Last year, emergency department nurses at Zuckerberg San Francisco General Hospital protested workplace violence at the facility, citing overcrowding, understaffing, assaults by patients and insufficient de-escalation training. Although the hospital claimed that the establishment of its Workplace Violence Prevention Committee in 2018 had reduced workplace violence incidents by 10% year over year, the problem persisted. In October, the nurses filed a safety complaint against the hospital with the California Division of Occupational Safety and Health. The dispute highlights the difficulties health care facilities face when trying to mitigate workplace violence risks.
According to the Occupational Safety and Health Administration (OSHA), over 10% of all workplace violence incidents and over 50% of all workplace assaults occur in the health care industry. Stopping workplace violence needs to be a priority for organizations in order to save health care workers—who dedicate their careers to helping other people—from assault, serious bodily injury and even death.
OSHA regulates all workplace violence prevention, including in health care facilities, using the general duty clause and citing employers who fail to prevent or abate known workplace violence hazards. Thus, employers must first identify various risk factors by asking questions like:
- Do employees have contact with the public?
- Is the workplace often understaffed?
- Do employees perform jobs that might put them in conflict with others?
- Do they ever perform duties that could upset people?
- Do they deal with people known or suspected of having a history of violence?
In health care, these questions are typically answered in the affirmative. Complicating the risk factors even more, almost all of them involve patients, who are an essential element of the health care process. So how can health care facilities stop violence?
There is no one-size-fits-all approach to workplace safety planning. Each facility must evaluate its physical workplace, the type of work performed, and the hazards and level of exposure to violence inherent in both. OSHA suggests beginning with a written workplace violence prevention program that includes five key elements:
1. Management commitment and employee participation is necessary to create a culture that acts against violence. Corporate or workplace culture is intangible, but vital for developing any kind of effective policy in all industries, including health care. A workplace violence prevention program is no different, and there must be support within the organization from top to bottom. Leadership must visibly champion the policy to emphasize its importance. Acknowledging that workplace violence exists and broadcasting that a safe workplace is a priority are essential first steps.
One suggestion is to set up committees comprised of employees from different departments and functions to represent their colleagues, identify risks, and recommend and implement safety improvements. It is important to include employees who interact with patients in various roles because each of these roles are exposed to unique risks.
Health care management must not only show its commitment to preventing workplace violence, but also provide the resources necessary to implement effective change, including funding, access to information, personnel, time, training, tools and equipment. Additionally, facility leadership should ensure that employees feel comfortable requesting whatever they need to make their workspaces safe. Employees and management must confront workplace violence as a unified team, focusing on including as many people as possible to create better results.
2. Worksite analysis is a proactive process that employers use to identify hazards and gather other important information about workplace violence to anticipate and prevent the next occurrence. Involving employees in this analysis is vital so they understand and can identify hazards. Senior managers and supervisors should also be involved. Using every source of available information will allow the best analysis, including examining records and hazards, and surveying employees and patients. Pertinent records include any incident reports, OSHA logs, workers compensation records, and any other documents that address injuries or violence. When analyzing hazards, participants should look closely at the relationship between employees’ duties, the tools they use and the environment. Patient records are also useful for assessing whether repeat customers may be repeat workplace violence offenders.
3. Hazard prevention and control should be based on worksite analysis and hazard identification results. OSHA classifies these efforts using various groups and headings. One way to categorize them is using a three-pronged approach made up of environmental, administrative and behavioral controls.
For health care facilities, the first prong should be a focus on environmental controls, including security measures (e.g., cameras, alarm systems, metal detectors, security guards and bulletproof glass); architecture and design (e.g., relaxing spaces with compartmentalized rooms to hold crowds and separate spaces that can be used to de-escalate people); adequate and fully accessible exits; and communication devices that are easy to use in emergency situations.
The second prong of hazard prevention and control is administration of the facility. When creating policies to prevent workplace violence in health care facilities, employers should address the following topics:
Tracking. Monitor patients with violent histories and keep detailed records.
Working alone. Avoid working alone by working in teams or in open areas that still preserve privacy. Establish entry procedures that reduce waiting times, ensure that everyone signs in with employee and visitor badges, and maintain a list of violent patients at entrances.
Potential weapons. Employees should not wear necklaces or carry keys, and should wear hair coverings to prevent others from grabbing their hair. They should also keep desks free of pens, pencils, glass objects and other potential weapons and lock doors to prevent access to other items that could be used to inflict harm.
Zero tolerance. Employers cannot tolerate violence of any sort against employees. Especially in health care, workplace violence is chronically underreported and addressing all reported violence will encourage reporting and make everyone safer.
Incident reporting. Management should encourage employees to report violence and threats of violence and educate employees on how to report violent incidents of any kind, including threats and verbal abuse.
Responsible parties. The policy should specify who receives employee incident reports, preferably identifying multiple individuals to create options that make employees more comfortable and preclude situations where designated people are involved in an incident.
Managing incidents. The policy should address how to diffuse violent and potentially violent situations, with procedures explaining scenarios such as escaping from violent situations and quickly alerting emergency services like security, managers and law enforcement. Security personnel should be trained and always available.
Post-incident procedures. If violence occurs in the workplace, employers should offer medical care and psychological support. Violence affects all employees, creating grief, stress and fear. Employers must investigate every incident and near-miss to create reports, identify root causes, and collect information from employees and management. Health care employers should not numb themselves to violence simply because it is common, and victims should have access to support.
The third prong of hazard prevention and control is focused on behavior, with an emphasis on the training that supports and implements the above policies and procedures. It is important to train employees to resolve personal conflict with other workers and patients without violence, including providing a neutral manager to resolve disputes, and to stress that employees should report all incidents. Health care facilities should tailor this training to individual positions, specifically considering that the contact certain employees have with patients may expose them to a greater risk of disputes.
4. Safety and health training is one of the most important components of any workplace violence prevention program. Employees, managers, security personnel, temporary and visiting staff, and contract workers must all understand hazards that workplace violence poses, as well as the policies and procedures in place to protect them. Training should explain hazards that the entire workforce faces, the policies to prevent and address workplace violence, and specific hazards based upon individual duties. According to OSHA, training helps raise the workforce’s overall safety and health knowledge, provides employees with tools to identify workplace safety and security hazards, and addresses potential problems before they arise, ultimately reducing the likelihood of worker assaults.
Health care facilities should offer employees workplace violence training before they are assigned to a new task, and annually as a refresher. In highly hazardous situations, facilities should not be held to a strict training schedule, but rather should provide training as frequently as necessary. A designated staff member should be responsible for reviewing and evaluating training each year. Everyone must understand OSHA’s concept of universal precautions for violence—that is, violence should be expected but can be avoided or mitigated through preparation.
5. Recordkeeping and program evaluation are key for showing progress and making any necessary improvements to the program. OSHA suggests maintaining OSHA 300 logs, records of any incidents, patient histories concerning violence and drug abuse, training records, and records of any meetings and hazard analyses. Track and review incidents to determine how to address them in the policy. OSHA states that the elements of a good program evaluation include:
- 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 of illnesses, injuries or fatalities caused by violence relative to initial or “baseline” rates
- Measuring improvement based upon 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 how well they work
- Surveying workers before and after making job or worksite changes or installing security measures or new systems to determine their effectiveness
- Tracking recommendations through completion
- Keeping abreast of new strategies to prevent and respond to violence in the health care fields as they develop
- Surveying workers periodically to learn if they experience hostile situations in their jobs;
- Complying with OSHA and state requirements for recording and reporting injuries, illnesses and fatalities
- Requesting periodic review of the worksite by law enforcement or outside consultant for recommendations on improving worker safety
Planning for Safety
Planning is the best tool to protect employees from workplace violence. Patients bring an element of unpredictability into health care workplaces, but they are also the reason health care exists. Most health care employees do their jobs because of patients, not despite them.
OSHA recognizes the challenges of workplace violence in health care and has issued and published voluminous guidance on the subject, but each worksite is different. Health care is a broad and varied field, and if employers do not already have controls in place, they should confer with trusted partners and labor experts to help them take the necessary steps to improve employee safety.
Benjamin Ross is an associate with the employment law firm Fisher Phillips.