Back to Basics is a weekly feature that highlights important but possibly overlooked information that any EHS professional should know. This week, we examine how to prevent workplace violence.
The Occupational Safety and Health Administration (OSHA) is working on the first federal workplace violence prevention standard.
The rulemaking, specifically for healthcare and social assistance,is one of the agency’s economically significant rulemakings. The other economically significant rulemakings are those for communication tower safety, emergency response, infectious diseases, process safety management (PSM) and the prevention of major chemical accidents, and tree care.
The agency currently plans to publish a notice of proposed rulemaking (NPRM) in December for workplace violence prevention in healthcare and social assistance.
In February, OSHA issued an NPRM for an emergency response rule, and last month, the agency released text of a proposed heat injury and illness prevention standard. So far, however, no NPRM for heat injury and illness prevention has appeared in the Federal Register.
In the absence of a federal workplace violence prevention standard, OSHA issued a set of voluntary guidelines for health care and social services in 2015. In December 2016, the agency issued a request for information (RFI) seeking input from healthcare employers, workers, and subject matter experts about a possible industry-specific standard. OSHA initiated a Small Business Regulatory Enforcement Fairness Act (SBREFA) review of the rulemaking at the end of 2022 that concluded in March 2023.
A federal healthcare and social assistance standard for workplace violence prevention could include requirements for a written program; worksite analysis and hazard identification; hazard controls, including administrative controls, engineering controls, and personal protective equipment (PPE); training; and recordkeeping.
OSHA’s General Duty Clause enforcement
According to a Government Accountability Office (GAO) report, there are nine states with workplace violence prevention requirements: California, Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Oregon, and Washington.
Because there’s no federal workplace violence prevention standard, OSHA continues to cite employers, usually following employee fatalities or hospitalizations, using its authority under the General Duty Clause (§5(a)(1)) of the Occupational Safety and Health Act of 1970.
For example, the agency recently cited convenience store chain Circle K after a store cashier in Orlando, Florida, suffered a serious gunshot injury. Because OSHA could only cite Circle K with a General Duty Clause violation, albeit a serious violation, the employer faces a $16,131 OSHA fine—the maximum amount allowed by law.
Agency inspectors learned that two unidentified men entered the Circle K location on Silver Star Road shortly after 1 a.m. on January 19, 2024; pointed firearms; and screamed at the cashier to open the register. As the employee moved back from the register, one of the assailants fired a shot that struck the employee in the left shoulder.
Circle K has contested the citation and penalty before the Occupational Safety and Health Review Commission. The commission has sometimes vacated OSHA General Duty Clause citations, calling the agency’s use of the statute’s provision a “gotcha” and “catch-all” for hazards without established standards.
However, the review panel has even vacated OSHA violations and penalties that cited formal safety standards. In 2021, the commission vacated an OSHA citation involving a fatal robbery attempt of a Pennsylvania Turnpike toll collection van.
Because an armed guard wasn’t wearing a bulletproof vest at the time of the robbery attempt, the agency cited the Turnpike Commission’s security contractor with a serious violation of the PPE standard (29 Code of Federal Regulations (CFR) 1910.132(a)).
The commissioners concluded that OSHA failed to demonstrate a “recognized” hazard necessitating the use of bulletproof vests and vacated the agency’s citation.
However, the commission and its administrative law judges (ALJs) have sometimes sided with OSHA in employers’ contests of workplace violence citations. Last year, an ALJ upheld the agency’s citation of UHS of Delaware Inc. (UHS-DE) and UHS of Fuller Inc. for exposing their employees to workplace violence without adequate protections at Fuller Hospital in Attleboro, Massachusetts.
The judge found that the two companies operated Fuller Hospital as a single employer and determined that OSHA’s proposed abatement measures were feasible and would materially reduce the hazard of workplace violence.
The agency’s proposed abatement measures included the following:
- Ensuring hospital units were adequately staffed to handle behavioral health emergencies,
- Providing employees with personal panic alarms,
- Adequately training new employees,
- Conducting post-incident debriefings and investigations, and
- Providing trained security personnel on all three shifts.
The ALJ also sanctioned both companies for destroying surveillance videos showing workplace violence; sanctioned UHS-DE for failing to comply with its discovery obligations; and ordered the two companies to pay the Department of Labor (DOL) $20,175 in attorneys’ fees.
In 2019, the commission upheld OSHA’s General Duty Clause citation of Integra Health Management, Inc., for failing to protect an employee who was stabbed and later died.
That decision (Secretary of Labor v. Integra Health Management, Inc.) touched on issues surrounding an employer’s responsibilities under the General Duty Clause, including:
- What is the “place of employment”?
- What is a “hazard”?
- Can the actions of third parties be considered “recognizable hazards”?
- Because the actions of third parties are beyond an employer’s control, is an employer responsible for abating the hazards of such actions?
The commissioners ruled that the “place of employment” is where work takes place and that the violent conduct of a third party can be a recognized hazard within the scope of the General Duty Clause.
On December 10, 2012, an Integra employee was repeatedly stabbed during a home visit to one of Integra’s clients who had a history of violent, criminal behavior. Integra’s client also had served nearly 15 years in prison for aggravated assault with a weapon, aggravated battery with a deadly weapon, battery, and grand theft of a motor vehicle. The client suffered from cardiovascular disease and schizophrenia.
During a service coordinator’s fourth in-home meeting with the client, he stabbed her nine times while chasing her across his front yard. A passerby found the employee lying on the ground and drove her to a hospital, where she died later that day.
In its citation of Integra, OSHA’s recommended abatement measures included the following:
- Creating a written workplace violence prevention program,
- Determining clients’ behavioral history,
- Having procedures in place to inform staff of previous incidents of violence,
- Training employees to recognize aggressive behavior and in methods of de-escalation,
- Providing staff members with reliable means of summoning assistance, and
- Establishing liaisons with local law enforcement agencies.
Vulnerable workers
Workplace violence is a risk in late-night retail establishments like convenience stores, gas stations, and fast-food restaurant drive-thrus, as well as in health care and social assistance.
In fact, robbery-related assaults and homicides are the leading cause of death for retail workers, according to National Institute for Occupational Safety and Health (NIOSH) research. In 2019, NIOSH noted that the rate of deadly workplace violence among convenience store workers was 14 times higher than the overall rate for private industry workers.
According to OSHA, deterrents that keep late-night retail employees safe from workplace violence include the following:
- Interior and exterior security cameras,
- Cash register barriers or enclosures,
- A drop safe or cash management device,
- Proper lighting inside and outside the store, and
- Signage explaining that the register holds $50 or less.
In 2009, OSHA released Recommendations for Workplace Violence
Prevention Programs in Late-Night Retail Establishments, employer guidance containing tips on designing and implementing workplace violence prevention programs.
Healthcare and social assistance settings at high risk of workplace violence include:
- Hospitals and other 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 service facilities like neighborhood clinics and mental health centers;
- Community care facilities like group homes and community-based and residential facilities; and
- Fieldwork, including home health care or social services home visits.
NIOSH and OSHA aren’t the only federal agencies calling on healthcare facilities to take workplace violence prevention steps. In 2022, the Centers for Medicare and Medicaid Services (CMS), the agency that administers Medicare and Medicaid reimbursements, urged healthcare industry leaders to take steps to protect healthcare workers from workplace violence. Steps recommended by CMS included ensuring workers receive adequate training, having sufficient staffing levels, providing ongoing assessment of patients and residents for aggressive behavior and indicators, and appropriately adapting patients’ or residents’ care interventions and environment.
Even the Joint Commission, a private organization that accredits hospitals and other healthcare facilities, issued new and revised workplace violence standards that took effect in 2022. According to the nonprofit, 73% of nonfatal workplace injuries and illnesses causing days of missed work in health care are related to workplace violence.
The standards encourage hospitals to manage safety and security risks, going as far as conducting an annual worksite analysis of a facility’s workplace violence prevention program. Other steps include creating and maintaining a culture of safety and quality throughout a hospital, ongoing staff education and training, and monitoring conditions in a facility’s environment.
Your workplace violence prevention
Steps toward developing a comprehensive program might include performing worksite analysis, hazard identification, and risk assessment; consulting employee assistance, HR, occupational safety and health, operations, and security staff; reviewing injury and illness logs and workers’ compensation claims; and performing individual job hazard analyses.
Workplace violence hazard controls include both:
- Administrative controls like login and logout procedures, reporting history or incidences of violence during shift changes, double-teaming and using “buddy systems” to ensure workers aren’t alone, and staffing trained security officers and personnel trained in de-escalation.
- Engineering controls like bright lighting, both indoors and outdoors; closed-circuit video cameras and metal detectors; curved mirrors at hallway intersections or other areas where sightlines are obscured; door locks; enclosures with bulletproof glass; and “panic” buttons at workstations or personal alarm devices employees can wear.
In addition to security personnel for prevention, you may need an emergency response team that’s responsible for providing immediate care to victims and debriefing victims and coworkers.
Once you have a program in place, you’ll have to train both employees and supervisors to recognize warning signs of potential violence. Training can cover written outlines or lesson plans, as well as company procedures for requesting police assistance or filing charges when assaulted.
If you have employees who interact with patients or clients receiving rehabilitation or social services or who handle money or guard valuables, they may be at risk, necessitating a workplace violence prevention program.