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Workplace violence prevention: OSHA looks to states for input, models


May 4, 2017

Wrinkles yet-to-be ironed out include disputes over necessity, cost, and definitions

Donna Gross clocked out for a dinner break one Saturday evening in 2010, and she never clocked back in. The 54-year-old psychiatric technician, who had worked for 14 years at Napa State Hospital in California, was found dead in a courtyard at work, strangled by one of her patients. The killer, who later pleaded no contest to a murder charge, had dragged Gross over a wall and stolen jewelry and a small amount of cash.

The case prompted reforms to curb workplace violence not only at the local healthcare facility, but at the state level as well. Last fall, six years after Gross died, regulators within the California Division of Occupational Safety and Health (Cal/OSHA) approved a new rule motivated in large part by her tragic death. The standard, which took effect in April, specifies steps that employers of healthcare professionals must take to develop and enact workplace violence prevention plans. It has been hailed as the first of its kind, and the federal government is now asking whether it should follow California’s lead.

With a nod to Gross’ case, OSHA issued a request for information late last year and began collecting stakeholder feedback regarding whether and how OSHA might implement a nationwide rule. While some questioned the necessity and efficacy of enacting a California-style standard on the federal level, commenters from coast to coast greeted the idea with applause.

“Healthcare facilities are no longer safe havens, and have joined other previously sacrosanct settings such as houses of worship and schools as prime venues for acts of violence,” wrote Bryan Warren, BS, MBA, CHPA, director of corporate security for Carolinas HealthCare System based in Charlotte, North Carolina, in response to OSHA’s request. He urged the administration to call upon the expertise of healthcare security leaders and move forward with its prospective rulemaking process.

“Since the vast majority of the violent incidents and injuries to caregivers are caused by the very persons that we are trying to help, healthcare professionals must be supported in the adoption of strategies to better understand the circumstances and events leading up to these types of behaviors,” Warren said. “A good foundation is the creation of rules and standards with which to better prevent and respond to incidents of workplace violence when they occur.”

The reservations voiced by others, however, signal just how difficult it could be for federal regulators to devise a standard that works for everyone.

Existing policy, law

Although federal OSHA officials praised California’s occupational health and safety standard as trailblazing, they acknowledged that there were already laws on the books in at least nine states—California, Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Oregon, and Washington—mandating some form of workplace violence prevention plan for healthcare facilities. These laws vary widely, each offering its own scope and set of requirements, along with differing definitions of workplace violence. Some point to this patchwork as evidence that a federal rule is needed.

Jeannie K. Tomlinson, MSN, RN, COHN-S, FAAOHN, president of the American Association of Occupational Health Nurses, Inc. (AAOHN), a Chicago-based group with members working in all 50 states, commented that the federal government should not leave policymaking in this area up to individual states because there is no way to guarantee that all of them will make workplace violence prevention a priority.

Available data suggest that healthcare and social assistance workers are far more likely to be injured in an incident of workplace violence than their counterparts in other sectors. In 2014, there were 8.2 injuries related to workplace violence per 10,000 full-time healthcare and social assistance workers—that’s more than quadruple the rate experienced by the private sector overall (which saw 1.7 injuries per 10,000 workers), according to an OSHA analysis of data from the U.S. Bureau of Labor Statistics. Violence rates were highest in psychiatric and substance abuse hospitals, where OSHA found 109.5 intentional injuries per 10,000 full-time workers.

Officials have long been aware of a need to proactively identify and mitigate threats, which is why OSHA published the first version of its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers more than two decades ago. (The latest version, which was updated in 2015, is available online for free: www.osha.gov/Publications/osha3148.pdf.) These voluntary guidelines include recommended policies and procedures to combat workplace violence in a variety of settings by focusing on five core “building blocks”:

  1. Management commitment and employee participation. Although the details will vary by locale, OSHA recommends establishing a joint committee involving managers and employees to address workplace violence or safety topics more generally.
  2. Work site analysis. Certain areas within a hospital will carry greater risks than others. Workers in admission areas, EDs, and behavioral health centers may need more protection than their counterparts elsewhere. A detailed analysis will enable facilities to spot local hazards.
  3. Hazard prevention and control. After identifying local risks, facilities can implement a number of controls to mitigate the threat of violence, including administrative tools (e.g., a zero-tolerance policy on violence), engineering tools (e.g., alarm systems, metal detectors, or physical barriers), PPE (e.g., gloves, sleeves, and blocking mats when caring for patients with certain developmental disabilities), and more innovative strategies.
  4. Safety and health training. Getting all staff members on the same page and keeping them up to date will maximize the efficacy and efficiency of any effort to deter violence.
  5. Recordkeeping and program evaluation. Employers are required to record certain workplace injuries and illnesses in the OSHA 300 Log. This and related documentation can be used to track risks and measure whether interventions are working.

Although federal OSHA guidelines do not specifically require employers to develop workplace violence prevention programs, the administration can issue citations under the General Duty Clause when providers fail to address known hazards. And if inspectors spot workplace violence hazards, but fewer than four of the above criteria are met, they can still issue a warning known as a “hazard alert letter” recommending that the employer voluntarily take steps to improve employee safety.

“The letters describe the specific hazardous conditions identified in an inspection, list corrective actions that can be taken to address them, and provide contact information to seek advice and consultation on addressing the hazards,” the GAO report states.

OSHA issued 48 such workplace violence–related letters from 2012 through May 2015, but the administration was reportedly unable to tell the GAO how many of those letters resulted in follow-up inspections.

James A. Tacci, MD, JD, MPH, FACOEM, FAACPM, president of the American College of Occupational and Environmental Medicine, said the time has come for OSHA to turn its voluntary guidance into an enforceable standard.

“Such a step would serve to level the playing field across the states,” Tacci wrote in a comment. “Evidence for the effectiveness of these standards is beginning to emerge.”

Defining workplace violence

Despite being widely discussed for decades, the phrase “workplace violence” can be slippery, both in its definition on paper and in the real world. That fact was evident in a public comment submitted to OSHA by Stacy Maitha, BS, RN, president of the Indiana Emergency Nurses Association. Maitha was working at IU Health in Bloomington when she stopped a patient care technician in the ED.

“What are you doing, Kelli?” Maitha recalled asking.

“I have to step away for a few minutes from the verbal assault I’m receiving back there,” the tech responded.

“Oh, you get used to it,” Maitha replied flippantly.

The dismissive comment elicited an expression of shock and disbelief from the tech, prompting Maitha to rethink her perspective. She used the story to explain that she had grown somewhat accustomed to having patients spit at, kick, curse at, and threaten her.

“Like most of the people I work with, I have come to expect this behavior from the people we serve in our community hospital,” Maitha said. “But that day, Kelli’s face reminded me that I shouldn’t expect it, and that I absolutely shouldn’t be telling my coworkers to just ‘get used to it.’ ”

Stakeholders generally agree that being intentionally kicked by a patient fits within the definition of workplace violence. But what about cursing and threats? Might a broad definition empower healthcare personnel and policymakers to better identify troubling behavior and trends before they result in injury or death?

Azita Mashayekhi, MHS, staff industrial hygienist for The International Brotherhood of Teamsters, argued in a comment that OSHA should implement a standard that defines “workplace violence” as California’s standard did, including “any act of violence or threat of violence that occurs at the work site,” excluding lawful defensive actions. OSHA’s request for information addressed only the prospect of violence from customers, clients, and patients, but Mashayekhi argued the focus should be expanded to include worker-on-worker violence, incidents stemming from personal relationships, and purely criminal acts (detached from the patient care relationship) as well.

Others, however, cautioned that defining workplace violence too broadly could quickly drown healthcare personnel in paperwork. Melinda Ward, associate CEO and director of support services for the nonprofit OHI, which serves adults with intellectual disabilities and mental illness in central Maine, said OSHA could easily find itself imposing overly burdensome rules, especially if it requires documentation not only of each injury but of every threat as well.

“Providers of services and OSHA could not possibly keep up with that amount of recording without considerable increases in administrative staff to record and follow these incidents,” Ward wrote in a comment.

Even so, proponents of a broader definition include industry heavyweights, like The Joint Commission’s CMS Policy Advisor Matthew Icenroad, who submitted a comment on behalf of the accrediting organization.

“The Joint Commission recommends OSHA include the threat of violence within their definition as these acts may predict future events and assist facilities in assessing their workplace violence prevention plans and objectives,” Icenroad wrote.

To whom should it apply?

Beyond disputes over what, specifically, should constitute workplace violence, there is potential for disagreement over whom a mandatory OSHA standard should apply to.

Andrea P. Thau, OD, president of the American Optometric Association, said it would seem appropriate for OSHA to take “a facilities-based approach” to determine which healthcare professionals must abide by which rules. An emergency room staffer in a high-volume hospital would likely face greater risk than a staffer in an eye doctor’s office, for instance, even if the two workers carry similar titles and qualifications.

“To include in a possible standard all members of a certain occupation, regardless of the unique characteristics of where they work, runs the risk of creating an unnecessary burden in many settings and the possibility of failing to protect low-risk employees in a high-risk setting,” Thau wrote in a comment.

The Joint Commission has advised healthcare employers to assess local risk factors for workplace violence in each facility. But the organization recommends also that OSHA implement standards encompassing “all employees regardless of job and facility/setting,” as Icenroad noted in his comment.

“Threats or actual violent acts may impact any type of healthcare settings, and therefore facilities should develop prevention programs regardless of their location and type of patients served,” Icenroad wrote.

Worth the cost?

South Dakota is among the states without a law mandating workplace violence prevention plans. Even so, most of the 54 hospitals, three large health systems, and 34 postacute care providers with membership in the South Dakota Association of Healthcare Organizations report already having a relevant program or policy in effect on an organizational level, according to Jen Porter, EdD, MBA, the group’s vice president of postacute care.

Association members worry that the cost of complying with a new nationwide standard (rather than continuing to rely on their own policies) could cost more than it’s worth, Porter wrote in a comment.

Michael Van Sickle, CEO of Bethany Lutheran Home, a faith-based residential facility in Council Bluffs, Iowa, argued that adding federal (or even state) regulation on workplace violence prevention would do nothing more than “penalize an employer for an uncontrollable situation.”

“We already have laws for assault that would cover family assaults on healthcare workers. We have laws about domestic violence that would cover family internal struggles. We have laws AND regulations that address patient assaults on caregivers,” Van Sickle wrote in a comment responding to OSHA’s request.


How to comply with the Cal/OSHA model

California’s workplace violence standard, as approved by the Office of Administrative Law, requires that employers establish, implement, and maintain an effective workplace violence prevention plan in writing. The plan must contain 12 things:

  1. Names or job titles of personnel responsible for implementing the plan
  2. Procedures to secure active involvement from employees and their representatives in crafting, using, and revising the plan
  3. Methods to coordinate implementation of the plan and ensure personnel understand their respective roles
  4. Procedures for contacting law enforcement during all shifts, including a policy expressly permitting employees to contact police and local emergency services on their own, without fear of reprisal, if a violent incident occurs
  5. Procedures for the employer to handle reports of workplace violence and prohibit retaliation against employees who file such reports
  6. Procedures to ensure compliance by supervisors and non-supervisors alike
  7. Procedures to communicate with employees regarding proper documentation and communication between shifts and units; ways to report violent threats, incidents, or other concerns without fear of backlash; and means by which concerns will be investigated and investigatory results delivered
  8. Procedures to develop and provide workplace violence prevention training
  9. Procedures to assess environmental risk factors, including community-based factors, for each facility, unit, service, or operation
  10. Procedures to identify risk factors specific to patients and to assess potential risks associated with other non-employers
  11. Procedures to correct workplace violence hazards in a timely manner, taking care of imminent hazards immediately and serious hazards within seven days
  12. Procedures for responding to and investigating violent incidents after the fact, including the provision of immediate medical care, subsequent trauma counseling, and a hindsight assessment of risk reduction efforts

In addition to the plan, employers subject to the California standard must maintain a log of violent incidents, with post-incident responses and investigations. The log, which includes threats of physical force and completed attacks alike, must be considered during an annual review of the plan’s effectiveness.

Incidents involving the use of physical force against an employee that “has a high likelihood of resulting in” injury or psychological trauma, or that actually results in such harm, must be reported to state authorities under the Cal/OSHA standard. The report must be made within 24 hours if the incident involves a firearm or other dangerous weapon, or if it otherwise presents “an urgent or emergent threat to the welfare, health, or safety of hospital personnel,” meaning “a realistic possibility of death or serious physical harm.” All other reports must be made within 72 hours.

The full version of California’s policy, along with other relevant documents, is available for download at www.dir.ca.gov/OSHSB/Workplace-Violence-Prevention-in-Health-Care.html.

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