Violence in the Healthcare Facility

The recent US Department of Labor – Occupational Safety and Health Administration (OSHA) citation against a Connecticut hospital for failing to provide its employees with adequate safeguards against workplace violence has opened a whole new area of risk exposure to healthcare providers across the nation. OSHA's action follows an inspection begun in January 2010, in response to worker complaints. In the Connecticut case, OSHA's inspection identified several instances during the past 18 months in which employees in the hospital's psychiatric ward, emergency ward and general medical floors were injured by violent patients and residents. In addition, there have been about 25 cases over the past five years in which hospital employees lost workdays or were put on restricted duty after being injured by patients and residents. OSHA found that the hospital's workplace violence program was incomplete and ineffective at preventing these incidents. And while we have known for the past year that OSHA was going to gear up their enforcement efforts against healthcare providers, this case is the first that we are aware of where Workplace Violence has been the basis for a citation. The Connecticut investigation, which resulted in a $6300 fine against the hospital, revealed several weaknesses in the hospital’s program, citing them specifically for:

• Failing to create a stand alone written violence prevention program for the entire hospital that includes a hazard/threat assessment, controls and prevention strategies, staff training and education, incident reporting and investigation, and periodic review of the program.
• Failing to ensure that the program addresses specific actions employees should take in the event of an incident and proper reporting procedures.  Failing to ensure that security staff members trained to deal with aggressive behavior are readily and immediately available to render assistance.
• Failing to ensure that all patients and residents receiving a psychiatric consultation are screened for a potential history of violence.
• Failing to use a system that flags a patient's chart any time there is a history or act of violence and training staff to understand the system.
• Failing to put in place administrative controls so that employees are not alone with potentially violent patients and residents in the psychiatric ward.

If you look closely at these, you can appreciate that each and every one of these citations could apply in any healthcare setting. OSHA has been very clear that their use of the term “healthcare” refers to and includes hospitals, long term care facilities, home care services, pre-hospital/EMS, out patient facilities, and more.

It is important that we not allow ourselves to be fooled into thinking that OSHA will focus on hospitals and not look at long term care. OSHA realizes that long term care providers are often faced with violence and aggressive residents, and that these healthcare professionals are at equal risk. The fact that the residents may be affected by conditions like Alzheimer’s or Dementia has no bearing…OSHA isn’t focused on motive, only on worker safety. Simply stated, any healthcare provider / facility is at risk of an OSHA violation / citation if your program isn’t where it needs to be! What is an act of workplace violence in a healthcare facility? OSHA has a very simple definition: "violence or the threat of violence against workers." Using that definition, it is easy to appreciate how simple it will be for ISHA to invoke citations and fines against healthcare providers. We prefer instead to use a bit more focused definition with our clients: “Workplace Violence is defined as any incident in which an employer or employee is threatened, intimidated, physically or verbally attacked, harassed, injured or killed”. We have adapted this definition for our healthcare clients in order to allow them to appreciate how liberal the OSHA definition is, and to develop a program that is focused on more specific threats and risks. So how does a healthcare facility prepare itself to deal with the risk, and minimize the risk of an OHA visit, citation, or penalty? First, let’s change our focus and forget about OSHA. Instead, let’s focus on a program that is designed to protect workers, resident, visitors, and vendors! If we take that approach, the worries about OSHA will take care of themselves. That said, I encourage all healthcare facilities to follow the steps outlined in OSHA 3148-01R 2004 titled “Guidelines for preventing Workplace Violence for Healthcare and Social Service Workers”. This document, while not an OSHA standard (law) serves as a very thorough and comprehensive guideline for developing and implementing a healthcare workplace violence prevention program, as serves as the foundation of all of our written programs and training programs.

• The risk of workplace violence against a healthcare facility comes from a variety of sources, including:
• The prevalence of handguns and other weapons among patients and residents, their families or friends;
• The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals;
• The increasing number of acute and chronic mentally ill patients and residents and residents being sent to long term care facilities or released from hospitals without follow-up care
• The availability of drugs or money at hospitals, clinics and pharmacies, making them likely robbery targets;
• Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly;
• The increasing presence of gang members, drug or alcohol abusers, trauma patients and/r distraught family members;
• Low staffing levels during times of increased activity such as mealtimes, visiting times and when staff are transporting patients and residents;
• Isolated work with clients during examinations or treatment;
• Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high-crime settings);
• Lack of staff training in recognizing and managing escalating hostile and assaultive behavior; and
• Poorly lit parking areas.

Under OSHA 3148, “healthcare facilities” include 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 workers, welfare workers and emergency medical care personnel. The guidelines may also be useful in reducing risks for ancillary personnel such as maintenance, dietary, clerical and security staff in the health care and social service industries.

A written Workplace Violence Prevention Program, incorporated into the facilities overall health and safety program is a critical starting point. Note that the program need not be lengthy or extreme; in smaller facilities the written program should be written to meet the level of risk identified. In every facility, quantifiable goals and objectives should be developed to help measure the efficacy of the program. At a minimum, workplace violence prevention programs should:  Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions.  Ensure that managers, supervisors, coworkers, clients, patients, residents, families, and visitors know about this policy.  Ensure that no employee who reports or experiences workplace violence faces reprisals.  Encourage employees to promptly report incidents and suggest ways to reduce or eliminate risks. Require records of incidents to assess risk and measure progress.  Outline a comprehensive plan for maintaining security in the workplace. This 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. Ensure that adequate resources are 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 issues such as preserving safety, supporting affected employees and facilitating recovery. The OSHA approach of five main components of any effective safety and health program also apply to the prevention of workplace violence:  Management commitment and employee involvement;  Worksite analysis;  Hazard prevention and control;  Safety and health training; and  Recordkeeping and program evaluation. When applying these components to a healthcare Workplace Violence Prevention program, each becomes a critical component. 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 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. Management commitment, including the endorsement and visible involvement of top management, provides the motivation and resources to deal effectively with workplace violence. This commitment should include:  Demonstrating organizational concern for employee emotional and physical safety and health;  Exhibiting equal commitment to the safety and health of workers and patients and residents/clients;  Assigning responsibility for the various aspects of the workplace violence prevention program to ensure that all managers, supervisors and employees understand their obligations;  Allocating appropriate authority and resources to all responsible parties;  Maintaining a system of accountability for involved managers, supervisors and employees;  Establishing a comprehensive program of medical and psychological counseling and debriefing for employees experiencing or witnessing assaults and other violent incidents; and  Supporting and implementing 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:  Understanding and complying with the workplace violence prevention program and other safety and security measures;  Participating in employee complaint or suggestion procedures covering safety and security concerns;  Reporting violent incidents promptly and accurately;  Participating in 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; and  Taking part in a continuing education program that covers techniques to recognize escalating agitation, assaultive behavior or criminal intent and discusses appropriate responses. Worksite Analysis A worksite analysis, performed by a qualified healthcare security specialist or team of specialists, 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 areas 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. This group may also be responsible for implementing the workplace violence prevention program. 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, they should be instituted. The recommended program for worksite analysis includes, but is not limited to:  Analyzing and tracking records;  Screening surveys; and  Analyzing workplace security. Records analysis and tracking This activity should include reviewing medical records (as legally allowed), safety records, and workers’ compensation and insurance records—including the OSHA Log of Work-Related Injury and Illness (OSHA Form 300), if the employer is required to maintain one—to pinpoint instances of workplace violence. Unit logs and employee and police reports of incidents or near-incidents of assaultive behavior should also be reviewed to identify and analyze trends in assaults relative to particular:  Departments;  Units/Wings;  Job titles;  Unit activities;  Workstations; and  Time of day. Tabulate these data to target the frequency and severity of incidents to establish a baseline for measuring improvement. Monitor trends and analyze 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. Conducting a workplace security analysis As previously stated, the analysis, whether done by an individual or a team, must be under the direct supervision of a qualified healthcare security professional. 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:  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 and residents (for example, those with psychiatric conditions or who are disoriented by drugs, alcohol or stress); physical risk factors related to building layout or design; isolated locations and job activities; lighting problems; lack of phones and other communication devices; areas of easy, unsecured access; and areas with previous security problems.  Evaluate the effectiveness of existing security measures, including engineering controls.  Determine if risk factors have been reduced or eliminated and take appropriate action. Hazard Prevention and Control

After hazards 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-incident response can be an important tool in preventing future incidents. Engineering controls 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 described in the following paragraphs. The selection of any measure, of course, should be based on the hazards identified in the workplace security analysis of each facility. Among other options, employers may choose to:  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.  Arrange for a reliable response system when an alarm is triggered.  Provide metal detectors—installed or hand-held, where appropriate—to detect guns, knives or other weapons, according to the recommendations of a qualified professional healthcare security consultant.  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, triage and admitting areas 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 or residents who “act out”.  Provide comfortable client or patient waiting rooms designed to minimize stress.  Ensure that counseling or patient care rooms have two exits.  Lock doors to staff counseling rooms and treatment rooms to limit access.  Arrange furniture to prevent entrapment of staff.  Use minimal furniture in interview rooms or crisis treatment areas and ensure that it is lightweight, without sharp corners or edges and affixed to the floor, if possible. 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, both indoors and outdoors.  Replace burned-out lights and broken windows and locks.

Keep automobiles well maintained if they are used in the field.  Lock automobiles at all times. Administrative and work practice controls affect the way staff perform jobs or tasks. Changes in work practices and administrative procedures can help prevent violent incidents. Some options for employers are to:  State clearly to patients and residents, clients and employees that violence is not permitted or tolerated.  Establish liaison with local police and state prosecutors. Report all incidents of violence. Give police physical layouts of facilities to expedite investigations.  Require employees to report all assaults or threats to a supervisor or manager (for example, through a confidential interview). Keep log books and reports of such incidents to help determine any necessary actions to prevent recurrence  Advise employees of company procedures for requesting police assistance or filing charges when assaulted and help them do so, if necessary.  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 to deal with aggressive behavior. Follow written security procedures.  Ensure that adequate and properly trained staff are available to restrain patients and residents or clients, if necessary.  Provide sensitive and timely information to people waiting in line or in waiting rooms. Adopt measures to decrease waiting time.  Ensure that adequate and qualified staff are available at all times. The times of greatest risk occur during patient transfers, emergency responses, and mealtimes and at night. .  Institute a sign-in procedure with passes for visitors. Enforce visitor hours and procedures.  Establish a list of “restricted visitors” for patients and residents with a history of violence or gang activity. Make copies available at security checkpoints, nurses’ stations and visitor sign-in areas.  Review and revise visitor check systems, when necessary.  Supervise the movement of psychiatric patients and residents 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. Do not allow employees to enter seclusion rooms alone.  Establish policies and procedures for secured areas and emergency evacuations.

 Determine the behavioral history of new and transferred patients and residents 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 residents and clients with assaultive behavior problems. Keep in mind patient confidentiality and worker safety issues. Update as needed.  Treat and interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (such as rooms with removable partitions).  Use case management conferences with coworkers and supervisors to discuss ways to effectively treat potentially violent patients and residents.  Prepare contingency plans to treat clients who are “acting out” or making verbal or physical attacks or threats. Consider using certified employee assistance professionals or in-house social service or occupational health service staff to help diffuse patient or client anger.  Transfer assaultive clients to acute care units, specialized units or other more restrictive settings.  Ensure that nurses and physicians are not alone when performing intimate physical examinations of patients and residents.  Discourage employees from wearing necklaces or chains to help prevent possible strangulation in confrontational situations. Do not use employee ID systems that require lanyards (even break-away design or retractable wire cords). Only clip on badges should be worn.  Urge community workers to carry only required identification and money.  Survey the facility periodically to remove tools or possessions left by visitors or maintenance staff that could be used inappropriately by patients and residents.  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. Ensure that parking areas are highly visible, well lit 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.  Advise staff to exercise extra care in elevators, stairwells and unfamiliar residences; leave the premises immediately 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 their whereabouts throughout the workday. Have the contact person follow up if an employee does not report in as expected

Employer responses to incidents of violence Post-incident response and evaluation are essential to an effective violence prevention program. All workplace violence programs should provide comprehensive treatment for employees who are victimized personally or 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 its severity. Provide the injured transportation to medical care if it is not available onsite. Victims of workplace violence suffer a variety of consequences in addition to their actual physical injuries. These may include:  Short- and long-term psychological trauma;  Fear of returning to work;  Changes in relationships with coworkers and family;  Feelings of incompetence, guilt, powerlessness; and  Fear of criticism by supervisors or managers.

Consequently, a strong follow-up program for these employees will not only help them to deal with these problems but also help prepare them to confront or prevent future incidents of violence. Several types of assistance 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 may provide this counseling or the employer may refer staff victims to an outside specialist. In addition, the employer may establish an employee counseling service, peer counseling or support groups. Counselors should 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, this type of counseling educates staff about workplace violence and positively influences workplace and organizational cultural norms to reduce trauma associated with future incidents. Safety and Health Training Training and education ensure that all staff are aware of potential security hazards and how to protect themselves and their coworkers through established policies and procedures. Training for all employees Every employee should understand the concept of “universal precautions for violence”—that is, that violence should be expected but can be avoided or mitigated through preparation. Frequent training also can reduce the likelihood of being assaulted. 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. It also includes instructions to limit physical interventions in workplace altercations whenever possible, unless enough staff or emergency response teams and security personnel are available. In addition, all employees should be trained to behave compassionately toward coworkers when an incident occurs. The training program should involve all employees, including supervisors and managers. New and reassigned employees should receive an initial orientation before being assigned their job duties. Visiting staff, such as physicians, should receive the same training as permanent staff. Qualified trainers in a recognized program 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 how to prevent and avoid assaults. A combination of training programs may be used, depending on the severity of the risk. Employees should receive required training annually. In large facilities, refresher programs may be needed more frequently, perhaps monthly or quarterly, to effectively reach and inform all employees. The training should cover topics such as:  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 to prevent or diffuse volatile situations or aggressive behavior, manage anger and appropriately use medications as chemical restraints;  A standard response action plan for violent situations, including the availability of assistance, response to alarm systems and communication procedures;  Ways to deal with hostile people other than patients and residents and clients, such as relatives and visitors;  Progressive behavior control methods and safe methods to apply restraints;  The location and operation of safety devices such as alarm 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;  Information on multicultural diversity to increase staff sensitivity to racial and ethnic issues and differences; and  Policies and procedures for obtaining medical care, counseling, workers’ compensation or legal assistance after a violent episode or injury. Training for supervisors and managers Supervisors and managers need to learn to recognize high-risk situations, so they can ensure that employees are not placed in assignments that compromise their safety. They also need training to ensure that they encourage employees to report incidents. Supervisors and managers 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.

Training for security personnel

If the facility employs security personnel (including employees in other departments that serve as security when needed), they too need specific training from the facility, including the psychological components of handling aggressive and abusive clients, types of disorders and ways to handle aggression and defuse hostile situations. Every training program should also include an evaluation. At least annually, the team or coordinator responsible for the program should review its content, methods and the frequency of training. Program evaluation may involve supervisor and employee interviews, testing and observing and reviewing reports of behavior of individuals in threatening situations. Recordkeeping and Program Evaluation Recordkeeping and evaluation of the violence prevention program are necessary to determine its overall effectiveness and identify any deficiencies or changes that should be made. Records employers should keep Recordkeeping is essential to the program’s success. Good records help employers determine the severity of the problem, evaluate methods of hazard control and identify training needs. Records can be especially useful 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 can help identify problems and solutions for an effective program. Important Records:  OSHA Log of Work-Related Injury and Illness (OSHA Form 300). Employers who are required to keep this log must record any new work-related injury that results in death, days away from work, days of restriction or job transfer, medical treatment beyond first aid, loss of consciousness or a significant injury diagnosed by a licensed health care professional. Injuries caused by assaults must be entered on the log if they meet the recording criteria. All employers must report, within 24 hours, a fatality or an incident that results in the hospitalization of three or more employees. 

Medical reports of work injury and supervisors’ reports for each recorded assault. These records should describe the type of assault, such as an unprovoked sudden attack, 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 work time that resulted and the nature of injuries sustained. These medical records are confidential documents and should be kept in a locked location under the direct responsibility of a health care professional.  Records of incidents of abuse, verbal attacks or aggressive behavior that may be threatening, such as pushing or shouting and acts of aggression toward other clients. This may be kept as part of an assaultive incident report. Ensure that the affected department evaluates these records routinely. (See sample violence incident forms in Appendix B.)  Information on patients and residents with a history of past violence, drug abuse or criminal activity recorded on the patient’s chart. All staff that care for a potentially aggressive, abusive or violent client should be aware of the person’s background and history. Log the admission of violent patients and residents to help determine potential risks.  Documentation of minutes of safety meetings, records of hazard analyses and corrective actions recommended and taken.  Records of all training programs, attendees and qualifications of trainers. The OSHA program for preventing and controlling violence in a healthcare facility is not new; what is new is that OSHA appears poised to begin an assaultive enforcement program against healthcare facilities and against the healthcare industry. Complying with the “guidelines” for preventing workplace violence in the healthcare setting is not difficult if the facility takes an organized approach, is diligent in its efforts, and has a qualified resource available for assistance and guidance. Steve Wilder, BA, CHSP, STS is President and COO of Sorensen, Wilder & Associates (SWA), a healthcare safety and security consulting group based in Champaign, IL. He is the co-author of the book The Essentials of Aggression Management in Healthcare: From Talkdown to Takedown. Steve can be reached at 800-568-2931 or at swilder@swa4safety.com.