Addressing the Challenge: Workplace Violence in LTC Setting

OSHA; Safety; Compliance; Regulations; Quality

Long term care (LTC) centers have always served as a place of comfort and safety for the elderly and individuals with disabilities, providing essential support and care in their daily lives. Unfortunately, in recent years, the issue of workplace violence in health care has gained increased national attention, and LTC centers are not immune. This article will cover some of the practical and regulatory issues with workplace violence in LTC settings, exploring its history, expectations, and anticipated action for prevention and intervention. It is essential that we understand this challenge and implement proactive measures.  


The Occupational Safety and Health Administration (OSHA) does not have, and has never issued, a formal workplace violence standard. Instead, since the late 1980s and early 1990s, OSHA has used the General Duty Clause to cite employers that do not follow basic workplace violence precautions. The clause states that “all employers have a duty to provide a place of employment “free from recognized hazards that are causing or are likely to cause death or serious injury.” 

Traditionally, even in LTC settings, workplace violence has always been thought of in terms of active-shooter scenarios or domestic violence extending into work, but increasingly, OSHA is focusing on a much more common occurrence: resident-on-employee violence. OSHA is currently in the process of creating a formal regulation to address resident behaviors in health care (the RFI is available here). However, because the timing of this new standard is not yet known, OSHA is trying to reduce instances of resident-on-employee violence by applying its General Duty Clause, which was previously covered in a previous article. Like in ergonomics, OSHA’s enforcement of the General Duty Clause for workplace violence is based on OSHA’s guidelines and expectations. As such, it is important to understand OSHA’s current expectations for prevention of workplace violence and anticipated action going forward. 

Current expectations: 

OSHA defines workplace violence broadly to include “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It can affect and involve workers, clients, customers, and visitors. [workplace violence] ranges from threats and verbal abuse to physical assaults and even homicide.” To reduce incidence of workplace violence, OSHA’s first recommendation is to develop a “zero-tolerance policy” covering staff, patients, visitors, and others, but that recommendation is difficult, if not impossible, to implement in most LTC settings. A more achievable expectation is to create a “Workplace Violence Prevention Program” to include a hazard analysis, control measures, training, and continued program re-evaluation.  

Hazard analysis can be completed on multiple levels, including as an entire facility, by unit, or by individual resident or patient. Facility-wide hazards might be, for instance, low lighting in certain areas or limitations for communication between staff. Resident-specific factors might include a history of violence, behaviors, or volatility. Fortunately, many LTC centers already complete resident-specific care plans that often identify a history of behaviors and implement interventions to address those behaviors. For all hazard assessments, OSHA recommends involving both facility management and staff. 

Controls will be highly dependent on the facility and resident population and, therefore, cannot be identified by a comprehensive list. 

Some examples from the hierarchy of controls might include: 

  • Substitution: While it may not always be possible, OSHA suggests that a facility’s best control might be “transferring a client or patient to a more appropriate facility” that is better suited to care for the resident and protection of others.  

  • Engineering: One control often mentioned in OSHA enforcement documentation is improving communication with other employees to call for help. In many instances, this might be a phone system, while in other high-risk settings, a panic button might be recommended. Additionally, OSHA often notes that improved monitoring and visibility can help reduce injuries due to violence, including surveillance cameras and positioning nursing stations in areas with high visibility. Like other controls, these engineering controls are highly facility specific and may not be necessary with certain resident populations. 

  • Work-practice and administrative: The primary work practice controls are resident-specific interventions, likely using care plans or trauma informed care. Additionally, staffing levels and turnover are frequently recognized risk factors. OSHA’s expectation is for a facility/community to have adequate and trained staff, possibly including security guards, to respond to a workplace violence event to minimize the potential for injury. Often, OSHA’s expectations for staffing can simply be having another employee within the area for easy communication to respond to a workplace violence event. 

  • Training: The most significant control for workplace violence is likely employee training. Training might include recognizing patient-specific risk factors, de-escalation techniques, and understanding when to call for help. In LTC centers with a population of mentally declining or incompetent individuals, including those with dementia, training on strategies to understand the patient’s mindset and challenges, like Hand-In-Hand training, might also be included in the Workplace Violence Prevention Program. 

In addition to hazard analysis and controls, OSHA recommends implementing a system for employees to report incidents and for those incidents to be investigated to determine the root cause. From those reports and investigations, further interventions or controls might be added to your Workplace Violence Prevention Program. 

More information on OSHA’s current expectations on workplace violence and worker safety in hospitals can be found on OSHA’s website, and in the following publications: 

Anticipated Action:

As stated above, OSHA is working through the “notice and comment” process to promulgate a workplace violence regulation specific to health care employers. That said, OSHA has not released an estimated date of issuance. In the meantime, the best preparation is likely to begin implementing a formal Workplace Violence Prevention Program, using the controls and interventions most appropriate for your facility. Those should create a solid foundation for any future OSHA regulation. 

Workplace violence in long term care settings demands attention and proactive measures. By prioritizing prevention, intervention, and support, facilities/communities can immediately create awareness, which fosters a safer environment for residents and staff.  This may include anything from implementing comprehensive violence prevention programs to simply training employees and encouraging a culture of safety. Operators should begin a process where long term care centers minimize the threat of workplace violence, ensuring that residents receive quality care and staff can fulfill their roles with confidence and security.