Workplace Violence

Wild Iris Medical Education is an approved provider for paramedic and EMT continuing education in California by the California Emergency Medical Services Agency: EMS CE Provider #49-0057.
Wild Iris Medical Education is an approved provider (#0007) of continuing education by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS).
This course is appropriate for EMTs, paramedics, and first responders.

This course covers the basic recommendations for annual workplace violence prevention training as outlined by the Occupational Safety & Health Administration (OSHA) of the U.S. Department of Labor. To augment this course, employers are encouraged to provide information regarding company-specific hazards and the steps taken to ensure employee safety on the job.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

Define workplace violence.
Name the four types of workplace violence.
Understand the risk factors for workplace violence in the healthcare industry.
Identify security hazards in the work environment.
Recognize security risks in the behavior of others.
List at least three prevention measures to reduce the risk of workplace violence.
Describe the elements of a workplace violence prevention program.

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 includes 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 violence in the workplace include the following:

Verbal threats to inflict bodily harm, including vague or covert threats
Attempting to cause physical harm: striking, pushing and other aggressive physical acts against another person
Disorderly conduct, such as shouting, throwing or pushing objects, punching walls, and slamming doors
Verbal harassment; abusive or offensive language, gestures or other discourteous conduct towards supervisors or fellow employees
Making false, malicious or unfounded statements against coworkers, supervisors, or subordinates which tend to damage their reputations or undermine their authority

CATEGORIES OF WORKPLACE VIOLENCE

Workplace violence has many sources. To better understand its causes and possible solutions, researchers have divided it into four categories dependent upon the type of perpetrator (person committing the violence). The four types are: violence by strangers, violence by customers or clients, violence by co-workers, and violence by someone in a personal relationship (University of Iowa, 2001).

Type I: Violence by a Stranger

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.

Type I is the most common source of worker homicide. Eighty-five percent of all workplace homicides fall into this category (University of Iowa, 2001).

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.

Type II: Violence by a Customer or Client

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, and inmates. The violence can be committed in the workplace or, as with service 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.

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.

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, or psychiatric facilities.

Type III: Violence by a Co-Worker

Type III violence occurs when an employee or past employee attacks or threatens co-workers. 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 co-worker accounts for approximately 7% of all workplace homicides (University of Iowa, 2001). 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.

Type IV: Violence by Someone in a Personal Relationship

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. Victims of type IV violence are overwhelmingly, but not exclusively, female (University of Iowa , 2001).

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.

INCIDENCE OF WORKPLACE VIOLENCE

Workplace violence has been recognized as an important occupational safety and health issue that crosses all occupational sectors. 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 (BLS) Census of Fatal Occupational Injuries, there were 551 workplace homicides in 2004 in the United States, out of a total of 5,703 fatal work injuries (Bureau of Labor Statistics, 2005).

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, according to a report published by the Bureau of Justice Statistics. An estimated 1.3 million (75%) of these incidents were simple assaults while an additional 19% were aggravated assaults (NIOSH, 2006).

Healthcare and Social Service Workers

For many years, healthcare and social service workers have faced a significant risk of job-related violence. Assaults represent a serious safety and health hazard within these industries. The BLS reports that there were 69 homicides in the health services from 1996 to 2000. Bureau data shows that, in 2000, 48% of all nonfatal injuries from occupational assaults and violent acts occurred in healthcare and social services. Most of these occurred in hospitals, nursing and personal care facilities, and residential care agencies. Nurses, aides, orderlies, and attendants suffered the most nonfatal assaults resulting in injury (OSHA, 2004).

Injury rates also reveal that healthcare and social service workers are at high risk of violent assault at work. The BLS rates measure the number of events per 10,000 full-time workers—in this case, assaults resulting in injury. In 2000 health workers overall had an incidence rate of 9.3 for injuries resulting from assaults and violent acts. The rate for social service workers was 15, and for nursing and personal care facility workers, 25. This compares to an overall private sector injury rate of 2 (OSHA, 2004).

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 costs an estimated $55 million annually in lost wages (OSHA, 2004). Lost productivity, legal expenses, property damage, diminished public image, and increased security measures add up to billions of dollars per year. Workplace violence is everyone's problem.

RISK FACTORS

Healthcare and social service workers face an increased risk of work-related assaults stemming from several factors. These include:

The prevalence of handguns and other weapons among patients, their families, and 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 being released from hospitals without follow-up care (these patients have the right to refuse medicine and 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
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, or distraught family members
Low staffing levels during times of increased activity such as mealtimes, visiting times, and when staff are transporting patients
Isolated work with clients during examinations or treatment Solo work, often in remote locations, with no backup or way to get assistance (ie, communication devices or alarm systems); this is particularly true in high-crime settings
Lack of staff training in recognizing and managing hostile and high-risk behavior as it escalates
Poorly lit parking areas.

SECURITY HAZARDS

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 co-workers and self.

In the Environment

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:

Isolated location or job activities
Uncontrolled access to the building
No locks on doors or between work areas
Lighting problems such as dark hallways and parking lots
Lack of phones or means of communication between employees
Early-morning or nighttime hours of employment
Unknown person(s) loitering outside workplace
Easy access to potential weapons such as knives or scissors

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:

Pay attention to your physical surroundings.
Trust your instincts. Remove yourself from uncomfortable situations if you can.
If possible, avoid locations that are poorly lit or have poor visibility.
Work with a partner or have an effective means of communication such as a cell phone or pager.
Use the locks and security systems available to you.
Report security hazards promptly to a supervisor.

In the Behavior of Others

Emergency medical 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 of over two hundred incidents of workplace violence revealed that, in each case, the suspect exhibited multiple pre-incident indicators that included the following:

Increased use of alcohol and/or illegal drugs
Unexplained increase in absenteeism
Noticeable decrease in attention to appearance and hygiene
Depression and withdrawal
Explosive outbursts of anger or rage without provocation
Threatens or verbally abuses co-workers and supervisors
Repeated comments that indicate suicidal tendencies
Frequent, vague physical complaints
Noticeably unstable emotional responses
Behavior which is suspect of paranoia
Preoccupation with previous incidents of violence
Increased mood swings
Has a plan to "solve all problems"
Resistance and over-reaction to changes in procedures
Increase of unsolicited comments about firearms and other dangerous weapons
Empathy with individuals committing violence
Repeated violations of company policies
Fascination with violent and/or sexually explicit movies or publications
Escalation of domestic problems
Large withdrawals from, or closing, an account in the company's credit union (Mattman, 2001)

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.

MEASURES OF PREVENTION

Employers

There are three general approaches that employers can take to prevent workplace violence:

Environmental: Secure the environment.
Organizational/administrative: Develop and implement safe work practices.
Behavioral/interpersonal: Train employees.

Employees

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.

Community-Based Employees

Working in the community, outside a traditional office building, increases the risk of coming in contact with potentially violent situations. Prevention measures for field workers should include consideration of the following:

Preparation of daily work plans/itinerary
Maintaining periodic contact throughout the day
Use of a buddy system
Telecommunication devices
Carry only minimal money and required identification into community settings
Avoid traveling alone into unfamiliar locations or situations whenever possible
Recognize potentially dangerous situations ahead of time, so backup can be started and employee does not handle situation alone

Effective Strategies

A security screening system in a Detroit hospital included stationary metal detectors supplemented by handheld units. The system prevented the entry of 33 handguns, 1,324 knives, and 97 mace-type sprays during a six-month period (NIOSH, 2002).

A violence reporting program in the Portland, Oregon, VA Medical Center identified patients with a history of violence in a computerized database. The program helped reduce the number of violent attacks by 91.6% by alerting staff to take additional safety measures when serving these patients (NIOSH, 2002).

A system restricting movement of visitors in a New York City hospital used identification badges and color-coded passes to limit each visitor to a specific floor. The hospital also enforced the limit of two visitors at a time per patient. Over 18 months, these actions reduced the number of reported violent crimes by 65% (NIOSH, 2002).

OSHA AND WORKPLACE VIOLENCE

In 1970 the Occupational Safety and Health Administration 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.

In 1989, OSHA published the Safety and Health Program Management Guidelines. The 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.

WORKPLACE VIOLENCE PREVENTION PROGRAM

A workplace violence prevention program demonstrates an organization's concern for employee emotional and physical safety and health. The program encompasses the following elements:

Management commitment and a system of accountability
Employee involvement
Worksite analysis
Hazard prevention and control
Training and education
Recordkeeping and evaluation of the program

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. Employee involvement enables workers to develop and express their commitment to safety and health.

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
Taking part in a continuing education program that covers techniques to recognize escalating agitation, high risk behavior or criminal intent and discusses appropriate responses

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.

CASE

Roosevelt 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. Roosevelt 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.

You work as the office manager and have been selected to represent the clinic as a member of the hospital safety committee. As a member of the threat assessment team your assignment for the upcoming meeting is to conduct a workplace violence hazard assessment for the reception area and parking lot of the clinic. You have worked at this facility for six years and have never felt threatened, nor have you had any complaints from your staff. You anticipate a quick assessment.

To prepare for the assignment you decide 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.

You begin by reviewing the following records:

OSHA 300 logs for the last three years
Incident reports dealing with assault or near-assault incidents
Insurance records
Police reports
Accident investigations
Training records
Filed grievances

You find 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 you that these are only the reported incidents; you decide it will be a good idea to interview staff to find out how many incidents were never reported.

Surprised by the number of incidents, you proceed to conduct an inspection of the workplace areas assigned to you. You discover 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, you review the tasks of the receptionists and find the following concerns:

Money is kept behind the main reception desk in an unlocked drawer
One receptionist works the early-morning and late-night hours
Hospital is in a high-crime area
Staffing levels are inadequate

After careful consideration, you decide that the building, work area design, and staffing will need to change, and written policies and procedures must be instituted to address the security hazards you have identified.

Your initial recommendations to the safety committee include:

Improved lighting in the parking lot and main entrance to the clinic
Security guard—minimally for the early-morning and evening hours
Locked main entrance during early-morning and evening hours
Secure the door between the reception area and the clinic
Install communication between the clinic area and reception desk
Remove money from the reception area
Review staffing for reception area and hours of operation
Develop policy, procedures, and training for:
Use of security equipment
Diffusing hostile or threatening situations
Summoning assistance in an emergency
Medical follow-up
Availability of counseling and referral
Incident reporting and investigation
Incident recordkeeping

From this exercise you were 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 an effective program can be implemented.

Posted October 9, 2006

Expires October 1, 2009

REFERENCES

Federal Bureau of Investigation (FBI). (March, 2004). Workplace Violence: Issues in Response. Quantico, VA: National Center for the Analysis of Violent Crime, FBI Academy.

Mattman J. (2001). Preventing Violence in the Workplace. Workplace Violence Research Institute. Retrieved August 30, 2006 from http://www.workviolence.com/articles/preventing_violence.htm.

National Institute for Occupational Safety and Health (NIOSH). (2006). Traumatic Occupational Injuries. Retrieved August 30, 2006 from http://www.cdc.gov/niosh/injury/traumaviolence.html.

National Institute for Occupational Safety and Health (NIOSH). (2004). Violence on the Job. DHHS (NIOSH) Publication No. 2004-100. Retrieved August 30, 2006 from http://www.cdc.gov/niosh/docs/video/violence.html.

National Institute for Occupational Safety and Health (NIOSH). (April 2002). Violence: Occupational Hazards in Hospitals. DHHS (NIOSH) Publication No. 2002–101.

Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. (2004). Guidelines for Preventing Workplace Violence for Healthcare and Social Workers. OSHA 3148-01R.

Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. (2002). OSHA Fact Sheet: Workplace Violence. Retrieved August 30, 2006 from http://www.osha.gov/OshDoc/data_General_Facts/factsheet-workplace-violence.pdf.

United States Bureau of Labor Statistics (BLS), U.S. Department of Labor. (2005, March). Fatal Occupational Injuries by Event or Exposure, 1999–2004 . Retrieved July 25, 2006 from http://www.bls.gov/news.release/cfoi.t01.htm.

United States Office of Personnel Management, Office of Workforce Relations. (1998). Dealing with Workplace Violence: A Guide for Agency Planners. OWR-09.

University of Iowa, Injury Prevention Research Center. (2001). Workplace Violence: A Report to the Nation. Iowa City, IA. Retrieved August 30, 2006 from http:// www.public-health.uiowa.edu/iprc/NATION.PDF.

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