Should you be concerned about violence in your facility? If you have employees who handle money or guard possessions, have regular contact with the public, or interact with patients or clients receiving rehabilitation or social services, your workers may be at risk.
If you’re in the healthcare or social services field, you no doubt know the Occupational Safety and Health Administration (OSHA) is moving forward with a workplace violence prevention rulemaking.
There currently is no federal standard for workplace violence, but there are state laws or regulations in California, Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Oregon, and Washington.
California and Oregon have regulations requiring workplace violence prevention programs in hospitals and other healthcare facilities, and New Mexico has security requirements for convenience stores.
The scope of the federal rulemaking is limited to health care and social assistance, and the agency also acknowledged it may decide to take no regulatory action.
The rulemaking is one of the significant rulemakings on OSHA’s agenda, along with a possible permanent COVID-19 standard; an infectious disease standard; and rules for process safety management and major chemical accidents, emergency response, and communications tower safety.
During the final days of the Obama administration, OSHA granted petitions for a rulemaking from the National Nurses Union and a coalition of other labor unions. It issued a request for information on December 7, 2016.
OSHA describes workplace violence as a “widespread problem” and says workers in health care and social services face unique safety risks. Bureau of Labor Statistics (BLS) data has shown that workers at psychiatric and substance abuse hospitals experience the highest rate of violent injuries that result in days away from work—a rate six times that for workers at nursing and residential care facilities.
OSHA has an existing set of guidelines for employers of healthcare and social services workers it issued in 2015. The 2015 guidelines cover common 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.
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 healthcare or social services home visits.
Risk factors in health care and social assistance include:
- Working in neighborhoods with high crime rates or directly with people who have a history of violence or 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 is blocked; and
- Working where firearms, knives, and other weapons are prevalent among patients and their families and friends.
Some of the elements of OSHA’s employer guidelines showed up in the agency’s 2016 request for information for the workplace violence prevention rulemaking. The agency also has an enforcement directive.
Federal enforcement
OSHA’s workplace violence enforcement relies on its authority under the General Duty Clause of the Occupational Safety and Health Act of 1970.
Through its enforcement activities, OSHA is aware of other industries where workers are at risk for workplace violence, including correctional facilities, late-night retail, and taxi driving.
However, nearly any facility or workplace may be susceptible to active shooter incidents. Industry standard-setting organizations have therefore compiled employer recommendations to address that hazard.
Risk factors for workplace violence identified by OSHA include:
- Contact with the public; the delivery of passengers, goods, or services; or exchange of money;
- Guarding valuable property or possession or working in a mobile workplace such as a taxicab; and
- Working late at night or during early morning hours and in high-crime areas.
Types of violence covered by OSHA’s enforcement directive include criminal intent such as robbery; client, customer, or patient interaction; and violence involving coworkers or personal relationships. However, OSHA area offices consider whether to inspect workplaces after incidents involving coworkers or personal relationships on a case-by-case basis, and the default policy is not to launch inspections in such incidents.
OSHA inspection procedures include a review of injury and illness records, any written workplace violence prevention program, and workplace violence hazard assessments.
Agency compliance safety and health officers (CSHOs) also will look at training records, as well as accident and near-miss logs, first-aid logs, insurance records, police reports, security reports, safety and health committee meeting minutes, and workers’ compensation records.
CSHOs may interview employees on all shifts but may not photograph or videotape inmates or prisoners, patients, or residents. Evidence to support a General Duty Clause citation must include the hazard, employer and/or industry recognition of the hazard, existing or potential injuries and fatalities, and feasible means of abatement.
However, a lack of abatement measures cannot be cited as a hazard.
Beyond OSHA enforcement
On-the-job assaults also can result in workers’ compensation claims. A study of claims over a 5-year period in Oregon found that assault claims averaged 58 lost workdays and $12,258 in claim costs per claim. The study by the state’s Department of Consumer and Business Services also found that:
- Nursing aides had the highest percentage of assault claims (17%), followed by police officers (12%), guards (6%), and teachers (6%).
- Private sector service industries accounted for 39% of accepted disability claims due to violence, and state and local governments accounted for 41% of claims.
- The assailant in 41% of compensable assault claims was a patient in a healthcare or residential care facility.
There also are nongovernmental standards or recommendations for workplace violence.
The Joint Commission, which accredits hospitals and healthcare facilities that receive reimbursements from Medicaid, Medicare, or private insurance, issued a revised workplace violence standard last summer that went into effect at the beginning of this year.
Seventy-three percent of nonfatal workplace injuries and illnesses causing days of missed work in health care are connected to workplace violence, according to the Joint Commission. However, actual figures may be higher due to underreporting.
The prevention program framework in the Joint Commission’s standard includes:
- Managing safety and security risks, conducting an annual worksite analysis related to the facility’s workplace violence prevention program, and taking actions to mitigate or resolve the workplace violence safety and security risks based on findings of the analysis;
- Collecting information to monitor conditions in the facility’s environment, such as equipment problems and problems with utility systems, fire safety management problems, incidents of property damage, injuries to patients and others within the facility, occupational illnesses and staff injuries, and safety and security incidents;
- Ongoing staff education and training at the time of hire, annually, and whenever changes are made to the workplace violence prevention program; and
- Creating a culture of safety and quality throughout the hospital with policies and procedures to prevent and respond to workplace violence; a process for reporting incidents to analyze them and identify trends; a process for follow-up and support for victims and witnesses affected by workplace violence, such as trauma and psychological counseling, if necessary; and a procedure for reporting workplace violence incidents to the hospital’s governing body.
There also are private industry recommendations for active shooter incidents: the National Fire Prevention Association’s (NFPA) NFPA 3000, “Standard for an Active Shooter/Hostile Event Response (ASHER) Program,” and the American Society of Safety Professionals’ (ASSP) technical report, “How to Develop and Implement an Active Shooter/Armed Assailant Plan” (ASSP TR-Z590.5).
The ASSP’s active shooter program recommendations include determining workplace vulnerabilities; hardening facilities with badge entry systems and security cameras; and training staff with tabletop drills, tactical drills, and practice sessions. The ASSP also recommends coordinating with local emergency response agencies, inviting firefighters, police officers, and other first responders to tour the facility to familiarize themselves with the site. It also suggests creating a business continuity plan in case the facility must remain closed while law enforcement agencies process the crime scene.
OSHA-identified control measures
Through its enforcement efforts, OSHA has identified engineering and administrative controls for workplace violence prevention.
Engineering controls all industries can consider include:
- Assessing plans for new construction or physical changes to a facility or workplace to eliminate or reduce security hazards;
- Installing and maintaining alarm systems and other security devices like cellular phones and private-channel radios, hand-held alarms or noise devices, and “panic buttons”;
- Establishing response procedures when an alarm is triggered;
- Installing fixed metal detectors or providing hand-held metal detectors, where appropriate and in accordance with recommendations of security consultants, to detect guns, knives, or other weapons;
- Using a closed-circuit recording on a 24-hour basis for high-risk areas and placing curved mirrors at hallway intersections or in areas where sightlines are obscured;
- Locking all unused doors to limit access but in accordance with local fire codes;
- Installing bright, effective lighting, both indoors and outdoors, and replacing burned-out lights, broken windows, and locks; and
- Locking automobiles at all times and keeping automobiles well maintained for use in the field.
Administrative controls—management policies and workplace practices—to prevent or mitigate workplace violence include:
- Conducting workplace violence hazard and security analyses, with a list of risk factors identified and how specific hazards will be addressed. Analyses may include analyzing vehicles used to transport clients or patients.
- Developing a comprehensive, written workplace violence prevention program, or improving an existing one, then reviewing it at least annually for any needed updates or improvements.
- Designing a recordkeeping system for reporting incidents of violence and reviewing reports after each incident and at least annually to analyze incident trends.
- Using trained security officers to deal with aggressive behavior.
- Developing procedures and responsibilities to be taken in the event of a violent incident.
- Training emergency response teams responsible for immediate care of victims and debriefing victims and coworkers, as well as providing Human Resources employee assistance following incidents.
- Promptly responding to all complaints of violence, following written security procedures, and providing management support during emergencies.
- Providing employees with training on workplace violence, using written outlines or lesson plans, and advising employees of company procedures for requesting police assistance or filing charges when assaulted and helping them do so.
In 1996, National Institute for Occupational Safety and Health (NIOSH) researchers compiled a current intelligence bulletin on violence in the workplace. The NIOSH findings inform many of OSHA’s employers’ guidelines and internal directives, as well as the workplace violence prevention rulemaking.