Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers

Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers

U.S. Department of Labor
Occupational Safety and Health Administration

OSHA 3148
1998
Material contained in this publication is in the public domain and may be reproduced, fully or partially, without permission of the Federal Government. Source credit is requested by not required.

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To The Reader

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Contents

Notice

Acknowledgments

Introduction

OSHA'S Commitment
Extent of Problem
Risk Factors
Overview of Guidelines

Violence Prevention Program Elements

Management Commitment and Employee Involvement
Written Program

Worksite Analysis

Records Analysis and Tracking
Monitoring Trends and Analyzing Incidents
Screening Surveys
Workplace Security Analysis

Hazard Prevention and Control

Engineering Controls and Workplace Adaptation
Administrative and Work Practice Controls
Post-Incident Response

Training and Education

All Employees
Supervisors, Managers, and Security Personnel

Recordkeeping and Evaluation of the Program

Recordkeeping
Evaluation
Sources of Assistance

Conclusion

References

Appendices

A: SHARP Staff Assault Study
B: Workplace Violence Checklist
C: Assaulted and/or Battered Employee Policy
D: Violence Incident Report Forms
E: Sources of OSHA Assistance
F: Suggested Readings

Notice

These guidelines are not a new standard or regulation. They are advisory in nature, informational in content, and are intended for use by employers seeking to provide a safe and healthful workplace through effective workplace violence prevention programs adapted to the needs and resources of each place of employment. The guidelines are not intended to address issues related to patient care. The guidelines are performance-oriented and the implementation of the recommendations will be different based upon an establishment's hazard analysis.

Violence inflicted upon employees may come from many sources -- i.e., patients, third parties such as robbers or muggers -- and may include co-worker violence. These guidelines address only the violence inflicted by patients or clients against staff. It is suggested, however, that workplace violence policies indicate a zero-tolerance for violence of any kind.

The Occupational Safety and Health Act of 1970 (OSH Act)¹ mandates that, in addition to compliance with hazard-specific standards, all employers have a general duty to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. OSHA will rely on Section 5(a) of the OSH Act, the "General Duty Clause,"² for enforcement authority. Employers can be cited for violating the General Duty Clause if there is a recognized hazard of workplace violence in their establishments and they do nothing to prevent or abate it. Failure to implement these guidelines is not in itself a violation of the General Duty Clause of the OSH Act. OSHA will not cite employers who have effectively implemented these guidelines.

Further, when Congress passed the OSH Act, it did so based on a finding that job-related illnesses and injuries were imposing both a hindrance and a substantial burden upon interstate commerce, "in terms of lost production, wage loss, medical expenses, and disability compensation payments."³

At the same time, Congress was mindful of the fact that workers' compensation systems provided state specific remedies for job-related injuries and illnesses. Issues on what constitutes a compensable claim and what the rate of compensation should be were left up to the states, their legislatures, and their courts to determine. Congress acknowledged this point in Section 4(b)(4) of the OSH Act, when it stated categorically: "Nothing in this chapter shall be construed to supersede or in any manner affect any workmen's compensation law . . . ."⁴ Therefore, these non-mandatory guidelines should not be viewed as enlarging or diminishing the scope of work-related injuries and are intended for use in any state and without regard to whether the injuries or fatalities, if any, are later deemed to be compensable.

¹ Public Law 91-596, December 29, 1970; and as amended by P.L. 101-552, Section 3101, November 5, 1990.
² "Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."
³ 29 U.S.C. 651(a).
⁴ 29 U.S.C. 653(b)(4).

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Acknowledgments

Many persons, including health care, social services, and employee assistance experts; researchers, educators; unions, and other stakeholders; OSHA professionals; and the National Institute for Occupational Safety and Health (NIOSH) contributed to these guidelines.

Also, several states have developed relevant standards or recommendations, such as the California OSHA (CAL/OSHA), CAL/OSHA Guidelines for Workplace Security, and Guidelines for Security and Safety of Health Care and Community Service Workers; the Joint Commission on Accreditation of Health Care Organizations, 1995 Accreditation Manuals for Hospitals; Metropolitan Chicago Healthcare Council, Guidelines for Dealing with Violence in Health Care; New Jersey Public Employees Occupational Safety and Health (PEOSH), Guidelines on Measures and Safeguards in Dealing with Violent or Aggressive Behavior in Public Sector Health Care Facilities; and the State of Washington Department of Labor and Industries, Violence in Washington Workplaces, and Study of Assaults on Staff in Washington State Psychiatric Hospitals. Information is available from these and other agencies to assist employers.

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Introduction

For many years, health care and social service workers have faced a significant risk of job-related violence. Assaults represent a serious safety and health hazard for these industries, and violence against their employees continues to increase.

OSHA'S new violence prevention guidelines provide the agency`s recommendations for reducing workplace violence developed following a careful review of workplace violence studies, public and private violence prevention programs, and consultations with and input from stakeholders.

OSHA encourages employers to establish violence prevention programs and to track their progress in reducing work-related assaults. Although not every incident can be prevented, many can, and the severity of injuries sustained by employees reduced. Adopting practical measures such as those outlined here can significantly reduce this serious threat to worker safety.

OSHA'S Commitment

The publication and distribution of these guidelines is OSHA'S first step in assisting health care and social service employers and providers in preventing workplace violence. OSHA plans to conduct a coordinated effort consisting of research, information, training, cooperative programs, and appropriate enforcement to accomplish this goal.

The guidelines are not a new standard or regulation. They are advisory in nature, informational in content, and intended for use by employers in providing a safe and healthful workplace through effective violence prevention programs, adapted to the needs and resources of each place of employment.

Extent of Problem

Today, more assaults occur in the health care and social services industries than in any other. For example, Bureau of Labor Statistics (BLS) data for 1993 showed health care and social service workers having the highest incidence of assault injuries (BLS, 1993). Almost two-thirds of the nonfatal assaults occurred in nursing homes, hospitals, and establishments providing residential care and other social services (Toscano and Weber, 1995).

Assaults against workers in the health professions are not new. According to one study (Goodman et al., 1994), between 1980 and 1990, 106 occupational violence-related deaths occurred among the following health care workers: 27 pharmacists, 26 physicians, 18 registered nurses, 17 nurses' aides, and 18 health care workers in other occupational categories. Using the National Traumatic Occupational Fatality database, the study reported that between 1983 and 1989, there were 69 registered nurses killed at work. Homicide was the leading cause of traumatic occupational death among employees in nursing homes and personal care facilities.

A 1989 report (Cannel and Hunter) found that the nursing staff at a psychiatric hospital sustained 16 assaults per 100 employees per year. This rate, which includes any assault-related injuries, compares with 8.3 injuries of all types per 100 full-time workers in all industries and 14.2 per 100 full-time workers in the construction industry (BLS, 1991). Of 121 psychiatric hospital workers sustaining 134 injuries, 43 percent involved lost time from work with 13 percent of those injured missing more than 21 days from work.

Of greater concern is the likely underreporting of violence and a persistent perception within the health care industry that assaults are part of the job. Underreporting may reflect a lack of institutional reporting policies, employee beliefs that reporting will not benefit them, or employee fears that employers may deem assaults the result of employee negligence or poor job performance.

Risk Factors

Health care and social service workers face an increased risk of work-related assaults stemming from several factors, including:

The prevalence of handguns and other weapons-as high as 25 percent⁵ -- among patients, their families, or friends. The increasing use of hospitals by police and the criminal justice systems for criminal holds and the care of acutely disturbed, violent individuals.
The increasing number of acute and chronically mentally ill patients now being released from hospitals without follow-up care, who now have the right to refuse medicine and who can no longer be hospitalized involuntarily unless they pose an immediate threat to themselves or others.
The availability of drugs or money at hospitals, clinics, and pharmacies, making them likely robbery targets.
Situational and circumstantial factors such as unrestricted. movement of the public in clinics and hospitals; the increasing presence of gang members, drug or alcohol abusers, trauma patients, or distraught family members; long waits in emergency or clinic areas, leading to client frustration over an inability to obtain needed services promptly.
Low staffing levels during times of specific increased activity such as meal times, visiting times, and when staff are transporting patients.
Isolated work with clients during examinations or treatment.
Solo work, often in remote locations, particularly in high-crime settings, with no back-up or means of obtaining assistance such as communication devices or alarm systems.
Lack of training of staff in recognizing and managing escalating hostile and assaultive behavior.
Poorly lighted parking areas.

Overview of Guidelines

In January 1989, OSHA published voluntary, generic safety and health program management guidelines for all employers to use as a foundation for their safety and health programs, which can include a workplace violence prevention programs.⁶ OSHA'S violence prevention guidelines build on the 1989 generic guidelines by identifying common risk factors and describing some feasible solutions. Although not exhaustive, the new workplace violence guidelines include policy recommendations and practical corrective methods to help prevent and mitigate the effects of workplace violence.

The goal is to eliminate or reduce worker exposure to conditions that lead to death or injury from violence by implementing effective security devices and administrative work practices, among other control measures.

The guidelines cover a broad spectrum of workers who provide health care and social services in 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 health care workers, social/welfare workers, and emergency medical care personnel. Further, the guidelines may be usefil in reducing risks for ancillary personnel such as maintenance, dietary, clerical, and security staff employed in the health care and social services industries.

⁵ According to a 1989 report (Wasserberger), 25 percent of major trauma patients treated in the emergency room carried weapons. Attacks in emergency rooms in gang-related shootings as well as planned escapes from police custody have been documented in hospitals. A 1991 report (Goetz et al.) also found that 17.3 percent of psychiatric patients searched were carrying weapons.
⁶ OSHA'S Safety and Health Program Management Guidelines (Fed Reg 54 (16):3904- 3916, January 26, 1989), provide for comprehensive safety and health programs containing these major elements. Employers with such programs can include workplace violence prevention efforts in that context.

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Violence Prevention Program Elements

There are four main components to any effective safety and health program that also apply to preventing workplace violence, (1) management commitment and employee involvement, (2) worksite analysis, (3) hazard prevention and control, and (4) safety and health training.

Management Commitment and Employee Involvement

Management commitment and employee involvement are complementary and essential elements of an effective safety and health program. To ensure an effective program, management and front-line employees must work together, perhaps through a team or committee approach. If employers opt for this strategy, they must be careful to comply with the applicable provisions of the National Labor Relations Act.⁷

Management commitment, including the endorsement and visible involvement of top management, provides the motivation and resources to deal effectively with workplace violence, and should include the following:

Demonstrated organizational concern for employee emotional and physical safety and health.
Equal commitment to worker safety and health and patient/client safety.
Assigned responsibility for the various aspects of the workplace violence prevention program to ensure that all managers, supervisors, and employees understand their obligations.
Appropriate allocation of authority and resources to all responsible parties.
A system of accountability for involved managers, supervisors, and employees.
A comprehensive program of medical and psychological counseling and debriefing for employees experiencing or witnessing assaults and other violent incidents.
Commitment to support and implement appropriate recommendations from safety and health committees.

Employee involvement and feedback enable workers to develop and express their own commitment to safety and health and provide useful information to design, implement, and evaluate the program.

Employee involvement should include the following:

Understanding and complying with the workplace violence prevention program and other safety and security measures.
Participation in an employee complaint or suggestion procedure covering safety and security concerns.
Prompt and accurate reporting of violent incidents.
Participation on safety and health committees or teams that receive reports of violent incidents or security problems, make facility inspections, and respond with recommendations for corrective strategies.
Taking part in a continuing education program that covers techniques to recognize escalating agitation, assaultive behavior, or criminal intent, and discusses appropriate responses.

Written Program

A written program for job safety and security, incorporated into the organization's overall safety and health program, offers an effective approach for larger organizations. In smaller establishments, the program need not be written or heavily documented to be satisfactory. What is needed are clear goals and objectives to prevent workplace violence suitable for the size and complexity of the workplace operation and adaptable to specific situations in each establishment.

The prevention program and startup date must be communicated to all employees. At a minimum, workplace violence prevention programs should do the following:

Create and disseminate a clear policy of zero- tolerance for workplace violence, verbal and nonverbal threats, and related actions. Managers, supervisors, co-workers, clients, patients, and visitors must be advised of this policy.
Ensure that no reprisals are taken against an employee who reports or experiences workplace violence.⁸
Encourage employees to promptly report incidents and to suggest ways to reduce or eliminate risks. Require records of incidents to assess risk and to measure progress.
Outline a comprehensive plan for maintaining security in the workplace, which includes establishing a liaison with law enforcement representatives 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. The written plan should ensure that there are adequate resources available for this effort and that the team or responsible individuals develop expertise on workplace violence prevention in health care 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 patient or client.
Set up a company briefing as part of the initial effort to address such issues as preserving safety, supporting affected employees, and facilitating recovery.

⁷ Title 29 U. S. C., Section 158(a)(2).
⁸ Section 11 (c)(1) of the OSH Act, which also applies to protected activity involving the hazard of workplace violence as it does for other health and safety matters: "No person shall discharge or in any manner discriminate against any employee because such employee has filed any complaint or instituted or caused to be instituted any proceeding under or related to this Act or has testified or is about to testify in any such proceeding or because of the exercise by such employee on behalf of himself or others of any right afforded by this Act."

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Worksite Analysis

Worksite analysis involves a step-by-step, commonsense look at the workplace to find existing or potential hazards for workplace violence. This entails reviewing specific procedures or operations that contribute to hazards and specific locales where hazards may develop.

A "Threat Assessment Team," "Patient Assault Team," similar task force, or coordinator may assess the vulnerability to workplace violence and determine the appropriate preventive actions to be taken. Implementing the workplace violence prevention program then may be assigned to this group. The team should include representatives from senior management, operations, employee assistance, security, occupational safety and health, legal, and human resources staff.

The team or coordinator can review injury and illness records and workers' compensation claims to identify patterns of assaults that could be prevented by workplace adaptation, procedural changes, or employee training. As the team or coordinator identifies appropriate controls, these should be instituted.

The recommended program for worksite analysis includes, but is not limited to, analyzing and tracking records, monitoring trends and analyzing incidents, screening surveys, and analyzing workplace security.

Records Analysis and Tracking

This activity should include reviewing medical, safety, workers' compensation and insurance records -- including the OSHA 200 log, if required -- to pinpoint instances of workplace violence. Scan unit logs and employee and police reports of incidents or near-incidents of assaultive behavior to identify and analyze trends in assaults relative to particular departments, units, job titles, unit activities, work stations, and/or time of day. Tabulate these data to target the frequency and severity of incidents to establish a baseline for measuring improvement.

Monitoring Trends and Analyzing Incidents

Contacting similar local businesses, trade associations, and community and civic groups is one way to learn about their experiences with workplace violence and to help identify trends. Use several years of data, if possible, to trace trends of injuries and incidents of actual or potential workplace violence.

Screening Surveys

One important screening tool is to give employees a questionnaire or survey to get their ideas on the potential for violent incidents and to identify or confirm the need for improved security measures. Detailed baseline screening surveys can help pinpoint tasks that put employees at risk. Periodic surveys -- conducted at least annually or whenever operations change or incidents of workplace violence occur -- help identify new or previously unnoticed risk factors and deficiencies or failures in work practices, procedures, or controls. Also, the surveys help assess the effects of changes in the work processes (see Appendix A for a sample survey used in the State of Washington). The periodic review process should also include feedback and follow up.

Independent reviewers, such as safety and health professionals, law enforcement or security specialists, insurance safety auditors, and other qualified persons may offer advice to strengthen programs. These experts also can provide fresh perspectives to improve a violence prevention program.

Workplace Security Analysis

The team or coordinator should periodically inspect the workplace and evaluate employee tasks to identify hazards, conditions, operations, and situations that could lead to violence.

To find areas requiring further evaluation, the team or coordinator should do the following:

Analyze incidents, including the characteristics of assailants and victims, an account of what happened before and during the incident, and the relevant details of the situation and its outcome. When possible, obtain police reports and recommendations.
Identify jobs or locations with the greatest risk of violence as well as processes and procedures that put employees at risk of assault, including how often and when.
Note high-risk factors such as types of clients or patients (e.g., psychiatric conditions or patients disoriented by drugs, alcohol, or stress); physical risk factors of the building; isolated locations/job activities; lighting problems; lack of phones and other communication devices, areas of easy, unsecured access; and areas with previous security problems. (See sample checklist for assessing hazards in Appendix B.)
Evaluate the effectiveness of existing security measures, including engineering control measures. Determine if risk factors have been reduced or eliminated, and take appropriate action.

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Hazard Prevention and Control

After hazards of violence are identified through the systematic worksite analysis, the next step is to design measures through engineering or administrative and work practices to prevent or control these hazards. If violence does occur, post-incidence response can be an important tool in preventing future incidents.

Engineering Controls and Workplace Adaptation

Engineering controls, for example, remove the hazard from the workplace or create a barrier between the worker and the hazard. There are several measures that can effectively prevent or control workplace hazards, such as those actions presented in the following paragraphs. The selection of any measure, of course, should be based upon the hazards identified in the workplace security analysis of each facility.

Assess any plans for new construction or physical changes to the facility or workplace to eliminate or reduce security hazards.
Install and regularly maintain alarm systems and other security devices, panic buttons, hand-held alarms or noise devices, cellular phones, and private channel radios where risk is apparent or may be anticipated, and arrange for a reliable response system when an alarm is triggered.
Provide metal detectors -- installed or hand-held, where appropriate -- to identify guns, knives, or other weapons, according to the recommendations of security consultants.
Use a closed-circuit video recording for high-risk areas on a 24-hour basis. Public safety is a greater concern than privacy in these situations.
Place curved mirrors at hallway intersections or concealed areas.
Enclose nurses' stations, and install deep service counters or bullet-resistant, shatter-proof glass in reception areas, triage, admitting, or client service rooms.
Provide employee "safe rooms" for use during emergencies.
Establish "time-out" or seclusion areas with high ceilings without grids for patients acting out and establish separate rooms for criminal patients.
Provide client or patient waiting rooms designed to maximize comfort and minimize stress.
Ensure that counseling or patient care rooms have two exits.
Limit access to staff counseling rooms and treatment rooms controlled by using locked doors.
Arrange furniture to prevent entrapment of staff. In interview rooms or crisis treatment areas, furniture should be minimal, lightweight, without sharp comers or edges, and/or affixed to the floor. Limit the number of pictures, vases, ashtrays, or other items that can be used as weapons.
Provide lockable and secure bathrooms for staff members separate from patient-client, and visitor facilities.
Lock all unused doors to limit access, in accordance with local fire codes.
Install bright, effective lighting indoors and outdoors.
Replace burned-out lights, broken windows, and locks.
Keep automobiles, if used in the field, well-maintained. Always lock automobiles.

Administrative and Work Practice Controls

Administrative and work practice controls affect the way jobs or tasks are performed. The following examples illustrate how changes in work practices and administrative procedures can help prevent violent incidents.

State clearly to patients, clients, and employees that violence is not permitted or tolerated.
Establish liaison with local police and state prosecutors. Report all incidents of violence. Provide police with physical layouts of facilities to expedite investigations.
Require employees to report all assaults or threats a supervisor or manager (e.g., can be confidential interview). Keep log books and reports of such incidents to help in determining any necessary actions to prevent further occurrences.
Advise and assist employees, if needed, of company procedures for requesting police assistance or filing charges when assaulted.
Provide management support during emergencies. Respond promptly to all complaints.
Set up a trained response team to respond to emergencies.
Use properly trained security officers, when necessary, to deal with aggressive behavior. Follow written security procedures.
Ensure adequate and properly trained staff for restraining patients or clients.
Provide sensitive and timely information to persons waiting in line or in waiting rooms. Adopt measures to decrease waiting time.
Ensure adequate and qualified staff coverage at all times. Times of greatest risk occur during patient transfers, emergency responses, meal times, and at night. Locales with the greatest risk include admission units and crisis or acute care units. Other risks include admission of patients with a history of violent behavior or gang activity.
Institute a sign-in procedure with passes for visitors, especially in a newborn nursery or pediatric department. Enforce visitor hours and procedures.
Establish a list of "restricted visitors" for patients with a history of violence. Copies should be available at security checkpoints, nurses' stations, and visitor sign-in areas. Review and revise visitor check systems, when necessary. Limit information given to outsiders on hospitalized victims of violence.
Supervise the movement of psychiatric clients and patients throughout the facility.
Control access to facilities other than waiting rooms, particularly drug storage or pharmacy areas.
Prohibit employees from working alone in emergency areas or walk-in clinics, particularly at night or when assistance is unavailable. Employees should never enter seclusion rooms alone.
Establish policies and procedures for secured areas, and emergency evacuations, and for monitoring high-risk patients at night (e.g., open versus locked seclusion).
Ascertain the behavioral history of new and transferred patients to learn about any past violent or assaultive behaviors. Establish a system-such as chart tags, log books, or verbal census reports -- to identify patients and clients with assaultive behavior problems, keeping in mind patient confidentiality and worker safety issues. Update as needed.
Treat and/or interview aggressive or agitated clients in relatively open areas that still maintain privacy and confidentiality (e.g., rooms with removable partitions).
Use case management conferences with co-workers and supervisors to discuss ways to effectively treat potentially violent patients.
Prepare contingency plans to treat clients who are "acting out" or making verbal or physical attacks or threats. Consider using certified employee assistance professionals (CEAPs) or in-house social service or occupational health service staff to help diffuse patient or client anger.
Transfer assaultive clients to "acute care units," "criminal units," or other more restrictive settings.
Make sure that nurses and/or physicians are not alone when performing intimate physical examinations of patients.
Discourage employees from wearing jewelry to help prevent possible strangulation in confrontational situations. Community workers should carry only required identification and money.
Periodically survey the facility to remove tools or possessions left by visitors or maintenance staff which could be used inappropriately by patients.
Provide staff with identification badges, preferably without last names, to readily verify employment.
Discourage employees from carrying keys, pens, or other items that could be used as weapons.
Provide staff members with security escorts to parking areas in evening or late hours. Parking areas should be highly visible, well-lighted, and safely accessible to the building.
Use the "buddy system," especially when personal safety may be threatened. Encourage home health care providers, social service workers, and others to avoid threatening situations. Staff should exercise extra care in elevators, stairwells and unfamiliar residences; immediately leave premises if there is a hazardous situation; or request police escort if needed.
Develop policies and procedures covering home health care providers, such as contracts on how visits will be conducted, the presence of others in the home during the visits, and the refusal to provide services in a clearly hazardous situation.
Establish a daily work plan for field staff to keep a designated contact person informed about workers' whereabouts throughout the workday. If an employee does not report in, the contact person should followup.
Conduct a comprehensive post-incident evaluation, including psychological as-well as medical treatment, for employees who have been subjected to abusive behavior.

Post-Incident Response

Post-incident response and evaluation are essential to an effective violence prevention program. All workplace violence programs should provide comprehensive treatment for victimized employees and employees who may be traumatized by witnessing a workplace violence incident. Injured staff should receive prompt treatment and psychological evaluation whenever an assault takes place, regardless of severity. (See sample hospital policy in Appendix C). Transportation of the injured to medical care should be provided if care is not available on-site.

Victims of workplace violence suffer a variety of consequences in addition to their actual physical injuries. These include short and long-term psychological trauma, fear of returning to work, changes in relationships with co-workers and family, feelings of incompetence, guilt, powerlessness, and fear of criticism by supervisors or managers. Consequently, a strong followup program for these employees will not only help them to deal with these problems but also to help prepare them to confront or prevent future incidents of violence (Flannery, 1991, 1993; 1995).

There are several types of assistance that can be incorporated into the post-incident response. For example, trauma-crisis counseling, critical incident stress debriefing, or employee assistance programs may be provided to assist victims. Certified employee assistance professionals, psychologists, psychiatrists, clinical nurse specialists, or social workers could provide this counseling, or the employer can refer staff victims to an outside specialist. In addition, an employee counseling service, peer counseling, or support groups may be established.

In any case, counselors must be well trained and have a good understanding of the issues and consequences of assaults and other aggressive, violent behavior. Appropriate and promptly rendered post-incident debriefings and counseling reduce acute psychological trauma and general stress levels among victims and witnesses. In addition, such counseling educates staff about workplace violence and positively influences workplace and organizational cultural norms to reduce trauma associated with future incidents.

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Training and Education

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

All Employees

Every employee should understand the concept of "universal Precautions for Violence," i.e., that violence should be expected but can be avoided or mitigated through preparation. Staff should be instructed to limit physical interventions in workplace altercations whenever possible, unless there are adequate numbers of staff or emergency response teams and security personnel available. Frequent training also can improve the likelihood of avoiding assault (Carrnel and Hunter, 1990).

Employees who may face safety and security hazards should receive formal instruction on the specific hazards associated with the unit or job and facility. This includes information on the types of injuries or problems identified in the facility and the methods to control the specific hazards.

The training program should involve all employees, including supervisors and managers. New and reassigned employees should receive an initial orientation prior to being assigned their job duties. Visiting staff, such as physicians, should receive the same training as permanent staff. Qualified trainers should instruct at the comprehension level appropriate for the staff. Effective training programs should involve role playing, simulations, and drills.

Topics may include Management of Assaultive Behavior Professional Assault Response Training; police assault avoidance programs, or personal safety training such as awareness, avoidance, and how to prevent assaults. A combination of training maybe used depending on the severity of the risk.

Required training should be provided to employees annually. In large institutions, refresher programs may be needed more frequently (monthly or quarterly) to effectively reach and inform all employees.

The training should cover topics such as the following:

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 of preventing or diffusing volatile situations or aggressive behavior, managing anger, and appropriately using medications as chemical restraints.
Information on multicultural diversity to develop sensitivity to racial and ethnic issues and differences.
A standard response action plan for violent situations, including availability of assistance, response to alarm systems, and communication procedures.
How to deal with hostile persons other than patients and clients, such as relatives and visitors.
Progressive behavior control methods and safe methods of restraint application or escape.
The location and operation of safety devices such as alarms 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.
Policies and procedures for obtaining medical care, counseling, workers' compensation, or legal assistance after a violent episode or injury.

Supervisors, Managers, and Security Personnel

Supervisors and managers should ensure that employees are not placed in assignments that compromise safety and should encourage employees to report incidents. Employees and supervisors should be trained to behave compassionately towards coworkers when an incident occurs.

They should learn how to reduce security hazards and ensure that employees receive appropriate training. Following training, supervisors and managers should be able to recognize a potentially hazardous situation and to make any necessary changes in the physical plant, patient care treatment program, and staffing policy and procedures to reduce or eliminate the hazards.

Security personnel need specific training from the hospital or clinic, including the psychological components of handling aggressive and abusive clients, types of disorders, and ways to handle aggression and defuse hostile situations.

The training program should also include an evaluation. The content, methods, and frequency of training should be reviewed and evaluated annually by the team or coordinator responsible for implementation. Program evaluation may involve supervisor and/or employee interviews, testing and observing, and/or reviewing reports of behavior of individuals in threatening situations.

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Recordkeeping and Evaluation of the Program

Recordkeeping and evaluation of the violence prevention program are necessary to determine overall effectiveness and identify any deficiencies or changes that should be made.

Recordkeeping

Recordkeeping is essential to the success of a workplace violence prevention program. Good records help employers determine the severity of the problem, evaluate methods of hazard control, and identify training needs. Records can be especially usefid to large organizations and for members of a business group or trade association who "pool" data. Records of injuries, illnesses, accidents, assaults, hazards, corrective actions, patient histories, and training, among others, can help identify problems and solutions for an effective program.

The following records are important:

OSHA Log of Injury and Illness (OSHA 200). OSHA regulations require entry on the Injury and Illness Log of any injury that requires more than first aid, is a lost-time injury, requires modified duty, or causes loss of consciousness.⁹ (This applies only to establishments required to keep OSHA logs.) Injuries caused by assaults, which are otherwise recordable, also must be entered on the log. A fatality or catastrophe that results in the hospitalization of 3 or more employees must be reported to OSHA within 8 hours. This includes those resulting from workplace violence and applies to all establishments.
Medical reports of work injury and supervisors' reports for each recorded assault should be kept. These records should describe the type of assault, i.e., unprovoked sudden attack or patient-to-patient altercation; who was assaulted; and all other circumstances of the incident. The records should include a description of the environment or location, potential or actual cost, lost time, and the nature of injuries sustained.
Incidents of abuse, verbal attacks or aggressive behavior-which may be threatening to the worker but do not result in injury, such as pushing or shouting and acts of aggression towards other clients-should be recorded, perhaps as part of an assaultive incident report. These reports should be evaluated routinely by the affected department. (See sample incident forms in Appendix D ).
Information on patients with a history of past violence, drug abuse, or criminal activity should be recorded on the patient's chart. All staff who care for a potentially aggressive, abusive, or violent client should be aware of their background and history. Admission of violent clients should be logged to help determine potential risks.
Minutes of safety meetings, records of hazard analyses, and corrective actions recommended and taken should be documented.
Records of all training programs, attendees, and qualifications of trainers should be maintained.

Evaluation

As part of their overall program, employers should evaluate their safety and security measures. Top management should review the program regularly, and with each incident, to evaluate program success. Responsible parties (managers, supervisors, and employees) should collectively reevaluate policies and procedures on a regular basis. Deficiencies should be identified and corrective action taken.

An evaluation program should involve the following:

Establishing a uniform violence reporting system and regular review of reports.
Reviewing reports and minutes from staff meetings on safety and security issues.
Analyzing trends and rates in illness/injury or fatalities caused by violence relative to initial or "baseline" rates.
Measuring improvement based on lowering the frequency and severity of workplace violence.
Keeping up-to-date records of administrative and work practice changes to prevent workplace violence to evaluate their effectiveness.
Surveying employees before and after making job or worksite changes or installing security measures or new systems to determine their effectiveness.
Keeping abreast of new strategies available to deal with violence in the health care and social service fields as these develop.
Surveying employees who experience hostile situations about the medical treatment they received initially and, again, several weeks afterward, and then several months later.
Complying with OSHA and state requirements for recording and reporting deaths, injuries, and illnesses.
Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving employee safety.

Management should share workplace violence prevention program evaluation reports with all employees. Any changes in the program should be discussed at regular meetings of the safety committee, union representatives, or other employee groups.

Sources of Assistance

Employers who would like assistance in implementing an appropriate workplace violence prevention program can turn to the OSHA Consultation service provided in their state. Primarily targeted at smaller companies, the consultation service is provided at no charge to the employer and is independent of OSHA'S enforcement activity. (See Appendix E.)

OSHA'S efforts to assist employers combat workplace violence are complemented by those of NIOSH (1-800-35 -NIOSH) and public safety officials, trade associations, unions, insurers, human resource, and employee assistance professionals as well as other interested groups. Employers and employees may contact these groups for additional advice and information.

⁹ The Occupational Safety and Health Act and recordkeeping regulations in Title 29 Code of Federal Regulations (CFR), Part 1904 provide specific recording requirements that comprise the framework of the occupational safety and health recording system (BLS, 1986a). BLS has issued guidelines that provide official Agency interpretations concerning the recordkeeping and reporting of occupational injuries and illnesses (BLS, 1986b).

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Conclusion

OSHA recognizes the importance of effective safety and health program management in providing safe and healthful workplaces. In fact, OSHA'S consultation services help employers establish and maintain safe and healthful workplaces, and the agency's Voluntary Protection Programs were specifically established to recognize worksites with exemplary safety and health programs. (See Appendix E.) Effective safety and health programs are known to improve both morale and productivity and reduce workers' compensation costs.

OSHA'S violence prevention guidelines are an essential component to workplace safety and health programs. OSHA believes that the performance-oriented approach of the guidelines provides employers with flexibility in their efforts to maintain safe and healthful working conditions.

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References

California State Department of Industrial Relations. (1995). CAL/OSHA Guidelines for Workplace Security. Division of Occupational Safety and Health, San Francisco, CA.

Carmel, H.; Hunter, M. (1989). "Staff Injuries from Inpatient Violence." Hosp Commty Psych 40(1):41-46.

Fox, S.; Freeman, C.; Barr, B. et al. (1994). "Identifying Reported Cases of Workplace Violence in Federal Agencies," Unpublished Report, Washington DC.

Goodman, R.; Jenkins, L; and Mercy, J. (1994). Workplace-Related Homicide Among Health Care Workers in the United States, 1980 through 1990." JAMA 272(21): 1686-1688.

Goetz, R.; Bloom, J.; Chene, S.; et al. (1981). "Weapons Possessed by Patients in a University Emergency Department." Ann Emerg Med 20(1 ): 8-10.

Liss, G. (1993). Examination of Workers' Compensation Claims Among Nurses in Ontario for Injuries Due to Violence. Health and Safety Studies Unit, Ontario Ministry of Labour.

Novello, A. (1992). "A Medical Response to Violence." JAMA 267:3007.

Oregon State Department of Consumer and Business Services. (1994). "Violence in the Workplace, Oregon, 1988 to 1992-A Special Study of Worker's Compensation Claims Caused by Violent Acts." Information Management Division, Salem, OR.

Ryan, J.; Poster, E. (1989a). "The Assaulted Nurse: Short-term and Long-term Responses." Arch Psychiat Nursing 3(6): 323-331.

Simonowitz, J. (1993). Guidelines for Security and Safety of Health Care and Community Service Workers. Division of Occupational Safety and Health. Department of Industrial Relations, San Francisco, CA.

State of Washington, Department of Labor and Industries. (1993). Study of Assaults on Staff in Washington State Psychiatric Hospitals.

___________(1995). Violence in Washington Workplaces, 1992.

Toscano, Guy; and Weber, William. (1995). Violence in the Workplace. Bureau of Labor Statistics. Washington, DC. Table 11.

U.S. Department of Justice, (1986)Criminal Victimization in the U.S. 1984. A National Crime Survey Report. Pub. No. NCJ-1OO435. Washington D.C.

U.S. Department of Labor, Bureau of Labor Statistics. (1995). Census of Fatal Occupational Injuries, 1994. News Bulletin 95-288.

___________(1991). Occupational Injuries and Illnesses in the United States by Industry, 1989. Bulletin 2379.

___________(1986a). A Brief Guide to Recordkeeping Requirements for Occupational Injuries and Illness, 29 CFR 1904. 19Pp.

___________(1986b). Recordkeeping Guidelines for Occupational Injuries and Illnesses. April 1986. 84Pp.

Wasserberger, J.; Ordog, G.; Kolodny, M. et al. (1989). "Violence in a Community Emergency Room." Arch Emer Med 6:266-269.

Wolfgang, M. (1986). "Homicide in Other Industrialized Countries." Bull NYAcad Med 62:400.

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Appendix A: SHARP Staff Assault Study

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence.

ID Number ___________________

I. Priorities

A number of factors maybe important in preventing assaults, or reducing the impact of assaults. We would like to know your views on what the most important factors are. For these questions, please use the following definition of assault: Physical contact that results in injury. (Injury may be major or minor; e.g., mild soreness, scratches, or bruises would be included.)

1. What do you think is the most important factor contributing to assaults on staff at Eastern and Western State Hospitals?

2. A number of factors have been suggested as possibly important in determining whether assaults occur, or the impact of assaults. Please indicate which factors you think are most important. Please indicate only your top five priorities. In other words, many of the following areas maybe important, but we are interested in which are most important. Please place a "1" next to the issue that you think is the top priority, and a "2" next to the issue that you think is the next highest priority, and so forth. If you have no opinion or don't know, please check "Don't know."

____ a. Staff training in self-defense/restraint procedures

____ b. Staff clinical and interpersonal skills

____ c. Staff fitness

____ d. An effective security alarm system

____ e. Adequate numbers of personnel

____ f. Hospital practices (e.g., handling patients' money)

____ g. Physical environment (e.g., noise)

____ h. Identifying patients with a history of assaults

____ i. Identifying patients with potentialy assaultive (e.g., agitated) behavior

____ j. Transfer of information at shift change about potentially assaultive patients

____ k. Procedures for transporting patients

____ l. Procedures for reporting assaults to administrators

____ m. Procedures for evaluating staff who have been involved in assaults

____ n. Procedures for reporting assaults to police

____ o. Legal penalties for competent assaultive patients

____ p. Structured psychological support for assaulted staff

____ q. Timeliness of L&I processing of Worker's Compensation claims

____ r. Fairness of L&I processing of Worker's Compensation claims

____ s. Timeliness of DSHS processing of Assault Pay claims

____ t. Fairness of DSHS processing of Assault Pay claims

____ u. Other _______________________________

____ v. Don't know

3. In which of the following areas do you think it is most important to make improvements at your hospital? Again, please indicate your top five priorities by placing a "1" next to the area you think is most important, a "2" next to the area you think is next most important, and so forth. If you have no opinion or don't know, please check "Don't know."

____ a. Staff training in self-defense/restraint procedures

____ b. Staff clinical and interpersonal skills

____ c. Staff fitness

____ d. An effective security alarm system

____ e. Adequate numbers of personnel

____ f. Hospital practices (e.g., handling patients' money)

____ g. Physical environment (e.g., noise)

____ h. Identifying patients with a history of assaultive behavior

____ i. Identifying patients with potentialy assaultive (e.g., agitated) behavior

____ j. Transfer of information at shift change about potentially assaultive patients

____ k. Procedures for transporting patients

____ l. Procedures for reporting assaults to administrators

____ m. Procedures for evaluating staff who have been involved in assaults

____ n. Procedures for reporting assaults to police

____ o. Legal penalties for competent assaultive patients

____ p. Structured psychological support for assaulted staff

____ q. Timeliness of L&I processing of Worker's Compensation claims

____ r. Fairness of L&I processing of Worker's Compensation claims

____ s. Timeliness of DSHS processing of Assault Pay claims

____ t. Fairness of DSHS processing of Assault Pay claims

____ u. Other ________

____ v. Don't know

4. Comments:

II. Training

5. Please indicate below which of the following types of training you have received during your employment at Eastern/Western. Also, for each type of training you have received, please indicate (on the scale of 1 -5) how helpful that training was to you.

a. Initial Training/Orientation	received	not at all very don't helpful helpful know 1 2 3 4 5
» Interpersonal communication	Yes No
» Assessing potential assaultiveness	Yes No
» Verbal de-escalation	Yes No
» Self-defense	Yes No
» Containment/restraint procedures	Yes No
b. Formal Training Updates	received	not at all very don't helpful helpful know 1 2 3 4 5
» Interpersonal communication	Yes No
» Assessing potential assaultiveness	Yes No
» Verbal de-escalation	Yes No
» Self-defense	Yes No
» Containment/restraint procedures	Yes No
c. Informal (on-the-job) training	received	not at all very don't helpful helpful know 1 2 3 4 5
» Interpersonal communication	Yes No
» Assessing potential assaultiveness	Yes No
» Verbal de-escalation	Yes No
» Self-defense	Yes No
» Containment/restraint procedures	Yes No

6. When was your most recent formal training in the management of assaultive patients?

Please list month and year: ____________

7. Comments:

III. Staffing

8. Please indicate how important you think it is to make improvements at your hospital in the following areas:

	not at all very important important 1 2 3 4 5
a. Adequate numbers of licensed nursing personnel (RNs & LPNs)
b. Adequate numbers of mental health technicians (MHTs & PSAS)
c. Adequate numbers of physicians
d. Adequate numbers of staff for afternoon & night shifts

9. Comments:

IV. Alarm Security Systems

10. In your opinion, what are the most important features of a security alarm system (an alarm system for calling for help in the event of an assault?) In other words, many of the features listed below maybe very important. Please indicate the five most important features by placing a " 1" next to the feature that you think is most important, and a "2" next to the feature that you think is the next most important, etc. If you have no opinion or don't know, check "Don't know."

____ a. Convenient to carry with you	____ f. In a room accessible only to staff (e.g., nursing station)
____ b. Works both indoors and outdoors	____ g. Identifies your location
____ c. Easy to activate	____ h. Brings immediate response
____ d. Sounds audible alarm	____ i. Operates reliably
____ e. Don't know	____ j. Other

11. Comments:

V. Health and Safety Committee

12. Do you know what role the joint labor-management Health and Safety Committee plays at your hospital, in general?

13. Do you know what role the joint labor-management Health and Safety Committee plays at your hospital, specifically with regard to staff assaults?

14. Do you know the name of at least one labor representative on the Health and Safety Committee?

15. Comments:

VI. Hospital Practices

16. In your opinion, which of the following practices are most likely to contribute to staff/patient disagreements of the type that may lead to assaults? Please indicate the five most important practices by placing a "1" next to the practice that you think is most likely to contribute to assaults, and a "2" next to the practice you think is next most likely to contribute to assaults, etc. If you have no opinion or don't know, check "Don't know."

Practices for handling:

____ a. Patients' money	____ i. Medication
____ b. Patients' sexual behavior	____ j. Programming (activities scheduled)
____ c. Vists with clinical staff	____ k. Scheduling activities (e.g., flexibility)
____ d. Seclusion and restraint	____ l. Transfers between wards
____ e. Visits from outside hospital	____ m. Dates of discharge
____ f. Patients' daytime access to own bedrooms	____ n. Access to outdoors/exercise
____ g. Smoking	____ o. Providing information about rules
____ h. Privacy	____ p. Diagnostic interviews
____ Don't know	____ q. Other

17. Comments:

VII. Physical Environment

18. In your opinion, which of the following aspects of the physical environment are most likely to contribute to assaults? Please indicate the five most important aspects by placing a "1" next to the aspect of the environment that you think is most likely to contribute to assaults, and a "2" next to the aspect you think is next most likely to contribute to assaults, etc. If you have no opinion or don't know, check "Don't know."

____ a. Noise levels	____ e. Overcrowding
____ b. Temperature levels	____ f. Cleanliness
____ c. Food	____ g. Privacy
____ d. Lighting	____ h. Other
____ Don't know

19. Comments:

VIII. Dangerous Situations

20. Please indicate whether any of the following situations have happened to you.

a. Only employee on ward
Has this ever happened?	Yes No
Does it happen frequently?	Yes No
b. Not within hearing of other employees
Has this ever happened?	Yes No
Does it happen frequently?	Yes No
c. Not within sight of other employees
Has this ever happened?	Yes No
Does it happen frequently?	Yes No

21. Comments:

IX. Job Satisfaction

All in all, how satisfied are you with your job?

Not at all satisfied
Not too satisfied
Somewhat satisfied
Very satisfied

How strongly would you recommend your job to someone else?

Not at all strongly
Not too strongly
Somewhat strongly
Very strongly

If you were looking for a job now, how likely is it that you would decide to take this job again?

Not at all likely
Not too likely
Somewhat likely
Very likely

To what extent is your supervisor willing to listen to your work-related problems?

Not at all willing
Not too willing
Somewhat willing
Very willing

How satisfied are you with:	not too satisfied 2	very satisfied 4

26. The way supervisors treat workers?

27. The way work policies are put into practice?

28. The competence of your supervisors?

29. The praise you get for doing a good job?

30. How satisfied are you that you can turn to fellow workers for help when something is troubling you?

31. How satisfied are you with the way your fellow workers respond to your emotions, such as anger, sorrow or laughter?

32. How satisfied are you that your fellow workers accept and support your new ideas or thoughts?

How often are you physically exhausted after work?

Never
Seldom
Often
Always

How often are you mentally exhausted after work?

Never
Seldom
Often
Always

Overall, how would you rate your health at the present time?

Poor
Fair
Good
Very Good
Excellent

How would you rate your health compared to other persons your age?

Poor
Fair
Good
Very Good
Excellent

X. Assault Experiences

37. Patients may be aggressive toward staff in a number of ways, some more serious than others. We are interested in how many times you personally have experienced each of the following forms of aggression by patients at your hospital. Please indicate the number of times you have experienced each form of aggression, within the last year or ever. Please use the following rating scale:

O = never 1 = once 2=2-5 times 3 = more than five times

Within the past 12 months:

_____ a. threat of assault but no physical contact

_____ b. physical contact but no physical injury

_____ c. mild soreness/surface abrasion/scratches/small bruises

_____ d. major soreness/cuts/large bruises

_____ e. severe laceration/fracture/head injury

_____ f. loss of limb/permanent physical disability

During your employment at this hospital:

_____ a. threat of assault but no physical contact

_____ b. physical contact but no physical injury

_____ c. mild soreness/surface abrasion/scratches/small bruises

_____ d. major soreness/cuts/large bruises

_____ e. severe laceratiordfracture/head injury

_____ f. loss of limb/permanent physical disability

38. If you have been assaulted, please answer the following questions. (If you have been assaulted more than once, please consider the most recent assault.)

a. When did the assault occur? (Please provide the approximate date) __________

b. What happened? Please describe the assault briefly (who assaulted you, what triggered the assault, what they did, whether they used a weapon, what happened after the assault.)

c. What could have prevented the assault or reduced your injuries?

d. Did you call for help in some way? Please describe. Did help arrive quickly?

e. Were you able to apply the training you had received? Please describe. If not, why not?

f. Please indicate whether you did each of the following:

Report the incident on daily ward report?	Yes No
If you didn't report the incident, why not?


Report the incident on Incident report?	Yes No
If you didn't report the incident, why not?


g. As you may know, Industrial Insurance (Workers' Compensation) claims are handled by the Dept. of Labor & Industries, and Assault Pay claims are handled by the Dept. of Social & Health Services. Please indicate what your experiences were regarding this assault. 1. Did you apply for Workers' Compensation benefits from L&I? Yes No 2. If yes, how satisfied were you with the service you received from L&I regarding your claim?

not at all         very     don't
satisfied        satisfied know
   1    2    3    4    5

Timeliness

Fairness

3. Did you apply for Assault Pay from DSHS?

4. If yes, how satisfied were you with the service you received from DSHS regarding your claim?

not at all         very     don't
satisfied        satisfied know
   1    2    3    4    5

Timeliness

Fairness

h. Comments:

XI. Respondent Information

39. What is your job classification?

40. In which area do you work?

Geriatric (GPU)

Legal offenders (LOU)

Other

41. How long have you worked at Eastern/Western? ______ years ______ months

XII. Comments

42. Are there other issues that you think are important? If so, please describe (feel free to use the back of this sheet as well.)

Source: Reprinted with permission of Lillian Bensley, Ph.D.; Nancy Nelson, Ph.D., M.P.H.; Joel Kaufman, M.D., M.P.H.; Barbara Silverstein, Ph.D., M.P.H.; and John Kalat, B. S., Washington State Department of Labor and Industries.

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Appendix B: Workplace Violence Checklist

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence.

This checklist helps identify present or potential workplace violence problems. Employers also maybe aware of other serious hazards not listed here.

Designated competent and responsible observers can readily make periodic inspections to identify and evaluate workplace security hazards and threats of workplace violence. These inspections should be scheduled on a regular basis; when new, previously unidentified security hazards are recognized; when occupational deaths, injuries, or threats of injury OCCW, when a safety, health and security program is established and whenever workplace security conditions warrant an inspection.

Periodic inspections for security hazards include identifying and evaluating potential workplace security hazards and changes in employee work practices which may lead to compromising security. Please use the following checklist to identify and evaluate workplace security hazards. TRUE notations indicate a potential risk for serious security hazards:

_____ T _____ F	This industry frequently confronts violent behavior and assaults of staff.
_____ T _____ F	Violence occurs regularly where this facility is located.
_____ T _____ F	Violence has occurred on the premises or in conducting business.
_____ T _____ F	Customers, clients, or coworkers assault, threaten, yell, push, or verbally abuse employees or use racial or sexual remarks.
_____ T _____ F	Employees are NOT required to report incidents or threats of violence, regardless of injury or severity, to employer.
_____ T _____ F	Employees have NOT been trained by the employer to recognize and handle threatening, aggressive, or violent behavior.
_____ T _____ F	Violence is accepted as "part of the job" by some managers, supervisors, and/or employees.
_____ T _____ F	Access and freedom of movement within the workplace are NOT restricted to those persons who have a legitimate reason for being there.
_____ T _____ F	The workplace security system is inadequate -- i.e., door locks malfunction, windows are not secure, and there are no physical barriers or containment systems.
_____ T _____ F	Employees or staff members have been assaulted, threatened, or verbally abused by clients and patients.
_____ T _____ F	Medical and counseling services have NOT been offered to employees who have been assaulted.
_____ T _____ F	Alarm systems such as panic alarm buttons, silent alarms, or personal electronic alarm systems are NOT being used for prompt security assistance.
_____ T _____ F	There is no regular training provided on correct response to alarm sounding.
_____ T _____ F	Alarm systems are NOT tested on a monthly basis to assure correct function.
_____ T _____ F	Security guards are NOT employed at the workplace.
_____ T _____ F	Closed circuit cameras and mirrors are NOT used to monitor dangerous areas.
_____ T _____ F	Metal detectors are NOT available or NOT used in the facility.
_____ T _____ F	Employees have NOT been trained to recognize and control hostile and escalating aggressive behaviors, and to manage assaultive behavior.
_____ T _____ F	Employees CANNOT adjust work schedules to use the "Buddy system" for visits to clients in areas where they feel threatened.
_____ T _____ F	Cellular phones or other communication devices are NOT made available to field staff to enable them to request aid.
_____ T _____ F	Vehicles are NOT maintained on a regular basis to ensure reliability and safety.
_____ T _____ F	Employees work where assistance is NOT quickly available.

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Appendix C: Assaulted and/or Battered Employee Policy

Hospital Memorandum
#118.13, June 30, 1994

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence.

I. Purpose:
To establish a formalized procedure to ensure that resources are available to provide support to all hospital employees who have recently been assaulted and/or battered.

II. Policy:
Each employee who is assaulted and/or battered will have access to treatment and services to manage the trauma.

III. Implementation:

A. Definition:
Assaulted employee: Any employee who is reasonably put in fear of being imminently struck by a patient, either by a menacing gesture, sudden move alone, or accompanied by a threat.
Battered employee: Any employee who experiences actual physical contact from another (whether or not a physical injury occurred).

B. Procedure:

1. Assaulted Employee:

a. Following an assault, the employee must notify his/her immediate supervisor. The supervisor must complete VA Form 10-2633 on all patient-on-staff assaults.

b. The Supervisor should refer the employee to the Employee Assistance Program. Timely referral, via electronic mail, is encouraged.

c. A member of the Employee Assistance Program staff will make contact with the employee to assist the employee with the services needed which may include: counseling, legal advice, information regarding workmens' compensation/medical insurance.

d. Following an assault, a community meeting must take place on the unit where the assault occurred, including patients and staff to process the incident as soon as possible.

2. Battered Employee:

a. Following in incident whereby an employee is battered, the employee must notify his/her immediate supervisor.

b. At the time of the incident, a CA-1 form and VA form2162 must be completed. If the employee is unable to do so, it must be completed by the supervisor. The supervisor must also complete VA Form 10-2633 on all patient-on-staff assaults.

c. The battered employee must report to Employee Health for evaluation and treatment of injuries. If the battery occurs on non-administrative duty hours, the employee should report to admissions to be evaluated by the O.D.

d. Following evaluation and treatment of injuries by Employee Health, the individual is referred by the Employee Health Practitioner to the Employee Assistance Program. Timely referral, via electronic mail, is encouraged.

e. The Employee Assistance Program initiates contact with the battered employee and

1. Informs employee of the service available.

2. Assists employees in attaining these services such as: counseling, legal advice via police service, workmens' compensation and medical benefits via Personnel Service, etc.

f. If a battered employee determines on his or her own to fiie an application for criminal prosecution with the Concord District Court, the treating psychiatrist may accompany the employee to court without need for legal process either to an informal hearing before a clerk-magistrate or a hearing before a judge. The physician may testify to facts known to him. He may not bring VA patient records unless a court orders them to be produced. The physician may, if asked by the court, offer an opinion regarding the competence or capacity of the patient to understand the nature of his actions or to understand the nature of the court's proceedings. The VA psychiatrist may not agree to undertake an evaluation of the patient in order to report back to the court. These duties may be performed by the court psychiatrist or, in the case of a period of hospitalization for evaluation, a state hospital. A court order or a request for the presentation of a medical record to the court must be referred to Medical Administration for Processing.

IV. References:
Hospital Memorandum, 003.07, Patient Injury Control, Preparation of VA Form 10-2633, Report of Special Incident Involving a Beneficiary.

Hospital Memorandum #05. 18, "Employee Assistance Program."

V. Rescissions:
Hospital Memorandum #l 18.13, May 14, 1991.

Source: Reprinted with permission of Marilyn Lewis Lanza, D.N.SC., A.R.N.P., C. S.; Judith Keefe, R. N.; and Margaret Henderson, R. N., M.Ed., Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.

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Appendix D: Violence Incident Report Forms SAMPLE

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence. (Sample/Draft - Adapt to your own location and business circumstances)

Confidential Incident Report

To:_________________________________ Date of Incident: ____________________

Location of Incident: _________________________

__________________________________________
Map/sketch on reverse side or attached

From: _______________ Phone: _______________ Time of Incident: _______________

Legal counsel advised of incident Yes No	EAP advised Yes No
Warning or preventative measures Yes No

Number of persons affected __________

(For each person complete a report; however, to the extent facts are duplicative, any person's report may incorporate another person's report.)

Name of affected person(s) ___________________ Service date _________________

Nature of the incident

Incident Response Team:

Team Leader _____________________________________ _____________________
Signature Date

Source: Reprinted with permission of Karen Smith Keinbaum, Esq., Counsel to the Law Firm of Abbott, Nicholson, Quilter, Esshaki & Youngblood, P. C., Detroit, MI

Violence Incident Report Forms SAMPLE

The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence.

A reportable violent incident should be defined as any threatening remark or overt act of physical violence against a person(s) or property whether reported or observed.

1. Date: __________________________ 2. Specific Location:
Day of week: ____________________
Time: __________________________
Assailant: Female _____ Male _______

3. Violence directed towards: ____ Patient ____ Staff ____ Visitor ____ Other
Assailant: ____ Patient ____ Staff ____ Visitor ____ Other
Assailant's Name: ____________________________________________
Assailant: ____ Unarmed ____ Armed (weapon) ____________

4. Predisposing factors:
________ Intoxication ________ Dissatisfied with care/waiting time
________ Grief reaction ________ Prior history of violence
________ Gang related
________ Other (Describe) ________________________________

5. Description of incident: 6. Injuries: 7. Extent of Injuries:
________ Physical abuse ________ Yes
________ Verbal abuse ________ No
________ Other

8. Detailed description of the incident:

9. Did any person leave the area because of incident?
________ Yes ________ No ________ Unable to determine

10. Present at time of incident:
______ Police ____________ Name of department
______ Hospital security officer

11. Needed to call:
______ Police ____________ Department
______ Hospital security

12. Termination of incident:
Incident diffused ________ Yes ________ No
Police notified ________ Yes ________ No
Assailant arrested ________ Yes ________ No

13. Disposition of assailant: 14. Restraints used: ___ Yes ___ No
Stayed on premises ________
Escorted off premises ________ Type: ____________________
Left on own ________
Other ________________________________

15. Report completed by: _________________ Title: ______________________
Witnesses: ______________________
Supervisor notified: _________________ Time: ______________________

Please put additional comments, according to numbered section, on reverse side of form.

Source: Reprinted with permission of the Metropolitan Chicago Healthcare Council, Guidelines for Dealing with Violence in Health Care, Chicago, IL, 1995.

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Appendix E: Sources of OSHA Assistance

Safety and Health Management

Effective management of worker safety and health protection is a decisive factor in reducing the extent and severity of work-related injuries and illnesses and their related costs. To assist employers and employees in developing effective safety and health programs, OSHA published recommended Safety and Health Program Management Guidelines (Fed Reg 54(18):3908-3916, January 26, 1989). These voluntary guidelines apply to all places of employment covered by OSHA. The guidelines identify four general elements that are critical to the development of a successful safety and health management program:

management commitment and employee involvement,
worksite analysis,
hazard prevention and control, and
safety and health training.

The guidelines recommend specific actions under each of these general elements to achieve an effective safety and health program. A single free copy of the guidelines can be obtained from the OSHA Publications Office, U.S. Department of Labor, P.O. Box 37535, Washington, DC 20213-7535, by sending a self-addressed mailing label with your request.

State Programs

The Occupational Safety and Health Act of 1970 encourages states to develop and operate their own job safety and health plans. States with plans approved under section 18(b) of the Act must adopt standards and enforce requirements that are at least as effective as federal requirements. There are currently 25 state plan states: 23 of these states administer plans covering both private and public (state and local government) employees; the other 2 states, Connecticut and New York, cover public employees only. Plan states must adopt standards comparable to federal requirements within 6 months of a federal standard's promulgation. Until such time as a state standard is promulgated, federal OSHA provides interim enforcement assistance, as appropriate, in these states.

Consultation Services

Consultation assistance is available on request to employers who want help in establishing and maintaining a safe and healthful workplace. Largely funded by OSHA, the service is provided at no cost to the employer. Primarily developed for smaller employers with more hazardous operations, the consultation service is delivered by state government agencies or universities employing professional safety consultants and health consultants. Comprehensive assistance includes an appraisal of all mechanical physical work practices, and environmental hazards of the workplace and all aspects of the employer's present job safety and health program.

The program is separate from OSHA'S inspection efforts. No penalties are proposed or citations issued for any safety or health problems identified by the consultant. The service is confidential.

For more information concerning consultation assistance, see the list of consultation projects elsewhere in this appendix.

Voluntary Protection Programs

Voluntary Protection Programs and onsite consultation services, when coupled with an effective enforcement program, expand worker protection to help meet the goals of the OSH Act. The three VPPs -- Star, Merit, and Demonstration -- are designed to recognize outstanding achievement by companies that have successfully incorporated comprehensive safety and health programs into their total management system. They motivate others to achieve excellent safety and health results in the same outstanding way as they establish a cooperative relationship between employers, employees, and OSHA.

For additional information on VPPS and how to apply, contact OSHA'S area or regional offices.

Training and Education

OSHA'S area offices offer a variety of informational services, such as publications, audiovisual aids, technical advice, and speakers for special engagements. OSHAs Training Institute in Des Plaines, IL, provides basic and advanced courses in safety and health for federal and state compliance officers, state consultants, federal agency personnel, and private sector employers, employees, and their representatives.

OSHA also provides funds to nonprofit organizations, through grants, to conduct workplace training an education in subjects where OSHA believes there is a lack of workplace training. Grants are awarded annually and grant recipients are expected to contribute 20 percent of the total grant cost.

For more information on grants, training, and education, contact the OSHA Training Institute, Office of Training and Education, 1555 Times Drive, Des Plaines, IL 60018, (847) 297-4810.

For further information on any OSHA program, contact your nearest OSHA area or regional office.

States with Approved Plans

Commissioner Alaska Department of Labor 1111 West 8th Street Room 306 Juneau, AK 99801 (907) 465-2700	Director Industrial Commission of Arizona 800 W. Washington Phoenix, AZ 85007 (602) 542-5795
Director California Department of Industrial Relations 45 Fremont Street San Francisco, CA 94105 (415) 972-8835	Director Connecticut Department of Labor Division of Occupational Safety and Health 200 Folly Brook Boulevard Wethersfield, CT 06109 (203) 566-5123
Director Hawaii Department of Labor and Industrial Relations 830 Punchbowl Street Honolulu, HI 96813 (808) 586-8844	Commissioner Indiana Department of Labor State Office Building 402 West Washington Street Room W 195 Indianapolis, IN 46204 (317) 232-2378
Commissioner Iowa Division of Labor Services 1000 E. Grand Avenue Des Moines, IA 50319 (515) 281-3447	Secretary Kentucky Labor Cabinet 1049 U.S. Highway, 127 South Frankfort, KY 40601 (502) 564-3070
Commissioner Maryland Division of Labor and Industry Department of Licensing and Regulation 501 St. Paul Place, 2nd Floor Baltimore, MD 21202-2272 (410) 333-4179	Director Michigan Department of Labor Victor Office Center 201 N. Washington Square P.O. Box 30015 Lansing, MI 48933 (517) 373-9600
Director Michigan Department of Public Health 3423 North Logan Street Box 30195 Lansing, MI 48909 (517) 335-8022	Commissioner Minnesota Department of Labor and Industry 443 Lafayette Road St. Paul, MN 55155 (612) 296-2342
Director Nevada Division of Industrial Relations 400 West King Street Carson City, NV 97502 (702) 687-3032	Secretary New Mexico Environmental Department Occupational Health and Safety Bureau 1190 St. Francis Drive P.O. BOX 26110 Santa Fe, NM 87502 (505) 827-2850
Commissioner New York Department of Labor State Office Building -12 Room 500 Albany, NY 12240 (518) 457-2741	Commissioner North Carolina Department of Labor 319 Chapanoke Road Raleigh, NC 27603 (919) 662-4585
Administrator Oregon Occupational Safety and Health Division Department of Consumer and Business Services, Room 430 Labor and Industries Building 350 Winter Street, NE Salem, OR 97310 (503) 378-3272	Secretary Puerto Rico Department of Labor and Human Resources Prudencio Rivera Martinez Building 505 Munoz Rivera Avenue HatoRey,PR00918 (809) 754-2119
Commissioner South Carolina Department of Labor 3600 Forest Drive P.O. BOX 11329 Columbia, SC 29211-1329 (803) 734-9594	Commissioner Tennessee Department of Labor Attention: Robert Taylor 710 James Robertson Parkway Gateway Plaza, 2nd Floor Nashville, TN 37243-0659 (615) 741-2582
Commissioner Industrial Commission of Utah 160 East 300 South, 3rd Floor P.O. BOX 146600 Salt Lake City, UT 84114-6600 (801) 530-6898	Commissioner Vermont Department of Labor and Industry 120 State Street Montpelier, VT 05620 (802) 828-2288
Commissioner Virgin Islands Department of Labor 2131 Hospital Street, Box 890 Christiansted St. Croix, VI 00820-4666 (809) 773-1994	Commissioner Virginia Department of Labor and Industry Powers-Taylor Building 13 South 13th Street Richmond, VA 23219 (804) 786-2377
Director Washington Department of Labor and Industries P.O. Box 44000 Olympia, WA 98504-4000 (360) 902-4200	Administrator Occupational Safety and Health Administration Herschler Building, 2nd Floor East 122 West 25th Street Cheyenne, WY 82002 (307) 777-7786

OSHA Consultation Project Directory

Alabama 7(c)(1) Onsite Consultation Program 425 Martha Parham West P.O. BOX 870388 Tuscaloosa, AL 35487 (205) 348-3033	Alaska Department of Labor Occupational Safety and Health 3301 Eagle Street P.O. BOX 107022 Anchorage, AK 99510 (907) 269-4954
Arizona Consultation and Training Division of Occupational Safety and Health Industrial Commission of Arizona 800 West Washington Phoenix, AZ 85007-9070 (602) 542-5795	Arkansas OSHA Consultation Arkansas Department of Labor 10421 West Markham Little Rock, AK 72205 (501) 682-4522
California CAL/OSHA Consultation Service Department of Industrial Relations Suite 1260 45 Fremont Street San Francisco, CA 94105 (415) 972-8515	Colorado Occupational Safety and Health Section Colorado State University 110 Veterinary Science Building Fort Collins, CO 80523 (907) 491-7778
Connecticut Division of Occupational Safety and Health Connecticut Department of Labor 200 Folly Brook Boulevard Wethersfield, CT 06109 (860) 566-4550	Delaware Occupational Safety and Health Division of Industrial Affairs Delaware Department of Labor 820 North French Street, 6th Floor Wilmington, DE 19801 (302) 577-3908
District of Columbia Office of Occupational Safety and Health District of Columbia Department of Employment Services 950 Upshur Street, N.W. Washington, DC 20011 (202) 576-6339	Florida 7(c)(1) Onsite Consultation Program Division of Industrial Safety Florida Department of Labor and Employment Security 2002 St. Augustine Road Building E, Suite 45 Tallahassee, FL 32399-0663 (904) 488-3044
Georgia 7(c)(l) Onsite Consultation Program Georgia Institute of Technology O'Keefe Building - Room 23 Atlanta, GA 30332 (404) 89402643	Guam OSHA Onsite Consultation Guam Department of Labor P.O. Box 9970 Tamuning, GU 6931 (671) 475-0136
Hawaii Consultation and Training Branch Department of Labor and Industrial Relations 830 Punchbowl Street Honolulu, HI 96813 (808) 586-9100	Idaho Safety and Health Consultation Program Boise State University Department of Health Studies 1910 University Drive, ET-338A Boise, ID 3725 (208) 385-3283
Illinois Industrial Services Division Department of Commerce and Community Affairs State of Illinois Center 100 West Randolph St. Suite 3-400 Chicago, IL 60601 (312) 814-7238	Indiana Division of Labor Bureau of Safety, Education and Training 402 West Washington Room W195 Indianapolis, IN 46204-2287 (317) 232-2688
Iowa 7(c)(1) Consultation Program Iowa Bureau of Labor 1000 East Grand Avenue Des Moines, IA 50319 (515) 281-5352	Kansas Kansas 7(c)(1) Consultation Program Kansas Department of Human Resources 512 South West 6th Street Topeka, KS 66603-3150 (913) 296-7476
Kentucky Division of Education and Training Kentucky Labor Cabinet 1049 U.S. Highway 127, South Frankfort, KY 4601 (502) 564-6896	Louisiana 7(c)(1) Consultation Program Louisiana Department of Employment and Training P.O. Box 94094 Baton Rouge, LA 70804-9094 (504) 342-9601
Maine Division of Industrial Safety Maine Department of Labor State Home Station 82 Augusta, ME 04333 (207) 624-6460	Maryland 7(c)(1) Consultation Services Division of Labor and Industry 501 Saint Paul Place, 3rd Floor Baltimore, MD 21202 (410) 333-4210
Massachusetts 7(c)(1) Consultion Program Division of Industrial Safety Massachusetts Department of Labor and Industries 1001 Watertown Street West Newton, MA 02165 (617) 727-3982	Michigan (Health) Michigan Department of Public Health Division of Occupational Health 3423 North Logan Street P.O. Box 30195 Lansing, MI 48909 (517) 335-8250
Michigan (Safety) Michigan Department of Labor Bureau of Safety and Regulation 7150 Harris Drive Lansing, MI 48909 (517) 322-1809	Minnesota Department of Labor and Industry Consultation Division 443 Lafayette Road St. Paul, MN 55155 (612) 297-5433
Mississippi 7(c)(1) Onsite Consultation Program Division of Occupational Safety and Health Mississippi Worker's Compensation Commission 2906 N. State Street Suite 201 Jackson, MS 39216 (601) 987-3981	Missouri Onsite Consultation Program Division of Labor Standards Department of Labor and Industrial Relations 3315 West Truman Boulevard Jefferson City, MO 65109 (314) 751-3403
Montana Department of Labor and Industry Bureau of Safety P.O. BOX 1728 Helena, MT 59624-1728 (406) 444-6418	Nebraska Division of Safety, Labor and Safety Standards Nebraska Department of Labor State Office Building, Lower Level 301 Centennial Mall, South Lincoln, NE 68509-5024 (402) 471-4717
Nevada Division of Preventive Safety Department of Industrial Relations 2500 W. Washington, Suite 104 Las Vegas, NV 89106 (702) 486-5016	New Hampshire Onsite Consultation Program New Hampshire Division of Public Health Services 6 Hazen Drive Concord, NH 03301-6527 (603) 271-2024
New Jersey Division of Workplace Standards New Jersey Department of Labor STATION PLAZA 4, CN953 22 South Clinton Avenue Trenton, NJ 08625-0953 (609) 292-3923	New Mexico OSHA Consultation Occupational Health and Safety Division P.O. BOX 26110 1190 St. Francis Drive Santa Fe, NM 87502 (505) 827-4422
New York Division of Safety and Health State Office Campus Building 12, Room 457 Albany, NY 12240 (518) 457-2481	North Carolina North Carolina Consultative Services North Carolina Department of Labor 319 Chapanoke Road, Suite 105 Raleigh, NC 27603-3432 (919) 662-4644
North Dakota Division of Environmental Engineering North Dakota State Department of Health 1200 Missouri Avenue, Room 304 P.O. BOX 5520 Bismark, ND 58502-5520 (701) 328-5188	Ohio Division of Onsite Consultation Department of Industrial Relations 145 S. Front Street Columbus, OH 43216 (614) 644-2246
Okahoma OSHA Division Oklahoma Department of Labor 4001 North Lincoln Blvd. Oklahoma City, OK 73105-5212 (405) 528-1500	Oregon 7(c)(1) Consultation Program Department of Consumer and Business Services Labor and Industries Building 350 Winter Street, N.E., Room 430 Salem, OR 97310 (503) 378-3272
Pennsylvania Indiana University of Pennsylvania Safety Sciences Department 205 Uhler Hall Indiana, PA 15705 (412) 357-2561	Puerto Rico Occupational Safety and Health Office Puerto Rico Department of Labor and Human Resources 505 Munoz Rivera Avenue, 21st Floor Hato Rey, PR 00918 (809) 754-2188
Rhode Island Division of Occupational Health Rhode Island Department of Health 3 Capital Hill Providence, RI 02908 (401) 277-2438	South Carolina 7(c)(1) Onsite Consultation Program Licensing and Regulation, SCDOL 3600 Forest Drive P.O. BOX 11329 Columbia, SC 29211 (803) 734-9614
South Dakota Engineering Extension Onsite Technical Division South Dakota State University P.O. Box510 Brookings, SD 57007-0510 (605) 688-4101	Tennessee OSHA Consultative Services Tennessee Department of Labor 710 James Robertson Parkway, 3rd Floor Nashville, TN 37243-0659 (615) 741-7036
Texas Texas Workers' Compensation Commission Health and Safety Division Southfield Building 4000 South I H 35 Austin, TX 78704 (512) 440-3834	Utah Utah Safety and Health Consultation Service 160 East 300 South, 3rd Floor P.O. BOX 146650 Salt Lake City, UT 84114-6650 (801) 530-6868
Vermont Division of Occupational Safety and Health Vermont Department of Labor and Industry National Life Building, Drawer #20 Montpelier, VT 05602 (802) 828-2765	Virginia Virginia Department of Labor and Industry Occupational Safety and Health Training and Consultation 13 S. 13th Street Richmond, VA 23219 (804) 786-6613
Virgin Islands Division of Occupational Safety and Health Virgin Islands Department of Labor 3012 Golden Rock Christiansted St Croix, VI 00820 (809) 772-1315	Washington Washington Department of Labor and Industries Division of Industrial Safety and Health P.O. Box 44643 Olympia, WA 98504 (360) 902-5443
West Virginia West Virginia Department of Labor State Capitol, Building 3, Room 319 1800 E. Washington Street Charleston, WV 25305 (304) 558-7890	Wisconsin (Health) Wisconsin Department of Health and Human Services Section of Occupational Health 1414 E. Washington Avenue Room 112 Madison, WI 53703 (608) 266-8579
Wisconsin (Safety) Wisconsin Department of Industry Labor and Human Relations Bureau of Safety Inspection 401 Pilot Court, Suite C Waukesha,WI53188 (414) 521-5188	Wyoming Occupational Health and Safety State of Wyoming 122 West 25th, Herschler Building 2nd Floor, East Cheyenne, WY 82002 (307) 777-7786

OSHA Area Offices

US Department of Labor - OSHA 2047 Canyon Road - Todd Mall Birmingham, AL 35216 (205) 731-1534	US Department of Labor - OSHA 3737 Government Blvd., Suite 100 Mobile, AL 36693 (205) 441-6131
US Department of Labor - OSHA 301 W. Northern Lights Blvd. Suite 407 Anchorage, AK 99503 (907) 271-5152	US Department of Labor - OSHA 3221 North 16th Street, Suite 100 Phoenix, AZ 85016 (602) 640-2007
US Department of Labor - OSHA 425 West Capitol Suite 450 Little Rock, AR 72201 (501) 324-6292	US Department of Labor - OSHA 71 Stevenson Street, Suite415 San Francisco, CA 94105 (415) 744-7120
US Department of Labor - OSHA 1391 North Speer Blvd. Suite 210 Denver, CO 80204 (303) 844-5285	US Department of Labor - OSHA 7935 E. Prentice Ave., Suite 209 Englewood, CO 80111-2714 (303) 843-4500
US Department of Labor - OSHA One Lafayette Square, Suite 202 Bridgeport, CT 06604 (203) 579-5579	US Department of Labor - OSHA Federal Office Building 450 Main Street, Room 508 Hartford, CT 06103 (203) 240-3152
US Department of Labor - OSHA Jacaranda Executive Court 8040 Peters Road Building H-1OO Fort Lauderdale, FL 33324 (305) 424-0242	US Department of Labor - OSHA Ribault Building 1851 Executive Center Drive Suite 227 Jacksonville, FL 32207 (904) 232-2895
US Department of Labor - OSHA 5807 Breckenridge Pkwy. Suite A Tampa, FL 33610 (813) 626-1177	US Department of Labor - OSHA 450 Mall Blvd., Suite J Savannah, GA 31406 (912) 652-4393
US Department of Labor - OSHA 2400 Herodian Way, Suite 250 Smyrna, GA 30080 (404) 984-8700	US Department of Labor - OSHA Bldg. 7, Suite 110 La Vista Perimeter Office Park Tucker, GA 30084 (404) 493-6644
US Department of Labor - OSHA 300 Ala Moana Blvd., Suite 5122 Honolulu, HI 96850 (808) 541-2685	US Department of Labor - OSHA 3050 N. Lakeharbor Lane Suite 134 Boise, ID 83703 (208) 334-1867
US Department of Labor - OSHA 1600 167th Street, Suite 12 Calumet City, IL 60409 (708) 891-3800	US Department of Labor - OSHA 2360 E. Devon Avenue Suite 1010 Des Plaines, IL 60018 (708) 803-4800
US Department of Labor - OSHA 344 Smoke Tree Business Park North Aurora, IL 60542 (708) 803-896-8700	US Department of Labor - OSHA 2918 West W111OW Knolls Road Peoria, IL 61614 (309) 671-7033
US Department of Labor - OSHA 46 East Ohio Street, Room 423 Indianapolis, IN 46204 (317) 226-7290	US Department of Labor - OSHA 210 Walnut Street, Room 815 Des Moines, IA 50309 (515) 284-4794
US Department of Labor - OSHA 300 Epic Center 301 N. Main Wichita, KS 67202 (316) 269-6644	US Department of Labor - OSHA John C. Watts Fed. Bldg., Room 108 330 W. Broadway Frankfort, KY 40601 (502) 227-7024
US Department of Labor - OSHA 2156 Wooddale Blvd. Hoover Annex, Suite 200 Baton Rouge, LA 70806 (504) 389-0474	US Department of Labor - OSHA U.S. Federal Building 202 Harlow Street, Room 211 Bangor, ME 04401 (207) 941-8177
US Department of Labor - OSHA 300 West Pratt Street Suite 280 Baltimore, MD 21201 (410) 962-2840	US Department of Labor - OSHA 639 Granite Street, 4th Floor Braintree, MA 02184 (617) 565-6924
US Department of Labor - OSHA Valley Office Park 13 Branch Street Methuen, MA 01844 (617) 565-8110	US Department of Labor - OSHA 1145 Main Street, Room 108 Springfield, MA 01103-1493 (413) 785-0123
US Department of Labor - OSHA 801 South Waverly Rd. Suite 306 Lansing, MI 48917-4200 (517) 377-1892	US Department of Labor - OSHA Federal Courts Bldg. 110 South 4th Street, Room 116 Minneapolis, MN 55401 (612) 348-1994
US Department of Labor - OSHA 3780 I-55 North Suite 210 Jackson, MS 39211 (601) 965-4606	US Department of Labor - OSHA 6200 Connecticut Avenue, Suite 100 Kansas City, MO 64120 (816) 483-9531
US Department of Labor - OSHA 911 Washington Avenue Room 420 St. Louis, MO 63101 (314) 425-4249	US Department of Labor - OSHA 19 N. 25th Street Billings, MT 59101 (406) 657-6649
US Department of Labor - OSHA Overland Wolf Building, Room 100 6910 Pacific Street Omaha, NE 68106 (402) 221-3182	US Department of Labor - OSHA 1050 East Williams, Suite 435 Carson City, NV 89701 (702) 885-6963
US Department of Labor - OSHA 279 Pleasant Street, Suite 201 Concord, NH 03301 (603) 225-1629	US Department of Labor - OSHA 1030 Saint Georges Avenue Plaza 35, Suite 205 Avenel, NJ 07001 (908) 750-3270
US Department of Labor - OSHA 500 Route 17 South, 2nd Floor Hasbrouck Heights, NJ 07604 (201) 288-1700	US Department of Labor - OSHA Marlton Executive Park 701 Route 73 South, Building 2 Suite 120 Marlton, NJ 08053 (609) 757-5181
US Department of Labor - OSHA 299 Cherry Hill Road, Suite 304 Parsippany, NJ 07054 (201) 263-1003	US Department of Labor - OSHA 505 Marquette Avenue, NW Suite 820 Albuquerque, NM 87102-2160 (505) 766-3411
US Department of Labor - OSHA 401 New Karner Road Suite 300 Albany, New York 12205-3809 (518) 464-6742	US Department of Labor - OSHA 42-40 Bell Boulevard, 5th Floor Bayside, NY 11361 (718) 279-9060
US Department of Labor - OSHA 5360 Genesee Street Bowmansville, NY 14026 (716) 684-3891	US Department of Labor - OSHA 90 Church Street, Room 1407 New York, NY 10007 (212) 264-9840
US Department of Labor - OSHA 3300 Vlkery Road, North New Syracuse, NY 13212 (315) 451-0808	US Department of Labor - OSHA 660 White Plaines Road 4th Floor Tarrytown, NY 10591-5107 (914) 524-7510
US Department of Labor - OSHA 990 Westbury Road Westbury, NY 11590 (516) 334-3344	US Department of Labor - OSHA Century Station, Room 438 300 Fayetteville Street Mall Raleigh, NC 27601 (919) 856-4770
US Department of Labor - OSHA 220 E. Rosser, Room 348 P.O. BOX 2439 Bismarck, ND 58501 (701) 250-4521	US Department of Labor - OSHA 36 Triangle Park Drive Cincinnati, OH 45246 (513) 841-4132
US Department of Labor - OSHA Federal Office Building, Room 899 1240 East Ninth Street Cleveland, OH 44199 (216) 522-3818	US Department of Labor - OSHA Federal Office Building, Room 620 200 N. High Street Columbus, OH 43215 (614) 469-5582
US Department of Labor - OSHA Federal Office Building, Room 734 234 North Summit Street Toledo, OH 43604 (419) 259-7542	US Department of Labor - OSHA 420 West Main Place, Suite 300 Oklahoma City, OK 73102 (405) 231-5351
US Department of Labor - OSHA 1220 S.W. Third Avenue, Room 640 Portland, OR 97294 (503) 326-2251	US Department of Labor - OSHA 850 N. 5th Street Allentown, PA 18102 (610) 776-0592
US Department of Labor - OSHA 3939 West Ridge Road Suite B-12 Erie, PA 16506-1857 (814) 833-5758	US Department of Labor - OSHA Progress Plaza 49 N. Progress Street Harrisburg, PA 17109 (717) 782-3902
US Department of Labor - OSHA U.S. Custom House, Room 242 Second and Chestnut Street Philadelphia, PA 19106 (215) 597-4955	US Department of Labor - OSHA Federal Building, Room 1428 1000 Liberty Avenue Pittsburgh, PA 15222 (412) 644-2903
US Department of Labor - OSHA Penn Place, Room 2005 20 North Pennsylvania Avenue Wilkes-Barre, PA 18701 (717) 826-6538	US Department of Labor - OSHA U.S. Courthouse and FOB Carlos Chardon Street, Room 559 HatoRey, PR 00918 (809) 766-5457
US Department of Labor - OSHA 380 Westminster Mall, Room 243 Providence, RI 02903 (401) 528-4669	US Department of Labor - OSHA 1835 Assembly Street, Room 1468 Columbia, SC 29201 (803) 765-5904
US Department of Labor - OSHA 2002 Richard Jones Road Suite C-205 Nashville, TN 37215 (615) 781-5423	US Department of Labor - OSHA 903 San Jacinto Blvd. Suite 319 Austin, TX 78701 (512) 482-5783
US Department of Labor - OSHA Wilson Plaza 606 N. Carancahua, Suite 700 Corpus Christi, TX 78476 (512) 884-2694	US Department of Labor - OSHA 8344 East R.L. Thornton Freeway Suite 420 Dallas, TX 75228 (214) 320-2400
US Department of Labor - OSHA North Star 2 Building Suite 430 8713 Airport Freeway Fort Worth, TX 76180-7604 (817) 885-7025	US Department of Labor - OSHA 17625 El Camino Real, Suite 400 Houston, TX 77058 (713) 286-0583
US Department of Labor - OSHA 350 North Sam Houston Parkway Suite 120 Houston, TX 77058 (713) 591-2438	US Department of Labor - OSHA Federal Building, Room 422 1205 Texas Avenue Lubbock, TX 79401 (806) 743-7681
US Department of Labor - OSHA 1781 South 300 West Salt Lake City, UT 84165-0200 (801) 524-5080	US Department of Labor - OSHA AFOB, Room 835 200 Granby Mall Norfolk, VA 23510 (804) 441-3820
US Department of Labor - OSHA 505 16th Avenue, N.E. Bellevue, WA 98004 (206) 553-7520	US Department of Labor - OSHA 550 Eagan Street, Room 206 Charleston, WV 25301 (304) 347-5937
US Department of Labor - OSHA 2618 North Ballard Road Appleton, WI 54915 (414) 734-4521	US Department of Labor - OSHA 4802 East Broadway Madison, WI 53716 (608) 264-5388
US Department of Labor - OSHA Henry S. Reuss Bldg. Suite 1180 310 West Wisconsin Ave. Milwaukee, WI 53203 (414) 297-3315

OSHA Regional Offices

Region I (CT,* MA, ME, NH, RI, VT*) 133 Portland Street 1st Floor Boston, MA 02114 (617) 565-7164	Region II (NJ, NY,* PR,* VI*) 201 Varick Street Room 670 New York, NY 10014 (212) 337-2378
Region III (DC, DE, MD,* PA, VA,* WV) Gateway Building, Suite 2100 3535 Market Street Philadelphia, PA 19104 (215) 596-1201	Region IV (AL, FL, GA, KY,* MS, NC, SC,* TN*) 1375 Peachtree Street, N.E. Suite 587 Atlanta, GA 30367 (404) 347-3573
Region V (IL, IN,* MI,* MN,* OH, WI) 230 South Dearborn Street Room 3244 Chicago, IL 60604 (312) 353-2220	Region VI (AR, LA, NM,* OK, TX) 525 Griffh Street Room 602 Dallas, TX 75202 (214) 767-4731
Region VII (IA,* KS, MO, NE) City Center Square 1100 Main Street, Suite 800 Kansas City, MO 64105 (816) 426-5861	Region VIII (CO, MT, ND, SD, UT,* WY*) Suite 1690 1999 Broadway Denver, CO 80202-5716 (303) 391-5858
Region IX (American Samoa, AZ,* CA,* Guam, HI,* NV,* Trust Territories of the Pacific) 71 Stevenson Street Room 420 San Francisco, CA 94105 (415) 744-6670	Region X (AK,* ID, OR,* WA*) 1111 Third Avenue Suite 715 Seattle, WA 98101-3212 (206) 553-5930

*These states and territories operate their own OSHA-approved job safety and health programs(Connecticut and New York plans cover public employees only), States with approved programs must have a standard that is identical to, or at least as effective as, the federal standard.

Return to Table of Contents

Appendix F: Suggested Readings

Adler, W.N.; Kreeger, C.; and Ziegler, P. (1983). Patient Violence in a Psychiatric Hospital." In J.R. Lion & W.H. Reid (Eds.). Assaults Within Psychiatric Facilities. Pp. 81-90.

Alspach, G. (1993). "Nurses as Victims of Violence." Crit Care Nurse 13(5): 13-17, October.

American College of Emergency Physicians. (1988). Position Statement on Emergency Department Violence Prevention and Management. Dallas, TX: ACEP.

American Medical Association, Young Physicians Section. (1995). Violence in the Medical Workplace: Prevention Strategies.

American Psychiatric Association. (1992). Clinician Safety. Task Force Report #33. Washington, DC: American Psychiatric Press.

Appelbaum, P. (1988). "The New Preventive Detention: Psychiatry's Problematic Responsibility for The Control of Violence." Am J Psych 145:779-785.

Bachman, R. (1994). "Violence and Theft in The Workplace." Crime Data Brief. U.S. Department of Justice, Bureau of Justice Statistics.

Bell, C. (1991). "Female Homicides in United States Workplaces, 1980- 1985." Am J Public Health. 81(1 6): 729-732.

Blair, T.; New, S. (1991). "Assaultive Behavior." J Psychosoc Nurs. 29(1 1): 25-29.

Bernstein, H, (1981). "Survey of Threats and Assaults Directed Toward Psychotherapists." Am J Psychother. 35(4): 542-549.

Blumenreich, Patricia, M. D.; Lippmann, Steven, M. D.; Bacani-Oropilla; and Teresita, M.D. (1991). "Violent Patients: Are You Prepared to Deal With Them?" Postgrad Med 90(2): 201-206.

Brayley, John; Lange, Ruth; Baggoley, Chris; Bond, Malcolm; and Harvey, Paula. (1994). "The Violence Management Team: An Approach to Aggressive Behaviour in a General Hospital." Med J Aust 161:254-58.

Caldwell, M.E. (1992). "The Incidence of PTSD Among Staff Victims of Patient Violence." Hosp Community Psychiatry 43:838-839.

Cannel, H., Hunter, M. (1990). "Compliance With Training in Managing Assaultive Behavior and Injuries from In-patient Violence." Hosp Community Psychiatry 41(5):558-560.

Centers for Disease Control (CDC). (1990). "Occupational Homicides Among Women - United States, 1980- 1985." MMWR 39:543 -544; 551-552.

Centers for Disease Control (CDC), National Institute for Occupational Safety and Health. (1992). Homicide in U.S. Workplaces: A Strategy for Prevention and Research. NIOSH #92-103.

Clifton, W. (1992). Convenience Store Robbery -- An Intervention Strategy by the Gainesville Police Department. Gainesville, FL.

Cohen, S.; Kamarck, T.; and Mermelstein, R. (1983). "A Global Measure of Perceived Stress." J Health Soc Behav 24385-396.

Comcare, Australia. (1993). "Guidelines for the Prevention and Management of Client Aggression." Quality of Working Life Strategy. Canberra.

Conn, L.; and Lion, J. (1983). "Assaults in a University Hospital." In: Assaults Within Psychiatric Facilities. Philadelphia, PA.: W.B. Saunders & Co. Pp. 61-69. (??)

Cox, T.; and Leather, P. (1994). "The Prevention of Violence at Work: Application of a Cognitive Behavioral Theory." In: C. Cooper & I. Robertson (Eds.) International Review of Industrial and Organizational Psychology. New York: John Wiley & Sons Ltd. P.9.

Craig, T. (1982). "An Epidemiological Study of Problems Associated with Violence Among Psychiatric Inpatients." Am J Psychiatry 139(10): 1262- 1266.

Cornin, M. (1991). "New Law Aims to Reduce Kidnappings." Nurse Week 5(3): 1; 24.

Cox, T; and Leather, P. (1994). "The Prevention of Violence at Work: Application of a Cognitive Behavioral Theory." Int Rev Ind Org Psychol 9: 213-245.

Davidson, P.; Jackson, C. (1985). "The Nurse as a Survivor: Delayed Post-Traumatic Stress Reaction and Cumulative Trauma in Nursing." Int J Nurs Studies 22(l): 1-13.

Davis, S. (1991). "Violence in Psychiatric Inpatients: A Review." Hosp Community Psychiatry 42,585-590.

Dawson, J.; Johnson, M.; Kehiayan, N.; Kyanko, S.; and Martinez, R. (1988). "Response to Patient Assault: A Peer Support Program for Nurses." J Psychosoc Nurs Merit Health Serv 26:8-15.

DiBenedetto, D.V. (1992). "Occupational Hazards of the Healthcare Industry: Protecting Healthcare Workers." AAOHN J 43(3), 131-137.

Dillon, S. (1992). "Social Workers: Targets in a Violent Society." NY Times: Al; Al8, November 1, 1992.

Eagle, F.; and Marsh, S. (1986). "Helping the Employee Victim of Violence in Hospitals." Hosp Community Psychiatry 37(2): 159-162.

Edelman, S. (1978). "Managing the Violent Patient in a Community Mental Health Center Community." Hosp Community Psychiatry 29(7): 460-462.

Eichelman, E. (1984). "A Behavioral Emergency Plan." Hosp Community Psychiatry 35(10): 1678.

Emergency Nurses Association. (1995). "Fact Sheet on 1994 Emergency Nurses Association Survey on Prevalence of Violence in U.S. Emergency Departments." Unpublished.

Emergency Nurses Association. (1987). "Verbal Abuse in Nursing." Nursing Management 18(9).

Felton, J.S. (1993). "Occupational Violence-An Intensified Work Concomitant." OEM Report 7(12): 101-103.

Fineberg, N.; James, D.; and Shah, A. (1988). "Agency Nurses and Violence in a Psychiatric Ward." Lancet 1:474.

Flannery, R. B., Jr. (1995). Violence in the Workplace. New York: Crossroad Press.

Flannery, R. B.; Jr., Fulton, P; Tausch, J.; and DeLoffi, A.Y. (1991). "A Program To Help Staff Cope with Psychological Sequelae of Assaults by Patients." Hosp Community Psychiatry 42:935- 938.

Flannery, R.B., Jr.; Hanson, M.A.; and Penk, W.E. (1994). "Risk Factors for Psychiatric Inpatient Assaults on Staff." J Ment Health Admin 21:24-31.

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