Guidelines For Security and Safety Of Health Care And Community Service Workers

Published to html on Tuesday, March 10, 1998

I. INTRODUCTION: THE PROBLEM

During the past two decades, we have seen a sharp increase in violence in our cities, country and society. Estimates show that nearly one-third of all Americans are victimized by crime each year (Poster & Ryan, 1989). Violence in the workplace is a manifestation of this problem, with homicide being the third leading cause of occupational death among all workers in the United States from 1980 to 1988 (Jenkins et al, 1992) and the leading cause of fatal occupational injuries among women from 1980 to 1985 (Levin et al, 1992).

Higher rates of occupational homicides were found in the retail and service industries, especially among sales workers (Jenkins et al, 1992). This increased risk may be explained by contact with the public and the handling of money (Kraus, 1987). Research into the causes of the increasing incidence of death and serious injury to health care workers has led to the theory that exposure to the public may be an important risk (Libscomb & Love, 1992, Lavoie et al, 1988). The risk is increased particularly in emotionally charged situations with mentally disturbed persons or when workers appear to be unprotected.

During the past few years, violence resulting in the death of California health care and community workers occurred in emergency rooms, psychiatric hospitals, community mental health clinics and social service offices. Assaults, hostage taking, rapes, robbery and other violent actions are also reported at these and other health care and community settings. In a study by Conn and Lion (1983), assaults by patients in a general hospital occurred in a variety of locations. Although forty-one percent of assaults occurred in the psychiatric units, they also occurred in emergency rooms (18%), medical units (13%), surgical units (8%), and even pediatric units (7%).

Carmel and Hunter (1989) found that the psychiatric nursing staff of a maximum security forensic hospital in California sustained 16 assault injuries per 100 employees per year. This investigation used the OSHA definition for occupational injury: an injury which results in death, lost work days, loss of consciousness, restriction of work or motion, termination of employment, transfer to another job or medical treatment other than first aid (Bureau of Labor Statistics, 1986). Work-related injuries reported on OSHA forms and reported to the Bureau of Labor Statistics (BLS) for 1989 occurred at a rate of 8.3 per 100 full-time workers in all industries combined. The highest rate, 14.2 per 100 full-time workers, was seen in the construction industry (Bureau of Labor Statistics, 1991). In comparison, data collected by Carmel and Hunter suggest that some psychiatric workers may be at a higher risk for injuries from assaults than the risk for injuries from all causes in the country's most hazardous industry (Lipscomb and Love, 1992).

Madden et al (1976), Lanza (1983) and Poster & Ryan (1989) have reported that 46 to 100% of nurses, psychiatrists and other therapists in psychiatric facilities experienced at least one assault during their career. Research on the causes and methods of prevention of violence in psychiatric facilities was funded by the California Department of Industrial Relations after the death of a psychiatric hospital worker in 1989. This investigation is in progress at the forensic hospital the the present time.

Lavoie et al (1988) investigated 127 large, university-based hospital emergency departments and reported that 43% (55) had at least one physical attack on a medical staff member per month. Seven percent (9) of the reported acts of violence in the last 5 years resulted in death. Emergency room personnel face a significant risk of injury from assaults by patients, but in addition, may be abused by relatives or other persons associated with the patient. Further, the violence which occurs in the emergency room is often shifted into the hospital when the patient is transferred to the receiving unit.

Bernstein (1981) reported that 26% of reported assaultive behaviors in a study of California psychotherapists occurred in the outpatient setting. The death of an outpatient psychiatric worker in 1989 in California at the hands of a homeless client underscores the risk that exists in this setting. Investigations by OSHA officials in two California Counties identified a nearly complete lack of security measures in outpatient facilities, leaving workers unprotected and vulnerable to abuse and assaults.

Community service workers are at risk of hostile behavior from the public when they visit clients at hotels, apartments or homes in unfamiliar or dangerous locations especially at night. Child welfare workers have reported that parents of children who are being taken to foster homes or other types of court action have become violent and assaulted workers with knives and fists. Sexual assaults with serious injury, other physical assaults and robberies have been reported by workers in the hospital and community. In addition, clients or their relatives and friends may direct their anger, which can be extreme or violent, at community workers. In Canada, in community settings, physical attacks by patients were reported by 1.1% to 14.1% nurses surveyed by the Manitoba Association of Registered Nurses, Liss (1993).

Few research investigations have focused on the incidence of violence to community workers, but reports have been received from many sources such as union workers or parking enforcement workers who have suffered abusive and at times violent behavior from hostile motorists. Hotel housekeepers are currently being studied after complaining of sexual abuse and threats in hotels in which they work. Much research is needed to identify the scope of violence in the medical field and the community as a whole.

A. Risk Factors

Risk factors may be viewed from the stand point of 1) the environment, 2) work practices and 3) victim and perpetrator profile.

Environmental Factors

Health care and community service workers are at increased risk of assaults because of increased violence in our society. This increase in violence is thought to be as a result of such factors as: the easy availability of guns and weapons; the use of violence by many in the population as a means of solving problems; the increase in unemployment, poverty and homelessness; the decrease in social services to the poor and mentally ill; the increase in gang-related activity and drug and alcohol use; violence depicted in television and movies; and the increasing use of hospitals by police and criminal justice systems for acutely disturbed patients. These may be thought of as a partial listing which may have a direct contribution to safety and security of workers.

An important risk factor at hospital at hospital and psychiatric facilities is the carrying of weapons by patients and their family or friends. Wasserberger et al (1989) reported that 25% of major trauma patients treated in the emergency room carried weapons. Attacks on emergency rooms in gang-related shootings have been documented in two Los Angeles hospitals (Long Beach Press Telegram, 1990). Goetz et al (1991) found that 17% of psychiatric patients searched were carrying weapons.

Other risk factors include the early release from hospitals of the acute and chronically mentally ill, the right of patients to refuse psychotropic treatment, inability to involuntarily hospitalize mentally ill persons unless they pose an immediate threat to themselves or others, and the use of hospitalization in lieu of incarceration of criminals. McNeil et al (1991) found that police referrals were significantly more likely to have displayed violent behavior such as physical attacks and fear inducing behavior during the 2 weeks before coming to the psychiatric emergency service and during the initial 24 hours of evaluation and treatment.

Work Practices

Many studies have implicated staffing patterns as contributors to violence. Both Jones (1985) and Fineberg et al (1988) found that shortage of staff and the reduction of trained, regular staff increased the incidence of violence. Assaults were associated with meal times, visiting times and times of increased staff responsibilities. This suggests that staffing evaluations do not take into account the potential hazards associated with increased activity in the units or for times when transportation of clients is needed. Assaults were also noted at night when staffing is usually reduced. Frequency of exposure to and interaction with patients or clients are known factors which increase a health care or community worker's vulnerability. Work in high crime areas, at an isolated work station or working alone without systems for emergency assistance may increase the risk of assaults. In addition, typical work activities may arouse anger or fear in some patients and result in acts of violence. Long waits in emergency rooms and inability to obtain needed services are seen as contributors to the problem of violence. This was evidenced in the emergency department shooting in Los Angeles were three doctors were shot by and angry dissatisfied and disturbed client.

Perpetrator and Victim Profile

It is difficult to predict when or which patients/clients will become violent since the majority of assaults are perpetrated by a minority of persons. More acute and untreated mentally ill persons are being admitted to and quickly released from psychiatric hospitals and are in need of intensive outpatient treatment and services. These services are often lacking due to funding cuts. Further, clearly only a small percentage of violence is perpetrated by the mentally ill. Gang members, distraught relatives, drug users, social deviants or threatened individuals are often aggressive or violent.

A history of violent behavior is one of the best indicators of future violence by an individual. This information, however, may not by available, especially for new patients or clients. Even if this information were available, workers not directly involved with the individual client would not have access to it. At times violence is not aimed at the actual care giver. Keep et al (1992) reported on the gun shot death of a nurse and an emergency medical technician student who were targets of a disturbed family member of a patient who died in surgery the previous day.

Workers who make home visits or community work cannot control the conditions in the community, and have little control over the individuals they may encounter in their work. Dillon (1992) reported the shooting death of four county workers in upstate New York and the beating death of a case worker who removed a 7-year-old child from a violent home. The victim of assault is often untrained and unprepared to evaluate escalating behavior and to know and practice methods of defusing hostility or protecting themselves from violence. Training, when provided is often not required as part of the job and may be offered infrequently. However, using training as the sole safety program element, creates an impossible burden on the employee for safety and security for him or herself, co-workers or other clients. Personal protective measures may be needed and communication devices are often lacking.

B. Cost of Violence

Little has been done to study the cost to employers and employees of work-related injuries and illnesses, including assaults. A few studies have shown an increase in assaults over the past two decades. Adler et al, (1983) reported 422 work days lost over a two year period due to violence to 28 workers, an increase from the previous two years in which 11 workers lost 62 work days. Carmel & Hunter (1989) reported that of 121 workers sustaining 134 injuries, 43% involved lost time from work with 13% of those injured missing more than 21 days from work. In this same investigation, an estimate of the costs of assault was that the 134 injuries from patient violence cost $766,000 and resulted in 4,291 days lost and 1,445 days of restricted duty. Lanza and Milner (1989) reported 78 assaults during a 4 month period. If this pattern were repeated for the remainder of the year, 312 assaults could be expected with a staggering cost per year from medical treatment and lost time. Additional costs may result from security or response team time, employee assistance program or other counseling services, facility repairs, training and support services for the unit involved, modified duty, and reduction of effectiveness of work productivity in all staff due to a heightened awareness of the potential for violence.

True rates of violence at health care and community service facilities however, must be assumed to be higher than documented rates. Episodes of violence are often unreported. If reported, records are not necessarily maintained. Nurses and other health care professionals are reluctant to report assaults or threatening behavior when the prevailing attitude of administrators and supervisors and sometimes other staff members, is that violence "comes with the territory" or "health professionals accept the risk when they enter the field." Administrators, peers and even the victims themselves, may initially assume that the violent act resulted from a failure to deal effectively or therapeutically with the client or patient and thus attribute the incident to professional incompetence. Lanza and Carifio (1991) in a study to determine causal attributions made to nurses who are victims of assault found that women are blamed more than men and that if injured, "the nurse must have done something wrong."

In addition to the blame and potential for improper evaluation of the worker's skills, physical and emotional injury may have occurred. Poster and Ryan (1989 a) report that cognitive emotional and physical sequel may be present long after the victim has returned to work. Davidson and Jackson (1985), Lanza (1983 and 1985 b) and Poster and Ryan (1989 a) reported that assaulted workers experience feelings of self-doubt, depression, fear, post-traumatic stress syndrome, loss of sleep, irritability, disturbed relationships with family and peers, decreased ability to function effectively at the workplace, increased absenteeism and flight from the health care profession. The mental costs to the victim of violence should be recognized and even if physical injury did not occur, professional counseling services may be required to aid in an employee's recovery. The articles referenced all describe the need for and the conduct of counseling programs. Ryan and Poster (1989 b) document the benefits of counseling for rapid recovery after assault. The costs to the employee are often unrecognized and thus are not included in any cost accounting of the problem.

White and Hatcher (1988) discuss costs to the organization and the victim of violence pointing to the increased costs due to the "2nd injury" phenomenon of perceived rejection of the victim by the agency, co-workers and even family, resulting in filing of lawsuits. These suits may cause substantial long term costs to the agency.

C. Prevention

Although it is difficult to pin-point specific causes and solutions for the increase in violence in the workplace and in particular health care settings, recognition of the problem is a beginning. Some solutions to the overall reduction of violence in this country may be found in actions such as eliminating violence in television programs, implementing effective programs of gun control, and reducing drug and alcohol abuse. All companies should investigate programs recently instituted by several convenience store chains or robbery deterrence strategies such as increased lighting, closed circuit TV monitors, visible money handling locations, if sales are involved, limiting access and egress and providing security staff.

Other methods of preventing assault may be in expanding the national data base with standardized reporting and information collection systems. It may also be necessary to fund and conduct research on post assault outcomes, the need for rehabilitation for returning to work, the length of employment after assault, and on techniques of preventing injury and death from occupational violence.

In a San Francisco hospital, methods have been developed to attempt to deal with violence issues with the formation of two focus groups. On group, "the Violence Task Force", functions to advise the administration regarding modification of hospital policy toward reducing incidents of violence. The second group, "San Francisco Emergency Workers Critical Incident Stress Debriefing Team", counsels victims of physical, sexual or verbal assault. This group also provides needed support to staff who may be exposed to bloody and brutal scenes in their work environment.

White and Hatcher (1988) have outlined management and medical objectives and responses to violence induced trauma as well as decision trees and checklists to aid in assessing and constructing a response plan. Although not necessarily incident preventing, a response plan should be incorporated into an overall plan of prevention.

Training employees in management of assaultive behavior or professional assault response has been shown by Carmel and Hunter (1990) to reduce the incidence of assaults to hospital staff. Infantino and Musingo (1985) and Blair and New (1991) also found that new and untrained staff were at risk for injury.

Keep and Glibert (1992) report that legislation is being proposed in California to make violence to emergency personnel reportable to local police and criminal charges pressed if there is sufficient evidence. This action is also recommended by Morrison and Herzog (1992) especially in relation to emergency department staff. Other staff of facilities such as psychiatric units should be advised and policies established to assist in the decision of the appropriateness and effectiveness of such action.

Administrative controls and mechanical devices are being recommended and gradually implemented but the problems appear to be escalating. Although long ignored by hospital and other administrators and professionals, the problem of workplace violence is being recognized. Increasing numbers of health care and community service workers, as well as OSHA professionals have come to the conclusion that injuries related to workplace violence should no longer be tolerated. In the past, little was done to protect workers from violence. Currently, as discussed, a variety of health care , community service facilities, unions and researchers are seeking solutions to the problem. Managers and administrators are being advised to make the provision of adequate measures to prevent violence a high priority. Some safety measures may seem expensive or difficult to implement, but are needed to adequately protect the health and well being of health care and community service workers. It is also important to recognize that the belief that certain risks are "part of the job" contributes to the continuation of violence and possibly the shortage of trained health care and community service workers.

Cal/OSHA recognizes its obligation to develop standards and guidelines to provide safe workplaces for health care and community service workers. These workplaces should be free from health and safety hazards, including fear and the threat of assaults. The Injury and Illness Prevention Program as defined under the General Industry Safety Order, Section 3203, requires all employers to develop an Injury and Illness Prevention Program for hazards unique to their place of employment. This Injury and Illness Prevention Program should provide the framework for each employer's program of preventing assaults - one of the major hazards of work in health care and community service and perhaps in the community as a whole.

These Cal/OSHA guidelines are designed to assist managers and administrators in the development and implementation of programs to protect their workers. While not exhaustive, these guidelines include philosophical approaches as well as practical methods to prevent and control assaults. The potential for violence may always exist for health care and community service workers, whether at large medical centers, community based drug treatment programs, mental health clinics, or for workers making home visits in the community. Because of the potential for injury to workers, health care and community service organizations must comply with Title 8 of the CCR, Section 3203. This regulation requires an Injury and Illness Prevention Program which stipulates that responsible persons perform worksite analyses, identify sentinel events, and establish controls and training programs to reduce or eliminate hazards to worker health and safety. We anticipate more states and Federal OSHA will eventually follow suite.

Many health care providers, researchers, educators, unions and OSHA enforcement professionals contributed to the development of these guidelines. The cooperation and commitment of employers is necessary, however, to translate these guidelines into an effective program for the occupational health and safety of health care and community service workers.

II. PROGRAM DEVELOPMENT

The guidelines are divided into two major divisions: 1) General provisions and program development. 2) Specific work setting requirements. General provisions and program development include provisions that must be adopted by all high risk industries to assess risk and to develop needed programs.

Within the specific work setting, guidelines will be subdivided into (a) engineering controls, (b) work practices, (c) personal protective measures, and (d) individualized training measures by major work site category, i.e. inpatient psychiatric hospitals and psychiatric units, hospital and emergency rooms, outpatient facilities and community workers.

A. General Program Essentials

1. Management Commitment and Employee Involvement

Commitment and involvement are essential elements in any safety and health program. Management provides the organizational resources and motivating forces necessary to deal effectively with safety and security hazards. Employee involvement, both individually and collectively, is achieved by encouraging participation in the worksite assessment, developing clear effective procedures and identifying existing and potential hazards. Employee knowledge and skills should be incorporated into any plan to abate and prevent safety and security hazards.

a. Commitment by Top Management

The implementation of an effective safety and security program includes a commitment by the employer to provide the visible involvement of administrators of hospitals, clinics and agencies, so that all employees, from managers to line workers, fully understand that management has a serious commitment to the program. An effective program should have a team approach with top management as the team leader, and should include the following:

i. The demonstration of management's concern for employee emotional and physical safety and health by placing a high priority on eliminating safety and security hazards.

ii. A policy which places employee safety and health on the same level of importance as patient/client safety. The responsible implementation of this policy requires management to integrate issues of employee safety and security with restorative therapeutic services to assure that this protection is part of the daily hospital/clinic or agency activity.

iii. Employer commitment to security through the philosophical refusal to tolerate violence in the institution and to employees and the assurance that every effort will be made to prevent its occurrence.

iv. Employer commitment to assign and communicate the responsibility for various aspects of safety and security to supervisors, physicians, social workers, nursing staff and other employees involved so that they know what is expected of them. Also to ensure that record keeping is accomplished and utilized using good principles of epidemiology to aid in meeting program goals.

v. Employer commitment to provide adequate authority and resources to all responsible parties so that assigned responsibilities can be met.

vi. Employer commitment to insure that each manager, supervisor, professional and employee responsible for the security and safety program in the workplace is accountable for carrying out those responsibilities.

vii. Employer develops and maintains a program of medical and emotional health care for employees who are assaulted or suffer abusive behavior.

viii. Development of a safety committee in keeping with requirements of GISO 3203 and which evaluates all reports and records of assaults and incidents of aggression. When this committee makes recommendations for correction, the employer reports back to the committee in a timely manner on actions taken on the recommendation.

b. Employee Involvement

An effective program includes a commitment by the employer to provide for, and encourage employee involvement in the safety and security program and in the decisions that affect worker safety and health as well as client well-being. Involvement may include the following:

i. An employee suggestion/complaint procedure which allows workers to bring their concerns to management and receive feedback without fear of reprisal or criticism of ability.

ii. Employees follow a procedure which requires prompt and accurate reporting of incidents with or without injury. If injury has occurred, prompt first aid or medical aid must be sought and treatment provided or offered.

iii. Employees participate in a safety and health committee that receives information and reports on security problems, makes facility inspections, analyzes reports and data and makes recommendations for corrections.

iv. Employees participate in case conference meetings, and present patient information and problems which may help employees to identify potentially violent patients and discuss safe methods of managing difficult clients (identification of potential perpetrators).

v. Employees participate in security response teams that are trained and possess required professional assault response skills.

vi. Employees participate in training and refresher courses in professional assault response training such as to learn techniques of recognizing escalating agitation, deflecting or controlling the undesirable behavior and, if necessary, of controlling assaultive behavior, protecting clients and other staff members.

vii. Participation in training as needed in non-hospital work settings, such as "dealing with the hostile client" or even the police department program of "personal safety" should be provided and required to be attended by all involved employees.

2. Written Program

Effective implementation requires a written program for job safety, health and security that is endorsed and advocated by the highest level of management and professional practitioners or medical board. This program should outline the employer's goals and objectives. The written program should be suitable for the size, type and complexity of the facility and its operations and should permit these guidelines to be applied to the specific hazardous situation of each health care unit or operation.

The written program should be communicated to all personnel regardless of number of staff or work shift. The program should establish clear goals and objectives that are understood by all members of the organization. The communication needs to be extended to physicians, psychiatrists, etc. and all levels of staff including housekeeping, dietary and clerical.

3. Regular Program Review and Evaluation

Procedures and mechanisms should be developed to evaluate the implementation of the security program and to monitor progress. This evaluation and recordkeeping program should be reviewed regularly by top management and the medical management team. At least semiannual reviews are recommended to evaluate success in meeting goals and objectives. This will be discussed further as part of the recordkeeping and evaluation.

III. PROGRAM ELEMENTS

An effective occupational safety and health program of security and safety in medical care facilities and community service includes the following major program elements: (i) worksite analysis, (ii) hazard prevention and control, (iii) engineering controls, (iv) administrative controls, (v) personal protective devices, (vi)medical management and counseling, (vii) education and training, (viii) recordkeeping and evaluation.

A. Worksite Analysis

Worksite analysis identifies existing hazards and conditions, operations and situations that create or contribute to hazards, and areas where hazards may develop. This includes close scrutiny and tracking of injury/illness and incident records to identify patterns that may indicate causes of aggressive behavior and assaults.

the objectives of worksite analyses are to recognize, identify, and to plan to correct security hazards. Analysis utilizes existing records and work site evaluations including:

1. Record Review

a. Analyze medical, safety, and insurance records, including the OSHA 200 log and information compiled for incidents or near incidents of assaultive behavior from clients or visitors. This process should involve health care providers to ensure confidentiality of records of patients and employees. this information should be used to identify incidence, severity and establish a base line for identifying change.

b. Identify and analyze any apparent trends in injuries relating to particular departments, units, job titles, unit activities or work stations, activity or time of day. It may include identification of sentinel events such as threatening of providers of care or identification and classification of clients anticipated to be aggressive.

2. Identification of Security Hazards

Worksite analysis should use a systematic method to identify those areas needing in-depth scrutiny of security hazards. This analysis should do the following:

a. Identify those work positions in which staff is at risk of assaultive behavior.

b. Use a checklist for identifying high risk factors that includes components such as type of client, physical risk factors of the building, isolated locations/job activities, lighting problems, high risk activities or situations, problem clients, uncontrolled access, and areas of previous security problems.

c. Identify low risk positions for light or relief duty or restricted activity work positions when injuries do occur.

d. Determine if risk factors have been reduced or eliminated to the extent feasible. Identify existing programs in place and analyze effectiveness of those programs, including engineering control measures and their effectiveness.

e. Apply analysis to all newly planned and modified facilities, or any public services program to ensure that hazards are reduced or eliminated before involving patients/clients or employees.

f. Conduct periodic surveys at least annually or whenever there are operation changes, to identify new or previously unnoticed risks and deficiencies and to assess the effects of changes in the building designs, work processes, patient services and security practices. Evaluation and analysis of information gathered and incorporation of all this information into a plan of correction and on going surveillance should be the result of the work site analysis.

B. Hazard Prevention and Control

Selected work settings have been utilized for discussion of methods of reducing hazards. Each of the selected work situations - psychiatric hospitals and psychiatric wards, hospitals and emergency rooms, outpatient facilities and community work settings will be addressed with general engineering concepts, specific engineering and administrative controls, work practice controls and personal protective equipment as appropriate to control hazards. These methods are contained in B through F.

1. Engineering, Administrative & Work Practice Controls For All Settings

a. General Building, Work Station and Area Designs

Hospital, clinic, emergency room and nurse's station designs are appropriate when they provide secure, well-lighted protected areas which do not facilitate assaults or other uncontrolled activity.

i. Design of facilities should ensure uncrowned conditions for staff and clients. Rooms for privacy and protection, avoiding isolation are needed. For example, doors must be fitted with windows. Interview rooms for new patients or known assaultive patients should utilize a system which provides privacy but which may also permit other staff to see activity. In psychiatric units "time out" or seclusion rooms are needed. In emergency departments, rooms are needed in which agitated patients may be confined safely to protect themselves, other clients and staff.

ii. Patient care rooms and counseling rooms should be designed and furniture arranged to prevent entrapment of the staff and/or reduce anxiety in clients. Light switches in patient rooms should be located outside the room. Furniture may be fixed to the floor, soft or with rounded edges and colors restful and light.

iii. Nurse's stations should be protected by enclosures which prevent patients form molesting, throwing objects, reaching into the station or otherwise creating a hazard or nuisance to staff: such barriers should not restrict communication but should be protective.

iv. Lockable and secure bathroom facilities and other amenities must be provided for staff members separate from client restrooms.

v. Client access to staff counseling rooms and other facility areas must be controlled; that is, doors from client waiting rooms must be locked and all outside doors locked from the outside to prevent unauthorized entry, but permit exit in cases of emergency or fire.

vi. Meal bars or protective decorative grating on outside ground level windows should be installed (in accordance with fire department codes) to prevent unauthorized entry.

vii. Bright and effective lighting systems must be provided for all indoor building areas as well as grounds around the facility and especially in the parking areas.

viii. Curved mirrors should be installed at intersections of halls or in areas where an individual may conceal his or her presence.

ix. All permanent and temporary employees who work in secured areas should be provided with keys to gain access to work areas when ever on duty.

x. Metal detectors should be installed to screen patients and visitors in psychiatric facilities. Emergency rooms should have available hand held metal detectors to use in identifying weapons.

b. Maintenance

i. Maintenance must be an integral part of any safety and security system. Prompt repair and replacement programs are needed to ensure the safety of staff and clients. Replacement of burned out lights, broken windows, etc. is essential to maintain the system in safe operating conditions.

ii. If an alarm system is to be effective, it must be used ,tested and maintained according to strict policy. Any personal slam devices should be carried and tested as required by the manufacturer and facility policy. Maintenance on personal and other alarm systems must take place monthly. Batteries and operation of the alarm devices must be checked by a security office to insure the function and safety of the system as prescribed by provisions of GISO 6184.

iii. Any mechanical device utilized for security and safety must be routinely tested for effectiveness and maintained on a scheduled basis.

C. Psychiatric Hospital/In-Patient Facilities

1. Engineering Control

Alarm systems are imperative for use in psychiatric units, hospitals, mental health clinics, emergency rooms, or where drugs are stored. Whereas alarm systems are not necessarily preventive, they may reduce serious injury when a client is escalating in abusive behavior or threatening with or without a weapon.

a. Alarm systems which rely on the use of telephones, whistles or screams are ineffective and dangerous. A proper system consists of an electronic device which activates an alert to a dangerous situation in two ways, visually and audibly. Such a system identifies the location of the room or action of the worker by means of an alarm sound and a lighted indicator which visually identifies the location. In addition, the alarm should be sounded in a security area or other response team areas which will summon aid. This type of alarm system typically utilizes a pen like device which is carried by the employee and can be triggered easily in an emergency situation. This system should be in accord with provisions of California Title 8, GISO Section 6184, Emergency Alarm Systems (State of California, Department of Industrial Relations GISO). Back up security personnel must be available to respond to the alarm.

b. "Panic buttons" are needed in medicine rooms, nurses stations, stairwells, and activity rooms. Any such alarm system may incorporate a telephone paging system in order to direct others to the location of the disturbance but alarm systems must not depend on the use of a telephone to summon assistance.

c. Video screening of high risk areas or activities may be of value and permits one security guard to visualize a number of high risk areas, both inside and outside the building.

d. Metal detection systems such as hand held devices or other systems to identify persons with hidden weapons should be considered. These systems are in use in courts, boards of supervisors, some Departments of Public Social Service, schools and emergency rooms. Although controversial, the fact remains that many people including homeless and mentally ill persons do or are forced to carry weapons for defense while living on the streets. Some system of identifying persons who are carrying guns, knives, ice picks, screw drivers, etc., may be useful and should be considered. In psychiatric facilities, patients who have been on leave or pass should be screened upon return for concealed weapons.

2. Administrative Controls

A sound overall security program includes administrative controls that reduce hazards form inadequate staffing, insufficient security measures and poor work practices.

a. In order to enable staff members to identify and deal effectively with clients who behave in a violent manner, the administrator must insist on plans for patient treatment regimens and management of clients which include a gradual progression of measures given to staff to prevent violent behavior from escalating. These measures should not encourage inappropriate use of medication, restraints or isolation. However, the least restrictive yet appropriate and effective plan for preventing a client from injuring staff, other clients and self must be developed and be part of every unit and care plan. This enables a staff member to take primary prevention steps to stop escalating aggressive behavior. These procedures should cover verbal or physical threats or acting out of disturbed clients to help both the client and staff to feel a sense of control within the unit.

b. Security guards must be provided. These security guards should be assigned to areas where there may be psychologically stressed clients such as emergency rooms or psychiatric services.

c. In order to staff safely, a written acuity system should be established that evaluates the level of staff coverage vis-a-vis patient acuity and activity level. Staffing of units where aggressive behavior may be expected should be such that there is always an adequate, safe staff/patient ratio. The provision of reserve or emergency teams should be utilized to prevent staff members being left with inadequate support (regardless of staffing quotas) or overwhelmed by circumstances of case load that would prevent adequate assessment of severity of illness. This also requires administrators to analyze and to identify times or areas where hostilities take place and provide a backup team of staff at levels which are safe, such as in admission units, crisis or acute units or during the night hours or meal times or any other time or activity identified as high risk.

Provision of sufficient staff of r interaction and clinical activity is important because patients/clients need access to medical assistance from staff. Possibility of violence often threatens staff when the structure of the patient/nurse relationship is weak. Therefore, sufficient staff members are essential to allow formation of therapeutic relationships and a safe environment.

d. It is necessary to establish on-call teams, reserve or emergency teams of staff who may provide services in hospitals such as, responding to emergencies, transportation or escort services, dining room assistance, or many of the other activities which tend to reduce available staff where assigned.

e. All oncoming staff or employees should be provided with a census report which indicates precautions for every client. Methods must be developed and enforced to inform float staff, new staff members or oncoming staff at change of shifts of any potential assaultive behavior problems with clients. These methods of identification should include chart tags, log books, census reports and/or any other information system within the facility. Other sources of information may include mandatory provision of probation reports of clients who may have had a history of violent behavior. However, the need for a program of "Universal Precautions for Violence" must be recognized and integrated in any patient care setting.

f. Staff members should be instructed to limit physical intervention in altercations between patients whenever possible, unless there are adequate numbers of staff or emergency response teams, and security called. In the case where serious injury is to be prevented, emergency alarm systems should always be activated. Administrators need to give clear messages to clients that violence is not permitted. Legal charges may be pressed against clients who assault other clients or staff members. Administrators should provide information to staff who wish to press charges against assaulting clients.

g. Policies must be provided 3with regard to safety and security of staff when making rounds for patient checks, key and door opening policy, open vs. locked seclusion policies, evacuation policy in emergencies and for patients in restraints. Monitoring high risk patients at nigh and whenever behavior indicates escalating aggression, needs to be addressed in policy as well as medical management protocols.

h. Escort services by security should be arranged so that staff members should not have to walk alone in parking lots or other parking areas in the evening or late hours.

i. Visitors and maintenance persons or crews should be escorted and observed while in any locked facility. Often they have tools or possessions which could be inadvertently left and inappropriately used by clients.

j. Administrators need to work with local police to establish liaison and response mechanisms for police assistance when calls are made for help by a clinic or facility, and conversely to facilitate the hospital's provisions of assistance to local police in handling emergency cases.

k. Assaultive clients may need to be considered for placement in more acute units or hospitals where greater security may be provided. It is not wise to force staff members to confront a continuingly threatening client, nor is it appropriate to allow aggressive behavior to go unchecked. Some programs may have the option of transferring clients to acute units, criminal units or to other more restrictive settings.

3. Work Practice Controls

a. Clothing should be worn which may prevent injury, such as low heeled shoes, use of conservative earrings or jewelry and clothing which is not provocative.

b. Keys should be inconspicuous and worn in such a manner to avoid incidents yet be readily available when needed.

c. Personal alarm systems described under engineering controls must be utilized by staff members and tested as scheduled.

d. No employee should be permitted to work alone in a unit or facility unless back up is immediately available.

D. Clinics and Outpatient Facilities

1. Engineering Controls

a. An emergency personal alarm system is of the highest priority. An alarm system may be of two types: the personal alarm device as identified under hospitals and in-patient facilities or the type which is triggered at the desk of the counselor or medical staff. This desk system may be silent in the counseling room, but audible in a central assistance area and must clearly identify the room in which the problem is occurring. "Panic buttons" are needed in medicine rooms, bathrooms and other remote areas such as stairwells, nurses stations, activity rooms, etc.

Such systems may use a back-up paging or public address system on the telephone in order to direct others to the location for assistance but alarm systems must not depend on the use of a telephone to summon assistance.

b. Maintenance is required for alarm systems as outlined in GISO, Section 6184.

c. Reception areas should be designed so that receptionist and staff may be protected by safety glass and locked doors to the clinic treatment areas.

d. F8urniture in crises treatment areas and quiet rooms should be kept to a minimum and be fixed to the floor. These rooms should have all equipment secured in locked cupboards.

e. First aid kits shall be available as required in GISO Section 3400.

All requirements of the Bloodborne Pathogen Standard, GISO Section 5193, apply to clinics where blood exposure is possible.

2. Work Practice and Administrative Controls

a. Psychiatric clients/patients should be escorted to and from waiting rooms and not permitted to move about unsupervised in clinic areas. Access to clinic facilities other than waiting rooms should be strictly controlled with security provisions in effect.

b. Security guards trained in principles of human behavior and aggression should be provided during clinic hours. Guards should be provided where there may be psychologically stressed clients or persons who have taken hostile actions, such as in emergency facilities, hospitals where there are acute or dangerous patients, or areas where drug or other criminal activity is common place.

c. Staff members should be given the greatest possible assistance in obtaining information to evaluate the history of, or potential for, violent behavior in patients. They should be required to treat and/or interview aggressive or agitated clients in open areas where other staff may observe interactions but still provide privacy and confidentiality.

d. Assistance and advice should be sought in case management conferences with co-workers and supervisors to aid in identifying treatment of potentially violent clients. Whenever an agitated client or visitor is encountered, treatment or intervention should be provided when possible to defuse the situation. However, security or assistance should be requested to assist in avoiding violence.

e. No employee should be permitted to work or stay in a facility or isolated unit when they are the only staff member present in the facility, if the location is so solitude that they are unable to obtain assistance if needed, or in the evening or at night if the clinic is closed.

f. Employees must report all incidents of aggressive behavior such as pushing, threatening, etc., with or without injury, and logs maintained recording all incidents or near incidents.

g. Records, logs or flagging charts must be updated whenever information is obtained regarding assaultive behavior or previous criminal behavior.

h. Administrators should work with local police to establish liaison and response mechanisms for police assistance when calls are made for help by a clinic. Likewise, this will also facilitate the clinics provision of assistance to local police in handling emergency cases.

i. Referral systems and pathways to psychiatric facilities need to be developed to facilitate prompt and safe hospitalization of clients who demonstrate violent or suicidal behavior. These methods may include: direct phone link to the local police, exchange of training and communication with local psychiatric services and written guidelines outlining commitment procedures.

j. Clothing and apparel should be worn which will not contribute to injury such as low heeled shoes, use of conservative earrings or jewelry and clothing which is not provocative.

k. Keys should be kept covered and worn in such a manner to avoid incidents, yet be available.

l. All protective devices and procedures should be required to be used by all staff.

E. Emergency Rooms and General Hospitals

1. Engineering Controls

a. Alarm systems or "panic buttons" should be installed at nurses' stations, triage stations. registration areas, hallways and in nurses lounge areas. These alarm systems must be relayed to security police or locations where assistance is available 24 hours per day. A telephone link to the local police department should be established in addition to other systems.

b. Metal detection systems installed at emergency room entrances may be used to identify guns, knives, or other weapons. Lockers can be used to store weapons and belongings or the weapons may be transferred to the local police department for processing if the weapons are not registered. Hand  metal detection devices are needed to identify concealed weapons if there is no larger system. Signs posted at the entrance will notify patients and visitors that screening will be performed.

c. Seclusion or security rooms are required for containing confused or aggressive clients. Although privacy may be needed both for the agitated patient and other patients, security and the ability to monitor the patient and staff is also required in any secluded or quiet room.

d. Bullet resistant glass should be used to provide protection for triage, admitting or other reception areas where employees may greet or interact with the public.

e. Strictly enforced limited access to emergency treatment areas are needed to eliminate unwanted or dangerous persons in the emergency room. Doors may be locked or key-coded.

f. Closed circuit TV monitors may be used to survey concealed areas or areas where problems may occur.

2. Work Practices and Administrative Controls

a. Security guards trained in principles of human behavior and aggression must be provided in all emergency rooms. Death and serious injury have been documented in emergency areas in hospitals, but the presence of security persons oft4en reduces the threatening or aggressive behavior demonstrated by patients, relatives, friends, or those seeking drugs. Armed guards must be considered in any risk assessment in high volume emergency rooms.

b. No staff person should be assigned alone in an emergency area or walk-in clinic.

c. After dark, all unnecessary doors are locked, access into the hospital is limited and patrolled by security.

d. A regularly updated policy be in place directing hostile patient management, use of restraints or other methods of management. This policy should be detailed and provide guidelines for progressively restrictive action as the situation calls for.

e. Any verbally threatening, aggressive or assaultive incident must be reported and logged.

f. Name tags need to be worn at all times in the hospital and emergency room. Hospital policy must demand that persons, including staff, who enter into the treatment area of the emergency room have or seek permission to enter the area to reduce the volume of unauthorized individuals.

g. When transferring a hostile or agitated patient (or one who may have relatives, friends or enemies who pose a security problem) to a unit within the hospital, security is required during transport and transfer to the unit. This security presence may be required until the patient is stabilized or controlled to protect staff who are providing care.

h. Emergency or hospital staff who have been assaulted should be permitted and/or assisted to request police assistance or file charges of assault against any patient or relative who injures, just as a private citizen has the right to do so. Being in the helping professions does not reduce the right of pressing charges or damages.

3. General Hospitals

a. Information must be clearly transmitted to the receiving unit of security problems with the patient. Charts must be flagged clearly noting and identifying the security risks involved with this patient.

b. If patients with any disorder or illness have a known history of violent acts, it is incumbent upon the administration to demand health care providers or physicians to disclose that information to hospital staff at the onset of hospitalization.

c. When ever patients display aggressive or hostile behavior to hospital staff members, it must be made part of the care plan that supervisors and managers are notified and protective measures and action are initiated.

d. Prompt medical or emotional evaluation treatment must be made available to any staff who has been subjected to abusive behavior from a client/patient, whether in emergency rooms, psychiatric units or general hospital settings.

e. Visitors should sign in and have an issued pass particularly in newborn nursery, pediatric departments or any other risk departments.

f. Social service/worker staff should be utilized to defuse situations. In-house social workers are an important part of the hospital staff as are employee health staff.

F. Home/Field Operations - Community Service Workers

1. Engineering Controls

a. In order to provide some measure of safety and to keep the employee in contact with headquarters or a source of assistance, cellular car phones should be installed/provided for official use when staff are assigned to duties which take them into private homes and the community. These workers may include (to name a few) parking enforcers, union business agents, psychiatric evaluators, public social service workers, children's' service workers, visiting nurses and home health aides.

b. Hand held alarm or noise devices or other effective alarm devices are highly recommended to be provided for all field personnel.

c. Beepers or alarm systems which alert a central office of problems should be investigated and provided.

d. Other protective devices should be investigated and provided such as pepper spray.

2. Work Practice and Administrative Controls

a. Employees are to be instructed not to enter any location where they feel threatened or unsafe. This decision must be the judgment of the employee. Procedures should be developed to assist the employee to evaluate the relative hazard in a given situation. In hazardous cases, the managers must facilitate and establish a "buddy system". This "buddy system" should be required whenever an employee feels insecure regarding the time of activity, the location of work, the nature of the clients health problem and history of aggressive or assaultive behavior or potential for aggressive acts.

b. Employers must provide for the field staff, a program or personal safety education. This program should be at the minimum, one provided by local police departments, or other agencies which includes training on awareness, avoidance, and action to take to prevent mugging, robbery, rapes and other assaults.

c. Procedures should be established to assist employees to reduce the likelihood of assaults and robbery from those seeking drugs or money, as well as procedures to follow in the case of threatening behavior and provision for a fail safe back-up in administration offices.

d. A fail safe back-up system is provided in the administrative office at all times of operation for employees in the field who may need assistance.

e. All incidents of threats or other aggression must be reported and logged. Records must be maintained and utilized to prevent future security and safety problems.

f. Police assistance and escorts should be required in dangerous or hostile situations or at night. Procedures for evaluating and arranging for such police accompaniment must be developed and training provided.

IV. MEDICAL MANAGEMENT

A medical program which provides knowledgeable medical and emotional treatment should be established. This program shall assure that victimized employees are provided with the same concern that is often shown to the abusive client. Violence is a major safety hazard in psychiatric and acute care facilities, emergency rooms, homeless shelters and other health care settings and workplaces. Medical and emotional evaluation and treatment are frequently needed but often difficult to obtain.

The consequences to employees who are abused by clients may include death and severe and life threatening injuries, in addition to short and long-term psychological trauma, post traumatic stress, anger, anxiety, irritability, depression, shock, disbelief, self-blame, fear of returning to work, disturbed sleep patters, headache, and change in relationships with co-workers and family. All have been reported by health care workers after assaults, particularly if the attack has come without warning. They may also fear criticism by managers, increase use of alcohol and medication to cope with stress, suffer from feelings of professional incompetence, physical illness, powerlessness, increase in absenteeism, and experience performance difficulties.

Administrators and supervisors have often ignored the needs of the physically or psychologically abused or assaulted staff, requiring them to continue working, obtain medical care from private medical doctors, or blame the individual for irresponsible behavior. Injured staff must have immediate physical evaluations, be removed form the unit and treated for acute injuries. Referral should be made for appropriate evaluation, treatment, counseling and assistance at the time of the incident and for any required follow-up treatment.

A. Medical Services Includes:

1. Provision of prompt medical evaluation and treatment whenever an assault takes place regardless of severity. A system of immediate treatment is required regardless of the time of day or night. Injured employees should be removed form the unit until order has been restored. Transportation of the injured to medical care must be provided if it is not available on-site or in an employee health service. Follow-up treatment provided at no cost to employees must also be provided.

B. Counseling Services

1. A trauma-crisis counseling or critical incident debriefing program must be established and provided on an on-going basis whichever staff are victims of assaults. This "counseling program" may be developed and provided by in-house staff as part of an employee health service, by a trained psychologist, psychiatrist, or other clinical staff members such as a clinical nurse specialist, a social worker or referral may be made to an outside specialist. In addition, peer counseling or support groups may be provided. Any counseling provided should be by well trained psychosocial counselors whether through EAP programs, in-house programs, or by other professionals away from the facility who must understand the issues of assault and its consequences.

2. Reassignment of staff should be considered when assaults have taken place. At times it is very difficult for staff to return to the same unit to face the assailant. Assailants often repeat threats and aggressive behavior and actions need to be taken to prevent this from occurring. Staff development programs should be provided to teach staff and supervisors to be more sensitive to the feelings and trauma experienced by victims of assaults. Some professionals advocate joint counseling sessions including the assaultive client and staff member to attempt to identify the motive when it occurs in inpatient facilities and to defuse situations which may lead to continued problems.

3. Unit staff should also receive counseling to prevent "blaming the victim syndrome" and to assist them with any stress problems they may be experiencing as a result of the assault. Violence often leaves staff fearful and concerned. They need to have the opportunity to discuss these fears and to know that administration is concerned and will take measures to correct deficiencies. This may be called a defusing or debriefing secession and unit staff members may need this activity immediately after an incident to enable them to continue working. First aid kits or materials must be provided on each unit or facility.

4. The replacement and transportation of the injured staff member must be provided for at earliest time. Do not leave a unit short staffed in the event of an assault. The development of an employee health service, staffed by a trained occupational health specialist, may be an important addition to the hospital team. Such employee health staff can provide treatment, arrange for counseling, refer to a specialist and should have procedures in place for all shifts. Employee health nurses should be trained in post traumatic counseling and may be utilized for group counseling programs or other assistance programs.

5. Legal advice regarding pressing charges should be available, as well as information regarding workers compensation benefits, and other employee rights must be provided regardless of apparent injury. If assignment to light duty is needed or disability is incurred, these services are to be provided without hesitation. Reporting to the appropriate local law enforcement agency and assistance in making this report is to be provided. Employees may not be discouraged or coerced when making reports or workers' compensation claims.

6. All assaults must be investigated, reports made and needed corrective action determined. However, methods of investigation must be such that the individual does not perceive blame or criticism for assaultive actions taken by clients. The circumstances of the incident or other information which will help to prevent further problems, needs to be identified, but not to blame the worker for incompetence and compound the psychological injury which is most commonly experienced.

V. RECORDKEEPING

Within the major program elements, recordkeepiing is the heart of the program, providing information for analysis, evaluation of methods of control, severity determinations, identifying training needs and overall program evaluations.

Records shall be kept of the following:

1. OSHA 200 log. OHSA regulations require entry on the Injury and Illness Log 20, of any injury which requires more than first aid, is a lost time injury, requires modified duty, or causes loss of consciousness. Assaults should be entered on the log. Doctors' reports of work injury and supervisors reports shall be kept of each recorded assault.

2. Incidents of abuse, verbal attacks or aggressive behavior which may be threatening to the worker but not resulting in injury, such as pushing, shouting, or an act of aggression toward other clients requiring action by staff should be recorded. This record may be an assaultive incident report of documented in come manner which can be evaluated on a monthly basis by department safety committee.

3. A system of recording and communicating should be developed so that all staff who may provide care for an escalating or potentially aggressive, abusive or violent client will be aware of the status of the client and of any problems experienced in the past. This information regarding history of past violence should be noted on the patient's chart, communicated in shift change report and noted in an incident log.

4. An information gathering system should be in place which will enable incorporation of past history of violent behavior, incarceration, probation reports or any other information which will assist health care staff to assess violence status. Employees are to be encouraged to seek and obtain information regarding history of violence whenever possible.

5. Emergency room staff should be encouraged to obtain and record from police and relatives, information regarding drug abuse, criminal activity or other information to adequately assist in assessing a patient. This would enable them to appropriately house, treat and refer potentially violent cases. They should document the frequency of admission of violent clients or hostile encounters with relatives and friends.

6. Records need to be kept concerning assaults, including the type of activity, i.e., unprovoked sudden attack, patient to patient altercation, and management of assaultive behavior actions. Information needed includes who was assaulted, and circumstances of the incident without focusing on any alleged wrong doing of staff persons. These records also need to include a description of the environment, location or any contributing factors, corrective measures identified, including building design, or other measures needed. Determination must be made of the nature of the injuries sustained. Severe, minor or the cause of long term disability, and the potential or actual cost to the facility and employee. Records of any lost time or other factors which may result from the incident should be maintained.

7. Minutes of the safety meetings and inspections shall be kept in accord with requirements of Title 8, Section 3203. Corrective actions recommended as a result of reviewing reports or investigating accidents or inspections need to be documented with the administration's response and completion dates of those actions should be included in the minutes and records.

8. Records of training program contents and sign-in sheets of all attendees should be kept. Attendance records at all "PART" or "MAB" training should be retained. Qualifications of trainers shall be maintained along with records of training.

VI. TRAINING AND EDUCATION

A. General

A major program element in an effective safety and security program is training and education. The purpose of training and education is to ensure that employees are sufficiently informed about the safety and security hazards to which they may be proposed and thus, are able to participate actively in their own and co-workers protection. All employees should be periodically trained in the employer's safety and security program.

Training and education are critical components of a safety and security program for employees who are potential victims of assaults. Training allows managers, supervisors, and employees to understand security and other hazards associated with a job or location within the facility, the prevention and control of these hazards, and the medical and psychological consequences of assault.

1. A training program should include the following individuals:

a. All affected employees including doctors, dentists, nurses, teachers, counselors, psychiatric technicians, social workers, dietary and housekeeping, in short, all health care and community service staff and all other staff members who may encounter or be subject to abuse or assaults from clients/patients.

b. Engineers, security officers, maintenance personnel.

c. Supervisors and managers.

d. Health care providers and counselors for employees and employee health personnel.

2. The program should be designed and implemented by qualified persons. Appropriate special training should be provided for personnel responsible for administering the training program.

3. Several types of programs are available and have been utilized, such as Management of Assaultive Behavior (MAB), Professional Assault Response Training (PART), Police Department Assault Avoidance Programs or Personal Safety training. A combination of such training may be incorporated depending on the severity of the risk and assessed risk. These management programs must be provided and attendance required at least yearly. Updates may be provided monthly/quarterly.

4. The program should be presented in the language and at a level of understanding appropriate for the individuals being trained. It should provide an overview of the potential risk of illness and injuries from assault, the causes and early recognition of escalating behavior or recognition of situations which may lead to assaults. The means of preventing or defusing volatile situations, safe methods of restraint or escape, or use of other corrective measures of safety devices which may be necessary to reduce injury and control behavior are critical areas of training. Methods of self protection and protection of co-workers, the proper treatment of staff and patient procedures, recordkeeping, and employee rights need to be emphasized.

5. The training program should also include a means for adequately evaluating its effectiveness. The adequacy of the frequency of training should be reviewed. The whole program evaluation may be achieved by using employee interviews, testing and observing and/or reviewing reports of behavior of individuals in situations that are reported to be threatening in nature.

6. Employees who are potentially exposed to safety and security hazards should be given formal instruction on the hazards associated with the unit of job and facility. This includes information on the types of injuries or problems identified in the facility, the policy and procedures contained in the overall safety program of the facility, those hazards unique to the unit or program, and the methods used by the facility to control the specific hazards. The information should discuss the risk factors that cause or contribute to assaults, etiology of violence and general characteristics of violent people, methods of controlling aberrant behavior, methods of protection, and reporting procedures and methods to obtain corrective action.

Training for affected employees should consist of both general and specific job training. "Specific job training" is contained in the following section or may be found in administrative controls in the specific work location section.

B. Job Specific Training

New employees and reassigned workers or registry staff should receive an initial orientation and hands-on-training prior to being placed in a treatment unit or job. Each new employee should receive a demonstration of alarm systems and protective devices and the required maintenance schedules and procedures. The training should also contain the use of administrative or work practice controls to reduce injury.

1. The initial training program should include:

a. Care, use and maintenance of alarm tools and other protection devices.

b. Location and operation of alarm systems.

c. MAB, PART, or other training.

d. Communication systems and treatment plans.

e. Policies and procedures for reporting incidents and obtaining medical care and counseling.

f. Injury and Illness Prevention Program (8 CCR 3203).

g. Hazard Communication Program (8 CCR 5194).

h. Bloodborne Pathogen Program if applicable (8 CCR 5193).

i. Rights of employees, treatment of injury and counseling programs.

2. On-the-job training should emphasize employee development and use of safe and efficient techniques, methods of deescalating aggressive behavior, self protection techniques, methods of communicating information which will help other staff to protect themselves and discussions of rights of employees vis-a-vis patient rights.

3. Specific measures at each location, such as protective equipment, location and use of alarm systems, determination of when to use the buddy system and so on as needed for safety, must be part of the specific training.

4. Training unit co-workers from the same unit and shift may facilitate team work in the work setting.

C. Training for Supervisors and Managers Maintenance & Security Personnel

1. Supervisors and managers are responsible for ensuring that employees are not placed in assignments that compromise safety and that employees feel comfortable in reporting incidents. They must be trained in methods and procedures which will reduce the security hazar4ds and train employees to behave compassionately with co-workers when an incident does occur. They need to ensure that employees of safe work practices and receive appropriate training to enable them to do this. Supervisors and managers therefore, should undergo training comparable to that of the employee and such additional training as will enable them to recognize a potentially hazardous situation, make changes in the physical plant, patient care treatment program, staffing policy and procedures, or other such situations which are contributing to hazardous conditions. They should be able to reinforce the employer's program of safety and security, assist security guards when needed and train employees as the need arises.

2. Training for engineers and maintenance should consist of an explanation or a discussion of the general hazards of violence, the prevention and correction of security problems and personal protection devices and techniques. They need to be acutely aware of how to avoid creating hazards in the process of their work.

3. Security personnel need to be recruited and trained whenever possible for the specific job and facility. Security companies usually provide general training on guard or security issues. However, specific training by the hospital or clinic should include psychological components of handling aggressive and abusive clients, types of disorders and the psychology of handling aggression and defusing hostile situations. If weapons are utilized by security staff, special training and procedures need to be developed to prevent inappropriate use of weapons and the creation of additional hazards.

VII. EVALUATION OF THE PROGRAM

Procedures and mechanisms should be developed to evaluate the implementation of the safety and security programs and to monitor progress and accomplishments. Top administrators and medical directors should review the program regularly. Semi-annual reviews are recommended to evaluate success in meeting goals and objectives. Evaluation techniques include some of the following:

A. Establishment of a uniform reporting system and regular review of reports.

B. Review of reports and minutes of safety and security committee.

C. Analyses of trends and rates in illness/injury or incident reports.

D. Survey employees.

E. Before and after surveys/evaluations of job or worksite changes or new systems.

F. Up to date records of job improvements or programs implemented.

G. Evaluation of employee experiences with hostile situations and results of medical treatment programs provided. Follow up should be repeated several weeks and several months after an incident.

Results of management's review of the program should be a written progress report and program update which should be shared with all responsible parties and communicated to employees. New or revised goals arising from the review identifying jobs, activities, procedures and departments should be shared with all employees. Any deficiencies should be identified and corrective action taken. Safety of employees should not be given a lesser priority than client safety as they are often dependent on one another. If it is unsafe for employees, the same problem sill be the source of risk to other clients or patients.

Managers, administrators, supervisors, medical and nursing directors should review the program frequently to reevaluate goals and objectives and discuss changes. Regular meetings with all involved including the safety committee, union representatives and employee groups at risk should be held to discuss changes in the program.

If we are to provide a safe work environment, it must be evident from administrators, supervisors, and peer groups that hazards from violence will be controlled. Employees in psychiatric facilities, drug treatment programs, emergency rooms, convalescent homes, community clinics or community settings are to be provided with a safe and secure work environment and injury from assault is not to be accepted or tolerated and is no longer "part of the job".

VIII. REFERENCES AND ADDITIONAL READINGS

Adler, W. N., Kreeger, C., & Ziegler, P. (1983). Patient violence in a psychiatric hospital. In J. R. Lion & W. H. Reid (Eds.). Assaults within Psychiatric Facilities, (pp. 81-90). Orlando, FL: Grune & Stratton, Inc.

Bell, C. ( 1991) Female homicides in United States workplaces, 1980-1985. American Journal of Public Health, 81(6), 729-732.

Blair, T., & New, S.A. (1991). Assault behavior. Journal of Psychosocial Nursing,29(11), 25-29.

Bernstein, H. A. (1981). Survey of threats and assaults directed toward psychotherapists. American Journal of Psychotherapy, 35(4), 542-549.

California Department of Industrial Relations, California Code of Regulations, Title 8, General Industry Safety Orders. Sections 3203, 6184 & 3400.

Carmel, H., & Hunter, M. (1989). Staff injuries from inpatient violence. Hospitals and Community Psychiatry, 40(1), 41-46.

Carmel, H., & Hunter, M. ( 1990). Compliance with training in managing assaultive behavior and injuries from in-patient violence. Hospital & Community Psychiatry, 41(5), 558-56.

Centers for disease control (CDC). (1990). Occupational Homicides Among Women-United States, 1980-1985. MMWR, 39, 543-544, 551-552.

Cohen, S., Kamarck, T., & Mermelstein, R. ( 1983, December). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396

Conn, L. M., & Lion, J.R. ( 1983). Assaults in a university hospital. Assaults Within Psychiatric Facilities, (pp. 61-69). Philadelphia, PA: W. B. Saunders & Co.

Craig, T. J. (1982). An epidemiological study of problems associated with violence among psychiatric inpatients. American Journal of Psychiatry, 139(10), 1262- 1266.

Cronin, Michael (1991). New law aims to reduce kidnappings. Nurse Week, 5(3), 1 & 24.

Davidson, P., & Jackson, C. (1985). The nurse as a survivor: delayed post-traumatic stress reaction and cumulative trauma in nursing. International Journal of Nursing Studies, 22(1), 1-13.

Dillion, S. (1992). Social workers: Targets in a violent society. New York Times, 11/18/92, pp. A1 & A18.

Edelman, S. E. (1978). Managing the violent patient in a community mental health center. Hospital & Community Psychiatric, 29(7), 460-462.

Eichelman, E. (1984). A behavioral emergency plan. Hospital & Community Psychiatry, 35(10), 1678.

Engle, F., & Marsh, S. (1986). Helping the employee victim of violence in hospitals. Hospital & Community Psychiatry, 37(2), 159-162.

Fineberg, N. A., James, D. V. & Shah, A. K. (1988). Agency nurses and violence in a psychiatric ward. The Lancet, 1, 474.

Goetz, R. R., Bloom, J. D., Chenell, S. L. & Moorhead, J. C. (1981). Weapons possessed by patients in a university emergency department. Annals of Emergency Medicine, 20(1), 8-10.

Gosnolk, D. K. (1978). The violence patient in the accident and emergency department. Royal Society of Health Journal, 98(4), 289-190.

Haffke, E. A., & Reid, W. H. (1983). Violence against mental health personnel in Nebraska. In J. R. Lion, & W. H. Reid (Eds.), Assaults within Psychiatric Facilities (pp. 91-102). Orlando FL: Grune and Stratton, Inc.

Hatti, S., Dubin, W. R., & Weiss, K. J. (1982). A study of circumstances surrounding patient assaults on psychiatrists. Hospital & Community Psychiatry, 33(8), 660-661.

Hodgkinson, P., Hillis, T. & Russell, D. (1984). Assault on staff in psychiatric hospitals. Nursing Times, 80, 44-46.

Infantino, A. J., & Musingo, S. (1983). Assaults and injuries among staff with and without training in aggression control techniques. Hospital & Community Psychiatry, 36, 1312-1314.

Ionno, J. A. (1983). A prospective study of assaultive behavior in female psychiatric inpatients. In J. R. Lion, & W. H. Reid (Eds). Assaults within Psychiatric Facilities, (pp. 71-80). Orlando, FL: Grune & Stratton, Inc.

Jones, M. K. (1985). Patient violence report of 200 incidents. Journal of Psychosocial Nursing and Mental Health Services, 23(6), 12-17.

Jenkins, L. E., Layne, L. & Kesner, S. (1992) Homicides in the workplace. The Journal of the American Association of Occupational Health Nurses, 40(5), 215-218.

Keep, N., & Gilbert, P., et al (1992). California Emergency Nurses Association's informal survey of violence in California emergency departments. Journal of Emergency Nursing, 18(5), 443-442.

Kraus, J. F. (1987). Homicide while at work: Persons, industries and occupations at high risk. American Journal of Public Health, 77, 1285-1289.

Kurlowitcz, L. (1990). Violence in the Emergency Department. American Journal of Nursing, 90(9), 34-37.

Kuzmits, F. E. (1990). When employees kill other employees: The case of Joseph T. Wesbecker. Journal of Occupational Medicine, 32(10), 1014-1020.

La Brash, L., Cain, J. (1984). A near-fatal assault on a psychiatric unit. Hospital & Community Psychiatry, 35(2), 168-169.

Lanza, M. L. (1983).The reactions of nursing staff to physical assault by a patient. Hospital and Community Psychiatry, 34(1), 44-47.

Lanza, M. L. (1984a). Factors affecting blame placement for patient assault upon nurses. Issues in Mental Health Nursing, 6 (1-2), 143-161.

Lanza, M. L. (1984b). A follow-up study of nurses' reactions to physical assault. Hospital & Community Psychiatry, 35(5), 492-494.

Lanza, M. L. (1984c). Victim assault support team for staff. Hospital & Community Psychiatry, 35(5), 414-417.

Lanza, M. L. (1985a). Counseling services for staff victims of patient assault. Administration in Mental Health, 12(3), 205-207.

Lanza, M. L. (1985b). How nurses react to patient assault. Journal of Psychosocial Nursing, 23(6), 6-11.

Lanza, M. L., & Carifio, J. (1991). Blaming the victim: complex ( non-linear) patterns of causal attribution by nurses in response to vignettes of a patient assaulting a nurse. Journal of Emergency Nursing, 17(5), 299-309.

Lanza, M. L., & Milner, J. (1989). The dollar cost of patient assaults. Hospital and Community Psychiatry, 40(12), 1227-1229.

Lavoie, F., Carter, G. L., Denzel, D. F., & Berg, R. L. (1988). Emergency department violence in United States teaching hospitals. Annals of Emergency Medicine, 17(11), 1227-1233.

Levin, P. F., Hewitt, J., Misner, S. (1992). Female workplace homicides. The Journal of the American Association of Occupational Health Nurses, 40(8), 229-236.

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IX. GLOSSARY

Abusive behavior: Actions which result in injury such as slapping, pinching, pulling hair or other actions such as pulling clothing, spitting, threats or other fear producing actions such as racial slurs, posturing, damage to property, throwing food or objects.

Assault: Any aggressive act of hitting, kicking, pushing, biting, scratching, sexual attack or any other such physical or verbal attacks directed to the worker by a patient/client, relative or associated individual which arises during or as a result of the performance of duties and which results in death, physical injury or mental harm.

Assaultive incident: An aggressive act or threat by a patient/client, relative or associated individual which may cause physical or mental injury, even of a minor nature, requiring first aid or reporting.

Community worker: All employed workers who provide service to the community in private homes, places of business or other locations which may present an unsafe or hostile environment. Examples of such workers includes, but is not limited to parking enforcement officers, psychiatric social workers, home health workers, union representatives, visiting or public health nurses, social service workers and home health aids. The location of the workplace may be mobile or fixed.

In-patient facility: A hospital, convalescent hospital, nursing home, board and care facility, homeless shelter, developmentally disabled facility, correction facility or any facility which provides 24 hour staffing and health care, supervision and protection.

Injury: Physical or emotional harm to an individual resulting in broken bones, lacerations, bruises and contusions, scratches, bites, breaks in the skin, strains and sprains, or other pain and discomfort immediate or delayed, caused by an interaction with a patient/client or in the performance of the job.

Management of Assaultive Behavior (MAB): A training program which trains staff to prevent assaultive incidents and to implement emergency measures when prevention fails.

Mental harm: Anxiety, fear, depression, inability to perform job functions, post traumatic stress syndrome, inability to sleep or other manifestations of emotional reactions to an assault or abusive incident.

Outpatient facility: Any health care facility or clinic, emergency, community mental health clinic, drug treatment clinic or other facility which provides drop-in or other "as needed care" or service to the community in fixed locations.

Professional Assault Response Training (PART): A training program designed to provide a systematic approach to recognition and control of escalating aggressive and assaultive behavior in a patient/client or of other hostile situations.

Psychiatric inpatient facility: Public or private psychiatric inpatient treatment facilities.

Threat: A serious declaration of intent to harm at the time or in the future.

Threat or verbal attack: Any words, racial slurs, gestures, or display of weapons which are perceived by the worker as a clear and real threat to their safety and which may cause fear, anxiety, or inability to perform job functions.

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