While workplace violence can happen in any industry or occupation, healthcare and social services workers face a high risk of job-related violence. Workplace assaults ranged from 23,540 and 25,630 annually over a 3-year period, and 70% to 74% of those occurred in healthcare and social services settings.
High-risk settings for healthcare and social services workers include:
- Hospitals and large institutional medical facilities;
- Residential treatment facilities, such as alcohol and drug addiction treatment facilities, nursing homes, psychiatric facilities, and other long-term care facilities;
- Nonresidential treatment or services facilities like small neighborhood clinics and mental health centers;
- Community care facilities like community-based residential facilities and group homes; and
- Fieldwork, including home health care or social services home visits.
Inpatient and acute psychiatric services, geriatric long-term care settings, and high-volume urban emergency departments and residential and day social services present the highest risks of workplace violence.
Risk factors include:
- Working in neighborhoods with high crime rates or directly with people who have a history of violence, who abuse drugs or alcohol, and gang members, as well as relatives of patients or clients;
- Working alone in a facility or in patients’ homes or in poorly designed environments where employees’ vision or route of escape from a violent incident are blocked; and
- Working where firearms, knives, and other weapons are prevalent among patients and their families and friends.
Despite the risks, assaults should not be considered acceptable behavior or part of a healthcare or social services worker’s job.
No OSHA Standard Yet
The Occupational Safety and Health Administration (OSHA) currently has no specific regulation on workplace violence. However, OSHA has created guidelines for employers to protect healthcare and social services workers.
A bill now in the U.S. Senate would require OSHA to establish a workplace violence prevention standard for healthcare and social services. The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1309) passed in the House November 21, 2019. It would require OSHA to establish an interim standard within 1 year based on its 2015 workplace violence prevention program guidelines.
OSHA’s 2015 guidelines cover typical safety and health program elements, such as management commitment and employee participation, worksite hazard analysis, hazard prevention and control methods, safety and health training, and recordkeeping and program evaluation.
Management commitment begins by recognizing workplace violence as a safety and health hazard, allocating resources, and designating authority for all aspects of a workplace violence prevention plan. It also requires a system of accountability for managers, supervisors, and workers.
Employees should be allowed and encouraged to participate in the development, implementation, evaluation, and modification of the workplace violence prevention program. Participation often involves safety and health committees that receive reports of violent incidents or security problems, make facility inspections, and review recommendations for corrective strategies.
Committees typically recommend and review workplace policies and procedures and monitor complaint and suggestion programs designed to improve safety and security. They also would investigate any incidents of workplace violence to identify root causes and make any recommendations for changes to the prevention program.
A prevention program should begin with a step-by-step assessment of the workplace to find existing or potential hazards that may lead to incidents of workplace violence. An assessment should be performed by a team that includes senior management, frontline supervisors, and workers.
The team also could include representatives from the employee assistance program, Human Resources, legal, occupational safety and health, operations, and security staff, depending on the size of the facility. Job hazard analysis can include reviews of incident or injury and illness logs, procedures for different jobs or units, employee surveys, and workplace security analysis.
Prevention, Engineering Controls
Hazard prevention and control should follow the industrial hygiene hierarchy of controls—elimination, substitution, engineering controls, and administrative controls and work practices.
Elimination and substitution may be difficult because the need for patient contact in a hospital or other healthcare setting may make eliminating hazards impractical.
While costly, engineering controls can be some of the most effective measures. Engineering controls in a hospital or residential care facility could include:
- Security/silent alarm systems, panic buttons or paging system at workstations, and personal alarm devices worn by employees;
- Installed or handheld metal detectors with properly trained staff to use equipment and remove weapons;
- Closed-circuit video inside and outside the facility, curved mirrors, glass panels in doors and walls for better monitoring, as well as proper placement of nurses’ stations to allow visual scanning of corridors and other areas;
- Employee “safe rooms” for emergencies; two exits from rooms, wherever possible; and furniture arranged to allow clear exit routes for employees;
- Enclosed receptionist desks with bulletproof glass, deep counters at nurses’ stations, and secure bathrooms for staff members—separated from patient/client and visitor facilities—with locks on the inside; and
- Lockable doors to limit access to unused rooms.
Providing comfortable waiting areas can reduce stress among patients, families, and friends; and dividing waiting areas can limit the spread of agitation. Other engineering controls to reduce risks of violence include:
- Changing or adding materials to reduce noise;
- Ensuring drug cabinets and syringe drawers have working locks;
- Installing bright, effective lighting, both indoors and outdoors on the grounds, in parking areas, and walkways; and ensuring burned-out lights are replaced immediately;
- Padding or replacing sharp-edged objects, such as metal table frames, and smoothing down or covering any sharp surfaces;
- Recessing any handrails, drinking fountains, or other protrusions; and
- Securing furniture and other items that could be used as weapons.
Engineering controls are less practical for community care, home healthcare, and social services workers. Helpful measures can include GPS tracking, mobile phones, and paging systems.
Community care, home health care, social services workers, and their managers should assess homes for exit routes, as well as areas for patients or clients to de-escalate. They should ensure that any carrying equipment for medical equipment, medicines, and valuables has working locks. They should ensure lighting is adequate wherever possible.
Administrative, Work Practice Controls
When engineering controls are infeasible or not completely protective, employers should implement administrative controls and safe work practices.
Administrative controls begin with clearly communicating to patients, clients, visitors, and workers that violence is not permitted and will not be tolerated.
Hospitals and residential treatment facilities should have properly trained security officers and counselors who can respond to aggressive behavior and disarm and de-escalate patients or visitors if necessary.
The movement of patients with a known history of violence should be supervised throughout the facility. Staff should be informed of violent histories or incidents during shift changes. All violent incidents should be reported to the employer.
Employees should determine the behavioral history of new and transferred patients and clients to learn about any past violent or assaultive behavior, including identifying:
- Any event triggers for patients or clients, such as certain dates or visitors;
- The type of past violence, including severity, pattern, and intended purpose; and
- Information that can be used to formulate individualized plans for early identification and prevention of future violence.
Employers should establish a system for identifying patients and clients with a history of violence, such as chart tags, logbooks, or verbal reports that cover triggers and best responses and means of de-escalation.
Other measures include:
- Treating and interviewing aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality;
- Ensuring workers are not alone when performing intimate physical examinations of patients;
- Advising staff to exercise extra care in elevators and stairwells;
- Limiting workers from working alone in emergency areas or walk-in clinics, particularly at night, and using a “buddy system,” especially when personal safety may be threatened;
- Providing security escorts to parking areas during evening and late hours; and
- Varying check-in and check-out times for workers if stalking is suspected and planning different travel routes for those workers.
For workers in all healthcare and social services settings, employers should provide staff with identification badges, preferably without last names; discourage workers from wearing necklaces or chains to prevent possible strangulation; and warn employees against wearing expensive jewelry or carrying large sums of money and keys or other items that could be used as weapons.
The use of head netting or a cap can prevent hair from being grabbed and used to pull or shove workers.
Administrative and work practice controls for community and home care or social services should include having log-in and log-out procedures that cover information such as:
- Name and address of client or patient visited,
- Scheduled time and duration of visit,
- A contact number and code word used to inform someone of an incident or threat, and
- Worker’s vehicle description and license plate number and details of any travel plans with a client.
Workers should be required to contact the office after each visit or if plans change, and managers should have procedures to follow if workers fail to contact the office after a scheduled visit.
Training, Records, Program Evaluation
All workers and supervisors should be trained and periodically retrained in all aspects of the workplace violence prevention program. Security personnel and counselors will need additional specialized training in handling incidents or threats of violence.
Key records in a workplace violence prevention program include:
- OSHA 300 logs of workplace injuries and illnesses;
- Medical and workers’ compensation records following employee injuries;
- Reports of abuse, verbal attacks, and aggressive behavior, including security personnel reports;
- Information on patients with a history of past violence, drug abuse, or criminal activity;
- Records of health and safety committee meetings; job hazard analyses; and equipment, policy, or procedure recommendations; and
- Records of training, including attendees and trainers’ qualifications.
Records should be reviewed regularly to evaluate the program’s effectiveness. In addition, surveying employees before and after making job or worksite changes or installing security measures or new systems can provide valuable insight into the strengths and weaknesses of existing measures.
The need for a workplace violence prevention program extends beyond any OSHA regulations or guidelines. Assaults comprise 10% to 11% of workplace injuries involving days away from work for healthcare workers compared with 3% of injuries for all private sector employees.
Some states, including California, include workplace violence prevention in their occupational safety and health regulations. Others require programs to address workplace violence under their healthcare facility laws and regulations. The Joint Commission’s Environment of Care standards have violence prevention requirements for employee, patient, and visitor safety. Hospitals need Joint Commission certification to be eligible for Medicare, Medicaid, and private insurance reimbursement.