The Occupational Safety and Health Administration (OSHA) have published Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. These guidelines are not new standards or regulations with which employers must comply. Rather, they are “advisory in nature.” However, the guidelines do state that failure to provide a workplace safe from violence will be enforced under the “general duty clause” of the OSH Act.
The general duty clause of the law provides that all employers have a general duty to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. A recognized hazard can be one which is recognized in the employer’s industry, not simply by the individual employer. There are several studies cited in the guidelines which report statistics showing that health care workers are much more likely to suffer a violent incident than workers in other industries. In addition, these materials state there is likely to be an under reporting of violence and a persistent perception within the health care industry that assaults are part of the job.”
Employers can be cited for violating the general duty clause if there is a recognized hazard of workplace violence in their establishments and they do nothing to prevent or abate it. Failure to implement the guidelines is not, in itself, a violation of the general duty clause, but, if there is an incident of workplace violence, the employer will not be cited by OSHA if the employer has established and effectively implemented a violence prevention program.
The guidelines expressly cover home health care workers, in addition to other health care personnel:
“The guidelines cover a broad spectrum of workers who provide health care and social services…they include physicians, registered nurses, pharmacists, nurse practitioners, physicians’ assistants, nurses’ aides, therapists, technicians, public health nurses, home health workers, social/welfare workers, and emergency medical care personnel.”
Elements of a Violence Prevention Program
According to the guidelines, there are four main components to an effective workplace violence prevention program: (1) management commitment and employee involvement; (2) worksite analysis; (3) hazard prevention and control; and, (4) safety and health training. Additionally, record keeping and evaluation are emphasized in the guidelines and are deemed essential to an effective program.
(1) Management Commitment and Employee Involvement.
Involvement by management and employees is necessary to a successful program. A written program is not required but is advisable.
Management Commitment
Management commitment 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 workplace violence prevention program.
• Appropriate allocation of authority and resources.
• A system of accountability for persons involved in the program.
• A program of medical and psychological counseling for employees involved in violent incidents.
• Commitment to support and implement appropriate recommendations made by safety and health committees.
Employee Involvement
Employee involvement should include the following:
• Understanding and complying with the program and other safety and security measures.
• Participation in an employee complaint or suggestion procedure.
• Prompt and accurate reporting of violent incidents.
• Participation on safety and health committees.
• Continuing education program that covers techniques to recognized escalating agitation, assaultive behavior, or criminal intent, and discussion of appropriate responses.
Written Program
The guidelines state a written 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 necessary are clear goals and objectives which are suitable for the size and complexity of the workplace operation and adaptable to specific situations in each establishment. Still, a written program is advisable because if offers proof of the program’s existence and its effective implementation.
At a minimum, workplace violence prevention programs should do the following:
• Create and disseminate a clear policy of zero-tolerance for workplace violence.
• Ensure that no reprisals are taken against an employee who reports or experiences workplace violence.
• Encourage employees to promptly report incidents and to suggest ways to reduce or eliminate risks. Require records of incidents.
• Outline a comprehensive plan for maintaining security in the workplace, which includes a liaison with law enforcement and others.
• Assign responsibility and authority for the program to individuals with appropriate training and skills.
• Affirm management commitment to a worker-supportive environment.
• Set up a company briefing as part of the initial effort.
(2) Worksite Analysis
Worksite analysis involves a step-by-step, common sense 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.
The suggestions in the guidelines are quite extensive and involve the activities of a “Threat Assessment” or “Patient Assault” Team. This is one place where there are no suggestions of how to scale back the program for a smaller employer. Nevertheless, in smaller organizations, two employees (one management and on line employee) assigned to this task should be sufficient.
The basic elements of worksite analysis are:
• Analyze records for your operation.
• Monitor trends for violence in your community and in the professions of your employees.
• Conduct periodic screening surveys of employees for their thoughts on the types of risks faced and possible security measures.
• Analyze your workplace by identifying types of locations which are likely to cause a risk of violence, identify high risk factors such as types of patients, family situation, etc., and evaluate the effectiveness of existing security measures.
(3) Hazard Prevention and Control.
Hazard prevention and control involves three elements: (1) Engineering Controls and Workplace Adaptation; (2) Administrative and Work Practice Controls; and, (3) Post-Incident Response.
Engineering Controls and Workplace Adaptation
The guideline’s suggestions concerning engineering controls and workplace adaptation are extensive and specific, but pertain to institutional settings. Unless there exists a potential for violence in the violence in the employer’s offices (such as those located in high crime areas; do not assume your offices are not – check with the police), these are generally inapplicable to home care agencies.
Nevertheless, some of the suggestions in this regard could be useful in inpatient hospice facilities. These include: assessing places for new construction or physical changes to eliminate or reduce security hazards; designing staff work areas which physically separate staff from patients and visitors to allow staff to remove themselves from potentially dangerous situations; and, providing waiting rooms or lounges designed to maximize comfort and minimize stress.
Administrative and Work Practice Controls
The suggestions here are very extensive and specific. Some of them are, again, specific to institutional settings and, therefore, generally inapplicable to home care agencies. However, some of the suggestions are pertinent:
• State clearly to patients, clients, and employees that violence is not permitted or tolerated.
• Establish liaison with local police and report all incidents of violence.
• Require employees to report all assaults.
• Advise employees of company procedures for requesting police assistance or filing charges and assist them in doing so.
• Provide management support and respond promptly to all complaints.
• Set up response team/individual to respond to emergencies.
• Ensure adequate and qualified staff coverage at all times.
• Establish a system to identify patients and clients with assaultive behavior problems, keeping in mind patient confidentiality.
• Use case management conferences to discuss ways to effectively treat potentially violent patients.
• 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 follow up.
• Conduct a post-incident evaluation, including treatment for employees who have been subjected to abusive behavior.
• Develop policies and procedures covering home care providers, such as written statements 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.
For inpatient hospices, some of the institutional suggestions can be helpful, such as: controlling access to the facility; instituting a sign-in procedure with passes for visitors; periodically surveying the facility to remove objects which could be used inappropriately in a violent situation; and, monitoring the physical status of the facility (e.g. functioning locks and lights.)
Post-Incident Response
Post-incident response is considered “essential” for an effective violence prevention program. This response should include medical and psychological treatment for an employee who experiences or witnesses a violent incident.
(4) Safety and Health Training.
Employees who may face safety and security hazards should receive formal instruction concerning the specific hazards associated with the job. Suggested topics may include: Management of Assaultive Behavior; Professional Assault Response Training; or, personal safety training such as awareness, avoidance, and how to prevent assaults. A combination of training may be used depending upon the severity of the risk.
Required training should be provided to employees annually. There is a list of twelve topics that the guidelines state the training should cover, including; the employer’s policy; risk factors; early recognition of warning signs; preventing or diffusing volatile situations; a response action plan; how to deal with hostile persons other than patients; ways to protect oneself; policies and procedures for reporting; and, record keeping.
Supervisors and managers should be charged with ensuring employees are not placed in assignments that compromise safety. They should be able to recognize a potentially hazardous situation and make the changes necessary to reduce or eliminate the hazard. There is a lot of the verbiage in the guidelines about what a training program should accomplish, especially for supervisory personnel, much of which is covered in the twelve-step program referred to above and in the evaluation section discussed below.
(5) Record Keeping and Evaluation of the Program.
Record keeping is considered a necessary element of a violence prevention program. The following records are listed as being particularly important:
• OSHA Log of Injury and Illness (OSHA 200).
• Medical reports of work injury and supervisor’s report for each recorded assault.
• Incidents of abuse, verbal attacks or aggressive behavior.
• Information on patients with a history or past violence or drug abuse.
• Minutes of safety meetings, records of corrective actions recommended.
• Records of all training programs and attendees and trainers.
There are ten items listed for what an evaluation program should involve. These include: establishing a reporting system and review of reports; analyzing trends and rates of injury; keeping up-to-date records of administrative and work practice changes to prevent workplace violence; keeping abreast of new strategies to deal with violence; surveying employees after making changes and after incidents; complying with OSHA and state requirements for recording and reporting; and, requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving employee safety.
Conclusion
Many of the suggestions which OSHA has incorporated into the guidelines for preventing workplace violence may be present in other employee policies developed by your organization. However, if a violent incident happens to one of your employees, having a separate policy which deals with workplace violence and which pays some attention to the details suggested by the OSHA guidelines is very valuable in avoiding an OSHA citation for failure to provide a safe workplace.
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A copy OSHA’s Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers (OSHA 3148, 1996) can be obtained by contacting U.S. Department of Labor/OSHA OSHA Publications, P.O. Box 37535, Washington, D.C. 20013-7535; telephone (202) 219-4667. Or, download it from the OSHA publications page at www.osha.gov/pls/publications/pubindex.list .
© 1996 - 2008 John C. Gilliland II
The original version of this article was first published in the September 1996 issue of “Home Health Care and the Law” published by the Indiana Association for Home Care.
The content of this article was last reviewed and updated as necessary on 03/14/08.
Disclaimer: The article is for educational informational purposes only, is not intended for legal advice, and should not be used for legal guidance or to resolve legal problems. Transmission or receipt of this article does not create an attorney-client relationship. Anyone reading this article should not act on the information in the article without seeking professional legal advice applicable to his or her own specific circumstances.
