8. Hazard Prevention and Control After hazards of violence are identified through a worksite analysis, the next step is to design measures through engineering or administrative changes to control these hazards. Engineering Controls and Workplace Adaptations Engineering controls, for example, remove the hazard from the workplace or create a barrier between the worker and the hazard. Here are some examples of Engineering Controls * Install and regularly maintain alarm systems and other security devices, panic buttons, hand-held alarms or noise devices or cellular phones, and arrange for a reliable response system when an alarm is triggered. * Provide metal detectors -- installed or hand-held, where appropriate * Use a closed-circuit video recording for high-risk areas on a 24-hour basis. * Place curved mirrors at hallway intersections or concealed areas. * Enclose work stations, and install deep service counters or bullet-resistant, shatter-proof glass. * Ensure that counseling or patient care rooms have two exits. * Limit or control access to areas by using locking doors. * Arrange furniture to prevent entrapment of employee. * Lock all unused doors to limit access, in accordance with local fire codes. Administrative and Work Practice Controls Administrative and work practice controls affect the way jobs or tasks are performed. The following are some examples of Administrative and Work Practice Controls. * State clearly to patients, clients, and employees that violence is not permitted or tolerated. * Establish liaison with local police and state prosecutors. * Require employees to report all assaults or threats to a supervisor or manager * Provide management support during emergencies. Respond promptly to all complaints. * Set up a trained response team to respond to emergencies. * Ensure adequate and properly trained employee for restraining patients or clients. * Provide employee with identification badges, preferably without last names, to readily verify employment. * Develop policies and procedures covering home health care providers, such as contracts on how visits will be conducted, the presence of others in the home during the visits, and the refusal to provide services in a clearly hazardous situation.

9. 5. Incident/Accident Investigation Develop a procedure for employees to report incidents The primary consideration in developing a reporting procedure is to make sure that it encourages employees to report all incidents, even minor ones. The following information is useful when included in a threat incident report: * Name of the threat-maker and his/her relationship to the company and to the recipient. * Name(s) of victims or potential victims. * When and where the incident occurred. * What happened immediately prior to the incident. * The specific language of the threat. * Any physical conduct that would substantiate an intention to follow through on the threat. * How the threat-maker appeared (physically and emotionally). * Names of others who were directly involved and any actions they took. Names of witnesses. * What happened to the threat-maker after the incident. * Names of any supervisory staff involved and how they responded. * What event(s) triggered the incident. * Suggestions for preventing workplace violence in the future. Analyze incidents and accidents to fix system weaknesses Symptoms Surface cause Root cause Controls Improvements (Choose one) 5=Fully Met 3=Mostly Met 1=Partially Met 0=Not Present Audit questions ____ 46. Violence Incidents/Accidents are investigated for root causes. ____ 47. Investigations are conducted to improve systems. ____ 48. Investigators are trained in violence prevention procedures. ____ 49. Serious acts of violence are investigated by teams. ____ 50. Analysis and recommendations involve all interested parties. Threat assessment investigations Threat assessment investigations differ from administrative or criminal investigations in that the purpose of the threat assessment investigation is to provide guidance on managing the situation in a way that protects the employee.

10. 6. Education and Training Education and training ensures that all employee are aware of potential security hazards and how to protect themselves and their co-workers through established policies and procedures. All Employees Every employee should understand the concept of ”Universal Precautions for Violence," i.e., that violence should be expected but can be avoided or mitigated through preparation. Employees should be instructed to limit physical interventions in workplace altercations whenever possible. Employees who may face safety and security hazards should receive formal instruction on the specific hazards associated with the unit or job and facility. The training program should involve all employees, including supervisors and managers. Qualified trainers should instruct at the level appropriate for the employee. Potential training topics include: * The workplace violence prevention policy. * Risk factors that cause or contribute to assaults. * Early recognition of escalating behavior or recognition of warning signs or situations that may lead to assaults. * Ways of preventing or diffusing volatile situations or aggressive behavior, and managing anger. * A standard response action plan for violent situations, including availability of assistance, response to alarm systems, and communication procedures. * How to deal with hostile persons. * Progressive behavior control methods and safe methods of restraint application or escape. * The location and operation of safety devices such as alarms systems, along with the required maintenance schedules and procedures. * Ways to protect oneself and coworkers, including use of the "buddy system." * Policies and procedures for reporting and recordkeeping. * Policies and procedures for obtaining medical care, counseling, workers' compensation, or * legal assistance after a violent episode or injury.

13. Follow these suggestions in your daily interactions with people to de-escalate potentially violent situations. If at any time a person’s behavior starts to escalate beyond your comfort zone, disengage. Do - Project calmness, move and speak slowly, quietly and confidently. - Encourage the person to talk and listen patiently. - Focus your attention on the other person to let them know you are interested. - Maintain a relaxed yet attentive posture and position yourself at a right angle rather than directly in front of the other person. - Establish ground rules if unreasonable behavior persists. - Use delaying tactics which will give the person time to calm down. For example, offer a drink of water (in a disposable cup). - Arrange yourself so that a visitor cannot block your access to an exit. Do Not - Use styles of communication which generate hostility such as apathy, brush off, coldness, condescension, going strictly by the rules or giving the run-around. - Reject all of a client’s demands from the start. - Pose in challenging stances such as standing directly opposite someone, hands on hips or crossing your arms. Avoid any physical contact, finger pointing or long periods of fixed eye contact. - Make sudden movements which can be seen as threatening. Notice the tone, volume and rate of your speech. - Challenge, threaten, or dare the individual. - Criticize or act impatiently toward the agitated individual. - Attempt to bargain with a threatening individual. - Try to make the situation seem less serious than it is. - Make false statements or promises you cannot keep. - Take sides or agree with distortions. - Invade the individual’s personal space. Make sure there is a space of three feet to six feet between you and the person. *From Combating Workplace Violence: Guidelines for Employers and Law Enforcement. International Association of Chiefs of Police. 1996. Note: Oregon OSHA is not recommending a specific response to any situation or in any way guaranteeing the effectiveness of a particular response. Personal Conduct to Minimize Violence

15. Appendix

17. PRACTICE ACTIVITY Read the scenario below The incident An employee called a member of the company crisis team for advice, saying that a coworker was picking on her, and expressing fear that something serious might happen. For several weeks, she said, a coworker has been making statements such as, "You actually took credit for my work and you're spreading rumors that I'm no good. If you ever get credit for my work again, that will be the last time you take credit for anybody's work. I'll make sure of that." She also said that her computer files have been altered on several occasions and she suspects it's the same coworker. When she reported the situation to her supervisor, he tried to convince her that there was no real danger and that she's blowing things out of proportion. However, she continued to worry. She said she spoke with her union representative who suggested she contact the agency's workplace violence team. (Talk to employees separately, contact other employees, referral to EAP, review historical information if available, be aware of your own reactions, what about the supervisor’s reaction? Is there a need for supervisor training, review of expectations, etc.? document, outcomes and actions will vary greatly depending upon what you find out.) ACTIONS TO DATE: The agency's response plan calls for involvement of Employee Relations, Security and the Employee Assistance Program (EAP) in cases involving threats. Immediately following the report to the response team, the Security Officer contacted the female employee to assist her in filing a police report on the threat and to discuss safety measures that she should be taking. The victim was also referred to the EAP, where she received brief counseling and educational materials on handling severe stress. An investigation was immediately conducted by an investigator from the security department. In her statement, the female employee repeated what she had reported to the supervisor earlier about the threat. In his statement, the male employee stated that, on the day in question, he had been upset about what he felt were some underhanded activities by the female employee and his only recollection about the conversation was that he made a general statement like, "You'll pay," to her. He stated that this was not a threat, just an expression. The investigation showed that the employee had several previous incidents of intimidating behavior which had resulted in disciplinary actions. The employee brought in medical documentation that said he had a psychiatric disability of Post Traumatic Stress Disorder, which caused his misconduct, and he requested a reasonable accommodation. (Whatever your policy directs you to do. There is no requirement to accommodate violent behavior. The next page has EEOC guideline information)

21. Hazard Identification Worksite Analysis Worksite analysis involves a step-by-step, commonsense look at the workplace to find existing or potential hazards for workplace violence. This entails reviewing specific procedures or operations that contribute to hazards and specific locales where hazards may develop. A "Threat Assessment Team," "Patient Assault Team," similar task force, or coordinator may assess the vulnerability to workplace violence and determine the appropriate preventive actions to be taken. Implementing the workplace violence prevention program then may be assigned to this group. The team should include representatives from senior management, operations, employee assistance, security, occupational safety and health, legal, and human resources employee. The team or coordinator can review injury and illness records and workers' compensation claims to identify patterns of assaults that could be prevented by workplace adaptation, procedural changes, or employee training. As the team or coordinator identifies appropriate controls, these should be instituted. The recommended program for worksite analysis includes, but is not limited to, analyzing and tracking records, monitoring trends and analyzing incidents, screening surveys, and analyzing workplace security. Records Analysis and Tracking This activity should include reviewing medical, safety, workers' compensation and insurance records -- including the OSHA 200 log, if required -- to pinpoint instances of workplace violence. Scan unit logs and employee and police reports of incidents or near-incidents of assaultive behavior to identify and analyze trends in assaults relative to particular departments, units, job titles, unit activities, work stations, and/or time of day. Tabulate these data to target the frequency and severity of incidents to establish a baseline for measuring improvement. Monitoring Trends and Analyzing Incidents Contacting similar local businesses, trade associations, and community and civic groups is one way to learn about their experiences with workplace violence and to help identify trends. Use several years of data, if possible, to trace trends of injuries and incidents of actual or potential workplace violence. Screening Surveys One important screening tool is to give employees a questionnaire or survey to get their ideas on the potential for violent incidents and to identify or confirm the need for improved security measures. Detailed baseline screening surveys can help pinpoint tasks that put employees at risk. Periodic surveys -- conducted at least annually or whenever operations change or incidents of workplace violence occur -- help identify new or previously unnoticed risk factors and deficiencies or failures in work practices, procedures, or controls. Also, the surveys help assess the effects of changes in the work processes. The periodic review process should also include feedback and follow-up.

24. T F Exits are accessible and clearly marked. T F Employees are able to locate emergency equipment such as fire alarm boxes or emergency-generator outlets. T F Emergency equipment is accessible and free from obstruction. T F Employees are able to locate cellular phones, power-failure phones and/or radios for emergency communication. T F Employees know proper procedures if a bomb threat is announced. T F Employee emergency call-back list is up-to-date and available. T F Employees provide privacy to reflect sensitivity and respect for clients and visitors. T F Employees use the "buddy system" to work together if problems arise. T F Employees working in the field have cellular phones or other communication devices to enable them to request aid. T F Staffing levels are appropriate for department/unit functions. T F Reference manuals are up-to-date and available to employees. T F There is a grievance policy available to employees. T F There is a Safety Committee available as a resource to staff for any hazard concern. Training T F Employees have received training on the company’s workplace violence prevention program. T F Employees know how to ask for assistance by phone or by alerting other staff. T F Employees have been trained to recognize and handle threatening, aggressive, or violent behavior. T F Employees have been trained in verbal de-escalation techniques. T F Employees have been trained in self-defense/restraint procedures. Incidents and Reporting T F This work unit/department has not experienced violent behavior and assaults or threats from strangers. T F This work unit/department has not experienced violent behavior and assaults or threats from clients or customers. T F This work unit/department has not experienced violent behavior and assaults or threats from others employed in the organization. T F This work unit/department has not experienced domestic violence issues. T F Employees are required to report incidents or threats of violence, regardless of injury or severity; the reporting system is clear. T F Medical and psychological counseling services were offered to employees who have been assaulted or threatened.

25. Employee Assault Survey The following items serve merely as an example of what might be used or modified by employers in these industries to help prevent workplace violence. ID Number ___________________ I. Priorities A number of factors maybe important in preventing assaults, or reducing the impact of assaults. We would like to know your views on what the most important factors are. For these questions, please use the following definition of assault: "Physical contact that results in injury." (Injury may be major or minor; e.g., mild soreness, scratches, or bruises would be included.) 1. What do you think is the most important factor contributing to assaults on employees? ___________________________________________________________ ___________________________________________________________ A number of factors have been suggested as possibly important in determining whether assaults occur, or the impact of assaults. Please indicate which factors you think are most important. Please indicate only your top five priorities. In other words, many of the following areas maybe important, but we are interested in which are most important. Please place a "1" next to the issue that you think is the top priority, and a "2" next to the issue that you think is the next highest priority, and so forth. If you have no opinion or don't know, please check "Don't know." ___ a. Employee training in self-defense/restraint procedures ___ b. Employee interpersonal skills ___ c. Employee fitness ___ d. An effective security alarm system ___ e. Adequate numbers of personnel ___ f. Business practices (e.g., handling money) ___ g. Physical environment (e.g., noise) ___ h. Identifying customers with a history of violence ___ i. Identifying employees with potentially assaultive (e.g., agitated) behavior ___ j. Transfer of information at shift change about potentially assaultive employees ___ l. Procedures for reporting assaults to administrators ___ m. Procedures for evaluating employee who have been involved in assaults ___ n. Procedures for reporting assaults to police ___ o. Legal penalties for competent assaultive employees ___ p. Structured psychological support for assaulted employee ___ q. Timeliness of L&I processing of Worker's Compensation claims ___ r. Other _______________________________ ___ s. Don't know

26. ELEMENT 5 – INCIDENT / ACCIDENT INVESTIGATION Analyze incidents and accidents to fix system weaknesses Symptoms Surface cause Root cause Controls Improvements Audit questions ____ 46. Violence Incidents/Accidents are investigated for root causes. ____ 47. Investigations are conducted to improve systems. ____ 48. Investigators are trained in violence prevention procedures. ____ 49. Serious acts of violence are investigated by teams. ____ 50. Analysis and recommendations involve all interested parties. Threat assessment investigations Threat assessment investigations differ from administrative or criminal investigations in that the purpose of the threat assessment investigation is to provide guidance on managing the situation in a way that protects the employee. Many cases involving threatening behavior can be handled expeditiously and effectively by a supervisor with the assistance of one or more members of the company's incident response team. The security or law enforcement representative on the company's team will ordinarily assess risks, often in consultation with the Employee Assistance Program and employee relations staff, and make recommendations for appropriate strategies and security measures to protect employees. However, it may be helpful for the company's planning group to identify experts in threat assessment ahead of time, in case a situation requires more expertise than team members can provide. Gathering information. It is also a good idea to work out ahead of time who will gather which types of information on an individual who makes a threat. Multiple sources of information need to be consulted to better understand the person's behavior. In some cases, the company's incident response team can collect current and reliable information (which would include an investigative report) and then consult with a threat assessment professional to develop options for managing the situation. In other cases, the company's incident response team uses a threat assessment professional to conduct the initial investigation, assess the risks, and make recommendations for managing the situation. Administrative Investigations It is important to use an investigator who conducts the investigation in a fair and objective manner. The investigation should be conducive to developing truthful responses to issues that may surface. It must be conducted with full appreciation for the legal considerations that protect individual privacy. It is imperative that the investigation, especially the interview, create an atmosphere of candor and propriety. Use a qualified investigator. If a decision is made to conduct an administrative investigation, it is important to use a qualified and experienced professional workplace violence investigator. The company planning group should train and qualify one or more such investigators before the need for an investigator arises. Investigation and Evaluation After an incident occurs, a detailed investigation is imperative. All incidents should be investigated as soon as possible. The investigation should focus on fact-finding to prevent recurrence and not fault-finding. Employers should maintain comprehensive records of the investigation.

31. Violence In The Workplace Presented by The Public Education Section Oregon Occupational Safety and Health Division (OR-OSHA) OR-OSHA 702 0203

33. In Compliance with the Americans with Disabilities Act (ADA), this publication is available in alternative formats by calling the OR-OSHA Public Relations Manager at (503) 378-3272 (V/TTY).