Osha 3148 01r 2004
www.osha.gov
Guidelines for
Preventing Workplace
Violence for Health Care &
Social Service Workers
OSHA 3148-01R 2004
This informational booklet provides a
general overview of a particular topic
related to OSHA standards. It does not alter
or determine compliance responsibilities in
OSHA standards or the Occupational Safety
and Health Act of 1970. Because interpreta-
tions and enforcement policy may change
over time, you should consult current OSHA
administrative interpretations and decisions
by the Occupational Safety and Health
Review Commission and the Courts for
additional guidance on OSHA compliance
requirements.
This publication is in the public domain
and may be reproduced, fully or partially,
without permission. Source credit is
requested but not required.
This information is available to sensory
impaired individuals upon request.
Voice phone: (202) 693-1999; teletypewriter
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Guidelines for
Preventing Workplace
Violence for Health Care &
Social Service Workers
U.S. Department of Labor
Occupational Safety and Health Administration
OSHA 3148-01R
2004
Contents
Notice...3
Acknowledgments...4
Introduction...4
Overview of Guidelines...7
Violence Prevention Programs...8
Management Commitment and Employee Involvement...10
Worksite Analysis...11
Hazard Prevention and Control...14
Safety and Health Training...19
Recordkeeping and Program Evaluation...21
Conclusion...24
References...25
OSHA assistance...25
Safety and Health Program Management Guidelines...25
State Programs...26
Consultation Services...26
Voluntary Protection Programs (VPP)...27
Strategic Partnership Program...27
Alliance Programs...28
OSHA Training and Education...28
Information Available Electronically...29
OSHA Publications...29
Contacting OSHA...30
OSHA Regional Offices...30
Appendices
Appendix A: Workplace Violence Program Checklists...32
Appendix B: Violence Incident Report Forms...40
Appendix C: Suggested Readings...42
2
Notice
These guidelines are not a new standard or regulation. They
are advisory in nature, informational in content and intended to
help employers establish effective workplace violence prevention
programs adapted to their specific worksites. The guidelines do
not address issues related to patient care. They are performance-
oriented, and how employers implement them will vary based on
the site’s hazard analysis.
Violence inflicted on employees may come from many sources—
external parties such as robbers or muggers and internal parties
such as coworkers and patients. These guidelines address only the
violence inflicted by patients or clients against staff. However, OSHA
suggests that workplace violence policies indicate a zero-tolerance
for all forms of violence from all sources.
The Occupational Safety and Health Act of 1970 (OSH Act)1
mandates that, in addition to compliance with hazard-specific
standards, all employers have a general duty to provide their
employees with a workplace free from recognized hazards likely to
cause death or serious physical harm. OSHA will rely on Section
5(a)(1) of the OSH Act, the “General Duty Clause,”2 for enforcement
authority. Failure to implement these guidelines is not in itself a
violation of the General Duty Clause. However, employers can be
cited for violating the General Duty Clause if there is a recognized
hazard of workplace violence in their establishments and they do
nothing to prevent or abate it.
When Congress passed the OSH Act, it recognized that workers’
compensation systems provided state-specific remedies for job-
related injuries and illnesses. Determining what constitutes a
compensable claim and the rate of compensation were left to the
states, their legislatures and their courts. Congress acknowledged this
point in Section 4(b)(4) of the OSH Act, when it stated categorically:
“Nothing in this chapter shall be construed to supersede or in any
manner affect any workmen’s compensation law. . ..”3 Therefore,
1 Public Law 91-596, December 29, 1970; and as amended by P.L. 101-552, Section
3101, November 5, 1990.
2 “Each employer shall furnish to each of his employees employment and a place of
employment which are free from recognized hazards that are causing or are likely
to cause death or serious physical harm to his employees.”
3 29 U.S.C. 653(b)(4).
3
these non-mandatory guidelines should not be viewed as enlarging
or diminishing the scope of work-related injuries. The guidelines are
intended for use in any state and without regard to whether any
injuries or fatalities are later determined to be compensable.
Acknowledgments
Many people have contributed to these guidelines. They include
health care, social service and employee assistance experts;
researchers; educators; unions and other stakeholders; OSHA
professionals; and the National Institute for Occupational Safety
and Health (NIOSH).
Also, several states have developed relevant standards or
recommendations, such as California OSHA’s CAL/OSHA Guidelines
for Workplace Security and Guidelines for Security and Safety of
Health Care and Community Service Workers; New Jersey Public
Employees Occupational Safety and Health’s Guidelines on
Measures and Safeguards in Dealing with Violent or Aggressive
Behavior in Public Sector Health Care Facilities; and the State of
Washington Department of Labor and Industries’ Violence in
Washington Workplaces and Study of Assaults on Staff in
Washington State Psychiatric Hospitals. Other organizations with
relevant recommendations include the Joint Commission on
Accreditation of Health Care Organizations’ Comprehensive
Accreditation Manuals for Hospitals, the Metropolitan Chicago
Healthcare Council’s Guidelines for Dealing with Violence in Health
Care, and the American Nurses Association’s Promoting Safe Work
Environments for Nurses. These and other agencies have
information available to assist employers.
Introduction
Workplace violence affects health care and
social service workers.
The National Institute for Occupational Safety and Health
(NIOSH) defines workplace violence as “violent acts (including
physical assaults and threats of assaults) directed toward persons
at work or on duty.”4 This includes terrorism as illustrated by the
4CDC/NIOSH. Violence. Occupational Hazards in Hospitals. 2002.
4
terrorist acts of September 11, 2001 that resulted in the deaths of
2,886 workers in New York, Virginia and Pennsylvania. Although
these guidelines do not address terrorism specifically, this type of
violence remains a threat to U.S. workplaces.
For many years, health care and social service workers have
faced a significant risk of job-related violence. Assaults represent a
serious safety and health hazard within these industries. OSHA’s
violence prevention guidelines provide the agency’s recommenda-
tions for reducing workplace violence, developed following a
careful review of workplace violence studies, public and private
violence prevention programs and input from stakeholders. OSHA
encourages employers to establish violence prevention programs
and to track their progress in reducing work-related assaults.
Although not every incident can be prevented, many can, and the
severity of injuries sustained by employees can be reduced.
Adopting practical measures such as those outlined here can
significantly reduce this serious threat to worker safety.
Extent of the problem
The Bureau of Labor Statistics (BLS) reports that there were
69 homicides in the health services from 1996 to 2000. Although
workplace homicides may attract more attention, the vast majority
of workplace violence consists of non-fatal assaults. BLS data shows
that in 2000, 48 percent of all non-fatal injuries from occupational
assaults and violent acts occurred in health care and social services.
Most of these occurred in hospitals, nursing and personal care
facilities, and residential care services. Nurses, aides, orderlies and
attendants suffered the most non-fatal assaults resulting in injury.
Injury rates also reveal that health care and social service
workers are at high risk of violent assault at work. BLS rates
measure the number of events per 10,000 full-time workers—in this
case, assaults resulting in injury. In 2000, health service workers
overall had an incidence rate of 9.3 for injuries resulting from
assaults and violent acts. The rate for social service workers was
15, and for nursing and personal care facility workers, 25. This
compares to an overall private sector injury rate of 2.
The Department of Justice’s (DOJ) National Crime Victimization
Survey for 1993 to 1999 lists average annual rates of non-fatal
violent crime by occupation. The average annual rate for non-fatal
5
violent crime for all occupa-
Incidence rates for nonfatal assaults
tions is 12.6 per 1,000 workers.
and violent acts by industry, 2000
The average annual rate for
Incidence rate per 10,000 full-time workers
physicians is 16.2; for nurses,
30
21.9; for mental health profes-
sionals, 68.2; and for mental
25
health custodial workers, 69.
(Note: These data do not
20
compare directly to the BLS
figures because DOJ presents 15
violent incidents per 1,000
workers and BLS displays
10
injuries involving days away
from work per 10,000
5
workers. Both sources,
however, reveal the same
0
Private
Health
Social
Nursing &
high risk for health care and
Sector
Services
Services
Personal
Overall
Overall
Care
social service workers.)
Facilities
As significant as these
Source: U.S. Department of Labor, Bureau of
numbers are, the actual
Labor Statistics. (2001). Survey of Occupational
Injuries and Illnesses, 2000.
number of incidents is prob-
ably much higher. Incidents of violence are likely to be underreported,
perhaps due in part to the persistent perception within the health
care industry that assaults are part of the job. Underreporting may
reflect a lack of institutional reporting policies, employee beliefs that
reporting will not benefit them or employee fears that employers
may deem assaults the result of employee negligence or poor job
performance.
The risk factors
Health care and social service workers face an increased risk
of work-related assaults stemming from several factors. These
include:
I
The prevalence of handguns and other weapons among
patients, their families or friends;
I
The increasing use of hospitals by police and the criminal justice
system for criminal holds and the care of acutely disturbed,
violent individuals;
I
The increasing number of acute and chronic mentally ill patients
being released from hospitals without follow-up care (these
6
patients have the right to refuse medicine and can no longer be
hospitalized involuntarily unless they pose an immediate threat
to themselves or others);
I
The availability of drugs or money at hospitals, clinics and
pharmacies, making them likely robbery targets;
I
Factors such as the unrestricted movement of the public in
clinics and hospitals and long waits in emergency or clinic areas
that lead to client frustration over an inability to obtain needed
services promptly;
I
The increasing presence of gang members, drug or alcohol
abusers, trauma patients or distraught family members;
I
Low staffing levels during times of increased activity such as
mealtimes, visiting times and when staff are transporting
patients;
I
Isolated work with clients during examinations or treatment;
I
Solo work, often in remote locations with no backup or way
to get assistance, such as communication devices or alarm
systems (this is particularly true in high-crime settings);
I
Lack of staff training in recognizing and managing escalating
hostile and assaultive behavior; and
I
Poorly lit parking areas.
Overview of Guidelines
In January 1989, OSHA published voluntary, generic safety and
health program management guidelines for all employers to use
as a foundation for their safety and health programs, which can
include workplace violence prevention programs.5 OSHA’s violence
prevention guidelines build on these generic guidelines by
identifying common risk factors and describing some feasible
solutions. Although not exhaustive, the workplace violence
guidelines include policy recommendations and practical corrective
methods to help prevent and mitigate the effects of workplace
violence.
5OSHA’s Safety and Health Program Management Guidelines (54 Federal Register
(16):3904–3916, January 26, 1989).
7
The goal is to eliminate or reduce worker exposure to conditions
that lead to death or injury from violence by implementing effective
security devices and administrative work practices, among other
control measures.
The guidelines cover a broad spectrum of workers who provide
health care and social services in psychiatric facilities, hospital
emergency departments, community mental health clinics, drug
abuse treatment clinics, pharmacies, community-care facilities and
long-term care facilities. They include physicians, registered nurses,
pharmacists, nurse practitioners, physicians’ assistants, nurses’
aides, therapists, technicians, public health nurses, home health
care workers, social workers, welfare workers and emergency
medical care personnel. The guidelines may also be useful in
reducing risks for ancillary personnel such as maintenance, dietary,
clerical and security staff in the health care and social service
industries.
Violence Prevention Programs
A written program for job safety and security, incorporated into
the organization’s overall safety and health program, offers an
effective approach for larger organizations. In smaller establish-
ments, the program does not need to be written or heavily
documented to be satisfactory.
What is needed are clear goals and objectives to prevent
workplace violence suitable for the size and complexity of the
workplace operation and adaptable to specific situations in each
establishment. Employers should communicate information about
the prevention program and startup date to all employees.
At a minimum, workplace violence prevention programs should:
I
Create and disseminate a clear policy of zero tolerance for
workplace violence, verbal and nonverbal threats and related
actions. Ensure that managers, supervisors, coworkers, clients,
patients and visitors know about this policy.
8
I
Ensure that no employee who reports or experiences workplace
violence faces reprisals.6
I
Encourage employees to promptly report incidents and suggest
ways to reduce or eliminate risks. Require records of incidents to
assess risk and measure progress.
I
Outline a comprehensive plan for maintaining security in
the workplace. This includes establishing a liaison with law
enforcement representatives and others who can help identify
ways to prevent and mitigate workplace violence.
I
Assign responsibility and authority for the program to indi-
viduals or teams with appropriate training and skills. Ensure that
adequate resources are available for this effort and that the team
or responsible individuals develop expertise on workplace
violence prevention in health care and social services.
I
Affirm management commitment to a worker-supportive
environment that places as much importance on employee
safety and health as on serving the patient or client.
I
Set up a company briefing as part of the initial effort to address
issues such as preserving safety, supporting affected employees
and facilitating recovery.
Elements of an effective violence prevention program
The five main components of any effective safety and health
program also apply to the prevention of workplace violence:
I
Management commitment and employee involvement;
I
Worksite analysis;
I
Hazard prevention and control;
I
Safety and health training; and
I
Recordkeeping and program evaluation.
6Section 11 (c)(1) of the OSH Act applies to protected activity involving the hazard of
workplace violence as it does for other health and safety matters:
“No person shall discharge or in any manner discriminate against any employee
because such employee has filed any complaint or instituted or caused to be
instituted any proceeding under or related to this Act or has testified or is about to
testify in any such proceeding or because of the exercise by such employee on
behalf of himself or others of any right afforded by this Act.”
9
Management Commitment and
Employee Involvement
Management commitment and employee involvement are
complementary and essential elements of an effective safety and
health program. To ensure an effective program, management and
frontline employees must work together, perhaps through a team or
committee approach. If employers opt for this strategy, they must
be careful to comply with the applicable provisions of the National
Labor Relations Act.7
Management commitment, including the endorsement and
visible involvement of top management, provides the motivation
and resources to deal effectively with workplace violence. This
commitment should include:
I
Demonstrating organizational concern for employee emotional
and physical safety and health;
I
Exhibiting equal commitment to the safety and health of workers
and patients/clients;
I
Assigning responsibility for the various aspects of the work-
place violence prevention program to ensure that all managers,
supervisors and employees understand their obligations;
I
Allocating appropriate authority and resources to all responsible
parties;
I
Maintaining a system of accountability for involved managers,
supervisors and employees;
I
Establishing a comprehensive program of medical and psycho-
logical counseling and debriefing for employees experiencing or
witnessing assaults and other violent incidents; and
I
Supporting and implementing appropriate recommendations
from safety and health committees.
Employee involvement and feedback enable workers to develop
and express their own commitment to safety and health and provide
useful information to design, implement and evaluate the program.
729 U.S.C. 158(a)(2).
10
Employee involvement should include:
I
Understanding and complying with the workplace violence
prevention program and other safety and security measures;
I
Participating in employee complaint or suggestion procedures
covering safety and security concerns;
I
Reporting violent incidents promptly and accurately;
I
Participating in safety and health committees or teams that
receive reports of violent incidents or security problems, make
facility inspections and respond with recommendations for
corrective strategies; and
I
Taking part in a continuing education program that covers
techniques to recognize escalating agitation, assaultive behavior
or criminal intent and discusses appropriate responses.
Worksite Analysis
Value of a worksite analysis
A worksite analysis involves a step-by-step, commonsense look
at the workplace to find existing or potential hazards for workplace
violence. This entails reviewing specific procedures or operations
that contribute to hazards and specific areas where hazards may
develop. A threat assessment team, patient assault team, similar
task force or coordinator may assess the vulnerability to workplace
violence and determine the appropriate preventive actions to be
taken. This group may also be responsible for implementing the
workplace violence prevention program. The team should include
representatives from senior management, operations, employee
assistance, security, occupational safety and health, legal and
human resources staff.
The team or coordinator can review injury and illness records
and workers’ compensation claims to identify patterns of assaults
that could be prevented by workplace adaptation, procedural
changes or employee training. As the team or coordinator identifies
appropriate controls, they should be instituted.
11
Focus of a worksite analysis
The recommended program for worksite analysis includes, but
is not limited to:
I
Analyzing and tracking records;
I
Screening surveys; and
I
Analyzing workplace security.
Records analysis and tracking
This activity should include reviewing medical, safety, workers’
compensation and insurance records—including the OSHA Log of
Work-Related Injury and Illness (OSHA Form 300), if the employer
is required to maintain one—to pinpoint instances of workplace
violence. Scan unit logs and employee and police reports of
incidents or near-incidents of assaultive behavior to identify and
analyze trends in assaults relative to particular:
I
Departments;
I
Units;
I
Job titles;
I
Unit activities;
I
Workstations; and
I
Time of day.
Tabulate these data to target the frequency and severity of
incidents to establish a baseline for measuring improvement.
Monitor trends and analyze incidents. Contacting similar local
businesses, trade associations and community and civic groups is
one way to learn about their experiences with workplace violence
and to help identify trends. Use several years of data, if possible,
to trace trends of injuries and incidents of actual or potential work-
place violence.
Value of screening surveys
One important screening tool is an employee questionnaire or
survey to get employees’ ideas on the potential for violent incidents
and to identify or confirm the need for improved security measures.
Detailed baseline screening surveys can help pinpoint tasks that put
12
employees at risk. Periodic surveys—conducted at least annually or
whenever operations change or incidents of workplace violence
occur—help identify new or previously unnoticed risk factors and
deficiencies or failures in work practices, procedures or controls.
Also, the surveys help assess the effects of changes in the work
processes. The periodic review process should also include feed-
back and follow-up.
Independent reviewers, such as safety and health professionals,
law enforcement or security specialists and insurance safety
auditors, may offer advice to strengthen programs. These experts
can also provide fresh perspectives to improve a violence pre-
vention program.
Conducting a workplace security analysis
The team or coordinator should periodically inspect the work-
place and evaluate employee tasks to identify hazards, conditions,
operations and situations that could lead to violence.
To find areas requiring further evaluation, the team or co-
ordinator should:
I
Analyze incidents, including the characteristics of assailants
and victims, an account of what happened before and during
the incident, and the relevant details of the situation and its
outcome. When possible, obtain police reports and recommen-
dations.
I
Identify jobs or locations with the greatest risk of violence as
well as processes and procedures that put employees at risk of
assault, including how often and when.
I
Note high-risk factors such as types of clients or patients
(for example, those with psychiatric conditions or who are dis-
oriented by drugs, alcohol or stress); physical risk factors related
to building layout or design; isolated locations and job activities;
lighting problems; lack of phones and other communication
devices; areas of easy, unsecured access; and areas with
previous security problems.
I
Evaluate the effectiveness of existing security measures,
including engineering controls. Determine if risk factors have
been reduced or eliminated and take appropriate action.
13
Hazard Prevention and Control
After hazards are identified through the systematic worksite
analysis, the next step is to design measures through engineering
or administrative and work practices to prevent or control these
hazards. If violence does occur, post-incident response can be an
important tool in preventing future incidents.
Engineering controls and workplace adaptations
to minimize risk
Engineering controls remove the hazard from the workplace or
create a barrier between the worker and the hazard. There are
several measures that can effectively prevent or control workplace
hazards, such as those described in the following paragraphs. The
selection of any measure, of course, should be based on the haz-
ards identified in the workplace security analysis of each facility.
Among other options, employers may choose to:
I
Assess any plans for new construction or physical changes to
the facility or workplace to eliminate or reduce security hazards.
I
Install and regularly maintain alarm systems and other security
devices, panic buttons, hand-held alarms or noise devices,
cellular phones and private channel radios where risk is
apparent or may be anticipated. Arrange for a reliable response
system when an alarm is triggered.
I
Provide metal detectors—installed or hand-held, where
appropriate—to detect guns, knives or other weapons,
according to the recommendations of security consultants.
I
Use a closed-circuit video recording for high-risk areas on a
24-hour basis. Public safety is a greater concern than privacy in
these situations.
I
Place curved mirrors at hallway intersections or concealed
areas.
I
Enclose nurses’ stations and install deep service counters or
bullet-resistant, shatter-proof glass in reception, triage and
admitting areas or client service rooms.
I
Provide employee “safe rooms” for use during emergencies.
I
Establish “time-out” or seclusion areas with high ceilings with-
14
out grids for patients who “act out” and establish separate
rooms for criminal patients.
I
Provide comfortable client or patient waiting rooms designed to
minimize stress.
I
Ensure that counseling or patient care rooms have two exits.
I
Lock doors to staff counseling rooms and treatment rooms to
limit access.
I
Arrange furniture to prevent entrapment of staff.
I
Use minimal furniture in interview rooms or crisis treatment
areas and ensure that it is lightweight, without sharp corners
or edges and affixed to the floor, if possible. Limit the number
of pictures, vases, ashtrays or other items that can be used
as weapons.
I
Provide lockable and secure bathrooms for staff members
separate from patient/client and visitor facilities.
I
Lock all unused doors to limit access, in accordance with local
fire codes.
I
Install bright, effective lighting, both indoors and outdoors.
I
Replace burned-out lights and broken windows and locks.
I
Keep automobiles well maintained if they are used in the field.
I
Lock automobiles at all times.
Administrative and work practice controls to minimize risk
Administrative and work practice controls affect the way staff
perform jobs or tasks. Changes in work practices and administrative
procedures can help prevent violent incidents. Some options for
employers are to:
I
State clearly to patients, clients and employees that violence is
not permitted or tolerated.
I
Establish liaison with local police and state prosecutors. Report
all incidents of violence. Give police physical layouts of facilities
to expedite investigations.
I
Require employees to report all assaults or threats to a
supervisor or manager (for example, through a confidential
interview). Keep log books and reports of such incidents to help
determine any necessary actions to prevent recurrences.
15
I
Advise employees of company procedures for requesting police
assistance or filing charges when assaulted and help them do
so, if necessary.
I
Provide management support during emergencies. Respond
promptly to all complaints.
I
Set up a trained response team to respond to emergencies.
I
Use properly trained security officers to deal with aggressive
behavior. Follow written security procedures.
I
Ensure that adequate and properly trained staff are available to
restrain patients or clients, if necessary.
I
Provide sensitive and timely information to people waiting in
line or in waiting rooms. Adopt measures to decrease waiting
time.
I
Ensure that adequate and qualified staff are available at all
times. The times of greatest risk occur during patient transfers,
emergency responses, mealtimes and at night. Areas with
the greatest risk include admission units and crisis or acute
care units.
I
Institute a sign-in procedure with passes for visitors, especially
in a newborn nursery or pediatric department. Enforce visitor
hours and procedures.
I
Establish a list of “restricted visitors” for patients with a history
of violence or gang activity. Make copies available at security
checkpoints, nurses’ stations and visitor sign-in areas.
I
Review and revise visitor check systems, when necessary. Limit
information given to outsiders about hospitalized victims of
violence.
I
Supervise the movement of psychiatric clients and patients
throughout the facility.
I
Control access to facilities other than waiting rooms, particularly
drug storage or pharmacy areas.
I
Prohibit employees from working alone in emergency areas or
walk-in clinics, particularly at night or when assistance is
unavailable. Do not allow employees to enter seclusion rooms
alone.
I
Establish policies and procedures for secured areas and
emergency evacuations.
16
I
Determine the behavioral history of new and transferred patients
to learn about any past violent or assaultive behaviors.
I
Establish a system—such as chart tags, log books or verbal
census reports—to identify patients and clients with assaultive
behavior problems. Keep in mind patient confidentiality and
worker safety issues. Update as needed.
I
Treat and interview aggressive or agitated clients in relatively
open areas that still maintain privacy and confidentiality
(such as rooms with removable partitions).
I
Use case management conferences with coworkers and
supervisors to discuss ways to effectively treat potentially
violent patients.
I
Prepare contingency plans to treat clients who are “acting out”
or making verbal or physical attacks or threats. Consider using
certified employee assistance professionals or in-house social
service or occupational health service staff to help diffuse patient
or client anger.
I
Transfer assaultive clients to acute care units, criminal units or
other more restrictive settings.
I
Ensure that nurses and physicians are not alone when per-
forming intimate physical examinations of patients.
I
Discourage employees from wearing necklaces or chains to help
prevent possible strangulation in confrontational situations.
Urge community workers to carry only required identification
and money.
I
Survey the facility periodically to remove tools or possessions
left by visitors or maintenance staff that could be used inappro-
priately by patients.
I
Provide staff with identification badges, preferably without last
names, to readily verify employment.
I
Discourage employees from carrying keys, pens or other items
that could be used as weapons.
I
Provide staff members with security escorts to parking areas in
evening or late hours. Ensure that parking areas are highly
visible, well lit and safely accessible to the building.
I
Use the “buddy system,” especially when personal safety may
be threatened. Encourage home health care providers, social
service workers and others to avoid threatening situations.
17
I
Advise staff to exercise extra care in elevators, stairwells and
unfamiliar residences; leave the premises immediately if there is
a hazardous situation; or request police escort if needed.
I
Develop policies and procedures covering home health care
providers, such as contracts on how visits will be conducted, the
presence of others in the home during the visits and the refusal
to provide services in a clearly hazardous situation.
I
Establish a daily work plan for field staff to keep a designated
contact person informed about their whereabouts throughout
the workday. Have the contact person follow up if an employee
does not report in as expected.
Employer responses to incidents of violence
Post-incident response and evaluation are essential to an
effective violence prevention program. All workplace violence
programs should provide comprehensive treatment for employees
who are victimized personally or may be traumatized by witnessing
a workplace violence incident. Injured staff should receive prompt
treatment and psychological evaluation whenever an assault takes
place, regardless of its severity. Provide the injured transportation
to medical care if it is not available onsite.
Victims of workplace violence suffer a variety of consequences
in addition to their actual physical injuries. These may include:
I
Short- and long-term psychological trauma;
I
Fear of returning to work;
I
Changes in relationships with coworkers and family;
I
Feelings of incompetence, guilt, powerlessness; and
I
Fear of criticism by supervisors or managers.
Consequently, a strong follow-up program for these employees
will not only help them to deal with these problems but also help
prepare them to confront or prevent future incidents of violence.
Several types of assistance can be incorporated into the post-
incident response. For example, trauma-crisis counseling, critical-
incident stress debriefing or employee assistance programs may
be provided to assist victims. Certified employee assistance pro-
fessionals, psychologists, psychiatrists, clinical nurse specialists
18
or social workers may provide this counseling or the employer may
refer staff victims to an outside specialist. In addition, the employer
may establish an employee counseling service, peer counseling or
support groups.
Counselors should be well trained and have a good understand-
ing of the issues and consequences of assaults and other aggres-
sive, violent behavior. Appropriate and promptly rendered post-
incident debriefings and counseling reduce acute psychological
trauma and general stress levels among victims and witnesses.
In addition, this type of counseling educates staff about workplace
violence and positively influences workplace and organizational
cultural norms to reduce trauma associated with future incidents.
Safety and Health Training
Training and education ensure that all staff are aware of
potential security hazards and how to protect themselves and their
coworkers through established policies and procedures.
Training for all employees
Every employee should understand the concept of “universal
precautions for violence”— that is, that violence should be expected
but can be avoided or mitigated through preparation. Frequent
training also can reduce the likelihood of being assaulted.
Employees who may face safety and security hazards should
receive formal instruction on the specific hazards associated with
the unit or job and facility. This includes information on the types
of injuries or problems identified in the facility and the methods to
control the specific hazards. It also includes instructions to limit
physical interventions in workplace altercations whenever possible,
unless enough staff or emergency response teams and security
personnel are available. In addition, all employees should be
trained to behave compassionately toward coworkers when an
incident occurs.
The training program should involve all employees, including
supervisors and managers.
New and reassigned employees should receive an initial
orientation before being assigned their job duties. Visiting staff,
such as physicians, should receive the same training as permanent
staff. Qualified trainers should instruct at the comprehension level
19
appropriate for the staff. Effective training programs should involve
role playing, simulations and drills.
Topics may include management of assaultive behavior, profes-
sional assault-response training, police assault-avoidance programs
or personal safety training such as how to prevent and avoid
assaults. A combination of training programs may be used,
depending on the severity of the risk.
Employees should receive required training annually. In large
institutions, refresher programs may be needed more frequently,
perhaps monthly or quarterly, to effectively reach and inform all
employees.
What training should cover
The training should cover topics such as:
I
The workplace violence prevention policy;
I
Risk factors that cause or contribute to assaults;
I
Early recognition of escalating behavior or recognition of
warning signs or situations that may lead to assaults;
I
Ways to prevent or diffuse volatile situations or aggressive
behavior, manage anger and appropriately use medications as
chemical restraints;
I
A standard response action plan for violent situations, including
the availability of assistance, response to alarm systems and
communication procedures;
I
Ways to deal with hostile people other than patients and clients,
such as relatives and visitors;
I
Progressive behavior control methods and safe methods to
apply restraints;
I
The location and operation of safety devices such as alarm
systems, along with the required maintenance schedules and
procedures;
I
Ways to protect oneself and coworkers, including use of the
“buddy system;”
I
Policies and procedures for reporting and recordkeeping;
I
Information on multicultural diversity to increase staff sensitivity
to racial and ethnic issues and differences; and
20
I
Policies and procedures for obtaining medical care, counseling,
workers’ compensation or legal assistance after a violent
episode or injury.
Training for supervisors and managers
Supervisors and managers need to learn to recognize high-risk
situations, so they can ensure that employees are not placed in
assignments that compromise their safety. They also need training
to ensure that they encourage employees to report incidents.
Supervisors and managers should learn how to reduce security
hazards and ensure that employees receive appropriate training.
Following training, supervisors and managers should be able to
recognize a potentially hazardous situation and to make any
necessary changes in the physical plant, patient care treatment
program and staffing policy and procedures to reduce or eliminate
the hazards.
Training for security personnel
Security personnel need specific training from the hospital or
clinic, including the psychological components of handling
aggressive and abusive clients, types of disorders and ways to
handle aggression and defuse hostile situations.
The training program should also include an evaluation. At least
annually, the team or coordinator responsible for the program
should review its content, methods and the frequency of training.
Program evaluation may involve supervisor and employee inter-
views, testing and observing and reviewing reports of behavior of
individuals in threatening situations.
Recordkeeping and Program Evaluation
How employers can determine program effectiveness
Recordkeeping and evaluation of the violence prevention
program are necessary to determine its overall effectiveness and
identify any deficiencies or changes that should be made.
Records employers should keep
Recordkeeping is essential to the program’s success. Good
records help employers determine the severity of the problem,
21
evaluate methods of hazard control and identify training needs.
Records can be especially useful to large organizations and for
members of a business group or trade association who “pool”
data. Records of injuries, illnesses, accidents, assaults, hazards,
corrective actions, patient histories and training can help identify
problems and solutions for an effective program.
Important Records:
I
OSHA Log of Work-Related Injury and Illness (OSHA Form 300).
Employers who are required to keep this log must record any
new work-related injury that results in death, days away from
work, days of restriction or job transfer, medical treatment
beyond first aid, loss of consciousness or a significant injury
diagnosed by a licensed health care professional. Injuries
caused by assaults must be entered on the log if they meet the
recording criteria. All employers must report, within 24 hours, a
fatality or an incident that results in the hospitalization of three
or more employees.8
I
Medical reports of work injury and supervisors’ reports for each
recorded assault. These records should describe the type of
assault, such as an unprovoked sudden attack or patient-to-
patient altercation; who was assaulted; and all other circum-
stances of the incident. The records should include a description
of the environment or location, potential or actual cost, lost work
time that resulted and the nature of injuries sustained. These
medical records are confidential documents and should be kept
in a locked location under the direct responsibility of a health
care professional.
I
Records of incidents of abuse, verbal attacks or aggressive
behavior that may be threatening, such as pushing or shouting
and acts of aggression toward other clients. This may be kept as
part of an assaultive incident report. Ensure that the affected
department evaluates these records routinely. (See sample
violence incident forms in Appendix B.)
I
Information on patients with a history of past violence, drug
abuse or criminal activity recorded on the patient’s chart. All staff
who care for a potentially aggressive, abusive or violent client
829 CFR Part 1904, revised 2001.
22
should be aware of the person’s background and history. Log the
admission of violent patients to help determine potential risks.
I
Documentation of minutes of safety meetings, records of hazard
analyses and corrective actions recommended and taken.
I
Records of all training programs, attendees and qualifications
of trainers.
Elements of a program evaluation
As part of their overall program, employers should evaluate
their safety and security measures. Top management should review
the program regularly, and with each incident, to evaluate its
success. Responsible parties (including managers, supervisors and
employees) should reevaluate policies and procedures on a regular
basis to identify deficiencies and take corrective action.
Management should share workplace violence prevention
evaluation reports with all employees. Any changes in the program
should be discussed at regular meetings of the safety committee,
union representatives or other employee groups.
All reports should protect employee confidentiality either by
presenting only aggregate data or by removing personal identifiers
if individual data are used.
Processes involved in an evaluation include:
I
Establishing a uniform violence reporting system and regular
review of reports;
I
Reviewing reports and minutes from staff meetings on safety
and security issues;
I
Analyzing trends and rates in illnesses, injuries or fatalities
caused by violence relative to initial or “baseline” rates;
I
Measuring improvement based on lowering the frequency and
severity of workplace violence;
I
Keeping up-to-date records of administrative and work practice
changes to prevent workplace violence to evaluate how well
they work;
I
Surveying employees before and after making job or worksite
changes or installing security measures or new systems to
determine their effectiveness;
23
I
Keeping abreast of new strategies available to deal with violence
in the health care and social service fields as they develop;
I
Surveying employees periodically to learn if they experience
hostile situations concerning the medical treatment they
provide;
I
Complying with OSHA and State requirements for recording and
reporting deaths, injuries and illnesses; and
I
Requesting periodic law enforcement or outside consultant
review of the worksite for recommendations on improving
employee safety.
Sources of assistance for employers
Employers who would like help in implementing an appropriate
workplace violence prevention program can turn to the OSHA
Consultation Service provided in their State. To contact this service,
see OSHA’s website at www.osha.gov or call (800) 321-OSHA.
OSHA’s efforts to help employers combat workplace violence are
complemented by those of NIOSH, public safety officials, trade
associations, unions, insurers and human resource and employee
assistance professionals, as well as other interested groups.
Employers and employees may contact these groups for additional
advice and information. NIOSH can be reached toll-free at (800)
35-NIOSH.
Conclusion
OSHA recognizes the importance of effective safety and health
program management in providing safe and healthful workplaces.
Effective safety and health programs improve both morale and pro-
ductivity and reduce workers’ compensation costs.
OSHA’s violence prevention guidelines are an essential
component of workplace safety and health programs. OSHA
believes the performance-oriented approach of these guidelines
provides employers with flexibility in their efforts to maintain safe
and healthful working conditions.
24
References
California State Department of Industrial Relations, Cal/OSHA.
(1998). Guidelines for Security and Safety of Health Care and
Community Service Workers.
www.dir.ca.gov/dosh/dosh%5Fpublications/hcworker.html
Centers for Disease Control and Prevention, National Institute for
Occupational Health. (2002). Occupational Hazards in Hospitals.
DHHS (NIOSH) Pub. No. 2002-101.
www.cdc.gov/niosh/2002-101.html
U.S. Department of Justice, Bureau of Justice Statistics. (2001).
National Crime Victimization Survey. Violence in the Workplace,
1993–99. www.ojp.gov/bjs/pub/pdf/vw99.pdf
U.S. Department of Labor, Bureau of Labor Statistics. (2002).
Census of Fatal Occupational Injuries, 2001.
www.bls.gov/iif/oshwc/cfoi/cfnr0008.pdf
U.S. Department of Labor, Bureau of Labor Statistics. (2001).
Survey of Occupational Injuries and Illnesses, 2000.
www.bls.gov/iif/oshwc/osh/os/osnr0013.pdf
Washington, Department of Labor and Industries. Workplace
Violence: Awareness and Prevention for Employers and
Employees, 2000. www.lni.wa.gov/ipub/417-140-000.htm
OSHA assistance
OSHA can provide extensive help through a variety of programs,
including technical assistance about effective safety and health
programs, state plans, workplace consultations, voluntary pro-
tection programs, strategic partnerships, training and education and
more. An overall commitment to workplace safety and health can
add value to your business, to your workplace and to your life.
Safety and Health Program Management Guidelines
Effective management of worker safety and health protection is
a decisive factor in reducing the extent and severity of work-related
injuries and illnesses and their related costs. In fact, an effective
safety and health program forms the basis of good worker pro-
tection and can save time and money (about $4 for every dollar
25
spent) and increase productivity and reduce worker injuries,
illnesses and related workers’ compensation costs.
To assist employers and employees in developing effective
safety and health programs, OSHA published recommended Safety
and Health Program Management Guidelines (54 Federal Register
(16): 3904-3916, January 26, 1989). These voluntary guidelines
apply to all places of employment covered by OSHA.
The guidelines identify four general elements critical to the
development of a successful safety and health management
program:
I
Management leadership and employee involvement.
I
Work analysis.
I
Hazard prevention and control.
I
Safety and health training.
The guidelines recommend specific actions, under each of
these general elements, to achieve an effective safety and health
program. The Federal Register notice is available online at
www.osha.gov.
State Programs
The Occupational Safety and Health Act of 1970 (OSH Act)
encourages states to develop and operate their own job safety and
health plans. OSHA approves and monitors these plans. There are
currently 26 state plans: 23 cover both private and public (state and
local government) employment; 3 states, Connecticut, New Jersey
and New York, cover the public sector only. States and territories
with their own OSHA-approved occupational safety and health
plans must adopt standards identical to, or at least as effective as,
the federal standards.
Consultation Services
Consultation assistance is available on request to employers
who want help in establishing and maintaining a safe and healthful
workplace. Largely funded by OSHA, the service is provided at no
cost to the employer. Primarily developed for smaller employers
with more hazardous operations, the consultation service is de-
livered by state governments employing professional safety and
health consultants. Comprehensive assistance includes an appraisal
of all-mechanical systems, work practices and occupational safety
26
and health hazards of the workplace and all aspects of the
employer’s present job safety and health program. In addition, the
service offers assistance to employers in developing and imple-
menting an effective safety and health program. No penalties are
proposed or citations issued for hazards identified by the con-
sultant. OSHA provides consultation assistance to the employer
with the assurance that his or her name and firm and any infor-
mation about the workplace will not be routinely reported to OSHA
enforcement staff.
Under the consultation program, certain exemplary employers
may request participation in OSHA’s Safety and Health Achievement
Recognition Program (SHARP). Eligibility for participation in SHARP
includes receiving a comprehensive consultation visit, demonstrat-
ing exemplary achievements in workplace safety and health by
abating all identified hazards and developing an excellent safety
and health program.
Employers accepted into SHARP may receive an exemption
from programmed inspections (not complaint or accident investiga-
tion inspections) for a period of one year. For more information
concerning consultation assistance, see the OSHA website at
www.osha.gov.
Voluntary Protection Programs (VPP)
Voluntary Protection Programs and onsite consultation services,
when coupled with an effective enforcement program, expand
worker protection to help meet the goals of the OSH Act. The
three levels of VPP are Star, Merit, and Demonstration designed to
recognize outstanding achievements by companies that have suc-
cessfully incorporated comprehensive safety and health programs
into their total management system. The VPPs motivate others to
achieve excellent safety and health results in the same outstanding
way as they establish a cooperative relationship between employers,
employees and OSHA.
For additional information on VPP and how to apply, contact the
OSHA regional offices listed at the end of this publication.
Strategic Partnership Program
OSHA’s Strategic Partnership Program, the newest member of
OSHA’s cooperative programs, helps encourage, assist and
recognize the efforts of partners to eliminate serious workplace
27
hazards and achieve a high level of worker safety and health.
Whereas OSHA’s Consultation Program and VPP entail one-on-one
relationships between OSHA and individual worksites, most
strategic partnerships seek to have a broader impact by building
cooperative relationships with groups of employers and
employees. These partnerships are voluntary, cooperative relation-
ships between OSHA, employers, employee representatives and
others (e.g., trade unions, trade and professional associations,
universities and other government agencies).
For more information on this and other cooperative programs,
contact your nearest OSHA office, or visit OSHA’s website at
www.osha.gov.
Alliance Programs
The Alliances Program enables organizations committed to
workplace safety and health to collaborate with OSHA to prevent
injuries and illnesses in the workplace. OSHA and the Alliance par-
ticipants work together to reach out to, educate and lead the
nation’s employers and their employees in improving and
advancing workplace safety and health.
Alliances are open to all groups, including trade or professional
organizations, businesses, labor organizations, educational institu-
tions and government agencies. In some cases, organizations may
be building on existing relationships with OSHA that were devel-
oped through other cooperative programs.
There are few formal program requirements for Alliances and
the agreements do not include an enforcement component.
However, OSHA and the participating organizations must define,
implement and meet a set of short- and long-term goals that fall
into three categories: training and education; outreach and commu-
nication; and promoting the national dialogue on workplace safety
and health.
OSHA Training and Education
OSHA area offices offer a variety of information services, such as
compliance assistance, technical advice, publications, audiovisual
aids and speakers for special engagements. OSHA’s Training
Institute in Arlington Heights, Ill., provides basic and advanced
courses in safety and health for federal and state compliance
officers, state consultants, federal agency personnel, and private
28
sector employers, employees and their representatives.
The OSHA Training Institute also has established OSHA Training
Institute Education Centers to address the increased demand for its
courses from the private sector and from other federal agencies.
These centers are nonprofit colleges, universities and other organi-
zations that have been selected after a competition for participation
in the program.
OSHA also provides funds to nonprofit organizations, through
grants, to conduct workplace training and education in subjects
where OSHA believes there is a lack of workplace training. Grants
are awarded annually. Grant recipients are expected to contribute
20 percent of the total grant cost.
For more information on grants, training and education, contact
the OSHA Training Institute, Office of Training and Education, 2020
South Arlington Heights Road, Arlington Heights, IL 60005, (847)
297-4810 or see “Outreach” on OSHA’s website at www.osha.gov.
For further information on any OSHA program, contact your nearest
OSHA area or regional office listed at the end of this publication.
Information Available Electronically
OSHA has a variety of materials and tools available on its
website at www.osha.gov. These include e-Tools such as Expert
Advisors, Electronic Compliance Assistance Tools (e-cats), Technical
Links; regulations, directives and publications; videos and other
information for employers and employees. OSHA’s software
programs and compliance assistance tools walk you through
challenging safety and health issues and common problems to find
the best solutions for your workplace.
OSHA’s CD-ROM includes standards, interpretations, directives
and more, and can be purchased on CD-ROM from the U.S.
Government Printing Office. To order, write to the Superintendent
of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954 or phone
(202) 512-1800, or order online at http://bookstore.gpo.gov.
OSHA Publications
OSHA has an extensive publications program. For a listing of
free or sales items, visit OSHA’s website at www.osha.gov or
contact the OSHA Publications Office, U.S. Department of Labor,
200 Constitution Avenue, NW, N-3101, Washington, DC 20210.
Telephone (202) 693-1888 or fax to (202) 693-2498.
29
Contacting OSHA
To report an emergency, file a complaint or seek OSHA advice,
assistance or products, call (800) 321-OSHA or contact your nearest
OSHA regional or area office listed at the end of this publication.
The teletypewriter (TTY) number is (877) 889-5627.
You can also file a complaint online and obtain more infor-
mation on OSHA federal and state programs by visiting OSHA’s
website at www.osha.gov.
OSHA Regional Offices
Region I
(CT,* ME, MA, NH, RI, VT*)
JFK Federal Building, Room E340
Boston, MA 02203
(617) 565-9860
Region II
(NJ,* NY,* PR,* VI*)
201 Varick Street, Room 670
New York, NY 10014
(212) 337-2378
Region III
(DE, DC, MD,* PA,* VA,* WV)
The Curtis Center
170 S. Independence Mall West
Suite 740 West
Philadelphia, PA 19106-3309
(215) 861-4900
Region IV
(AL, FL, GA, KY,* MS, NC,* SC,* TN*)
61 Forsyth Street, SW
Atlanta, GA 30303
(404) 562-2300
Region V
(IL, IN,* MI,* MN,* OH, WI)
230 South Dearborn Street, Room 3244
Chicago, IL 60604
(312) 353-2220
30
Region VI
(AR, LA, NM,* OK, TX)
525 Griffin Street, Room 602
Dallas, TX 75202
(214) 767-4731 or 4736 x224
Region VII
(IA,* KS, MO, NE)
City Center Square
1100 Main Street, Suite 800
Kansas City, MO 64105
(816) 426-5861
Region VIII
(CO, MT, ND, SD, UT,* WY*)
1999 Broadway, Suite 1690
PO Box 46550
Denver, CO 80201-6550
(303) 844-1600
Region IX
(American Samoa, AZ,* CA,* HI, NV,* Northern Mariana Islands)
71 Stevenson Street, Room 420
San Francisco, CA 94105
(415) 975-4310
Region X
(AK,* ID, OR,* WA*)
1111 Third Avenue, Suite 715
Seattle, WA 98101-3212
(206) 553-5930
*These states and territories operate their own OSHA-approved job
safety and health programs (Connecticut, New Jersey and New York plans
cover public employees only). States with approved programs must have a
standard that is identical to, or at least as effective as, the federal standard.
Note: To get contact information for OSHA Area Offices, OSHA-
approved State Plans and OSHA Consultation Projects, please visit us
online at www.osha.gov or call us at 1-800-321-OSHA.
31
Appendix A:
Workplace Violence Program Checklists
Reprinted with permission of the American Nurses Association,
Promoting Safe Work Environments for Nurses, 2002.
Checklist 1:
Organizational Assessment Questions Regarding
Management Commitment and Employee Involvement
I
Is there demonstrated organizational concern for employee
emotional and physical safety and health as well as that of the
patients?
I
Is there a written workplace violence prevention program in your
facility?
I
Did front-line workers as well as management participate in
developing the plan?
I
Is there someone clearly responsible for the violence prevention
program to ensure that all managers, supervisors, and
employees understand their obligations?
I
Do those responsible have sufficient authority and resources to
take all action necessary to ensure worker safety?
I
Does the violence prevention program address the kinds of
violent incidents that are occurring in your facility?
I
Does the program provide for post-assault medical treatment
and psychological counseling for health-care workers who
experience or witness assaults or violence incidents?
I
Is there a system to notify employees promptly about specific
workplace security hazards or threats that are made? Are
employees aware of this system?
I
Is there a system for employees to inform management about
workplace security hazards or threats without fear of reprisal?
Are employees aware of this system?
I
Is there a system for employees to promptly report violent
incidents, “near misses,” threats, and verbal assaults without
fear of reprisal?
I
Is there tracking, trending, and regular reporting on violent
incidents through the safety committee?
32
I
Are front-line workers included as regular members and partici-
pants in the safety committee as well as violence tracking
activities?
I
Does the tracking and reporting capture all types of violence—
fatalities, physical assaults, harassment, aggressive behavior,
threats, verbal abuse, and sexual assaults?
I
Does the tracking and reporting system use the latest categories
of violence so data can be compared?
I
Have the high-risk locations or jobs with the greatest risk of
violence as well as the processes and procedures that put
employees at risk been identified?
I
Is there a root-cause analysis of the risk factors associated with
individual violent incidents so that current response systems can
be addressed and hazards can be eliminated and corrected?
I
Are employees consulted about what corrective actions need to
be taken for single incidents or surveyed about violence
concerns in general?
I
Is there follow-up of employees involved in or witnessing violent
incidents to assure that appropriate medical treatment and
counseling have been provided?
I
Has a process for reporting violent incidents within the facility to
the police or requesting police assistance been established?
Identifying Risks for Violence by Unit/Work Area
Perform a step-by-step review of each work area to identify
specific places and times that violent incidents are occurring and
the risk factors that are present. To ensure multiple perspectives, it
is best for a team to perform this worksite analysis. Key members
of the analysis team should be front-line health care workers,
including nurses from each specialty unit, as well as the facility’s
safety and security professionals.
Find Out What’s Happening on Paper
The first step in this worksite analysis is to obtain and review
data that tells the “who, what, when, where and why” about violent
incidents. These sources include:
I
Incident report forms
I
Workers’ compensation reports of injury
33
I
OSHA 300 injury and illness logs
I
Security logs
I
Reports to police
I
Safety committee reports
I
Hazard inspection reports
I
Staff termination records
I
Union complaints
Using this information, attempt to answer the questions in
Checklist 2.
Checklist 2:
Analyze Workplace Violence Records
I
How many incidents occurred in the last 2 years?
I
What kinds of incidents occurred most often (assault, threats,
robbery, vandalism, etc.)?
I
Where did incidents most often occur?
I
When did incidents most often occur (day of week, shift, time,
etc.)?
I
What job task was usually being performed when an incident
occurred?
I
Which workers were victimized most often (gender, age, job
classification, etc.)?
I
What type of weapon was used most often?
I
Are there any similarities among the assailants?
I
What other incidents, if any, are you aware of that are not
included in the records?
I
Of those incidents you reviewed, which one or two were most
serious?
Use the data collected to stimulate the following
discussions:
I
Are there any important patterns or trends among the incidents?
I
What do you believe were the main factors contributing to
violence in your workplace?
34
I
What additional corrective measures would you recommend to
reduce or eliminate the problems you identified?
Conduct a Walkthrough
It is important to keep in mind that injuries from violence are
often not reported. One of the best ways to observe what is really
going on is to conduct a workplace walkthrough.
A walkthrough, which is really a workplace inspection, is the first
step in identifying violence risk factors and serves several important
functions. While on a walkthrough, hazards can be recognized and
often corrected before anyone’s health and safety is affected.
While inspecting for workplace violence risk factors, review the
physical facility and note the presence or absence of security
measures. Local police may also be able to conduct a security audit
or provide information about experience with crime in the area.
Ask the Workers
A simple survey can provide valuable information often not
found in department walkthroughs and injury logs. Some staff may
not report violent acts or threatening situations formally but will
share the experiences and suggestions anonymously. This can
provide information about previously unnoticed deficiencies or
failures in work practices or administrative controls. It also can help
increase employee awareness about dangerous conditions and
encourage them to become involved in prevention activities.
Types of questions that employees should be asked include:
I
What do they see as risk factors for violence?
I
The most important risk factors in their work areas
I
Aspects of the physical environment that contribute to
violence
I
Dangerous situations or “near misses” experienced
I
Assault experiences—past year, entire time at facility
I
Staffing adequacy
I
How are current control measures working?
I
Hospital practices for handling conflict among staff and
patients
I
Effectiveness of response to violent incidents
35
I
How safe they feel in the current environment
I
What ideas do employees have to protect workers?
I
Highest priorities in violence prevention
I
Ideas for improvements and prevention measures
I
How satisfied are they in their jobs?
I
With managers/fellow workers
I
Adequacy of rewards and praise
I
Impact on health
Checklist 3:
Identifying Environmental Risk Factors for Violence
Use the following checklist to assist in your workplace
walkthrough.
General questions about approach:
I
Are safety and security issues specifically considered in the early
stages of facility design, construction, and renovation?
I
Does the current violence prevention program provide a way to
select and implement controls based on the specific risks
identified in the workplace security analysis? How does this
process occur?
Specific questions about the environment:
I
Do crime patterns in the neighborhood influence safety in the
facility?
I
Do workers feel safe walking to and from the workplace?
I
Are entrances visible to security personnel and are they well lit
and free of hiding places?
I
Is there adequate security in parking or public transit waiting
areas?
I
Is public access to the building controlled, and is this system
effective?
I
Can exit doors be opened only from the inside to prevent unau-
thorized entry?
36
I
Is there an internal phone system to activate emergency
assistance?
I
Have alarm systems or panic buttons been installed in high-risk
areas?
I
Given the history of violence at the facility, is a metal detector
appropriate in some entry areas? Closed-circuit TV in high-risk
areas?
I
Is there good lighting?
I
Are fire exits and escape routes clearly marked?
I
Are reception and work areas designed to prevent unauthorized
entry? Do they provide staff good visibility of patients and
visitors? If not, are there other provisions such as security
cameras or mirrors?
I
Are patient or client areas designed to minimize stress, including
minimizing noise?
I
Are drugs, equipment, and supplies adequately secured?
I
Is there a secure place for employees to store their belongings?
I
Are “safe rooms” available for staff use during emergencies?
I
Are door locks in patient rooms appropriate? Can they be
opened during an emergency?
I
Do counseling or patient care rooms have two exits, and is
furniture arranged to prevent employees from becoming
trapped?
I
Are lockable and secure bathrooms that are separate from
patient-client and visitor facilities available for staff members?
Checklist 4:
Assessing the Influence of Day-to-Day Work Practices on
Occurrences of Violence
I
Are identification tags required for both employees and visitors
to the building?
I
Is there a way to identify patients with a history of violence? Are
contingency plans put in place for these patients—such as restrict-
ing visitors and supervising their movement through the facility?
I
Are emergency phone numbers and procedures posted or
readily available?
37
I
Are there trained security personnel accessible to workers in a
timely manner?
I
Are waiting times for patients kept as short as possible to avoid
frustration?
I
Is there adequate and qualified staffing at all times, particularly
during patient transfers, emergency responses, mealtimes, and
at night?
I
Are employees prohibited from entering seclusion rooms alone
or working alone in emergency areas of walk-in clinics, particu-
larly at night or when assistance is unavailable?
I
Are broken windows, doors, locks, and lights replaced promptly?
I
Are security alarms and devices tested regularly?
Checklist 5:
Post-Incident Response
I
Is comprehensive treatment provided to victimized employees
as well as those who may be traumatized by witnessing a
workplace violence incident? Required services may include
trauma-crisis counseling, critical incident stress debriefing, psy-
chological counseling services, peer counseling, and support
groups.
Checklist 6:
Assessing Employee and Supervisor Training
I
Does the violence prevention program require training for all
employees and supervisors when they are hired and when job
responsibilities change?
I
Do agency workers or contract physicians and house staff
receive the same training that permanent staff receive?
I
Are workers trained in how to handle difficult clients or patients?
I
Does the security staff receive specialized training for the health-
care environment?
I
Is the training tailored to specific units, patient populations, and
job tasks, including any tasks done in the field?
I
Do employees learn progressive behavior control methods and
safe methods to apply restraints?
38
I
Do workers believe that the training is effective in handling
escalating violence or violent incidents?
I
Are drills conducted to test the response of health-care facility
personnel?
I
Are workers trained in how to report violent incidents, threats, or
abuse and obtain medical care, counseling, workers’ compensa-
tion, or legal assistance after a violent episode or injury?
I
Are employees and supervisors trained to behave compassion-
ately toward coworkers when an incident occurs?
I
Does the training include instruction about the location and
operation of safety devices such as alarm systems, along with
the required maintenance schedules and procedures?
Checklist 7:
Recordkeeping and Evaluation
Does the violence prevention program provide for:
I
Up-to-date recording in the OSHA Log of Work-Related Injury
and Illness (OSHA 300)?
I
Records of all incidents involving assault, harassment,
aggressive behavior, abuse, and verbal attack with attention to
maintaining appropriate confidentiality of the records?
I
Training records?
I
Workplace walkthrough and security inspection records?
I
Keeping records of control measures instituted in response to
inspections, complaints, or violent incidents?
I
A system for regular evaluation of engineering, administrative,
and work practice controls to see if they are working well?
I
A system for regular review of individual reports and trending
and analysis of all incidents?
I
Employee surveys regarding the effectiveness of control
measures instituted?
I
Discussions with employees who are involved in hostile
situations to ask about the quality of post-incident treatment
they received?
I
A provision for an outside audit or consultation of the violence
programs for recommendations on improving safety?
39
Appendix B
Violence Incident Report Forms
Sample 1
The following items serve merely as an example of what might be used or
modified by employers in these industries to help prevent workplace violence.
(Sample/Draft—Adapt to your own location and business circumstances.)
Confidential Incident Report
To:
Date of Incident:
Location of Incident (Map/sketch on reverse side or attached):
From:
Phone:
Time of Incident:
Nature of the Incident (“X” all applicable boxes):
❑ Assaults or Violent Acts: Type “l”
Type “2” Type “3”
Other
❑ Preventative or Warning Report
❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No
❑ Transportation Accident ❑ Contacts with Objects or Equipment
❑ Falls ❑ Exposures ❑ Fires or Explosions ❑ Other
Legal Counsel Advised of Incident? ❑ Yes ❑ No EAP Advised? ❑ Yes ❑ No
Warning or Preventative Measures? ❑ Yes ❑ No
Number of Persons Affected:
(For each person, complete a report; however, to the extent facts are duplicative, any
person’s report may incorporate another person’s report.)
Name of Affected Person(s):
Service Date:
Position:
Member of Labor Organization? ❑ Yes ❑ No
Supervisor:
Has Supervisor Been Notified? ❑ Yes ❑ No
Family:
Has Been Notified by: ? ❑ Yes ❑ No
Lost Work Time? ❑ Yes ❑ No Anticipated Return to Work:
Third parties or non-employee involvement (include contractor and lease
employees, visitors, vendors, customers)? ❑ Yes ❑ No
Nature of the Incident
Briefly describe: (1) event(s); (2) witnesses with addresses and status
included; (3) location details; (4) equipment/weapon details; (5) weather;
(6) other records of the incident (e.g., police report, recordings, videos);
(7) the ability to observe and reliability of witnesses; (8) were the parties
possibly impaired because of illness, injury, drugs or alcohol? (were tests
taken to verify same?); (9) parties notified internally (employee relations,
medical, legal, operations, etc.) and externally (police, fire, ambulance,
EAP, family, etc.).
Previous or Related Incidents of This Type? ❑ Yes ❑ No
Or by This Person? ❑ Yes ❑ No Preventative Steps? ❑ Yes ❑ No
OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No
Incident Response Team:
Team Leader:
Signature
Date
Source: Reprinted with permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm of
Abbott, Nicholson, Quilter, Esshaki & Youngblood, P. C., Detroit, MI.
40
Sample 2
The following items serve merely as an example of what might be used or
modified by employers in these industries to help prevent workplace violence.
A reportable violent incident should be defined as any threatening remark
or overt act of physical violence against a person(s) or property whether
reported or observed.
1. Date:
Day of Week: Time: Assailant: ❑ Female ❑ Male
2. Specific Location:
3. Violence Directed Toward: ❑ Patient ❑ Staff ❑ Visitor ❑ Other
Assailant: ❑ Patient ❑ Staff ❑ Visitor ❑ Other
Assailant’s Name:
Assailant: ❑ Unarmed ❑ Armed (weapon)
4. Predisposing Factors:
❑ Intoxication
❑ Dissatisfied with Care/Waiting Time
❑ Grief Reaction
❑ Prior History of Violence
❑ Gang Related
❑ Other (Describe)
5. Description of Incident:
❑ Physical Abuse ❑ Verbal Abuse ❑ Other
6. Injuries:
❑ Yes ❑ No
7. Extent of Injuries:
8. Detailed Description of the Incident:
9. Did Any Person Leave the Area because of Incident?
❑ Yes ❑ No ❑ Unable to Determine
10. Present at Time of Incident:
❑ Police Name of Department:
❑ Hospital Security Officer
11. Needed to Call:
❑ Police Name of Department:
❑ Hospital Security
12. Termination of Incident:
Incident Diffused ❑ Yes ❑ No Police Notified ❑ Yes ❑ No
Assailant Arrested ❑ Yes ❑ No
13. Disposition of Assailant:
❑ Stayed on Premises ❑ Escorted off Premises ❑ Left on Own ❑ Other
14. Restraints Used: ❑ Yes ❑ No Type:
15. Report Completed By:
Title:
Witnesses:
Supervisor Notified:
Time:
Please put additional comments, according to numbered section, on reverse side of form.
Source: Reprinted with permission of the Metropolitan Chicago Healthcare
Council, Guidelines for Dealing with Violence in Health Care, Chicago, IL, 1995.
41
Appendix C
Suggested Readings
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Carroll, V. and Morin, K.H. (1998). “Workplace Violence Affects
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Centers for Disease Control and Prevention, National Institute for
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101.html
Centers for Disease Control and Prevention, National Institute for
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Colling, R.L. (1997). “Controlling Workplace Violence: A Security
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Healthcare Organizations: Environment of Care/PTSM Series
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Colorado Nurses Association, Task Force on Workplace Violence.
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42
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Morgan, L. (1999). “In Harm’s Way: Health Care Professionals Face
Increasing Abuse in the Workplace.” Nurseweek, August 2, 1999.
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43
National Security Institute. (1995). “Guidelines for Workplace
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44
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