Make copies available at security

checkpoints, nurses’ stations and visitor sign-in areas. 

■ Review and revise visitor check systems, when necessary. Limit

information given to outsiders about hospitalized victims of

violence.

■ Supervise the movement of psychiatric clients and patients

throughout the facility.

■ Control access to facilities other than waiting rooms, particularly

drug storage or pharmacy areas.

■ Prohibit employees from working alone in emergency areas or

walk-in clinics, particularly at night or when assistance is

unavailable. Do not allow employees to enter seclusion rooms

alone.

■ Establish policies and procedures for secured areas and

emergency evacuations.

16
■ Determine the behavioral history of new and transferred patients

to learn about any past violent or assaultive behaviors. 

■ Establish a system—such as chart tags, log books or verbal

census reports—to identify patients and clients with assaultive

behavior problems. Keep in mind patient confidentiality and

worker safety issues. Update as needed.

■ Treat and interview aggressive or agitated clients in relatively

open areas that still maintain privacy and confidentiality 

(such as rooms with removable partitions).

■ Use case management conferences with coworkers and

supervisors to discuss ways to effectively treat potentially

violent patients.

■ Prepare contingency plans to treat clients who are “acting out”

or making verbal or physical attacks or threats. Consider using

certified employee assistance professionals or in-house social

service or occupational health service staff to help diffuse patient

or client anger.

■ Transfer assaultive clients to acute care units, criminal units or

other more restrictive settings.

■ Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients.

■ Discourage employees from wearing necklaces or chains to help

prevent possible strangulation in confrontational situations.

Urge community workers to carry only required identification

and money.

■ Survey the facility periodically to remove tools or possessions

left by visitors or maintenance staff that could be used inappropriately by patients.

■ Provide staff with identification badges, preferably without last

names, to readily verify employment.

■ Discourage employees from carrying keys, pens or other items

that could be used as weapons.

■ Provide staff members with security escorts to parking areas in

evening or late hours. Ensure that parking areas are highly

visible, well lit and safely accessible to the building.

■ Use the “buddy system,” especially when personal safety may

be threatened. Encourage home health care providers, social

service workers and others to avoid threatening situations. 

17
■ Advise staff to exercise extra care in elevators, stairwells and

unfamiliar residences; leave the premises immediately if there is

a hazardous situation; or request police escort if needed.

■ Develop policies and procedures covering home health care

providers, such as contracts on how visits will be conducted, the

presence of others in the home during the visits and the refusal

to provide services in a clearly hazardous situation.

■ Establish a daily work plan for field staff to keep a designated

contact person informed about their whereabouts throughout

the workday. Have the contact person follow up if an employee

does not report in as expected.

Employer responses to incidents of violence

Post-incident response and evaluation are essential to an

effective violence prevention program. All workplace violence

programs should provide comprehensive treatment for employees

who are victimized personally or may be traumatized by witnessing

a workplace violence incident. Injured staff should receive prompt

treatment and psychological evaluation whenever an assault takes

place, regardless of its severity. Provide the injured transportation

to medical care if it is not available onsite.

Victims of workplace violence suffer a variety of consequences

in addition to their actual physical injuries. These may include:

■ Short- and long-term psychological trauma; 

■ Fear of returning to work;

■ Changes in relationships with coworkers and family;

■ Feelings of incompetence, guilt, powerlessness; and

■ Fear of criticism by supervisors or managers. 

Consequently, a strong follow-up program for these employees

will not only help them to deal with these problems but also help

prepare them to confront or prevent future incidents of violence. 

Several types of assistance can be incorporated into the postincident response. For example, trauma-crisis counseling, criticalincident stress debriefing or employee assistance programs may 

be provided to assist victims. Certified employee assistance professionals, psychologists, psychiatrists, clinical nurse specialists 

18
or social workers may provide this counseling or the employer may

refer staff victims to an outside specialist. In addition, the employer

may establish an employee counseling service, peer counseling or

support groups.

Counselors should be well trained and have a good understanding of the issues and consequences of assaults and other aggressive, violent behavior. Appropriate and promptly rendered postincident debriefings and counseling reduce acute psychological

trauma and general stress levels among victims and witnesses. 

In addition, this type of counseling educates staff about workplace

violence and positively influences workplace and organizational

cultural norms to reduce trauma associated with future incidents.

Safety and Health Training

Training and education ensure that all staff are aware of

potential security hazards and how to protect themselves and their

coworkers through established policies and procedures.

Training for all employees 

Every employee should understand the concept of “universal

precautions for violence”— that is, that violence should be expected

but can be avoided or mitigated through preparation. Frequent

training also can reduce the likelihood of being assaulted.

Employees who may face safety and security hazards should

receive formal instruction on the specific hazards associated with

the unit or job and facility. This includes information on the types 

of injuries or problems identified in the facility and the methods to

control the specific hazards. It also includes instructions to limit

physical interventions in workplace altercations whenever possible,

unless enough staff or emergency response teams and security

personnel are available. In addition, all employees should be

trained to behave compassionately toward coworkers when an

incident occurs.

The training program should involve all employees, including

supervisors and managers.

New and reassigned employees should receive an initial

orientation before being assigned their job duties. Visiting staff,

such as physicians, should receive the same training as permanent

staff. Qualified trainers should instruct at the comprehension level

19
appropriate for the staff. Effective training programs should involve

role playing, simulations and drills.

Topics may include management of assaultive behavior, professional assault-response training, police assault-avoidance programs

or personal safety training such as how to prevent and avoid

assaults. A combination of training programs may be used,

depending on the severity of the risk.

Employees should receive required training annually. In large

institutions, refresher programs may be needed more frequently,

perhaps monthly or quarterly, to effectively reach and inform all

employees.

What training should cover

The training should cover topics such as:

■ The workplace violence prevention policy;

■ Risk factors that cause or contribute to assaults;

■ Early recognition of escalating behavior or recognition of

warning signs or situations that may lead to assaults;

■ Ways to prevent or diffuse volatile situations or aggressive

behavior, manage anger and appropriately use medications as

chemical restraints;

■ A standard response action plan for violent situations, including

the availability of assistance, response to alarm systems and

communication procedures;

■ Ways to deal with hostile people other than patients and clients,

such as relatives and visitors;

■ Progressive behavior control methods and safe methods to

apply restraints; 

■ The location and operation of safety devices such as alarm

systems, along with the required maintenance schedules and

procedures;

■ Ways to protect oneself and coworkers, including use of the

“buddy system;”

■ Policies and procedures for reporting and recordkeeping;

■ Information on multicultural diversity to increase staff sensitivity

to racial and ethnic issues and differences; and

20
■ Policies and procedures for obtaining medical care, counseling,

workers’ compensation or legal assistance after a violent

episode or injury.

Training for supervisors and managers

Supervisors and managers need to learn to recognize high-risk

situations, so they can ensure that employees are not placed in

assignments that compromise their safety. They also need training

to ensure that they encourage employees to report incidents. 

Supervisors and managers should learn how to reduce security

hazards and ensure that employees receive appropriate training.

Following training, supervisors and managers should be able to

recognize a potentially hazardous situation and to make any

necessary changes in the physical plant, patient care treatment

program and staffing policy and procedures to reduce or eliminate

the hazards.

Training for security personnel

Security personnel need specific training from the hospital or

clinic, including the psychological components of handling

aggressive and abusive clients, types of disorders and ways to

handle aggression and defuse hostile situations. 

The training program should also include an evaluation. At least

annually, the team or coordinator responsible for the program

should review its content, methods and the frequency of training.

Program evaluation may involve supervisor and employee interviews, testing and observing and reviewing reports of behavior of

individuals in threatening situations.

Recordkeeping and Program Evaluation

How employers can determine program effectiveness

Recordkeeping and evaluation of the violence prevention

program are necessary to determine its overall effectiveness and

identify any deficiencies or changes that should be made.

Records employers should keep

Recordkeeping is essential to the program’s success. Good

records help employers determine the severity of the problem,

21
evaluate methods of hazard control and identify training needs.

Records can be especially useful to large organizations and for

members of a business group or trade association who “pool”

data. Records of injuries, illnesses, accidents, assaults, hazards,

corrective actions, patient histories and training can help identify

problems and solutions for an effective program. 

Important Records:

■ OSHA Log of Work-Related Injury and Illness (OSHA Form 300).

Employers who are required to keep this log must record any

new work-related injury that results in death, days away from

work, days of restriction or job transfer, medical treatment

beyond first aid, loss of consciousness or a significant injury

diagnosed by a licensed health care professional. Injuries 

caused by assaults must be entered on the log if they meet the

recording criteria. All employers must report, within 24 hours, a

fatality or an incident that results in the hospitalization of three

or more employees.8

■ Medical reports of work injury and supervisors’ reports for each

recorded assault. These records should describe the type of

assault, such as an unprovoked sudden attack or patient-topatient altercation; who was assaulted; and all other circumstances of the incident. The records should include a description

of the environment or location, potential or actual cost, lost work

time that resulted and the nature of injuries sustained. These

medical records are confidential documents and should be kept

in a locked location under the direct responsibility of a health

care professional. 

■ Records of incidents of abuse, verbal attacks or aggressive

behavior that may be threatening, such as pushing or shouting

and acts of aggression toward other clients. This may be kept as

part of an assaultive incident report. Ensure that the affected

department evaluates these records routinely. (See sample

violence incident forms in Appendix B.)

■ Information on patients with a history of past violence, drug

abuse or criminal activity recorded on the patient’s chart. All staff

who care for a potentially aggressive, abusive or violent client

22

8

29 CFR Part 1904, revised 2001.
should be aware of the person’s background and history. Log the

admission of violent patients to help determine potential risks.

■ Documentation of minutes of safety meetings, records of hazard

analyses and corrective actions recommended and taken.

■ Records of all training programs, attendees and qualifications 

of trainers. 

Elements of a program evaluation 

As part of their overall program, employers should evaluate

their safety and security measures. Top management should review

the program regularly, and with each incident, to evaluate its

success. Responsible parties (including managers, supervisors and

employees) should reevaluate policies and procedures on a regular

basis to identify deficiencies and take corrective action.

Management should share workplace violence prevention

evaluation reports with all employees. Any changes in the program

should be discussed at regular meetings of the safety committee,

union representatives or other employee groups. 

All reports should protect employee confidentiality either by

presenting only aggregate data or by removing personal identifiers

if individual data are used. 

Processes involved in an evaluation include:

■ Establishing a uniform violence reporting system and regular

review of reports;

■ Reviewing reports and minutes from staff meetings on safety

and security issues;

■ Analyzing trends and rates in illnesses, injuries or fatalities

caused by violence relative to initial or “baseline” rates;

■ Measuring improvement based on lowering the frequency and

severity of workplace violence;

■ Keeping up-to-date records of administrative and work practice

changes to prevent workplace violence to evaluate how well

they work;

■ Surveying employees before and after making job or worksite

changes or installing security measures or new systems to

determine their effectiveness;

23
■ Keeping abreast of new strategies available to deal with violence

in the health care and social service fields as they develop;

■ Surveying employees periodically to learn if they experience

hostile situations concerning the medical treatment they

provide;

■ Complying with OSHA and State requirements for recording and

reporting deaths, injuries and illnesses; and

■ Requesting periodic law enforcement or outside consultant

review of the worksite for recommendations on improving

employee safety.

Sources of assistance for employers

Employers who would like help in implementing an appropriate

workplace violence prevention program can turn to the OSHA

Consultation Service provided in their State. To contact this service,

see OSHA’s website at www.osha.gov or call (800) 321-OSHA. 

OSHA’s efforts to help employers combat workplace violence are

complemented by those of NIOSH, public safety officials, trade

associations, unions, insurers and human resource and employee

assistance professionals, as well as other interested groups.

Employers and employees may contact these groups for additional

advice and information. NIOSH can be reached toll-free at (800) 

35-NIOSH.

Conclusion

OSHA recognizes the importance of effective safety and health

program management in providing safe and healthful workplaces.

Effective safety and health programs improve both morale and productivity and reduce workers’ compensation costs. 

OSHA’s violence prevention guidelines are an essential

component of workplace safety and health programs. OSHA

believes the performance-oriented approach of these guidelines

provides employers with flexibility in their efforts to maintain safe

and healthful working conditions. 

24
References

California State Department of Industrial Relations, Cal/OSHA.

(1998). Guidelines for Security and Safety of Health Care and

Community Service Workers.

www.dir.ca.gov/dosh/dosh%5Fpublications/hcworker.html

Centers for Disease Control and Prevention, National Institute for

Occupational Health. (2002). Occupational Hazards in Hospitals.

DHHS (NIOSH) Pub. No. 2002-101. 

www.cdc.gov/niosh/2002-101.html

U.S. Department of Justice, Bureau of Justice Statistics. (2001).

National Crime Victimization Survey. Violence in the Workplace,

1993–99. www.ojp.gov/bjs/pub/pdf/vw99.pdf

U.S. Department of Labor, Bureau of Labor Statistics. (2002).

Census of Fatal Occupational Injuries, 2001.

www.bls.gov/iif/oshwc/cfoi/cfnr0008.pdf

U.S. Department of Labor, Bureau of Labor Statistics. (2001).

Survey of Occupational Injuries and Illnesses, 2000.

www.bls.gov/iif/oshwc/osh/os/osnr0013.pdf

Washington, Department of Labor and Industries. Workplace

Violence: Awareness and Prevention for Employers and

Employees, 2000. www.lni.wa.gov/ipub/417-140-000.htm

OSHA assistance

OSHA can provide extensive help through a variety of programs,

including technical assistance about effective safety and health

programs, state plans, workplace consultations, voluntary protection programs, strategic partnerships, training and education and

more. An overall commitment to workplace safety and health can

add value to your business, to your workplace and to your life.

Safety and Health Program Management Guidelines

Effective management of worker safety and health protection is

a decisive factor in reducing the extent and severity of work-related

injuries and illnesses and their related costs. In fact, an effective

safety and health program forms the basis of good worker protection and can save time and money (about $4 for every dollar

25
26

spent) and increase productivity and reduce worker injuries,

illnesses and related workers’ compensation costs.

To assist employers and employees in developing effective

safety and health programs, OSHA published recommended Safety

and Health Program Management Guidelines (54 Federal Register

(16): 3904-3916, January 26, 1989). These voluntary guidelines

apply to all places of employment covered by OSHA.

The guidelines identify four general elements critical to the

development of a successful safety and health management

program:

■ Management leadership and employee involvement.

■ Work analysis.

■ Hazard prevention and control.

■ Safety and health training.

The guidelines recommend specific actions, under each of 

these general elements, to achieve an effective safety and health

program. The Federal Register notice is available online at

www.osha.gov. 

State Programs

The Occupational Safety and Health Act of 1970 (OSH Act)

encourages states to develop and operate their own job safety and

health plans. OSHA approves and monitors these plans. There are

currently 26 state plans: 23 cover both private and public (state and

local government) employment; 3 states, Connecticut, New Jersey

and New York, cover the public sector only. States and territories

with their own OSHA-approved occupational safety and health

plans must adopt standards identical to, or at least as effective as,

the federal standards. 

Consultation Services

Consultation assistance is available on request to employers

who want help in establishing and maintaining a safe and healthful

workplace. Largely funded by OSHA, the service is provided at no

cost to the employer. Primarily developed for smaller employers

with more hazardous operations, the consultation service is delivered by state governments employing professional safety and

health consultants. Comprehensive assistance includes an appraisal

of all-mechanical systems, work practices and occupational safety
27

and health hazards of the workplace and all aspects of the

employer’s present job safety and health program. In addition, the

service offers assistance to employers in developing and implementing an effective safety and health program. No penalties are

proposed or citations issued for hazards identified by the consultant. OSHA provides consultation assistance to the employer

with the assurance that his or her name and firm and any information about the workplace will not be routinely reported to OSHA

enforcement staff.

Under the consultation program, certain exemplary employers

may request participation in OSHA’s Safety and Health Achievement

Recognition Program (SHARP). Eligibility for participation in SHARP

includes receiving a comprehensive consultation visit, demonstrating exemplary achievements in workplace safety and health by

abating all identified hazards and developing an excellent safety

and health program.

Employers accepted into SHARP may receive an exemption

from programmed inspections (not complaint or accident investigation inspections) for a period of one year. For more information

concerning consultation assistance, see the OSHA website at

www.osha.gov.

Voluntary Protection Programs (VPP)

Voluntary Protection Programs and onsite consultation services,

when coupled with an effective enforcement program, expand

worker protection to help meet the goals of the OSH Act. The 

three levels of VPP are Star, Merit, and Demonstration designed to

recognize outstanding achievements by companies that have successfully incorporated comprehensive safety and health programs

into their total management system. The VPPs motivate others to

achieve excellent safety and health results in the same outstanding

way as they establish a cooperative relationship between employers,

employees and OSHA.

For additional information on VPP and how to apply, contact the

OSHA regional offices listed at the end of this publication.

Strategic Partnership Program

OSHA’s Strategic Partnership Program, the newest member of

OSHA’s cooperative programs, helps encourage, assist and

recognize the efforts of partners to eliminate serious workplace
hazards and achieve a high level of worker safety and health.

Whereas OSHA’s Consultation Program and VPP entail one-on-one

relationships between OSHA and individual worksites, most

strategic partnerships seek to have a broader impact by building

cooperative relationships with groups of employers and

employees. These partnerships are voluntary, cooperative relationships between OSHA, employers, employee representatives and

others (e.g., trade unions, trade and professional associations, 

universities and other government agencies). 

For more information on this and other cooperative programs,

contact your nearest OSHA office, or visit OSHA’s website at

www.osha.gov.

Alliance Programs

The Alliances Program enables organizations committed to

workplace safety and health to collaborate with OSHA to prevent

injuries and illnesses in the workplace. OSHA and the Alliance participants work together to reach out to, educate and lead the

nation’s employers and their employees in improving and

advancing workplace safety and health. 

Alliances are open to all groups, including trade or professional

organizations, businesses, labor organizations, educational institutions and government agencies. In some cases, organizations may

be building on existing relationships with OSHA that were developed through other cooperative programs. 

There are few formal program requirements for Alliances and

the agreements do not include an enforcement component.

However, OSHA and the participating organizations must define,

implement and meet a set of short- and long-term goals that fall

into three categories: training and education; outreach and communication; and promoting the national dialogue on workplace safety

and health. 

OSHA Training and Education

OSHA area offices offer a variety of information services, such as

compliance assistance, technical advice, publications, audiovisual

aids and speakers for special engagements. OSHA’s Training

Institute in Arlington Heights, Ill., provides basic and advanced

courses in safety and health for federal and state compliance

officers, state consultants, federal agency personnel, and private

28
sector employers, employees and their representatives.

The OSHA Training Institute also has established OSHA Training

Institute Education Centers to address the increased demand for its

courses from the private sector and from other federal agencies.

These centers are nonprofit colleges, universities and other organizations that have been selected after a competition for participation

in the program.

OSHA also provides funds to nonprofit organizations, through

grants, to conduct workplace training and education in subjects

where OSHA believes there is a lack of workplace training. Grants

are awarded annually. Grant recipients are expected to contribute

20 percent of the total grant cost.

For more information on grants, training and education, contact

the OSHA Training Institute, Office of Training and Education, 2020

South Arlington Heights Road, Arlington Heights, IL 60005, (847)

297-4810 or see “Outreach” on OSHA’s website at www.osha.gov.

For further information on any OSHA program, contact your nearest

OSHA area or regional office listed at the end of this publication.

Information Available Electronically

OSHA has a variety of materials and tools available on its

website at www.osha.gov. These include e-Tools such as Expert

Advisors, Electronic Compliance Assistance Tools (e-cats), Technical

Links; regulations, directives and publications; videos and other

information for employers and employees. OSHA’s software

programs and compliance assistance tools walk you through

challenging safety and health issues and common problems to find

the best solutions for your workplace.

OSHA’s CD-ROM includes standards, interpretations, directives

and more, and can be purchased on CD-ROM from the U.S.

Government Printing Office. To order, write to the Superintendent

of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954 or phone

(202) 512-1800, or order online at http://bookstore.gpo.gov.

OSHA Publications

OSHA has an extensive publications program. For a listing of

free or sales items, visit OSHA’s website at www.osha.gov or

contact the OSHA Publications Office, U.S. Department of Labor,

200 Constitution Avenue, NW, N-3101, Washington, DC 20210.

Telephone (202) 693-1888 or fax to (202) 693-2498. 

29
Contacting OSHA

To report an emergency, file a complaint or seek OSHA advice,

assistance or products, call (800) 321-OSHA or contact your nearest

OSHA regional or area office listed at the end of this publication.

The teletypewriter (TTY) number is (877) 889-5627.

You can also file a complaint online and obtain more information on OSHA federal and state programs by visiting OSHA’s

website at www.osha.gov.

OSHA Regional Offices

Region I

(CT,* ME, MA, NH, RI, VT*) 

JFK Federal Building, Room E340

Boston, MA 02203

(617) 565-9860

Region II

(NJ,* NY,* PR,* VI*)

201 Varick Street, Room 670

New York, NY 10014

(212) 337-2378

Region III

(DE, DC, MD,* PA,* VA,* WV)

The Curtis Center

170 S. Independence Mall West

Suite 740 West

Philadelphia, PA 19106-3309

(215) 861-4900

Region IV 

(AL, FL, GA, KY,* MS, NC,* SC,* TN*)

61 Forsyth Street, SW

Atlanta, GA 30303

(404) 562-2300

Region V

(IL, IN,* MI,* MN,* OH, WI)

230 South Dearborn Street, Room 3244

Chicago, IL 60604

(312) 353-2220

30
Region VI

(AR, LA, NM,* OK, TX)

525 Griffin Street, Room 602

Dallas, TX 75202

(214) 767-4731 or 4736 x224

Region VII

(IA,* KS, MO, NE)

City Center Square

1100 Main Street, Suite 800

Kansas City, MO 64105

(816) 426-5861

Region VIII

(CO, MT, ND, SD, UT,* WY*)

1999 Broadway, Suite 1690

PO Box 46550

Denver, CO 80201-6550

(303) 844-1600

Region IX 

(American Samoa, AZ,* CA,* HI, NV,* Northern Mariana Islands)

71 Stevenson Street, Room 420

San Francisco, CA 94105

(415) 975-4310

Region X

(AK,* ID, OR,* WA*)

1111 Third Avenue, Suite 715

Seattle, WA 98101-3212

(206) 553-5930

*These states and territories operate their own OSHA-approved job

safety and health programs (Connecticut, New Jersey and New York plans

cover public employees only). States with approved programs must have a

standard that is identical to, or at least as effective as, the federal standard.

Note: To get contact information for OSHA Area Offices, OSHAapproved State Plans and OSHA Consultation Projects, please visit us

online at www.osha.gov or call us at 1-800-321-OSHA.

31
Appendix A:

Workplace Violence Program Checklists

Reprinted with permission of the American Nurses Association,

Promoting Safe Work Environments for Nurses, 2002. 

Checklist 1: 

Organizational Assessment Questions Regarding

Management Commitment and Employee Involvement

■ Is there demonstrated organizational concern for employee

emotional and physical safety and health as well as that of the

patients?

■ Is there a written workplace violence prevention program in your

facility?

■ Did front-line workers as well as management participate in

developing the plan?

■ Is there someone clearly responsible for the violence prevention

program to ensure that all managers, supervisors, and

employees understand their obligations?

■ Do those responsible have sufficient authority and resources to

take all action necessary to ensure worker safety?

■ Does the violence prevention program address the kinds of

violent incidents that are occurring in your facility?

■ Does the program provide for post-assault medical treatment

and psychological counseling for health-care workers who

experience or witness assaults or violence incidents?

■ Is there a system to notify employees promptly about specific

workplace security hazards or threats that are made? Are

employees aware of this system?

■ Is there a system for employees to inform management about

workplace security hazards or threats without fear of reprisal?

Are employees aware of this system?

■ Is there a system for employees to promptly report violent

incidents, “near misses,” threats, and verbal assaults without

fear of reprisal? 

■ Is there tracking, trending, and regular reporting on violent

incidents through the safety committee?

32
■ Are front-line workers included as regular members and participants in the safety committee as well as violence tracking

activities?

■ Does the tracking and reporting capture all types of violence—

fatalities, physical assaults, harassment, aggressive behavior,

threats, verbal abuse, and sexual assaults?

■ Does the tracking and reporting system use the latest categories

of violence so data can be compared? 

■ Have the high-risk locations or jobs with the greatest risk of

violence as well as the processes and procedures that put

employees at risk been identified?

■ Is there a root-cause analysis of the risk factors associated with

individual violent incidents so that current response systems can

be addressed and hazards can be eliminated and corrected?

■ Are employees consulted about what corrective actions need to

be taken for single incidents or surveyed about violence

concerns in general?

■ Is there follow-up of employees involved in or witnessing violent

incidents to assure that appropriate medical treatment and

counseling have been provided?

■ Has a process for reporting violent incidents within the facility to

the police or requesting police assistance been established?

Identifying Risks for Violence by Unit/Work Area

Perform a step-by-step review of each work area to identify

specific places and times that violent incidents are occurring and

the risk factors that are present. To ensure multiple perspectives, it

is best for a team to perform this worksite analysis. Key members

of the analysis team should be front-line health care workers,

including nurses from each specialty unit, as well as the facility’s

safety and security professionals.

Find Out What’s Happening on Paper

The first step in this worksite analysis is to obtain and review

data that tells the “who, what, when, where and why” about violent

incidents. These sources include:

■ Incident report forms

■ Workers’ compensation reports of injury

33
■ OSHA 300 injury and illness logs

■ Security logs

■ Reports to police

■ Safety committee reports

■ Hazard inspection reports

■ Staff termination records

■ Union complaints

Using this information, attempt to answer the questions in

Checklist 2. 

Checklist 2:

Analyze Workplace Violence Records

■ How many incidents occurred in the last 2 years?

■ What kinds of incidents occurred most often (assault, threats,

robbery, vandalism, etc.)?

■ Where did incidents most often occur?

■ When did incidents most often occur (day of week, shift, time,

etc.)?

■ What job task was usually being performed when an incident

occurred?

■ Which workers were victimized most often (gender, age, job

classification, etc.)?

■ What type of weapon was used most often?

■ Are there any similarities among the assailants?

■ What other incidents, if any, are you aware of that are not

included in the records?

■ Of those incidents you reviewed, which one or two were most

serious?

Use the data collected to stimulate the following

discussions:

■ Are there any important patterns or trends among the incidents?

■ What do you believe were the main factors contributing to

violence in your workplace?

34
■ What additional corrective measures would you recommend to

reduce or eliminate the problems you identified?

Conduct a Walkthrough

It is important to keep in mind that injuries from violence are

often not reported. One of the best ways to observe what is really

going on is to conduct a workplace walkthrough. 

A walkthrough, which is really a workplace inspection, is the first

step in identifying violence risk factors and serves several important

functions. While on a walkthrough, hazards can be recognized and

often corrected before anyone’s health and safety is affected. 

While inspecting for workplace violence risk factors, review the

physical facility and note the presence or absence of security

measures. Local police may also be able to conduct a security audit

or provide information about experience with crime in the area. 

Ask the Workers

A simple survey can provide valuable information often not

found in department walkthroughs and injury logs. Some staff may

not report violent acts or threatening situations formally but will

share the experiences and suggestions anonymously. This can

provide information about previously unnoticed deficiencies or

failures in work practices or administrative controls. It also can help

increase employee awareness about dangerous conditions and

encourage them to become involved in prevention activities. 

Types of questions that employees should be asked include:

■ What do they see as risk factors for violence?

■ The most important risk factors in their work areas

■ Aspects of the physical environment that contribute to 

violence

■ Dangerous situations or “near misses” experienced

■ Assault experiences—past year, entire time at facility

■ Staffing adequacy

■ How are current control measures working?

■ Hospital practices for handling conflict among staff and 

patients

■ Effectiveness of response to violent incidents

35
■ How safe they feel in the current environment

■ What ideas do employees have to protect workers?

■ Highest priorities in violence prevention

■ Ideas for improvements and prevention measures

■ How satisfied are they in their jobs?

■ With managers/fellow workers

■ Adequacy of rewards and praise

■ Impact on health

Checklist 3:

Identifying Environmental Risk Factors for Violence 

Use the following checklist to assist in your workplace

walkthrough.

General questions about approach:

■ Are safety and security issues specifically considered in the early

stages of facility design, construction, and renovation?

■ Does the current violence prevention program provide a way to

select and implement controls based on the specific risks

identified in the workplace security analysis? How does this

process occur?

Specific questions about the environment:

■ Do crime patterns in the neighborhood influence safety in the

facility?

■ Do workers feel safe walking to and from the workplace?

■ Are entrances visible to security personnel and are they well lit

and free of hiding places?

■ Is there adequate security in parking or public transit waiting

areas?

■ Is public access to the building controlled, and is this system

effective?

■ Can exit doors be opened only from the inside to prevent unauthorized entry?

36
■ Is there an internal phone system to activate emergency

assistance?

■ Have alarm systems or panic buttons been installed in high-risk

areas?

■ Given the history of violence at the facility, is a metal detector

appropriate in some entry areas? Closed-circuit TV in high-risk

areas?

■ Is there good lighting?

■ Are fire exits and escape routes clearly marked?

■ Are reception and work areas designed to prevent unauthorized

entry? Do they provide staff good visibility of patients and

visitors? If not, are there other provisions such as security

cameras or mirrors?

■ Are patient or client areas designed to minimize stress, including

minimizing noise?

■ Are drugs, equipment, and supplies adequately secured?

■ Is there a secure place for employees to store their belongings?

■ Are “safe rooms” available for staff use during emergencies?

■ Are door locks in patient rooms appropriate? Can they be

opened during an emergency?

■ Do counseling or patient care rooms have two exits, and is

furniture arranged to prevent employees from becoming

trapped? 

■ Are lockable and secure bathrooms that are separate from

patient-client and visitor facilities available for staff members?

Checklist 4:

Assessing the Influence of Day-to-Day Work Practices on

Occurrences of Violence

■ Are identification tags required for both employees and visitors

to the building?

■ Is there a way to identify patients with a history of violence? Are

contingency plans put in place for these patients—such as restricting visitors and supervising their movement through the facility?

■ Are emergency phone numbers and procedures posted or

readily available?

37
■ Are there trained security personnel accessible to workers in a

timely manner?

■ Are waiting times for patients kept as short as possible to avoid

frustration?

■ Is there adequate and qualified staffing at all times, particularly

during patient transfers, emergency responses, mealtimes, and

at night?

■ Are employees prohibited from entering seclusion rooms alone

or working alone in emergency areas of walk-in clinics, particularly at night or when assistance is unavailable?

■ Are broken windows, doors, locks, and lights replaced promptly?

■ Are security alarms and devices tested regularly?

Checklist 5:

Post-Incident Response

■ Is comprehensive treatment provided to victimized employees

as well as those who may be traumatized by witnessing a

workplace violence incident? Required services may include

trauma-crisis counseling, critical incident stress debriefing, psychological counseling services, peer counseling, and support

groups.

Checklist 6:

Assessing Employee and Supervisor Training

■ Does the violence prevention program require training for all

employees and supervisors when they are hired and when job

responsibilities change?

■ Do agency workers or contract physicians and house staff

receive the same training that permanent staff receive?

■ Are workers trained in how to handle difficult clients or patients?

■ Does the security staff receive specialized training for the healthcare environment?

■ Is the training tailored to specific units, patient populations, and

job tasks, including any tasks done in the field?

■ Do employees learn progressive behavior control methods and

safe methods to apply restraints?

38
■ Do workers believe that the training is effective in handling

escalating violence or violent incidents? 

■ Are drills conducted to test the response of health-care facility

personnel?

■ Are workers trained in how to report violent incidents, threats, or

abuse and obtain medical care, counseling, workers’ compensation, or legal assistance after a violent episode or injury?

■ Are employees and supervisors trained to behave compassionately toward coworkers when an incident occurs? 

■ Does the training include instruction about the location and

operation of safety devices such as alarm systems, along with

the required maintenance schedules and procedures?

Checklist 7:

Recordkeeping and Evaluation

Does the violence prevention program provide for:

■ Up-to-date recording in the OSHA Log of Work-Related Injury

and Illness (OSHA 300)?

■ Records of all incidents involving assault, harassment,

aggressive behavior, abuse, and verbal attack with attention to

maintaining appropriate confidentiality of the records?

■ Training records?

■ Workplace walkthrough and security inspection records?

■ Keeping records of control measures instituted in response to

inspections, complaints, or violent incidents?

■ A system for regular evaluation of engineering, administrative,

and work practice controls to see if they are working well?

■ A system for regular review of individual reports and trending

and analysis of all incidents?

■ Employee surveys regarding the effectiveness of control

measures instituted?

■ Discussions with employees who are involved in hostile

situations to ask about the quality of post-incident treatment

they received?

■ A provision for an outside audit or consultation of the violence

programs for recommendations on improving safety? 

39
Appendix B

Violence Incident Report Forms

Sample 1

The following items serve merely as an example of what might be used or

modified by employers in these industries to help prevent workplace violence.

(Sample/Draft—Adapt to your own location and business circumstances.)

Confidential Incident Report

To: Date of Incident:

Location of Incident (Map/sketch on reverse side or attached):

From: Phone: Time of Incident: 

Nature of the Incident (“X” all applicable boxes):

❑ Assaults or Violent Acts: Type “l” Type “2” Type “3” Other

❑ Preventative or Warning Report

❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No

❑ Transportation Accident ❑ Contacts with Objects or Equipment

❑ Falls ❑ Exposures ❑ Fires or Explosions ❑ Other

Legal Counsel Advised of Incident? ❑ Yes ❑ No EAP Advised? ❑ Yes ❑ No

Warning or Preventative Measures? ❑ Yes ❑ No

Number of Persons Affected:

(For each person, complete a report; however, to the extent facts are duplicative, any

person’s report may incorporate another person’s report.)

Name of Affected Person(s): Service Date:

Position: Member of Labor Organization? ❑ Yes ❑ No

Supervisor: Has Supervisor Been Notified? ❑ Yes ❑ No

Family: Has Been Notified by: ? ❑ Yes ❑ No

Lost Work Time? ❑ Yes ❑ No Anticipated Return to Work: 

Third parties or non-employee involvement (include contractor and lease

employees, visitors, vendors, customers)? ❑ Yes ❑ No

Nature of the Incident

Briefly describe: (1) event(s); (2) witnesses with addresses and status

included; (3) location details; (4) equipment/weapon details; (5) weather; 

(6) other records of the incident (e.g., police report, recordings, videos); 

(7) the ability to observe and reliability of witnesses; (8) were the parties

possibly impaired because of illness, injury, drugs or alcohol? (were tests

taken to verify same?); (9) parties notified internally (employee relations,

medical, legal, operations, etc.) and externally (police, fire, ambulance, 

EAP, family, etc.).

Previous or Related Incidents of This Type? ❑ Yes ❑ No 

Or by This Person? ❑ Yes ❑ No Preventative Steps? ❑ Yes ❑ No

OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No

Incident Response Team: 

Team Leader:

Signature Date 

Source: Reprinted with permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm of 

Abbott, Nicholson, Quilter, Esshaki & Youngblood, P. C., Detroit, MI.

40
Sample 2

The following items serve merely as an example of what might be used or

modified by employers in these industries to help prevent workplace violence.

A reportable violent incident should be defined as any threatening remark

or overt act of physical violence against a person(s) or property whether

reported or observed.

1. Date: Day of Week: Time: Assailant: ❑ Female ❑ Male

2. Specific Location:

3.Violence Directed Toward: ❑ Patient ❑ Staff ❑ Visitor ❑ Other

Assailant: ❑ Patient ❑ Staff ❑ Visitor ❑ Other

Assailant’s Name: 

Assailant: ❑ Unarmed ❑ Armed (weapon) 

4. Predisposing Factors:

❑ Intoxication ❑ Dissatisfied with Care/Waiting Time

❑ Grief Reaction ❑ Prior History of Violence

❑ Gang Related ❑ Other (Describe)

5. Description of Incident: ❑ Physical Abuse ❑ Verbal Abuse ❑ Other 

6. Injuries: ❑ Yes ❑ No

7. Extent of Injuries:

8. Detailed Description of the Incident:

9. Did Any Person Leave the Area because of Incident?

❑ Yes ❑ No ❑ Unable to Determine

10. Present at Time of Incident:

❑ Police Name of Department:

❑ Hospital Security Officer 

11. Needed to Call:

❑ Police Name of Department:

❑ Hospital Security 

12.Termination of Incident:

Incident Diffused ❑ Yes ❑ No Police Notified ❑ Yes ❑ No

Assailant Arrested ❑ Yes ❑ No

13. Disposition of Assailant:

❑ Stayed on Premises ❑ Escorted off Premises ❑ Left on Own ❑ Other

14. Restraints Used: ❑ Yes ❑ No Type:

15. Report Completed By: Title: 

Witnesses:

Supervisor Notified: Time: 

Please put additional comments, according to numbered section, on reverse side of form.

Source: Reprinted with permission of the Metropolitan Chicago Healthcare

Council, Guidelines for Dealing with Violence in Health Care, Chicago, IL, 1995.

41
Appendix C

Suggested Readings

Alspach, G. (1993). “Nurses as Victims of Violence.” Critical Care

Nurse 13(5):13–17.

Biles, P.D. (1997). “OSHA’s Guidelines for Protecting Health Care

Workers from Workplace Violence.” Joint Commission on

Accreditation of Healthcare Organizations: Environment of

Care/PTSM Series 3:29–35.

Cal/OSHA. (1998). “Guidelines for Security and Safety of Health

Care and Community Service Workers.”

www.dir.ca.gov/dosh/dosh%5Fpublications/hcworker.html

Carroll, V. and Morin, K.H. (1998). “Workplace Violence Affects

One-Third of Nurses.” nursingworld.org/tan/98sepoct/violence.htm

Centers for Disease Control and Prevention, National Institute for

Occupational Health. (2002). “Occupational Hazards in Hospitals.”

DHHS (NIOSH) Pub. No. 2002–101. www.cdc.gov/niosh/2002-

101.html

Centers for Disease Control and Prevention, National Institute for

Occupational Safety and Health. (1996). “Violence in the Workplace:

Risk Factors and Preventive Strategies.” Current Intelligence Bulletin

57, DHHS (NIOSH) Pub. No. 96-100.

www.cdc.gov/niosh/violcont.html

Colling, R.L. (1997). “Controlling Workplace Violence: A Security

Management Plan Approach.” Joint Commission on Accreditation of

Healthcare Organizations: Environment of Care/PTSM Series

3:37–47.

Colorado Nurses Association, Task Force on Workplace Violence.

(1998). “Survey on Workplace Violence of Nurses in Seven State

Nurses Associations.” Available from Colorado Nurses Association,

Denver, CO. www.nurses-co.org

Davis, S. (1991). “Violence in Psychiatric Inpatients: A Review.”

Hospital and Community Psychiatry 42:585–590.

DiBenedetto, D.V. (1992). “Occupational Hazards of the Healthcare

Industry: Protecting Healthcare Workers.” AAOHN Journal

43(3):131–137.

Dillon, S. (1992). “Social Workers: Targets in a Violent Society.”

New York Times: Al; Al8, November 1, 1992.

42
Distasio, C.A. (2002) “Protecting Yourself From Violence in the

Workplace.” Nursing 2002 32(6):58–63. www.

nursingcenter.com/library/JournalArticle. asp?Article_ID=273445

Elliott, P.P. (1997). “Violence in Health Care: What Nurse

Managers Need to Know.” Nursing Management 28 (12):38–41.

Fazzone, P.A.; Barloon, L.F.; McConnell, S.J.; and Chitty, J.A.

(2000). “Personal Safety, Violence and Home Health.” Public Health

Nursing 17(1):43–52.

Flannery, R.B., Jr. (1995). “Violence in the Workplace.” New York:

Crossroad Press.

Flannery, R.B., Jr.; Hanson, M.A.; and Penk, W.E. (1994). “Risk

Factors for Psychiatric Inpatient Assaults on Staff.” Journal of Mental

Health Administration 21:24–31.

Gates, D.M.; Fitzwater, E.; and Meyer, U. (1999). “Violence

Against Caregivers in Nursing Homes.” Journal of Gerontological

Nursing 25(4):12–22. 

Gilmore–Hall, A. (2001). “Violence in the Workplace: Are You

Prepared?” American Journal of Nursing 101(7):55–56.

Hansen, B. (1996). “Workplace Violence in the Hospital Psychiatric

Setting.” AAOHN Journal 44(12):575–580.

Hunter, E. (1997). “Violence Prevention in the Home Health

Setting.” Home Healthcare Nurse 15(6):403–409.

Joint Commission on Accreditation of Healthcare Organizations.

(2002). “Comprehensive Accreditation Manual for Hospitals.”

Oakbrook, IL: JCAHO.

Kinkle, S.L. (1993). “Violence in the Emergency Department: How

to Stop it Before it Starts.” American Journal of Nursing 93(7):22–24.

Morgan, L. (1999). “In Harm’s Way: Health Care Professionals Face

Increasing Abuse in the Workplace.” Nurseweek, August 2, 1999.

www.nurseweek.com/features/99-8/violence.html

Morrison, E., and Herzog, E. (1992). “What Therapeutic and

Protective Measures, As Well As Legal Actions, Can Staff Take When

They Are Attacked by Patients?” Journal of Psychosocial Nursing

30(7):41–44.

Morrison, E.F. (1993). “Toward a Better Understanding of Violence

in Psychiatric Settings: Debunking the Myths.” Archives of

Psychiatric Nursing (7)6:328–335.

Nadwairski, J.A. (1992). “Inner-City Safety for Home Care

Providers.” Journal of Nursing Administration 22(9):42–47.

43
National Security Institute. (1995). “Guidelines for Workplace

Violence Prevention Programs for Health Care Workers in

Institutional and Community Settings.”

nsi.org/library/work/violenc1.html

Ore, T. (2002). “Occupational Assault among Community Care

Workers.” Journal of Healthcare Management 18(1):72–89.

Rippon, T.J. (2000). “Aggression and Violence in Health Care

Professions.” Journal of Advanced Nursing 31(2):452–460.

Rusting Publications. (2001). “What Hospital Security Should be

Doing Now to Better Prepare for Future Terrorist Activity.” Hospital

Security and Safety Management 22(6):5–10.

Schulte, J.M., et al. (1998). “Violence and Threats of Violence

Experienced by Public Health Workers.” Journal of the American

Medical Association 280(5):439–442.

Simonowitz, J.A. (1995). “Violence in Health Care: A Strategic

Approach.” Nurse Practitioner Forum 6(2):120–129.

Simonowitz, J.A.; Rigdon, J.E.; and Mannings, J. (1997).

“Workplace Violence: Prevention Efforts by the Occupational Health

Nurse.” AAOHN Journal 45(6):305–316.

Smith-Pittman, M.H. and McKay, Y.D. (1999). “Workplace Violence

in Health Care Environments.” Nursing Forum 34(3):5–13.

www.cinahl.com/cgi-bin/jrlgetarticle?nfor3403

Snyder, W., III. (1994). “Hospital Downsizing and Increased

Frequency of Assaults on Staff.” Hospital and Community Psychiatry

45:378–379.

Sygnatur, E.F. and Toscano, G.A. (2000). “Work-Related

Homicides: The Facts.” Compensation and Working Conditions 5(1).

www.bls.gov/opub/cwc/2000/spring/art1full.pdf

University of Iowa, Injury Prevention Research Center. (2001).

“Workplace Violence: A Report to the Nation.” www.publichealth.uiowa.edu/IPRC/NATION.PDF

Worthington, K. and Franklin, P. (2001). “Workplace Violence: What

to Do if You’re Assaulted.” American Journal of Nursing 101(4):73.

Worthington, K. (2000). “Violence in the Health Care Workplace.”

American Journal of Nursing 100(11):69–70.

Yassi, A., et al. (1998). “Causes of Staff Abuse in Health Care

Facilities: Implications for Prevention.” AAOHN Journal 46(10):484–491.

44
www.osha.gov