Prevention of Workplace Violence in Healthcare and Social Assistance
Request for Information (RFI).
CFR Part: "29 CFR Part 1910"
RIN Number: "RIN 1218-AD 08"
Citation: "81 FR 88147"
Document Number: "Docket No.
Page Number: "88147"
"Proposed Rules"
SUMMARY: Workplace violence against employees providing healthcare and social assistance services is a serious concern. Evidence indicates that the rate of workplace violence in the industry is substantially higher than private industry as a whole.
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Table of Contents
I. Overview
II. Background
A.
1. Guidelines for Preventing Workplace Violence for Healthcare and Social Assistance
2. Enforcement Directive
B. State Laws
C. Recommendations From Governmental, Professional and Public Interest Organizations
D. Questions for Section II
III. Defining Workplace Violence
A. Definition and Types of Events Under Consideration
B. Questions for Section III
IV. Scope
A. Health Care and Social Assistance
B. Questions for Section IV
V. Workplace Violence Prevention Programs
A. Elements of Violence Prevention Program
1. Management Commitment and Employee Participation
2. Worksite Analysis and Hazard Identification
3. Hazard Prevention and Control
a. Engineering Controls
b. Administrative Controls
c. Personal Protective Equipment
d. Innovative Strategies
4. Safety and Health Training
5. Recordkeeping and Program Evaluation
a. Recordkeeping
b. Program Evaluation
B. Questions for Section V
1. Questions on the Overall Program, Management Commitment and Employee Participation
2. Questions on Worksite Analysis and Hazard Identification
3. Questions on Hazard Prevention and Control
4. Questions on Safety and Health Training
5. Questions on Recordkeeping and Program Evaluation
VI. Costs, Economic Impacts, and Benefits
A. Questions for Costs, Economic Impacts, and Benefits
B. Impacts on Small Entities
C. Questions for Section VI
VII. References
I. Overview
OSHA is considering whether to commence rulemaking proceedings on a standard aimed at preventing workplace violence in healthcare and social assistance workplaces perpetrated by patients or clients. Workplace violence affects a myriad of healthcare and social assistance workplaces, including psychiatric facilities, hospital emergency departments, community mental health clinics, treatment clinics for substance abuse disorders, pharmacies, community-care facilities, residential facilities and long-term care facilities. Professions affected include physicians, registered nurses, pharmacists, nurse practitioners, physicians' assistants, nurses' aides, therapists, technicians, public health nurses, home healthcare workers, social and welfare workers, security personnel, maintenance personnel and emergency medical care personnel.
OSHA's analysis of available data suggest that workers in the Health Care and Social Assistance sector (NAICS 62) face a substantially increased risk of injury due to workplace violence. Table 1 compiles data from the
Table 1--Cases of Intentional Injury by Other Person(s) by Industry Sectors in 2014 Nonfatal injury cases *1 Rate per 10,000 full time workers *2 All Private Sector 15,980 1.7 Industries Goods Producing 260 0.1 Service Producing 15,710 2.1 Trade-Transportation-and 1,950 0.9 Utilities Leisure and Hospitality 1,160 1.2 Professional and Business 470 0.3 Services Information 40 0.2 Financial Activities 90 0.1 Other Services, Except 80 0.3Public Administration Educational and Health 11,920 7.7 Services Educational Services 810 4.4 Health Care and Social 11,100 8.2 Assistance Ambulatory Healthcare 960 1.9 Services Hospitals 3,410 8.9 Nursing and Residential 4,690 18.7 Care Facilities Social Assistance 2,050 9.8 *1 BLS Table R4, 2015, http://www.bls.gov/iif/oshwc/osh/case/ostb4370.pdf. *2 BLS Table R100, 2015, http://www.bls.gov/iif/oshwc/osh/case/ostb4466.pdf.
BLS relies on employers to report injury and illness data and employers do not always record or accurately record workplace injuries and illnesses (Ruser, 2008;
Surveys of healthcare and social assistance workers provide another source of data useful for describing the extent of the problem. In one survey, 21 percent of registered nurses and nursing students reported being physically assaulted in a 12-month period (ANA, 2014). The
A survey of 175 licensed social workers and 98 agency directors in a western state found that 25 percent of social workers had been assaulted by a client, nearly 50 percent had witnessed violence in a workplace, and more than 75 percent were fearful of violent acts (Rey, 1996). A similar survey of a national sample of 633 workers randomly drawn from the
Though non-fatal injuries predominate by a large extent, homicides accounted for 14 fatalities in healthcare and social service settings that occurred in 2014, and 10 that occurred in 2013 (BLS SOII and CFOI Data, 2011-2014). /1/
FOOTNOTE 1 Many of the deaths in the healthcare setting involved a shooting, with many perpetrated by someone the worker knew, such as a domestic partner or coworker (US GAO, 2016). While such incidents often garner media attention, they are not the typical foreseeable workplace violence incidents that are associated with predictable risk factors that employers can reduce or eliminate.
This RFI is focused on workplace violence occurring in health care and social assistance for several reasons. While workplace violence occurs in other industries, health care services and social assistance services have a common set of risk factors related to the unique relationship between the care provider and the patient or client. The complex culture of healthcare and social assistance, in which the health care provider is typically cast as the patient's advocate, increases resistance to the notion that healthcare workers are at risk for patient-related violence (McPhaul and Lipscomb, 2004). In addition, the number of healthcare and social assistance workers is likely to grow as the sector is a large and growing component of the
OSHA has a history of providing guidance to employees and employers in this sector since 1996 (see Sections II and V). In addition, a body of knowledge has emerged in recent years from research about the factors that increase the risk of violence and the interventions that mitigate or reduce the risk in health care and social assistance. As a result, workplace violence is recognized as an occupational hazard for healthcare and social assistance, which, like other hazards, can be avoided or minimized when employers take appropriate precautions to reduce risk factors that have been shown to increase the risk of violence. See Section V.A.2., Worksite analysis and hazard identification, for a discussion of risk factors.
Though OSHA has no intention of including violence that is solely verbal in a potential regulation, the Agency does ask a series of questions about threats that could reasonably be expected to result in violent acts. These threats could be verbal or written, or could be marked by body language.
In order to chart the best course going forward and inform
* The scope of the problem in healthcare and social assistance--frequency of incidents of workplace violence, where those incidents most commonly occur, and who is most often the victim in those incidents;
* The common risk factors that could be addressed;
* Interventions and controls that data show are working already in the field;
* The efficacy, feasibility and cost of different options.
The remainder of the
II. Background
A.
1. Guidelines for Preventing Workplace Violence for Healthcare and Social Assistance
Protecting healthcare and social assistance workers from workplace violence is not a new focus for
OSHA's Guidelines are based on industry best practices and feedback from stakeholders, and provides recommendations for policies and procedures to eliminate or reduce workplace violence in a range of healthcare and social services settings. Information on five settings was included in the updated guidelines: Hospital settings, residential treatment settings, non-residential treatment/services settings, community care settings, and field work settings. In addition, the updated 2015 version covers a broader spectrum of workers in comparison with previously published guidelines because healthcare is increasingly being provided in other settings such as nursing homes, free-standing surgical and outpatient centers, emergency care clinics, patients' homes, and pre-hospitalization emergency care settings.
The Guidelines recommend a comprehensive violence prevention program that consists of five core elements or "building blocks": (1) Management commitment and employee participation; (2) worksite analysis; (3) hazard prevention and control; (4) safety and health training; and (5) recordkeeping and program evaluation. These elements are discussed further in Section V below. While these guidelines provide much detailed, research-based information on specific controls and strategies for various healthcare and social assistance settings to help employers and employees prevent violence, they are recommendations and therefore non-mandatory.
Lipscomb and colleagues (2006) report the results of a participatory intervention study that implemented and then evaluated violence prevention programs that were based on the 1996 OSHA Guidelines in three
In 2015,
2. Enforcement Directive
Although OSHA has no standard specific to the prevention of workplace violence, the Agency currently enforces Section 5(a)(1) (
To prove a violation of the General Duty Clause,
Prior to 2011, federal
A relatively small percentage of the inspections related to workplace violence in health care facilities resulted in general duty clause citations. From 2011 through 2015,
B. State Laws
As of
Tragic events are often the impetus for legislation. Such was the case when a psychiatric technician was strangled on the
In
Some studies in the published literature evaluated whether healthcare facilities located in states with state laws have higher quality violence prevention programs than in states with no requirements, as a measure of the value or efficacy of state laws (Peek-Asa et al., 2007; Peek-Asa et al., 2009, Casteel et al., 2009). Peek-Asa et al. (2007) compared workplace violence programs in high-risk emergency departments among a representative sample of hospitals in
Two years later, the same authors (Peek-Asa et al., 2009) conducted studies that compared workplace violence programs in a representative sample of psychiatric units and facilities in
One study examined the effects of a state law on workers' compensation costs, and supports the conclusion that
C. Recommendations From Governmental, Professional and Public Interest Organizations
In response to a request from members of
During its investigation, GAO identified nine states with workplace violence prevention requirements for healthcare employers, examined workplace violence incidents, conducted a literature review, and interviewed
Table 2--Examples of Workplace Violence Incidents Reported by the Health Care Workers GAO Interviewed Health care Examples of reported workplace violence incidents facilities Hospitals with . Worker hit in the head by a patient when drawing the emergency rooms patient's blood and suffered a concussion and a permanent injury to the neck. . Worker knocked unconscious by a patient when starting intravenous therapy on the patient. Psychiatric . Worker punched and thrown against a wall by a hospitals patient and had to have several surgeries. As a result of the injuries, the worker was unable to return to work. . Patient put worker in a head-lock, and worker suffered neck pain and headaches and was unable to carry out regular workload. . Patient broke healthcare worker's hand when the healthcare worker intervened in a conflict between two patients. Residential care . Patient became upset after being deemed unfit to facilities return home and attacked the worker. . Worker hit in the head by a patient and suffered both physical and emotional problems as a result of the incident. Home health care . Worker attacked by patient with dementia and had to services defend self. . Worker was sexually harassed by a patient when the patient grabbed the worker while rendering care. Source: GAO, Workplace Safety and Health: Additional Efforts Needed toHelp Protect Healthcare Workers from Workplace Violence, 2016.
In its final report, the GAO recommended that
In
In recent years, several nursing professional associations have published statements on workplace violence (ANA, 2015; APNA, 2008; ENA, 2010). In addition, the ANA has published a model state law, "The Violence Prevention in Health Care Facilities Act," recommending that healthcare facilities establish violence prevention programs to protect healthcare workers from acts of violence (ANA, 2011).
Some organizations have recommended specific programmatic elements, policies, procedures and processes to reduce and prevent workplace violence. In 2008, APNA published recommendations for addressing workplace violence. In 2011, it published a report that included recommendations for adequate staffing, increased security, video monitoring, and safe areas for nurses (
In 2013, Public Citizen published "Health Care Workers Unprotected; Insufficient Inspections and Standards Leave Safety Risks Unaddressed," which recommended that
The Society for Human Resource Management's (SHRM) Workplace Violence Policy provides guidance on prohibited conduct, reporting procedures, risk reduction measures, employees at risk, dangerous/emergency situations, and enforcement for human resource professionals.
D. Questions for Section II
The following questions are intended to solicit information on the topics covered in this section. In general,
Question II.1: What state are you employed in or where is your facility located? If your state has a workplace violence law, what has been your experience complying with these requirements? Are there any specific provisions included in your workplace violence law that you think should or should not be included in an
Question II.2: For employers and managers: If your state has a workplace violence prevention law, have you or are you conducting an evaluation of the effectiveness of its programs or policies? If you are conducting such an analysis, how are you doing it? Have you been able to demonstrate improved tracking of workplace violence incidents and/or a change in the frequency or severity of violent incidents? If you think it is effective, please explain why. If you think it is ineffective, please explain why.
Question II.3: If your state has workplace violence prevention laws, how many hours do you spend each year (month) complying with these laws?
Question II.4: Please specify the number or percentage of staff participating in workplace violence prevention activities required under your state laws.
Question II.5: Do you have experience implementing any of the workplace violence prevention practices recommended by the
III. Defining Workplace Violence
A. Definition and Types of Events Under Consideration
As discussed in the overview above, the data show that injuries and fatalities in the health care and social assistance sector due to workplace violence are substantially elevated compared to the private sector overall. This section addresses the question of how to define the universe of workplace violence that
The National Institute of Occupational Safety and Health (NIOSH) defines workplace violence as "violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty" (https://www.cdc.gov/niosh/docs/2002-101/). Examples of violence include threats (expressions of intent to cause harm, including verbal threats, threatening body language, and written threats), physical assaults (attacks ranging from slapping and beating to rape, homicide, and the use of weapons such as firearms, bombs, or knives), and muggings (aggravated assaults, usually conducted by surprise and with intent to rob) (NIOSH at: http://www.cdc.gov/niosh/docs/2002-101/default.html).
Further, workplace violence can be classified into the following four categories, based on the relationship between the perpetrator and the victim/worker: Type I (criminal intent; the perpetrator has no legitimate relationship to the business), Type II (customer/client/patient), Type III (worker-on-worker), and Type IV (personal relationship) (UIIPRC, 2001). Type II events occur most commonly in healthcare and social assistance and these events are the type addressed by this
OSHA intends to address only Type II, or customer/client/patient violence in this
B. Questions for Section III
The following questions are intended to solicit information on the topics covered in this section. Wherever possible, please indicate the title of the person providing the information and the type and number of employees of your healthcare and/or social assistance facility or facilities.
Question III.1:
Question III. 2: Do employers encourage reporting and evaluation of verbal threats? If so, are verbal threats reported and evaluated? If evaluated, how do employers currently evaluate verbal threats (i.e., who conducts the evaluation, how long does such an evaluation take, what criteria are used to evaluate verbal threats, are such investigations/evaluations effective)?
Question III.3: Though OSHA has no intention of including violence that is solely verbal in a potential regulation, what approach might the Agency take regarding those threats, which may include verbal, threatening body language, and written, that could reasonably be expected to result in violent acts?
Question III.4: Employers covered by
Question III.5: Currently, a mental illness sustained as a result of an assault in the workplace, e.g., Posttraumatic Stress Disorder (PTSD), is not required to be recorded on the
Question III.6: Are you aware of cases of PTSD or psychological trauma related to workplace violence in your facility? If so, was it captured in the recordkeeping system and how? Please provide examples, omitting personal data and information.
Question III.7: Are there other indicators of the extent and severity of workplace violence in healthcare or social assistance that
IV. Scope
A. Health Care and Social Assistance
The Health Care and Social Assistance sector is composed of a wide range of establishments providing varying levels of healthcare and social assistance services, from general medical-surgical hospitals to at-home patient care to treatment facilities for substance abuse disorders, and different types of establishments providing social assistance, such as child day care services, vocational rehabilitation and food to the needy. In 2015 the healthcare industry had a total of 1,432,801 establishments and employed 18,738,870 workers in both healthcare and non-healthcare occupations (BLS, Census of Employment and Wages, 2016 and Occupational Employment Statistics, 2015).
Table 3--Top 5 Occupations in Healthcare and Social Assistance Industry Between 2005 and 2015 2005 2015 (million) (million) Healthcare and social assistance industry 15.2 18.7 Healthcare practitioners and technical occupations 5.1 6.3 Healthcare support occupations 2.9 3.5 Office and administrative support occupations 2.5 2.7 Personal care and service occupations 1.0 1.9 Community and social services occupations 0.8 1.0 BLS, Occupational Employment Statistics,April 2016 .
Across all industries there were 8.0 million Health Care Practitioners and Technical workers employed in 2015 and can be found in various parts of the private sector outside of the Health Care and Social Assistance sector, for example in Air Transportation, Accommodations, Recreation, and Retail Trade. Of the almost 8.0 million Healthcare Practitioners and Technical workers, 515,970 are employed at retail trade facilities, the majority are specifically at Health and Personal Care Stores.
For purposes of assessing workplace violence risk,
The rate of intentional injury in the Healthcare and Social Assistance sector as a whole was 8.2 per 10,000 full time workers, over four times the rate across all private industry, 1.7 per 10,000 full-time workers in 2014 (BLS Table R8,
FOOTNOTE 2 The term "
Table 4--Incident Rate for Violence and Other Injuries by Private Industry inthe United States per 10,000Full Time Workers in 2014 Intentional injury by other person All Private Industry 1.7 Health care and social assistance 8.2 Ambulatory health care services 1.9 Offices of physicians 0.4 Offices of physicians except mental 0.3 health Offices of mental health physicians 8.5 Offices of other health practitioners -- Outpatient care centers 4.1 Medical and diagnostic laboratories 5.6 Home health care services 5.0 Other ambulatory health care services 3.1 Ambulance services 5.3 All other ambulatory health care -- services Hospitals 8.9 General medical and surgical hospitals 6.7 Psychiatric and substance abuse 109.5 hospitals Other hospitals 7.3 Nursing and residential care 18.7 facilities Nursing care facilities 15.8 Residential mental health facilities 34.9 Community care facilities for the 7.2 elderly Other residential care facilities 39.9 Social assistance 9.8 Individual and family services 10.2 Child and youth services 4.0 Services for the elderly and disabled 11.0 Emergency and other relief services -- Community housing services -- Vocational rehabilitation services 20.8 Child day care services 6.5 (BLS Table R8,November 2015 ). Note: Dash indicates data do not meet BLS publication guidelines for their Survey of Occupational Injuries and Illnesses.
The industries in the Social Assistance subsector provide a wide variety of services directly to clients, and include industries with incident rates of intentional injury that are higher than those in the Ambulatory Health Care sector. The highest incident rate within this sector for intentional injury by other person was in Vocational Rehabilitation Services with 20.8 per 10,000 full time workers in 2014. The next highest industry in this sector was Services for the Elderly and Disabled with an incident rate of 11 per 10,000 full time workers. This sector includes, among other industries, services for children and youth, the elderly, and persons with disabilities; community food and housing services; vocational rehabilitation; and day care centers. Consequently, the risk of workplace violence to healthcare workers differs depending on the nature of the setting and the level of interaction with patients.
The severity of workplace violence in the Health Care and Social Assistance sector is even greater in state government entities where the incident rate for intentional injury by other person(s) in 2014 was 79.3 per 10,000 full time workers. Across state government sectors the incident rate for intentional injury by other persons in the Health Care and Social Assistance sector is the highest even compared to the sector for
Table 5--Incident Rate for Violence and Other Injuries bySelect State Industries inthe United States per 10,000Full Time Workers in 2014 Intentional injury by other person ALL STATE GOVERNMENT 15.8 SERVICE PROVIDING 16.2 Healthcare and Social Assistance 79.3 Hospitals 97.4 Nursing and Residential Care 116.8 FacilitiesPublic Administration 10.5 Justice, Public Order, and Safety 23.1 Activities Police Protection 8.7 Correctional Institutions 37.2 BLS Table S8,April 2016 .
Locally-run health care and social assistance facilities, on the other hand, appear to present risks that are comparable to private facilities, the incident rate of intentional injury by other persons in sector of Healthcare and Social Assistance was 13.1 per 10,000 full time workers. The overall incident rate for the
Table 6--Incident Rate for Violence and Other Injuries bySelect Local Government Industries inthe United States per 10,000Full Time Workers in 2014 Intentional injury by other person ALL LOCAL GOVERNMENT 8.7 SERVICE PROVIDING 8.8 Healthcare and Social Assistance 13.1 Hospitals 13.0 Nursing and Residential Care 39.9 FacilitiesPublic Administration 11.1 Justice, Public Order, and Safety 22.5 Activities Police Protection 36.8 Fire Protection 7.1 BLS Table L8,April 2016 .
Another way to consider the data is by occupation. Nursing-Psychiatric and Home Health Aides (which includes Psychiatric Aids and Nursing Assistants) had the highest rates of violence in 2014 across three of the four sectors. Out of the 4,690 injury cases in Nursing and Residential Care Facilities (based on data from BLS provided upon request), 2,640 of the cases of workplace violence were perpetrated against Nursing-Psychiatric and Home Health Aides in 2014 (BLS SOII 2014 Data, requested
Table 7--Cases of Intentional Injury by Other Person(s) by Industry and Occupation in 2014 2014All Private Sector Industries 15,980 Goods Producing 260 Service Producing 15,710 Healthcare and Social Assistance 11,100 AmbulatoryHealthcare Services 960Counselors- Social Workers - andOther Community and Social Service 100 Specialists Health Diagnosing and Treating Practitioners 150 Health Technologists and Technicians 230 Nursing- Psychiatric- and Home Health Aides 290 Occupational Therapy and Physical Therapist Assistants and Aides -- OtherPersonal Care and Service Workers 100 Hospitals 3,410Counselors- Social Workers - andOther Community and Social Service 180 Specialists Health Diagnosing and Treating Practitioners 1,110 Health Technologists and Technicians 610 Other Healthcare Practitioners and Technical Occupations 20 Nursing- Psychiatric- and Home Health Aides 1,030 Occupational Therapy and Physical Therapist Assistants and Aides -- OtherPersonal Care and Service Workers 100 Nursing and Residential Care Facilities 4,690Counselors- Social Workers - andOther Community and Social Service 370 Specialists Health Diagnosing and Treating Practitioners 170 Health Technologists and Technicians 310 Nursing- Psychiatric- and Home Health Aides 2,640 Occupational Therapy and Physical Therapist Assistants and Aides -- OtherPersonal Care and Service Workers 770 Social Assistance 2,050Counselors- Social Workers - andOther Community and Social Service 190 Specialists Health Diagnosing and Treating Practitioners 30 Health Technologists and Technicians -- Nursing- Psychiatric- and Home Health Aides 150Other Personal Care and Service Workers 1,060 BLS SOII 2014 Data, requestedJune 2016 . Note: Dash indicates data do not meet BLS publication guidelines for their Survey of Occupational Injuries and Illnesses.
Violence in the workplace is a topic that has been studied heavily using different data sources such as workers' compensation data, and occupation specific surveys. The results from these studies highlight similar findings to that of BLS's SOII data by industry, both showing that workplace injury rates of workers in the healthcare industry rank among the highest across private sector industries. In one study,
FOOTNOTE 3 The term "
The four subsectors that make up the Health Care and Social Assistance sector include a wide range of establishments providing varying types of services to the general public, and placing workers at elevated levels of exposure to workplace violence relative to other economic sectors.
B. Questions for Section IV
The following questions are intended to solicit information on the topics covered in this section. Wherever possible, please indicate the title of the person completing the question and the type and employee size of your healthcare and/or social assistance facility.
Question IV.1: Rates of workplace violence vary widely within the healthcare and social assistance sector, ranging from extremely high to below private industry averages. How would you suggest
Question IV.2: If OSHA issues a standard on workplace violence in healthcare, should it include all or portions of the Social Assistance subsector? Are the appropriate preventive measures in this subsector sufficiently similar to those appropriate to healthcare for a single standard addressing both to make sense?
Question IV.3: The only comparative quantitative data provided by BLS is for lost workday injuries.
Question IV.4:
Question IV.5: The GAO Report relied on BLS SOII data, HHS NEISS data and DOJ NCVS data. Are there any other data sets or data sources
Question IV.6: The data provided by BLS are for relatively aggregated industries. Instance of high risk of workplace violence can be found aggregated with industries with low average risk, and low risk of workplace violence within industries with high risk. Please describe if your establishment's experience with workplace violence is consistent with the relative risks reported by BLS in the tables found in this section? If you are in an industry with high rates, are there places within your industry where establishments or kinds of establishments have lower rates than the industry as a whole? If you are in an industry with relatively low rates, are there work stations within establishments or within the industry that have higher rates?
Question IV.7: Are there special circumstances in your industry or establishment that
Question IV.8: Please comment if the workplace violence prevention efforts put in place at your establishments are specific to certain settings or activities within the facility, and how they are triggered.
Question IV.9:
V. Workplace Violence Prevention Programs; Risk Factors and Controls/Interventions
A. Elements of Violence Prevention Programs
OSHA has recognized the unique challenges of workplace violence in healthcare and social assistance for decades.
1. Management Commitment and Employee Participation
OSHA's Guidelines for Preventing Workplace Violence for
OSHA is interested in hearing from employers and individuals working in healthcare and social assistance about their experiences with management commitment and employee participation. Specific questions regarding these topics are at the end of Section V.
2. Worksite Analysis and Hazard Identification
OSHA's guidelines emphasize worksite analysis and hazard identification. A worksite analysis involves a mutual step-by-step assessment of the workplace to find existing or potential hazards that may lead to incidents of workplace violence.
Healthcare and social assistance workers face a number of risk factors that are known to contribute to violence in the workplace. Common risk factors (or factors that have been shown to increase the risk of harm if one is exposed to a hazard) for workplace violence generally fall into two groups: (1) Patient, client and setting-related and (2) organizational-related (
Organizational risks (the second group) arise from workplace policies, or the lack thereof. Examples include a lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff; working when understaffed, especially during mealtimes and visiting hours; inadequate security and mental health personnel on site; not permitting smoking; allowing unrestricted movement of the public in clinics and hospitals; allowing a perception that violence is tolerated and victims will not be able to report the incident to police and/or press charges; and an overemphasis on customer satisfaction over staff safety (
Studies show that staff working in some hospital units or areas are at greater risks than others. High-risk areas include emergency departments (EDs), admission areas, long-term care and geriatrics settings, behavioral health, waiting rooms, and obstetrics and pediatrics, among others (DeSanto et al., 2013).
Assault rates for nurses, physicians and other staff working in EDs have been shown to be among the highest (Crilly et al., 2004; Gerberich et al., 2005;
Workers in the healthcare occupations of psychiatric aides, psychiatric technicians, and nursing assistants experienced higher rates of workplace violence compared to other healthcare occupations and workers overall (BLS Table R100, 2015; Pompeii et al., 2015). Some studies have found that nursing assistants in long-term care have the highest incidence of assaults among all workers in the
Surveys of nurses have identified risk factors including patient mental health or behavioral issues, medication withdrawal, pain, history of a substance abuse disorder, and being unhappy with care (Pompeii et al., 2015).
OSHA is interested in hearing from employers and individuals working in healthcare and social assistance about their experiences with worksite analysis and hazard identification, including how they use risk factors. Specific questions regarding these topics are at the end of Section V.
3. Hazard Prevention and Control
Once workplace violence hazards are identified, controls can be designed and implemented to prevent and control them.
a. Engineering Controls
Engineering controls attempt to remove the hazard from the workplace or create a barrier between the worker and the hazard. Examples of engineering controls include the installation of alarm systems, panic buttons, hand-held alarms, or noise devices, installation of door locks and increased lighting or use of closed-circuit video monitoring on a 24-hour basis (Haynes, 2013). Other examples include improvements to the layout of the admission area, nurses' stations and rooms. Where appropriate, some hospitals may have metal detectors installed to detect for guns, knives, box cutters, razors, and other weapons.
Effective interventions that have been described in the literature include K-9 security dog teams, metal detectors, and the installation of a security system, that includes metal detectors, cameras, and security personnel (
b. Administrative Controls
Administrative controls, sometimes referred to as management policies, include organizational factors and can have a major impact on day-to-day operations in healthcare and social assistance, for both staff and patients/residents. For example, staffing issues, such as mandatory overtime and inadequate staffing levels can lead to increased and unscheduled absences, high turnover, low morale and increased risk of violence for both healthcare and social assistance workers and their patients. Adequate numbers of well-trained staff can help ensure that situations with the potential for violence can be diffused before they escalate into full-blown violent incidents, resulting in fewer injuries. Adequate numbers of staff to address the needs of the patients can result in a higher level of safety and comfort for both patients and staff. Effective training can increase staff confidence and control in preventing, managing and de-escalating these incidents, resulting in a greater sense of safety for both staff and patients.
Employer policies often include security measures to prevent workplace violence, including policies for monitoring and maintaining premises security (e.g., access control systems, video monitoring security systems) and data security (e.g., measures to prevent unauthorized use of employer computer systems and other forms of electronic communication by a patient with a history of violence to obtain personal information about a staff member). Many organizations also have policies that limit or monitor access of nonemployees to the premises. Emergency departments (EDs), because they are typically open 24 hours a day, expose hospitals to the community at large and can pose unique safety and security concerns. If the hospital is located in a community or area with a high crime rate, the crime can spill into the ED.
Zero Tolerance policies are policy statements from employers/management that state that any violence to employees and patients/customers will not be tolerated. In general, zero tolerance policies require and encourage staff to report all assaults or threats to a supervisor or manager. Supervisors and managers keep a log of incidents, and all reports of workplace violence are investigated to help determine what actions to take to prevent future incidents. Some studies in the literature describe and discuss the effectiveness of zero-tolerance policies (Nachreiner et al., 2005; Lipscomb and
Policies that encourage employees to report incidents help ensure that hazards are addressed; however, the current evidence shows that many assaults go unreported (
Research has shown that injured healthcare and social assistance workers and their employers are reluctant to report violent incidents and resulting injuries out of fear of stigmatizing the patients or residents who are the perpetrators of the violence, particularly when they are mentally ill, developmentally disabled, or cognitively impaired elderly. There is also an attitude among many that violence toward those working with the public, especially with individuals with cognitive impairment, mental illness, or brain injury, is part of the job (Lipscomb and
c. Personal Protective Equipment
In OSHA's hierarchy of controls, personal protective equipment is the least-preferred type of control because these methods rely on the compliance of all individuals, and often places a burden on the individual worker rather than on the organization as a whole. However, there may be circumstances where the use of personal protective equipment (PPE) is appropriate for preventing workplace violence. For example, the ANA identified the use of gloves, sleeves, and blocking mats as a barrier method to protect staff from bites and scratches when caring for individuals with certain developmental disabilities and where other types of controls are infeasible (Lipscomb and
d. Innovative Strategies
In addition to controls that fall into the traditional
New Hampshire Hospital, a state-run behavioral health facility, serves as a teaching hospital through its affiliation with the
OSHA is interested in hearing from employers and individuals working in healthcare and social assistance about their experiences with hazard prevention and control. Specific questions regarding these topics are at the end of Section V.
4. Safety and Health Training
OSHA's Guidelines for Preventing Workplace Violence for
Training provides opportunities to learn and practice strategies to improve both patient safety and worker safety. The nationwide movement toward reducing the use of restraints (physical and medication) and seclusion in behavioral health--which is mandated in some states--along with the movement toward "trauma-informed care," means that workers are relying more on approaches that minimize physical contact with patients, intervening with verbal de-escalation strategies before an incident turns into a physical assault thereby reducing injuries. Trauma-informed care is a strengths-based approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment (SAMHSA). The results can be a "win-win" for patient and worker safety (
Staff training on policies and procedures is usually conducted at orientation and periodically (e.g., annually or semi-annually) afterward. A number of studies show that training can be effective in reducing workplace violence (Swain, 2014; Martin, 1995; Allen, 2013).
Because duties, work locations, and patient interactions vary by job, violence prevention training can be customized to address the needs of different groups of healthcare personnel, particularly: Nurses and other direct caregivers; emergency department (ED) staff; support staff (e.g., dietary, housekeeping, maintenance); security personnel; and supervisors and managers (
OSHA is interested in hearing from employers and individuals working in healthcare and social assistance about their experiences with the various types of training and their effectiveness. Specific questions regarding training are at the end of Section V.
5. Recordkeeping and Program Evaluation
a. Recordkeeping
OSHA's recordkeeping regulations require employers to record certain workplace injuries and illnesses. The
All employers, including those who are partially exempt from keeping records, must report any work-related fatality to
Employers do not always record or accurately record workplace injuries and illnesses in general. Specifically, in a 2012 report
OSHA is interested in hearing from employers and individuals in healthcare and social assistance facilities about their experiences with both recordkeeping to comply with
b. Program Evaluation
Programs are evaluated to identify deficiencies and opportunities for improvement. Accurate records of injuries and illnesses can help employers gauge the effectiveness of intervention efforts. The evaluation of a comprehensive workplace violence prevention program typically includes, but is not limited to, measuring improvement based on lowering the frequency and severity of workplace violence incidents; keeping up-to-date records of administrative and work practice changes implemented 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 evaluate their effectiveness; tracking recommendations through to completion; keeping abreast of new strategies available to prevent and respond to violence as they develop; and establishing an ongoing relationship with local law enforcement and educating them about the nature and challenges of working with potentially violent patients. The quality and effectiveness of training is particularly important to assess.
OSHA is interested in hearing from employers and individuals in healthcare and social assistance facilities about their experiences with program evaluation. Specific questions regarding program evaluation are located in section V.3. below.
B. Questions for Section V
OSHA is interested in hearing from employers and individuals in facilities that provide healthcare and social assistance about their experiences with the various components of workplace violence prevention programs that are currently being implemented by their facilities. Wherever possible, please indicate the title of the person completing the question and the type and employee size of your facility. In particular, the Agency appreciates respondents addressing the following:
1. Questions on the Overall Program, Management Commitment and Employee Participation
Question V.1: Does your facility have a workplace violence prevention program or policy? If so, what are the details of the program or policy? Please describe the requirements of your program, or submit a copy, if feasible. When and how did you implement the program or policy? How many hours did it take to develop the requirements? Did you consult your workers through union representatives?
Question V.2: How is your program or policy communicated to workers? (e.g., Web site, employee meetings, signage, etc.) How are employees involved in the design or implementation of the program or policy?
Question V.3: In your experience, what are the important factors to consider when implementing a workplace violence prevention program or policy?
Question V.4: At what level in your organization was the workplace violence prevention program or policy implemented? Who has responsibility for implementation? What are the qualifications of the person responsible for its implementation?
Question V.5: How well is your program or policy followed? Have you received sufficient support from management? Employees? The union, if there is one?
Question V.6: How did you select the approach to workplace violence prevention outlined in your facility program or policy (e.g., triggered by an incident, following existing guidelines, listening to staff needs, complying with state laws)?
Question V.7: Do you have a safety and health program in place in your facility? If so, what is the relationship between the workplace violence prevention program and the safety and health management system?
Question V.8: Does your facility subscribe to a management philosophy that encompasses quality measures, e.g., lean sigma, high reliability? If so, are metrics for worker safety included?
Question V.9: Does your facility have a safety and health committee? Does your facility also have a workplace violence committee? If so, what is the function of these committees? How are they held accountable? How is progress measured?
Question V.10: Does your facility have a workplace violence prevention committee that is separate from the general safety committee or part of it? If separate, how do the two committees communicate and share information? How many hours do they spend meeting or doing committee work? How many hours of employee time does this require per year?
Question V.11: If the facility does not have a committee, are there reasons for that?
Question V.12: What is the make-up of the committee? How are the committee members selected? What is the highest level of management that participates? Are worker/union representatives included in a committee? Is there a rotation for the committee members?
Question V.13: What does the decision making process look like? Do the committee members play an equal role in the decision making? Is there a meeting agenda? Does the committee keep minutes and records of decisions made?
Question V.14: How are the workplace violence prevention committee's decisions disseminated to the staff and management? Does the committee address employees' safety concerns in a timely manner?
Question V.15: If OSHA were to require management commitment, how should the Agency determine compliance?
Question V.16: If OSHA were to issue a standard that included a requirement for employee participation, how might compliance be determined?
2. Questions on Worksite Analysis and Hazard Identification
Question V.17: Are workplace analysis and hazard identification performed regularly? If so, what is the frequency or triggers for these activities? Are there any assessment tools or overall approaches that you have found to be successful and would recommend? Please describe the types of successes or problems your facility encountered with reviewing records, administering employee surveys to identify violence-related risk factors, and conducting regular walkthrough assessments.
Q uestion V.18: Who is involved in workplace analysis? How are the individuals selected and trained to conduct the workplace analysis and hazard identification? How long does it take to perform the workplace analysis?
Question V.19: What areas of the facility are covered during the routine workplace assessment? Please specify why these areas are included in the assessment and how many of these areas are part of the assessment.
Question V.20: What records do you find most useful for identifying trends and risk factors with regards to workplace violence? How many of these records are collected per year?
Question V.21: What screening tools do you use for the worksite analysis? Are these screening tools designed specifically to meet your facility's needs? Are questionnaires and surveys an effective way to collect information about the potential and existing workplace violence hazards? Why or why not?
Question V.22: Who provides post-assessment feedback? Is it shared with other employees and if so, how is it shared with the other employees?
Question V.23: Does your facility use patient threat assessment? If so, do you use an existing tool or did you develop your own? If you develop your own, what criteria do you use?
Question V.24: Does your facility conduct accident/incident investigations? If so, who conducts them? How are follow-ups conducted and changes implemented?
Question V.25: How much time is required to conduct your patient assessments? What is the occupational background of persons who do these assessments?
Question V.26: If OSHA were to implement a standard with a requirement for hazard identification and worksite analysis, how might compliance be determined?
Question V.27: What do you know or perceive to be risk factors for violence in the facilities you are familiar with?
3. Questions on Hazard Prevention and Controls
Question V.28: Are you aware of any specific controls or interventions that have been found to be effective in reducing workplace violence in an ED environment? How was effectiveness determined? If so, can you provide cost information?
Question V.29: Are you aware of any specific controls or interventions that have been found to be effective in reducing workplace violence in a behavioral health, psychiatric or forensic mental health setting? How was effectiveness determined? If so, can you provide cost information?
Question V.30: Are you aware of any specific controls or interventions that have been found to be effective in reducing workplace violence in a nursing home or long-term care environment? How was effectiveness determined? If so, can you provide cost information?
Question V.31: Are you aware of any specific controls or interventions that have been found to be effective in reducing workplace violence in a hospital environment? How was effectiveness determined? If so, can you provide cost information?
Question V.32: Are you aware of any specific controls or interventions that have been found to be effective in reducing workplace violence in a home health environment? How was effectiveness determined? If so, can you provide cost information?
Question V.33: Are you aware of any specific controls or interventions that have been found to be effective in reducing workplace violence of any other environments where healthcare and/or social assistance workers are employed? How was effectiveness determined? If so, can you provide cost information?
Question V.34: Are you aware of any existing or modified infrastructure and work practices, or cross-disciplinary tools and strategies that have been found to be effective in reducing violence?
Question V.35: Have you made modifications of your facility to reduce risks of workplace violence? If so, what were they and how effective have those modifications been? Please provide cost for each modification made. Please specify the type of impact the modification made and whether the modification resulted in a safer workplace.
Question V.36: Does your facility have controls for workplace violence prevention (security equipment, alarms, or other devices)? If so, what kind of equipment does your facility use to prevent workplace violence? Where is the equipment located? Are there any barriers that prevent using the equipment? What labor requirements or other operating costs does this equipment have (e.g., have you hired security guards to monitor video cameras)?
Question V.37: Who is usually involved in selecting the equipment? If a committee, please list the titles of the committee members. Is new equipment tested before purchase, and if so, by whom? Are there any pieces of equipment purchased that are rarely used? If so, why?
Question V.38: Is there a process for evaluating the effectiveness of controls once they are implemented? What are the evaluation criteria?
Question V.39: What best practices are in use in your facility for workplace violence prevention?
Question V.40: How do you assure that the program is followed and controls are used? What are the ramifications for not following the program or using the equipment? If
Question V.41: Do you have information on changes in work practices or administrative controls (other than engineering controls and devices) that have been shown to reduce or prevent workplace violence either in your facility or elsewhere?
Question V.42: Do you have a zero tolerance policy? If so please share it. Do you think it has been successful in reducing workplace violence incidents? Why or why not?
Question V.43: If you have a policy for reporting workplace violence incidents, what steps have you taken to assure that all incidents are reported? What requirements do you have to ensure that adequate information about the incident is shared with coworkers? Do you think these policies have been effective in improving the reporting and communication about workplace violence incidents? Why or why not?
Question V.44: What factors do you consider in staffing your security department? What are the responsibilities of your security staff?
Question V.45: Have you instituted policies or procedures to identify patients with a history of violence, either before they are admitted or upon admission? If so, what costs are associated with this? How is this information used and conveyed to staff? Whose responsibility is it and what is the process? Has it been effective?
4. Questions on Safety and Health Training
Question V.46: What kind of training on workplace violence prevention is provided to the healthcare and/or social assistance workers at your facility? If this is copyrighted/branded training, please provide the name.
Question V.47: What is the scope and format of the training, and how often is workplace violence prevention training conducted?
Question V.48: What occupations (e.g., registered nurses, nursing assistants, etc.) attend the training sessions? Are the staff members required to attend the training sessions or is attendance voluntary? Are staff paid for the time they spend in training? Who administers the training sessions? Are they in-house training staff or a contractor? How is the effectiveness of the training measured? What is the duration of the training sessions or cost of the contractor?
Question V.49: Do all employees have education or training on hazard recognition and controls?
Question: V.50: Are contract and per diem employees trained?
Question V.51: Are patients educated on the workplace violence prevention program and, if so, how?
Question V.52: Does training cover workers' rights (including non-retaliation) and incident reporting procedures?
Question V.54: If OSHA were to require workplace violence prevention training, how might compliance be assessed?
5. Questions on Recordkeeping and Program Evaluation
Question V.55: Does your facility have an injury and illness recordkeeping policy and/or standard operating procedures? Please describe how it works. How are records maintained; online, paper, in person?
Question V.56: Who is responsible for injury and illness recordkeeping in your facility?
Question V.57: Does your facility use a workers' compensation form, the
Question V.58: Where are the
Question V.59: Would the
Question V.60: Are you aware of any issues with reporting (either underreporting or overreporting) of
Question V.61: Do you regularly evaluate your program? If so, how often? Is there an additional assessment after a violent event or a near miss? If so, how do you measure the success of your program? How many hours does the evaluation take to complete?
Question V.62: Who is involved in a program evaluation at your facility? Is this the same committee that conducted the workplace analysis and hazard identification?
Question V.63: If you have or are conducting an evaluation of the effectiveness of your workplace violence prevention program, have you been able to demonstrate improved tracking of workplace violence incidents and/or a reduction in the frequency or severity of violent incidents?
Question V.64: What are the most effective parts of your program? What elements of your program need improvement and why?
Question V.65: When conducting program evaluations, do you use the same tools and metrics you used for the initial worksite assessment? If not, please explain.
Question V.66: If OSHA were to develop a standard to prevent workplace violence and included a requirement for program or policy evaluation, how might compliance be determined?
Question V.67: Could you provide information characterizing the nature and extent of the difficulties in implementing your facility's program or policy?
Question V.68: What actions are taken based on the results of the program evaluation at your facility?
VI. Costs, Economic Impacts, and Benefits
As part of the Agency's consideration of a possible workplace violence standard,
Workplace violence exacts a high cost today. It harms workers often both physically and emotionally, and employers also bear several costs. A single serious injury can lead to workers' compensation losses of thousands of dollars, along with thousands of dollars in additional costs for overtime, temporary staffing, or recruiting and training a replacement. Even if a worker does not have to miss work, violence can still lead to "hidden costs" such as higher turnover and deterioration of productivity and morale. In the study of
In addition to the out-of-pocket costs by the employer and employee, healthcare workers who experience workplace violence have reported short term and long term emotional effects which can negatively impact productivity. It was found by
OSHA requests any workers' compensation data related to workplace violence. Any other information on your facility's experience would also be appreciated.
Several studies have evaluated the effectiveness of various engineering and administrative workplace violence controls in a variety of settings (e.g., hospitals, nursing homes). The implementation of a comprehensive workplace violence prevention program that includes administrative and engineering controls has been shown to lead to lower injury rates and workers' compensation costs (
A. Questions for Costs, Economic Impacts, and Benefits
The following questions are intended to solicit information on the topics covered in this section. Wherever possible, please indicate the title of the person providing the information and the type and number of employees at your healthcare and/or social assistance facility.
Question VI.1: Are there additional data (other than workers' compensation data) from published or unpublished sources that describe or inform about the incidence or prevalence of workplace violence in healthcare occupations or settings?
Question VI.2: As the Agency considers possible actions to address the prevention and control of workplace violence, what are the potential economic impacts associated with the promulgation of a standard specific to the risk of workplace violence? Describe these impacts in terms of benefits from the reduction of incidents; effects on revenue and profit; and any other relevant impact measure.
Question VI.3: If you have implemented a workplace violence prevention program or policy, what was the cost of implementing the program or policy, in terms of both time and expenditures for supplies and equipment? Please describe in detail the resource requirements and associated costs expended to initiate the program(s) and to conduct the program(s) annually. If you have any other estimates of the costs of preventing or mitigating workplace violence, please provide them. It would be helpful to
Question VI.4: What are the ongoing operating and maintenance costs for the program?
Question VI.5: Has your program reduced incidents of workplace violence and by how much? Can you identify which elements of your program most reduced incidents? Which elements did not seem effective?
Question VI.6: Has your program reduced costs for your facility (e.g., reduced insurance premiums, workers' compensation costs, fewer lost workdays)? Please quantify these reductions, if applicable.
Question VI.7: Has your program reduced indirect costs for your facility (e.g., reductions in absenteeism and worker turnover; increases in reported productivity, satisfaction, and level of safety in the workplace)?
Question VI.8: If you are in a state with standards requiring programs and/or policies to reduce workplace violence, how did implementing the program and/or policy affect the facility's budget and finances?
Question VI.9: What changes, if any, in market conditions would reasonably be expected to result from issuing a standard on workplace violence prevention? Describe any changes in market structure or concentration, and any effects on services, that would reasonably be expected from issuing such a standard.
B. Impacts on Small Entities
As part of the Agency's consideration of a workplace violence prevention standard,
If the Agency pursues development of a standard that would have such impacts on small businesses,
C. Questions for Impacts on Small Entities
Question VI.10: How many, and what type of small firms, or other small entities, have a workplace violence prevention training, or a program, and what percentage of their industry (NAICS code) do these entities comprise? Please specify the types of workplace violence risks you face.
Question VI.11: How, and to what extent, would small entities in your industry be affected by a potential
Question VI.12: How many, and in what type of small healthcare entities, is workplace violence a threat, and what percentage of their industry (NAICS code 622) do these entities comprise?
Question VI.13: How, and to what extent, would small entities in your industry be affected by an
Question VI.14: Are there alternative approaches
Question VI.15: For very small entities, what types of workplace violence threats are faced by workers? Does your experience with workplace violence reflect the lower rates reported by BLS?
Question VI.16: For very small entities, what are the unique challenges establishments face in addressing workplace violence, including very small non-profit healthcare facilities and at small jurisdictions?
VI. References
I. Overview
Jayaratne, S.,Vinokur-Kaplan, D., Nagda, B.A; Chess, W.A. (1996). A national study on violence and harassment of social workers by clients.
McPhaul, K, and Lipscomb, J. (2004). Workplace Violence in Health Care: Recognized but not Regulated,
Pompeii L.A., Dement J., Schoenfisch, A.L., Lavery A. (2013). Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (Type II) on hospital workers: a review of the literature and existing occupational injury data.
Rey L. (1996) What Social Workers Need to Know About Client Violence. Families in Society:
Ruser, J. (2008). Examining evidence on whether BLS undercounts workplace injuries and illnesses. Monthly Labor Review. Retrieved from: http://www.bls.gov/opub/mlr/2008/08/art2full.pdf.
United States Government Accountability Office [GAO]. (2016). Workplace safety and health: Additional efforts needed to help protect health care workers from workplace violence. Retrieved from http://www.gao.gov/assets/680/675858.pdf.
II. Background
Cal/
Casteel, C., Peek-Asa, C., and
Lipscomb. J., McPhaul, K., Rosen. J., Brown, J. G., Soeken, K., Vignola, V.,
Peek-Asa, C., Casteel, C., Allareddy, V.,
Peek-Asa, C., Casteel, C., Allareddy, V.,
Public Citizen. (2013). Health care workers unprotected: Insufficient inspections and standards leave safety risks unaddressed. Retrieved from https://www.citizen.org/documents/health-care-workers-unprotected-2013-report.pdf.
Romney, L., (2010) Patient aggression intensifies at
Senate Bill No. 1299, Chapter 842, An act to add Section 6401.8 to the Labor Code, relating to Occupational Safety and Health.
State of
United States Government Accountability Office [GAO]. (2016). Workplace safety and health: Additional efforts needed to help protect health care workers from workplace violence. Retrieved from http://www.gao.gov/assets/680/675858.pdf.
III. Defining Workplace Violence
Gerberich, S.G., Church T.R., McGoven, P.M., Hasen, H. (2004). An epidemiological study of the magnitude and consequence of work related violence: the
Lipscomb J., and
IV. Scope
Kelly, E.L.,
United States Government Accountability Office [GAO]. (2016). Report to Congressional Requesters-Workplace Safety and Health--Additional Efforts Needed to
V. Workplace Violence Prevention Programs; Risk Factors and Controls/Interventions
Allen D. (2013). Staying safe: re-examining workplace violence in acute psychiatric settings.
Arnetz, J.E., Hamblin, L., Ager, J., Luborsky, M.J. (2015). Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents.
Bensley L., Nelson N., Kaufman J., Silverstein B. (1997). Injuries due to assaults on psychiatric hospital employees in
29 CFR 1904.35(b)(1)(iii) and 29 CFR. 1904.35(b)(1)(iv) Other OSHA injury and Illness Recordkeeping Requirements. Retrieved from: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12779#1904.35(b)(1).
Crilly, J., Chaboyer, W., Creedy, D. (2004). Violence towards emergency department nurses by patients. Accident and Emergency Nursing, 12(2), 67-73.
DeSanto, J.,
Gates D., Fitzwater, E., & Succop, P. (2005). Reducing a ssaults against nursing home caregivers. Nursing Research. 54(2), 119-127.
Gerberich S.G., Church T.R., McGoven P.M., & Hansen H. (2005) Risk factors for work-related assaults on nurses. Epidemiology, 16(5), 704-709.
Haynes, M.I. (2013). Workplace violence: Why every state must adopt a comprehensive workplace violence prevention law. Retrieved from http://digitalcommons.ilr.cornell.edu/chrr/47/.
Kowalenko, T.D.,
Lipscomb, J., and
Martin, K.H., (1995). Improving staff safety through an aggression management program. Archives of Psychiatric Nursing 9, 211-215.
May, D.D., and Grubbs, L.M. (2002). The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center.
Nachreiner, N.M., Gerbersch, S.G., McGovern, P.M., Church, T.R. (2005). Relation between policies and work related assault:
Non-violent Crisis Intervention Training, 2014. Retrieved from: http://www.crisisprevention.com/Specialties/Nonviolent-Crisis-Intervention.
Occupational Safety and Health Act, Section 11(c)(1) (1970). https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=3365 29 CFR 1904.35(b)(1)(iii) and 29 CFR 1904.35(b)(1)(iv) Other OSHA injury and Illness Recordkeeping Requirements. Retrieved from: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12779#1904.35(b)(1).
Pompeii L.A., Schoenfisch A.L., Lipscomb H.J., Dement J.M., Smith C.D., and Upadhyaya M. (2015). Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six
Stokowski, L.A. (2010). Violence: Not in My Job Description. Retrieved from http://www.medscape.com/viewarticle/727144_4.
Swain, N., Gale, C. (2014). A communication skills intervention for community healthcare workers reduces perceived patient aggression: a pretest-posttest study.
VI. Costs, Economic Impacts, and Benefits
McGovern, P., Kochevar, L., Lohman, W., Zaidman, B., Gerberich, S.G., Nyman, J., & Findorff-Dennis, M. (2000). The cost of work-related physical assaults in
Gerberich, S.G., Church T.R., McGoven, P.M., Hasen, H. (2004). An epidemiological study of the magnitude and consequence of work related violence: the
Authority and Signature:
Dr.
Signed at
Assistant Secretary of Labor for Occupational Safety and Health.
[FR Doc. 2016-29197 Filed 12-6-16;
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