Back to Basics is an article series that highlights important, but possibly overlooked, information facilities management professionals should know.
While some workers and workplaces face higher risks of violence, it can happen to any worker in any work setting.
Earlier this year, the Bureau of Labor Statistics (BLS) reported that violent acts were the third-leading cause of fatal occupational injuries in the United States. Of the 5,283 fatal workplace injuries in 2023, 740 fatalities were due to violent acts, according to the BLS’s Census of Fatal Occupational Injuries (CFOI). Homicides (458) accounted for 61.9% of violent acts and 8.7% of all work-related fatalities.
Certain factors may increase the risk of violence for some workers at certain worksites, according to research cited by the Occupational Safety and Health Administration (OSHA). These factors can include exchanging money with the public and working with volatile, unstable people. Working alone or in isolated areas may also contribute to the potential for violence, as well as providing services and care and working where alcohol is served.
Even the time of day and location of work, such as working late at night or in areas with high crime rates, are risk factors. Workers like delivery and taxi/rideshare drivers, healthcare professionals, social workers, public service workers, customer service agents, and law enforcement personnel may be at higher risk.
While there’s no federal occupational safety and health hazard for workplace violence prevention, OSHA and the National Institute for Occupational Safety and Health (NIOSH) do provide employer guidance.
OSHA suggests that one of the best protections is to establish a “zero-tolerance” policy toward workplace violence, covering all workers, patients, clients, visitors, contractors, and anyone else who may encounter employees.
Establishing and implementing a well-written workplace violence prevention program, along with engineering controls, administrative controls, and training, can reduce the potential for workplace violence.
In 2024, NIOSH researchers analyzed trends in workplace and non-workplace homicides using BLS and Federal Bureau of Investigation (FBI) data. They found that both workplace and non-workplace homicides in the United States had declined for over 30 years until recently. Both decreased significantly from 1994 through 2014; however, while workplace homicides showed no significant trend from 2014 through 2021, non-workplace homicides showed a significant average annual increase of 4.1% from 2014 through 2020. Decreases in workplace homicides during a criminal act, such as robbery, leveled off and started to increase by the end of the study period (2021). Criminal activities, such as robbery, appear to be the largest contributor to recent increases in workplace homicides.
Men were three times more likely than women to die of workplace homicides, NIOSH researchers found. The rate of workplace homicides was highest among black workers, followed by Hispanic and white workers.
The occupation with the highest rate of workplace homicides was protective services, with 2.74 homicides per 100,000 employees in 2021. Taxi drivers and chauffeurs were second highest, followed by retail sales.
The industry with the highest rate of workplace homicides was gasoline stations, with 5.55 homicides per 100,000 employees.
Earlier this year, the Washington State Department of Labor and Industries issued a worker hazard alert for gas station convenience store workers. Killings at gas stations represented 31% of deadly intentional violence in all retail industries, with 75% done by robbers who shot their victims in most cases, according to the alert.
According to the state Fatality Assessment & Control Evaluation (FACE) program, protecting cashiers involves implementing a written violence prevention program, robbery response training, and effective store security features.
The FACE program recommends that convenience stores:
- Conduct a store security assessment to identify hazards, conditions, operations, and situations that could lead to violence.
- Avoid scheduling employees to work alone, and improve store layout, lighting, visibility, video, cash limit signage, cash control methods, and incident tracking.
- Develop a workplace violence prevention program with clear, store-specific policies. Policies can be part of a store’s standard operating procedures (SOPs), step-by-step instructions in a stand-alone document, or part of an employee handbook.
- Establish prevention policies that cover how to lock doors and storage areas; making sure lights, panic buttons, alarms, and surveillance systems work properly; not engaging robbers or resisting their demands; calling 911 and store management; and making frequent cash deposits using “dropsafes” to minimize cash kept in the register.
- Conduct training that covers where all exits, alarms, panic buttons, and emergency information are located; how to look for signs that a robbery or violent attack is about to happen; how to de-escalate an emerging robbery situation; and how to render first aid.
Confronting Workplace Violence
Workplace violence can take and has taken a variety of forms, including an active shooter showing up at a facility; a gunman coming to rob a convenience store; an employee’s ex-spouse or partner trespassing at the workplace looking for revenge; difficult patients, clients, or patients’ families assaulting a healthcare or social worker; or a recently terminated employee returning to the workplace to settle a score.
While there’s no current federal standard for workplace violence prevention, OSHA cites employers, often after an incident of workplace violence, using its authority under the General Duty Clause of the Occupational Safety and Health Act. However, the independent Occupational Safety and Health Review Commission hasn’t always affirmed the agency’s General Duty Clause citations.
California has its own workplace violence prevention standard for health care, and the state Division of Occupational Safety and Health (Cal/OSHA) is working on developing a workplace violence prevention standard for general industry (non-healthcare settings). The state Occupational Safety and Health Standards Board (OSHSB) must adopt a standard no later than December 31.
California’s workplace violence prevention in health care standard applies to the following healthcare facilities and operations:
- Health facilities;
- Home health care and home-based hospice;
- Emergency medical services and medical transport, including those services provided by firefighters and other emergency responders;
- Drug treatment programs; and
- Outpatient medical services to the incarcerated in correctional and detention settings.
The requirements of California’s standard include a workplace violence prevention plan, a violent incident log, other recordkeeping, training, and plan review.
The state agency has a collection of educational materials and other resources for employers.
Federal guidance available on the OSHA website includes the following:
- “Recommendations for Workplace Violence Prevention Programs in Late-Night Retail Establishments” (OSHA 3153-12R, 2009)
- “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers” (OSHA 3148-06R, 2016)
OSHA also has a “How to Prevent Robbery and Violence” fact sheet for taxi drivers and a web page for worker safety at hospitals titled “Preventing Workplace Violence in Healthcare.” The agency’s 2017 “Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence” directive details how OSHA personnel conduct workplace inspections for workplace violence controls.
OSHA’s workplace prevention in healthcare and social services guidelines recommend establishing programs that include management commitment and employee participation, worksite hazard analysis, hazard prevention and control methods, safety and health training, recordkeeping, and program evaluation.
High-risk healthcare and social services work settings include the following:
- Hospitals and other institutional medical facilities;
- Residential treatment facilities, including alcohol and drug addiction treatment facilities, nursing homes, psychiatric facilities, and other long-term care facilities;
- Nonresidential treatment or services facilities, such as small neighborhood clinics and mental health centers;
- Community care facilities like community-based residential facilities and group homes; and
- Fieldwork, such as home healthcare or social services home visits.
Risk factors for healthcare and social services workers include working in neighborhoods with high crime rates, working directly with gang members or people who have a history of violence or drug use, and working alone in patients’ homes or poorly designed facilities where employees’ line of sight or route of escape is blocked.
Engineering controls in a hospital or residential care facility can be some of the most effective prevention measures, according to OSHA. Examples of controls include the following:
- Closed-circuit cameras inside and outside a facility, curved mirrors, and glass panels in doors and walls for better monitoring;
- Metal detectors or hand-held wands, with staff trained to use the equipment and remove weapons;
- Lockable doors that limit access to unused rooms;
- Proper placement of nurses’ stations, allowing visual scanning of corridors and other areas;
- Silent or other security alarm systems, such as panic buttons or paging systems at workstations and personal alarm devices worn by employees;
- Reception desks enclosed in bulletproof glass, deep counters at nurses’ stations, and secure bathrooms for staff members that are separate from patient/client and visitor facilities, with locks on the inside; and
- Wherever possible, having two exits from patient or treatment rooms, furniture arranged to allow clear exit routes for employees, and employee “safe rooms” for emergencies.
In all industries, effective engineering controls include door locks and physical barriers like enclosures with bulletproof glass, monitoring systems and panic buttons, and accessible exits and additional lighting.
When engineering controls are infeasible, healthcare facilities can implement certain administrative controls and safe work practices. Hospitals and residential treatment facilities sometimes use trained security officers and counselors who respond to aggressive behavior and disarm or de-escalate patients or visitors when necessary. Patients with a known history of violence can be supervised throughout a facility, and staff should be informed during shift changes of patients’ violent histories or incidents.
The Joint Commission, an organization that accredits hospitals and healthcare facilities receiving reimbursements from Medicaid, Medicare, or private insurers, has its own workplace violence standard for healthcare facilities seeking certification. The Joint Commission revised its standard in 2022. Like OSHA’s voluntary guidelines, aspects of the Joint Commission’s standard include organizational and management support for workplace violence prevention, non-management stakeholder engagement, education and training, and data-driven analysis and evaluation.
The American Society of Safety Professionals (ASSP) released a technical report in 2019 on developing and implementing active shooter/armed assailant plans (ASSP TR-Z590.5-2019). The group recommends performing a risk assessment, developing employee communication and training, having incident response and post-incident procedures, and implementing ongoing program audits.
The Department of Homeland Security (DHS) has an “Active Shooter: How to Respond” booklet available on its website and cautions that active shooter situations are unpredictable and can quickly evolve. Active shooter situations are often over within 10 to 15 minutes, before law enforcement officers can arrive. The Federal Emergency Management Agency’s (FEMA) Emergency Management Institute offers a web-based “Active Shooter: What You Can Do” course for non-law enforcement staff, employees, and volunteers. The Cybersecurity & Infrastructure Security Agency (CISA) has its own “Active Shooter Preparedness” approach.
You may want to perform a hazard analysis to determine whether you need a workplace violence prevention program in your workplace.