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Assaults on health care workers have become a problem of such magnitude in recent years that the U.S. Occupational Safety and Health Administration (OSHA), the National Institute of Occupational Safety and Health (NIOSH), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) all are taking action to help ensure that hospitals are safe environments for workers, patients, and visitors.
Hospital violence is not just a problem for large urban or inner-city institutions. A few years ago in Sandy, UT, a small, quiet community southeast of Salt Lake City, a maternity nurse was shot and killed by a patient’s angry husband, who abducted her and several other nurses from 70-bed Alta View Hospital. (See related story in Hospital Employee Health, November 1993, pp. 149-153.) In fact, a recent report released by the International Association for Healthcare Security and Safety (IAHSS) in Lombard, IL, reveals that while crime in urban/suburban hospitals in 1995 leveled off after a sharp increase reported for 1994, rural hospitals showed a 9% increase in crime in 1995 over 1994.1
Inner-city hospitals continue to lead urban/suburban and rural hospitals in most crime categories, including assault, rape, murder, bomb threats, arson, and theft, the report states. William A. Farnsworth, CHPA, IAHSS president, says the trend toward violence in hospitals mirrors the same trends in communities.
"When communities get more violent, hospital crimes get more violent. The majority of hospital violence is caused by patients on staff. It is increasing, and it is directly reflective of the community in which the hospital is located," he says.
Increasing violence has spurred many hospitals to formulate written policies and take other actions designed to bolster security. Policies should define violence and specify procedures for employees to report violent and threatening incidents, says Farnsworth, who also is director of security for Baptist St. Vincent’s Health System in Jacksonville, FL. In addition, he suggests that all employees be trained to deal with violent situations, and that hospitals appoint "the most professional, knowledgeable person they can find" to evaluate and manage security.
Closer scrutiny by OSHA and the Joint Commission will make hospitals increasingly responsible for protecting workers, patients, and visitors from violence, Farnsworth states. A hospital’s security needs are best determined by an annual risk assessment performed by a security manager and reported to administrators or a board of trustees.
"The trick is to figure out what will work in your particular circumstances," he says. (See editor’s note at end of article for information on health care security consultants.)
To help hospitals determine what will work for them, OSHA last year released guidelines for preventing workplace violence among health care workers.2 The document outlines elements of a violence prevention program, including management commitment and employee involvement, work site analysis, hazard prevention and control, and training and education. It also specifies record keeping and evaluation components.
Assaults on HCWs represent "a serious safety and health hazard," OSHA states, adding that more assaults occur in health care and social services than in any other industry. The agency notes that from 1980 to 1990, 106 occupational violence-related deaths occurred among HCWs. The document also cites figures from a psychiatric hospital study that found nursing staff sustained 16 assaults per 100 employees per year, compared with 8.3 injuries of all types per 100 workers in all industries. Of 121 psychiatric hospital workers sustaining 134 occupational assault-related injuries, 43% involved lost time from work, with 13% of those injured missing more than 21 days of work.2
In addition, incidents of violence in the health care industry likely are underreported, at least partly due to the "persistent perception" among workers that assaults are part of the job, the guidelines state.
The guidelines cover a broad spectrum of HCWs, including physicians, pharmacists, nurses, aides, therapists, technicians, home health care workers, and emergency medical care personnel, as well as ancillary personnel such as dietary, clerical, maintenance, and security staff.
Although the OSHA document is not a formal standard, hospitals could be cited under OSHA’s general duty clause, which states that an employer failed to provide a safe and healthful workplace. However, no violence-related citations have been issued since the guidelines were released, says Patricia D. Biles, OSHA workplace violence coordinator, but that may be due more to the agency’s recent focus on education rather than inspection. In recent years prior to the guidelines, the agency did cite two psychiatric hospitals after patient attacks on staff, but OSHA presently is concentrating on disseminating the document to hospitals and on outreach to concerned groups across the country. (For information on obtaining a copy of the guidelines, see editor’s note at end of article.)
Nevertheless, "appropriate enforcement" will be part of a coordinated effort consisting of research, information, training, and cooperative programs to help health care employers prevent workplace violence, the guidelines state.
"I get a sense that people working in the health care profession are concerned and want to do something to help make a more secure environment for their employees," Biles says. "People want the information to see what they can do."
Health care administrators have become particularly interested since the JCAHO has incorporated much of the guidelines in its updated security standard this year, she adds.
"A lot of hospitals know they’re going to need to do this for accreditation purposes. The Joint Commission’s security standard is much more detailed and inclusive than our guidelines and goes far beyond what OSHA calls for," she says.
To make hospitals safer for employees and the public, the JCAHO is sending hospitals quarterly updates to the accreditation manual. The updates contain specific examples for managing the environment to enhance security, for training employees to recognize the signs of impending violence and take appropriate action to intervene, and for assessing patients’ and visitors’ potential for violence in areas such as the emergency room, says Carole H. Patterson, MN, RN, deputy director of the JCAHO’s department of standards.
Updates are a more appropriate response to the immediacy of the problem because generating new standards takes more time, she notes.
"The statistics that are out there in terms of workplace violence in health care show that this is an indeed an issue," she says. "There’s more violence in the health care workplace than in the general population. We monitor this, and as part of the OSHA educational partnership [see related story in Hospital Employee Health, December 1996, pp. 137-139], we are aware of their guidelines."
JCAHO surveyors already are asking hospitals what they’ve done to help prevent workplace violence, Patterson says. Evidence of a hospital’s performance in this area is found through one or more primary survey methods: interview, observation, visits to patients and families, and documents.
So far, urban hospitals are doing well in taking action against violence, "but they can do better," she states. "The rural hospitals tend to say, Huh?’ It may not be necessary for them to do as much as urban hospitals, but they need to be sensitive to [the potential for violence]. It doesn’t matter if you’re military or a 50-bed hospital out in the middle of Montana; this can happen to you, unfortunately."
Jane Lipscomb, PhD, RN, a NIOSH senior scientist, agrees that no health care setting is immune to violence.
"No work site is free from this. We really need to think about prevention of violence in universal-precautions terms. Hospitals should be aware of this problem and should be addressing it through standard mechanisms, which is what the federal [OSHA] guidelines say. It should be part of an overall safety and health program," says Lipscomb, who in June spoke at the Emergency Health Care Conference in San Francisco on the topic, "Violence in the Workplace: A Growing Crisis Among Health Care Workers."
The problem has yet to be adequately addressed, Lipscomb states. Hospital workplace violence has been recognized as a serious occupational hazard only for about the last five years. Previously it was acknowledged by workers in mental health and psychiatry, but was viewed as merely part of the job. Studies are needed to look at the effects of employee training programs, staffing levels, environmental design, and other interventions.
"Health care workers would benefit from some systematic studies of training, such as crisis intervention, nonviolent response to conflict, and security measures to minimize risk," she says.
In addition, few hospitals have addressed the OSHA guidelines, Lipscomb says. NIOSH, too, approached the problem in a report issued last year, which stated that HCWs are at greatly increased risk of workplace assaults.3 The report lists risk factors and prevention strategies, and suggests that hospital officials design programs that address actual or potential violent incidents. (See related story in Hospital Employee Health, December 1996, pp. 140-142.)
Historically, psychiatric and mental health unit employees were at greatest risk of assault, "but now a lot of those patients are being treated in other units, so employees throughout the hospital are at risk," she notes.
[Editor’s note: To be referred to an expert health care security consultant in your area, contact the IAHSS, P.O. Box 637, Lombard, IL 60148. Telephone: (630) 953-0990.
To obtain a copy of the OSHA guidelines, send a check for $3.75 to the Government Printing Office, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Telephone: (202) 512-1800. Refer to the document by name and order no.: 029-016-00172-7. The guidelines also are available on the World Wide Web at http://www. osha.gov/oshpubs/workplace/.
For a copy of the NIOSH report, contact Publications Dissemination, EID, NIOSH, 4676 Columbia Parkway, Cincinnati, OH 45226-1998. Telephone: (800) 35-NIOSH. E-mail: pubstaft@ niosdt1.em.cdc.gov.]