States lead the way as HCWs push for violence prevention
Maryland passes 10th state law, California mulls new rule
In February, Evelyn Lynch, a 70-year-old nurse at Brookdale Hospital in Brooklyn, NY, was removing a catheter from a patient when he suddenly knocked her to the ground and began beating and stomping on her. She suffered facial fractures and head injuries and was hospitalized in critical condition.
The incident served as yet another brutal reminder of the risk of workplace violence in health care. High profile cases in the last few years — strangulation of a psychiatric technician in California, stabbing death of a nurse in Texas, shootings at hospitals in Connecticut, Pennsylvania and Maryland — have led to new efforts to require workplace violence prevention programs.
In March, Maryland became the 10th state to pass a law requiring a comprehensive workplace violence prevention program in health care. The California standards board is considering a request for the nation’s first workplace violence prevention standard. And the U.S. Occupational Safety and Health Administration has cited nursing homes, hospitals and other health care employers, based on their "general duty" to maintain a workplace free of the serious hazard of workplace violence.
"The state level activity and OSHA’s use of the general duty’ clause on workplace violence are really important advances," says Jane Lipscomb, PhD, RN, FAAN, professor in the University of Maryland School of Nursing and Medicine in Baltimore and an expert on workplace violence.
It is important for regulators, employees and health care workers themselves to realize that workplace violence can be prevented and is not just "part of the job," she says. "To have workplace violence [recognized] as an occupational hazard is a lot of progress from where we were 15 years ago," she says. (See related story on nurses’ perception of the hazard on p. 51.)
Advocates for workplace violence prevention hope to build nationwide support for a law or regulation. "There’s a certain momentum when you have all these state actions taking place," says Jonathan Rosen, MS, CIH, of AJ Rosen & Associates LLC, who was instrumental in advocating for a New York law covering public employees when he was with the Public Employees Federation.
We should be able to prevent it’
Every week, Richard Negri, health & safety director of SEIU Loca1 121RN in Pasadena, CA, receives a new set of reports about assaults on health care workers. For example, one nurse at an acute care hospital recently reported that a patient kicked her in the chest, knocking her into a wall.
"The incidents of violence are so frequent at this point that we actually could predict fairly well where and when things will occur," he says. "We should be able to prevent it."
California has a workplace violence prevention law that requires annual security and safety assessments and a prevention plan, but it is part of the state’s Health and Safety Code handled by the Department of Public Health and cannot be enforced by Cal-OSHA. The state also has an Injury and Illness Prevention Program standard that requires employers to identify hazards and develop ways to address them.
Those measures are not enough to protect the state’s health care workers from violence, Negri says. A coalition of unions has petitioned the state’s standards board for a workplace violence rule, which they are calling the Safe Care Standard.
"We need to change the system that’s broken — that accepts violence in hospitals," says Katherine Hughes, RN, liaison for SEIU Nurse Alliance of California.
Maryland’s Health Care Facilities Workplace Violence Prevention Act requires an annual risk assessment, a violence prevention committee that includes frontline staff members, training and a post-incident response system.
Lipscomb called it "something very positive that will give health care workers a tool for prevention."
A history of violence
With or without laws and regulations, some patients who are confused or disoriented due to dementia, alcohol or drug abuse may become aggressive. Yet it is vital to view assault as an occupational hazard that can be mitigated, says Michael Wood, CSP, administrator of Oregon OSHA. Oregon passed a workplace violence prevention law for health care in 2007.
"Intent doesn’t really dictate whether the hazard is present. It doesn’t matter if the individual intended to hurt someone," he says. "What matters is whether the employer can do something to reduce the potential for injury."
Oregon’s law requires periodic assessments, a prevention program and training of employees. It also requires health care employers to maintain a log of physical assaults.
In 2008, Oregon OSHA required employers to report the information from their logs. There were 1,061 incidents, virtually all (99%) in hospitals and 57% of them involving behavioral health patients. Certified nursing assistants, orderlies and aides were most likely to be assaulted (42%), but one-third of the incidents occurred among nurses. About half of the patients had behavioral health or emotional issues, and one-quarter had a history of violence.
The most common site: A patient room or corridor. Employers were asked to record incidents that involved someone "intentionally, knowingly, or recklessly causing physical injury." Most of those injuries were minor, in terms of the physical injury, but analyzing those events can improve prevention, Wood says.
"For employers to deal with [workplace violence], they need to have an awareness of what’s going on in their organization," he says.
Wood advises employers to look at their areas of greatest risk and to devise methods to reduce the risk, as they would with other job hazards. "Where there’s a recognized hazard, employers have an obligation to do what they can to avoid the risk of serious injury," he says.
OSHA: Violence a recognized hazard’
There is no federal regulation that addresses workplace violence hazards, but federal OSHA has taken steps that make it clear that this is a "recognized hazard" in health care. A 2011 compliance directive instructed OSHA inspectors how to use the "general duty" clause of the Occupational Safety and Health Act to address workplace violence.
"Employers may be found in violation of the general duty clause if they fail to reduce or eliminate serious recognized hazards," the directive said.
Since then, OSHA included workplace violence as an area of focus on the Nursing Home National Emphasis program. Each regional office has a workplace violence coordinator to provide guidance and monitor enforcement, says Mikki Holmes, a supervisory program analyst who is the workplace violence specialist in OSHA’s Directorate of Enforcement Programs.
Since the directive was issued, OSHA has cited workplace violence at a hospital and issued eight citations at nursing homes or residential care facilities. In addition, 10 hazard alert letters have been issued at hospitals and 15 at nursing homes or residential care facilities.
An OSHA inspection may occur in response to a complaint, or an inspector on a programmed inspection may notice a pattern of incidents on the injury log, Holmes says. The inspector would then look for a prevention program, steps taken to reduce hazards such as barriers or panic buttons, and may ask employees about training.
"If the employer is aware that there are incidents that are occurring they should be keeping track of them — discussing what the problems have been and what they intend to do to try to eliminate the hazard," Holmes says.
OSHA also plans to release an update to workplace violence prevention guidelines by the end of 2014, she says. (For more information about the guidelines, see www.osha.gov/dte/library/wp-violence/healthcare/.)
Employers need to understand the scope of the problem — and requirements for reporting or assessment can help them see the escalating events, says Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, president of the Emergency Nurses Association.
"If we don’t understand the issue, we can’t prevent it," she says.
Special Report: Preventing Workplace Violence
Violence remains pervasive in health care — from frequent verbal and minor physical assaults to more serious attacks and even deaths. In this special issue of HEH, we examine steps being taken to promote or require workplace violence prevention and assess the impact violent incidents have on health care workers.
