Excerpt: Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers
Excerpt: Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers
Hazard Prevention and Control
After hazards of violence are identified through the systematic work site analysis, the next step is to design measures through engineering or administrative and work practices to prevent or control these hazards. If violence does occur, post-incidence response can be an important tool in preventing future incidents.
Engineering Controls and Workplace Adaptation
Engineering controls, for example, remove the hazard from the workplace or create a barrier between the worker and the hazard. There are several measures that can effectively prevent or control workplace hazards, such as those actions presented in the following paragraphs. The selection of any measure, of course, should be based upon the hazards identified in the workplace security analysis of each facility.
- Assess any plans for new construction or physical changes to the facility or workplace to eliminate or reduce security hazards.
- Install and regularly maintain alarm systems and other security devices, panic buttons, hand-held alarms or noise devices, cellular phones, and private channel radios where risk is apparent or may be anticipated, and arrange for a reliable response system when an alarm is triggered.
- Provide metal detectors — installed or hand-held, where appropriate — to identify guns, knives, or other weapons, according to the recommendations of security consultants.
- Use a closed-circuit video recording for high-risk areas on a 24-hour basis. Public safety is a greater concern than privacy in those situations.
- Place curved mirrors at hallway intersections or concealed areas.
- Enclose nurses’ stations and install deep service counters or bullet-resistant, shatter-proof glass in reception areas, triage, admitting, or client service rooms.
- Provide employee "safe rooms" for use during emergencies.
- Establish "time-out" or seclusion areas with high ceilings without grids for patients acting out and separate rooms for criminal patients.
- Provide client or patient waiting rooms designed to maximize comfort and minimize stress.
- Ensure counseling or patient care rooms have two exits.
- Limit access to staff counseling rooms and treatment rooms controlled by using locked doors.
- Arrange furniture to prevent entrapment of staff. In interview rooms or crisis treatment areas, furniture should be minimal, lightweight, without sharp comers or edges, and/or affixed to the floor. Limit the number of pictures, vases, ashtrays, or other items that can be used as weapons.
- Provide lockable and secure bathrooms for staff members separate from patient-client and visitor facilities.
- Lock all unused doors to limit access, in accordance with local fire codes.
- Install bright, effective lighting indoors and outdoors.
- Replace burned-out lights, broken windows, and locks.
- Keep automobiles, if used in the field, well-maintained. Always lock automobiles.
Administrative and Work Practice Controls
Administrative and work practice controls affect the way jobs or tasks are performed. The following examples illustrate how changes in work practices and administrative procedures can help prevent violent incidents.
- State clearly to patients, clients, and employees that violence is not permitted or tolerated.
- Establish liaison with local police and state prosecutors. Report all incidents of violence. Provide police with physical layouts of facilities to expedite investigations.
- Require employees to report all assaults or threats to a supervisor or manager (e.g., can be confidential interview). Keep log books and reports of such incidents to help determine any necessary actions to prevent further occurrences.
- Advise and assist employees, if needed, of company procedures for requesting police assistance or filing charges when assaulted.
- Provide management support during emergencies. Respond promptly to all complaints.
- Set up a trained response team to respond to emergencies.
- Use properly trained security officers when necessary to deal with aggressive behavior. Follow written security procedures.
- Ensure adequate and properly trained staff for restraining patients or clients.
- Provide sensitive and timely information to persons waiting in line or in waiting rooms. Adopt measures to decrease waiting time.
- Ensure adequate and qualified staff coverage at all times. Times of greatest risk occur during patient transfers, emergency responses, meal times, and at night. Locales with the greatest risk include admission units and crisis or acute-care units. Other risks include admission of patients with a history of violent behavior or gang activity.
- Institute a sign-in procedure with passes for visitors, especially in a newborn nursery or pediatric department. Enforce visitor hours and procedures.
- Establish a list of "restricted visitors" for patients with a history of violence. Copies should be available at security checkpoints, nurses’ stations, and visitor sign-in areas. Review and revise visitor check systems, when necessary. Limit information given to outsiders on hospitalized victims of violence.
- Supervise the movement of psychiatric clients and patients throughout the facility.
- Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas.
- Prohibit employees from working alone in emergency areas or walk-in clinics, particularly at night or when assistance is unavailable. Employees should never enter seclusion rooms alone.
- Establish policies and procedures for secured areas, emergency evacuations, and for monitoring high-risk patients at night (e.g., open vs. locked seclusion).
- Ascertain the behavioral history of new and transferred patients to learn about any past violent or assaultive behaviors. Establish a system — such as chart tags, log books, or verbal census reports — to identify patients and clients with assaultive behavior problems, keeping in mind patient confidentiality and worker safety issues. Update as needed.
- Treat and/or interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (e.g., rooms with removable partitions).
- Use case management conferences with co-workers and supervisors to discuss ways to effectively treat potentially violent patients.
- Prepare contingency plans to treat clients who are "acting out" or making verbal or physical attacks or threats. Consider using certified employee assistance professionals (CEAPs) or in-house social service or occupational health service staff to help diffuse patient or client anger.
- Transfer assaultive clients to acute-care units, "criminal units," or other more restrictive settings.
- Make sure that nurses and/or physicians are not alone when performing intimate physical examinations of patients.
- Discourage employees from wearing jewelry to help prevent possible strangulation in confrontational situations. Community workers should carry only required identification and money.
- Periodically survey the facility to remove tools or possessions left by visitors or maintenance staff that could be used inappropriately by patients.
- Provide staff with identification badges, preferably without last names, to readily verify employment.
- Discourage employees from carrying keys, pens, or other items that could be used as weapons.
- Provide staff members with security escorts to parking areas in evening or late hours. Parking areas should be highly visible, well-lighted, and safely accessible to the building.
- Use the "buddy system," especially when personal safety may be threatened.
- Conduct a comprehensive post-incident evaluation, including psychological as well as medical treatment, for employees who have been subjected to abusive behavior.
Post-Incident Response
Post-incident response and evaluation are essential to an effective violence prevention program. All workplace violence programs should provide comprehensive treatment for victimized employees and employees who may be traumatized by witnessing a workplace violence incident. Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of severity. Transportation of the injured to medical care should be provided if care is not available on site.
Victims of workplace violence suffer a variety of consequences in addition to their actual physical injuries. These include short and long-term psychological trauma, fear of returning to work, changes in relationships with co-workers and family, feelings of incompetence, guilt, powerlessness, and fear of criticism by supervisors or managers. Consequently, a strong follow-up program for these employees will not only help them to deal with these problems, but also to help prepare them to confront or prevent future incidents of violence.
There are several types of assistance that can be incorporated into the post-incident response. For example, trauma-crisis counseling, critical incident stress debriefing, or employee assistance programs may be provided to assist victims. CEAPs, psychologists, psychiatrists, clinical nurse specialists, or social workers could provide this counseling, or the employer can refer staff victims to an outside specialist. In addition, an employee counseling service, peer counseling, or support groups may be established.
In any case, counselors must be well-trained and have a good understanding of the issues and consequences of assaults and other aggressive, violent behavior. Appropriate and promptly rendered post-incident debriefings and counseling reduce acute psychological trauma and general stress levels among victims and witnesses. In addition, such counseling educates staff about workplace violence and positively influences workplace and organizational cultural norms to reduce trauma associated with future incidents.
Training and Education
Training and education ensure all staff are aware of potential security hazards and how to protect themselves and their co-workers through established policies and procedures.
All Employees
Every employee should understand the concept of "universal precautions for violence," i.e., that violence should be expected but can be avoided or mitigated through preparation. Staff should be instructed to limit physical interventions in workplace altercations whenever possible, unless there are adequate numbers of staff or emergency response teams and security personnel available. Frequent training also can improve the likelihood of avoiding assault.
Employees who may face safety and security hazards should receive formal instruction on the specific hazards associated with the unit or job and facility. This includes information on the types of injuries or problems identified in the facility and the methods to control the specific hazards.
The training program should involve all employees, including supervisors and managers. New and reassigned employees should receive an initial orientation prior to being assigned their job duties. Visiting staff, such as physicians, should receive the same training as permanent staff. Qualified trainers should instruct at the comprehension level appropriate for the staff. Effective training programs should involve role playing, simulations, and drills.
Topics may include Management of Assaultive Behavior Professional Assault Response Training, police assault avoidance programs, or personal safety training such as awareness, avoidance, and how to prevent assaults. A combination of training may be used depending on the severity of the risk.
Required training should be provided to employees annually. In large institutions, refresher programs may be needed more frequently (monthly or quarterly) to effectively reach and inform all employees.
The training should cover topics such as:
- the workplace violence prevention policy;
- risk factors that cause or contribute to assaults;
- early recognition of escalating behavior or recognition of warning signs or situations that may lead to assaults;
- ways of preventing or diffusing volatile situations or aggressive behavior, managing anger, and appropriately using medications as chemical restraints;
- information on multicultural diversity to develop sensitivity to racial and ethnic issues and differences;
- a standard response action plan for violent situations, including availability of assistance, response to alarm systems, and communication procedures;
- how to deal with hostile persons other than patients and clients, such as relatives and visitors;
- progressive behavior control methods and safe methods of restraint application or escape;
- the location and operation of safety devices such as alarm systems, along with the required maintenance schedules and procedures;
- ways to protect oneself and co-workers, including use of the "buddy system"
- policies and procedures for reporting and record keeping;
- policies and procedures for obtaining medical care, counseling, workers’ compensation, or legal assistance after a violent episode or injury.
Supervisors, Managers, and Security Personnel
Supervisors and managers should ensure employees are not placed in assignments that compromise safety, and encourage employees to report incidents. Employees and supervisors should be trained to behave compassionately toward co-workers when an incident occurs.
They should learn how to reduce security hazards and ensure employees receive appropriate training. Following training, supervisors and managers should be able to recognize a potentially hazardous situation and make any necessary changes in the physical plant, patient care treatment program, and staffing policy and procedures to reduce or eliminate hazards.
Security personnel need specific training from the hospital or clinic, including the psychological components of handling aggressive and abusive clients, types of disorders, and ways to handle aggression and defuse hostile situations.
The training program also should include an evaluation. The content, methods, and frequency of training should be reviewed and evaluated annually by the team or coordinator responsible for implementation. Program evaluation may involve supervisor and/or employee interviews, testing and observing, and/or reviewing reports of behavior of individuals in threatening situations.
Record keeping and Evaluation of the Violence Prevention Program
Record keeping and evaluation of the violence prevention program are necessary to determine overall effectiveness and identify any deficiencies or changes that should be made.
Record keeping
Record keeping is essential to the success of a workplace violence prevention program. Good records help employers determine the severity of the problem, evaluate methods of hazard control, and identify training needs. Records can be especially useful to large organizations and for members of a business group or trade association who "pool" data. Records of injuries, illnesses, accidents, assaults, hazards, corrective actions, patient histories, and training, among others, can help identify problems and solutions for an effective program.
The following records are important:
- Occupational Safety and Health Administration (OSHA) Log of Injury and Illness.
OSHA regulations require entry on the Injury and Illness Log of any injury that requires more than first aid, is a lost-time injury, requires modified duty, or causes loss of consciousness. (This applies only to establishments required to keep OSHA logs.) Injuries caused by assaults, which are otherwise recordable, also must be entered on the log. A fatality or catastrophe that results in the hospitalization of three or more employees must be reported to OSHA within eight hours. This includes those resulting from workplace violence and applies to all establishments.
- Medical reports of work injury and supervisors’ reports for each recorded assault should be kept.
These records should describe the type of assault, i.e., unprovoked sudden attack or patient-to-patient altercation; who was assaulted; and all other circumstances of the incident. The records should include a description of the environment or location, potential or actual cost, lost time, and the nature of injuries sustained.
- Incidents of abuse, verbal attacks, or aggressive behavior — which may be threatening to the worker but do not result in injury, such as pushing or shouting and acts of aggression toward other clients — should be recorded, perhaps as part of an assaultive incident report.
These reports should be evaluated routinely by the affected department.
- Information on patients with a history of past violence, drug abuse, or criminal activity should be recorded on the patient’s chart.
All staff who care for a potentially aggressive, abusive, or violent client should be aware of their background and history. Admission of violent clients should be logged to help determine potential risks.
- Minutes of safety meetings, records of hazard analyses, and corrective actions recommended and taken should be documented.
- Records of all training programs, attendees, and qualifications of trainers should be maintained.
Evaluation
As part of their overall program, employers should evaluate their safety and security measures. Top management should review the program regularly, and with each incident, to evaluate program success. Responsible parties (managers, supervisors, and employees) should collectively re-evaluate policies and procedures on a regular basis. Deficiencies should be identified and corrective action taken.
An evaluation program should involve:
- establishing a uniform violence reporting system and regular review of reports;
- reviewing reports and minutes from staff meetings on safety and security issues;
- analyzing trends and rates in illness/injury or fatalities caused by violence relative to initial or "baseline" rates;
- measuring improvement based on lowering the frequency and severity of workplace violence;
- keeping up-to-date records of administrative and work practice changes to prevent workplace violence to evaluate their effectiveness;
- surveying employees before and after making job or work site changes or installing security measures or new systems to determine their effectiveness;
- keeping abreast of new strategies available to deal with violence in the health care and social service fields as they develop;
- surveying employees who experience hostile situations about the medical treatment they received initially and, again, several weeks afterward, and then several months later;
- complying with OSHA and state requirements for recording and reporting deaths, injuries, and illnesses;
- requesting periodic law enforcement or outside consultant review of the work site for recommendations on improving employee safety.
Management should share workplace violence prevention program evaluation reports with all employees. Any changes in the program should be discussed at regular meetings of the safety committee, union representatives, or other employee groups.
Source: Occupational Safety and Health Administration, Washington, DC. Web: www.osha.gov.
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