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VIOLENCE
Occupational
Hazards in Hospitals
DHHS
(NIOSH) Publication No. 2002101
April
2002
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Contents
Ordering
Information
Disclaimer
About
NIOSH
Introduction
What
is workplace violence?
Who
is at risk?
Where
may violence occur?
What
are the effects of violence?
What
are the risk factors for violence?
Prevention
Strategies for Employers
Environmental
Designs
Administrative
Controls
Behavior Modifications
Dealing
With the Consequences of Violence
Safety
Tips for Hospital Workers
Summary
Bibliography
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Disclaimer
This
document is in the public domain and may be freely copied or reprinted.
Mention
of any company or product does not constitute endorsement by NIOSH.
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Ordering
Information
To receive documents
or more information about occupational safety and health topics, contact
the National Institute for Occupational Safety and Health (NIOSH) at
NIOSH-Publications
Dissemination
4676 Columbia Parkway
Cincinnati, OH 45226-1998
Telephone:
1-800-35-NIOSH (1-800-356-4674)
Fax:
513-533-8573
E-mail:
pubstaft@cdc.gov
or visit the NIOSH
Web site at www.cdc.gov/niosh
DHHS
(NIOSH) Publication No. 2002-101
April
2002
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About NIOSH
As
part of the Centers for Disease Control and Prevention (CDC), the National
Institute for Occupational Safety and Health (NIOSH) conducts research
and makes recommendations to prevent work-related illness and injury.
NIOSH works with industries, labor organizations, and universities to
understand and improve worker safety and health.
NIOSH is often
confused with OSHA (the Occupational Safety and Health Administration).
However, NIOSH and OSHA are separate agencies with different functions.
NIOSH is a CDC research agency in the U.S. Department of Health and
Human Services. OSHA is a regulatory agency in the U.S. Department of
Labor.
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Introduction
Today
more than 5 million U.S. hospital workers from many occupations perform
a wide variety of duties. They are exposed to many safety and health
hazards, including violence. Recent data indicate that hospital workers
are at high risk for experiencing violence in the workplace. According
to estimates of the Bureau of Labor Statistics (BLS), 2,637 nonfatal
assaults on hospital workers occurred in 1999-a rate of 8.3 assaults
per 10,000 workers. This rate is much higher than the rate of nonfatal
assaults for all private-sector industries, which is 2 per 10,000 workers.
Several studies
indicate that violence often takes place during times of high activity
and interaction with patients, such as at meal times and during visiting
hours and patient transportation. Assaults may occur when service is
denied, when a patient is involuntarily admitted, or when a health care
worker attempts to set limits on eating, drinking, or tobacco or alcohol
use.
The purpose of
this brochure is to increase worker and employer awareness of the risk
factors for violence in hospitals and to provide strategies for reducing
exposure to these factors.
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What is workplace violence?
Workplace
violence ranges from offensive or threatening language to homicide.
NIOSH defines workplace violence as violent acts (including physical
assaults and threats of assaults) directed toward persons at work or
on duty.
Examples
of violence include the following:
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.
Muggings:
Aggravated assaults, usually conducted by surprise and with intent
to rob.
Case Reports
An elderly
patient verbally abused a nurse and pulled her hair when she prevented
him from leaving the hospital to go home in the middle of the
night.
An
agitated psychotic patient attacked a nurse, broke her arm, and
scratched and bruised her.
A
disturbed family member whose father had died in surgery at the
community hospital walked into the emergency department and fired
a small-caliber handgun, killing a nurse and an emergency medical
technician and wounding the emergency physician.
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These
circumstances of hospital violence differ from the circumstances
of workplace violence in general. In other workplaces such as
convenience stores and taxicabs, violence most often relates to
robbery. Violence in hospitals usually results from patients and
occasionally from their family members who feel frustrated, vulnerable,
and out of control.
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Who is at risk?
Although
anyone working in a hospital may become a victim of violence, nurses
and aides who have the most direct contact with patients are at higher
risk. Other hospital personnel at increased risk of violence include
emergency response personnel, hospital safety officers, and all health
care providers.
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Where may violence occur?
Violence
may occur anywhere in the hospital, but it is most frequent in the following
areas:
- Psychiatric
wards
- Emergency rooms
- Waiting rooms
- Geriatric units
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What are the effects of violence?
The
effects of violence can range in intensity and include the following:
- Minor physical
injuries
- Serious physical
injuries
- Temporary and
permanent physical disability
- Psychological
trauma
- Death
Violence may also
have negative organizational outcomes such as low worker morale, increased
job stress, increased worker turnover, reduced trust of management and
coworkers, and a hostile working environment.
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What are the risk factors for violence?
The
risk factors for violence vary from hospital to hospital depending on
location, size, and type of care. Common risk factors for hospital violence
include the following:
- Working directly
with volatile people, especially, if they are under the influence
of drugs or alcohol or have a history of violence or certain psychotic
diagnoses
- Working when
understaffed-especially during meal times and visiting hours
- Transporting
patients
- Long waits
for service
- Overcrowded,
uncomfortable waiting rooms
- Working alone
- Poor environmental
design
- Inadequate
security
- Lack of staff
training and policies for preventing and managing crises with potentially
volatile patients
- Drug and alcohol
abuse
- Access to firearms
- Unrestricted
movement of the public
- Poorly lit
corridors, rooms, parking lots, and other areas
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Prevention Strategies for Employers
To
prevent violence in hospitals, employers should develop a safety and
health program that includes management commitment, employee participation,
hazard identification, safety and health training, and hazard prevention,
control, and reporting. Employers should evaluate this program periodically.
Although risk factors for violence are specific for each hospital and
its work scenarios, employers can follow general prevention strategies.
Environmental
Designs
- Develop emergency
signaling, alarms, and monitoring systems.
- Install security
devices such as metal detectors to prevent armed persons from entering
the hospital.
- Install other
security devices such as cameras and good lighting in hallways.
- Provide security
escorts to the parking lots at night.
- Design waiting
areas to accommodate and assist visitors and patients who may have
a delay in service.
- Design the
triage area and other public areas to minimize the risk of assault:
- Provide
staff restrooms and emergency exits.
- Install
enclosed nurses' stations.
- Install
deep service counters or bullet-resistant and shatterproof glass
enclosures in reception areas.
- Arrange
furniture and other objects to minimize their use as weapons.
Administrative
Controls
- Design staffing
patterns to prevent personnel from working alone and to minimize patient
waiting time.
- Restrict the
movement of the public in hospitals by card-controlled access.
- Develop a system
for alerting security personnel when violence is threatened.
Behavior
Modifications
- Provide all
workers with training in recognizing and managing assaults, resolving
conflicts, and maintaining hazard awareness.
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Dealing With the Consequences of Violence
Violence
may occur in the workplace in spite of preventive measures. Employers
should be prepared to deal with the consequences of this violence by
providing an environment that promotes open communication and by developing
written procedures for reporting and responding to violence. Employers
should offer and encourage counseling whenever a worker is threatened
or assaulted.
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Safety Tips for Hospital Workers
Watch
for signals that may be associated with impending violence:
- Verbally expressed
anger and frustration
- Body language
such as threatening gestures
- Signs of drug
or alcohol use
- Presence of
a weapon
Maintain
behavior that helps diffuse anger:
- Present a calm,
caring attitude.
- Don't match
the threats.
- Don't give
orders.
- Acknowledge
the person's feelings (for example, "I know you are frustrated").
- Avoid any behavior
that may be interpreted as aggressive (for example, moving rapidly,
getting too close, touching, or speaking loudly).
Be
alert:
- Evaluate each
situation for potential violence when you enter a room or begin to
relate to a patient or visitor.
- Be vigilant
throughout the encounter.
- Don't isolate
yourself with a potentially violent person.
- Always keep
an open path for exiting-don't let the potentially violent person
stand between you and the door.
Take
these steps if you can't defuse the situation quickly:
- Remove yourself
from the situation.
- Call security
for help.
- Report any
violent incidents to your management.
Case
Reports: Prevention Strategies That Have Worked
A security
screening system in a Detroit hospital included stationary metal
detectors supplemented by hand-held units. The system prevented
the entry of
33 handguns, 1,324 knives, and 97 mace-type sprays during a 6-month
period.
A violence
reporting program in the Portland, Oregon, VA Medical Center identified
patients with a history of violence in a computerized database.*
The program helped reduce the number of all violent attacks by
91.6% by alerting staff to take additional safety measures when
serving these patients.
A system
restricting movement of visitors in a New York City hospital used
identification badges and color-coded passes to limit each visitor
to a spe cific floor. The hospital also enforced the limit of
two visitors at a time per patient. Over 18 months, these actions
reduced the number of reported violent crimes by 65%.
_________________
*Health information and the electronic recording of this information
must comply with appliscable Federal standards on privacy under
Titles 42 and 45 of the U.S. Code.
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Summary
All
hospitals should develop a comprehensive violence prevention program.
No universal strategy exists to prevent violence. The risk factors vary
from hospital to hospital and from unit to unit. Hospitals should form
multidisciplinary committees that include direct-care staff as well
as union representatives (if available) to identify risk factors in
specific work scenarios and to develop strategies for reducing them.
All hospital workers
should be alert and cautious when interacting with patients and visitors.
They should actively participate in safety training programs and be
familiar with their employers' policies, procedures, and materials on
violence prevention.
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Bibliography
AMA [1995]. Violence
in the medical workplace: prevention strategies. Chicago, IL: American
Medical Association.
Felton JS [1997].
Violence prevention at the health care site. Occup Med: State of the
Art Reviews 12(4):701-715.
Goodman RA, Jenkins
EL, Mercy JA [1994]. Workplace-related homicide among health care workers
in the United States, 1980 through 1990. JAMA 272(21):1686-1688.
Lipscomb J [1994].
Violence in the health care industry: greater recognition prompting
occupational health and safety interventions. In: Charney W, ed. Essentials
of modern hospital safety. Vol. 3. Boca Raton, FL: Lewis Publishers,
pp. 29-104.
Lipscomb J [1999].
Violence in the workplace: a growing crisis among health care workers.
In: Charney W, Fragala G, eds. The epidemic of health care worker injury.
Boca Raton, FL: CRC Press, pp.163-165.
NIOSH [1996]. Current
intelligence bulletin 57: violence in the workplace; risk factors and
prevention strategies. Cincinnati, OH: U.S. Department of Health and
Human Services, Public Health Service, Centers for Disease Control and
Prevention, National Institute for Occupational Safety and Health, DHHS
(NIOSH) Publication No. 96-100.
OSHA [1996]. Guidelines
for preventing workplace violence for health care and social service
workers. Washington, DC: U.S. Department of Labor, Occupational Safety
and Health Administration, OSHA 3148-1996.
Simonowitz JA [1996].
Health care workers and workplace violence. Occup Med: State of the
Art Reviews 11(2):277-291.
Turner JT, ed.
[1984]. Violence in the medical care setting: a survival guide. Rockville,
MD: Aspen Systems Corporation.
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