Workers in many industries face hazards related to workplace violence, but the problem is particularly acute in healthcare. Data from the U.S. Bureau of Labor Statistics (BLS) indicate that while healthcare workers experience less than 20 percent of all workplace injuries, they suffer 50 percent of violent assaults. In 2010, BLS estimated that nearly 8 of every 10,000 workers in general medical and surgical hospitals incurred a non-fatal injury from workplace violence that required at least one day away from work. These data are supported by a forthcoming paper in the American Journal of Industrial Medicine, which estimates hospital workers’ career prevalence of experiencing workplace violence to be around 50 percent. Industrial hygienists at hospitals and other healthcare facilities may be asked to play a role in developing and implementing a workplace violence prevention program—a daunting task, for sure. Workplace violence is unlike many of the traditional hazards familiar to industrial hygienists. Carbon monoxide is the same villain wherever it is found, but workplace violence has myriad forms and affects everyone differently. Unlike bloodborne pathogens or chemical stressors, the target organ of workplace violence could be any part of the body. It also affects the mental health of the victim. You can’t take a gas meter and detect workplace violence concentrations. You can’t take measurements and design a workplace violence arrest system. This is the nature of violence: it is not unique to a hospital or an industry. It is an omnipresent condition of humanity that permeates all settings, including the workplace. CHARACTERIZING VIOLENCE Since at least 1996, researchers have used a common system for classifying acts of workplace violence. The classifications are based on the relationship between the victim and the perpetrator:
  • Type I: homicides and acts with criminal intent where there is no relationship between the victim and the perpetrator
  • Type II: customer or client violence against employees
  • Type III: worker-on-worker violence
  • Type IV: domestic violence that spills over into the workplace
The most prevalent type of workplace violence suffered by healthcare personnel is Type II. The perpetrator is a patient who becomes violent while being served by the worker. In 2000, AIHA adopted a white paper on prevention of workplace violence, which acknowledged that Type I and Type II were the most frequent fatal and non-fatal violent acts in the workplace. Reflecting a belief that occupational health protection strategies would be more effective in combating Type I and Type II events, the white paper called on occupational safety and health professionals to concentrate on Type I and Type II acts and the countermeasures that can prevent and mitigate them. This year, employers and EHS professionals received two important contributions and some much needed guidance for mitigating workplace violence in the healthcare setting: new guidelines from OSHA, and a position statement from the American Nurses Association (ANA). OSHA GUIDELINES The surveillance of Type II violence in the healthcare setting is essential to informing prevention and mitigation strategies. However, under-reporting of Type II violent events on the part of workers is often a barrier to adequate measurement and management of these events. Studies suggest that workers talk to their managers and coworkers about these events but that formal reporting into a system with oversight by occupational safety and health professionals doesn’t happen unless the worker incurs a physical injury. Even then, workers often do not report. To improve surveillance of Type II violence, hospitals must develop a comprehensive program that considers the safety and health of workers. OSHA recently published “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers,” which outlines five essential elements of a workplace violence prevention program:
  1. management commitment and worker participation in which both parties are involved in the creation and operation of a workplace violence prevention program
  2. work site analysis and hazard identification, including a step-by-step assessment for identifying potential or existing workplace violence hazards
  3. hazard prevention and control in which data collected as part of the work site analysis are used to inform the development of prevention strategies
  4. workplace violence prevention training for staff and management, including training workers on where and how to report events
  5. recordkeeping and program evaluation
Data on Type II violent events are essential to a program’s success. For work site analysis and hazard identification, OSHA provides recommendations for using existing or newly collected data to examine specific jobs and tasks with high Type II violence rates. Hazard prevention and control involves a range of engineering, administrative, and work practice controls. Hospitals should have post-incident procedures and services to ensure victims are appropriately cared for and supported, followed by an incident investigation to collect contextual details about the events. Recordkeeping and program evaluation go hand-in-hand; the workplace violence program can’t be evaluated without a comprehensive recordkeeping approach. OSHA recommends that the numerous data sources where workers report be pooled together and that hospitals establish a uniform violence reporting system as well as a mechanism for managers to report events they learn about from their workers. It’s essential that your organization have a mechanism for measuring what is happening with respect to workplace violence.
A CULTURE OF RESPECT In 2014, the American Nurses Association (ANA) invited 23 of its members to serve on its Professional Issues Panel for Incivility, Bullying, and Workplace Violence. The panel’s purpose was to develop a new position statement on workplace violence and incivility, describe evidence of related issues, and provide detailed guidance supported by evidence to help registered nurses (RNs) and employers promote and sustain healthy workplaces. More than 400 additional members were selected to provide feedback and help develop resources. The position statement was released this August and is available as a PDF from the ANA website. The key excerpt from the statement is:
All RNs and employers in all settings, including practice, academia, and research, must collaborate to create a culture of respect that is free of incivility, bullying, and workplace violence. Evidence-based best practices must be implemented to prevent and mitigate incivility, bullying, and workplace violence; to promote the health, safety, and wellness of RNs; and to ensure optimal outcomes across the health care continuum. Although the document is written for RNs, the content is relevant to other healthcare professionals and stakeholders who create and sustain a safe and healthy workplace. ANA is eager to share this work beyond nursing and to forge inter-professional collaborations to address incivility, bullying, and workplace violence. In addition to a detailed background section and lists of references and recommended resources, the document also outlines evidence-based primary, secondary, and tertiary recommendations for RNs and employers. This article focuses on the recommendations related to workplace violence. The panel outlined key elements of a comprehensive workplace violence prevention program. The recommendations align with OSHA’s “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers”: Management commitment and employee involvement. Employer commitment is the foundation for an effective workplace violence prevention program. Further, an inter-professional safety committee or workplace violence prevention committee should be involved in the implementation of each phase of the prevention program. Work site analysis. A thorough analysis is necessary to identify trends and risk factors. Analysis should use all available data sources, such as OSHA logs and injury reports. Regular walk-throughs to observe the work environment should be conducted. Hazard prevention and control. Prevention and control measures should be designed in accordance with the results of the work site analysis. The hierarchy of controls should be used. Examples of engineering controls may include modifying the layout of the admissions area, ensuring adequate lighting, and securing or eliminating furniture or equipment that may be used as weapons. Engineering controls may also include personal alarm devices, panic buttons, and cellular phones. Administrative controls may include developing related policies and procedures, such as an active shooter code, and conducting additional staff training. Training and education. Employers should provide training and education for all employees and relevant stakeholders as needed to ensure familiarity with elements of the workplace violence prevention program.
Comprehensive evaluation system. A plan for reporting, tracking, and evaluating incidents and near misses should be developed and implemented. NEW OPPORTUNITIES While EHS professionals hope to eliminate a hazard such as carbon monoxide by ensuring CO levels are always below the occupational exposure limits, workplace violence is similar to a bloodborne pathogen. You can’t expect to eliminate all needlestick accidents, and you can’t expect to eliminate all violent acts. In a hospital setting, full compliance with OSHA’s Bloodborne Pathogen Standard does not guarantee zero exposure incidents; we can identify a risky phlebotomist device and replace it with a safer one, but we can’t replace patients infected with HIV or Hepatitis B with uninfected ones. Similarly, we can’t replace patients inclined to violence with less dangerous patients. And a patient who will commit a violent act during treatment often looks just like the patients who won’t. OSHA’s new guidance and ANA’s position statement are new opportunities to address the complex problem of workplace violence. But solving it will require extensive cooperation and coordination among RNs, IHs, and other EHS professionals. COREY BENDER, CIH, is an industrial hygienist for CSS-Dynamac. He can be reached at or (703) 881-6187. JAIME MURPHY DAWSON, MPH, is senior policy advisor, occupational safety and health in the Department of Nursing Practice and Work Environment at the American Nurses Association. She can be reached at or (301) 628-5130. LISA POMPEII, PHD, COHN-S, FAAOHN, is an associate professor at the University of Texas School of Public Health. She can be reached at or (713) 500-9474.
New Guidance for Protecting Healthcare Workers
A patient who will commit a violent act during treatment often looks just like the patients who won’t.
American Journal of Industrial Medicine: “Physical assault, physical threat and verbal abuse perpetrated against hospital workers by patients and/or visitors in six U.S. hospitals” (2015, in early view). American Nurses Association: Position Statement: Incivility, Bullying, and Workplace Violence (PDF, 2015). Bureau of Labor Statistics: Survey of Occupational Injuries and Illnesses in Cooperation with Participating State Agencies, Tables R4, R8, and R116 (2010). Occupational Medicine - State of the Art Reviews: “State and local regulatory approaches to preventing workplace violence” (December 1996). OSHA: “Guidelines for preventing workplace violence for healthcare and social service workers” (PDF, 2015). University of Iowa Injury Prevention and Resource Center: “Workplace Violence: A Report to the Nation” (February 2001).
AIHA's Director of Government Affairs, Aaron Trippler, reported in October that OSHA is working on an updated compliance directive for workplace violence. The updated directive is expected to be released in February 2016.