• Violence Prevention Plan
• Management and Employee Commitment
• Worksite Analysis, Hazard Prevention and Control

• Safety and Health Training
• Post-Incident Response
• Evaluation and Recordkeeping

Exposure to workplace violence because no violence prevention program was in place to help reduce hazards.

OSHA recommends that employers establish and maintain a violence prevention program as part of their facility's safety and health program. The prevention program should:

• Be made available to all employees, including managers and supervisors; and all employees should receive specific training concerning its content and implementation.
  
  
• Track their progress in reducing work-related assaults,
  
  
• reduce the severity of injuries sustained by employees,
  
  
• decrease the threat to worker safety.
  
  
• Reflect the level and nature of threat faced by employees.

The main components that should be included in a facility's Violence Prevention Program are:

• Management Commitment and Employee Involvement:
  
  
  • Demonstrated concern for employee emotional and physical safety and health, incorporated into a written program for safety and security.
  
  
• Worksite Analysis: A step by step common sense look at the workplace to find existing or potential hazards for workplace violence.
  
  
• Hazard Prevention and Control: Implementation of engineering and work practices to prevent and control identified hazards.
  
  
• Safety and Health Training: To make all staff aware of security hazards and how to protect themselves through established policies, procedures and training.
  
  
• Recordkeeping and Evaluation of Program: OSHA required recordkeeping, and evaluation.

Violence Prevention Written Plan: To prevent workplace violence a written program should incorporate the above areas and state clear goals and objectives suitable to the size and complexity of the given workplace.

• Although not every incident can be prevented, many can be, and the severity of injuries sustained by employees reduced by following a violence prevention plan.
  
  
• "Universal Precautions" for violence, states that violence should be expected but can be avoided or mitigated through preparation.

A violence prevention written plan:

• Creates and disseminates a clear policy that violence, verbal and nonverbal threats, and related actions, will not be tolerated.
  
  
• Ensures that no reprisals are taken against employees who report or experience workplace violence.
  
  
• Encourages prompt reporting of all violent incidents and recordkeeping of incidents to assess risk and to measure progress.
  
  
• Establishes a plan for maintaining security in the workplace which includes law enforcement officials and other specialists.
  
  
• OSHA Workplace Violence Awareness Prevention Program provides a:
  
  
  • Sample Violence Prevention Program, which could be used to develop a facility's individual written violence prevention program.

• Violence Occupational Hazards in Hospitals. US Department of Health and Human Services (DHHS), National Institute of Occupational Safety and Health (NIOSH) Publication No. 2002-101, (2002, April). This brochure's purpose 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.

Exposure to workplace violence because of lack of management support and employee involvement.

It is recommended that management and employees work together to reduce workplace violence.

Management Commitment: Provides the motivation and resources to deal effectively with workplace violence and should include: A policy that violence, threats, harassment, intimidations, and other disruptive behavior in our workplace will not be tolerated; that is all reports of incidents will be taken seriously and will be dealt with appropriately. Management should to be committed to:

• Emotional as well as physical health of the employee.
  
  
• Appropriate allocation of authority and resources to responsible parties.
  
  
• Equal commitment to worker safety and health and patient/client safety.
  
  
• A system of accountability for involved managers and employees.
  
  
• A comprehensive program of medical and psychological counseling for employees experiencing or witnessing violent incidents.
  
  
• No employee reprisals for reporting incidents.

Employee Involvement

Employees should:

• Understand, support, and comply with the established workplace violence program.
  
  
• Participate in employee complaint or suggestions sessions.
  
  
• Provide prompt and accurate reporting of all workplace violence incidents.

Employees should understand that:

• Reporting violence will benefit them, and enable management to identify, address, and solve problems.
  
  
• No reprisals will be taken by management or employer.

Employees often do not report violent incidents because:

• Of lack of administrative reporting policies, or procedures.
  
  
• They are afraid employer will think they can't handle the job effectively.
  
  
• Of misperception that violence is part of the job.
  
  
• Of fear of employer reprisals.

Exposure to workplace violence because:

• A worksite analysis was not performed.
  
  
• Potential hazards of the workplace were not identified and addressed.

Complete a worksite analysis: It is recommended that a worksite analysis be completed by an appointed Threat Assessment Team or similar task force, or coordinator. This "team" analyzes records, trends, workplace security, and gives screening surveys to staff to help identify hazards. OSHA has provided the following surveys to assist employers in identifying hazards.

• Sample Workplace Violence Checklist.

Taken from: Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. OSHA Publication No. 3148, (2003), 624 KB PDF, 47 pages.

Identify potential reasons why hospitals may be hazardous, such as:

• The availability of drugs or money in the pharmacy area, making them likely robbery targets.
  
  
• Hospital/healthcare personnel must work evenings and night shifts at facilities hat may be located in high-crime areas.
  
  
• Overall prevalence of firearms.
  
  
• Low staffing levels, high turnover rates, and stress.
  
  
• Hazard of exposure to violent, confused or mentally unstable patients.
  
  
• Dealing with combative, disoriented, uncooperative patients.
  
  
• Mentally unstable patients, that are possibly dangerous.
  
  
• Exposure to workplace violence in rooms not prepared for violent patients:
  
  
  • Moveable furniture that could be used as weapons, or to entrap employees.
    
    
  • Possible items on countertops that could be thrown at workers.

Identify hazard prevention and control: identify hazards found in the worksite analysis and then provide administrative and work practice controls to make hospitals a safer workplace, for example:

	Provide better visibility and good lighting, especially in areas of high risk such as the pharmacy area, or in isolated treatment areas.
	Implement safety measures to deter handguns inside facility; for example using metal detectors.
	Install plexi-glass in the payment window in the pharmacy area.
	Use of security devices such as panic buttons, beepers, surveillance cameras, alarm systems, two-way mirrors, card-key access systems, and security guards.
	Place curved mirrors at hallway intersections or concealed areas.
	Control access to work areas.
	Provide training for staff in recognizing and managing hostile and assaultive behavior.
	Provide adequate staffing even during night shifts. Increase staffing in areas where assaults by patients are likely (e.g., Emergency Department). Increase worker safety during arrival and departure by encouraging car pools and by providing security escorts and shuttle service to and from parking lots and public transportation.
	Ensure accurate reporting of all violent behavior.
	Make patients aware of zero tolerance policy for violence.
	Establish liaison with police authorities and contact them when indicated.
	Obtain previous records of patients to learn of any past violent behaviors.
	Establish a system to chart or track and evaluate possible assaultive behaviors, including a way to pass on information from one shift to another.
	Implement a violence prevention plan to develop strategies to deal with possibly violent patients.

	Has furniture arranged to prevent entrapment of staff, furniture should be minimal, lightweight, without sharp corners, and/or affixed to the floor.
	Is free from clutter, nothing available on countertops to throw at workers or use as weapons.
	Is provided with a secondary door for escape in case main door is blocked by patient.
	Is one entered with a buddy, do not be alone with patient.
Accessibility Assistance: Contact the OSHA Directorate of Science, Technology and Medicine at 202-693-2300 for assistance accessing OSHA PDF materials.

Increased risk of violence because ineffective training of staff to deal with or identify potential violence problems.

It is recommended that facilities have a workplace violence protection program in place that includes training of employees.

• Training is a critical component of any prevention strategy for staff, supervisors and other employees.
  
  
• Training could be conducted by a team of individuals, police force, or others that have specialties in this area.
  
  
• Personally knowing team members responsible for workplace safety programs encourages employees and supervisors to seek assistance from them at a much earlier stage.

Training could include:

• An understanding of the facility's workplace violence policy and program.
  
  
• Encouragement and support to report incidents.
  
  
• Ways of preventing or diffusing volatile situations or aggressive behavior, conflict resolution.
  
  
• The dynamics of violence.
  
  
• How to recognize and deal with hostile aggressive persons, nonviolent responses.
  
  
• Managing anger.
  
  
• Techniques and skills to resolve conflicts.
  
  
• Stress management, relaxation techniques.
  
  
• Security procedures.
  
  
• Personal security measures, self defense.
  
  
• Techniques for victim support.
  
  
• The use of training tools:
  
  
  • Workplace Violence. OSHA.

Health care workers, given inadequate support following a violent incident, may quit or be fearful to go back to work.

It is recommended that employers provide a program of support for workers involved in violent incidents and workers observing violent incidents.

• Set up trained response teams to respond to emergencies, and provide post-incident response assistance to the worker that includes:
  
  
  • Prompt medical treatment and psychological evaluation
    
    
  • Follow-up program in place to offer:
    
    
    • counseling, support groups, stress debriefing, trauma-crisis counseling, employee assistance programs

OSHA provides some sample forms in: Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. OSHA Publication No. 3148, (2003), 624 KB PDF, 47 pages, to assist employers in developing their policies and procedures following a violent incident.

• Assaulted or Battered Employee Policy.
  
  
• Confidential Incident Report Form.
  
  
• Violence Incident Report Form.

Employers not evaluating their violence prevention programs:

• Overall effectiveness of the program is reduced because of inability to identify and correct problems.

No recordkeeping:

• Loss of records and information.
  
  
• Unable to evaluate trends in violence.

Implement adequate evaluation and recordkeeping practices.

Comply with OSHA Recordkeeping Standards:

• The Recordkeeping Rule went into effect January 1, 2002.
• Recordkeeping forms: The OSHA Form 300, Log of Work-Related Injuries and Illnesses has been revised. The forms, which are required for employers to use in recording injuries and illnesses, have changed in several important ways for 2004. The new forms must be in use by January 1, 2004.
• New Recordkeeping Rule. OSHA Fact Sheet, 63 KB PDF, 2 pages.
• A fatality or catastrophe that results in the hospitalization of 3 or more employees must be reported to OSHA within 8 hours.

Recordkeeping is important to the success of a workplace violence prevention program and can:

• Help to identify the severity of the problem, evaluate methods of hazard control and identify training needs.
  
  
• Be useful for gathering or "pooling" data for other applications.

It is recommended that other records be considered such as:

• Medical reports of work injury.
  
  
• Incidents of abuse, (such as verbal abuse, or other acts of aggression, that do not result in injury.
  
  
• Information on patients with a history of past violence should be recorded on the patient's chart, and staff made aware of the possible potential for aggression.
  
  
• Training records.

Evaluation of a facility's violence prevention program is recommended for determining it's effectiveness. The evaluation:

• Identifies any problems or deficiencies that can then be corrected.
  
  
• Allows for management to review program effectiveness, and re-evaluate policies and procedures on a regular basis.
  
  
• Helps management to analyze trends, measure improvements, and keep abreast of new trends to reduce workplace violence.

• 29 CFR 1904, Recording and reporting occupational injuries and illnesses.
• Recordkeeping Policies and Procedures Manual. CPL 02-00-135, (2004, December 30).
• Recordkeeping. OSHA Safety and Health Topics Page.