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Reducing Workplace Violence
An Improvement Initiative

Submitted by Daniel Ramberger, MS, BSN, RN, NEA-BC

The American Nurses Association (ANA) takes the firm stance that incivility, bullying, and violence in the workplace are unacceptable. Nurses are professionals that care for a broad range of patients and families in often emotionally-charged situations. Therefore, it is critical that nurses feel safe while in the workplace. With this in mind, several states recently passed legislation focused on protecting health care workers from workplace violence, including the state of California. The California Senate Bill 1299 (SB 1299) mandates that Cal/OSHA creates standards requiring hospitals to establish workplace violence prevention plans to protect health care workers and other facility personnel from aggressive and violent behavior.


In 2018, a multidisciplinary team came together to develop and implement a comprehensive employee workplace violence (WPV) program. This dynamic team's goal was to increase WPV recognition, reporting, and response to thereby reduce WPV experienced by SHC's employees. Working together, the team utilized LEAN/A3 continual improvement methodology to frame the work and then developed key interventions to address ongoing WPV concerns. 

When reviewing background data for their project, the team noted that from 2017 to 2018, incidents of workplace violence at SHC had increased by 34%. Additionally, in 2018 SHC conducted an interprofessional needs assessment that highlighted the need for a comprehensive program to address disruptive behavior and to support staff. 


Members of the 2019/2020 Clinical Effectiveness Leadership Training (CELT) team pictured above.


The WPV Reduction team implemented several impactful interventions which included:

  • Education- three WPV educational live streaming webinars offered monthly:

    • Managing Workplace Violence and Escalating Behaviors in the Healthcare Setting

    • Therapeutic Techniques to Support a Caring and Healthy Work Environment

    • Promoting Civility in the Workplace Workshop

  • Developing a WPV one-page document

  • Expanded signage setting behavioral expectations for all located at:

    • All nursing units at entrances and on unit

    • Entrances to the hospital

    • Guest Services Check-in

    • Ambulatory Clinics

  • The Distress Activation Response Team (DART) Program was established. The DART Program is an interdisciplinary approach to addressing WPV and disruptive behavior in real time. The DART's interdisciplinary team consists of nursing (primary RN, charge RN, nursing leadership), providers (Attending MD, Resident MD, Advanced Practice Providers), Social Worker and Security. The key feature of this team is that the patient's current care team members are utilized, not pre-set response members. This team focuses on disruptive behavior from patients and visitors who have the ability to modify their behavior. The official DART program was piloted on five Medicine Service Line nursing units starting in February 2019. 

After the successful pilot, the DART program was expanded in September 2020 to all inpatient AAUs, using the train the trainer method to educate the frontline staff. Instrumental to this roll-out and sustainability was unit-based leadership, a DART one-page training document, and the creation of a WPV Committee.

The DART program, in tandem with additional organizational initiatives, increased staff recognition, reporting, and response to WPV. In 2021 a survey that mirrored the 2018 needs assessment found:

  • The overall sense of feeling adequately protected at work increased by 20%

  • Staff feelings of management support increased by 17%

  • Staff reported perceptions of more access to support services increased by 15%

This project yielded crucial WPV infrastructure, sustainable WPV education, and the successful creation and implementation of the DART program. This important initiative has facilitated a safer work environment for all SHC healthcare workers and is another crucial step to prevent WPV and transform our culture. Currently, there is continual monitoring and evaluation of WPV to identify gaps and additional areas of need as SHC continues to address this critical topic.

Workplace Violence Abstract Authors

  • Daniel Ramberger, MS, BSN, RNDirector of Clinical Services

  • Hirut Truneh, MSN, RNDirector of Clinical Services

  • Hurley SmithDirector-Performance Improvement

  • Tom RoussinDirector of Security Services

  • Dana Jones, BSN, RN PCCN, Clinical Nurse III

  • Aubrey Florom-Smith, PhD, RNNurse Scientist

  • Neera Ahuja, MD, FACPDivision Chief-Hospital Medicine

This team's abstract was presented at the 2022 Western Institute of Nursing (WIN) Conference in Portland, Oregon​.

DART sign.png

Thank you to the members of the WPV Reduction Team and the numerous contributors to this project for all of your efforts to promote a safe and healing work environment for not only our patients, but also the members of our healthcare teams.

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