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
Manatoba 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.
Risk factors may be viewed from the stand point of 1) the environment, 2) work
practices and 3) victim and perpetrator profile.
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.
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.
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 slients. 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.
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 ober 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.
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 assulitive 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, thowing 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 judgement 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.
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
hazards 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.
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 assualtive 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.
Levy, P., & Hartocollis, P. (1976). Nursing aides and patient violence. American
Journal of Psychiatry, 133(4), 429-431.
Lion, J. R., & Pasternak, S. A. (1973). Counter transference reactions to
violent patients. American Journal of Psychiatry, 130(2), 207-210.
Lion, J. R., & Reid, W. H. (Eds) (1983). Assaults within Psychiatric Facilities.
Orlando, FL: Grune & Stratton, Inc.
Lion, J. R., & Snyder, W., & Merrill, G. L. ( 1981). Underreporting of
assaults on staff in a state hospital. Hospital & Community Psychiatry, 32(7),
497-498.
Lipscomb, J. A. & Love, C. (1992). Violence toward health care workers. The
Journal of the American Association of Occupational Health Nurses, 40(5),
219-228.
Liss, G. M. ( 1993). Examination of workers' compensation claims among nurses in
Ontario for injuries due to violence. Unpublished report, Health & Safety
Studies Unit- Ministry of Labor.
Long Beach (Calif.) Press Telegram ( 1990), April 15,:1.
Lusk, S. L. (1992). Violence experienced by nurses' aides in nursing homes. The
Journal of the American Association of Occupational Health Nurses, 40(5),
237-241.
Madden, D. J., Lion, J. R., Penna, M. W. (1976). Assault on psychiatrists by
patients. American Journal of Psychiatry, 133(4), 422-425.
Mantel, M. (1987). The crises response team reports on Edmond, Oklahoma massacre.
Nova Newsletter 11.
McNeil, D. E. et al (1991). Characteristics of persons referred by police to
psychiatric emergency room. Hospital & Community Psychiatry, 42(4),
425-427.
Meddis, S. V. (1991). 7 cities lead violence epidemic. USAToday, April
29, 1991.
Monohan, J., & Shah, S. A. (1989). Dangerousness and commitment of the mentally
disordered in the United States. Schizpphrenia Bulletin, 15(4), 541-553.
Morrison, E. F., & Herzog, E. A. (1992). What therapeutic and protective
measures, as well as legal actions, can staff take when they are attacked by patients.
Journal of Psychosocial Nursing, 30(7), 41-44.
Navis, E. S. (1987). Controlling violent patients before they control you. Nursing
87, 17, 52-54.
Ochitill, H. N. (1983). Violence in a general hospital. In J. R. Lion & W.
H. Reid (Eds.), Assaults within Psychiatric Facilities, (pp.103-118). Orlando, FL:
Grune & Stratton, Inc.
Phelan, L. A., Mills, M. J., & Ryan, J. A. (1985). Prosecuting psychiatric
patients for assaults. Hospital & Community Psychiatry, 36(6),
581-582.
Poster, E. C., Ryan, J. A. (1989). Nurses' attitudes toward physical assaults by
patients. Archives of Psychiatric Nursing, 3(6), 315-322.
Rossi, A. M., Jacobs, M., Monteleone, M., Olson, R., Surber, R. W., Winkler, E., &
Wommack, A. (1985). Violent or fear-inducing behavior associated with hospital
admission. Hospital & Community Psychiatry, 36(6), 643-647.
Ruben, I., Wolkon, G., Yamamoto, J. (1980). Physical attacks on psychiatric
residents by patients. Journal of Nervous and Mental Disease, 168(4),
243-245.
Ryan, J. A., Poster, E. C. (1989 a). The assaulted nurse: Short-term and long-term
responses. Archives of Psychiatric Nursing, 3(6), 323-331.
Ryan, J. A., Poster, E. C. (1989b). Supporting your staff after a patient assault.
Nursing, 89, (12), 32k, 32n,32p.
Ryan, J. A., Poster, E. C. (1991). When a patient hits you. Canadian Nurse,
87(8), 23-25.
Schwartz, C. J., & Greenfield, G. P. (1978). Charging a patient with assault of
a nurse on a psychiatric unit. Canadian Psychiatric Association Journal, 23(4),
197-200.
Scott, J. R., Whitehead, J. J. (1981). An administrative approach to the problem of
violence. Journal of Mental Health Administration, 8(2), 36-40.
Sosowsky, L. (1980). Explaining the increased arrest rate among mental patients: A
cautionary note. American Journal of Psychiatry, 137(12), 1602-1605.
State of California/ Internal Memorandum (1980). Employee lost workday injuries from
client violence, 1973-1980.
Tardiff, K. (1983). A survey of assault by chronic patients in a state hospital
system. In J. R. Lion & W. H. Reid (Eds), Assaults within Psychiatric
Facilities (pp. 3-20). Orlando, FL: Grune & Stratton, Inc.
Tardiff, K. & Koenigsberg, H. W. (1985). Assaultive behavior among psychiatric
outpatients. American Journal of Psychiatry, 142(8), 960-963.
Tardiff, K., & Sweillam, A. (1980). Assault, suicide and mental illness. Archives
of General Psychiatry, 37(2), 164-169.
Tardiff, K., & Sweillam, A. (1982). Assaultive behavior among chronic
inpatients. American Journal of Psychiatry, 139(2), 212-215.
Teplin, L. (1990). The prevalence of severe mental disorder among male urban jail
detainees: Comparison with the epidemiological catchment area program. American
Journal of Public Health, 80(6), 663-669.
U. S. Department of Labor, Bureau of Labor Statistics, (1991). Occupational Injuries
and Illness in the United States by Industry, 1989. Bulletin 2379.
U. S. Department of Labor, Bureau of Labor Statistics, (1986). A Brief Guide to
Recordkeeping Requirements for Occupational Injuries and Illness. 29 CFR 1904.
Wasserberger, J., Ordog, G. J., Harden, E., Kolodny, M. & Allen, K. (1992). Violence
in the Emergency Department. Topics in Emergency Medicine, 14(2), 71-78.
Wasserberger, J., Ordog, G. J., Kolodny, M., & Allen, K. (1989). Violence in a
Community Emergency Room. Archives of Emergency Medicine, 6, 266-269.
White, S. G., & Hatcher, C. ( 1988). Violence and trauma response & Larsen,
R. C., & Felton, J. S. (Editor), Psychiatric injury in the workplace. Occupational
Medicine: State of the Art Reviews, 3(4), 677-694. Hanley& Belfus, Inc.,
Philadelphia.
Whitman, R. M., Armao, B. B., & Dent, O. B. (1976). Assault on the therapist.
American Journal of Psychiatry, 133(4), 426-429.
Wilkinson, T. (1990). Drifter judged sane in killing a mental health therapist, Los
Angeles Times, December 11, 1990, B1-B4.
Winterbottom , S. (1979). Coping with the violent patient in accident and emergency.
Journal of Medical Ethics, 5(3), 124-127.
Yesavage, J. A., Werner, P. D., Becker, J. et al. (1981). Inpatient evaluation of
aggression in psychiatric patients. Journal of Nervous and Mental Disease, 169(5),
299-302.
Zitrin, A., Hardesty, A. S., Burdock, E. L., & Drossman, A. K. (1976). Crime and
violence among mental patients. American Journal of Psychiatry, 133(2),
142-149.
