Practice Tips

The Occupational Safety and Health Administration (OSHA) defines workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers and visitors.

Identify Sources:

Take an approach to workplace violence with the mindset that it can occur at any time in any place. Incorporate all potential sources who may perpetrate workplace violence into the plan. This would include:

1. Patients
2. Staff
3. Strangers
4. Vendors
5. Families/Partners
6. Friends/Acquaintances

Acts of violence by patients upon health care staff, other patients, or visitors can be an extremely difficult situation for the health care team. There may be occasions where, such an act, is clearly an action well thought out by the patient and clearly should be dealt with the local authorities as well as organizational security staff. But many times, patients lack capacity and may cause injury to others. These situations need careful and sensitive review.

Assess and Identify Areas of Risk:

OSHA identifies the following patient, client, and setting-related risk factors:

• Exchange money with the public
• Delivery of passengers, goods, or services
• Mobile workplace such as a taxicab or police cruiser
• Persons in health care, social service, or criminal justice settings
• Working alone or in small numbers
• Working late at night or during early morning hours
• Working in high-crime areas
• Transporting patients and clients
• Working directly with people who have had a history of violence
• Poor environmental design of workplace; poorly lit corridors, rooms, parking lots and other area
• Prevalence of firearms, knives and other weapons among patients and their families
• Guarding valuable property or possessions, working in community-based settings

Organizational Risk Factors:

• Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff/
• Working when understaffed
• Inadequate security and mental health personnel on site
• Long waits for patients or clients and overcrowded waiting rooms
• Unrestricted movement of the public in clinics and hospitals
• Perception that violence is tolerated and victims will not be able to report the incident to police

Develop a Program:

Employers can be fined under OSHA’s General Duty Clause if they fail to provide their employees with a safe working environment, which can include acts of workplace violence. The Occupational Health and Safety Administration Guidelines recommend a written comprehensive workplace violence prevention program which includes the following elements:

1. Management commitment and employee participation
   • Acknowledgement of the value of a safe and violence-free workplace for both the workers and patients/clients
   • Allocating appropriate authority and resources to all responsible parties
   • Assign and ensure all managers and supervisors understand their role and maintain a system of accountability. Include employees from high risk areas
   • Supporting and implementing appropriate recommendations from committees assigned to oversee this work
   • Establishing a comprehensive coverage of medical and psychological counseling
   • Establishing policies that ensure the reporting, recording, and monitoring of incidents and near misses. Foster an open environment to promote the reporting of any act of violence
2. Worksite analysis

   Analysis involves a mutual step-by-step assessment of the workplace to find existing or potential hazards that may lead to incidents of workplace violence. Information is generally collected through surveys from employees, patients/clients, job hazard analysis, and record analysis.

3. Hazard prevention and control

   After worksite analysis is complete the next steps an organization should take are:

   • Identify and evaluate control options for each hazard
   • Select effective controls to eliminate or at minimum reduce hazard/
   • Implement controls
   • Follow up on controls once in place to confirm that they are being used and maintained correctly
   • Continue to evaluate the controls making changes as needed
4. Safety and health training

   Training should be for all workers (include vendors and volunteers). It can help raise knowledge regarding safety, provide tools needed to identify hazards, and address potential problems ahead of time reducing the likelihood of an incident.

   Training should cover the policies and procedures, de-escalation, and self-defense techniques. Other examples of training topics are risk factors that cause or contribute to assaults, early recognition of escalating behavior or recognition of warning signs, and ways to deal with hostile people other than patients.

   Supervisors and managers must be trained to recognize high-risk situations. This will allow them to ensure that workers are not placed in an assignment that compromises their safety. This training should include encouragement to all workers to report any incident and to seek appropriate care should an incident happen. Leadership should also be trained on how to reduce hazards and ensure employees receive training.

   Security personnel need to be trained from the hospital or clinic, this training should include how to handle hostile situations, ways to handle aggression, and also the psychological component of handling abusive and aggressive individuals.

   At least yearly the team or person(s) responsible for the training program should complete a review. This review should include methods, timing, and content of the training program. The evaluation could include discussion/interviews with employee and also review of reports generated from information involving any incidents.

5. Record keeping and program evaluation

   It is necessary to keep records and evaluate the violence prevention program. This will help determine if what you are doing is working and will help identify those areas that need work.

   Examples of some of the documents are: minutes from committee meetings; hazard analyses; corrective action plans; training program; and who attended.

   The program should be reviewed regularly and with a major incident. In addition policies and procedures should be reviewed on a regular basis as well.

   Processes involved in an evaluation include:

   • Consistent reporting system and reports are reviewed regularly
   • Review of safety meeting minutes and reports
   • Review trends and rates in incidents
   • Measure improvements
   • Stay up-to-date on administrative and work practice changes
   • Close the loop on all recommendations
   • Survey employees
   • Comply with all regulatory requirements
   • Invite law enforcement to come in to review worksites and make recommendations for improvements

Other Considerations:

Post-incident procedures and services

If an incident occurs, the very first steps are to provide care for the injured and take any action necessary to prevent anyone else from being injured. Make sure you have a strong follow-up program with those involved in the incident.

Investigation of Incidents

Once the immediate needs are met, the investigation should start. Basic steps are as follows:

• Report as required
• Involve workers involved
• Identify root causes
• Collect and review other information
• Also be sure to investigate any near misses

Hiring Procedures

Perform pre-employment screening. Check personal references and an applicant's criminal record. Confirm application information. Require letters of reference that will help verify information supplied by an applicant. Look for a gap in employment and incomplete or false information on an application. Prior violent behavior at work, frequent job changes, or geographic moves may indicate instability in an individual's life or work.

References:

Noncompliant/Nonadherent Patient Management
https://www.osha.gov/OshDoc/data_General_Facts/factsheet-workplace-violence.pdf
http://www.lni.wa.gov/Safety/Topics/AtoZ/WPV/
https://www.osha.gov/SLTC/workplaceviolence/evaluation.html
https://www.osha.gov/Publications/osha3148.pdf
https://www.crisisprevention.com/Blog/June-2011/Workplace-Violence
https://www.osha.gov/Publications/OSHA3828.pdf
https://www.osha.gov/Publications/osha3148.pdf
https://www.crisisprevention.com/Blog/September-2011/Combating-the-Varieties-of-Violence-at-Work
https://www.jointcommission.org/assets/1/18/SEA_40.PDF
http://www.ashrm.org/resources/workplace_violence/index.dhtml
https://www.cdc.gov/niosh/topics/violence/training_nurses.html
https://www.jointcommission.org/assets/1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf
https://www.dhs.gov/active-shooter-preparedness
https://www.ecri.org/components/HRC/Pages/SafSec3.aspx
https://www.ecri.org/components/HRC/Pages/MenH2.aspx