AOHP Urges OSHA to Pursue ‘Zero-Tolerance’ Violence Reg
AHA cites current efforts in dismissing need for standard
By Gary Evans, Medical Writer
As the comment period closes and efforts to promulgate a standard to protect healthcare workers against violence begin, OSHA should broaden its approach and take a “zero-tolerance” stance against all forms of assaults and verbal threats, urges the Association of Occupational Health Professionals in Healthcare (AOHP).
“AOHP, too, has been concerned about escalating workplace violence events, as it is all too often viewed as ‘part of the job,’” the association wrote in comments submitted to OSHA. “The definition of workplace violence (WPV) must include both physical acts and threats of harm to the worker. OSHA is proposing that Type II or customer/client/patient violence be addressed in the standard. By focusing only on one type of WPV, employers may not devote the necessary resources to address the other types of [workplace violence], which are also major concerns, albeit with less frequency. … OSHA should advocate for zero-tolerance WPV policies that encompass all types of [workplace violence].”
The American Association of Occupational Health Nurses (AAOHN) echoed this concern, recommending that OSHA expand its definition of workplace violence beyond “physical assault and threat of assault” to include WPV subcategories typically used by hospitals to define patient- and visitor-perpetrated violence, physical assault, physical threat, and verbal abuse.
“OSHA’s proposed definition is anchored in ‘assault’ only, inferring that physical assault is more serious than other forms of Type II violence,” the AAOHN stated. “In many cases, it may be — but this is not absolute. Verbal abuse has been associated with decrease in job satisfaction, depression, anxiety, and leaving the profession. The negative impact of these types of events are worthy of inclusion in the definition and capturing on the OSHA Log or other surveillance method.”
In addition, the AAOHN recommended expanding the definition of workplace violence and broadening inclusion criteria of the OSHA Log for injury and incident reporting.
Similarly, the AOHP also advised OSHA to err on the side of inclusion across jobs and healthcare settings.
“A potential WPV standard should include all types of healthcare and social assistance settings and all types of workers,” the AOHP said. “It would be very difficult to carve out only certain settings or workers, as those of us who work in healthcare are concerned about injuries that occur with all staff. Nurses and nursing assistants/aides are the most commonly injured staff in the acute care setting. However, non-clinical staff may be involved in a WPV event. An example of this would be a housekeeper who inadvertently becomes involved in a WPV event in the emergency department where he/she was working.”
For their part, ED workers face risk of violence that has become more volatile with rampant drug use in some communities, the AOHP said.
“In addition, healthcare workers and clinical providers are now experiencing patient threats with the reduction of opioid prescriptions,” the AOHP noted. “Revised clinical guidelines for pain management and clinical conditions such as back pain are likely to increase these events in provider offices/clinics.”
In addition, prisoners who are brought to acute care facilities for care pose a threat to healthcare workers, as do patients with dementia who may have unexpected violent outbursts.
“There are times in any healthcare setting where a violent situation cannot be anticipated or de-escalated,” the AOHP commented.
Thus, the call for a zero-tolerance policy backed by engaged management.
“Facility leadership must take ownership of the policy and ensure that it is being implemented appropriately,” the AOHP said. “Departmental safety champions who are front-line staff can be trained to work with their managers to support the facility policy to report all WPV and to serve as a staff resource when WPV questions arise. In addition, the safety champions can become staff trainers using the train-the-trainer model.”
All employees should be educated about the organization’s WPV policy at the time of hire, receive additional training if working in an identified high-risk area, and, at a minimum, receive annual training or more frequent training as indicated. Initial training should include a review of the WPV policy (zero tolerance) emphasizing that these acts are not “part of the job,” to whom to report these events, and how to take concerns through the chain of command if not satisfactorily managed by the immediate supervisor, AOHP told OSHA.
After a request for information1 (RFI) about a possible standard, OSHA announced Jan. 10, 2017, that it will promulgate a proposed regulation on healthcare violence. OSHA issued the RFI on Dec. 7, 2016, asking for comments and suggestions on how to best proceed with violence prevention strategies in healthcare. The comment period closed April 6, 2017.
According to OSHA, healthcare workers suffer workplace violence-related injuries at an estimated incidence rate of 8.2 per 10,000 full-time workers, more than four times higher than the rate of 1.7 per 10,000 workers in the private sector overall. Moreover, according to a government watchdog report2 that prompted the OSHA action, the incidence of violence in healthcare is likely underreported because workers fear negative repercussions.
“Healthcare workers in all five of our discussion groups said that they do not report all cases of workplace violence unless they result in a severe injury,” the Government Accountability Office (GAO) noted in its report to Congress. “Healthcare workers in four discussion groups also said that they do not report all cases of workplace violence because the reporting process is too burdensome and because management discouraged reporting. Healthcare workers in two of our discussion groups reported fear of being blamed for causing the attack, losing their job, as well as financial hardships associated with their inability to work due to injury, as reasons for not formally reporting all cases of workplace violence.”
In its comments, the AAOHN echoed the concerns, saying a lack of feedback on the part of hospital management and administration is a barrier to future reporting by workers.
“Workers reported that their formal reports about being victims of WPV went ‘into a black hole,’” the occupational nursing group wrote, citing a recent study.3 “Some indicated that they only heard from management about a report of WPV if they had ‘done something wrong.’ We recommend that the proposed OSHA WPV prevention standard include requirements that employers have a process in place for conducting post-event assessments that involve the workers, as well as management, security, risk management, and occupational safety.”
AHA: Regulation Not Needed
In sharp contrast, the nation’s leading hospital group cited the many anti-violence measures already in place in saying there was no need for a “one-size-fits-all” federal regulation.
“OSHA’s support of research that identifies the effectiveness of best practices for different workplace settings and circumstances and its wide dissemination of information about these effective best practices would do more to ensure the advancement and promotion of workplace safety than its adoption of a ‘one-size-fits-all’ standard for compliance and enforcement,” the American Hospital Association wrote in comments to OSHA. “[T]he establishment of a uniform workplace violence standard for the field guarantees that organizations will use a narrowly focused, and thereby less effective compliance strategy in addressing the problem of workplace violence.”
Most hospitals already have established organization-wide initiatives aimed at addressing workplace violence, the AHA emphasized, citing as evidence its 2016 Hospital Security Survey conducted by the American Society for Healthcare Engineering and Health Facilities Management.
“A majority of hospitals responding (78%) conduct security risk assessment at least annually, with almost half using a combination of in-house and outside security experts to conduct these assessments,” the AHA said. “Workplace violence policies are in place for 97% of respondent facilities, and 95% also have active shooter policies. Moreover, in response to the increasing challenges of maintaining secure environments over the past two years, a majority of hospitals are using aggressive management training as a proactive way to prevent the occurrence of security incidents and to be better prepared to respond effectively should any incident actually arise.”
A critical component of the AHA’s anti-violence initiative includes developing tools and resources to highlight and share with the hospital field programs, the association emphasized. The AHA also cited the increasing number of behavioral health patients showing up in EDs, and the aforementioned violence associated with a national opioid epidemic.
“While we realize that OSHA’s responsibilities and authorities do not extend to making decisions about funding for expanded and improved delivery of behavioral healthcare, the agency could do much to support the field’s efforts to secure necessary funds, expansions, and improvements by sharing relevant data with agencies, members of Congress, and other stakeholders,” the AHA commented. “[There is] continued underfunding of treatment and service delivery for growing numbers of behavioral healthcare and opioid-addicted patients in emergency rooms and other acute care hospital settings.”
To clarify, OSHA has not proposed promulgating a “one-size-fits-all standard,” asking in the RFI, “How, and to what extent, would small entities in your industry be affected by an OSHA standard regulating workplace violence? Are there conditions that make controlling workplace violence more difficult for small entities than for large entities?”
In its comments to the agency, the Joint Commission recommended that OSHA “tailor a standard for smaller entities. For example, home care, ambulatory, and behavioral health providers may have additional challenges in addressing workplace violence. Home care staff are in patient homes and travelling through communities in isolation, making deliveries, providing clinical care and personal support. These staff members are a potential target for violence in patient homes, including risk of theft due to the sensitive materials being carried — for example, medical records, personal information, medical equipment, computers, medications, hypodermic needles, etc. Ambulatory and behavioral healthcare providers may be in small freestanding offices or facilities, or in remote locations with small staffs.”
The Joint Commission Aligns With OSHA
Citing several accreditation standards that apply to workplace violence, The Joint Commission said it “stands ready to assist OSHA in the development of a standard and any other associated guidance.” The Joint Commission recommended reporting verbal threats and including a broad reach of employees and settings covered by a regulation.
“The Joint Commission recommends OSHA ensure any standards that are created do not conflict with existing accreditation standards to help avoid confusion and competing priorities,” the group stated. “[Our] leadership chapter provides an overall framework for engaging leadership in the operations of a healthcare facility. Specifically, organizational leadership who engage in operational activities and embrace a safety culture can help lead the facility to become a high-reliability organization.”
The Joint Commission requires organizations to manage safety and security risks at the facility under the environment of care standard, EC.02.01.01.
“These risks may be identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessment of high-risk processes, and from credible external sources,” The Joint Commission stated. “The Emergency Management standard, EM.01.01.01, requires healthcare organizations to perform a hazard vulnerability analysis (HVA) annually. This HVA is designed for healthcare organizations to engage senior leadership, medical staff, and the community in participating in the planning and development of an Emergency Operations Plan, which may include workplace violence.”
In general, The Joint Commission requires accredited hospitals to take the following actions that could address the threat of violence:
- minimize or eliminate identified safety and security risks in the physical environment;
- maintain all grounds and equipment;
- identify individuals entering its facilities;
- control access to and from areas it identifies as security-sensitive;
- has written procedures to follow in the event of a security incident, including an infant or pediatric abduction.
- OSHA. Prevention of Workplace Violence in Healthcare and Social Assistance. Fed Reg 2016-29197. Dec. 7, 2016: http://bit.ly/2hB5gL5.
- GAO. Workplace Safety and Health: Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence. April 14, 2016: http://bit.ly/1Nzd8Ti.
- Pompeii LA, Schoenfisch AL, Lipscomb HJ, et al. The Management of Patient/Visitor (Type II) Violence by the Hospital Unit Nurse Manager and Staff. EPICOH Chicago, June 2014.
As the comment period closes and efforts to promulgate a standard to protect healthcare workers against violence begin, OSHA should broaden its approach and take a “zero-tolerance” stance against all forms of assaults and verbal threats, urges the Association of Occupational Health Professionals in Healthcare.
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