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Healthcare Wide Hazards
Workplace Violence

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The prevention of workplace violence has emerged as an important safety issue in and around hospitals and healthcare facilities. Workplace violence such as physical assaults, or threatening or violent behavior, are a growing problem in the workplace. The workplace may be any location either permanent or temporary where an employee performs any work-related duty.

Common safety and health topics:

Violence Prevention Plan
In 1999 Bureau of Labor Statistics estimate 2,637 nonfatal assaults on hospital workers-a rate of 8.3 assaults per 10,000 workers. This rate is much higher than the rate of nonfatal assaults for all private-sector industries, which is 2 per 10,000 workers.

Potential Hazard

  • Exposure to workplace violence because no violence prevention program was in place to help reduce hazards.

Possible Solutions

  • OSHA recommends that employers establish and maintain a violence prevention program as part of their facility's safety and health program. The prevention program should:

    • Be made available to all employees, including managers and supervisors; and all employees should receive specific training concerning its content and implementation.

    • Track their progress in reducing work-related assaults,

    • Reduce the severity of injuries sustained by employees,

    • Decrease the threat to worker safety.

    • Reflect the level and nature of threat faced by employees.

    The main components that should be included in a facility's Violence Prevention Program are:

    Violence Prevention Written Plan: To prevent workplace violence a written program should incorporate the above areas and state clear goals and objectives suitable to the size and complexity of the given workplace.

    • Although not every incident can be prevented, many can be, and the severity of injuries sustained by employees reduced by following a violence prevention plan.

    • "Universal Precautions" for violence, states that violence should be expected but can be avoided or mitigated through preparation.
    A violence prevention written plan:

    • Creates and disseminates a clear policy that violence, verbal and nonverbal threats, and related actions, will not be tolerated.

    • Ensures that no reprisals are taken against employees who report or experience workplace violence.

    • Encourages prompt reporting of all violent incidents and recordkeeping of incidents to assess risk and to measure progress.

    • Establishes a plan for maintaining security in the workplace which includes law enforcement officials and other specialists.

Additional Information

  • Violence Occupational Hazards in Hospitals. US Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No. 2002-101, (2002, April). This brochure's purpose is to increase worker and employer awareness of the risk factors for violence in hospitals and to provide strategies for reducing exposure to these factors.

Management and Employee Commitment
Management and employee commitment are complementary and essential elements of an effective violence prevention program.

Potential Hazard

Possible Solutions

  • It is recommended that management and employees work together to reduce workplace violence.

    Management Commitment: Provides the motivation and resources to deal effectively with workplace violence and should include:

    A policy that violence, threats, harassment, intimidations, and other disruptive behavior in our workplace will not be tolerated; that is all reports of incidents will be taken seriously and will be dealt with appropriately. Management should to be committed to:

    • Emotional as well as physical health of the employee.

    • Appropriate allocation of authority and resources to responsible parties.

    • Equal commitment to worker safety and health and patient/client safety.

    • A system of accountability for involved managers and employees.

    • A comprehensive program of medical and psychological counseling for employees experiencing or witnessing violent incidents.

    • No employee reprisals for reporting incidents.
    Employee Involvement

    Employees should:

    • Understand, support, and comply with the established workplace violence program.

    • Participate in employee complaint or suggestions sessions.

    • Provide prompt and accurate reporting of all workplace violence incidents.
    Employees should understand that:

    • Reporting violence will benefit them, and enable management to identify, address, and solve problems.

    • No reprisals will be taken by management or employer.
    Employees often do not report violent incidents because:

    • Of lack of administrative reporting policies, or procedures.

    • They are afraid employer will think they can't handle the job effectively.

    • Of misperception that violence is part of the job.

    • Of fear of employer reprisals.

Worksite Analysis, Hazard Prevention and Control
Potential Hazard

Possible Solutions

  • Complete a worksite analysis: It is recommended that a worksite analysis be completed by an appointed Threat Assessment Team or similar task force, or coordinator. This "team" analyzes records, trends, workplace security, and gives screening surveys to staff to help identify hazards. OSHA has provided the following surveys to assist employers in identifying hazards.

    Taken from: Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers [624 KB PDF*, 47 pages]. OSHA Publication 3148, (2003).

    Identify potential reasons why hospitals may be hazardous, such as:

    • The availability of drugs or money in the pharmacy area, making them likely robbery targets.

    • Hospital/healthcare personnel must work evenings and night shifts at facilities hat may be located in high-crime areas.

    • Overall prevalence of firearms.

    • Low staffing levels, high turnover rates, and stress.

    • Hazard of exposure to violent, confused or mentally unstable patients.

    • Dealing with combative, disoriented, uncooperative patients.

    • Mentally unstable patients, that are possibly dangerous.

    • Exposure to workplace violence in rooms not prepared for violent patients:

      • Moveable furniture that could be used as weapons, or to entrap employees.

      • Possible items on countertops that could be thrown at workers.
  • Identify hazard prevention and control: Identify hazards found in the worksite analysis and then provide administrative and work practice controls to make hospitals a safer workplace, for example:

    • Provide better visibility and good lighting, especially in areas of high risk such as the pharmacy area, or in isolated treatment areas.

    • Implement safety measures to deter handguns inside facility; for example using metal detectors.

    • Install plexi-glass in the payment window in the pharmacy area.

    • Use of security devices such as panic buttons, beepers, surveillance cameras, alarm systems, two-way mirrors, card-key access systems, and security guards.

    • Place curved mirrors at hallway intersections or concealed areas.

    • Control access to work areas.

    • Provide training for staff in recognizing and managing hostile and assaultive behavior.

    • Provide adequate staffing even during night shifts. Increase staffing in areas where assaults by patients are likely (e.g., Emergency Department).

    • Increase worker safety during arrival and departure by encouraging car pools and by providing security escorts and shuttle service to and from parking lots and public transportation.

    • Ensure accurate reporting of all violent behavior.

    • Make patients aware of zero tolerance policy for violence.

    • Establish liaison with police authorities and contact them when indicated.

    • Obtain previous records of patients to learn of any past violent behaviors.

    • Establish a system to chart or track and evaluate possible assaultive behaviors, including a way to pass on information from one shift to another.

    • Implement a violence prevention plan to develop strategies to deal with possibly violent patients.
  • A safer room for a possibly violent patient:

    • Has furniture arranged to prevent entrapment of staff, furniture should be minimal, lightweight, without sharp corners, and/or affixed to the floor.

    • Is free from clutter, nothing available on countertops to throw at workers or use as weapons.

    • Is provided with a secondary door for escape in case main door is blocked by patient.

    • Is one entered with a buddy, do not be alone with patient.

Safety and Health Training
You can't always prevent violence, because it can be unpredictable, but you can reduce the risk by planning ahead and being prepared to act swiftly to deal with threats, intimidation and other disruptive behavior at an early stage.

Potential Hazard

  • Increased risk of violence because ineffective training of staff to deal with or identify potential violence problems.

Possible Solutions

  • It is recommended that facilities have a workplace violence protection program in place that includes training of employees.

    • Training is a critical component of any prevention strategy for staff, supervisors and other employees.

    • Training could be conducted by a team of individuals, police force, or others that have specialties in this area.

    • Personally knowing team members responsible for workplace safety programs encourages employees and supervisors to seek assistance from them at a much earlier stage.
    Training could include:

    • An understanding of the facility's workplace violence policy and program.

    • Encouragement and support to report incidents.

    • Ways of preventing or diffusing volatile situations or aggressive behavior, conflict resolution.

    • The dynamics of violence.

    • How to recognize and deal with hostile aggressive persons, nonviolent responses.

    • Managing anger.

    • Techniques and skills to resolve conflicts.

    • Stress management, relaxation techniques.

    • Security procedures.

    • Personal security measures, self defense.

    • Techniques for victim support.

    • The use of training tools:

Post-Incident Response
Potential Hazard

  • Health care workers, given inadequate support following a violent incident, may quit or be fearful to go back to work.

Possible Solutions

  • It is recommended that employers provide a program of support for workers involved in violent incidents and workers observing violent incidents.

  • Set up trained response teams to respond to emergencies, and provide post-incident response assistance to the worker that includes:

    • Prompt medical treatment and psychological evaluation

    • Follow-up program in place to offer:

      • counseling, support groups, stress debriefing, trauma-crisis counseling, employee assistance programs

OSHA provides some sample forms in: Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers [624 KB PDF*, 47 pages], to assist employers in developing their policies and procedures following a violent incident.

Evaluation and Recordkeeping
Potential Hazard

Possible Solutions

  • Implement adequate evaluation and recordkeeping practices.

    Comply with OSHA Recordkeeping Standards:

    • The Recordkeeping Rule went into effect January 1, 2002.

    • Recordkeeping forms: The OSHA Form 300, Log of Work-Related Injuries and Illnesses has been revised. The forms, which are required for employers to use in recording injuries and illnesses, have changed in several important ways for 2004. The new forms must be in use by January 1, 2004.

    • New Recordkeeping Rule [63 KB PDF*, 2 pages]. OSHA Fact Sheet.

    • A fatality or catastrophe that results in the hospitalization of 3 or more employees must be reported to OSHA within 8 hours.
    Recordkeeping is important to the success of a workplace violence prevention program and can:

    • Help to identify the severity of the problem, evaluate methods of hazard control and identify training needs.

    • Be useful for gathering or "pooling" data for other applications.
    It is recommended that other records be considered such as:

    • Medical reports of work injury.

    • Incidents of abuse, (such as verbal abuse, or other acts of aggression, that do not result in injury.

    • Information on patients with a history of past violence should be recorded on the patient's chart, and staff made aware of the possible potential for aggression.

    • Training records.
    Evaluation of a facility's violence prevention program is recommended for determining it's effectiveness. The evaluation:

    • Identifies any problems or deficiencies that can then be corrected.

    • Allows for management to review program effectiveness, and re-evaluate policies and procedures on a regular basis.

    • Helps management to analyze trends, measure improvements, and keep abreast of new trends to reduce workplace violence.

Additional Information:

Accessibility Assistance: Contact the OSHA Directorate of Technical Support and Emergency Management at (202) 693-2300 for assistance accessing PDF materials.

*These files are provided for downloading.

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