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U.S. Department of Labor Occupational Safety and Health Administration

OSHA 3148-01R 2004

This informational booklet provides a general overview of a particular topic related to OSHA standards. It does not alter or determine compliance responsibilities in OSHA standards or the Occupational Safety and Health Act of 1970. Because interpretations and enforcement policy may change over time, you should consult current OSHA administrative interpretations and decisions by the Occupational Safety and Health Review Commission and the Courts for additional guidance on OSHA compliance requirements.

This publication is in the public domain and may be reproduced, fully or partially, without permission. Source credit is requested but not required.

This information is available to sensory impaired individuals upon request. Voice phone: (202) 693-1999; teletypewriter (TTY) number: (877) 889-5627.


These guidelines are not a new standard or regulation. They are advisory in nature, informational in content and intended to help employers establish effective workplace violence prevention programs adapted to their specific worksites. The guidelines do not address issues related to patient care. They are performance-oriented, and how employers implement them will vary based on the site's hazard analysis.

Violence inflicted on employees may come from many sources— external parties such as robbers or muggers and internal parties such as coworkers and patients. These guidelines address only the violence inflicted by patients or clients against staff. However, OSHA suggests that workplace violence policies indicate a zero-tolerance for all forms of violence from all sources.

The Occupational Safety and Health Act of 1970 (OSH Act)(1) mandates that, in addition to compliance with hazard-specific standards, all employers have a general duty to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. OSHA will rely on Section 5(a)(1) of the OSH Act, the "General Duty Clause,"(2) for enforcement authority. Failure to implement these guidelines is not in itself a violation of the General Duty Clause. However, employers can be cited for violating the General Duty Clause if there is a recognized hazard of workplace violence in their establishments and they do nothing to prevent or abate it.

When Congress passed the OSH Act, it recognized that workers' compensation systems provided state-specific remedies for job-related injuries and illnesses. Determining what constitutes a compensable claim and the rate of compensation were left to the states, their legislatures and their courts. Congress acknowledged this point in Section 4(b)(4) of the OSH Act, when it stated categorically: "Nothing in this chapter shall be construed to supersede or in any manner affect any workmen's compensation law. . .."(3) Therefore, these non-mandatory guidelines should not be viewed as enlarging or diminishing the scope of work-related injuries. The guidelines are intended for use in any state and without regard to whether any injuries or fatalities are later determined to be compensable.

  • Extent of the problem:

The Bureau of Labor Statistics (BLS) reports that there were 69 homicides in the health services from 1996 to 2000. Although workplace homicides may attract more attention, the vast majority of workplace violence consists of non-fatal assaults. BLS data shows that in 2000, 48 percent of all non-fatal injuries from occupational assaults and violent acts occurred in health care and social services. Most of these occurred in hospitals, nursing and personal care facilities, and residential care services. Nurses, aides, orderlies and attendants suffered the most non-fatal assaults resulting in injury.

Injury rates also reveal that health care and social service workers are at high risk of violent assault at work. BLS rates measure the number of events per 10,000 full-time workers—in this case, assaults resulting in injury. In 2000, health service workers overall had an incidence rate of 9.3 for injuries resulting from assaults and violent acts. The rate for social service workers was 15, and for nursing and personal care facility workers, 25. This compares to an overall private sector injury rate of 2.

The Department of Justice's (DOJ) National Crime Victimization Survey for 1993 to 1999 lists average annual rates of non-fatal violent crime by occupation. The average annual rate for non-fatal violent crime for all occupations is 12.6 per 1,000 workers. The average annual rate for physicians is 16.2; for nurses, 21.9; for mental health professionals, 68.2; and for mental health custodial workers, 69. (Note: These data do not compare directly to the BLS figures because DOJ presents violent incidents per 1,000 workers and BLS displays injuries involving days away from work per 10,000 workers. Both sources, however, reveal the same high risk for health care and soical service workers.)

As significant as these numbers are, the actual number of incidents is probably much higher. Incidents of violence are likely to be underreported, perhaps due in part to the persistent perception within the health care industry that assaults are part of the job. Underreporting may reflect a lack of institutional reporting policies, employee beliefs that reporting will not benefit them or employee fears that employers may deem assaults the result of employee negligence or poor job performance.

  • The risk factors:

Health care and social service workers face an increased risk of work-related assaults stemming from several factors. These include:

The prevalence of handguns and other weapons among patients, their families or friends;

The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals;

The increasing number of acute and chronic mentally ill patients being released from hospitals without follow-up care (these patients have the right to refuse medicine and can no longer be hospitalized involuntarily unless they pose an immediate threat to themselves or others);

The availability of drugs or money at hospitals, clinics and pharmacies, making them likely robbery targets;

Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly;

Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly;

Low staffing levels during times of increased activity such as mealtimes, visiting times and when staff are transporting patients;

Isolated work with clients during examinations or treatment;

Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high-crime settings);

Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high-crime settings);

Poorly lit parking areas.

Overview of Guidelines

In January 1989, OSHA published voluntary, generic safety and health program management guidelines for all employers to use as a foundation for their safety and health programs, which can include workplace violence prevention programs.(5) OSHA's violence prevention guidelines build on these generic guidelines by identifying common risk factors and describing some feasible solutions. Although not exhaustive, the workplace violence guidelines include policy recommendations and practical corrective methods to help prevent and mitigate the effects of workplace violence.

The goal is to eliminate or reduce worker exposure to conditions that lead to death or injury from violence by implementing effective security devices and administrative work practices, among other control measures.

The guidelines cover a broad spectrum of workers who provide health care and social services in psychiatric facilities, hospital emergency departments, community mental health clinics, drug abuse treatment clinics, pharmacies, community-care facilities and long-term care facilities. They include physicians, registered nurses, pharmacists, nurse practitioners, physicians' assistants, nurses' aides, therapists, technicians, public health nurses, home health care workers, social workers, welfare workers and emergency medical care personnel. The guidelines may also be useful in reducing risks for ancillary personnel such as maintenance, dietary, clerical and security staff in the health care and social service industries.

Violence Prevention Programs

A written program for job safety and security, incorporated into the organization's overall safety and health program, offers an effective approach for larger organizations. In smaller establishments, the program does not need to be written or heavily documented to be satisfactory.

What is needed are clear goals and objectives to prevent workplace violence suitable for the size and complexity of the workplace operation and adaptable to specific situations in each establishment. Employers should communicate information about the prevention program and startup date to all employees.

  • At a minimum, workplace violence prevention programs should:

Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions. Ensure that managers, supervisors, coworkers, clients, patients and visitors know about this policy. Ensure that no employee who reports or experiences workplace violence faces reprisals.(6) Encourage employees to promptly report incidents and suggest ways to reduce or eliminate risks. Require records of incidents to assess risk and measure progress. Outline a comprehensive plan for maintaining security in the workplace. This includes establishing a liaison with law enforcement representatives and others who can help identify ways to prevent and mitigate workplace violence. Assign responsibility and authority for the program to individuals or teams with appropriate training and skills. Ensure that adequate resources are available for this effort and that the team or responsible individuals develop expertise on workplace violence prevention in health care and social services. Affirm management commitment to a worker-supportive environment that places as much importance on employee safety and health as on serving the patient or client. Set up a company briefing as part of the initial effort to address issues such as preserving safety, supporting affected employees and facilitating recovery.

  • Elements of an effective violence prevention program:

The five main components of any effective safety and health program also apply to the prevention of workplace violence:

Management commitment and employee involvement;

Worksite analysis;

Hazard prevention and control;

Hazard prevention and control;

Recordkeeping and program evaluation.

Hazard Prevention and Control

After hazards are identified through the systematic worksite analysis, the next step is to design measures through engineering or administrative and work practices to prevent or control these hazards. If violence does occur, post-incident response can be an important tool in preventing future incidents.

Engineering controls and workplace adaptations to minimize risk

Engineering controls remove the hazard from the workplace or create a barrier between the worker and the hazard. There are several measures that can effectively prevent or control workplace hazards, such as those described in the following paragraphs. The selection of any measure, of course, should be based on the hazards identified in the workplace security analysis of each facility.

Administrative and work practice controls to minimize risk

Administrative and work practice controls affect the way staff perform jobs or tasks. Changes in work practices and administrative procedures can help prevent violent incidents. Some options for employers are to: State clearly to patients, clients and employees that violence is not permitted or tolerated. Establish liaison with local police and state prosecutors. Report all incidents of violence. Give police physical layouts of facilities to expedite investigations. Require employees to report all assaults or threats to a supervisor or manager (for example, through a confidential interview). Keep log books and reports of such incidents to help determine any necessary actions to prevent recurrences. Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do so, if necessary. Provide management support during emergencies. Respond promptly to all complaints. Set up a trained response team to respond to emergencies. Use properly trained security officers to deal with aggressive behavior. Follow written security procedures. Ensure that adequate and properly trained staff are available to restrain patients or clients, if necessary. Provide sensitive and timely information to people waiting in line or in waiting rooms. Adopt measures to decrease waiting time. Ensure that adequate and qualified staff are available at all times. The times of greatest risk occur during patient transfers, emergency responses, mealtimes and at night. Areas with the greatest risk include admission units and crisis or acute care units. Institute a sign-in procedure with passes for visitors, especially in a newborn nursery or pediatric department. Enforce visitor hours and procedures. Establish a list of "restricted visitors" for patients with a history of violence or gang activity. Make copies available at security checkpoints, nurses' stations and visitor sign-in areas. Review and revise visitor check systems, when necessary. Limit information given to outsiders about hospitalized victims of violence. Supervise the movement of psychiatric clients and patients throughout the facility. Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas. Prohibit employees from working alone in emergency areas or walk-in clinics, particularly at night or when assistance is unavailable. Do not allow employees to enter seclusion rooms alone. Establish policies and procedures for secured areas and emergency evacuations. Determine the behavioral history of new and transferred patients to learn about any past violent or assaultive behaviors. Establish a system—such as chart tags, log books or verbal census reports—to identify patients and clients with assaultive behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed. Treat and interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (such as rooms with removable partitions). Use case management conferences with coworkers and supervisors to discuss ways to effectively treat potentially violent patients. Prepare contingency plans to treat clients who are "acting out" or making verbal or physical attacks or threats. Consider using certified employee assistance professionals or in-house social service or occupational health service staff to help diffuse patient or client anger. Transfer assaultive clients to acute care units, criminal units or other more restrictive settings. Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients. Discourage employees from wearing necklaces or chains to help prevent possible strangulation in confrontational situations. Urge community workers to carry only required identification and money. Survey the facility periodically to remove tools or possessions left by visitors or maintenance staff that could be used inappropriately by patients. Provide staff with identification badges, preferably without last names, to readily verify employment. Discourage employees from carrying keys, pens or other items that could be used as weapons. Provide staff members with security escorts to parking areas in evening or late hours. Ensure that parking areas are highly visible, well lit and safely accessible to the building. Use the "buddy system," especially when personal safety may be threatened. Encourage home health care providers, social service workers and others to avoid threatening situations. Advise staff to exercise extra care in elevators, stairwells and unfamiliar residences; leave the premises immediately if there is a hazardous situation; or request police escort if needed. Develop policies and procedures covering home health care providers, such as contracts on how visits will be conducted, the presence of others in the home during the visits and the refusal to provide services in a clearly hazardous situation. Establish a daily work plan for field staff to keep a designated contact person informed about their whereabouts throughout the workday. Have the contact person follow up if an employee does not report in as expected.

Employer responses to incidents of violence

Post-incident response and evaluation are essential to an effective violence prevention program. All workplace violence programs should provide comprehensive treatment for employees who are victimized personally or may be traumatized by witnessing a workplace violence incident. Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of its severity. Provide the injured transportation to medical care if it is not available onsite.

Victims of workplace violence suffer a variety of consequences in addition to their actual physical injuries. These may include: Short- and long-term psychological trauma; Fear of returning to work; Changes in relationships with coworkers and family; Feelings of incompetence, guilt, powerlessness; and Fear of criticism by supervisors or managers. Consequently, a strong follow-up program for these employees will not only help them to deal with these problems but also help prepare them to confront or prevent future incidents of violence.

Several types of assistance can be incorporated into the post-incident response. For example, trauma-crisis counseling, critical-incident stress debriefing or employee assistance programs may be provided to assist victims. Certified employee assistance professionals, psychologists, psychiatrists, clinical nurse specialists or social workers may provide this counseling or the employer may refer staff victims to an outside specialist. In addition, the employer may establish an employee counseling service, peer counseling or support groups.

Counselors should be well trained and have a good understanding of the issues and consequences of assaults and other aggressive, violent behavior. Appropriate and promptly rendered post-incident debriefings and counseling reduce acute psychological trauma and general stress levels among victims and witnesses. In addition, this type of counseling educates staff about workplace violence and positively influences workplace and organizational cultural norms to reduce trauma associated with future incidents.

Safety and Health Training

Training and education ensure that all staff are aware of potential security hazards and how to protect themselves and their coworkers through established policies and procedures.

Training for all employees

Every employee should understand the concept of "universal precautions for violence"— that is, that violence should be expected but can be avoided or mitigated through preparation. Frequent training also can reduce the likelihood of being assaulted.

Employees who may face safety and security hazards should receive formal instruction on the specific hazards associated with the unit or job and facility. This includes information on the types of injuries or problems identified in the facility and the methods to control the specific hazards. It also includes instructions to limit physical interventions in workplace altercations whenever possible, unless enough staff or emergency response teams and security personnel are available. In addition, all employees should be trained to behave compassionately toward coworkers when an incident occurs.

The training program should involve all employees, including supervisors and managers.

New and reassigned employees should receive an initial orientation before being assigned their job duties. Visiting staff, such as physicians, should receive the same training as permanent staff. Qualified trainers should instruct at the comprehension level appropriate for the staff. Effective training programs should involve role playing, simulations and drills.

Topics may include management of assaultive behavior, professional assault-response training, police assault-avoidance programs or personal safety training such as how to prevent and avoid assaults. A combination of training programs may be used, depending on the severity of the risk.

Employees should receive required training annually. In large institutions, refresher programs may be needed more frequently, perhaps monthly or quarterly, to effectively reach and inform all employees.

1.    Violence Prevention Plan:   A violence prevention plan may help reduce workplace violence in healthcare facilities, according to the USDL. These plans should be created by administration, but should be made available to all employees of the facility. Specific training on its contents should be given to all employees, as well. These plans reflect the level of threat in the facility, making employees aware of what they face. A "zero-tolerance" policy toward workplace violence should be adopted and made clear in the prevention plan. State clearly in the plan that no reprisals will be taken against employees reporting violence. These assurances will promote prompt reporting of workplace violence.

Employee and Management Commitment:   Employee and management commitment are essential to an effective violence prevention plan, according to the USDL. This commitment will make employees feel like they are working on a team with management to reduce violence. Clear policies regarding violence and training to teach employees the benefits of reporting violence will help bolster confidence, which will in turn increase commitment to the violence prevention plan.

Analysis:   Healthcare facilities should be analyzed for possible threats, according to the USDL. Look for the availability of money and drugs in the pharmacy area, as this is a likely place for robbery. Measure employees' exposure to mentally unstable patients and make sure employees are trained to deal with possible outbursts. Analyze employee turnover and stress, as these factors can lead to tired or angry workers.

Safety and Health Training: Train employees to deal with threats quickly, as not all workplace violence can be avoided. Training should include conflict resolution and how to control anger, according to the USDL. Victim support techniques and self-defense should be taught, as well.

Post-Incident: Employees and management should be trained on what to do if they are a victim of or witness to workplace violence, according to the USDL. A support program for victims should be in place in healthcare facilities, as without support, employees may be afraid to resume working. Victims should be treated promptly after an incident, both with needed medical treatment and a psychological evaluation.

Health and social care workers:

Have a right to expect a safe and secure workplace. But reports indicate that they can be up to four times more likely to experience work-related violence and aggression than other workers.

The term ‘violence’ covers a wide range of incidents, not all of which involve injury.

HSE defines work-related violence as: ‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.’

Staff should not accept incidents of aggression or violent behavior as a normal part of the job. Employers and employees should work together to establish systems to prevent or reduce aggressive behavior.What you need to know

In both the health and social care sectors, violence and aggression is the third biggest cause of major injuries and over-3-day injuries reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). Slips and trips and manual handling are the first and second most frequent.
In healthcare, HSE received 1414 major and over-3-day injury reports as a result of physical assaults in 2009/10. This is a small decrease from the 2008/09 figure of 1423. In social care, HSE received 980 major and over-3-day injury reports as a result of physical assaults.

There is a high level of non-reporting within this sector, as many accept acts of aggression as part of the job. We know this because of the huge difference in numbers of RIDDOR reports collected by HSE and data collected by NHS Protect. [1]

NHS Protect [2] collects data on the number of physical assaults from NHS organisations in England. In 2009/10 there were 56,718 assaults, up from 54,758 in the previous year, a rise of 3.5%. Some 38,959 were in the mental health and learning disability sector, 13,219 were in acute hospitals and 1,262 were against ambulance staff. Another 3,278 occurred in primary care, including GP surgeries.The main factors that can create a risk

The main factors that can lead to violent or aggressive behaviour and create a risk for employees are:

·         inherent aggression or mental instability

·         impatience (due to waiting, lack of information or boredom)

·         frustration (due to lack of information or boredom)

·         anxiety (lack of choice, lack of space)

·         resentment (lack of rights)

·         alcohol and drugs

·         poor design of premisesWhat the law says

Health and safety law applies to risks from violence, just as it does to other risks from work activity. Relevant legislation includes:

·         The Health and Safety at Work etc Act 1974. [3]Employers have a legal duty under this Act to ensure, so far as it is reasonably practicable, the health, safety and welfare at work of their employees.

·         The Management of Health and Safety at Work Regulations 1999[4]. Employers must consider the risks to employees (including the risk of reasonably foreseeable violence); decide how significant these risks are; decide what to do to prevent or control the risks; and develop a clear plan to achieve this.

·         The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR). [5]Employers must notify their enforcing authority in the event of an accident at work to any employee resulting in death, major injury, or incapacity for normal work for more than three days. This includes any act of non-consensual physical violence to a person at work. What you need to do

If risks from violence and aggression are to be managed successfully, there must be support from those at the top of the organisation, no matter what size. This can be expressed in a clear statement of policy, supported by organisational arrangements, to ensure that the statement is implemented. Key elements include:

·         recognition of the risks

·         commitment to introducing precautions to reduce that risk

·         a statement of clear roles and responsibilities

·         an explanation of what is expected from individual employees

·         a commitment to supporting people who have been assaulted or suffered verbal abuse Should I complete a risk assessment?

You must manage the health and safety risks in your workplace. If there is a risk of violence and aggression or challenging behaviour in your organisation, you must manage that risk. To do this you should undertake a risk assessment, which will help you to:

·         identify violence and aggression hazards

·         evaluate violence and aggression risks

·         implement, monitor and review measures to reduce the risk

The risk assessment process for managing the risks of violence and aggression may not be as straightforward as that of other risk assessments you have completed. You may need to have a number of different types of risk assessment in place, for example:

·         generic risk assessments

·         individual person risk assessments

·         unit / departmental risk assessments 

It is important to involve all staff (clinical and others) in the risk assessment process. Generic risk assessments

These assessments should consider the overall needs of the organisation, for example:

·         general risks to staff from patients, service users and their relatives or visitors

·         risks associated with the design of the work environment, ie layout of rooms, alarm systems, access to car parks at night

·         risks associated with lone working, whether working in the community or alone in work premises

·         identification of appropriate instructions, information and training Individual risk assessments

Where individuals pose a risk of violence and aggression, an individual risk assessment should be completed and regularly reviewed as part of the care planning process. This should consider:

·         the mental, emotional and physical condition of the person

·         the effect of  medical conditions or ingestion of drugs, alcohol or medicines

·         their stress levels

·         whether they have a history of challenging, violent or aggressive behaviour

·         whether they consider others a threat

All staff likely to be exposed to potentially violent individuals should know the potential trigger situations and the prevention measures identified by the risk assessment. These should be recorded in the person’s care plan. Particular care is needed when:

·         new members of staff or agency staff are involved

·         new people are admitted, especially those with a history of challenging behaviour

·         there has been a change in a person’s mental or physical state, medication, behaviour, mood etcUnit / departmental risk assessments 

Organisations with several units or departments may need to have specific risk assessments for different departments. They may have different risks and therefore require different control measures.

HSE has guidance on completing risk assessments [6]to help you assess the risks in your workplace. Identifying control measures  

Identify appropriate control measures as part of your risk assessment process. Suggested precautions you can take to help prevent or control aggression / violence towards staff are given below. (This is not an exhaustive list and it is important to make sure the measures identified adequately control the risks in your organisation.)  Work activities and communication

·         Consider the jobs people do and how they are done. For example, do cleaners and caterers come into contact with people that present challenging behaviour?

·         Provide clear instructions – verbal or written.

·         Ensure appropriate training at the right level to help staff work safely when dealing with potentially aggressive or violent people.

·         Ensure suitable systems are in place for recording and exchanging information about patients, service users and, potentially, their relatives (individual risk assessments, handover briefings, indicators on care plans, prompts in bedrooms etc).

·         Ensure adequate staffing levels according to level of risk. Do certain times of the day present a higher risk of challenging behaviour, ie bathing or meal times?

·         Respond to and record incidents appropriately.

·         Manage new patients or service users – check you have the right information about any violent behaviour at referral, and share it early with staff.

·         If staff make community visits, make sure you have appropriate procedures in place, ie leaving lists of visits and regular telephone contact.Work environment

·         Ensure the work environment is as safe and secure as possible to reduce the risk of violence and aggression. Risk assessments should consider:

·         good visibility – open spaces and reduced trapping points

·         diffused and glare-free lighting

·         arranging seats in clusters rather than ranks

·         plants and pictures (firmly fixed to prevent use as weapons)

·         locking buildings when staff are working on their own or at night

·         access to car parks and isolated areas

·         security systems such as fixed alarms or personal alarms. Are these regularly tested and maintained?  Training

Training in the prevention and management of violence / aggression can provide staff with appropriate skills to reduce or defuse potential incidents. Training should be available to all employees in contact with service users, including ancillary staff such as cleaners, maintenance, temporary or agency staff.

The right level of training will be identified through your risk assessment process. Basic training in the principles of managing challenging behaviour should include:

·         causes of violence

·         recognition of warning signs

·         relevant interpersonal skills, ie verbal and non-verbal communication

·         de-escalation techniques

·         details of local working practices and control measures

·         incident reporting procedures

Note: In England, NHS Protect [7] provides specific guidance on the training requirements for NHS staff.    

All staff who have the potential to be involved in an aggressive incident should receive the basic level of training. However, you must ensure the level of training provided to staff reflects the specific needs of their work activities. For example, those caring for people:

·         who present a low risk of aggressive behaviour – may only require basic training

·         with dementia – may need specific dementia awareness training as well as basic training

·         who present a serious risk of physical aggression – may need training in physical intervention techniques as well as basic training

Confidence and capability are important when dealing with a potentially aggressive or violent incident. Staff will need refresher training from time to time to update their skills. Training requirements should be documented. Are incidents of violence reportable under RIDDOR?

Many staff accept incidents of violence and aggression as ‘part of the job’ and may need encouragement to report incidents, particularly those that don’t cause serious injury, such as hair pulling, pinching or verbal abuse.

For detail on what incidents are reportable under the RIDDOR visit the RIDDOR website[8].

Although not all incidents of violence and aggression are reportable under RIDDOR, it is important that staff report all incidents and understand why this is important. For example, quite often a number of minor incidents can escalate to a major incident. 
Helping staff after an incident

It can be useful to bring staff together after an incident to discuss what happened. This process of debriefing has two potential functions: to establish the details of what happened; and to provide emotional help and support. It is sometimes appropriate to supplement debriefing with confidential counselling.

You may improve staff morale and confidence if there is a visible, genuine commitment from employers to pursue prosecution in cases of serious assault.Further guidanceCase studies

These case studies were developed by the Health and Safety Laboratory (HSL). They demonstrate how employers have actually tackled the problem of violence to lone workers. Small businesses

·         Health Centre[9]

·         Drop-in Centre[10]Lone working

·         Community midwives[11]

·         Community mental health staff[12]

·         Social workers / personal care assistants[13]Work with other organisations

NHS Protect content [14] (previously NHS Security Management Service) leads on work to identify and tackle crime across the health service. The aim is to protect NHS staff and resources from activities that would otherwise undermine their effectiveness and their ability to meet the needs of patients and professionals.

HSE recognises NHScontent Protect [15]as an influential stakeholder in tackling the risks of violence in healthcare services in England. As a result we have a concordat with NHS Protect which provides a framework to enable liaison and co-operation between the two organisations on areas of mutual interest.

Through national and local liaison meetings, we identify opportunities for joint working and share information and intelligence about practices across the NHS. HSE contributes to NHS Protect’s evolving guidance for the NHS on managing the risks of violence [16].

We are committed to continue with our collaborative activities with contentNHS Protect [17]. We believe that this will contribute to significant improvements in tackling the risks of violence against NHS staff and ultimately create a safer working environment.

Partnership for Occupational Safety and Health in Healthcare (POSHH)

The Partnership for Occupational Safety and Health in Healthcare [18] is the occupational health and safety sub-group of the NHS Staff Council. The membership of the POSHH sub-group includes NHS employers plus:

·         representatives nominated to reflect the variety of healthcare settings within the NHS and the independent sector

·         representatives from Amicus, BMA, CSP, RCN, Unison, SOR and RCM

·         attending advisers, including HSE, NHS Protect, Independent Healthcare Advisory Services and NHS Litigation Authority


 Violence at work

·         A guide for employers AT WORK a guide for employers

·         This is a web-friendly version of leaflet INDG69(rev), revised

·         People who deal directly with the public may face aggressive or violent behavior. They may be sworn at, threatened or even attacked.

·         This document gives practical advice to help you find out if violence is a problem for your employees, and if it is, how to tackle it. The advice is aimed at employers, but should also interest employees and safety representatives.

·         Violence is ...

·         The Health and Safety Executive’s definition of work-related violence is:

·         ‘Any incident, in which a person is abused, threatened or assaulted in circumstances relating to their work’.

·         Verbal abuse and threats are the most common types of incident. Physical attacks are comparatively rare.

·         Who is at risk?

·         Employees whose job requires them to deal with the public can be at risk from violence. Most at risk are those who are engaged in:

·         ■ giving a service

·         ■ caring

·         ■ education

·         ■ cash transactions

·         ■ delivery/collection

·         ■ controlling

·         ■ representing authority


·         Is it my concern?

·         Both employer and employees have an interest in reducing violence at work. For employers, violence can lead to poor morale and a poor image for the organization, making it difficult to recruit and keep staff. It can also mean extra cost, with absenteeism, higher insurance premiums and compensation payments. For employees, violence can cause pain, distress and even disability or death. Physical attacks are obviously dangerous but serious or persistent verbal abuse or threats can also damage employees’ health through anxiety or stress.

·         1 of 7 pages Health and Safety Executive