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COURSE OBJECTIVE: The purpose of this course is to give healthcare providers information about workplace violence and workplace violence prevention training as outlined by the Occupational Safety & Health Administration of the U.S. Department of Labor (OSHA).
Upon completion of this course, you will be able to:
The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as violent acts directed toward persons at work or on duty. Workplace violence is any physical assault, threatening behavior, or verbal abuse occurring in the work setting. A work setting is defined as any location, either permanent or temporary, where an employee performs work-related duties. This comprises, but is not limited to, the buildings and surrounding perimeters, including the parking lots, field locations, clients’ homes, and traveling to and from work assignments.
Workplace violence ranges broadly, from offensive or threatening language to homicide. Elements of workplace violence include beatings, stabbings, suicides, shootings, rapes, psychological traumas, threats or obscene phone calls, intimidation, harassment of any kind, as well as being sworn at, shouted at, or followed.
EXAMPLES OF WORKPLACE VIOLENCE
In the mid-1990s, as more researchers were becoming engaged in the study of occupational violence, the California Occupational Safety and Health Administration developed a model that described three distinct types of workplace violence based on the perpetrator’s (person committing the violence) relationship to the victim and/or the place of employment. Later, the typology was modified to define four types of workplace violence, creating the system that remains in wide use today. This typology has proven useful not only in studying and communicating about workplace violence but also in developing prevention strategies (NIOSH, 2006).
The four types are:
In this type of workplace violence the perpetrator is a stranger and has no legitimate relationship to the organization or its employees. Typically, a crime is being committed in conjunction with the violence. The primary motive is usually robbery, but it could also be shoplifting or criminal trespassing. A deadly weapon is often involved, increasing the risk of fatal injury. Crimes of violence in this category include assault, sexual assault, robbery, and homicide.
Type I, violence by criminals otherwise unconnected to the workplace, is the most common source of worker homicide, accounting for over 75% of workplace homicides between 1997 and 2009 (BLS, 2010b).
Workers who are at higher risk for type I violence are those who exchange cash with customers as part of the job, work late-night hours, and/or work alone. Convenience store clerks, taxi drivers, and security guards are all examples of the kinds of workers who are at increased risk for type I workplace violence.
In type II incidents, the perpetrator has a legitimate relationship with the organization by being the recipient or object of services provided by the workplace or the victim. This category includes customers, clients, patients, students, inmates, and any other group for which the business provides services. The violence can be committed in the workplace or, as with service and healthcare providers; outside the workplace but while the worker is performing a job-related function.
Violence of this kind is divided into two categories. One category involves people who may be inherently violent, such as prison inmates, mental-health service recipients, or other client populations. Attacks from “unwilling” clients, such as prison inmates on guards or crime suspects on police officers, are examples of this type of workplace violence. The risk of violence to some workers in this category may be constant or even routine.
Memorial Medical Center is a mid-sized hospital located in a suburb of a large metropolitan area. The hospital provides general medical/surgical inpatient and outpatient services. The eight-bed emergency room remains relatively quiet unless they are treating overflow patients from the trauma unit downtown. Nine months ago, the hospital’s board of directors agreed to allocate space in the ER for the local police department to admit suspected drunk drivers for assessment and short-term intervention until they are ready to be released home or moved to the police department for processing. The program has had a slow start. To date there have been fewer than a handful of cases.
Eric is a college student and works part-time on the night shift as a lab technician. He was on duty when a 28-year-old male was admitted for assessment after hitting a parked car while leaving a party. The client was initially cooperative while the police officer was present and was taken by a nurse to one of the assessment rooms at the end of the hall. He then began to get agitated, denied he had done anything wrong, jumped up, and demanded to be released.
Eric entered the room to take a blood sample just as the nurse was responding to the patient’s angry request by grabbing onto his arm and saying that he was not allowed to leave yet. The patient grabbed a small metal canister off the counter, threw it at Eric, and ran out of the room toward the entrance, where he was subdued by the hospital security guard and two additional staff members. The canister hit Eric in the face, injuring his left eye.
The hospital’s safety committee was asked to review the incident and make recommendations for preventing future occurrences. The committee evaluated the specific incident as well as the following:
The committee proposed that a better response to the situation would have included the following:
It was determined that the hospital had overlooked some of the risks involved with the new program, and they responded quickly to the committee’s suggestions by implementing the following improvements:
The other category involves people who are not known to be inherently violent but are situationally violent. Something in the situation induces an otherwise nonviolent client or customer to become violent. Provoking situations may be those that are frustrating to the client or customer, such as denial of needed or desired services or delays in receiving such services.
Type II violence accounted for 6.7% of workplace homicides reported from 1997 to 2009 (BLS, 2010b). Service providers, including healthcare workers, schoolteachers, social workers, and bus and train operators, are among the most common targets of type II violence. A large proportion of customer/client incidents occur in the healthcare industry in settings such as nursing homes, hospitals, and psychiatric facilities.
Alice Adams is a 70-year-old resident at Hillcrest Manor, a skilled nursing and long-term care facility. She was admitted six months ago after she was found wandering a few blocks away from her long-time family home. She was recently diagnosed with second-stage Alzheimer’s disease. Prior to her admission she lived alone with daily help from her two sons, their wives, and several grandchildren. Her husband died eighteen months ago after a fall from a ladder while cleaning leaves out of the gutters.
The older son, Jack, still feels guilty for not helping his father with the gutter clean-up and blames himself for his father’s death. He was not in favor of the decision to admit his mother to Hillcrest but reluctantly agreed when the other family members and Alice’s physician decided it was the best option. Jack has been a frequent caller to the facility administrator’s office with complaints about Alice’s care. He thinks that she is not checked often enough, that she needs more help with meals, and that she should be taken for walks more frequently. He believes that his mother’s health is worse and blames the facility for a decline in his mother’s mental capacity.
Today Jack arrives to find Alice dozing in her recliner chair with her supper tray sitting untouched on the table next to her. He storms out of her room into the hallway and shouts that he needs help right away. The evening shift nurse is just down the hall making rounds and responds immediately, as does the patient-care assistant helping a resident in the next room. Jack grasps the assistant’s shoulders and pushes her into his mother’s room, asking why his mother has not been helped yet with her meal. He curses and states that this is the last time he is going to ask nicely.
The patient-care assistant recognizes Jack and is familiar with his frequent complaints about his mother’s care. She steps aside and exits the room. Standing in the doorway, she calls him by name, calmly stating, “Mr. Adams, I can see that you are upset. I was just finishing up next door and was going to help Mrs. Adams next. It sounds like you would like to talk with someone about your concerns. I will get the supervisor, who will be glad to meet with you.” Jack visibly relaxes and sits down.
The evening shift nurse arrived in time to see the incident and steps into the room. She helps Jack set up his mother’s dinner tray and calls another patient-care assistant to help Alice with her meal. She then suggests that Jack meet with her in a nearby conference room.
She asks Jack to describe what happened, and as he does, he acknowledges that his behavior was out of line. He apologizes for his outburst and shares how frustrated he is with his mother’s health decline and not being able to do anything to prevent it. The nurse acknowledges his feelings and how difficult it must be for him to deal with the kind of changes he has been faced with. She states that his behavior was inappropriate and will be reported to the facility’s security manager. She tells Jack that any additional incidents like she witnessed that evening will result in further action to ensure the safety of the residents and the employees. She reminds him that he can communicate any concerns about his mother’s care to the administrator or to her if it is the evening shift.
She then suggests that Jack may benefit from talking with the facility’s social worker, who also runs the local caregivers support group, and provides him with the phone number. Jack agrees that the suggestion sounds like a good idea and returns to his mother’s room to resume his visit.
Type III violence occurs when an employee or past employee attacks or threatens coworkers. This category includes violence by employees, supervisors, managers, and owners. In some cases, these incidents can take place after a series of increasingly hostile behaviors from the perpetrator. The motivating factor is often one, or a series of, interpersonal or work-related disputes. The perpetrator may be seeking revenge for what is perceived as unfair treatment.
Violence by a coworker accounts for approximately 10% of all workplace homicides (BLS, 2010b). Because some of these incidents appear to be motivated by disputes, managers and others who supervise workers may be at greater risk of being victimized.
EXAMPLES OF COWORKER VIOLENCE
Workplace violence and harassment experts identify the following behaviors that constitute coworker violence in the workplace (Hawaii Nurses Association, 2008):
In a position statement on workplace violence published in 2008, the American Psychiatric Nurses Association (APNA) highlighted the prevalence of violence by a coworker and characterized the violence as either vertical or horizontal.
Violence by a coworker occurs vertically when someone in authority perpetrates violence over those in lower positions or when individuals are violent toward those in higher positions. Bullying is an example of vertical violence. Bullying is usually associated with a perpetrator at a higher level or authority gradient, for example, a supervisor to staff member.
Workplace bullying is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators that takes one or more of the following forms:
Horizontal violence, also known as lateral violence, occurs between workers holding the same or similar positions. Horizontal violence is hostile and aggressive behavior by individual or group members toward another member or group of members of the larger group (APNA, 2008).
The most frequent manifestations of horizontal aggression are not acts of overt aggression but less dramatic psychologically aggressive acts, such as spreading rumors about and giving dirty looks to colleagues. Also common are nonverbal innuendos, verbal affronts, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences. Acts of horizontal violence also can include belittling or criticizing a colleague in front of others, blocking a chance for promotion, and isolating or freezing a colleague out of group activities (APNA, 2008).
George, a paramedic, had worked as a field supervisor for over twenty years when ABC Ambulance Service was acquired by a large metropolitan hospital system in a nearby community. George interviewed for three different management positions with the newly reorganized ambulance service but was instead offered a staff-level job on the day shift. He grudgingly accepted the position and has been a thorn in the new day shift supervisor’s side ever since. The new supervisor, James, is several years younger than George and transferred from the hospital system’s emergency transport division.
George’s aggressive tactics were subtle at first but are becoming more flagrant. He does not openly disagree with his supervisor or refuse an assignment. However, he regularly belittles James when talking with other staff members, criticizing his decisions and questioning his management skills. He has nicknamed him Mr. Know-Nothing. George jokes about James’s past experience and insinuates that James was given the job because he is having an intimate relationship with the manager of the business office.
George was trying to organize a shift-wide boycott of his supervisor’s monthly staff meeting when a coworker on the night shift alerted his own supervisor about George’s behavior and asked for help.
In type IV workplace violence, the perpetrator usually has or has had a personal relationship with the intended victim and does not have a legitimate relationship with the workplace. The incident may involve a current or former spouse, lover, relative, friend, or acquaintance. The perpetrator is motivated by perceived difficulties in the relationship or by psychosocial factors that are specific to the situation and enters the workplace to harass, threaten, injure, or kill. Seven percent of the workplace homicides that occurred between 1997 and 2009 have been attributed to type IV workplace violence (BLS, 2010b).
This type of violence is often the spillover of domestic violence into the workplace. In some cases, a domestic violence situation can arise between individuals in the same workplace. These situations can have a substantial effect on the work environment. They can manifest as high absenteeism and low productivity on the part of a worker who is enduring abuse or threats, or the sudden, prolonged absence of an employee fleeing abuse.
Some 2 million American workers are victims of workplace violence each year. Workplace violence can strike anywhere, and no one is immune. Its most extreme form—homicide—is the fourth-leading cause of fatal occupational injury in the United States. According to the Bureau of Labor Statistics Census of Fatal Occupational Injuries (2010), there were 521 workplace homicides in the United States in 2009 out of a total of 4,349 fatal work injuries.
Although workplace homicides may attract more attention, the vast majority of workplace violence consists of nonfatal assaults. From 1993 through 1999, an average of 1.7 million people per year were victims of violent crime while working or on duty in the United States (NIOSH, 2008). In 2008, there were 16,330 cases of nonfatal assaults and violent acts by persons requiring days away from work in private industry (BLS, 2010a).
Healthcare and social service workers face significant risk of job-related violence. Assaults represent a serious safety and health hazard within these industries.
As significant as these numbers are, the actual number of incidents is probably much higher. Incidents of violence are likely to be underreported, perhaps due in part to the persistent perception within the healthcare 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.
Workplace violence extracts a significant toll on everyone involved. In addition to the physical, emotional, and mental effects on the victim, other negative effects include: financial loss resulting from insurance claims, lost productivity, legal expenses, property damage, increased security measures, diminished public image, and possible staff replacement costs. The aggregate cost of workplace violence to U.S. employers is estimated to be more than $36 billion as a result of expenses associated with lost business and productivity, litigation, medical care, psychiatric care, higher insurance rates, increased security measures, negative publicity, and loss of employees (Encyclopedia of Small Business, 2011).
|To Individuals||To Organizations|
Nothing can guarantee that an employee will not become a victim of workplace violence. However, several steps can help reduce the risk: Learn how to recognize, avoid, or diffuse potentially violent situations by attending personal safety training programs. Alert supervisors to any concerns about safety or security and report all incidents immediately in writing. Be familiar with laws and regulations regarding workplace violence and your facility’s violence prevention program.
The prevalence of workplace violence in the healthcare sector has prompted studies and organizational initiatives aimed at addressing the problem.
In January 2007, the International Association for Healthcare Security and Safety issued its first set of “Healthcare Security Basic Industry Guidelines,” a resource for healthcare institutions in developing and managing a security management plan, addressing security training, conducting investigations, identifying areas of high risk, and more (The Joint Commission, 2010).
In February 2008, the Center for American Nurses issued the position statement “Lateral Violence and Bullying in the Workplace” (CAN, 2008). The Center for Occupational and Environmental Health of the American Nurses Association is currently working with the National Institute of Occupational Safety and Health on a violence-prevention training module for nurses (Wood, 2011).
The Joint Commission introduced a new leadership standard that addresses workplace violence by coworkers. The standard covers several suggested actions aimed at reducing intimidating and disruptive behaviors between coworkers. Hospitals, nursing homes, home health agencies, laboratories, ambulatory care facilities, and behavioral healthcare facilities must have a code of conduct in place that determines which behaviors are tolerated and which are not and that creates a formal procedure for managing any unacceptable behavior (The Joint Commission, 2010).
The American Nurses Association State Legislative Agenda includes initiatives to address workplace violence in healthcare settings. ANA created a model bill, “The Violence Prevention in Health Care Facilities Act,” which requires a healthcare employer to establish a program with emphasis on prevention and reporting (ANA, 2010). Prompted by the death of a member nurse, the California Nurses Association began working with state officials to draft legislation that would address violence at hospitals, correctional institutions, and other facilities (Slupski, 2011).
Healthcare and social service workers face an increased risk of work-related assaults stemming from several factors. These include:
Workplace location—particularly emergency rooms and psychiatric units—elevates the risk for workplace violence. Facilities for older adults were found to generate particularly high levels of verbal abuse. Further, male nurses run a greater risk for violence than female nurses, which may result from the assignment of male nurses to more risky, potentially abusive patients and environments. One fourth of physical violence and almost one third of psychological violence were directed at nurses by patients’ relatives (Campbell, 2011).
As described above, security hazards are circumstances present in the physical surroundings of the workplace and in the behavior of others that increase the risk of violence. Early recognition of security hazards calls for enhanced awareness of the physical environment and the behavior of coworkers and self.
Security hazards in the physical environment are factors that isolate employees, allow others easy access to buildings and work sites, or place potential weapons within reach. Workplace security hazards include:
SECURITY HAZARDS IN HEALTHCARE SETTINGS
Hospitals and other healthcare settings have unique characteristics that add to the potential of environmental security hazards. The reasons vary by setting and include:
It is important to assess in advance of any incident the particular security hazards present in the workplace. Managers and workers should take steps to reverse those circumstances that isolate employees, allow others easy access to buildings and work sites, or place potential weapons within reach.
There are a number of actions that employees can take to minimize the risks associated with security hazards in the work environment. Awareness is the first step. Then:
Healthcare personnel have an increased risk of encountering potentially violent behavior because clients may be disoriented by drugs, alcohol, stress, or physical trauma. No one can predict human behavior, and there is no specific profile of a potentially dangerous individual. However, indicators of increased risk of violent behavior are available. Research on over 200 incidents of workplace violence (Mattman, 2009) revealed that, in each case, the suspect exhibited multiple pre-incident indicators that included the following:
Early recognition of potentially dangerous situations is the first step in a response strategy. By anticipating, recognizing, and responding to a hazardous situation appropriately, employees may be able to prevent violence from happening. Each of the behavioral indicators mentioned is a clear sign that something is wrong. None should be ignored.
Some behaviors require immediate police or security involvement, and others indicate a need to arrange supportive intervention. It is important to learn and use nonviolent crisis-intervention and conflict-resolution techniques. Trust personal instincts, and when you feel uncomfortable with the behavior of others, remove yourself from the situation or promptly seek assistance.
Working in the community outside a traditional office building increasesthe risk of coming in contact with potentially violent situations.Prevention measures for field workers should include consideration of the following:
Janice is an occupational therapy student at the local state college who is working part-time as a home health aide two evenings per week and on weekends. She shares an apartment on campus with two other students and commutes 30 minutes to the Visiting Nurse Care home health agency for work. She is required to check in at the main office before her shift starts to pick up her assignments, attend occasional staff meetings and training sessions, and restock her patient care supplies. She is not required to return to the office at the end of her shift. Rather, she can go home after she finishes with her last client.
Janice attended hazard assessment and safety training when she was hired for the job as a home health aide. The training is repeated on an annual basis for each home care worker at the agency. Janice remembers hearing about a case in a nearby city where a home health aide was assaulted by an angry family member, and the story has stuck with her. The injured employee was the same age as Janice. She does not need to be talked into attending the training sessions when they are offered.
Janice readily follows the safety protocols that have been established by the home care agency and has added a few of her own.
By following these steps, Janice feels comfortable that she is taking the necessary precautions to avoid finding herself in a potentially dangerous situation.
There are three general approaches that employers can take to prevent workplace violence:
EFFECTIVE EMPLOYER INITIATIVES
In 1970 the Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor issued workplace safety standards that included a General Duty clause. The General Duty clause requires employers to provide a place of employment that is free from recognized hazards causing, or likely to cause, death or serious physical harm, including the prevention and control of workplace violence. Employers can be cited and fined when incidents of worker illness or injury are attributed to the workplace. Surveyors will evaluate the following:
In 1989, OSHA published the Safety and Health Program Management Guidelines. These guidelines, while not mandatory, are intended for use by employers who are seeking to provide a safe and healthful workplace through effective workplace violence prevention programs.
The OSHA 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 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 can be reduced.
A workplace violence prevention program demonstrates an organization’s concern for employee emotional and physical safety and health. The program encompasses the following elements:
The first two elements—management commitment and employee involvement—are complementary and essential to a successful workplace violence prevention program.
Management commitment provides the motivating force for dealing effectively with workplace violence. Policies should be established to clearly communicate that violence, threats, harassment, intimidations, and other disruptive behavior in the workplace will not be tolerated. Another key element of organizational policy should establish that all reports of incidents will be taken seriously and will be dealt with appropriately. Management should to be committed to:
Employee involvement enables workers to develop and express their commitment to safety and health. Employee involvement should include:
A key element of the workplace violence prevention program is the threat assessment team, or safety committee. The primary function of the team is to provide a thorough workplace security/hazard analysis and establish prevention strategies. An effective team will assess the organization’s vulnerability to workplace violence, make recommendations for preventive actions, develop employee training programs in violence prevention, establish a plan for responding to acts of violence, and evaluate the overall workplace violence prevention program on a regular basis.
The victim’s immediate response to a violent workplace incident can range from passive acceptance or avoidance to verbal defense to more active negotiation and physical defense. The management response to incidents of workplace violence should reflect the organizational commitment to overall employee health and safety. Post-incident actions should include:
Downtown Free Clinic is located in the center of the city and is slated for renovation. This clinic has been a staple walk-in medical care facility for inner-city residents. Downtown Clinic is open six days a week from 6 a.m. to 10 p.m. The clinic sees an average of 120 patients per day. The clinic has just been acquired by the local hospital and is now a division of the hospital conglomerate.
Cynthia works as the office manager and has been selected to represent the clinic as a member of the hospital safety committee. As part of the threat assessment team, her assignment for the upcoming meeting is to conduct a workplace violence hazard assessment for the reception area and parking lot of the clinic. She have worked at this facility for six years and has never felt threatened, nor has she had any complaints from her staff. She anticipates a quick assessment.
To prepare for the assignment, Cynthia decides to review the hospital’s workplace violence prevention plan. The policy statement reinforces the hospital’s commitment to zero tolerance for violence in the workplace and further commits all managers and supervisors to implement all aspects of the program, thus ensuring a safe environment for all employees. The threat assessment team has been charged with developing employee training, communicating the plan to employees, analyzing and reviewing existing records related to assault incidents, inspecting the workplace, and evaluating all work tasks to determine the presence of hazards or situations that may place workers at risk for violent acts.
She begins by reviewing the following records:
She finds several incidents involving verbal threats to receptionists from clinic patrons, ten incidents involving pushing/shoving in the parking lot where police were called to intervene, no staff training records, and twenty insurance claims for damages to cars in the parking lot. It occurs to her that it would also be a good idea to interview staff to find out how many incidents were never reported.
Surprised by the number of incidents, Cynthia proceeds to conduct an inspection of the workplace areas assigned to her. She discovers that the main entrance to the clinic is not controlled; the door is unlocked for all hours of operation. There is no lock on the door between the reception area and the clinic. The parking lot is not well lit, and unidentified persons often loiter there. There is no method of communication between the reception desk and the main treatment area of the clinic.
Concerned with the hazards from the inspection, she reviews the tasks of the receptionists and finds the following concerns:
After careful consideration, Cynthia decides that the building, work area design, and staffing will need to change and that written policies and procedures must be instituted to address the security hazards she has identified. Her initial recommendations to the safety committee include:
From this exercise, Cynthia was surprised to discover a significant number of incidents involving violence to employees or patrons at the clinic. Many of these incidents could have been prevented with an effective violence prevention program. It is reassuring to have the hospital concerned with the safety and health of the employees by committing authority and budgetary resources to the managers and supervisors so that an effective program can be implemented.
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