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OSHA

& Worker Safety

Guidelines for Zero Tolerance

New OSHA publication helps prevent violence in the health care setting


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ccording to the Bureau of Labor Statistics, in 2013, 27 of the 100 fatalities that occurred in

health care and social service settings were due to assaults and violent acts. Moreover, of all the assaults that occurred between 2011 and 2013 in all work- places across the country—an average of 24,000 per year—70% to 74% occurred in health care and social service settings.

Now consider this: Research indicates that workplace violence (WPV) is under- reported—suggesting that the actual rates may be much higher.

“There’s a culture in many health care settings that accepts violence as a part

of the job, that expects it when working with a patient or client who has a violent history,” says Dionne Williams, director, Office of Health Enforcement for the Occupational Safety and Health Admin- istration (OSHA). “Often, the thinking is, ‘Let’s not get the patient or client in trouble. Let’s not escalate the issue.’ It’s one of the alarming things we’ve learned about WPV.”

One of the best protections employ- ers can offer their workers is a policy of zero tolerance toward violence in the workplace. A second protection is a well-written and implemented WPV- prevention program.

“Health care organizations rightfully focus significant effort on improving patient outcomes,” says Williams. “One measure we see is the avoidance of patient restraints, even for those who act out or become potentially violent. A few states have laws that prohibit restraints. We’re trying to come up with recommen-

dations that balance improvement in patient health with employee safety.”


New WPV guidelines from OSHA

In 2015, OSHA updated its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. The 2015 edition makes use of new data, research, and experience to recommend procedures for reducing—or, ideally, eliminating—WPV. The guidelines explain the components of a WPV- prevention program, and they include checklists to identify risk factors.

Williams notes that the new guidelines focus on particulars of the setting and how they relate to causes and controls.

Citing epidemiological studies, for exam- ple, the guidelines note that “inpatient and acute psychiatric services, geriatric long term care settings, high-volume urban emergency departments, and resi- dential and day social services present the highest risks. Pain, devastating prognoses, unfamiliar surroundings, mind- and mood-altering medications, drugs, and disease progression can all cause agitation and violent behaviors.”

Williams particularly mentions the effort OSHA has made to address key differences between settings, remark- ing that each has its own risk factors, some related to patients or settings—for example, being located in a high-crime

area—and others related to the organiza- tion—for example, lack of WPV-related training or policies.

The guidelines consider these five settings:


Building blocks for WPV prevention

The new OSHA guidelines recom- mend the following five components for a violence-prevention program in the workplace:

  1. Leadership commitment and employee participation. The visible involvement of top management provides motivation and resources for workers and employers to deal effec- tively with WPV. In addition, a team of employees with appropriate training and skills—and adequate resources— will be in the best position to develop and implement the program. This team should create and disseminate a clear policy of zero tolerance for WPV. This zero tolerance should extend even to verbal and nonverbal threats. Williams emphasizes the importance of both management commitment and employee involvement in the WPV-prevention program.

  2. Worksite analysis and hazard identification. A team that includes senior management, supervisors, and


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    Table 1. An Excerpt of Sample Engineering Controls:

    For Health Care and Social Service Settings


    Field Workers

    Residential Nonresidential (Home Health Care, Hospital Treatment Treatment/Service Community Care Social Service)

    Security/silenced alarm systems


    Exit routes

    emergencies.

    Metal detectors— handheld or installed


    Monitoring systems and natural surveillance

  3. Hazard prevention and control. Once the worksite analysis is com- plete, the organization should take the following five steps:

    1. Identify and evaluate control options for existing workplace hazards. Controls can be catego- rized as the following:

      –Substitution—for example, transferring a patient to a more appropriate facility if the client has a history of violent behavior

      –Engineering controls, which are physical changes that either

      remove the hazard from the work-

      place or create a barrier between the worker and the hazard. (See Table 1, above, for examples geared to each work setting.)

      –Administrative and work practice controls, such as establishing policies related to WPV response or training. (See Table 2, page 10, for examples geared to each

      work setting.)

    2. Select effective and feasible controls to eliminate or reduce hazards.

    3. Implement these controls.

    4. Follow up to confirm that the controls are being used and main- tained properly.

      (continued on page 10)


      Copyright 2015 The Joint Commission

      Page 9


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      Table 2. An Excerpt of Sample Administrative and Work-Practice Controls:

      For Health Care and Social Service Settings



      Hospital


      Residential Treatment


      Nonresidential Treatment/Service


      Community Care

      Field Workers (Home Health Care, Social Service)

      Workplace violence response policy


      Tracking workers*

      Traveling workers should:

      log-in and log-out procedures

      Workers should:

      procedures

      incident/threat

      Tracking clients with a known history of violence

      • Clearly state to patients, clients, visitors, and workers that violence is not permitted and will not be tolerated.

      • Such a policy makes it clear to workers that assaults are not considered part of the job or acceptable behavior.

      • Have specific

      • Be required to contact the office after each visit; managers should have procedures to follow up if workers fail to do so

      • Have specific log-in and log-out

      • Be required to contact the office after each visit; managers should have procedures to follow up if workers fail to do so

      • Be given discretion as to whether or not they begin or continue a visit if they feel threatened or unsafe

      • Log-in/log-out procedures should include:

        • Name and address of client visited ■ Worker’s vehicle description and license plate

        • Scheduled time and duration of visit number

        • Contact number ■ Details of any travel plans with client

        • Code word used to inform someone of an ■ Contacting office/supervisor with any changes

      • Supervise the movement of patients throughout the facility

      • Update staff in shift report about violent history or incident

      • Update staff in shift report about violent history or incident

      • Report all violent incidents to employer

      • Massachusetts Department of Mental Health Task Force on Staff and Client Safety. (2011) Report of the Massachusetts Department of Mental Health Task Force on Staff and Client Safety.

      Source: OSHA. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. (Updated: Apr 2, 2015.) Accessed Jul 1, 2015. https://www.osha.gov/Publications/osha3148.pdf. For a list of administrative and work-practice controls, see pp. 17–22.


      OSHA & Worker Safety: Guidelines for Zero Tolerance (continued from page 9)


    5. Evaluate the effectiveness of con- trols and improve, expand, or update them as needed.

      In addition, when a violent inci- dent occurs, organizations should have procedures and services in place for the victim, such as first aid, emergency care, and follow-up that addresses trauma and fears related

      to returning to work or criticism from supervisors. Employees should be encouraged to promptly report incidents and suggest ways to reduce or eliminate risks, and no employee who reports or experiences WPV should face reprisals. Essential post- incident procedures also include investigations to determine root

      causes and correct them. When root causes are not addressed, similar incidents inevitably occur.

  4. Safety and health training. In general, training should cover the facility’s procedures as well as de-escalation and self-defense techniques. Both

    de-escalation and self-defense training should include hands-on components. Training is essential for ensuring that all staff members are aware of potential hazards related to patients and how to protect themselves and their coworkers.

    “Training ensures that employ- ees know what the policies are and whom to contact. They should know there’s no retaliation for making a complaint,” says Williams. Staff who fear retaliation, she points out, suffer rather than make a complaint. “In a

    number of organizations, WPV train-

    ing focuses on employee–employee violence and the fact that the organi- zation won’t tolerate it. But the pro- grams often make no mention at all of violence from patients or clients.”

  5. Recordkeeping and program eval- uation. Accurate records related to incidents and responses determine a program’s overall effectiveness and

help identify deficiencies or changes that should be made. “All components of this program are important, but tracking and follow-up are vital—not only when someone gets seriously hurt but also for the near-misses—the threats that could escalate,” Williams says. “Some serious cases are preceded by threats that went uninvestigated and undocumented.” However, if there’s a record of such threats, the next worker knows that the situation exists.


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Changing the culture

Primarily due to the violent behavior of their patients, clients, and/or residents, health care and social service workers face significant risks of job-related violence. It is OSHA’s mission to help employers address these serious hazards. A written program for WPV preven- tion, incorporated into an organization’s overall safety and health program, can reduce or eliminate the risk of violence in the workplace.

“We hear from employees who fear they might lose their jobs or be blamed if they complain,” says Williams. “When they experience management compla- cency related to WPV, when nothing happens in response to an incident or

a complaint, they stop complaining. That’s why we say that management must communicate and enforce a policy of zero tolerance for violence.

“The majority of our inspections come from complaints related to violent

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incidents, either from someone who suffered an assault or through a union representative,” adds Williams. “When we follow up on those complaints, we see that many facilities expect workplace violence. We’re trying to change that culture and offer guidance.” EC


Resource for article: Occupational Safety and Health Administration. Workplace Violence. Accessed Jul 2, 2015. https:// www.osha.gov/SLTC/workplaceviolence/.

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Copyright 2015 The Joint Commission


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