Threat Assessment Strategies to Mitigate Violence in Healthcare

There is mounting evidence, however, that Zero Tolerance policies may not work as intended.  Such policies may discourage nursing staff from using other available resources to problem solve and may limit how nurses listen to patients.[11]  In the education field, where the policy is prominent, the results are mixed.  The information available suggests the results gleaned from Zero Tolerance policies tend to contradict the goals of reducing violence.[12]  Great Britain tried a Zero Tolerance initiative for violence in healthcare in 1999 that was replaced by a different program in 2003. Overall assessment of the program is difficult for a variety of reasons, including a likely increase of incident reporting due to the initiative; however, the overall result appeared to be a 70% increase in violent incidents against healthcare workers over the four year period.[13]  Adhering to Zero Tolerance policies is generally not advised by threat management experts who avoid such language because it implies harsh justice without thorough investigation.”[14] 


Another commonly recommended strategy – implementing a comprehensive workplace violence program (WVP) – does not appear to have had consistent, positive results on violence incidents either.[15],[16],[17]  While these programs can be very successful, they are dependent on commitment from all levels of the organization, especially the top leadership, organizational culture and politics, training components and overall structure of the program.  This creates significant variation in program implementation and success across organizations. 

TA is one of the less commonly applied strategies for managing violence in healthcare, though it is more common in other at-risk sectors including retail, hospitality and especially education.  There is minimal research regarding the use of TA in healthcare specifically, so comparisons must be drawn to similarities with other industries to discuss its applicability. Education is the most similar sector with which to draw comparisons because it also involves vulnerable populations as well as a potentially on-going relationship with the institution.    


Before continuing to evaluate TA as a potential violence mitigation strategy, it is necessary to review the complicated regulatory environment that addresses workplace violence overall.  Federal and state agencies, accrediting organizations and international bodies all view and manage workplace violence in differing ways. 



The Department of Labor regulates the safety of workers in the United States under the Occupational Safety and Health Act of 1970.  OSHA has an online resource center dedicated to prevention and management of workplace violence[18] and an additional website focused solely on the healthcare sector.[19] However, even with the heavy focus, there is no federal workplace violence standard in the OSHA regulations. Violence is currently regulated under the General Duty Clause, Section 5(a)(1) of the Act, which states employers are required to provide a place of employment that is “free from recognized hazards that are causing or are likely to cause death or serious harm.”[20]  OSHA provided initial guidance on how to apply the general duty clause when investigating violence incidents in 2011. [21]  During the subsequent years, the agency has leveraged fines against organizations who they found to be in violation.


A recent example of OSHA fines is UHS of Westwood Pembroke, one of the nation’s largest healthcare management companies. It operates 350 behavioral health facilities, acute care hospitals, ambulatory centers and freestanding emergency departments in multiple countries. In Boston, Massachusetts, one of its facilities does business as the Lowell Treatment Center, a 41-bed psychiatric hospital that offers inpatient hospitalization and partial hospitalization for adolescents and adults.  In May 2015, Lowell was cited for failure to provide a workplace violence program (WVP).  As part of a settlement, Lowell agreed to implement a WVP.  In January 2017, during a re-inspection, it was determined that Lowell had not implemented the agreed upon WVP and that “employees throughout the Lowell Treatment Center continued to be exposed to incidents of workplace violence that could have been greatly reduced had the employer fully implemented the settlement agreement.”[22]  Lowell was cited for a general duty clause violation for workplace violence with a proposed penalty of $207,690.  UHS of Westwood Pembroke is appealing the citation; however, if it is upheld, it will be the largest citation in the U.S. for workplace violence to date. 

OSHA has considered whether to develop a new standard specific to violence in healthcare and social assistance workplaces perpetrated by patients and clients. As recently as 2016 it was up for consideration, however, no further action has been taken by OSHA to develop the standard.[23]

Centers for Medicare and Medicaid (CMS)/The Joint Commission

In order for healthcare facilities to receive payment for services from CMS for Medicare and Medicaid patients, they must be accredited.  There are several accrediting agencies that work on behalf of CMS, the most prevalent of which is The Joint Commission.  Because Medicare and Medicaid make up a large proportion of healthcare payments, complying with standards is a primary focus for healthcare facilities.  CMS’s focus is the safety and health of patients.  Their regulations say little about worker safety, sometimes putting healthcare workers at risk.  In June 2010, The Joint Commission issued its first Sentinel Event Alert related to workplace violence.  While the alert has some useful strategies to mitigate the overall risk of violence in a healthcare facility, the focus of the alert is to address assault, rape or homicide of patients perpetrated by staff, visitors, other patients and intruders to the institution.[24]  In August 2018, Sentinel Event Alert 59 was issued.  This alert acknowledges that healthcare workers are at high risk for workplace violence and provides substantive guidance on how to implement a program and mitigate issues in the workplace.  It does not, however, address the conflicting issue of prioritizing the protection of patients over the protection of employees.[25] 


The U.S. Senate Health Appropriations Subcommittee has recognized the disconnect between OSHA and CMS regulations and is trying to rectify the discrepancy.  In a provision in the June 2018 health appropriations bill, CMS and OSHA were asked to issue a joint report to lay clear groundwork for the agencies to collaborate on regulatory guidance for hospital employees.[25]   Missouri Health Association President Herb Kuhn, who has taken a lead on pushing for federal action, says, “The disconnect between CMS’ and OSHA’s responsibilities make it more complicated for hospital employees to try to de-escalate situations or to manage them without getting penalized. The CMS conditions of participation and certification rules make sure hospitals are taking care of patients and keeping them safe, but they don’t have jurisdiction over hospital employees. That falls to OSHA, under the Labor Department.  The point is to at least ask HHS and the Department of Labor to get together…on regulations, so that if employees are accosted there are better ways they can protect themselves.” [26]  The report was due in April 2019, but it had yet to be released upon publication of this article. 

The U.S. House of Representatives proposed the Healthcare Workplace Violence Prevention Act in March 2018. This bill, titled H.R. 5223, would have directed OSHA to create a standard that required healthcare facilities to develop and implement specific workplace violence prevention plans.  That bill did not move forward, but was reintroduced in February 2019 as H.R. 1309.  The current bill “requires the Department of Labor to address workplace violence in the healthcare and social service sectors. Specifically, Labor must promulgate an occupational safety and health standard that requires certain employers in the health care and social service sectors, as well as employers in sectors that conduct activities similar to the activities in the health care and social service sectors, to develop and implement a comprehensive plan for protecting health care workers, social service workers, and other personnel from workplace violence.” [27]  In addition, employers must investigate workplace violence incidents, risks, or hazards; provide training and education to employees; and, meet record keeping requirements.  The bill also prohibits acts of discrimination or retaliation against employees for reporting workplace violence incidents, threats or concerns.

As of the publication of this article, H.R. 1309 remains in committee and has not been brought to a vote.

[11] Do zero tolerance policies deskill nurses, (Nursing Times, 2014).

[12] American Psychological Association Zero Tolerance Task Force, Are Zero Tolerance Policies Effective in Schools, (American Psychologist, 2008), 857.

[13] Brodie Paterson et. al., Discourse, Rhetoric and Failure: Zero Tolerance and Violence in Services for People with Mental Health Needs, (Mental Health Practice, 2008), 29-30.

[14] Sheridan Ryan, Healthcare Threat Management, 2.

[15] Gordon Lee Gillespie et. al., Implementation of a Comprehensive Intervention to Reduce Physical Assaults and Threats in the Emergency Department, (Journal of Emergency Nursing, 2014), 589-590.

[16] Linda Anderson et. al., An integrative literature review of interventions to reduce violence against emergency department nurses, (Journal of Clinical Nursing, 2010), 2528.

[17] Corinne Peek-Asa, et. al., Workplace Violence Prevention Programs in Hospital Emergency Departments, (Journal of Occupational and Environmental Medicine, 2007), 761.



[20] Occupational Safety and Health Administration, Preventing Workplace Violence in Healthcare,

[21] Occupational Safety and Health Administration, Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents, (OSHA Instruction, directive number: CPL 02-01-052, 2011).

[22] Occupational Safety and Health Administration, OSHA Investigation Finds Psychiatric Hospital Workers Remain Exposed to Serious Hazards, (OSHA News Release – Region 1, 2017).

[23] Occupational Safety and Health Administration, Prevention of Workplace Violence in Healthcare and Social Assistance. (Federal Register, 2016).

[24] The Joint Commission, Sentinel Event Alert 45 – Preventing violence in the healthcare setting, (2010, rev. 2019). 

[25] The Joint Commission, Sentinel Event Alert 59 – Physical and verbal violence against healthcare workers, (2018). 

[26] Kelly Gooch, Senator, hospitals seek federal plan to address workplace violence, (Becker’s Hospital Review, 2019).

[27] Susannah Luthi, Sen. Blunt pushes OSHA, CMS for plan to deal with hospital workplace violence, (Modern Healthcare, 2019).

[28] Workplace Violence Prevention for Health Care and Social Service Workers Act, H. R. 1309, 116th Cong. (2019-2020).