Healthcare workers experience a disproportionately high occurrence of assaults compared to the U.S. workforce as a whole. These assaults are most common in hospital facilities but also occur in smaller clinics, psychiatric and social service facilities, nursing homes and other long-term care facilities, homes visited by workers, and during transportation of patients. The wide variety of settings, plus the even greater variation of conditions within each type of facility, combine to make it difficult for any organization to offer a single set of guidelines for protecting healthcare workers.
OSHA has developed several guidance documents that offer so many suggestions, healthcare employers may be overwhelmed by the choices before them. Here we will condense the information in one OSHA document (Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers) by focusing on the five components of a prevention program, which can be applied in almost any setting.
OSHA states that its violence prevention guidelines are based on industry best practices and feedback from stakeholders. The specific measures an employer will include under each of the five components depends on multiple factors, including history of assault in the facility, effectiveness of existing measures, physical configuration of the facility, characteristics of the surrounding neighborhood (e.g., crime rate), and rate of staff turnover. The employer’s access to funds is, of course, also a factor, but it is not one that OSHA brings up; neither does OSHA discuss the expense employers may face in developing an effective program to protect their healthcare workers or revising an existing program. However, under the Occupational Safety and Health Act of 1970, employers have a responsibility to provide a safe workplace. Employers must expend the necessary funds to accomplish ensure that employees are protected from hazards, including workplace violence.
Management commitment and worker participation
No violence prevention program will succeed absent the full support of top management and participation and steady feedback from employees. This dual level of involvement is essential to safety in any organization and is not unique to health care. OSHA notes that management commitment should be both verbal (e.g., a written policy with goals) and visible (e.g., management participation in facility inspections and discussions with employees). Management commitment also comprises:
- Allocating appropriate authority and resources to all responsible parties. Resource needs often go beyond financial needs and include access to information, personnel, time, training, tools, and equipment.
- Assigning responsibility and authority for the various aspects of the workplace violence prevention program to ensure that all managers and supervisors understand their obligations.
- Maintaining a system of accountability for managers, supervisors, and workers.
- Supporting and implementing appropriate recommendations from safety and health committees.
- Establishing a comprehensive program of medical and psychological counseling and debriefing for workers who have experienced or witnessed assaults and ensuring that trauma-informed care is available.
- Establishing policies that ensure the reporting, recording, and monitoring of incidents and near misses and that there are no reprisals against anyone who does so in good faith.
Employee involvement should include:
- Participation in the development, implementation, evaluation, and modification of the violence prevention program;
- Participation in safety and health committees that receive reports of violent incidents or security problems, making facility inspections, and responding to recommendations for corrective strategies;
- Providing input on additions to or redesigns of facilities;
- Identifying the daily activities that employees believe put them most at risk;
- Discussions and assessments to improve policies and procedures, including complaint and suggestion programs designed to improve safety and security;
- Ensuring that there is a way to report and record incidents and near misses and that issues are addressed appropriately;
- Ensuring that there are procedures to ensure that there is no retaliation against employees who voice concerns or report injuries; and
- Employee training and continuing education programs.
Worksite analysis and hazard identification
A worksite analysis is a step-by-step assessment of the workplace that senior management, supervisors, and workers conduct to find existing or potential hazards that may lead to workplace violence. Once complete, the analysis should be used to identify the types of hazard prevention and control measures needed to reduce or eliminate the possibility of a violent incident. The assessment team should also determine how often and under what circumstances worksite analyses should be conducted (e.g., after every incident or near miss).
The advice of independent reviewers, such as safety and health professionals, law enforcement or security specialists, and insurance safety auditors may be solicited to strengthen programs. Reviews of records of previous assaults and other violent incidents are also essential. If an employer is required to keep records of workplace injuries and illnesses, OSHA 300 logs can be another good source of information. One benefit of such reviews is identification of factors that may be more associated with violence (e.g., departments or units, work areas, job titles, activities, and time of day).
Analysis can also include:
- Job hazard analysis—that is, a review of procedures and operations connected to specific tasks or positions to determine if they contribute to hazards related to workplace violence and/or can be modified to reduce the likelihood of violence occurring.
- Employee surveys that contain questions such as:
- What daily activities expose you to the greatest risk of violence?
- What work activities make you feel unprepared to respond to a violent action?
- Can you recommend changes or additions to the workplace violence prevention training you received?
- Can you describe how a change in a patient’s daily routine affected the precautions you take to address the potential for workplace violence?
Hazard prevention and control
Based on the results of the analysis/hazard identification, employers should identify and evaluate control options for workplace hazards; select effective and feasible controls to eliminate or reduce hazards; implement these controls in the workplace; follow up to confirm that these controls are being used and maintained properly; and evaluate the effectiveness of controls and improve, expand, or update them as needed. Controls include:
- Elimination. Eliminate the hazard or substitute a safer work practice. For example, if possible, transfer a patient with a violent history to a more appropriate facility.
- Engineering controls. In large institutions, such controls include physical barriers, metal detectors, panic buttons, improved lighting, accessible exits, closed-circuit TV, and bulletproof glass. OSHA’s document lists many other engineering controls. Apart from personal communication devices the worker carries, engineering controls are often not feasible in home health care settings.
- Administrative and work practice controls. When engineering controls are not feasible, changing the way a job is performed is the next option. For example, training for administrative and treatment staff should include therapeutic procedures that are sensitive to the cause and stimulus of violence. Trauma-informed services are based on an understanding of the vulnerabilities or triggers of trauma for survivors and can be more supportive than traditional service delivery approaches, thus avoiding retraumatization. Again, OSHA lists many types of possible administrative and work practice controls for different healthcare and social service settings.
- Postincident. When an incident occurs, the immediate first steps are to provide first aid and emergency care for the injured worker(s) and take any measures necessary to prevent others from being injured. All workplace violence programs should provide comprehensive treatment for workers who are victimized or may be traumatized by witnessing workplace violence. Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of its severity—free of charge.
- Investigation. All incidents must be investigated, beginning with management reporting to the appropriate parties inside and outside the institution. Workers should be involved in investigations, which should identify root causes. Near misses should also be investigated.
All healthcare workers are trained to protect their patients and clients; however, training to help healthcare workers keep themselves safe is equally important. Training should aim to raise the overall safety and health knowledge across the workforce; provide employees with the tools needed to identify workplace safety and security hazards; and address potential problems before they arise and ultimately reduce the likelihood of workers being assaulted.
Every worker should understand the concept of universal precautions for violence, that is, that violence should be expected but can be avoided or mitigated through preparation. In addition, workers should understand the importance of a culture of respect, dignity, and active mutual engagement in preventing workplace violence.
New and reassigned workers should receive an initial orientation before being assigned their job duties. All workers should receive mandatory training annually. In high-risk settings and institutions, refresher training may be needed more frequently, perhaps monthly or quarterly, to effectively reach and inform all workers. Visiting staff, such as physicians, should receive the same training as permanent staff and contract workers. Qualified trainers should instruct at the comprehension level appropriate for the staff. Effective training programs should involve role-playing, simulations, and drills.
The OSHA document includes 14 training topics, including early recognition of escalating behavior, diffusing volatile situations, action plans for violent situations, and self-defense.
Recordkeeping and evaluation
Recordkeeping and evaluation of the violence prevention program are necessary to determine its effectiveness and identify any deficiencies or changes that should be made. In addition to OSHA’s Form 300 log, key records include:
- Medical reports of work injury, workers’ compensation reports, and supervisors’ reports for each recorded assault;
- Records of incidents of abuse, reports conducted by security personnel, verbal attacks or aggressive behavior that may be threatening, such as pushing or shouting and acts of aggression toward other clients;
- Information on patients with a history of past violence, drug abuse, or criminal activity recorded on the patient’s chart;
- Documentation of minutes of safety meetings, records of hazard analyses, and corrective actions recommended and taken; and
- Records of all training programs, attendees, and qualifications of trainers.
Finally, as part of their program, employers should evaluate their safety and security measures. Processes comprising an evaluation include:
- Establishing a uniform violence reporting system;
- Tracking recommendations through to completion;
- Keeping abreast of new strategies available to prevent and respond to violence in the healthcare and social service fields; and
- Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving worker safety.
The OSHA document includes many checklists that can be used in evaluations and a lengthy bibliography for additional reading and research.