Spotlight on the Workplace Violence Bill: Violence starts before the facility begins counting

When a healthcare facility documents an incident of workplace violence, the official story may begin with the moment a patient yelled, threatened, pushed, struck, bit, kicked, or spat at someone.

But the actual encounter often started well before that point.

It may have begun when the person asked for help and received no response. When no interpreter was provided. When nobody explained what was happening. When pain went untreated. When a frightened person was prevented from leaving, surrounded by security, stripped of their belongings, touched without permission, threatened with forced medication, or physically restrained.

It may be the result of days, weeks, months, or even years of disrespect, disregard, and loss of power.

If we record only the final act, we make everything that preceded it disappear.

That does not mean workers cause every assault or that violence is acceptable. It means prevention requires us to examine the entire interaction—not simply assign all responsibility to the person with the least institutional power.

What the available research shows

A systematic review of 71 studies examined events preceding violence and aggression in adult psychiatric inpatient settings. Staff-patient interactions were the most frequently identified category, estimated to precede more than one-third of incidents.

The most common interaction involved restricting a patient’s freedom or denying a request. Those situations accounted for an estimated 25% of the antecedents identified.

These findings do not tell us that every restriction was unreasonable or that every subsequent action was inevitable. They do tell us that what staff and institutions do is a substantial part of the safety equation.

A person’s actions do not occur in a vacuum simply because the incident-reporting system begins counting when they become disruptive.

How often does forced treatment precede an incident?

We do not have a reliable national percentage for how often force precedes an incident of violence in a healthcare setting. That absence is itself meaningful.

Workplace-violence data often document who was harmed, where the incident happened, and what the patient did. They much less consistently record whether the person was being held involuntarily, had been touched or searched without consent, was attempting to leave, had just been denied something, was being restrained, was threatened with forced medication, or believed they were defending themself.

Even the categories used to describe an incident can erase its sequence. If a worker grabs someone and that person pulls away, whose use of force becomes the official “violent incident”? If several people pin someone down and the person bites one of them while struggling to breathe, the bite may be counted while the force surrounding it is classified as procedure.

The question is not only who defines “violence,” but who defines “safety”—and whose safety is the primary consideration.

Loss of power can intensify danger

Healthcare settings, particularly psychiatric and emergency settings, can involve an extraordinary removal of control. A person may be transported against their will, prevented from leaving, searched, deprived of belongings and privacy, placed under constant observation, medicated over objection, secluded, or restrained.

For people with histories of assault, institutionalization, racism, transphobia, ableism, incarceration, or medical abuse, these actions may recreate earlier trauma. A command delivered without explanation may be experienced as a threat. Several staff members approaching at once may be experienced as an attack—especially when they engage in that telltale act of putting on gloves. Touch intended as control may trigger panic, resistance, or an attempt to escape.

Calling the resulting response “unprovoked” because the person in the service-recipient role was not supposed to react does not make it so.

The answer is not a vague instruction that workers should be nicer while institutions place them in impossible circumstances. Workers cannot consistently slow down, listen, explain, offer choices, or build trust while responsible for too many people and moving from crisis to crisis. They cannot integrate collaborative, trauma-informed approaches without consistent training, feedback, and supervisors who have already developed those skills.

Conditions that can increase risk

Research and patient accounts repeatedly identify conditions that can heighten fear, frustration, confusion, and conflict:

long waits, overcrowding, untreated pain, hunger, exhaustion, and sensory overload;
requests that are ignored, repeatedly deferred, or denied without explanation;
conflicting information, unclear expectations, or rules enforced inconsistently;
being spoken about rather than spoken to;
language barriers, communication disabilities, or failure to provide qualified interpreters and accessible explanations;
sudden approaches, crowding, touching without warning, or immediately involving security;
humiliation, misgendering, racism, ableism, and assumptions that a distressed person is manipulative or deliberately “noncompliant”;
restrictions or changes imposed without warning, explanation, meaningful choice, or a clear review process; and
exhausted and unsupported workers, insufficient training and supervision, and complaint systems that routinely favor employees or fail to respond at all.

Emergency-department overcrowding has long been associated with prolonged suffering, frustration, patient dissatisfaction, and violence. These are not merely matters of “customer service.” They are workplace-safety conditions.

Changing staff practices can reduce conflict

Safewards is a model developed around the interactions and conditions that generate conflict in psychiatric units. Its interventions include clearer and more respectful communication, consistent expectations, efforts to calm rather than dominate, mutual understanding between staff and patients, and attention to the points where conflict commonly develops.

In a randomized controlled trial involving 31 psychiatric wards, Safewards reduced conflict events by 15% and containment events—including restraint, seclusion, and forced or emergency medication—by 23.2% compared with the control intervention.

That is only one example, and implementation quality matters. But it provides something penalty enhancements do not: controlled evidence that changing institutional and staff practices can reduce conflict.

Trauma-informed care should similarly emphasize physical and emotional safety, transparency, collaboration, cultural responsiveness, and meaningful choice. It should require institutions to recognize how trauma, racism, disability, gender, and previous coercion shape a person’s response to authority and force.

It should not become another certificate placed in an employee file while routine practices remain coercive, nor should it be reduced to teaching staff better techniques for obtaining “compliance.” The goal—and the use of language such as “compliance”—itself requires significant re-evaluation.

A genuinely trauma-informed system changes who holds power, how decisions are explained, how often force is used, whether meaningful alternatives exist, and whether people can report harm without retaliation.

This is not “blaming workers”

Healthcare workers can be injured and traumatized. People receiving services can also be abused, neglected, humiliated, and traumatized by healthcare workers. Both realities must remain visible.

Acknowledging harmful staff conduct is not an attack on every worker. Acknowledging structural conditions does not excuse an individual worker who abuses someone. And examining what preceded a service recipient’s action does not mean no patient is ever responsible for harm.

It is an attempt to prevent the harm in the first place.

Workers and people receiving services are frequently placed in conflict by decisions made above them. Administrators determine staffing levels, physical environments, training budgets, security practices, complaint systems, and whether workers have enough time to respond before a problem becomes a crisis.

When those systems fail, a frontline worker may be left frightened or injured. A person who came for “help” may end up restrained, traumatized, or arrested. The institution may then describe the encounter as an unpredictable act committed by a dangerous individual.

That explanation protects the institution remarkably well. It does much less for either person who was harmed.