Workplace Violence Workgroup Report

Tamara Cafaro, Christina Jolley, Amy LaValla, Rebecca Schroeder
Advisor: R. John Repique

Current Environment

Workplace violence is a serious problem in health care and one of great concern to psychiatric-mental health nurses. When compared to other industries, the rate of workplace violence is highest among hospital workers, 8.3 per 10,000 workers vs. 2 per 10,000 workers, and among this group nurses are the most ‘at risk’. (Howerton & Mentes, 2010; Privitera, Weisman, Cerulli, Tu, & Groman, 2005). These numbers are especially concerning when one considers violence toward health care workers in the mental health field. For patients with acute mental illness, reduced impulse control combined with fewer resources and limited treatment options increases the likelihood for workplace violence to occur. (Privitera,, 2005) This, in addition to cuts in staffing, all contribute to a vicious cycle affecting recruitment and retention of qualified staff. (Privitera, et al., 2005)

The World Health Organization defines violence as a major global public health issue (Howerton & Mentes, 2010) and although definitions vary, workplace violence can be divided into four main types: physical, sexual, verbal and horizontal violence (Copeland, 2007). The American Psychiatric Nurses Association (APNA) has long recognized the impact of violence in the workplace and in 2008 published a comprehensive position paper addressing its significance (APNA Task Force on Workplace Violence Steering Committee).

The impact of violence and assault is often underestimated. Documented accounts related to workplace violence represent only those which are reported. Evidence shows the majority of nurses who experience one or more forms of violence do not report the incident to their supervisor or law enforcement authorities. When this type of under-reporting persists, any effort to bring issues of workplace violence out of the shadows often falls flat (Emergency Nurses Association, 2011).

In 2010, a tragic occurrence at Napa State Hospital in California resulted in the murder of a psychiatric technician on hospital grounds. This incident once again brought the issue of workplace violence to the forefront and has been instrumental in garnering public attention. Both the recent publicly reported event and responses to a 2011 survey completed by members of the APNA, underscore the lack of movement towards addressing this seemingly indomitable problem and the importance of doing so.

Stakeholder Needs

In 2011, APNA conducted a survey among its members to elicit information about individual concerns regarding this thorny issue. Over 300 members responded and results from this survey highlighted the lack of violence prevention policies in various mental health organizations. When asked about the presence of a zero-tolerance policy within their institution, over 63% of survey respondents stated one existed in their workplace, but many admitted it was neither enforced nor supported by the administration. Others indicated skepticism about such a policy, citing it as ineffective, unrealistic, and difficult to enforce. While over 59% of the respondents reported that a culture of violence is not actually condoned, 72% of those who commented said that in practice, violence is often expected and tolerated. Most felt that has been little movement towards addressing the problem.


The human costs associated with workplace violence have considerable implications for the health of the workforce and organization as a whole due to its effects on staff turnover, absenteeism, staff morale and patient outcomes. Other consequences include such things as compassion fatigue, substance abuse, PTSD, psychological implications, missed work, costs for legal services and treatment for the individual affected (Howerton & Mentes, 2010). Therefore, a workplace environment that accepts violence “as part of the job” and does not actively nurture a culture built upon zero tolerance presents a public health risk on many levels.

There were questions raised in the APNA Workplace Violence Workgroup’s 2011 Survey about whether or not certain behaviors should be considered workplace violence or simply symptomatology consistent with mental illness. Issues such as dementia, verbal berating towards nursing staff by patients, and staff-to-staff conflict related to workplace stress were mentioned as factors indicative of workplace aggression. Creating a clear definition of workplace violence may lead to policies that support action versus inaction. When considering these effects and analyzing the responses from the Workplace Violence Workgroup’s 2011 Survey, recommendations for confronting this issue can be approached using a public health framework. 


  • Although psychiatric facilities may be viewed as high risk environments for violence, respondents to the 2011 Survey recommended numerous measures which should be taken prior to the onset of violence. Primary prevention measures included sufficient staffing based on acuity rather than staffing models driven only by census. Increased security, video monitoring, and safe nursing areas were important safety measures that were mentioned. Practices such as self-locking doors and safety badges to access secure areas, coordinating and training staff in safety plans, and creating workplace violence prevention committees were seen as vital. Suggestions were made to tailor the physical environment to include metal detectors and hidden panic buttons or safety phones in areas where staff could potentially be isolated with patients. Respondents further suggested a zero tolerance policy, the availability of standard orders, and policy and procedures that are all disseminated, enforced, and supported by administration.
  • Other recommendations for the psychiatric environment involved measures such as robust and continuous education for all staff, including education on employee rights. In addition, encouragement and assistance from employers was acknowledged as a means for preventing and discouraging future workplace violence.  
  • Lastly, since the impact of assault is often underestimated, individuals commonly have strong emotional reactions regardless of whether or not actual physical injury has occurred. The aftermath of a violent event often leaves the victim traumatized and without adequate support. Tertiary prevention recommendations suggested by the respondents included the option of taking legal action once workplace violence had occurred and offering adequate follow up care and necessary treatment after the violent event.
  • The need for support and adequate resources for staff who have been victims of violence is crucial. It has been suggested that we no longer need to document the gravity of the problem, since the severity is well known, but must instead move from inaction to action by developing successful prevention and intervention approaches. (Lanza, Zeiss & Rierdan, 2009) Others have asserted that the current discourse on aggression and violence in the workplace maintains the status quo and argues that a new explanatory model is needed (Luck, Jackson, & Usher, 2006). Despite these arguments, there is a groundswell of evidence that indicates we have not stemmed the tide of violent events nor recognized ‘at risk’ staff who may be insufficiently trained to manage a psychiatric patient population. 
  • The Department of Labor and Occupational Safety and Health Administration views workplace violence education as highly important and offers suggestions and recommendations to reduce the incidence (Privitera, et al., 2005). These views were substantiated by the APNA 2011 survey respondents. As professionals, we must adequately coach nurses (psychiatric nurses, in particular) to insist on safer work environments, educate staff, and support those who have been victims of violence by helping them deal with the trauma that may emerges once a violent event occurs.


Submitted to the APNA Board of Directors February 2012 
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