Danielle Pierotti, PhD, RN
The high-profile murders of Joyce Grayson, LPN, in Connecticut, and Douglass Brandt, RN, in Washington shook us all. However, once the shock wore off, we were tempted to excuse it, believing these extreme incidences are so rare that they do not pose a risk. There are approximately 600 million annual home health visits by Medicare-certified agencies alone (Ankota, 2025). Death is rare. The risk is not.
What is WPV?
The Occupational Safety and Health Administration (OSHA) defines workplace violence (WPV) as “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site.” (OSHA, 2012) This definition encompasses all varieties of verbal abuse, physical and sexual threats or acts.
Prevalence of WPV in home health
Workplace violence (WPV), encompassing physical, verbal, psychological, and sexual assault, is a prevalent issue in all healthcare settings, including home healthcare. The data on WPV in health care and home health care is consistent, with rates on the rise nationally and globally. Studies report that up to 87% of home healthcare workers have experienced WPV during their careers (Phoo & Reid, 2022). Healthcare and social assistance professionals consistently suffer the highest number and rate of workplace violence, with women experiencing almost five times as many instances as men (BLS 2018, 2022). Efforts to quantify the experience of violence in health care are limited by poor confidence due to underreporting (Phoo & Reid, 2022; Zhong & Shorey, 2023). Between 18% to 65% of home healthcare workers have experienced verbal abuse, 3% to 44% have reported physical abuse, and up to 41% have experienced some form of sexual abuse from patients or other people in the home during visits (Felice et al., 2021).
Who poses a high risk for WPV in home health?
Patients and family members who pose a high risk for committing violence against home health care workers include those with dementia and other forms of cognitive impairment, uncontrolled psychiatric disorders, uncontrolled pain, active drug addictions, and those experiencing overwhelming stress (Ma & Thomas, 2023; Felice et al., 2021; Huckenpahler & Gold, 2022). Home health workers regularly care for people in all these categories, often more than one. Additionally, they are entering unknown, uncontrolled environments alone. Homes include weapons, animals, and other people. Despite asking patients to control the environment and reduce the risk to the healthcare worker, this is not a reliable safety mechanism. People have varying levels of tolerance. Patients may assert that a gun is controlled because the safety is on or believe that their pet poses no risk. Nevertheless, combined with poor lighting, memory, confusion, the effect of medications, or generalized fear, both guns and animals can inflict harm. The isolation of home-based care adds to the risk. There are no witnesses, no one to call for help, unpredictable exits, and, in rural areas, unreliable phone coverage.
Why many workers tolerate or excuse WPV
Home healthcare workers are prone to tolerating WPV and even excusing it. Ideas that violence is part of the job, that it is not the patient’s fault or intention, and that nursing ethics obligates them not to abandon a patient are cited as reasons for underreporting (Kim et al., 2022; Zhong & Shorey, 2023). Cultural issues complicate the identification of WPV. Verbal abuse is mainly subjective. Current divisions in society create more significant risks for many groups of workers struggling to manage experiences of violence at work and home. Economic pressures to keep a job can overwhelm many home health workers.
Duration and consequences of WPV
The experience of WPV can be a single event or an ongoing experience. Verbal abuse is the most commonly reported experience. Verbal abuse includes a wide variety of experiences from aggressive language to personal insults and threats to cause other harm. The repetitive and, at times, long-term nature of home-based care can leave a worker under continuous stress and result in a myriad of issues. Physical injuries, primarily musculoskeletal, are common. Long-term back injuries and pain can impair a worker’s life. WPV results in emotional and psychological trauma. Depression, anxiety, and the long-term effects of trauma cause suffering and lead to more physical ailments, disengagement, poor-quality care, burnout, and resignations (Lim et al., 2022; Menendez et al., 2024). For the agency, these injuries are costly. Lost work, poor quality of care, missed visits, worker’s compensation claims, and turnover pose a significant financial impact (AHA, 2024).
Organizations can change WPV
Workplace violence in home health is a complex, multifaceted phenomenon. It’s influenced by physical illness, economic conditions, and cultural changes. But it’s also something we can change. By working together, patients, workers, agencies, and the system can influence the risk and occurrence of workplace violence. None of the causes of workplace violence act in isolation. The risk for workplace violence cannot be reduced to an algorithm or math problem. It’s the result of the interplay of many factors. But it’s also something we can address. It’s understudied, underreported, poorly defined, and causes suffering. But it’s also something we can change.
Knowing that there is widespread suffering is enough to take action. In WPV, the worker and often the patient perpetrating the violence are suffering. Regardless of the incomplete evidence, home healthcare agencies, including all members of leadership and all levels of workers, can take action to reduce the incidence and experience of WPV.
Incorporate quality improvement for addressing WPV
A quick internet search reveals dozens of tools to provide specific guidance steps to tackle WPV in home health. In general, each approach is a variation of a quality improvement process:
- Start by gathering a group of people to collaborate.
- Ensure leadership commitment to the work.
- Assess what is known in the literature and what you know about your specific agency.
Then, start making changes:
- Write a policy to define and report the experiences of WPV.
- Design classes to teach workers how to protect themselves and identify and reduce risk.
- Find ways to change dangerous cultural beliefs, such as “nurses need to accept this.”
- Consider how technology can improve safety by knowing where workers are and how to stay in contact with them.
- Partner with local law enforcement to learn skills and develop safety plans.
- Improve communication with referral sources.
- Invest in emotional support for workers and make it easy and normal to talk about WPV.
- Examine time off policies to support recovery.
- Talk with the community about the risks and engage local advisors.
These suggestions can get home health nurse leaders started. When the goal is to keep everyone safe, no idea is bad. Every step can reduce the risk of WPV, reduce suffering from WPV, and ultimately improve patient care. Recognizing that WPV is high risk and occurs every day in home health care is the critical first step. Remembering Joyce Grayson, LPN, and Douglass Brandt, RN, is important. Honoring them with action makes an impact.
References:
American Hospital Association (AHA). (2024, June 1). Fact sheet: Workplace violence and intimidation, and the need for a federal legislative response. Aha.org. Retrieved January 12, 2025, from https://www.aha.org/fact-sheets/2023-04-19-fact-sheet-workplace-violence-and-intimidation-and-need-federal-legislative-response
Ankota. (2025). Home care industry overview and statistics. Ankota.com. Retrieved January 12, 2025, from https://www.ankota.com/home-care-industry-overview-and-statistics
U.S. Bureau of Labor Statistics (BLS). (n.d.). Injuries, illnesses and fatalities: Workplace violence in healthcare 2018. Bls.gov. Retrieved January 12, 2025, from https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm
U.S. Bureau of Labor Statistics (BLS). (2024, October 8). Injuries, illnesses and fatalities. Bls.gov. Retrieved January 12, 2025, from https://www.bls.gov/iif/factsheets/workplace-violence-2021-2022.htm
Felice, S., Goodwin, S., Oliverie, A., Socias-Morales, C., Castillo, D., & Olawoyin, R. (2021, September 2). Home health care workers: A growing and diverse workforce at high risk for workplace violence. Cdc.gov. Retrieved January 12, 2025, from https://blogs.cdc.gov/niosh-science-blog/2021/09/02/hhc-violence/
Huckenpahler, A. L., & Gold, J. A. (2022). Risky business: Violence in healthcare. Missouri Medicine, 119(6), 514-518.
Kim, S., Lynn, M. R., Baernholdt, M., Kitzmiller, R., & Jones, C. B. (2022). How does workplace violence-reporting culture affect workplace violence, nurse burnout and patient safety? Journal of Nursing Care Quality, 38(1), 11-18.
Lim, M. C., Jeffree, M. S., Saupin, S. S., Giloi, N., & Lukman, K. A. (2022). Workplace violence in healthcare settings: The risk factors, implications, and collaborative preventive measures. Annals of medicine and surgery (2012), 78, 103727. https://doi.org/10.1016/j.amsu.2022.103727
Ma PF, Thomas J. Workplace Violence in Healthcare. [Updated 2023 Apr 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK592384/
Menendez, C. C., Arespacochaga, E., Begley, R., Bhatnagar, M., Ross, P., Schaefer, M. E., & Spring, C. (2024, May 29). Prioritizing our healthcare workers: The importance of addressing the intersection of workplace violence and mental health and wellbeing. CDC.gov. Retrieved January 12, 2025, from https://blogs.cdc.gov/niosh-science-blog/2024/05/29/hcw_violence_mh/
Occupational Safety and Health Administration (OSHA). (2012). Healthcare: Workplace violence. OSHA.gov. Retrieved January 12, 2025, from https://www.osha.gov/healthcare/workplace-violence#:~:text=Workplace%20violence%20(WPV)%20is%20a,such%20assaults%20reported%20in%202009
Phoo, N. N., & Reid, A. (2022). Determinants of violence towards care workers working in the home setting: A systematic review. American Journal of Industrial Medicine, 65, 447-467. https://doi.org/10.1002/ajim.23351
Zhong, X.F. & Shorey, S. (2023). Experiences of workplace violence among healthcare workers in home care settings: A qualitative systematic review. International Nursing Review, 70, 596–605. https://doi.org/10.1111/inr.12822
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