Violence in the Outpatient Setting: Tips for Keeping Healthcare Workers Safe

Physicians, nurses and other staff members are experiencing a significant and growing incidence of workplace violence in the outpatient office setting. In fact, healthcare workers suffer from higher rates of workplace violence than almost every other profession. It is estimated that between 8% and 38% of healthcare workers experience physical violence during their careers. Though it is uncommon, occasionally a violent incident will escalate, leading to serious injury or death for healthcare workers. More than twice as many healthcare workers reported harassment at work in 2022 than in 2018 – rising from 6% in 2018 to 13% in 2022.  

Workplace violence has been extensively studied in hospitals, yet far less is known about violence in outpatient settings. The heavy workloads and the work environment associated with outpatient facilities, which is often standalone buildings without security personnel, expose staff to an increased risk of violence.  

Workplace violence can take on many forms, including emotional, mental, verbal and physical harassment or abuse. It can even extend online in the form of cyberbullying and stalking. Violence directed toward healthcare staff often comes from patients or patients’ family members. It can also come from a colleague, supervisor or other co-worker, or even someone with whom they have a personal relationship, such as a partner or family member. 

The impact of harassment on healthcare workers’ mental health is substantial. Those who experience harassment at work are more likely to report feelings of anxiety, depression and burnout. The negative outcomes not only affect the healthcare worker but also trickle down to patient safety and satisfaction. Organizations also suffer consequences as a result of workplace violence, including liability risks, higher staff turnover and a damaged reputation. 

Healthcare workers tend to underreport violence because they subconsciously accept it as a part of the job. Additionally, they may be empathetic toward patients whose violent or abusive behavior is due to physical injury or mental incapacity. However, with the dramatic changes in medicine, including longer wait times, reduced face-to-face interaction, higher co-pays and deductibles, shrinking pharmacy formularies and endless bureaucracy, the environment is ripe for increased and sometimes misplaced anger against the healthcare community.  

Leaders of ambulatory care organizations have a duty to provide a safe environment for patients, visitors, providers and employees. The Occupational Safety and Health Act’s General Duty Clause requires employers to provide a workplace free from recognized hazards that are causing or likely to cause death or serious physical harm. Additionally, Joint Commission accreditation standards require leadership to develop and enforce a workplace violence prevention program. 

Below are strategies that leaders of ambulatory care organizations can implement to help keep providers and staff safe: 

1. Anticipation – One of the best ways to avoid a negative situation is to be aware it could occur. Teaching your staff to identify situations that could lead to a patient breakdown should be a priority. For example, communication between patient care staff and reception staff can keep waiting patients updated. A polite apology and explanation for long wait times can often diffuse frustration.
2. Organizational Tone – Clearly communicate that any violence against healthcare workers is unacceptable by establishing a zero-tolerance policy that extends to staff, patients and visitors. Enforce the policy with a strong, consistent response.
3. De-escalation Techniques – De-escalation protocols should be used for specific patient encounters. Using a combination of verbal and non-verbal techniques to build rapport with an agitated patient can be highly effective. Active listening, reflective language and creating a calm environment are key strategies. Having a patient support representative or office manager available can also help resolve these tense situations while allowing the physician to focus on patient care.
4. Environmental Design – Patient care layout is crucial. Reception staff should serve as gatekeepers to the patient care area. A physical distinction between the waiting area and patient rooms, such as a locked door operated electronically via office ID tag or remotely via button, can enhance security. Patients or visitors should only be allowed to enter under direct staff supervision. 
5. Video Surveillance Systems – Consider implementing external and internal continuous video surveillance. Important areas to monitor include reception desks, nurses’ stations, common patient thoroughfares and all entrances/exits to the building. Ensure compliance with state laws regarding audio/video surveillance in patient settings, including prohibiting surveillance in sensitive areas and posting notification signs in public areas.
6. Emergency Alert Plans – Establish situational awareness alert systems for both physicians and staff. Use a non-threatening code word or hand signal known only to staff to signal for help in the presence of an unstable situation. For example, asking staff to call for “Dr. Grey” can be a code for privately calling 911. If financially feasible, carrying a wireless panic button or installing one in each patient care room can also enhance safety. Additionally, having a medical staff member serve as a patient chaperone and witness can provide another layer of security.
7. Situational Awareness of Weapons – Weapons can enter the office setting both legally and illegally. Posting a weapons policy at the patient entrance that is consistent with state law should be strongly considered to protect staff and patients. Leadership should prepare staff to stay alert for an armed intruder or active shooter. At a minimum, every facility should have an emergency response plan and an established relationship with the local police department.
8. Practice Drills – Conduct regular drills to ensure all staff members are informed and prepared for worst-case scenarios. Professional trainers can serve as mentors to help healthcare staff handle these increasingly common situations. 
9. Culture of Trust – Create and maintain a culture where providers and staff trust one another and feel comfortable reporting issues without fear of repercussions. Encourage the reporting of physical and/or verbal abuse, as well as any suspicious behavior.

Additional resources include:

• MagMutual Video: Workplace Violence and Active Shooter Response
• OSHA Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers  
• CDC Workplace Safety & Health Topics: Occupational Violence
• AHRQ National Action Alliance for Patient and Workforce Safety 

For more information and guidance regarding office security, please reach out to us at [email protected] or call us at 1-800-282-4882.