EMPLOYER RESPONSIBILITIES

Federal and state job safety laws require employers to make reasonable efforts to provide a safe workplace. Employers may be liable for negligence if they fail to exercise ordinary care to avoid potential violence. No federal law explicitly establishes an employer’s duty to prevent or remedy workplace violence against employees. However, the Occupational Safety and Health Act (OSH Act) of 1970 states that employers have a “general duty” to provide a place of employment that is free from recognized hazards causing, or likely to cause, death or serious physical harm, including the prevention and control of workplace violence (USDOL, 1970).

The OSH Act also prohibits employers from retaliating against employees for exercising their rights under the law, including the right to raise a health and safety concern or report an injury. Employers can be cited and fined when incidents of worker illness or injury are attributed to the workplace (USDOL, 1970).

TOLERANCE TOWARD VIOLENCE IN THE HEALTHCARE SETTING

In the healthcare setting, workplace violence has been underreported, ubiquitous, and persistent. It has been tolerated, considered “part of the job,” and often ignored. A serious problem involving violence in the healthcare setting is the lack of support from hospital administrations and the judicial system. Police and prosecutors do not necessarily feel that this is a big issue unless an individual is very severely injured, even though there are felony laws in place. Healthcare workers who report attacks often say that acceptance of and tolerance for violence runs through the hospital administration as well as the judicial system (Docksai, 2023).

OSHA Workplace Safety Standards

The Occupational Safety and Health Administration (OSHA) publishes Safety and Health Program Management Guidelines. OSHA standards are mandatory, enforceable rules that must be followed. OSHA guidelines, however, are voluntary recommendations for compliance with general workplace safety and training initiatives. The guidelines are intended for use by employers that are seeking to provide a safe and healthful workplace through effective workplace violence prevention programs (McKay, n.d.).

OSHA encourages employers to establish violence prevention programs and to track their progress in reducing work-related assaults. Although not every incident can be prevented, many can, and the severity of injuries sustained by employees can be reduced.

OSHA mandates the following employer responsibilities:

  • Provide a workplace free from serious recognized hazards and comply with standards, rules, and regulations.
  • Examine workplace conditions to make sure they conform to applicable OSHA standards.
  • Use codes, posters, labels, or signs to warn employees of potential hazards.
  • Provide safety training in a language and vocabulary that employees can understand.
  • Establish or update operating procedures and communicate them to employees.
  • Employers with hazardous chemicals in the workplace must develop and implement a written hazard communication program and train employees on the hazards they are exposed to and proper precautions.
  • Provide medical examinations and training when required by OSHA standards.
  • Post, at a prominent location within the workplace, the OSHA poster (or the state-plan equivalent) informing employees of their rights and responsibilities.
  • Report to the nearest OSHA office all work-related fatalities within eight hours, and all work-related inpatient hospitalizations, all amputations, and all losses of an eye within 24 hours.
  • Keep records of work-related injuries and illnesses.
  • Provide employees, former employees, and their representatives access to the Log of Work-Related Injuries and Illnesses.
  • Provide access to employee medical records and exposure records to employees or their authorized representatives.
  • Not discriminate against employees who exercise their rights under the Act.
  • Post OSHA citations at or near the work area involved.
  • Correct cited violations by the deadline set in the OSHA citation.
    (OSHA, 2023)

Workplace Violence Prevention Programs

A workplace violence prevention program demonstrates an organization’s concern for employee emotional and physical safety and health. The OSHA recommended guidelines present a step-by-step approach to implementing a safety and health program. The building blocks for developing an effective workplace violence prevention program include:

  • Management commitment
  • Employee participation
  • Worksite analysis
  • Hazard prevention and control
  • Safety and health training
  • Record-keeping and program evaluation
    (OSHA, 2016)

The 2016 guidelines place great emphasis on worker participation and collaboration between managers and workers to find, fix, and prevent incidents.

MANAGEMENT COMMITMENT

Management commitment provides the motivating force for dealing effectively with workplace violence. Policies should be established to clearly communicate that violence, threats, harassment, intimidations, and other disruptive behavior in the workplace will not be tolerated. Another key element of organizational policy is to establish that all reports of incidents will be taken seriously and dealt with appropriately. Management commitment should include:

  • Acknowledging the value of a safe and healthful, violence-free workplace and equal commitment to the safety and health of workers and patients/clients
  • Allocating appropriate authority and resources to all responsible parties
  • Assigning responsibility and authority for the various aspects of the workplace violence prevention program
  • Maintaining a system of accountability for involved managers, supervisors, and health committees
  • Supporting and implementing appropriate recommendations from safety and health committees
  • Establishing a comprehensive program of medical and psychological counseling and debriefing for workers who have experienced or witnessed assaults and other violent incidents and ensuring that trauma-informed care is available
  • Establishing policies that ensure the reporting, recording, and monitoring of incidents and near misses and that no reprisals are made against anyone who does so in good faith
    (OSHA, 2016)

EMPLOYEE INVOLVEMENT

Employee involvement enables workers to develop and express their commitment to safety and health. Employee involvement should include:

  • Participating in the development, implementation, evaluation, and modification of the workplace violence prevention program
  • Participating in safety and health committees that receive reports of violent incidents or security problems, make facility inspections, and respond to recommendations for corrective strategies
  • Providing input on additions to or redesigns of facilities
  • Identifying the daily activities that employees believe put them most at risk for workplace violence
  • Participating in discussions and assessments to improve policies and procedures, including complaint and suggestion programs designed to improve safety and security
  • Being aware of and following employer policies on reporting incidents and near misses
  • Taking proactive approaches to ensure incidents are addressed
  • Actively participating in employee training and continuing education programs
    (OSHA, 2016)

WORKSITE ANALYSIS

A key element of a workplace violence prevention program is the threat assessment team, or safety committee. The primary function of the team is to provide a thorough workplace security/hazard analysis and to establish prevention strategies. An effective team will:

  • Assess the organization’s vulnerability to workplace violence
  • Ensure communication between workers and employers
  • Make recommendations for preventive actions
  • Develop employee training programs in violence prevention
  • Establish a plan for responding to acts of violence
  • Evaluate the overall workplace violence prevention program on a regular basis
    (OSHA, 2016)

Barriers to Implementation of Workplace Violence Prevention Programs

A 2021 qualitative study identified the following barriers to implementation of workplace violence prevention programs.

  • High tolerance of workplace violence among staff
  • High frequency of violent events, resulting in staff failing to report violent incidents
  • A lack of support from law enforcement
  • Lack of information about a history of violent behavior by patients
  • In the emergency department, patients/families who become aggressive to achieve goals, such as avoiding long waits in the waiting room
  • Lack of follow-up
  • Lack of managerial support
    (Thomas et al., 2021)
CASE

Violence Prevention Program

Downtown Free Clinic (DFC) is located in the center of the city and is slated for renovation. This clinic has been a long-time walk-in medical care facility for inner-city residents. DFC is open six days a week from 6 a.m. to 10 p.m. The clinic sees an average of 120 patients per day. The clinic has just been acquired by a large hospital system.

Cynthia works as a nurse manager at DFC and has been selected to represent the clinic as a member of the hospital system’s safety committee. As part of the threat assessment team, her assignment for the upcoming meeting is to lead a workplace violence hazard assessment for the clinic. She has worked at the facility for six years and has never felt threatened, nor has she had any complaints from her staff. She anticipates a quick assessment.

To prepare for the assignment, Cynthia decides to review the hospital’s existing workplace violence prevention plan. The policy statement includes a commitment to zero tolerance for violence in the workplace and further commits all managers and supervisors to implement all aspects of the program, thus ensuring a safe environment for all employees.

Cynthia has been charged with analyzing and reviewing existing records related to assault incidents, inspecting the workplace, and evaluating all work tasks to determine the presence of hazards or situations that may place workers at risk for violent acts. She begins by reviewing the following records for the last three years:

  • OSHA 300 logs (injury and illness recordkeeping forms)
  • Incident reports dealing with assault or near-assault incidents
  • Insurance records
  • Police reports
  • Accident investigations
  • Training records
  • Filed grievances

She finds the following:

  • Several incidents involving verbal threats to receptionists from clinic patrons
  • Ten incidents involving pushing/shoving in the parking lot in which police were called to intervene
  • No staff training records
  • Twenty insurance claims for damages to cars in the parking lot

Cynthia also interviews managers and staff of the clinic, asking about all instances of violence that they may have witnessed over the past six months but which were not reported. Surprised by the number of unreported incidents, Cynthia proceeds to conduct an inspection of the workplace areas assigned to her. She discovers that:

  • Access through the main entrance to the clinic is not controlled; the door is unlocked for all hours of operation.
  • There is no lock on the door between the reception area and the treatment area.
  • The parking lot is not well lit, and unidentified persons often loiter there.
  • There is no method of communication between the reception desk and the treatment area of the clinic.
  • There is no security camera in the parking lot or on the route to it.

Concerned with the hazards from the inspection, she further reviews the tasks of the receptionists and identifies the following concerns:

  • Money is kept behind the main reception desk in an unlocked drawer.
  • One receptionist works alone during the early-morning and late-night hours.
  • The clinic is in a high-crime area.

After careful consideration, Cynthia decides that the building, work area design, and staffing will need to change and that written policies and procedures must be instituted to address the security hazards she has identified. Her initial recommendations to the hospital safety committee include:

  • Improve lighting in the parking lot and main entrance to the clinic.
  • Install security cameras along the route employees take from the clinic to the parking lot.
  • Hire a security guard—minimally for the early-morning and evening hours.
  • Lock the main entrance during early-morning and evening hours.
  • Install a buzzer for patients to use when the door is locked.
  • Secure the door between the reception area and the clinic.
  • Install communication between the clinic area and reception desk.
  • Limit the amount of cash kept in the reception area and remove excess cash on a varying schedule.
  • Review staffing and hours of operation for the reception area and revise as needed.
  • Develop policy, procedures, and training for:
    • Use of security equipment
    • Diffusing hostile or threatening situations
    • Summoning assistance in an emergency
    • Medical follow-up
    • Availability of counseling and referral
    • Incident reporting and investigation
    • Incident recordkeeping

From this exercise, Cynthia was surprised to discover a significant number of incidents involving violence to employees or patients at the clinic. Many of these incidents could have been prevented with an effective violence prevention program. It is reassuring to have the hospital concerned with the safety and health of the employees by committing authority and budgetary resources to the managers and supervisors so that an effective program can be implemented.

EMPLOYEE ASSISTANCE PROGRAMS

An employee assistance program (EAP) is a voluntary, work-based program offering free and confidential assessments, short-term counseling, referrals, and follow-up services to employees with personal and/or work-related problems.

EAPs address a wide range of issues affecting mental and emotional well-being. Services are confidential. EAP counselors also work with managers and supervisors to address employee and organizational challenges and needs. EAPs offer behavioral counseling as well as help in a personal/family crisis or something that affects the workplace or a person’s effectiveness in the workplace (U.S. OPM, n.d.).

Post-Event Response

An institution’s response to incidents of workplace violence should reflect an organizational commitment to overall employee health and safety. After the immediate danger has passed post-incident actions should include:

  • Examining power dynamics from the perspective of the healthcare professionals and the patient
  • Discussing what de-escalation tactics and crisis intervention strategies were used
  • Examining the role of hospital management and security in the event
  • Reviewing the healthcare professional’s perception of administrative support and follow-up care
  • Determining what the healthcare team can learn from the event about prevention and how the event was handled
    (NIOSH, 2020c)
CASE

Post-Event Response

(continued)

The hospital’s safety committee was asked to review an incident in which an angry, intoxicated patient acted out violently in the hospital emergency department following admission by the local police for short-term intervention. As part of their work, the committee was to make recommendations for preventing future occurrences.

The committee evaluated the specific incident as well as the:

  • Physical layout of the emergency department and location of the assessment rooms used for the program
  • Supplies and equipment available in the assessment rooms and how they are stored
  • Security provided at the entrance and within the department
  • Staffing levels
  • Training initially provided to the staff at the start of the program
  • Program policies and procedures
  • Training provided to all hospital staff members on the topic of workplace violence

The committee proposed that a better response to the situation might have included:

  • A police officer present during the intake process to explain to the patient what to expect and how long he would be there and to help determine what kind of security or restraining measures would be necessary
  • A second staff member in the room during the assessment process or called in right away when the patient began to show signs of anger
  • The nurse acknowledging that the patient had questions about why he needed to be there, calmly stating that she will check how things are going, leaving the room quickly to get help, and not attempting to restrain the patient
  • Telling hospital staff members about the circumstances surrounding the case prior to their entering the room and checking with the nurse before going into the room to perform any patient care

It was determined that the hospital had overlooked some of the risks involved with the new program, and they responded quickly to the committee’s suggestions by implementing the following improvements:

  • The assessment room used for this program will be closer to the main desk whenever possible.
  • A second staff member will be present for the initial assessment process.
  • Employees are to use the emergency call button located in each assessment room immediately at the first signs of an agitated patient. This will summon additional personnel and security.
  • Supplies in the assessment rooms are to be stored inside cupboards rather than in loose containers on the countertops.
  • Personnel are to be trained on how to recognize signs of possible violence and how to respond when faced with a variety of potentially dangerous situations.
  • Training will include role-playing and a review of the program policies and procedures. Since there are a low number of admissions to the program, the training is to be provided at least twice per year to help remind staff members of program policies and reinforce how to respond to escalating situations.
  • A debriefing conference will be held after any incident of workplace violence to review what happened, to offer support to the staff members involved, and to determine what can be learned from the incident.

Institutional Initiatives

Although there are no federal standards requiring workplace violence protection, the prevalence of workplace violence in the healthcare sector has prompted studies and organizational initiatives aimed at addressing the problem. Nursing and other healthcare professional organizations and unions are advocating for federal standards and regulations that require healthcare institutions to practice effective violence prevention and response.

The International Association for Healthcare Security and Safety Industry Guidelines and Design Guidelines are intended to assist healthcare administrators in providing a safe and secure environment and support national, state, county, and local requirements. They are also intended to be in agreement with all regulatory, accreditation, and other healthcare professional association requirements (IAHSS, 2022).

In 2015, the American Nurses Association released a position statement calling on healthcare employers to implement violence prevention programs. The statement declared that the nursing profession “will no longer tolerate violence of any kind from any source. Taking this clear and strong position is critical to ensure the safety of patients, nurses, and other healthcare workers.” The statement called on RNs and employers to share responsibility to create a culture of respect and to implement evidence-based strategies (ANA, n.d.).

Effective January 1, 2022, the Joint Commission released new workplace violence standards that provide a framework to guide hospitals and critical access hospitals in defining workplace violence; developing strong workplace violence prevention systems; and developing a leadership structure, policies and procedures, reporting systems, post-incident strategies, training, and education to decrease workplace violence (TJC, 2022).

A CULTURE OF SAFETY

The Joint Commission (2021b) recognizes that uncivil, disrespectful, threatening, and intimidating behaviors in the healthcare environment undermine a culture of safety, increase medical errors, decrease patient satisfaction, increase adverse outcomes, and incur higher costs and loss of qualified staff. The Joint Commission has stated that such behaviors are unprofessional and cannot be tolerated.

The Agency for Healthcare Research and Quality (AHRQ, 2022) also offers recommendations for a culture of safety including fostering beliefs, values, and norms that are shared and supported by administration, management, and staff as well as adopting a zero-tolerance policy for workplace violence.

When surveying for the adequacy of patient safety culture, the following factors should be evaluated:

  • Openness of communication, including incidents and errors
  • Ongoing learning with a goal of continuous improvement
  • Response to errors and events
  • Staffing adequacy
  • Managerial support for patient (and staff) safety
  • Teamwork
  • Work pressure and pace