Minimizing workplace violence in LTC facilities

The recent U.S. Department of Labor—Occupational Safety and Health Administration (OSHA) National Emphasis Program for Long Term Care and Residential Facilities includes a new compliance challenge for long-term care providers: preventing workplace violence against employees.

In recent years, OSHA has aggressively investigated complaints of workplace violence against healthcare workers, typically in emergency departments and mental health departments of hospitals. In about 25 cases over the past five years, hospital employees lost workdays or were put on restricted duty after being injured by patients and residents. Now, OSHA has expanded this program to include episodes of workplace violence in long-term care. Fortunately, compliance is not as difficult as one might expect.

The common errors that long-term care facilities make, based on OSHA compliance audits, include:

• Failing to create a stand-alone written violence prevention program.
• Failing to ensure that the program addresses specific actions employees should take in the event of an incident and the proper reporting procedures.
• Failing to ensure that staff members trained to deal with aggressive behavior are readily and immediately available to render assistance.
• Failing to ensure that all residents receiving a psychiatric consultation are screened for a potential history of violence.
• Failing to use a system that flags a resident’s chart any time there is a history or act of violence.
• Failing to train staff to understand the resident charting system.
• Failing to put in place administrative controls so that employees are not alone with potentially violent residents in the facility.

OSHA’s definition of workplace violence is simple: "acts of violence or the threat of violence against workers." Using that definition, it is easy to appreciate how simple it will be for OSHA to invoke citations and fines against long-term care facilities. For our clients, we prefer to use a more focused definition: “Workplace Violence is defined as any incident in which an employer or employee is threatened, intimidated, physically or verbally attacked, harassed, injured or killed.” We have adapted this definition for our long-term care clients in order to allow them to appreciate how liberal the OSHA definition is, and to develop a program that is focused on more specific threats and risks.

So how does a long-term care facility prepare itself to deal with the risk, and minimize the risk of an OSHA visit, citation or penalty? First, I encourage all long-term care facilities to follow the steps outlined in OSHA 3148-01R 2004, titled “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.”

Under OSHA 3148, “healthcare facilities” include psychiatric facilities, hospital emergency departments, community mental health clinics, drug abuse treatment clinics, pharmacies, community-care facilities and long-term care facilities. They include physicians, registered nurses, pharmacists, nurse practitioners, physicians’ assistants, nurses’ aides, therapists, technicians, public health nurses, home healthcare workers, social workers, welfare workers and emergency medical care personnel. The guidelines also may be useful in reducing risks for ancillary personnel such as maintenance, dietary, clerical and security staff in the healthcare and social service industries.

A written workplace violence prevention program, incorporated into the facility’s overall health and safety program, is a critical starting point. At a minimum, workplace violence prevention programs should:

• Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions.
• Ensure that managers, supervisors, coworkers, clients, patients, residents, families and visitors know about this policy.
• Ensure that no employee who reports or experiences workplace violence faces reprisals.
• Encourage employees to report incidents promptly and suggest ways to reduce or eliminate risks. Require records of incidents to assess risk and measure progress.
• Outline a comprehensive plan for maintaining security in the workplace. This includes establishing a liaison with law enforcement and others who can help identify ways to prevent and mitigate workplace violence.
• Assign responsibility and authority for the program to individuals or teams with appropriate training and skills. Ensure that adequate resources are available for this effort and that those responsible develop expertise on workplace violence prevention in healthcare and social services.
• Affirm management commitment to a worker-supportive environment that places as much importance on employee safety and health as on serving the resident or client.
• Set up a company briefing as part of the initial effort to address issues such as preserving safety, supporting affected employees and facilitating recovery.

TRAINING

Training and education ensure that all staff are aware of potential security hazards and how to protect themselves and their coworkers through established policies and procedures.

Every employee should understand the concept of “universal precautions for violence”—that is, that violence should be expected but can be avoided or mitigated through preparation. Frequent training also can reduce the likelihood of being assaulted.

The training should cover topics such as:

• The workplace violence prevention policy
• Risk factors that cause or contribute to assaults
• Early recognition of escalating behavior or recognition of warning signs or situations that may lead to assaults
• Ways to prevent or diffuse volatile situations or aggressive behavior, to manage anger and to use medications properly as chemical restraints
• A standard response action plan for violent situations, including the availability of assistance, response to alarm systems and communication procedures
• Ways to deal with hostile people other than residents and clients, such as relatives and visitors
• Progressive behavior control methods and safe methods to apply restraints
• The location and operation of safety devices such as alarm systems, along with the required maintenance schedules and procedures
• Ways to protect oneself and coworkers, including use of the “buddy system”
• Policies and procedures for reporting and recordkeeping
• Information on multicultural diversity to increase staff sensitivity to racial and ethnic issues and differences
• Policies and procedures for obtaining medical care, counseling, workers’ compensation or legal assistance after a violent episode or injury

Every training program should also include an evaluation. At least annually, the team or coordinator responsible for the program should review its content, methods and the frequency of training. Program evaluation may involve supervisor and employee interviews, testing and observing and reviewing reports of behavior of individuals in threatening situations.

RECORDKEEPING AND PROGRAM EVALUATION

Recordkeeping and evaluation of the violence prevention program are necessary to determine its overall effectiveness and identify any deficiencies or changes that should be made. Recordkeeping is essential to the program’s success. Good records help employers determine the severity of the problem, evaluate methods of hazard control and identify training needs.

Records employers should keep:

• OSHA Log of Work-Related Injury and Illness (OSHA Form 300).
• Medical reports of work injury and supervisors’ reports for each recorded assault. These records should describe the type of assault (such as an unprovoked sudden attack), who was assaulted and all other circumstances of the incident.
• Records of incidents of abuse, verbal attacks or aggressive behavior that may be threatening, such as pushing or shouting and acts of aggression toward other clients.
• Information on residents with a history of past violence, drug abuse or criminal activity recorded on the resident’s chart. All staff that care for a potentially aggressive, abusive or violent client should be aware of the person’s background and history. Log the admission of violent residents to help determine potential risks.
• Documentation of discussions at safety committee meetings, records of hazard analyses and corrective actions recommended and taken.
• Records of all training programs, attendees and qualifications of trainers.

The OSHA program for preventing and controlling violence in a long-term care facility is not new; what is new is that OSHA appears poised to begin an aggressive enforcement program against long-term care facilities and against the healthcare industry. Complying with the “guidelines” for preventing workplace violence in the healthcare setting is not difficult if the facility takes an organized approach, is diligent in its efforts and has a qualified resource available for assistance and guidance.

Steve Wilder, BA, CHSP, STS, is President and CEO of Sorensen, Wilder & Associates (SWA), a healthcare safety and security consulting group based in Bourbonnais, IL.  He is the co-author of the book The Essentials of Aggression Management in Healthcare: From Talkdown to Takedown. Steve can be reached at (800) 568-2931 or at swilder@swa4safety.com.

Steve Wilder

Steve Wilder, CHSP, STS, is president and chief operating officer of Sorensen, Wilder & Associates (SWA), a healthcare safety and security consulting group based in Bourbonnais, Ill. SWA performs workplace safety compliance audits and security vulnerability assessments in all types of healthcare facilities. Wilder can be reached at (800) 568-2931 or swilder@swa4safety.com.