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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


Violence, Occupational Hazards in Hospitals


 Occupational Hazards in Hospitals

 DHHS (NIOSH) Publication No. 2002-101

 April 2002

 This document is also available in Adobe's PDF format.


 Today more than 5 million U.S. hospital workers from many occupations
 perform a wide variety of duties. They are exposed to many safety and
 health hazards, including violence. Recent data indicate that hospital
 workers are at high risk for experiencing violence in the workplace.
 According to estimates of the Bureau of Labor Statistics (BLS), 2,637
 nonfatal assaults on hospital workers occurred in 1999-a rate of 8.3
 assaults per 10,000 workers. This rate is much higher than the rate of
 nonfatal assaults for all private-sector industries, which is 2 per
 10,000 workers.

 Several studies indicate that violence often takes place during times of
 high activity and interaction with patients, such as at meal times and
 during visiting hours and patient transportation. Assaults may occur
 when service is denied, when a patient is involuntarily admitted, or
 when a health care worker attempts to set limits on eating, drinking, or
 tobacco or alcohol use.

 The purpose of this brochure is to increase worker and employer
 awareness of the risk factors for violence in hospitals and to provide
 strategies for reducing exposure to these factors.

 Who is at risk?

 Although anyone working in a hospital may become a victim of violence,
 nurses and aides who have the most direct contact with patients are at
 higher risk. Other hospital personnel at increased risk of violence
 include emergency response personnel, hospital safety officers, and all
 health care providers.


 Where may violence occur?

 Violence may occur anywhere in the hospital, but it is most frequent in
 the following areas:

 · Psychiatric wards

 · Emergency rooms

 · Waiting rooms

 · Geriatric units

 What are the effects of violence?

 The effects of violence can range in intensity and include the

 · Minor physical injuries

 · Serious physical injuries

 · Temporary and permanent physical disability

 · Psychological trauma

 · Death

 Violence may also have negative organizational outcomes such as low
 worker morale, increased job stress, increased worker turnover, reduced
 trust of management and coworkers, and a hostile working environment.

 What are the risk factors for violence?

 The risk factors for violence vary from hospital to hospital depending
 on location, size, and type of care. Common risk factors for hospital
 violence include the following:

 · Working directly with volatile people, especially, if they are under
 the influence of drugs or alcohol or have a history of violence or
 certain psychotic diagnoses

 · Working when understaffed-especially during meal times and visiting

 · Transporting patients

 · Long waits for service

 · Overcrowded, uncomfortable waiting rooms

 · Working alone

 · Poor environmental design

 · Inadequate security

 · Lack of staff training and policies for preventing and managing crises
 with potentially volatile patients

 · Drug and alcohol abuse

 · Access to firearms

 · Unrestricted movement of the public

 · Poorly lit corridors, rooms, parking lots, and other areas

 Prevention Strategies for Employers

 To prevent violence in hospitals, employers should develop a safety and
 health program that includes management commitment, employee
 participation, hazard identification, safety and health training, and
 hazard prevention, control, and reporting. Employers should evaluate
 this program periodically. Although risk factors for violence are
 specific for each hospital and its work scenarios, employers can follow
 general prevention strategies.

 Environmental Designs

 · Develop emergency signaling, alarms, and monitoring systems.

 · Install security devices such as metal detectors to prevent armed
  persons from entering the hospital.

 · Install other security devices such as cameras and good lighting in

 · Provide security escorts to the parking lots at night.

 · Design waiting areas to accommodate and assist visitors and patients
 who may have a delay in service.

 · Design the triage area and other public areas to minimize the risk of

 Provide staff restrooms and emergency exits.

 Install enclosed nurses' stations.

 Install deep service counters or bullet-resistant and shatterproof glass
 enclosures in reception areas.


 Arrange furniture and other objects to minimize their use as weapons.

 Administrative Controls

 Design staffing patterns to prevent personnel from working alone and to
 minimize patient waiting time.

 Restrict the movement of the public in hospitals by card-controlled

 Develop a system for alerting security personnel when violence is

 Behavior Modifications

 Provide all workers with training in recognizing and managing assaults,
 resolving conflicts, and maintaining hazard awareness.

 Dealing With the Consequences of Violence

 Violence may occur in the workplace in spite of preventive measures.
 Employers should be prepared to deal with the consequences of this
 violence by providing an environment that promotes open communication
 and by developing written procedures for reporting and responding to
 violence. Employers should offer and encourage counseling whenever a
 worker is threatened or assaulted.

 Safety Tips for Hospital Workers

 Watch for signals that may be associated with impending violence:

 Verbally expressed anger and frustration

 Body language such as threatening gestures

 Signs of drug or alcohol use

 Presence of a weapon

 Maintain behavior that helps diffuse anger:

 Present a calm, caring attitude.

 Don't match the threats.

 Don't give orders.

 Acknowledge the person's feelings (for example, "I know you are

 Avoid any behavior that may be interpreted as aggressive (for example,
 moving rapidly, getting too close, touching, or speaking loudly).

 Be alert:

 Evaluate each situation for potential violence when you enter a room or
 begin to relate to a patient or visitor.

 Be vigilant throughout the encounter.

 Don't isolate yourself with a potentially violent person.

 Always keep an open path for exiting-don't let the potentially violent
 person stand between you and the door.

Take these steps if you can't defuse the situation quickly:

 Remove yourself from the situation.

 Call security for help.

Report any violent incidents to your management.

 Case Reports: Prevention Strategies That Have Worked

 A security screening system in a Detroit hospital included stationary
 metal detectors supplemented by hand-held units. The system prevented
 the entry of 33 handguns, 1,324 knives, and 97 mace-type sprays during a
 6-month period.

 A violence reporting program in the Portland, Oregon, VA Medical Center
 identified patients with a history of violence in a computerized
 database.* The program helped reduce the number of all violent attacks
 by 91.6% by alerting staff to take additional safety measures when
 serving these patients.
 A system restricting movement of visitors in a New York City hospital
 used identification badges and color-coded passes to limit each visitor
 to a spe cific floor. The hospital also enforced the limit of two
 visitors at a time per patient. Over 18 months, these actions reduced
 the number of reported violent crimes by 65%.


 *Health information and the electronic recording of this information
 must comply with appliscable Federal standards on privacy under Titles
 42 and 45 of the U.S. Code.


 All hospitals should develop a comprehensive violence prevention
 program. No universal strategy exists to prevent violence. The risk
 factors vary from hospital to hospital and from unit to unit. Hospitals
 should form multidisciplinary committees that include direct-care staff
 as well as union representatives (if available) to identify risk factors
 in specific work scenarios and to develop strategies for reducing them.

 All hospital workers should be alert and cautious when interacting with
 patients and visitors. They should actively participate in safety
 training programs and be familiar with their employers' policies,
 procedures, and materials on violence prevention.


 AMA [1995]. Violence in the medical workplace: prevention strategies.
 Chicago, IL: American Medical Association.

 Felton JS [1997]. Violence prevention at the health care site. Occup
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 Goodman RA, Jenkins EL, Mercy JA [1994]. Workplace-related homicide
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 Lipscomb J [1994]. Violence in the health care industry: greater
 recognition prompting occupational health and safety interventions. In:
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 FL: Lewis Publishers, pp. 29-104.

 Lipscomb J [1999]. Violence in the workplace: a growing crisis among
 health care workers. In: Charney W, Fragala G, eds. The epidemic of
 health care worker injury. Boca Raton, FL: CRC Press, pp.163-165.

 NIOSH [1996]. Current intelligence bulletin 57: violence in the
 workplace; risk factors and prevention strategies. Cincinnati, OH: U.S.
 Department of Health and Human Services, Public Health Service, Centers
 for Disease Control and Prevention, National Institute for Occupational
 Safety and Health, DHHS (NIOSH) Publication No. 96-100.

 OSHA [1996]. Guidelines for preventing workplace violence for health
 care and social service workers. Washington, DC: U.S. Department of
 Labor, Occupational Safety and Health Administration, OSHA 3148-1996.

 Simonowitz JA [1996]. Health care workers and workplace violence. Occup
 Med: State of the Art Reviews 11(2):277-291.

 Turner JT, ed. [1984]. Violence in the medical care setting: a survival
 guide. Rockville, MD: Aspen Systems Corporation.