Prioritizing our Healthcare Workers: The Importance of Addressing the Intersection of Workplace Violence and Mental Health and Wellbeing

 

Workplace violence impacts the mental health and wellbeing of the healthcare workforce. The negative outcomes not only affect the healthcare worker but can trickle down to patient safety and satisfaction. It is important that healthcare institutions implement workplace violence prevention programs that benefit the entire healthcare workforce. This blog post highlights current efforts across government and industry to address this critical issue.

The Healthcare Workforce

There are roughly 15 million healthcare workers employed in the United States. This includes home health aides and nursing assistants, physicians, nurses and nurse practitioners, mental health counselors, massage therapists, and pharmacy and emergency medical technicians. Current Population Survey estimates for 2022 reveal women make up 85% of the almost 5 million employed as healthcare support workers (e.g., home health aides, nursing assistants, psychiatric aides) and 50% of physicians and dentists. Nearly 25% of healthcare support workers are Black, compared with less than 10% of physicians and dentists. A large proportion of healthcare workers are between 25 and 34 years old and 28% were born outside of the United States. It is important that workplace violence prevention programs benefit the entire health workforce, including all ages, genders, and racial and ethnic backgrounds, and those who come to the U.S. to provide patient care.

Workplace Violence and Healthcare

Workplace violence is the act or threat of violence, ranging from verbal abuse and threats to physical assaults directed toward persons at work or on duty. Workplace violence has even occurred offsite when perpetrators stalk victims in anger and revenge. The two types of violence that most often lead to nonfatal injuries in the healthcare industry are:

• violence that is directed at a healthcare worker from the patient, patient’s family member, or visitors, and
• violence that is directed at a healthcare worker from a colleague, supervisor, or other co-worker.

Another type of violence that can occur in the healthcare industry is:

• violence that is directed at a healthcare worker from someone they have a personal relationship with, such as an intimate partner or family member.

Workplace violence in the healthcare industry accounted for a rate of 14 nonfatal injuries involving days away from work per 10,000 full-time equivalents (FTEs) in 2021-2022 (BLS, 2023a). This is more than triple the overall rate for all industries combined (4.3 per 10,000 FTE) (BLS, 2023a). While healthcare workers make up 10% of the workforce, they experience 48% of the nonfatal injuries due to workplace violence (BLS, 2023b). Healthcare workers experiencing workplace violence may experience suicidal ideation, posttraumatic stress disorder, depression, anxiety, burnout, and continue to feel anger and fear and other emotions (Nigam et al, 2023; Lanctot & Guay, 2014). In addition to understanding the perpetrator’s relationship to the healthcare worker, it is also critical to identify the triggers and the goals of the violence (i.e., determining if it is reactive or predatory) to prevent recurrence.

In addition to the various health issues that can result from workplace violence, there are many costs associated with workplace violence in healthcare. Workers’ compensation insurance will typically pay the cost of a workplace injury in treatment and lost wages (OSHA, 2015), with other costs including the replacement of a healthcare worker, lower patient satisfaction (McHugh et al, 2011), and reduced patient safety (e.g., medication errors, patient infections) (Hall et al, 2016).

The Impact of Workplace Violence on Mental Health and Wellbeing

According to a 2023 CDC Vital Signs report, more than double the number of healthcare workers reported harassment at work in 2022 than in 2018 – rising from 6% in 2018 to 13% in 2022. The impact of this harassment on healthcare worker mental health is substantial. Workers who experienced harassment at work were more likely to report feelings of anxiety, depression, and burnout.

NIOSH launched the Impact Wellbeing campaign in October 2023 to provide hospital leaders evidence-informed solutions to reduce healthcare worker burnout, sustain wellbeing, and build a system where healthcare workers thrive. In March 2024, NIOSH released the Impact Wellbeing Guide, a tested tool designed to help hospital leaders and executives accelerate or supplement professional wellbeing work in their hospitals at the operational level. This includes fostering a safe work environment.

The Impact of Workplace Violence on Patient Safety

In 2023, the Agency for Healthcare Research and Quality (AHRQ) convened a subcommittee of its National Advisory Council to establish goals for the National Action Alliance for Patient and Workforce Safety. The first aim of the Alliance is to facilitate healthcare systems’ commitment to performing safety self-assessments, including assessing their approaches to support workforce safety.  The subcommittee noted early in its discussions that patient and healthcare worker safety are intrinsically linked. This conclusion is supported by recent research that has reported on the intersection of patient safety culture, healthcare worker burnout and workplace violence (Kim et al, 2022; Kim et al, 2023). Kim et al found that in most instances, a positive patient safety culture was associated with lower workplace violence and lower workforce burnout scores (Kim et al, 2022), and a culture of reporting workplace violence—when it occurs—may reduce the effect of burnout on patient safety (Kim et al, 2023). The AHRQ’s Surveys on Patient Safety Culture^TM (SOPS^©) include the Workplace Safety Supplement Item Set, which measures items describing healthcare workers’ perceptions of workforce safety (Zebrak K et al, 2022). Topics of emphasis include:

• Workplace hazards
• Moving, transferring, or lifting patients
• Addressing workplace aggression from patients or visitors
• Workplace aggression policies, procedures, and training
• Addressing verbal aggression from providers or staff
• Supervisor, manager, or clinical leader support
• Hospital management support
• Workplace safety and reporting
• Work stress/burnout

Risk Factors for Workplace Violence in Healthcare Settings

In 2013 NIOSH released a free, interactive online course designed to help healthcare workers better understand the scope and nature of violence in the workplace. According to the Workplace Violence Prevention for Nurses online training, the following are some of the risk factors for patient-based workplace violence:

• Clinical Risk Factors:
  • Substance use or misuse
  • Patients who are in pain
  • History of violence by the patient
  • Cognitive impairment

• Environmental Risk Factors:
  • Accessibility to healthcare workers
  • Increased stress (such as confusing signage or disturbing noise levels in the facility)
  • Security measures that limit staff’s ability to respond appropriately to violent incidents

• Organizational Risk Factors:
  • Complacent attitudes towards workplace violence prevention
  • Inadequate security procedures and protocols
  • Lack of staff training and preparedness

See Unit 3 of the training to learn more about risk factors for patient-based violence.

The following are some of the risk factors for co-worker-based workplace violence:

• Individual Risk Factors (Joint Commission, 2021):
  • Stressful and emotional work
  • Fatigue
  • Inadequate interpersonal, coping or conflict management skills

• Systemic Risk Factors (Joint Commission, 2021):
  • Productivity demands
  • Cost containment requirements
  • Embedded hierarchies
  • Changing professional roles
  • Staff and schedule changes

See Unit 4 of the training and publications cited above for more risk factors and details.

What Employers Can Do

Employers in the healthcare industry can take steps to prevent workplace violence including:

• Engaging employees in efforts to promote a safe workplace
• Implementing violence prevention programs using guidelines established by OSHA
• Providing training in workplace violence such as the NIOSH free online training
• Meeting standards for workplace violence prevention set forth by The Joint Commission
• Collaborating with other institutions, organizations, and other beneficiaries to implement best practices for workplace violence prevention in the healthcare industry
• Creating a formal system for threat assessment after a first incident, to understand the drivers for the assault
• Incorporating tracking systems in the clinical chart/records management system

What Hospitals Are Doing to Mitigate Workplace Violence

Hospitals and health systems report that workplace violence and intimidation make it more difficult for staff to provide quality patient care. Nurses, physicians, and allied health professionals cannot provide attentive care when they are afraid for their personal safety, distracted by disruptive patients or family members, or traumatized from prior attacks. The American Hospital Association (AHA) prioritizes addressing workplace violence and its impact on health worker wellbeing. Guided by its Task Force on Workforce, the AHA has issued a report on strategies and resources for supporting the health and well-being of healthcare workers.

Further, the AHA’s Hospitals Against Violence (HAV) initiative shares examples and best practices about workplace and community violence prevention. The Building a Safer Workplace and Community framework guides health care leaders through building a culture of safety, mitigating risk, violence intervention strategies, and trauma support. The framework also highlights the critical components for success in designing a violence mitigation strategy, including data collection, accountability, and training and education at all levels of the organization.

This year, on June 7, AHA is hosting the eighth annual #HAVhope Friday, a national day of awareness to highlight how America’s hospitals and health systems combat violence in health care settings and in communities. AHA invites all interested parties to join #HAVhope Friday to see how hospitals and health systems use partnerships, innovations and creative thinking to foster peace and make a safer environment for workers and patients.

Government Efforts to Mitigate Workplace Violence

OSHA

The Occupational Safety and Health Administration provided a Road Map in 2013 for safety and health management systems in hospitals that is still relevant today. It provides 6 core elements:

• Management leadership
• Employee participation
• Hazard identification and assessment
• Hazard prevention and control
• Education and training
• System evaluation and improvement

The Road Map defines the core elements, justifies their importance, describes what is needed to incorporate them, and offers best practices and examples. These safety and health management system principles are also expanded upon even more specifically with regard to addressing workplace violence in OSHA’s 2015 Guidelines for Prevention of Workplace Violence for Healthcare and Social Service Workers (OSHA Publication 3148).

OSHA staff also collaborated with NIOSH, the Veterans Health Administration (VHA), and private sector researchers to develop a checklist with criteria statements to support internal audits of institutional programs. These criteria statements provide straight-forward approaches to evaluating whether a program contains critical elements. The checklist follows the general structure of the OSHA Guidelines for Preventing Workplace Violence for Healthcare and Social Services Workers. Other OSHA efforts include:

• A request for information (RFI) on Prevention of Workplace Violence in Healthcare and Social Assistance industry sectors in 2016.
• A public meeting on workplace violence prevention in healthcare and social assistance industries in 2017.
• A potential rule to address Prevention of Workplace Violence in Healthcare and Social Assistance is on OSHA’s regulatory agenda.
• Under the requirements of the Small Business Regulatory and Enforcement Fairness Act (SBREFA), OSHA engaged with a diverse set of representatives from small businesses and non-profit entities in healthcare and social assistance industry sectors in Spring of 2023 to receive input on the potential impacts of a workplace violence prevention regulation.
• In addition to guidance, OSHA has developed Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence, which provides guidance and procedures to be followed when conducting inspections and issuing citations related to occupational exposure to workplace violence.

The Joint Commission

The Joint Commission published a report that crosswalks each workplace violence prevention standard with the supporting requirements, rationale, and references (The Joint Commission, 2021). The report contains important statements on program completeness. Recently, an update was published for behavioral healthcare and human services organizations (The Joint Commission, 2023). In addition, the Joint Commission recently developed an overview tool for de-escalation, with practical summaries for implementation through the Quick Safety 47: De-escalation in Healthcare (The Joint Commission, 2019).

NIOSH

In addition to the online training and the Impact Wellbeing campaign mentioned above, NIOSH researchers continue to conduct research on workplace violence. NIOSH supports health worker wellbeing through the Total Worker Health Program®, Healthcare and Social Assistance Program and the Traumatic Injury Prevention Program.

AHRQ

In addition to helping lead the National Action Alliance for Patient and Workforce Safety on behalf of HHS, AHRQ is supporting a new funding opportunity to address to explore systems-based approaches to improve patient safety by improving healthcare worker safety and well-being.

Workplace Violence Prevention Matters

Efforts to address the mental health and wellbeing of our nation’s workforce must include the prevention of workplace violence. Share with us in the comment section below how your workplace has addressed violence against health workers.

 

Cammie Chaumont Menendez, MS, MPH, PhD, Research Epidemiologist with the Division of Safety Research, National Institute for Occupational Safety and Health

Elisa Arespacochaga, MBA, Vice President, Clinical Affairs and Workforce, American Hospital Association

Robyn Begley, DNP, RN, NEA-BC, FAAN, Chief Executive Officer and Chief Nursing Officer, American Hospital Association

Melissa Bhatnagar, PharmD, MPA, Senior Staff Service Fellow with the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality

Priscilla Ross, Executive Director, Executive Branch Relations, Senior Director, Federal Relations, American Hospital Association

Megan E. Schaefer, Group Vice President, Governance, American Hospital Association

Christina Spring, MA, Associate Director for the Office of Communications, National Institute for Occupational Safety and Health

The Agency for Healthcare Research and Quality and the Occupational Safety and Health Administration also contributed to this blog.

References

Arbury S, Collins NR, Magtahas J, Holmes M, Hodgson MJ.  OSHA Workplace Violence Enforcement. .J Occup Environ Med. 2022 Apr 1;64(4):e211-e216. doi: 10.1097/JOM.0000000000002482. Epub 2022 Jan 11.PMID: 35019893

Bureau of Labor Statistics. 2023a. Table R8. Annualized incidence rates for nonfatal occupational injuries and illnesses involving days away from work, restricted activity, or job transfer (DSR), days away from work (DAFW), and days of restricted work activity, or job transfer (DJTR) by industry and selected events or exposures leading to injury or illness, private industry, 2021-2022. Accessed online 2.21.24 at https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.bls.gov%2Fiif%2Fnonfatal-injuries-and-illnesses-tables%2Fcase-and-demographic-characteristics-table-r8-2021-2022.xlsx&wdOrigin=BROWSELINK.

Bureau of Labor Statistics. 2023b. Table R12. Number of nonfatal occupational injuries and illnesses involving days away from work, restricted activity, or job transfer (DART), days away from work (DAFW), and days of restricted work activity, or job transfer (DJTR) by occupation and selected events or exposures leading to injury or illness, private industry, 2021-2022. Available at: https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.bls.gov%2Fiif%2Fnonfatal-injuries-and-illnesses-tables%2Fcase-and-demographic-characteristics-table-r12-2021-2022.xlsx&wdOrigin=BROWSELINK.

Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. 2016. Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS One, 11(7):e0159015. Doi: 10.1371/journal.pone.0159015.

Kim S, Kitzmiller R, Baernholdt M, Lynn MR, Jones CB. 2022. Patient safety culture: The impact on workplace violence and health worker burnout. American Association of Occupational Health Nurses. 71(2). https://doi.org/10.1177/21650799221126364

Kim S, Lynn MR, Baernholdt M, Kitzmiller R, Jones, CB. 2023. How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? Journal of Nursing Care Quality. 38(1):11-18. https://doi.org/10.1097/NCQ.0000000000000641

Lanctôt N & Guay S. 2014.  The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggression and Violent Behavior, 19(5):492-501. https://doi.org/10.1016/j.avb.2014.07.010

McHugh MD, Kutney-Lee A, Cimiotti JP, Sloane DM, Aiken LH. 2011. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2):202-210.

Nigam JAS, Barker RM, Cunningham TR, Swanson NG, Chosewood LC. 2023. Vital Signs: Health worker-perceived working conditions and symptoms of poor mental health — Quality of Worklife Survey, United States, 2018–2022. MMWR, 72(44):1197-1205. https://www.cdc.gov/mmwr/volumes/72/wr/mm7244e1.htm.

NIOSH. 2013. Workplace Violence Prevention for Nurses. 2013-155. Available at: https://wwwn.cdc.gov/WPVHC/Nurses/Course/Slide/Unit4_6.

Nowrouzi-Kia et al. 2019. Antecedent factors in different types of workplace violence against nurses: A systematic review. Aggression and Violent Behavior. 44:1-7.

Occupational Safety and Health Administration. 2015. Workplace violence in healthcare: Understanding the Challenge. No. 3826. https://www.osha.gov/sites/default/files/OSHA3826.pdf.

The Joint Commission Division of Healthcare Improvement. Quick Safety: De-escalation in healthcare. Issue 47, January 29, 2019.

The Joint Commission, Sentinel Event Alert. June 18, 2021 update. Available at: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea-40-intimidating-disruptive-behaviors-final2.pdf

The Joint Commission. R³Report/ Requirement, Rationale, Reference. Workplace Violence Prevention Standards. Issue 30, June 18, 2021. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3_20210618.pdf.

The Joint Commission. R³Report/ Requirement, Rationale, Reference. Workplace Violence Prevention in Behavioral Health Care and Human Services. Issue 42, December 20, 2023.  https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpv-for-bhc-r3.pdf.

Zebrak K, Yount N, Sorra J, Famolaro T, Gray L, Carpenter D, Caporaso A. 2022. Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture^TM (SOPS^©) workplace safety supplemental items for hospitals. International Journal of Environmental Research and Public Health. 19(11):6815. https://doi.org/10.3390/ijerph19116815