RECOGNIZING AND RESPONDING TO WORKPLACE RISK FACTORS

A number of actions can be taken to minimize the risk of violence in the workplace. These precautions acknowledge that violence should be expected but can be avoided or mitigated through preparation, which includes:

  • Paying attention to physical surroundings
  • Trusting personal instincts
  • Presenting a strong, confident image by posture, stride, and eye contact (however, it is important to be aware of different cultures’ perceptions regarding eye contact)
  • Leaving an uncomfortable situation, if possible
  • Avoiding locations that are poorly lit or have poor visibility, if possible
  • Carrying and using a flashlight if the surroundings are poorly lit or when traveling at night
  • Working with a partner or having an effective means of communication, such as a cell phone or pager
  • Using the locks and security systems that are available
  • Reporting security hazards promptly to a supervisor
  • Not using a cell phone or personal music system while on route to or from the workplace
  • Taking a self-defense class or requesting that the facility offer one
  • Dressing for safety
    • Removing anything that can be used as a weapon or grabbed by someone
    • Tucking long hair away
    • Not wearing earrings or necklaces that can be pulled
    • Avoiding overly tight clothing that can restrict movement
    • Avoiding overly loose clothing or scarves that can be grabbed
    • Using breakaway safety cords or lanyards for glasses, keys, or name tags
    (Columbia University, 2023; Vaughn, 2022)

Identifying Risk Factors

Nothing can guarantee that an employee will not become a victim of workplace violence. However, every employee can be aware of the risk factors that contribute to workplace violence and what can be done to avoid it.

RISK FACTORS IN THE HEALTHCARE ENVIRONMENT

Healthcare and social service workers face an increased risk of work-related assaults stemming from several risk factors. These include:

  • Altered mental status of clients due to dementia, delirium, substance intoxication, or decompensated mental illness
  • Lack of community mental health care and increasing numbers of mental health clients discharged without adequate follow-up care
  • Stressful patient conditions, such as long wait times, crowding in the clinical environment, being given upsetting news related to a diagnosis or prognosis
  • Lack of training for security and staff to recognize and de-escalate hostile and assaultive behaviors
  • Unrestricted public access to hospital rooms and clinics
  • Easy movements by clients and visitors in healthcare facilities
  • Providing care for clients in police custody or gang members
  • Domestic disputes among clients or visitors
  • The presence of firearms or other types of weapons
  • Inadequate security and mental health personnel on site
  • Understaffing, especially during times when clients have visitors
  • Staff working in isolation or in situations in which they can be trapped without an escape route
  • Isolated work environments with clients, patients, and families
  • Poor lighting or other factors restricting vision in corridors, rooms, parking lots, and other areas
  • No access to emergency communication, such as a cell phone or call bell
  • Belief that violence is “part of the job”
  • Lack of managerial and/or administrative support
    (CDC, 2020a; TJC, 2021b; Wells, 2022)

RISK FACTORS IN THE PHYSICAL ENVIRONMENT

Early recognition of risk factors calls for enhanced awareness of the security hazards in the physical environment that isolate employees, allow others easy access to buildings and work sites, or place potential weapons within reach.

General workplace security hazards include:

  • Isolated location or job activities
  • Numerous points of entry and exit and uncontrolled access to the building
  • No locks on doors or between work areas
  • Lighting problems, such as dark hallways and parking lots
  • Lack of phones or means of communication between employees
  • Lack of adequate security systems
  • Early-morning or night-time hours of employment
  • Unknown person(s) loitering outside workplace
  • Easy access to potential weapons, such as knives or scissors
    (CDC, 2020a; NIOSH, 2020b)
AREAS MOST AFFECTED BY WORKPLACE VIOLENCE IN HEALTHCARE

Research indicates that nurses and other direct patient care providers are at highest risk of workplace violence. Violence most often occurs in psychiatric wards, emergency rooms, waiting rooms, and geriatric units. Violence is also most likely to occur at the following times:

  • Patient transportation
  • Emergency department stabilization
  • Mealtimes
  • Visiting hours
    (TDI, 2022)

RISK FACTORS IN THE BEHAVIOR OF OTHERS

No one can predict human behavior, and there is no specific profile of a potentially dangerous individual. There are, however, “red flags” that can alert others to a potentially threatening and violent person in the workplace. There are three levels of warning signs, which include:

Level One (early warning signs). The person is:

  • Intimidating/bullying
  • Discourteous/disrespectful
  • Uncooperative
  • Verbally abusive

Level Two (escalation). The person:

  • Argues with customers, vendors, coworkers, and management
  • Refuses to obey facility policies and procedures
  • Sabotages equipment and steals property for revenge
  • Sends threatening note(s) to coworker(s) and/or management
  • Sees self as victimized by management

Level Three (emergency response usually required). The person displays intense anger resulting in:

  • Suicide threats
  • Physical aggression
  • Destruction of property
  • Extreme rage
  • Utilization of weapons to harm others
    (USDOL, n.d.)

(See also “Recognizing and Responding to Workplace Violence” later in this course.)

RISK FACTORS FOR HOME CARE EMPLOYEES

For persons who work in home care, patient’s homes are often in unfamiliar and/or unsafe neighborhoods. Community-based employees must rely on their own resources to deal with abuse and violence, evaluating each situation for possible violence by being alert and watching for signs of impending violent assault. Risk factors for violence against home care workers include:

  • Typically working alone in communities that have varying degrees of violence
  • Decreased control of the work environment
  • Lack of policies and procedures related to workplace violence in the home care setting
  • Insufficient training in ways to deal with workplace violence in the home care setting

Working in any community setting outside a traditional office building increases the risk of coming in contact with potentially violent situations. An estimated 18%–65% of home healthcare workers have experienced verbal abuse from patients, 41% reported sexual harassment, and 25%–44% reported being physically assaulted. These workers may also have to deal with aggressive pets, neighborhoods in violent crime areas, the presence of firearms in the home, and racial/ethnic discrimination. Prevention measures for home care workers include consideration of the following:

  • Participating in training regarding environmental awareness and how to prevent and/or respond to workplace violence
  • Trusting one’s instincts; if circumstances do not feel “right,” seeking a safe location
  • Reporting to supervisory staff when observing or hearing something that is unsafe
  • Preparing a daily work plan/itinerary, including both locations and estimated times of arrival and departure
  • Conducting post-visit assessments, recordkeeping, and evaluations
  • Including an itinerary of anticipated public transport routes if such transport will be used and sharing that itinerary with a supervisor
  • Avoiding traveling alone into unfamiliar locations or situations and/or traveling with another employee or security escort whenever possible
  • Varying travel routes (both in and out of a vehicle) when making repeat visits to a location
  • Maintaining periodic contact with others throughout the day
  • Carrying a fully charged cell phone
  • Using telecommunication devices such as access buttons or voice activation tools on ID badges
  • Carrying minimal money and payment cards and carrying them in a variety of places in clothing and equipment
  • Carrying required identification, also in varied places
  • Recognizing potentially dangerous situations ahead of time and initiating backup
    (Small et al., 2021; Stanlay & Oliveri, 2021)
CASE

Risk Awareness in the Home Care Environment

Janice is working part-time as a home health aide two evenings per week and on weekends. She shares an apartment with two housemates and commutes 30 minutes to Visiting Nurse Care, a home health agency, for work. She is required to check in at the main office before her shift starts to pick up her assignments, attend occasional staff meetings and training sessions, and restock her patient care supplies. She is not required to return to the office at the end of her shift. Rather, she can go home after she finishes with her last client.

Janice attended hazard assessment and safety training when she was hired for the job as a home health aide. The training is repeated on an annual basis for each home care worker at the agency. Janice remembers hearing about a case in a nearby city in which a home health aide was assaulted by an angry family member, and the story has stuck with her. The injured employee was the same age as Janice. She does not need to be talked into attending the training sessions when they are offered.

Janice readily follows the safety protocols that have been established by the home care agency and has added a few of her own.

  • She shares a copy of her scheduled home visits with her supervisor, including the client’s name, phone number, and street address.
  • She takes a few minutes prior to leaving for the first client visit to familiarize herself with the locations she will be visiting and determine if there are known high-risk areas in the vicinity; she plans the routes she will use to travel from one client home to the next, avoiding any potentially dangerous areas.
  • She trusts her instincts, avoiding situations that do not “feel right.”
  • She makes sure her car is in good repair and the gas tank is full. She carries a spare key in her supply bag and hides another one in a purpose-made device on the car’s bumper.
  • She travels with her car doors locked and windows rolled up.
  • She parks in the client’s driveway or in well-lighted areas located as close to the client’s home as possible.
  • She locks her home care supplies and equipment and personal belongings out of sight in the trunk of the car.
  • She carries a cell phone and makes sure the battery is fully charged at the beginning of each shift.
  • She is familiar with the emergency notification system at work and the number to call to request back-up.
  • She arranges to use the buddy system put in place by the agency whenever her instincts tell her it would be a good idea; she has done this for her coworkers and does not hesitate to ask for help for herself.
  • She confirms with her clients ahead of time by telephone so that her arrival is expected.
  • Before getting out of the car, she checks the surrounding area and does not leave the car if she feels uneasy.
  • In the home setting, she sits or stands near the door.
  • She keeps her shoes on; if asked to remove them, she says that it is a health and safety policy that her shoes remain on.
  • She uses diversional tactics to help agitated persons calm down if a threatening situation develops.
  • If she is threatened and unable to gain control of the situation, she leaves immediately and goes to a safe place.
  • She calls 911 if help is needed.
  • She calls one of her roommates at the end of her last client home visit to report where she is and when she will be home.
  • She documents and reports any incidents.

By following these steps, Janice feels comfortable that she is taking the necessary precautions to avoid finding herself in a potentially dangerous situation.

CASE

Responding to Violence in the Home

Zoe is a home health aide working for a private home care agency. She has been assigned six-hour shifts providing care for Eleanor, an elderly woman who experienced a stroke and requires assistance with daily activities. A care plan describes Zoe’s duties, which include bathing, dressing, feeding, toileting, changing bed linens, and straightening Eleanor’s bedroom.

Eleanor’s daughter Kathy has agreed to come to the house regularly to do the laundry and cleaning. She also is going to do Eleanor’s grocery shopping. When Zoe meets Kathy, she quickly becomes aware that Kathy is angry and resentful over having to take care of these things for her mother. As time passes, Kathy begins to complain that she is tired of doing these tasks for her mother and that Zoe is “lazy” and not “worth the money.”

Soon, Kathy tells Zoe she wants her to clean the house and do the laundry. Zoe politely informs Kathy that these duties are not her role in Eleanor’s care plan and that she will not be able to do them. Kathy immediately becomes angry, shouting, “We’ll see about that!” She begins picking up things and throwing them about, yelling that she has had enough of caring for that “old bat.”

With the situation seeming to spiral out of control, Zoe begins moving toward the door. She sees Kathy reach for a knife from the kitchen counter. Zoe quickly runs out the door toward her car, pulling her cell phone from her pocket. Once safely in her car, she calls 911.

When the police arrive, they subdue Kathy and ensure that Eleanor is safe. Kathy is arrested for assault. Zoe calls her supervisor to report what has happened and is told a replacement will be sent right away. Zoe informs the police officer that she is willing to go to the police station to make a statement as soon as her replacement arrives. While waiting, she returns to the home and reassures Eleanor that they are both safe and that she is there to assist her.