Last updated on 4/19/24 | First published on 4/19/24 | Literature review current through Nov. 2024
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INTRODUCTION
Overview
This topic is part of a document published by the U.S. National Institute for Occupational Safety and Health (NIOSH), which is in the public domain and may be freely copied or reprinted.[1]
Serving patients in the community is the essence of home healthcare. Yet, the community setting makes home healthcare providers more vulnerable to violent assaults. Home healthcare workers face an unprotected and unpredictable environment each time they enter the patient’s community and home. According to estimates of the Survey of Occupational Injuries and Illnesses (SOII)[2], 330 nonfatal assaults on home healthcare workers occurred in 2006—a rate of 5.5 per 10,000 full-time workers, more than twice the rate for all U.S. workers.
An effective violence protection program requires the following:
- The patient and family should provide a safe environment in the home.
- The worker should be able to assess risks in the environment.
- The employer should provide information about the responsibility of the patients family.
- The employer should train the staff to assess risks and implement acceptable interventions.[3]
WORKPLACE VIOLENCE
What are some factors that increase the risk of violence to home healthcare workers?
The patient’s home may be in a high-risk area for violence; there may be drug traffic or high-crime areas nearby. A patient’s history
of mental illness, alcoholism, drug abuse, or violence may also increase the risk. More time spent in the patient’s home may result in a higher risk of violence.[4] The employer may underestimate the risks to the workers and overestimate the support they receive.[5][6]
What does workplace violence include?
The spectrum of workplace violence ranges from verbal abuse and threats of assault (by human or animal) to homicide. Examples of violence include the following:
- Threats: expressions of intent to cause harm (verbal, body language, written)
- Physical assaults: attacks including slapping, beating, rape, homicide, and the use of weapons such as firearms, bombs, knives
- Mugging: an aggressive assault, usually by surprise and with intent to rob
Home healthcare workers may need to resolve violence issues without immediate help from their employers or coworkers. The patients may have complex physical, psychological, psychiatric, and social needs. The potential for alcohol and drug abuse and the presence of firearms in patient homes further endangers the worker.[7][8][9] Family issues are more likely to increase in intensity and become out of control in the home than in the hospital setting. Chaotic family relationships, poor resources or lack thereof, poor hygiene, and presence of animals all may increase risk of violence directed at or in the vicinity of the home healthcare worker.
Verbal abuse is a form of workplace violence and is a source of workplace stress. Verbal abuse may come from the patient, family members, or people in the community. Verbal abuse may be as subtle as constantly requesting that the home healthcare worker perform duties out of the scope of her or his job (such as cleaning) or complaining about their job performance or appearance.
Home healthcare workers don’t always report to their employer when they meet with violence while at work. Therefore, the true extent of violence in the home healthcare industry is unknown.[10] The following are reasons why violence is often not reported:
- There is no consistent definition of violence or standardized reporting procedures.
- Workers fear accusations of incompetence, or they think their employer might assume that they were the cause of the violence.
- Workers may believe that dealing with violent behavior is part of the job.
- Workers may be embarrassed and hesitant to report violent behavior.
What are some effects of this violence?
The effects of violence can range from minor to serious physical injuries to temporary or
permanent physical disability to psychological trauma. Violence can even lead to death: five home healthcare workers lost their lives in 2006 because of assaults and violent acts.
[11]Violence may also have undesirable organizational outcomes:
- Low worker morale
- Increased job stress
- Increased worker turnover
- Reduced trust of employer and coworkers
Violence or safety concerns may adversely affect the quality of patient care. If home healthcare workers do not feel safe and limit the length of time of the visits or reduce the frequency of visits, patient assessment and education will decrease. Staff may be fearful and refuse to provide services in high crime areas. All these factors may affect patient outcomes.
[4][12]PREVENTION
How can I prevent and control violence in a patient’s home?
In its document Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, OSHA
[13] encourages employers to establish violence prevention programs and to track their progress in reducing work-related assaults. At a minimum, a violence prevention program should create a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions.
Recommendations for Employers
- Develop a standard definition of workplace violence.
- Create a zero tolerance policy for workplace violence.
- Ask employees to report each incident, even if they think it won’t happen again or it might not be serious.
- Develop a written plan for ensuring personal safety, reporting violence, and calling the police.
- Conduct training on the workplace violence plan when the employee is hired and annually thereafter.
- Let workers know about the risks of their assignments and how to assess the safety of their work environment and its surroundings.
- Train employees to recognize verbal abuse.
- Train employees to identify different types of illegal drugs and drug paraphernalia.
- Train employees to recognize the signs and body language associated with violent assault and how to manage or prevent violent behavior, such as verbal de-escalation techniques, management of angry patients, recognizing and protecting themselves from gangs and gang behavior.
- Investigate all reports of a dangerous work environment and of violent assault.
- Analyze reports of violent assault, and use them for revising safety procedures.
- Do not place workers in assignments that compromise safety. Before initiating each home health service, consider the following steps:
- Check with the local police station about the safety of the location.
- Obtain consultation in the case of patients with psychiatric illnesses for an assessment of the potential for violent behavior.
- Have a social worker evaluate the family and home situation.
- Provide security or police support if needed.[4][14]
- Keep close track of staff members’ schedules.
- In the case of an unacceptable home environment, advise the patient on working with social service agencies, the local police department, or family members and neighbors to make the home less hazardous so care can continue.
- Provide cell phones to all staff on duty. Reports of surveys and focus groups indicate that home healthcare workers consider cell phones to be lifelines.[6]
- Consider other equipment, such as employer-supplied vehicles, emergency alarms, two-way radios, and personal bright flashlights to enhance safety.[6][7]
- Establish a no-weapons policy in patient homes.
- If such a policy is not required, request at a minimum that, before service is provided, all weapons be disabled, removed from the area where care is provided, and stored in a secure location.
Recommendation for Workers
- If possible, visits in high-crime areas should be scheduled during daylight hours.
- Consider working in pairs in high-crime areas.
- Always know where you are going. Have accurate directions to the house or apartment.
- Always let your employer know where you are and when to expect you to report back.
- When driving alone, have the car windows rolled up and doors locked.
- Park the car in a well-lighted area.
- Park in an area away from large trees or shrubs that a person could hide behind.
- Keep healthcare equipment, supplies, and personal belongings locked out of sight in the trunk of the vehicle.
- Before getting out of the car, check the surrounding location and activity. If you feel uneasy, do not get out of the car.
- During the visit, use basic safety precautions:
- Be alert.
- Evaluate each situation for possible violence.
- Watch for signals of impending violent assault, such as verbally expressed anger and frustration, threatening gestures, signs of drugs or alcohol abuse, or the presence of weapons.
- Maintain behavior that helps to diffuse anger:
- Present a calm, caring attitude.
- Do not match threats.
- Do not give orders.
- Acknowledge the person’s feelings.
- Avoid behaviors that may be interpreted as aggressive (for example, moving rapidly or getting too close, touching unnecessarily, or speaking loudly).
- If possible, keep an open pathway for exiting.
- Trust your own judgment; avoid situations that don’t feel right.
- If you cannot gain control of the situation, take these steps:
- Shorten the visit. Remove yourself from the situation.
- If you feel threatened, leave immediately.
- Use your cell phone to call your employer or 911 for help (depending on the severity of the situation).
- Report any incident of violence to your employer.
- Notify your employer if you observe an unsecured weapon in the patient’s home.
- If you notice strong chemical odors or suspect that there’s a drug lab in the area, notify the local police and your employer.
- If someone approaches you looking for ephedrine or pseudoephedrine, notify the local police and your employer.
- If someone approaches you looking for needles, notify your employer.
- If you are being verbally abused, ask the abuser to stop the conversation.
- If the abuser does not stop the conversation, leave the premises and notify your employer.
RESOURCES
- NIOSH. Violence on the job. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,DHHS (NIOSH) Publication No. 2004– 100d [www.cdc.gov/niosh/docs/video.html].
- NIOSH. Violence: occupational hazards in hospitals. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2002–101. (Available in English [www.cdc.gov/niosh/docs/2002-101/] and Spanish [www.cdc.gov/spanish/ niosh/docs/2002-101sp.html].)
- OSHA. U.S. Department of Labor, Workplace violence [www.osha.gov/SLTC/workplaceviolence/]. An example incident reporting form is available at [www.osha.gov/Publications/OSHA3148/osha3148.html].
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