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Guidelines for Preventing Workplace Violence for Health Care and
Social Service Workers
Objectives: After completing this course the student will have an
understanding of OSHA guidelines regarding prevention of violence in the
workplace including, risk factors, hazard prevention and controls.
Introduction
For many years, health care and social service workers have faced a
significant risk of job-related violence. Assaults represent a serious
safety and health hazard for these industries, and violence against their
employees continues to increase.
OSHA'S new violence prevention guidelines provide the agency`s
recommendations for reducing workplace violence developed following a
careful review of workplace violence studies, public and private violence
prevention programs, and consultations with and input from
stakeholders.
OSHA encourages employers to establish violence prevention programs and
to track their progress in reducing work-related assaults. Although not
every incident can be prevented, many can, and the severity of injuries
sustained by employees reduced. Adopting practical measures such as those
outlined here can significantly reduce this serious threat to worker
safety.
OSHA'S Commitment
The publication and distribution of these guidelines is OSHA'S first
step in assisting health care and social service employers and providers
in preventing workplace violence. OSHA plans to conduct a coordinated
effort consisting of research, information, training, cooperative
programs, and appropriate enforcement to accomplish this goal.
The guidelines are not a new standard or regulation.
They are advisory in nature, informational in content, and intended for
use by employers in providing a safe and healthful workplace through
effective violence prevention programs, adapted to the needs and resources
of each place of employment.
Extent of Problem
Today, more assaults occur in the health care and social services
industries than in any other. For example, Bureau of Labor Statistics
(BLS) data for 1993 showed health care and social service workers having
the highest incidence of assault injuries (BLS, 1993). Almost two-thirds
of the nonfatal assaults occurred in nursing homes, hospitals, and
establishments providing residential care and other social services
(Toscano and Weber, 1995).
Assaults against workers in the health professions are not new.
According to one study (Goodman et al., 1994), between 1980 and 1990, 106
occupational violence-related deaths occurred among the following health
care workers: 27 pharmacists, 26 physicians, 18 registered nurses, 17
nurses' aides, and 18 health care workers in other occupational
categories. Using the National Traumatic Occupational Fatality database,
the study reported that between 1983 and 1989, there were 69 registered
nurses killed at work. Homicide was the leading cause of traumatic
occupational death among employees in nursing homes and personal care
facilities.
A 1989 report (Cannel and Hunter) found that the nursing staff at a
psychiatric hospital sustained 16 assaults per 100 employees per year.
This rate, which includes any assault-related injuries, compares with 8.3
injuries of all types per 100 full-time workers in all
industries and 14.2 per 100 full-time workers in the construction industry
(BLS, 1991). Of 121 psychiatric hospital workers sustaining 134 injuries,
43 percent involved lost time from work with 13 percent of those injured
missing more than 21 days from work.
Of greater concern is the likely underreporting of violence and a
persistent perception within the health care industry that assaults are
part of the job. Underreporting may reflect a lack of institutional
reporting policies, employee beliefs that reporting will not benefit them,
or employee fears that employers may deem assaults the result of employee
negligence or poor job performance.
Risk Factors
Health care and social service workers face an increased risk of
work-related assaults stemming from several factors, including:
- The prevalence of handguns and other weapons-as high as 25
percent5
-- among patients, their families, or friends. The increasing use of
hospitals by police and the criminal justice systems for criminal holds
and the care of acutely disturbed, violent individuals.
- The increasing number of acute and chronically mentally ill patients
now being released from hospitals without followup care, who now have
the right to refuse medicine and who can no longer be hospitalized
involuntarily unless they pose an immediate threat to themselves or
others.
- The availability of drugs or money at hospitals, clinics, and
pharmacies, making them likely robbery targets.
- Situational and circumstantial factors such as unrestricted.
movement of the public in clinics and hospitals; the increasing presence
of gang members, drug or alcohol abusers, trauma patients, or distraught
family members; long waits in emergency or clinic areas, leading to
client frustration over an inability to obtain needed services promptly.
- Low staffing levels during times of specific increased activity such
as meal times, visiting times, and when staff are transporting patients.
- Isolated work with clients during examinations or treatment.
- Solo work, often in remote locations, particularly in high-crime
settings, with no back-up or means of obtaining assistance such as
communication devices or alarm systems.
- Lack of training of staff in recognizing and managing escalating
hostile and assaultive behavior.
- Poorly lighted parking areas.
Overview of Guidelines
In January 1989, OSHA published voluntary, generic safety and health
program management guidelines for all employers to use as a foundation for
their safety and health programs, which can include a workplace violence
prevention programs.6
OSHA'S violence prevention guidelines build on the 1989 generic guidelines
by identifying common risk factors and describing some feasible solutions.
Although not exhaustive, the new workplace violence guidelines include
policy recommendations and practical corrective methods to help prevent
and mitigate the effects of workplace violence.
The goal is to eliminate or reduce worker exposure to conditions that
lead to death or injury from violence by implementing effective security
devices and administrative work practices, among other control
measures.
The guidelines cover a broad spectrum of workers who provide health
care and social services in psychiatric facilities, hospital emergency
departments, community mental health clinics, drug abuse treatment
clinics, pharmacies, community care facilities, and long-term care
facilities. They include physicians, registered nurses, pharmacists, nurse
practitioners, physicians' assistants, nurses' aides, therapists,
technicians, public health nurses, home health care workers,
social/welfare workers, and emergency medical care personnel. Further, the
guidelines may be usefil in reducing risks for ancillary personnel such as
maintenance, dietary, clerical, and security staff employed in the health
care and social services industries.
5 According to a 1989 report (Wasserberger),
25 percent of major trauma patients treated in the emergency room carried
weapons. Attacks in emergency rooms in gang-related shootings as well as
planned escapes from police custody have been documented in hospitals. A
1991 report (Goetz et al.) also found that 17.3 percent of psychiatric
patients searched were carrying weapons.
6
OSHA'S Safety and Health Program Management Guidelines (Fed Reg 54
(16):3904- 3916, January 26, 1989), provide for comprehensive safety and
health programs containing these major elements. Employers with such
programs can include workplace violence prevention efforts in that
context.
Violence
Prevention Program Elements
There are four main components to any effective safety and health
program that also apply to preventing workplace violence, (1) management
commitment and employee involvement, (2) worksite analysis, (3) hazard
prevention and control, and (4) safety and health training.
Management Commitment and Employee Involvement
Management commitment and employee involvement are complementary and
essential elements of an effective safety and health program. To ensure an
effective program, management and front-line employees must work together,
perhaps through a team or committee approach. If employers opt for this
strategy, they must be careful to comply with the applicable provisions of
the National Labor Relations Act.7
Management commitment, including the endorsement and visible
involvement of top management, provides the motivation and resources to
deal effectively with workplace violence, and should include the
following:
- Demonstrated organizational concern for employee emotional and
physical safety and health.
- Equal commitment to worker safety and health and patient/client
safety.
- Assigned responsibility for the various aspects of the workplace
violence prevention program to ensure that all managers, supervisors,
and employees understand their obligations.
- Appropriate allocation of authority and resources to all responsible
parties.
- A system of accountability for involved managers, supervisors, and
employees.
- A comprehensive program of medical and psychological counseling and
debriefing for employees experiencing or witnessing assaults and other
violent incidents.
- Commitment to support and implement appropriate recommendations from
safety and health committees.
Employee involvement and feedback enable workers to develop and express
their own commitment to safety and health and provide useful information
to design, implement, and evaluate the program.
Employee involvement should include the following:
- Understanding and complying with the workplace violence prevention
program and other safety and security measures.
- Participation in an employee complaint or suggestion procedure
covering safety and security concerns.
- Prompt and accurate reporting of violent incidents.
- Participation on safety and health committees or teams that receive
reports of violent incidents or security problems, make facility
inspections, and respond with recommendations for corrective strategies.
- Taking part in a continuing education program that covers techniques
to recognize escalating agitation, assaultive behavior, or criminal
intent, and discusses appropriate responses.
Written Program
A written program for job safety and security, incorporated into the
organization's overall safety and health program, offers an effective
approach for larger organizations. In smaller establishments, the program
need not be written or heavily documented to be satisfactory. What is
needed are clear goals and objectives to prevent workplace violence
suitable for the size and complexity of the workplace operation and
adaptable to specific situations in each establishment.
The prevention program and startup date must be communicated to all
employees. At a minimum, workplace violence prevention programs should do
the following:
- Create and disseminate a clear policy of zero- tolerance for
workplace violence, verbal and nonverbal threats, and related actions.
Managers, supervisors, co-workers, clients, patients, and visitors must
be advised of this policy.
- Ensure that no reprisals are taken against an employee who reports
or experiences workplace violence.8
- Encourage employees to promptly report incidents and to suggest ways
to reduce or eliminate risks. Require records of incidents to assess
risk and to measure progress.
- Outline a comprehensive plan for maintaining security in the
workplace, which includes establishing a liaison with law enforcement
representatives and others who can help identify ways to prevent and
mitigate workplace violence.
- Assign responsibility and authority for the program to individuals
or teams with appropriate training and skills. The written plan should
ensure that there are adequate resources available for this effort and
that the team or responsible individuals develop expertise on workplace
violence prevention in health care and social services.
- Affirm management commitment to a worker- supportive environment
that places as much importance on employee safety and health as on
serving the patient or client.
- Set up a company briefing as part of the initial effort to address
such issues as preserving safety, supporting affected employees, and
facilitating recovery.
7 Title 29 U. S. C., Section 158(a)(2).
8 Section 11 (c)(1) of the OSH Act, which also
applies to protected activity involving the hazard of workplace violence
as it does for other health and safety matters: "No person shall discharge
or in any manner discriminate against any employee because such employee
has filed any complaint or instituted or caused to be instituted any
proceeding under or related to this Act or has testified or is about to
testify in any such proceeding or because of the exercise by such employee
on behalf of himself or others of any right afforded by this Act."
Worksite
Analysis
Worksite analysis involves a step-by-step, commonsense look at the
workplace to find existing or potential hazards for workplace violence.
This entails reviewing specific procedures or operations that contribute
to hazards and specific locales where hazards may develop.
A "Threat Assessment Team," "Patient Assault Team," similar task force,
or coordinator may assess the vulnerability to workplace violence and
determine the appropriate preventive actions to be taken. Implementing the
workplace violence prevention program then may be assigned to this group.
The team should include representatives from senior management,
operations, employee assistance, security, occupational safety and health,
legal, and human resources staff.
The team or coordinator can review injury and illness records and
workers' compensation claims to identify patterns of assaults that could
be prevented by workplace adaptation, procedural changes, or employee
training. As the team or coordinator identifies appropriate controls,
these should be instituted.
The recommended program for worksite analysis includes, but is not
limited to, analyzing and tracking records, monitoring trends and
analyzing incidents, screening surveys, and analyzing workplace
security.
Records Analysis and Tracking
This activity should include reviewing medical, safety, workers'
compensation and insurance records -- including the OSHA 200 log, if
required -- to pinpoint instances of workplace violence. Scan unit logs
and employee and police reports of incidents or near-incidents of
assaultive behavior to identify and analyze trends in assaults relative to
particular departments, units, job titles, unit activities, work stations,
and/or time of day. Tabulate these data to target the frequency and
severity of incidents to establish a baseline for measuring
improvement.
Monitoring Trends and Analyzing Incidents
Contacting similar local businesses, trade associations, and community
and civic groups is one way to learn about their experiences with
workplace violence and to help identify trends. Use several years of data,
if possible, to trace trends of injuries and incidents of actual or
potential workplace violence.
Screening Surveys
One important screening tool is to give employees a questionnaire or
survey to get their ideas on the potential for violent incidents and to
identify or confirm the need for improved security measures. Detailed
baseline screening surveys can help pinpoint tasks that put employees at
risk. Periodic surveys -- conducted at least annually or whenever
operations change or incidents of workplace violence occur -- help
identify new or previously unnoticed risk factors and deficiencies or
failures in work practices, procedures, or controls. Also, the surveys
help assess the effects of changes in the work processes (see Appendix A
for a sample survey used in the State of Washington). The periodic review
process should also include feedback and followup.
Independent reviewers, such as safety and health professionals, law
enforcement or security specialists, insurance safety auditors, and other
qualified persons may offer advice to strengthen programs. These experts
also can provide fresh perspectives to improve a violence prevention
program.
Workplace Security Analysis
The team or coordinator should periodically inspect the workplace and
evaluate employee tasks to identify hazards, conditions, operations, and
situations that could lead to violence.
To find areas requiring further evaluation, the team or coordinator
should do the following:
- Analyze incidents, including the characteristics of assailants and
victims, an account of what happened before and during the incident, and
the relevant details of the situation and its outcome. When possible,
obtain police reports and recommendations.
- Identify jobs or locations with the greatest risk of violence as
well as processes and procedures that put employees at risk of assault,
including how often and when.
- Note high-risk factors such as types of clients or patients (e.g.,
psychiatric conditions or patients disoriented by drugs, alcohol, or
stress); physical risk factors of the building; isolated locations/job
activities; lighting problems; lack of phones and other communication
devices, areas of easy, unsecured access; and areas with previous
security problems. (See sample checklist for assessing hazards in
Appendix B.)
- Evaluate the effectiveness of existing security measures, including
engineering control measures. Determine if risk factors have been
reduced or eliminated, and take appropriate action.
Hazard Prevention and
Control
After hazards of violence are identified through the systematic
worksite analysis, the next step is to design measures through engineering
or administrative and work practices to prevent or control these hazards.
If violence does occur, post-incidence response can be an important tool
in preventing future incidents.
Engineering Controls and Workplace
Adaptation
Engineering controls, for example, remove the hazard from the workplace
or create a barrier between the worker and the hazard. There are several
measures that can effectively prevent or control workplace hazards, such
as those actions presented in the following paragraphs. The selection of
any measure, of course, should be based upon the hazards identified in the
workplace security analysis of each facility.
- Assess any plans for new construction or physical changes to the
facility or workplace to eliminate or reduce security hazards.
- Install and regularly maintain alarm systems and other security
devices, panic buttons, hand-held alarms or noise devices, cellular
phones, and private channel radios where risk is apparent or may be
anticipated, and arrange for a reliable response system when an alarm is
triggered.
- Provide metal detectors -- installed or hand-held, where appropriate
-- to identify guns, knives, or other weapons, according to the
recommendations of security consultants.
- Use a closed-circuit video recording for high-risk areas on a
24-hour basis. Public safety is a greater concern than privacy in these
situations.
- Place curved mirrors at hallway intersections or concealed areas.
- Enclose nurses' stations, and install deep service counters or
bullet-resistant, shatter-proof glass in reception areas, triage,
admitting, or client service rooms.
- Provide employee "safe rooms" for use during emergencies.
- Establish "time-out" or seclusion areas with high ceilings without
grids for patients acting out and establish separate rooms for criminal
patients.
- Provide client or patient waiting rooms designed to maximize comfort
and minimize stress.
- Ensure that counseling or patient care rooms have two exits.
- Limit access to staff counseling rooms and treatment rooms
controlled by using locked doors.
- Arrange furniture to prevent entrapment of staff. In interview rooms
or crisis treatment areas, furniture should be minimal, lightweight,
without sharp comers or edges, and/or affixed to the floor. Limit the
number of pictures, vases, ashtrays, or other items that can be used as
weapons.
- Provide lockable and secure bathrooms for staff members separate
from patient-client, and visitor facilities.
- Lock all unused doors to limit access, in accordance with local fire
codes.
- Install bright, effective lighting indoors and outdoors.
- Replace burned-out lights, broken windows, and locks.
- Keep automobiles, if used in the field, well-maintained. Always lock
automobiles.
Administrative and Work Practice Controls
Administrative and work practice controls affect the way jobs or tasks
are performed. The following examples illustrate how changes in work
practices and administrative procedures can help prevent violent
incidents.
- State clearly to patients, clients, and employees that violence is
not permitted or tolerated.
- Establish liaison with local police and state prosecutors. Report
all incidents of violence. Provide police with physical layouts of
facilities to expedite investigations.
- Require employees to report all assaults or threats a supervisor or
manager (e.g., can be confidential interview). Keep log books and
reports of such incidents to help in determining any necessary actions
to prevent further occurrences.
- Advise and assist employees, if needed, of company procedures for
requesting police assistance or filing charges when assaulted.
- Provide management support during emergencies. Respond promptly to
all complaints.
- Set up a trained response team to respond to emergencies.
- Use properly trained security officers, when necessary, to deal with
aggressive behavior. Follow written security procedures.
- Ensure adequate and properly trained staff for restraining patients
or clients.
- Provide sensitive and timely information to persons waiting in line
or in waiting rooms. Adopt measures to decrease waiting time.
- Ensure adequate and qualified staff coverage at all times. Times of
greatest risk occur during patient transfers, emergency responses, meal
times, and at night. Locales with the greatest risk include admission
units and crisis or acute care units. Other risks include admission of
patients with a history of violent behavior or gang activity.
- Institute a sign-in procedure with passes for visitors, especially
in a newborn nursery or pediatric department. Enforce visitor hours and
procedures.
- Establish a list of "restricted visitors" for patients with a
history of violence. Copies should be available at security checkpoints,
nurses' stations, and visitor sign-in areas. Review and revise visitor
check systems, when necessary. Limit information given to outsiders on
hospitalized victims of violence.
- Supervise the movement of psychiatric clients and patients
throughout the facility.
- Control access to facilities other than waiting rooms, particularly
drug storage or pharmacy areas.
- Prohibit employees from working alone in emergency areas or walk-in
clinics, particularly at night or when assistance is unavailable.
Employees should never enter seclusion rooms alone.
- Establish policies and procedures for secured areas, and emergency
evacuations, and for monitoring high-risk patients at night (e.g., open
versus locked seclusion).
- Ascertain the behavioral history of new and transferred patients to
learn about any past violent or assaultive behaviors. Establish a
system-such as chart tags, log books, or verbal census reports -- to
identify patients and clients with assaultive behavior problems, keeping
in mind patient confidentiality and worker safety issues. Update as
needed.
- Treat and/or interview aggressive or agitated clients in relatively
open areas that still maintain privacy and confidentiality (e.g., rooms
with removable partitions).
- Use case management conferences with co-workers and supervisors to
discuss ways to effectively treat potentially violent patients.
- Prepare contingency plans to treat clients who are "acting out" or
making verbal or physical attacks or threats. Consider using certified
employee assistance professionals (CEAPs) or in-house social service or
occupational health service staff to help diffuse patient or client
anger.
- Transfer assaultive clients to "acute care units," "criminal units,"
or other more restrictive settings.
- Make sure that nurses and/or physicians are not alone when
performing intimate physical examinations of patients.
- Discourage employees from wearing jewelry to help prevent possible
strangulation in confrontational situations. Community workers should
carry only required identification and money.
- Periodically survey the facility to remove tools or possessions left
by visitors or maintenance staff which could be used inappropriately by
patients.
- Provide staff with identification badges, preferably without last
names, to readily verify employment.
- Discourage employees from carrying keys, pens, or other items that
could be used as weapons.
- Provide staff members with security escorts to parking areas in
evening or late hours. Parking areas should be highly visible,
well-lighted, and safely accessible to the building.
- Use the "buddy system," especially when personal safety may be
threatened. Encourage home health care providers, social service
workers, and others to avoid threatening situations. Staff should
exercise extra care in elevators, stairwells and unfamiliar residences;
immediately leave premises if there is a hazardous situation; or request
police escort if needed.
- Develop policies and procedures covering home health care providers,
such as contracts on how visits will be conducted, the presence of
others in the home during the visits, and the refusal to provide
services in a clearly hazardous situation.
- Establish a daily work plan for field staff to keep a designated
contact person informed about workers' whereabouts throughout the
workday. If an employee does not report in, the contact person should
followup.
- Conduct a comprehensive post-incident evaluation, including
psychological as-well as medical treatment, for employees who have been
subjected to abusive behavior.
Post-Incident Response
Post-incident response and evaluation are essential to an effective
violence prevention program. All workplace violence programs should
provide comprehensive treatment for victimized employees and employees who
may be traumatized by witnessing a workplace violence incident. Injured
staff should receive prompt treatment and psychological evaluation
whenever an assault takes place, regardless of severity. (See sample
hospital policy in Appendix C). Transportation of the injured to medical
care should be provided if care is not available on-site.
Victims of workplace violence suffer a variety of consequences in
addition to their actual physical injuries. These include short and
long-term psychological trauma, fear of returning to work, changes in
relationships with co-workers and family, feelings of incompetence, guilt,
powerlessness, and fear of criticism by supervisors or managers.
Consequently, a strong followup program for these employees will not only
help them to deal with these problems but also to help prepare them to
confront or prevent future incidents of violence (Flannery, 1991, 1993;
1995).
There are several types of assistance that can be incorporated into the
post-incident response. For example, trauma-crisis counseling, critical
incident stress debriefing, or employee assistance programs may be
provided to assist victims. Certified employee assistance professionals,
psychologists, psychiatrists, clinical nurse specialists, or social
workers could provide this counseling, or the employer can refer staff
victims to an outside specialist. In addition, an employee counseling
service, peer counseling, or support groups may be established.
In any case, counselors must be well trained and have a good
understanding of the issues and consequences of assaults and other
aggressive, violent behavior. Appropriate and promptly rendered
post-incident debriefings and counseling reduce acute psychological trauma
and general stress levels among victims and witnesses. In addition, such
counseling educates staff about workplace violence and positively
influences workplace and organizational cultural norms to reduce trauma
associated with future incidents.
Training and
Education
Training and education ensure that all staff are aware of potential
security hazards and how to protect themselves and their co-workers
through established policies and procedures.
All Employees
Every employee should understand the concept of "universal Precautions
for Violence," i.e., that violence should be expected but can be avoided
or mitigated through preparation. Staff should be instructed to limit
physical interventions in workplace altercations whenever possible, unless
there are adequate numbers of staff or emergency response teams and
security personnel available. Frequent training also can improve the
likelihood of avoiding assault (Carrnel and Hunter, 1990).
Employees who may face safety and security hazards should receive
formal instruction on the specific hazards associated with the unit or job
and facility. This includes information on the types of injuries or
problems identified in the facility and the methods to control the
specific hazards.
The training program should involve all employees, including
supervisors and managers. New and reassigned employees should receive an
initial orientation prior to being assigned their job duties. Visiting
staff, such as physicians, should receive the same training as permanent
staff. Qualified trainers should instruct at the comprehension level
appropriate for the staff. Effective training programs should involve role
playing, simulations, and drills.
Topics may include Management of Assaultive Behavior Professional
Assault Response Training; police assault avoidance programs, or personal
safety training such as awareness, avoidance, and how to prevent assaults.
A combination of training maybe used depending on the severity of the
risk.
Required training should be provided to employees annually. In large
institutions, refresher programs may be needed more frequently (monthly or
quarterly) to effectively reach and inform all employees.
The training should cover topics such as the following:
- The workplace violence prevention policy.
- Risk factors that cause or contribute to assaults.
- Early recognition of escalating behavior or recognition of warning
signs or situations that may lead to assaults.
- Ways of preventing or diffusing volatile situations or aggressive
behavior, managing anger, and appropriately using medications as
chemical restraints.
- Information on multicultural diversity to develop sensitivity to
racial and ethnic issues and differences.
- A standard response action plan for violent situations, including
availability of assistance, response to alarm systems, and communication
procedures.
- How to deal with hostile persons other than patients and clients,
such as relatives and visitors.
- Progressive behavior control methods and safe methods of restraint
application or escape.
- The location and operation of safety devices such as alarms systems,
along with the required maintenance schedules and procedures.
- Ways to protect oneself and coworkers, including use of the "buddy
system."
- Policies and procedures for reporting and recordkeeping.
- Policies and procedures for obtaining medical care, counseling,
workers' compensation, or legal assistance after a violent episode or
injury.
Supervisors, Managers, and Security Personnel
Supervisors and managers should ensure that employees are not placed in
assignments that compromise safety and should encourage employees to
report incidents. Employees and supervisors should be trained to behave
compassionately towards coworkers when an incident occurs.
They should learn how to reduce security hazards and ensure that
employees receive appropriate training. Following training, supervisors
and managers should be able to recognize a potentially hazardous situation
and to make any necessary changes in the physical plant, patient care
treatment program, and staffing policy and procedures to reduce or
eliminate the hazards.
Security personnel need specific training from the hospital or clinic,
including the psychological components of handling aggressive and abusive
clients, types of disorders, and ways to handle aggression and defuse
hostile situations.
The training program should also include an evaluation. The content,
methods, and frequency of training should be reviewed and evaluated
annually by the team or coordinator responsible for implementation.
Program evaluation may involve supervisor and/or employee interviews,
testing and observing, and/or reviewing reports of behavior of individuals
in threatening situations.
Recordkeeping
and Evaluation of the Program
Recordkeeping and evaluation of the violence prevention program are
necessary to determine overall effectiveness and identify any deficiencies
or changes that should be made.
Recordkeeping
Recordkeeping is essential to the success of a workplace violence
prevention program. Good records help employers determine the severity of
the problem, evaluate methods of hazard control, and identify training
needs. Records can be especially usefid to large organizations and for
members of a business group or trade association who "pool" data. Records
of injuries, illnesses, accidents, assaults, hazards, corrective actions,
patient histories, and training, among others, can help identify problems
and solutions for an effective program.
The following records are important:
- OSHA Log of Injury and Illness (OSHA 200). OSHA regulations require
entry on the Injury and Illness Log of any injury that requires more
than first aid, is a lost-time injury, requires modified duty, or causes
loss of consciousness.9
(This applies only to establishments required to keep OSHA logs.)
Injuries caused by assaults, which are otherwise recordable, also must
be entered on the log. A fatality or catastrophe that results in the
hospitalization of 3 or more employees must be reported to OSHA
within 8 hours. This includes those resulting from workplace
violence and applies to all establishments.
- Medical reports of work injury and supervisors' reports for each
recorded assault should be kept. These records should describe the type
of assault, i.e., unprovoked sudden attack or patient-to-patient
altercation; who was assaulted; and all other circumstances of the
incident. The records should include a description of the environment or
location, potential or actual cost, lost time, and the nature of
injuries sustained.
- Incidents of abuse, verbal attacks or aggressive behavior-which may
be threatening to the worker but do not result in injury, such as
pushing or shouting and acts of aggression towards other clients-should
be recorded, perhaps as part of an assaultive incident report. These
reports should be evaluated routinely by the affected department. (See
sample incident forms in Appendix D ).
- Information on patients with a history of past violence, drug abuse,
or criminal activity should be recorded on the patient's chart. All
staff who care for a potentially aggressive, abusive, or violent client
should be aware of their background and history. Admission of violent
clients should be logged to help determine potential risks.
- Minutes of safety meetings, records of hazard analyses, and
corrective actions recommended and taken should be documented.
- Records of all training programs, attendees, and qualifications of
trainers should be maintained.
Evaluation
As part of their overall program, employers should evaluate their
safety and security measures. Top management should review the program
regularly, and with each incident, to evaluate program success.
Responsible parties (managers, supervisors, and employees) should
collectively reevaluate policies and procedures on a regular basis.
Deficiencies should be identified and corrective action taken.
An evaluation program should involve the following:
- Establishing a uniform violence reporting system and regular review
of reports.
- Reviewing reports and minutes from staff meetings on safety and
security issues.
- Analyzing trends and rates in illness/injury or fatalities caused by
violence relative to initial or "baseline" rates.
- Measuring improvement based on lowering the frequency and severity
of workplace violence.
- Keeping up-to-date records of administrative and work practice
changes to prevent workplace violence to evaluate their effectiveness.
- Surveying employees before and after making job or worksite changes
or installing security measures or new systems to determine their
effectiveness.
- Keeping abreast of new strategies available to deal with violence in
the health care and social service fields as these develop.
- Surveying employees who experience hostile situations about the
medical treatment they received initially and, again, several weeks
afterward, and then several months later.
- Complying with OSHA and state requirements for recording and
reporting deaths, injuries, and illnesses.
- Requesting periodic law enforcement or outside consultant review of
the worksite for recommendations on improving employee safety.
Management should share workplace violence prevention program
evaluation reports with all employees. Any changes in the program should
be discussed at regular meetings of the safety committee, union
representatives, or other employee groups.
Sources of Assistance
Employers who would like assistance in implementing an appropriate
workplace violence prevention program can turn to the OSHA Consultation
service provided in their state. Primarily targeted at smaller companies,
the consultation service is provided at no charge to the employer and is
independent of OSHA'S enforcement activity. (See Appendix E.)
OSHA'S efforts to assist employers combat workplace violence are
complemented by those of NIOSH (1-800-35 -NIOSH) and public safety
officials, trade associations, unions, insurers, human resource, and
employee assistance professionals as well as other interested groups.
Employers and employees may contact these groups for additional advice and
information.
9 The Occupational Safety and Health Act and
recordkeeping regulations in Title 29 Code of Federal Regulations (CFR),
Part 1904 provide specific recording requirements that comprise the
framework of the occupational safety and health recording system (BLS,
1986a). BLS has issued guidelines that provide official Agency
interpretations concerning the recordkeeping and reporting of occupational
injuries and illnesses (BLS, 1986b).
Conclusion
OSHA recognizes the importance of effective safety and health program
management in providing safe and healthful workplaces. In fact, OSHA'S
consultation services help employers establish and maintain safe and
healthful workplaces, and the agency's Voluntary Protection Programs were
specifically established to recognize worksites with exemplary safety and
health programs. (See Appendix E.) Effective safety and health programs
are known to improve both morale and productivity and reduce workers'
compensation costs.
OSHA'S violence prevention guidelines are an essential component to
workplace safety and health programs. OSHA believes that the
performance-oriented approach of the guidelines provides employers with
flexibility in their efforts to maintain safe and healthful working
conditions.
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