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GUIDELINES FOR WORKPLACE VIOLENCE PREVENTION PROGRAMS
GUIDELINES FOR WORKPLACE VIOLENCE PREVENTION PROGRAMS FOR HEALTH
CARE WORKERS IN INSTITUTIONAL AND COMMUNITY SETTINGS
JUNE 21, 1995
Draft # 5
CONTENTS
I. INTRODUCTION
A. Risk factors
B. Safety and health and prevention of violence programs
II. GENERAL PROGRAM DEVELOPMENT
A. Management commitment and employee involvement
B. Written program
III. GENERAL PROGRAM ELEMENTS
A. Worksite analysis
B. Hazard prevention and control
1. General engineering controls
2. General administrative and work practice controls
3. Maintenance controls
4. Post-incident response
IV. SPECIFIC PROGRAM ELEMENTS
A. Psychiatric hospital/inpatient facilities
B. Clinics and outpatient facilities
C. Emergency rooms/general hospitals
D. Home/field operations/community service
V. TRAINING AND EDUCATION
VI. RECORDKEEPING AND EVALUATION OF THE PROGRAM
VII. REFERENCES
VIII.ADDITIONAL READING
IX. GLOSSARY
X. APPENDIX A, CHECKLIST
I. INTRODUCTION
Violence is a major public health problem in the United States today, Novello
(1992). The United States has one of the highest reported homicide rates
in the industrialized world, a rate 10 times higher than England and 25
times higher than Spain, Wolfgang(1986). This is a problem that is spilling
over into the workplace. According to the Bureau of Labor Statistics (1993),
homicide accounted for 17% of the 6083 fatal work injuries in 1992, more
than three deaths each day in the United States. Violence is the leading
cause of fatal occupational injuries in women and the first, second, or
third leading cause of death for all workers depending on the area reporting,
Bureau of Labor Statistics, Census on Fatal Occupational Injuries (1994).
Violence in the health care industry is endemic. Although it is increasing
in severity and frequency, violence against employees in areas such as psychiatric
facilities, community mental health clinics, infirmaries in corrections
departments, pharmacies and community care facilities has been a serious
problem for many years. Health care workers are at risk for both fatal and
non-fatal violence-related injuries. Goodman et al. (1994) found that between
1980 and 1990, 106 occupational violence deaths occurred among the following
health care workers: 27 pharmacists, 26 physicians, 18 registered nurses,
17 nurses' aides, and 18 health care workers in other occupational categories.
Bureau of Labor Statistics data for 1993 revealed that health care workers
have the highest incidence of assault injuries. In 1989, Carmel and Hunter
found that the nursing staff at a psychiatric hospital sustained 16 assaults
per 100 employees per year. This rate, which includes any assault-related
injuries, compares with 8.3 injuries of all types per 100 full time workers
in all industries and 14.2 per 100 full time workers in the construction
industry, Bureau of Labor Statistics (1991). Fox et al.(1994) found that
in 1993, nurses in several agencies had the highest rate of injury from
workplace violence in a group of twenty-six Federal Government agencies
studied for injury rates. Assaults on health care workers are found in all
areas of practice and constitute a serious hazard.
In the psychiatric practice areas, some experts believe violence is the
major health and safety hazard, contributing to serious injury, high stress,
and "burn out." Carmel and Hunter (1989) reported that of 121
psychiatric hospital workers sustaining 134 injuries, 43% involved lost
time from work with 13% of those injured missing more than 21 days from
work.
A. Risk Factors
Risk factors may be viewed from the standpoints of 1) the environment, 2)
administrative and work practices, and 3) perpetrator and victim. Home and
community worker risks are discussed separately.
1. Environmental Factors
Health care and community workers are at increased risk of work-related
assaults in part due to several factors. Root causes may include the prevalence
of handguns, the decrease in medical and mental health care for the mentally
ill; and the increasing use of hospitals by police and the criminal justice
systems for acutely disturbed violent cases whether from drug overdose,
severe mental illness, or other aberrant behavior.
Other risk factors include the early release from hospitals of the acute
and chronically mentally ill, the right of patients to refuse medicine,
and the inability to involuntarily hospitalize mentally ill persons unless
they pose an immediate threat to themselves or others. Hospitals, clinics,
and pharmacies frequently have drugs or money and may be viewed as sources
of such by those who intend to rob.
An important risk factor at hospitals and psychiatric facilities is that
patients and their family or friends may carry weapons. Wasserberger et
al. (1989) reported that 25% of major trauma patients treated in the emergency
room carried weapons. Attacks in emergency rooms in gang-related shootings
have been documented in hospitals. Goetz et al. (1991) found that 17.3%
of psychiatric patients searched were carrying weapons.
2. Administrative and Work Practices
Many studies and reports have implicated staffing patterns as a major contributor
to the problem of violence. Both Jones (1985) and Fineberg (1988) found
that shortages of staff and the reduction of trained, regular staff increased
the incidence of violence. Assaults in psychiatric facilities were associated
with times of specific increased activity such as meal times, visiting times,
and times when staff are transporting patients. This suggests that staffing
evaluations do not take into account the potential hazards associated with
increased activity or transportation of clients or acuity of patients.
Other work practices which place health care workers at increased risk include
the following: (1) Isolated work with clients in examination or treatment
activities. (2) Working alone or in remote locations or night work, particularly
in high crime areas. (3) Long waits in emergency or clinic areas and the
inability as perceived by clients to obtain needed services. (4) Allowing
the public to move about clinics and hospitals freely. (5) Poorly lighted
parking areas.
3. Perpetrator and Victim
In the health care setting, age is not a significant prediction factor.
Perpetrators of violence in health care settings are more often male, with
a wide age range, depending on the type of facility and the circumstances.
For example, robbers of pharmacists may be young and have used drugs or
alcohol, whereas very old patients may assault nurses' aides or orderlies
in long term care facilities.
In psychiatric hospitals, the risk is greater that a violent episode will
be perpetrated by a client suffering from a mental illness. A history of
violent behavior in the individual is one of the best indicators of future
violence in all settings. Although this information is not always available,
it is important to ask about past history whenever possible. Other violent
individuals may include people seeking revenge, distraught family members,
gang members, drug or alcohol abusers, social deviants, or individuals who
feel threatened and desperate. Drug and alcohol abuse may contribute to
violent behavior due to the lowering of inhibitions and the problems associated
with addiction. Some medical conditions and medication side effects can
also cause an individual to have violent episodes that may be time limited
but dangerous to the staff.
Health care recipients, emergency and psychiatric patients as well as the
homeless, frequently carry weapons. Guns are often used by perpetrators
of violence against health care workers. Early release of psychiatric patients
from hospitals without follow-up care contributes to the growing number
of acutely or chronically mentally ill sent to emergency rooms by police.
Victims of violence in the health care setting are male or female and are
often in a position of lesser authority such as nurses' aides. At increased
risk are employees who are newly hired. Health care employees may have,
or appear to have, money, drugs or some other object of value. They often
work alone at night, and may not have back-up or means of obtaining assistance.
They may work in correctional facilities or other high risk areas such as
drug abuse clinics, mental health clinics, family planning clinics, and
emergency rooms. In hospitals, health care workers believe their mission
is healing and, without knowledge of risks, are caught off guard when patients/clients
abuse or assault them. They are often untrained in recognizing and controlling
escalating hostile behavior and management of assaultive people Often they
have no protective equipment such as communication devices or alarm systems
or their employer has few resources for obtaining assistance.
Home health and community workers experience the same risk factors as other
health care workers as well as unique factors due to their work in the community
outside of a fixed worksite. They may be male or female, work in areas with
which they are not familiar, and in some neighborhoods or projects that
even armed police don't like to visit. They may not have a means of communication
with headquarters or other sources of assistance. While required to enter
unknown persons' homes without the ability to pre-assess the environment,
they are often untrained in recognition and control of escalating hostile
behavior, have no training in management of assaults, and often have no
protective equipment or resources for obtaining assistance such as communication
devices or alarm systems, Geis (1986).
B. Safety and Health and Prevention of Violence Programs
In January 1989, OSHA published voluntary, general Safety and Health Program
Management Guidelines (Federal Register,Vol. 54, Number 16, January 26,
1989, pp 3904-3916), which all employers can use as a foundation for their
safety and health programs, including a workplace violence prevention program.
Using this framework, OSHA has developed the following workplace violence
prevention program guidelines specifically for the health care industry.
These guidelines are designed to assist health care providers, employers
of health care workers, security and safety personnel, compliance officers,
and other interested persons in developing, implementing and evaluating
programs to protect health care workers. While not exhaustive, the guidelines
include policy recommendations and practical corrective methods to help
prevent and mitigate the effects of assaults. Just as banks may always be
high-risk targets for violent robberies, the potential for assault may always
exist for health care workers, but the likelihood of violent incidents can
be significantly decreased, resulting in fewer injuries and in reduced costs
for those injuries.
The agency has developed a checklist (See appendix A) to help employers
determine whether or not they have a potential or present problem and whether
they should be placing high priority on their workplace violence prevention
program. This is not intended to be an exhaustive listing, and the health
care employer may be aware of other serious hazards not listed here. Also,
several states have developed standards or recommendations in the health
care area such as: New Jersey Public Employees Occupational Safety and Health
(PEOSH), "Guidelines on Measures and Safeguards in Dealing with Violent
or Aggressive Behavior in Public Sector Health Care Facilities"; and
California OSHA (CAL/OSHA) has developed "Guidelines for General Workplace
Violence," (1994) and for "Security and Safety of Health Care
and Community Service Workers" (1993). Information is available from
these and other agencies to assist employers.
Many health care providers, researchers, educators, unions, and OSHA professionals
contributed to these guidelines. This will be a coordinated effort involving
research, information, training, cooperative programs, and enforcement.
The cooperation and commitment of employers is necessary, however, to translate
these guidelines into an effective program for the safety and security of
health care workers in every community.
The guidelines are not a new standard or regulation. They are intended for
use by employers who are seeking to provide a safe and healthful workplace
through effective workplace violence prevention programs. Failure to implement
the guidelines is not in itself a violation of the General Duty Clause of
the OSH Act, but employers can be cited if there is a recognized hazard
of workplace violence in their establishments and they do nothing to prevent
or abate it.
II. GENERAL PROGRAM DEVELOPMENT
The guidelines are divided into two major divisions: 1) general provisions
and program development and, 2) specific work setting requirements. General
provisions and program development include provisions that should be adopted
by all types of health care facilities, hospitals, clinics, psychiatric
treatment facilities, correctional clinics, and other types, to assess risk
and to develop needed programs.
A. Management Commitment and Employee Involvement
Commitment and involvement are essential in any safety and health program.
Management provides the organizational resources and motivating forces necessary
to deal effectively with safety and security hazards. Employees can be involved,
both individually and collectively, through participation in the worksite
assessment, assisting in developing clear effective procedures, and identifying
existing and potential hazards. Employee knowledge and experience should
be incorporated into any written plan to abate and prevent safety and security
hazards.
1. Commitment by Top Management
The implementation of an effective safety and security program requires
the public commitment of hospital, clinic and agency administrators. Such
a commitment provides a context for decisions and planning. An effective
program should include the following:
a. Demonstration of management's concern for employees'safety and health
by placing a high priority on eliminating safety and security hazards.
b. A policy which places employee safety and security on the same level
of importance as patient/client safety. The responsible implementation of
this policy requires management to integrate issues of employee safety and
security with restorative and therapeutic services to assure that this protection
is part of the daily hospital/clinic or agency activity.
c. Employer commitment to assign and communicate the responsibility for
various aspects of safety and security to managers, supervisors, physicians,
social workers, nursing staff, human resources, and other employees involved
so that they know what is expected of them; also, commitment to ensure that
appropriate records are kept and used.
d. Employer refusal to tolerate violence in the institution and the assurance
that every effort will be made to prevent violent incidents.
e. Employer commitment to provide adequate authority and budgetary resources
to responsible parties so that identified goals and assigned responsibilities
can be met.
f. Employer commitment to insure that each manager, supervisor, professional,
and employee responsible for the security and safety program in the workplace
is accountable for carrying out their responsibilities.
g. A program of medical care for employees who are assaulted.
h. A process of employee participation which includes receiving input from
all levels of workers and managers, that evaluates all reports and records
of assaults, incidents of aggression, and employee complaints related to
violence. A suitable means of follow-up should be implemented to ensure
that all measures taken are implemented properly and their effectiveness
evaluated.
2. Employee Involvement
An effective program includes a commitment by the employer to provide for
and encourage employee involvement in the safety and security program and
in the decisions that affect worker safety and health as well as the well-being
of the client. Some methods of obtaining involvement are:
a. An employee suggestion/complaint procedure that allows workers to bring
their concerns to management and receive feedback without fear of reprisal.
b. A procedure which requires prompt and accurate reporting of incidents
with or without injury.
c. Employee participation in whatever process or system is devised to receive
information and reports on security problems, make facility inspections,
analyze reports and data, and make recommendations for corrections.
d. Employee participation in case conference meetings to present patient
information and to identify problems which may help to identify potentially
violent patients and to plan safe methods of managing difficult clients.
e. Employee participation in security emergency teams that are trained in
required professional assault response skills.
f. Employee participation in training and refresher courses in professional
assault response training, management of assaultive behavior, or disaster
plan response. Such training should include recognition of escalating agitation,
diverting or controlling undesirable behavior and any other methods of handling
assaults and of protecting the individual, clients and other staff members.
Programs provided by police departments on "personal safety,"
or other commonly provided classes on "handling the hostile customer,"
can often be arranged for employees to participate in on-site.
B. Written Program
In large organizations in particular, effective implementation requires
a written program for job safety, health, and security that is endorsed
and advocated by the highest level of management, including professional
practitioners or the medical board. In small establishments, the program
may not need to be written or heavily documented. The program should establish
the employer's goals and objectives.
The written program should be suitable for the anticipated hazards, and
for the size, type, and complexity of the facility and its operations. These
guidelines should be applied to the specific hazardous situation of each
health care unit or operation. A large institution should have different
plans and programs for high-risk and low-risk facilities.
The written program should be communicated to all personnel. The program
should establish clear goals and objectives that are communicated to and
understood by all members of the organization, including housekeeping, dietary,
clerical.
III. GENERAL PROGRAM ELEMENTS
An effective security and safety program in health care and community service
facilities includes the following major program elements: A. worksite analysis,
B. hazard prevention and control, C. education and training, D. recordkeeping
and evaluation. Suggestions on program content are provided to assist in
assessment but are not exhaustive.
The "health care workplace" covers a broad spectrum of workers.
In order to define appropriate risk factors and control methods, health
care providers are specified by major work locations. Health care providers
may include physicians, registered nurses, pharmacists, nurse practitioners,
physician assistants, nurses' aides, therapists, technicians, dental workers
and field personnel such as public health nurses, home health workers, social/welfare
workers, and emergency medical care personnel, and any other workers typically
involved in provision of health care. Sic codes included are: 5912, 8011-8099,
8399, 8322, 8361.
A. Worksite Analysis
The objectives of worksite analyses are to recognize, identify, and plan
to correct security hazards. Criminal activity or occurrences that may be
considered to be a security risk should be part of the information that
every company uses to start its worksite analysis. Analysis also utilizes
existing workplace records and worksite evaluations including:
1. Record Review
a. Analyze medical, safety, and insurance records, including the OSHA Log
of Injury and Illness to determine incidences of workplace violence-related
injuries.
b. Review information compiled from employee reports of incidents or near-incidents
of assaultive behavior from clients or visitors.
c. Identify and analyze any apparent trends in injuries by departments,
units, job title, unit activities, work stations, and/or time of day. This
may include identification of sentinel events such as repeated threats to
providers of care.
2. Identification of Security Hazards. (Facility Inspection)
Identify those areas needing in-depth scrutiny of security hazards:
a. Analyze incidents, noting characteristics of assailants and victims,
brief account of what happened before and during the incident, noting relevant
details of the situation, and its outcome. When possible, obtain reports
of police who investigated the incident, and their recommendations.
b. Identify, based upon the risk factors identified in these guidelines,
those work positions in which staff are at risk of assaultive behavior.
c. Identify processes and procedures which put employees at risk of assault.
When do these occur? (eg., on all shifts?)
d. Use a checklist to identify high risk factors that includes type of client
or patient, (eg., psychiatric conditions or patients disoriented by drugs,
alcohol, or stress), physical risk factors of the building, isolated locations/job
activities, lighting problems, lack of communication devices, areas with
uncontrolled access, and areas of previous security problems. Using the
checklist (see appendix A), make a walk-through inspection of the facility
and adjacent areas.
d. Identify existing programs in place and analyze effectiveness of those
programs, including engineering control measures and their effectiveness.
Determine if risk factors have been reduced or eliminated to the extent
feasible.
e. Assess plans for modifications or new construction to ensure that security
hazards are reduced or eliminated prior to staffing the area.
f. Conduct periodic surveys, at least annually or whenever there are operation
changes or new information, to identify risks and to assess the effectiveness
of the program and to plan for any needed improvement in corrective measures,
policies, or training.
B. Hazard Prevention and Control
Measures should be taken in almost every health care work setting to improve
security. These measures are presented generally in the following section
entitled "all settings". Following that section are specific recommendations
for psychiatric hospitals/inpatient facilities, clinics and outpatient facilities,
emergency rooms/general hospitals , and community health care settings.
These suggestions cover additional specific engineering, administrative
and work practice controls, and personal protective equipment as appropriate
to control hazards in these selected high hazard health care locations.
(These are not exhaustive recommendations).
1. Protective Control Systems For "All Settings"
a. Engineering Controls
In general, all work areas should be secure, well-lighted, and protected
to reduce the likelihood of assaults.
i. Design of facilities should ensure uncrowded service conditions for staff.
Rooms for interviewing clients should ensure privacy while avoiding isolation
of the staff. In psychiatric or developmentally disabled facilities, "Time
Out" or seclusion rooms are needed. In emergency departments, rooms
are needed in which agitated patients or family may be separated safely
to protect themselves, other clients, and staff.
ii. Client waiting rooms should be comfortable so as to avoid causing confusion,
agitation, or anger. This could include: appropriate room temperature, availability
of magazines, T.V., fresh water, restrooms, and pay telephones. It may also
be useful to post information regarding services or other information which
will help clients to obtain services or more calmly wait for services.
iii. Nurses' stations should be protected by enclosures which prevent patients
from molesting, throwing objects, or reaching into the station. Such barriers
should not restrict communication but protect employees.
Client service rooms should have deep service counters or use bullet-resistant
glass to prevent clients from reaching staff.
iv. Bright and effective lighting systems should be provided for all indoor
building areas as well as grounds around the facility and parking structures
or areas. Parking for staff should be close to the building, lighted and
free from heavy brush or anything that could conceal potential assailants.
v. Curved mirrors may be installed at hallway intersections or concealed
areas.
vi. Alarm systems or panic buttons should be installed and maintained where
risk is apparent or may be anticipated. Alarm systems are imperative for
use in psychiatric units, hospitals, mental health clinics, emergency rooms,
and where drugs are stored or dispensed. Whereas alarm systems are not necessarily
preventive, they may reduce serious injury when a client is escalating in
abusive behavior or threatening with or without a weapon.
Use of the alarm should be required. Training on the use of the system is
essential as is periodic testing. Trained response teams must be available
to respond to this alarm 24 hours a day. A telephone link to the local police
department should also be established.
vii. All permanent and temporary employees who work in a secured area should
be given keys to gain access or egress when on duty.
viii.Metal detectors should be installed to screen patients and visitors
in psychiatric facilities.in order to identify guns, knives, or other weapons.
Emergency departments may wish to install a metal detector or use a hand
held metal detection device to reveal concealed weapons. Signs posted at
the entrance will notify patients and visitors of screening.
ix. Counseling or service rooms should be designed with two exits, if possible,
and furniture should be arranged to prevent entrapment of staff.
x. Client access to staff counseling rooms, treatment rooms and other facility
areas should be controlled. All doors from client waiting rooms should be
locked from the inside and outside doors locked from the outside (in accordance
with fire codes) to prevent unauthorized entry.
xi. Lockable and secure bathrooms and other amenities should be provided
for staff members, separate from client restrooms.
xii. Administrators should work with local police to establish liaison and
response mechanisms for police assistance and, conversely, to facilitate
the hospital's assistance to local police in handling emergency cases. Standard
operating procedure should require the reporting of incidents of workplace
violence to local police. All assaults should be investigated, reports made,
and needed corrective action determined.
b. Administrative and Work Practice Controls
i. Unpredictable and unremitting workloads may lead to fatigue and a diminished
ability for early identification and control of potentially violent situations.
There should be sufficient flexibility in staffing to identify and adjust
levels to meet security needs during patient escort, emergency responses,
and meal times. There should be adequate cover for all shifts, during weekends,
and during shift change.
ii. Health care workers should not be left alone in situations where there
is a potential for violence.
iii. Where there is a well-established risk, there should be a trained response
team which can provide transport or escort services or respond to emergencies
without depleting or leaving another unit's staff at risk.
iv. Managers should be available to assist in emergencies, provide advice,
make decisions, and help with difficult individuals or situations.
c. Maintenance
i. General maintenance must be an integral part of any safety and security
system. Prompt repair and replacement of burned out lights, broken windows
or locks, etc., is essential to maintain the system in a safe operating
condition.
ii. To be effective, alarm systems, including personal alarm devices, must
be tested and maintained according to manufacturer and facility policy.
Batteries and operation of the alarm devices should be checked by competent
persons to insure that the system functions properly.
iii. Any mechanical device utilized for security and safety should be routinely
tested for effectiveness and maintained on a scheduled basis and in accord
with manufacturers' recommendations.
4. POST-INCIDENT RESPONSE
Although post-incident response is not a preventive measure, all workplace
violence programs should make some provisions for employees who have been
assaulted. Employers should set up a program that provides treatment for
victimized employees and for other employees who may be traumatized by a
workplace violence catastrophe. The consequences to employees who are abused
by clients may include death and severe and life threatening injuries, in
addition to short and long term psychological trauma, fear of returning
to work, and a change in relationships with co-workers and family. All have
been reported by health care workers after assaults, particularly if the
attack has come without warning. They may also fear criticism by managers;
suffer from feelings of professional incompetence, experience physical illness
or powerlessness, increase absentee days, and experience performance difficulties.
Injured staff should have prompt medical evaluation and treatment whenever
an assault takes place regardless of severity or the time of day or night.
Transportation of the injured to medical care should be provided if care
is not available on-site or in an employee health service.
Many people who have observed a violent confrontation or death of a co-worker
may have similar mental health problems. Thus, when a unit or office or
institution has a serious violent episode, many more people are affected
than the immediate victim, and plans for intervention must include a wide
group of affected individuals.
A trauma-crisis counseling or critical incident debriefing program should
be established and provided whenever staff are victims of assaults. This
"counseling program" may be developed and provided by in-house
staff as part of an employee health service. Trained psychologists, psychiatrists,
or other clinical staff members such as a clinical nurse specialist or a
social worker could provide this counseling or the employer can refer staff
victims to an outside specialist. In addition, peer counseling or support
groups may be provided. Counselors must be well trained with a good understanding
of the issues of assault and its consequences.
IV. SPECIFIC PROGRAM ELEMENTS
A. PSYCHIATRIC HOSPITAL/IN-PATIENT FACILITIES
1. Engineering Controls
a. Use of alarm systems and "panic buttons." (See general engineering
controls)
b. Closed circuit video recording of high risk areas or activities permits
one security guard to visualize a number of high risk areas, both inside
and outside the building.
c. Items that can be made into weapons or actual weapons themselves should
never be permitted into the psychiatric hospital. Metal detection systems
such as hand held devices or other systems to identify persons with hidden
weapons should be utilized. In psychiatric facilities, patients who have
been on leave or pass should be screened upon return for concealed weapons.
2. Administrative Controls
A sound overall security program includes administrative controls that reduce
hazards resulting from inadequate staffing, insufficient security measures
and poor work practices.
a. In order to enable staff members to identify and deal effectively with
patients who behave in a violent manner, the administrator should insist
on plans for treatment which include a gradual progression of measures to
prevent violent behavior from escalating. The least restrictive yet appropriate
and effective plan for preventing a client from injuring staff, other clients
and self should be on every unit.
Care plans should be made with input from all levels of care providers.
Effective plans and procedures cover verbal or physical threats or "acting
out" by disturbed clients to help both the client and staff to feel
a sense of control within the unit.
b. Security guards may be needed and should be provided with training by
the institution in principles of human behavior and control of the violent
patient, in addition to their usual training. They should be assigned to
areas such as emergency rooms or psychiatric services where there may be
psychologically stressed clients.
c. In order to provide a safe level of staffing, a written acuity system
should be established that evaluates the level of staff coverage vis-a-vis
patient acuity and activity level. Staffing of units where aggressive behavior
may be expected should be such that there is always an adequate, safe staff/patient
ratio. The provision of reserve or emergency teams should be utilized to
prevent staff members from being left with inadequate support. Administrators
should also analyze incident reports to identify times or areas where hostilities
occur and provide a backup team or staff at levels which are safe, such
as in admission units, crisis or acute units or during the night hours,
meal times, or any other time or activity identified as high risk.
d. Immediately upon admission, every effort should be made to ascertain
for new or transferred clients an accurate history of any past violent or
assaultive behavior or incarceration for violent acts.
e. All oncoming staff or employees should be provided with a census report
which indicates precautions for each client. Methods should be developed
and enforced to inform "float" staff, new staff members, or oncoming
staff at change of shifts of any potential assaultive behavior problems
with clients. Methods of identification may include chart tags, log books,
verbal census reports and/or any other information system within the facility.
Other sources of information may include mandatory provision of probation
reports of clients who may have had a conviction for any act of criminal
violence. However, the need for a program of "UNIVERSAL PRECAUTIONS
FOR VIOLENCE" (the concept that violence should be expected and prepared
for) must be recognized and integrated in any patient care setting.
f. Staff members should be instructed to limit physical interventions in
altercations between patients whenever possible, unless there are adequate
numbers of staff or emergency response teams, and security available.
Administrators and staff need to give clear messages to clients that violence
is not permitted. Clients who assault other clients or staff members may
be prosecuted. Administrators should provide pertinent procedural information
to staff who wish to press charges against assaulting clients.
g. Staff should have procedures to follow to ensure their safety during
patient checks. Policies should be established to cover key and door opening,
open vs. locked seclusion, handling evacuation in emergencies, and for handling
patients in restraints. The policy should also address the monitoring of
high risk patients at night and whenever behavior indicates aggression.
h. Escort services by security should be arranged so that staff members
do not have to walk alone in parking lots or other parking areas in the
evening or late hours.
i. Visitors and maintenance persons or crews should be escorted and observed
while in any locked facility. Often, they have tools or possessions which
could be left inadvertently and used inappropriately by clients.
j. Same-sex chaperones should accompany physicians during male and female
genital examinations.
k. Administrators need to work with local police to establish liaison and
response mechanisms.
l. Consider assaultive clients for placement in more acute units or hospitals,
where greater security can be provided. Some programs may have the option
of transferring clients to "acute units", "criminal units"
or to other, more restrictive settings.
3. Work Practice Controls
a. Staff should wear clothing such as low heeled shoes, which limits the
risk of injury. They also should limit jewelry to discourage theft and strangulation.
b. Employees need to carry or wear keys in an inconspicuous manner to avoid
incidents, yet have them readily available when needed.
c. Personal alarm systems described under engineering controls should be
utilized by staff members when required by policy or standard operating
procedure and tested as scheduled.
d. No employee should be permitted to work alone in a unit or facility unless
assistance is immediately available.
B. CLINICS AND OUTPATIENT FACILITIES
1. Engineering Controls
a. An emergency personal alarm system is of the highest priority. (See general
engineering controls).
b. In high-risk clinic settings, reception areas should be designed so that
the receptionist and staff are protected by safety glass. The clinic treatment
areas should be separated by doors locked from the inside.
c. Furniture in crisis treatment areas and quiet rooms should be kept to
a minimum and be affixed to the floor. These rooms should have all equipment
secured in locked cupboards.
d. First aid supplies should be available.
2. Administrative Controls
a. Psychiatric clients/patients should be escorted to and from the waiting
rooms and not be permitted to move about unsupervised in the clinic areas.
Access to clinic facilities other than waiting rooms should be strictly
controlled.
b. If security guards are utilized, they should be trained in principles
of human behavior and aggression. This is particularly important where there
may be psychologically stressed clients or persons who have taken hostile
actions such as in emergency facilities, family planning clinics, hospitals
where there are acute or dangerous patients, or drug treatment clinics.
c. Staff members should be given the greatest possible assistance in obtaining
information to evaluate the history of, or potential for, violent behavior
in patients. They should be required to treat and/or interview aggressive
or agitated clients in open areas where other staff may observe interactions
but still provide privacy and confidentiality.
d. Case management conferences with co-workers and supervisors should be
utilized to identify, and aid in the development of, effective treatment
of potentially violent clients.
Whenever an agitated client or visitor is encountered, security or assistance
should be alerted to assist in avoiding violence.
e. No employee should be permitted to work alone in a facility or isolated
unit in the evening or at night when the clinic is closed, particularly
if the employee is unable to obtain assistance if needed.
f. Employees should report all incidents of aggressive behavior such as
pushing, threatening, etc., with or without injury. The facility should
maintain logs recording all incidents or near incidents.
g. Records, logs and chart flags must be updated whenever information is
obtained regarding assaultive behavior or previous criminal behavior. Threats
or assaults must be recorded in client/patient files to establish a record
of abusive behavior and to warn other staff.
h. Administrators should work with local police to establish liaison and
response mechanisms for police assistance when calls for help come from
a clinic. Likewise, this will also facilitate the clinic's provision of
assistance to local police in handling emergency cases.
i. Referral systems and pathways to psychiatric facilities need to be developed
to facilitate prompt and safe hospitalization of clients who demonstrate
violent or suicidal behavior. These methods may include: direct phone link
to the local police, exchange of training and communication among local
psychiatric services, and written guidelines outlining commitment procedures.
j. Staff should be required to use protective devices and follow security
procedures.
C. EMERGENCY ROOMS/GENERAL HOSPITALS
1. Engineering Controls
a. Alarm systems or "panic buttons" should be installed at nurses'
stations, registration areas, hallways, and nurses' lounge areas. (See general
engineering controls).
b. Metal detection systems should be used. Hand-held metal detectors may
be needed to identify concealed weapons if there is no larger system.
c. Seclusion or security rooms are needed for containing confused or aggressive
clients or family. Although privacy may be important both for the agitated
patient and other patients, security and the ability to visibly monitor
the patient and staff is equally important.
d. Protective devices such as bullet resistant glass should be used to provide
protection for triage, admitting or other reception areas where employees
may greet or interact with the public. Evaluating community, as well as
other local emergency room experience, and speaking with employees may aid
in determining the extent of protection needed.
e. Strictly enforced limited access to emergency treatment areas is needed
to eliminate unwanted or dangerous persons. Doors may be locked one way
or key-coded, and visitors controlled.
f. Closed circuit tv or other devices can provide surveillance of concealed
areas or areas where problems may occur.
2. Administrative Controls
a. The use of security guards trained in principles of human behavior and
aggression control may be necessary in emergency rooms. Death and serious
injury have been documented in emergency areas in hospitals. The need for
armed guards may be a consideration in a risk assessment for high volume
emergency rooms or for hospitals that have large unsecured grounds or are
located in high-crime areas.
b. Do not assign any staff person to work alone in an emergency area or
walk-in clinic. Buddy systems or other administrative methods should be
utilized.
c. Lock all unused doors at night to limit access into the hospital (in
accordance with local fire department regulations). Security guards should
patrol the area as well.
d. Establish policies for managing hostile patients and using restraints
or other methods of management. The policies should be detailed and provide
guidelines for progressively restrictive action as necessary.
e. Instruct staff to report any verbally threatening, aggressive, or assaultive
incident.
f. Require staff to wear name tags at all times in the hospital and emergency
room. Restrict entry to the emergency room to authorized persons.
g. Take adequate security measures when transferring a hostile or agitated
patient (or one who may have relatives, friends, or enemies who pose a security
problem) to a unit within the hospital. Security assistance may be required
on the unit until the patient is stabilized or controlled to protect staff
who are providing care.
h. Permit or encourage emergency or hospital staff who have been assaulted
to request police assistance or file charges of assault against any patient
or relative who injures.
3. General Hospitals a. Information regarding security problems or
violent behavior by a patient should be clearly communicated to the unit
where the patient will be transferred from the emergency room or admitting
area. Charts must be flagged, clearly noting and identifying the security
risk involved with this patient.
b. If patients with any disorder or medical condition have a known history
of violent acts, it is incumbent upon the administration to demand that
health care providers or physicians disclose that information to hospital
staff at the onset of hospitalization. Aggressive acts should be recorded
in an obvious place on the patient file.
c. Whenever patients display aggressive or hostile behavior, supervisors
or managers should be notified as well as any staff providing care; then
necessary protective measures must be taken.
d. Post-incident evaluation and treatment should be made available to employees
who have been subjected to abusive behavior from a client/patient, whether
in emergency rooms, psychiatric units, or general hospital settings.
e. Visitors should sign in and receive a pass particularly in a newborn
nursery, pediatric departments, or any other high risk departments.
Any patient with a history of violence should be placed on a "restricted
visitor list." Restricted visitor lists should be maintained and updated
by security, the nurses' station and visitor sign-in areas.
f. Social service staff may help diffuse hostile situations. In-house social
workers, as well as employee health services, may assist staff who have
been assaulted or threatened.
D. HOME/FIELD OPERATIONS/COMMUNITY SERVICE WORKERS
1. Engineering Controls
a. To provide some measure of safety and to keep the employee in contact
with headquarters or a source of assistance, cellular phones should be provided
for official use when staff must go into private homes and the community.
This includes visiting nurses, social service workers, children's service
workers, home health aides, emergency responders, psychiatric evaluators,
or others.
b. All field personnel should carry hand held alarm or noise devices or
other effective alarm devices.
c. Protective devices, such as pepper spray, should be evaluated and provided
if appropriate. Staff should be trained to use such devices safely and appropriately.
2. Administrative Controls
a. Employees should be told not to enter any location where they feel threatened
or unsafe. The employee must make this decision based upon procedures that
have been developed to help them evaluate the relative hazard in a given
situation. Managers should facilitate and establish a "buddy system"
or escort service for hazardous situations. Use of this "buddy system"
or an escort should be required whenever an employee feels insecure regarding
the time of the activity, the location of work, the nature of the client's
health problem, patient or family history of aggressive or assaultive behavior,
or potential for aggressive acts.
b. Field staff should prepare a daily work plan and keep the contact person
informed as to their location throughout the work day. The work plan would
not monitor production but rather enable supervisors to locate the individual
in emergency situations. This reporting system should be consistently adhered
to by both employees and supervisors. Follow-up contacts should be made
whenever an employee does not report in at the end of the day or designated
time.
c. Procedures should be established to reduce the likelihood of assaults
and robbery from those seeking drugs, alcohol, or money, as well as procedures
to follow in the case of threatening behavior. There should also be a response
system in administration offices.
d. All incidents of threats or other aggression must be reported and logged.
Records should be maintained and analyzed to prevent future security and
safety problems and to develop appropriate training courses.
e. Ensure that staff know about agency policy changes and administrative
problems (such as cancelled appointments) which may upset clients and elicit
aggravated responses.
f. Escorts should be used in dangerous or hostile situations or at night.
Procedures for evaluating and arranging for such accompaniment must be developed
and training provided.
g. Employers should provide for the field staff a program of personal safety
education. At a minimum, this could be a safety seminar offered by local
police departments or other agencies. This training should include awareness,
avoidance, and action to take to prevent mugging, robbery, rapes and other
assaults.
h. The employer should respond to incidents of assault promptly and discuss
the circumstances with all staff members. Ways to avoid such problems should
be discussed with staff members with opportunities for them to share information
and experience. This also demonstrates concern for the hazards of field
work.
i. When agencies provide equipment used in the field, including automobiles,
it should be well maintained. Employees should be encouraged to carry only
absolutely required identification and money. They should not leave any
valuables in automobiles and should leave purses at the office or home.
j. When staff must visit clients who are located in high-rise buildings
that seem to present security hazards, they should exercise special care
in elevators, stairwells and unfamiliar residences.
Risks can include alcohol or drug abusing family or friends, or psychotic
individuals. In such situations, and according to the procedures that have
been established, staff should immediately leave the premises. They should
not return unless escorted or until the hazard has been removed. Home health
care services should establish policies including refusal to provide services
in a clearly hazardous situation.
V. TRAINING AND EDUCATION
A. General
Training and education is a major program element in an effective safety
and security program. Training and education ensures that employees know
about potential security hazards and know the measures they should take
to protect themselves and their co-workers. Training should be general as
well as specific. In addition, increased frequency of training can improve
the likelihood of avoiding assault, Carmel & Hunter(1990).
1. A training program should include:
a. All health care and community service staff and other staff members who
may encounter or be subject to abuse or assaults from clients/patients.
b. Facility managers and administrators so that they understand staff requests
for assistance or resources.
2. The program should be designed and implemented by persons qualified by
training and experience.
3. Some options include Management of Assaultive Behavior (MAB), Professional
Assault Response Training (PART), Police Department Assault Avoidance Programs
or Personal Safety Training. Management may use a combination of training
depending on the severity of the risk. Training should be offered on a regular
basis and employees required to attend. Updates may be provided monthly/quarterly
or in large institutions, offered monthly to reach employees more effectively.
4. The program should be presented in the language and at a level of understanding
appropriate for the workers.
5. General training should include an overview of:
a. potential risk of illness and injuries from assault.
b. the causes and early recognition of escalating behavior or recognition
of warning signs or situations which may lead to assaults.
c. means of preventing or diffusing volatile situations
d. safe methods of restraint application or escape.
e. use of other corrective measures or safety devices.
f. methods of self-protection and of protecting co-workers
g. reporting and recordkeeping requirements
6. Clear directives covering:
a. action to be taken by individual staff in violent situations
b. use of restraints
c. progressive behavior control methods
d. availability of assistance
e. responding to alarm systems
f. interaction with hostile relatives of clients and with the public
7. Clear explanation of reporting procedures and the programs for care and
treatment after a violent episode should be included.
8. The training program should also include an evaluation component. Content,
methods and the frequency of training should be reviewed periodically. Program
evaluation may involve supervisor interviews, employee interviews, testing
and observing and/or reviewing reports of behavior of individuals in situations
that are reported to be threatening in nature.
B. Job Specific Training
Employees who are potentially exposed to safety and security hazards should
be given 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, the policy and procedures contained
in the overall safety program of the facility, those hazards unique to the
unit or program, and the methods used by the facility to control the specific
hazards. The training program should review risk factors that cause or contribute
to assaults, etiology of violence and general characteristics of violent
people, methods of controlling aberrant behavior, methods of protection,
reporting procedures and methods to obtain corrective action.
New employees, reassigned workers, or registry staff should receive an initial
orientation and hands-on-training prior to being placed in a treatment unit
or job. This should include a demonstration of alarm systems and protective
devices along with the required maintenance schedules and procedures. The
training should also cover administrative or work practice controls.
1. The specific training program should include:
a. all items in general training program
b. care, use, and maintenance of alarm tools and other protection devices
c. location and operation of alarm systems in facility or unit
d. MAB, PART, or other training specific to type of violence to be encountered
e. communication systems and treatment plans for individual units, disaster
plans for job location
f. policies and procedures for reporting incidents and obtaining medical
care and counseling
g. rights of employees: treatment of injury and counseling programs, legal
assistance and workers' compensation
2. On-the-job training should emphasize:
a. use of safe and efficient work and patient management techniques
b. methods of de-escalating aggressive behavior
c. self- protection techniques
d. methods of communicating information that will help other staff to protect
themselves
e. discussions of rights of employees vis-a-vis patient rights
f. specific measures at each location, such as protective equipment and
location and use of alarm systems
g. determination of when to use the buddy system as needed for safety
3. Joint training of workers from the same unit and shift may facilitate
team work.
C. Training for Supervisors and Managers, Maintenance and Security Personnel
1. Supervisors and managers must ensure that employees are not placed in
assignments that compromise safety and that employees report incidents.
They should be trained in methods and procedures which will reduce the security
hazards. Employees and supervisors should be trained to behave compassionately
towards co-workers when an incident does occur. They need to ensure that
employees follow safe work practices and receive appropriate training to
enable them to do this. Supervisors and managers therefore, should undergo
comparable training plus additional training to enable them to recognize
a potentially hazardous situation or to make any necessary changes in the
physical plant, patient care treatment program, staffing policy and procedures,
etc. They should be able to reinforce the employer's program of safety and
security, and train employees as the need arises.
2. Training for engineers and maintenance workers should cover the general
hazards of violence, the prevention and correction of security problems,
and personal protection devices and techniques. They need to be acutely
aware of how to avoid creating hazards in the process of their work. Their
work should be observed and analyzed to identify possible hazards which
they may cause in the course of performing their duties, as well as hazards
to them from potentially violent patients.
3. Security personnel need to be recruited and trained whenever possible
for the specific job and facility. Security companies usually provide general
training on guard or security issues. However, specific training by the
hospital or clinic should include psychological components of handling aggressive
and abusive clients, types of disorders, and the psychology of handling
aggression and defusing hostile situations.
VI. RECORDKEEPING AND EVALUATION OF THE PROGRAM
A. RECORDKEEPING
Recordkeeping is an essential element of a workplace violence prevention
program. It provides the information that is necessary to conduct risk analyses,
identify training needs and conduct program evaluations. Records should
be kept of the following:
* OSHA 200 log,.if applicable. OSHA regulations require entry on the Injury
and Illness Log of any injury which requires more than first aid, is a lost
time injury, requires modified duty, or causes loss of consciousness. Assaults
should be entered on the log. Doctors' reports of work injury and supervisors'
reports shall be kept of each recorded assault. Fatalities or catastrophes
should be reported to OSHA.
* Records kept concerning assaults should describe the type of activity,
i.e., unprovoked sudden attack, patient to patient altercation; who was
assaulted, and all other circumstances of the incident. The records should
include a description of the environment/ location, potential or actual
cost, lost time, nature of injuries sustained.
* Incidents of abuse, verbal attacks or aggressive behavior which may be
threatening to the worker but not resulting in injury, such as pushing or
shouting. Acts of aggression towards other clients should be recorded. This
record may be an assaultive incident report that can be evaluated routinely
by the department safety committee.
* History of past violence or other factors such as drug abuse and criminal
activity. Such information should be obtained from police or relatives,
if necessary, and recorded on the patient's chart. Employees should be encouraged
to seek and obtain information regarding history of violence whenever possible.
All staff who may provide care for a potentially aggressive, abusive or
violent client should be aware of this information. The frequency of admission
of violent clients should also be documented in a log for usage in conducting
hazard analyses.
* Minutes of safety meetings and inspections. Corrective actions relative
to workplace violence recommended, along with the administration's response
and completion dates of those actions should be included.
* Records of training program contents, i.e., "PART", "MAB"
training. Attendance records and qualifications of trainers should be maintained
along with other records of training.
B. EVALUATION
Employers should develop procedures and mechanisms to evaluate the safety
and security programs and to monitor progress and accomplishments. Top administrators
and medical directors should review the program regularly, preferably semi-annually.
An evaluation program may include some of the following means of gathering
and analyzing information:
* Establishing a uniform reporting system and regular review of reports
* Reviewing reports and minutes of safety and security committee meetings
* Analyzing trends and rates in illness/injury or incident reports with
attention to violence-related injuries, including establishment of initial
or "baseline" rates, if appropriate
* Surveying employees including before and after survey/evaluations of job
or worksite changes or new systems relative to effectiveness of security
measures
* Keeping up-to-date records of job improvements or programs implemented
for violence prevention
* Conducting up-to-date literature reviews
* Evaluating employee experiences with hostile situations and results of
medical treatment programs provided. Follow up should be repeated several
weeks and several months after an incident.
A written progress report and program update can be shared with all responsible
parties and communicated to employees. New or revised goals arising from
the review identifying jobs, activities, procedures and departments should
be shared with all employees. Any deficiencies should be identified and
corrective action taken. Employee safety should receive the same priority
as patient safety as they are often dependent on one another. If it is unsafe
for employees, the same problem will be a source of risk to clients or patients.
Administrators, supervisors, and medical and nursing staff should review
the program frequently to reevaluate goals and objectives and discuss changes.
Regular meetings with all involved including the safety committee, if any,
union representatives and employee groups at risk should be held to discuss
changes in the program.
SUMMARY
Today's working world is sometimes confusing, hostile, and stressful. In
the shrinking job market, employees feel they must prove themselves and
devote more and more time to their careers. Employers struggle to keep companies
productive and successful. Both employers and employees have need to be
reminded that a safe, secure work environment enables both to achieve their
goals.
If we are to provide a secure work environment, administrators, supervisors,
and employees must be confident that hazards from violence will be controlled.
Employees in psychiatric facilities, drug treatment programs, emergency
rooms, convalescent homes, community clinics or community settings should
be provided with a safe and secure work environment where injury from assault
is not accepted or tolerated and is no longer "part of the job."
As many people have said, investing in employee well-being and security
is good business.
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IX. GLOSSARY
Abusive behavior: Actions which result in injury such as slapping, pinching,
pulling hair or other actions such as pulling clothing, spitting, threats
or other fear producing actions such as racial slurs, posturing damage to
property, throwing food or objects.
Assaults: Any aggressive act of hitting, kicking, pushing, biting, scratching,
sexual attack or any other such physical or verbal attacks directed to the
worker by a patient/client, relative or associated individual which arises
during or as a result of the performance of duties and which results in
death, physical or mental injury.
Assaultive incident: An aggressive act or threat by a patient/ client, relative
or associated individual which may cause physical or mental injury, even
of minor nature, requiring first aid or reporting.
Community worker: All employed workers who provide service to the community
in private homes, places of business or other locations which may present
an unsafe or hostile environment, Examples of such workers includes, but
is not limited to psychiatric social worker, home health workers, visiting
or public health nurses, social service workers and home health aides. The
location of the workplace may be mobile or fixed.
In-patient facility: A hospital, convalescent hospital, nursing home, board
and care facility, homeless shelter, developmentally disabled facility,
correction facility or any facility which provides 24-hour staffing and
health care, supervision and protection.
Injury: Physical or emotional harm to an individual resulting in broken
bones, lacerations, bruises and contusions, scratches, bites, breaks in
the skin, strains and sprains, or other pain and discomfort, immediate or
delayed, caused by an interaction with a patient/client or other individual
in the performance of the job.
Management of Assaultive Behavior (MAB): A training program which trains
staff to prevent assaultive incidents and to implement emergency measures
when prevention fails.
Mental harm: Anxiety, fear, depression, inability to perform job functions,
post traumatic stress syndrome, inability to sleep or other manifestations
of adverse emotional reactions to an assault or abusive incident.
Outpatient facility: Any health care facility or clinic, urgent care, community
mental health clinic, drug treatment clinic or other facility which provides
drop-in or other "as needed care" or service to the community
in fixed locations.
Professional Assault Response Training (PART): A training program designed
to provide a systematic approach to recognition and control of escalating
aggressive and assaultive behavior in a patient/client or in other situations.
Psychiatric inpatient facility: Public or private psychiatric inpatient
treatment facilities.
Threat or verbal attack: A serious declaration of intent to harm at the
time or in the future. Any words, racial slurs, gestures or display of weapons
which are perceived by the worker as a clear and real threat to their safety
and which may cause fear, anxiety, or inability to perform job functions.
APPENDIX A.
X. WORKPLACE VIOLENCE CHECKLIST
Periodic inspections to identify and evaluate workplace security hazards
and threats of workplace violence are performed by the following competent
and responsible observer in the following areas of the workplace:
Periodic inspections are performed according to the following schedule:
1. Frequency: regular calendar schedule, every______month;
2. When new, previously unidentified security hazards are recognized;
3. When occupational death, injuries, or threats of injury occur;
4. When Safety, Health and Security Program is established;
5. Whenever workplace security conditions warrant an inspection.
Periodic inspections for security hazards include identification and evaluation
of potential workplace security hazards and changes in employee work practices
which may lead to compromising security. Most workplaces may require assessment
for all three types of work place violence, that is Type I: Criminal or
robbery, Type II, Assault from clients or customers, Type III, Employee,
supervisor or work related abuse. Please use the checklist to identify and
evaluate workplace security hazards.
Evaluation for all types of workplace security hazards include assessing
the following factors. YES answers indicate a potential for serious security
hazard risk.
__ Y ___N, Is this industry frequently targeted for violent behavior, ie.
robbery, assaults on staff?
___Y ___N, Is the area in which the business is located known for regular
occurrences of violence?
___Y ___N, Have violent acts occurred in any way on the premises or in the
conduct of business?
___Y ___N, Do customers or clients assault, threaten, yell, push, or verbally
abuse staff members or use racial or sexual remarks?
___Y ___N, Employees are not required to report incidents or threats of
violence, regardless of injury or severity, to employer?
___Y ___N, Employees have not been trained by employer to recognize and
handle threatening, aggressive, or violent behavior?
___Y ___N, Is violence thought to be "part of the job" by some
managers, supervisors and/or employees? (eg. police, community health workers,
psychiatric hospital workers)
Inspections for Type I workplace security hazards, (retail establishments
or those who might experience robbery or criminal activity) include assessing
the following questions. NO answers indicate areas where corrective action
should be taken if appropriate for the establishment.
___Y ___N, Is the entrance to the building easily seen from the street and
free of heavy shrub growth?
__Y ___N, Are security cameras and mirrors placed in locations that would
deter robbers or provide greater security for employees?
__Y ___N, Are signs posted notifying the public that limited cash, no drugs,
or other valuables are kept on the premises?
__Y ___N, Drop safes or time access safes are utilized.
__Y ___N, Lighting is bright in the parking and adjacent areas.
__Y ___N, There is a second room in which one or more employees may be working
unknown to the attacker.
__Y ___N, Windows and view outside and inside are clear of advertising or
other obstructions.
__Y ___N, The cash register is in plain view of customers, police cruisers,
etc. to deter robberies.
__Y ___N, Employees work with at least one other person.
__Y ___N, The facility is closed during the night or during the high risk
hours of 9pm-6am.
__Y ___N, Emergency telephone numbers for law enforcement, fire and medical
services are posted in areas where employees have access to a telephone
with an outside line.
__Y ___N, Employees have been trained in the proper response during a robbery
or other criminal act.
__Y ___N, Employees have been trained in procedures to use for reporting
suspicious persons or activities.
Inspections for type II workplace security hazards (hospitals, security
guards, police, risk from clients/patients) include assessing the following
factors. NO answers indicate areas where corrective action should be taken
if appropriate for the establishment.
___Y ___N, Access and freedom of movement within the workplace is restricted
to only those who have a legitimate reason for being there.
___Y ___N, The workplace security system is adequate, such asi functioning
door locks, secure windows, physical barriers and containment systems.
___Y ___N, Employees or staff members have never been assaulted,threatened,
or verbally abused by recipients of service.
___Y ___N. Medical and counseling services have been offered to employees
who have been assaulted.
___Y ___N, Alarm systems such as panic alarm buttons, or personal electronic
alarm systems have been installed to provide prompt security assistance
___Y ___N, There is regular training provided on correct response to alarm
sounding.
___Y ___N, Alarm systems are tested on a monthly basis to assure correct
function.
___Y ___N, Security guards are employed at the work place.
___Y ___N, Personal protective devices are provided and must be worn or
used.
___Y ___N, Closed circuit cameras and mirrors are used to monitor dangerous
areas.
___Y ___N, Hand held or other metal detectors are available and used in
the facility.
___Y ___N, Employees have been trained in recognition and control of hostile
behavior, escalating aggressive behavior, and management of assaultive behavior.
___Y ___N, Employees do have the option of adjusting work schedules to use
the "Buddy system" for visits to clients in areas where they feel
threatened.
___Y ___N, Cellular phones or other communication devices are made available
to field staff for requesting aid.
___Y ___N, Vehicles are maintained on a regular basis to insure reliability
and safety.
___Y ___N, Equipment is provided that may add to the security officer's
safety and ability to do the job, such as closed circuit cameras, silent
alarms.
___Y ___N, Employees work with others where assistance is not immediately
present, in detention, in caregiver or other potentially hazardous work
settings?
Inspections for type III workplace security hazards including disgruntled
employees, former employees or acquaintances of employees include assessing
the following factors. NO answers indicate areas where corrective action
should be taken if appropriate for the establishment.
___Y ___N, Employees, supervisors and managers have been effectively informed
about the establishment's anti-violence policy.
___Y ___N, It is known how employees feel about management treatment of
employees or personnel policies.
___Y ___N, Employees, supervisors, and managers have been trained to recognize
warning signs of potential workplace violence.
___Y ___N, Access to and freedom of movement within the workplace by non-employees
is restricted, including persons who have threatened employees.
___Y ___N, Employees are never threatened by supervisors or other employees
with physical or verbal abuse.
___Y ___N, Threats and violent acts, damage, or other signs of strain or
pressure in the workplace are always handled effectively by management,ie;
recorded, investigated, and action taken to correct.
___Y ___N, There is a policy to assure that employee disciplinary and discharge
procedures are handled fairly and effectively, recognizing the employee's
rights, and every effort's made to assist the employee in transition.
___Y ___N, There is an Employee Assistance Program (EAP) or other mental
health assistance provided for employees who may be experiencing personal
problems, who may have exhibited aggressive behavior, or who have made other
employees fearful of being assaulted by the employee.
When you complete this checklist, YES answers on the first seven questions
indicate that there is a serious potential for violence to occur. No answers
in the remainder of the questions indicate areas in which there is a need
to improve on policies or procedures or take corrective action to adequately
prevent violence in the workplace.
Procedures to take to investigate incidents of workplace violence may include:
1. Review all previous incidents involving violence including threats and
verbal abuse.
2. Visit the scene of an incident as soon as possible.
3. Interview the injured or threatened employee and witnesses.
4. Examine the workplace for security risk factors associated with the incident,
including any reports of inappropriate behavior by the perpetrator.
5. Determine the cause(s) of the incident, ie. unlawful entry, unresolved
grievance, alarm system malfunction, barriers not effective, training not
provided etc.
6. Determine locations, people, or activities which pose the highest risk,
eg. persons with a history of violence, stations with close, and possibly
emotional contact with clients, exchange of money, drugs, or isolated services.
7. Take corrective action(s) to prevent the incident from recurring.
8. Record the findings and corrective action taken including medical treatment
or psychological counseling provided.
9. Record in OSHA Log of Injury & Illness if applicable and report to OSHA
if a fatality or catastrophe occurs.
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