[Federal Register Volume 81, Number 235 (Wednesday, December 7, 2016)]
[Proposed Rules]
[Pages 88147-88167]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-29197]


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DEPARTMENT OF LABOR

Occupational Safety and Health Administration

29 CFR Part 1910

[Docket No. OSHA--2016-0014]
RIN 1218-AD 08


Prevention of Workplace Violence in Healthcare and Social 
Assistance

AGENCY: Occupational Safety and Health Administration (OSHA), DOL.

ACTION: Request for Information (RFI).

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SUMMARY: Workplace violence against employees providing healthcare and 
social assistance services is a serious concern. Evidence indicates 
that the rate of workplace violence in the industry is substantially 
higher than private industry as a whole. OSHA is considering whether a 
standard is needed to protect healthcare and social assistance 
employees from workplace violence and is interested in obtaining 
information about the extent and nature of workplace violence in the 
industry and the nature and effectiveness of interventions and controls 
used to prevent such violence. This RFI provides an overview of the 
problem of workplace violence in the healthcare and social assistance 
sector and the measures that have been taken to address it. It also 
seeks information on issues that might be considered in developing a 
standard, including scope and the types of controls that might be 
required.

DATES: Submit comments on or before April 6, 2017. All submissions must 
bear a postmark or provide other evidence of the submission date.

ADDRESSES: Submit comments and additional materials by any of the 
following methods:
    Electronically: Submit comments and attachments electronically at 
http://www.regulations.gov, which is the Federal eRulemaking Portal. 
Follow the instructions online for making electronic submissions.
    Facsimile: OSHA allows facsimile transmission of comments and 
additional material that are 10 pages or fewer in length (including 
attachments). Send these documents to the OSHA Docket Office at (202) 
693-1648. OSHA does not require hard copies of these documents. Instead 
of transmitting facsimile copies of attachments that supplement these 
documents (for example, studies, journal articles), commenters must 
submit these attachments to the OSHA Docket Office, Technical Data 
Center, Room N-3653, OSHA, U.S. Department of Labor, 200 Constitution 
Avenue NW., Washington, DC 20210. These attachments must identify 
clearly the sender's name, the date, subject, and docket number OSHA-
2016-0014 so that the Docket Office can attach them to the appropriate 
document.
    Regular mail, express mail, hand delivery, or messenger (courier) 
service: Submit comments and any additional material (for example, 
studies, journal articles) to the OSHA Docket Office, Docket No. OSHA-
2016-0014 or RIN 1218-AD 08, Technical Data Center, Room N-3653, OSHA, 
U.S. Department of Labor, 200 Constitution Ave., NW., Washington, DC 
20210; telephone: (202) 693-2350. (OSHA's TTY number is (877) 889-
5627.) Contact the OSHA Docket Office for information about security 
procedures concerning delivery of materials by express mail, hand 
delivery, and messenger service. The hours of operation for the OSHA 
Docket Office are 10 a.m. to 3:00 p.m., e.t.
    Instructions: All submissions must include the Agency's name and 
the docket number for this Request for Information (OSHA-2016-0014). 
OSHA will place comments and other material, including any personal 
information, in the public docket without revision, and these materials 
will be available online at http://www.regulations.gov. Therefore, OSHA 
cautions commenters about submitting statements they do not want made 
available to the public and submitting comments that contain personal 
information (either about themselves or others) such as Social Security 
numbers, birth dates, and medical data.
    If you submit scientific or technical studies or other results of 
scientific research, OSHA requests (but is not

[[Page 88148]]

requiring) that you also provide the following information where it is 
available: (1) Identification of the funding source(s) and sponsoring 
organization(s) of the research; (2) the extent to which the research 
findings were reviewed by a potentially affected party prior to 
publication or submission to the docket, and identification of any such 
parties; and (3) the nature of any financial relationships (e.g., 
consulting agreements, expert witness support, or research funding) 
between investigators who conducted the research and any 
organization(s) or entities having an interest in the rulemaking and 
policy options discussed in this RFI. Disclosure of such information is 
intended to promote transparency and scientific integrity of data and 
technical information submitted to the record. This request is 
consistent with Executive Order 13563, issued on January 18, 2011, 
which instructs agencies to ensure the objectivity of any scientific 
and technological information used to support their regulatory actions. 
OSHA emphasizes that all material submitted to the record will be 
considered by the Agency if it engages in rulemaking.
    Docket: To read or download submissions or other material in the 
docket, go to: http://www.regulations.gov or the OSHA Docket Office at 
the address above. The http://www.regulations.gov index lists all 
documents in the docket. However, some information (e.g., copyrighted 
material) is not available publicly to read or download through the Web 
site. All submissions, including copyrighted material, are available 
for inspection at the OSHA Docket Office. Contact the OSHA Docket 
Office for assistance in locating docket submissions.

FOR FURTHER INFORMATION CONTACT: Press Inquiries: Frank Meilinger, 
Director, OSHA Office of Communications, Room N-3647, U.S. Department 
of Labor, 200 Constitution Avenue NW., Washington, DC 20210; telephone: 
202-693-1999; email: [email protected].
    General and technical information: Lyn Penniman, OSHA Directorate 
of Standards and Guidance, Room N-3609, U.S. Department of Labor, 200 
Constitution Avenue NW., Washington, DC 20210; telephone: 202-693-2245; 
email: [email protected].

SUPPLEMENTARY INFORMATION: 
    Copies of this Federal Register notice: Electronic copies are 
available at: http://www.regulations.gov. This Federal Register notice, 
as well as news releases and other relevant information, also are 
available at OSHA's Web page at http://www.osha.gov.
    References and Exhibits (optional): Documents referenced by OSHA in 
this request for information, other than OSHA standards and Federal 
Register notices, are in Docket No. OSHA-2016-0014 (Prevention of 
Workplace Violence in Healthcare). The docket is available at: http://www.regulations.gov, the Federal eRulemaking Portal. For additional 
information on submitting items to, or accessing items in, the docket, 
please refer to the Addresses section of this RFI. Most exhibits are 
available at http://www.regulations.gov; some exhibits (e.g., 
copyrighted material) are not available to download from that Web page. 
However, all materials in the dockets are available for inspection and 
copying at the OSHA Docket Office, Room N-3653, U.S. Department of 
Labor, 200 Constitution Avenue NW., Washington, DC.

Table of Contents

I. Overview
II. Background
    A. OSHA's Prior Actions To Protect Healthcare and Social 
Assistance Workers From Violence
    1. Guidelines for Preventing Workplace Violence for Healthcare 
and Social Assistance
    2. Enforcement Directive
    B. State Laws
    C. Recommendations From Governmental, Professional and Public 
Interest Organizations
    D. Questions for Section II
III. Defining Workplace Violence
    A. Definition and Types of Events Under Consideration
    B. Questions for Section III
IV. Scope
    A. Health Care and Social Assistance
    B. Questions for Section IV
V. Workplace Violence Prevention Programs
    A. Elements of Violence Prevention Program
    1. Management Commitment and Employee Participation
    2. Worksite Analysis and Hazard Identification
    3. Hazard Prevention and Control
    a. Engineering Controls
    b. Administrative Controls
    c. Personal Protective Equipment
    d. Innovative Strategies
    4. Safety and Health Training
    5. Recordkeeping and Program Evaluation
    a. Recordkeeping
    b. Program Evaluation
    B. Questions for Section V
    1. Questions on the Overall Program, Management Commitment and 
Employee Participation
    2. Questions on Worksite Analysis and Hazard Identification
    3. Questions on Hazard Prevention and Control
    4. Questions on Safety and Health Training
    5. Questions on Recordkeeping and Program Evaluation
VI. Costs, Economic Impacts, and Benefits
    A. Questions for Costs, Economic Impacts, and Benefits
    B. Impacts on Small Entities
    C. Questions for Section VI
VII. References

I. Overview

    OSHA is considering whether to commence rulemaking proceedings on a 
standard aimed at preventing workplace violence in healthcare and 
social assistance workplaces perpetrated by patients or clients. 
Workplace violence affects a myriad of healthcare and social assistance 
workplaces, including psychiatric facilities, hospital emergency 
departments, community mental health clinics, treatment clinics for 
substance abuse disorders, pharmacies, community-care facilities, 
residential facilities and long-term care facilities. Professions 
affected include physicians, registered nurses, pharmacists, nurse 
practitioners, physicians' assistants, nurses' aides, therapists, 
technicians, public health nurses, home healthcare workers, social and 
welfare workers, security personnel, maintenance personnel and 
emergency medical care personnel.
    OSHA's analysis of available data suggest that workers in the 
Health Care and Social Assistance sector (NAICS 62) face a 
substantially increased risk of injury due to workplace violence. Table 
1 compiles data from the Bureau of Labor Statistics' (BLS) Survey of 
Occupational Injuries and Illnesses (SOII). In 2014, workers in this 
sector experienced workplace-violence-related injuries at an estimated 
incidence rate of 8.2 per 10,000 full time workers, over 4 times higher 
than the rate of 1.7 per 10,000 workers in the private sector overall 
(BLS Table R8, 2015). Individual portions of the healthcare sector have 
much higher rates. Psychiatric hospitals have incidence rates over 64 
times higher than private industry as a whole, and nursing and 
residential care facilities have rates 11 times higher than those for 
private industry as a whole. The overall rate for violence-related 
injuries in just the social assistance subsector was 9.8 per 10,000, 
and individual industries, such as vocational rehabilitation with rates 
of 20.8 per 10,000 full-time workers are higher. In 2014, 79 percent of 
serious violent incidents reported by employers in healthcare and 
social assistance settings were caused by interactions with patients 
(BLS, 2015, Table R3, p. 40).

[[Page 88149]]



   Table 1--Cases of Intentional Injury by Other Person(s) by Industry
                             Sectors in 2014
------------------------------------------------------------------------
                                                             Rate per
                                             Nonfatal       10,000 full
                                           injury cases    time workers
                                                \1\             \2\
------------------------------------------------------------------------
All Private Sector Industries...........          15,980             1.7
Goods Producing.........................             260             0.1
Service Producing.......................          15,710             2.1
    Trade-Transportation-and Utilities..           1,950             0.9
    Leisure and Hospitality.............           1,160             1.2
    Professional and Business Services..             470             0.3
    Information.........................              40             0.2
    Financial Activities................              90             0.1
    Other Services, Except Public                     80             0.3
     Administration.....................
    Educational and Health Services.....          11,920             7.7
        Educational Services............             810             4.4
        Health Care and Social                    11,100             8.2
         Assistance.....................
            Ambulatory Healthcare                    960             1.9
             Services...................
            Hospitals...................           3,410             8.9
            Nursing and Residential Care           4,690            18.7
             Facilities.................
            Social Assistance...........           2,050             9.8
------------------------------------------------------------------------
\1\ BLS Table R4, 2015, http://www.bls.gov/iif/oshwc/osh/case/ostb4370.pdf.
\2\ BLS Table R100, 2015, http://www.bls.gov/iif/oshwc/osh/case/ostb4466.pdf.

    BLS relies on employers to report injury and illness data and 
employers do not always record or accurately record workplace injuries 
and illnesses (Ruser, 2008; Robinson, 2014; BLS, 2014). In addition, 
healthcare and social assistance employees may be reluctant to report 
incidents of workplace violence (see Section V.A.3.b below).
    Surveys of healthcare and social assistance workers provide another 
source of data useful for describing the extent of the problem. In one 
survey, 21 percent of registered nurses and nursing students reported 
being physically assaulted in a 12-month period (ANA, 2014). The U.S. 
Department of Health and Human Services (HHS) National Electronic 
Injury Surveillance System-Work Supplement (NEISS-WORK) reported that, 
of the cases where healthcare workers sought treatment for workplace 
violence related injuries in 2011 in hospital emergency rooms, patients 
were perpetrators an estimated 63 percent of the time (US GAO, 2016). 
Other perpetrators include patients' families and visitors, and co-
workers (Stokowski, 2010; BLS Data, 2013).
    A survey of 175 licensed social workers and 98 agency directors in 
a western state found that 25 percent of social workers had been 
assaulted by a client, nearly 50 percent had witnessed violence in a 
workplace, and more than 75 percent were fearful of violent acts (Rey, 
1996). A similar survey of a national sample of 633 workers randomly 
drawn from the National Association of Social Workers Membership 
Directory reported that 17.4 percent of the respondents reported being 
physically threatened, and 2.8 percent being assaulted. Verbal abuse 
was prevalent and was reported by 42.8 percent respondents (Jayaratne 
et al., 1996).
    Though non-fatal injuries predominate by a large extent, homicides 
accounted for 14 fatalities in healthcare and social service settings 
that occurred in 2014, and 10 that occurred in 2013 (BLS SOII and CFOI 
Data, 2011-2014).\1\
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    \1\ Many of the deaths in the healthcare setting involved a 
shooting, with many perpetrated by someone the worker knew, such as 
a domestic partner or coworker (US GAO, 2016). While such incidents 
often garner media attention, they are not the typical foreseeable 
workplace violence incidents that are associated with predictable 
risk factors that employers can reduce or eliminate. OSHA does not 
intend to address these types of incidents in any rulemaking 
activity.
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    This RFI is focused on workplace violence occurring in health care 
and social assistance for several reasons. While workplace violence 
occurs in other industries, health care services and social assistance 
services have a common set of risk factors related to the unique 
relationship between the care provider and the patient or client. The 
complex culture of healthcare and social assistance, in which the 
health care provider is typically cast as the patient's advocate, 
increases resistance to the notion that healthcare workers are at risk 
for patient-related violence (McPhaul and Lipscomb, 2004). In addition, 
the number of healthcare and social assistance workers is likely to 
grow as the sector is a large and growing component of the U.S. 
economy.
    OSHA has a history of providing guidance to employees and employers 
in this sector since 1996 (see Sections II and V). In addition, a body 
of knowledge has emerged in recent years from research about the 
factors that increase the risk of violence and the interventions that 
mitigate or reduce the risk in health care and social assistance. As a 
result, workplace violence is recognized as an occupational hazard for 
healthcare and social assistance, which, like other hazards, can be 
avoided or minimized when employers take appropriate precautions to 
reduce risk factors that have been shown to increase the risk of 
violence. See Section V.A.2., Worksite analysis and hazard 
identification, for a discussion of risk factors.
    Though OSHA has no intention of including violence that is solely 
verbal in a potential regulation, the Agency does ask a series of 
questions about threats that could reasonably be expected to result in 
violent acts. These threats could be verbal or written, or could be 
marked by body language.
    In order to chart the best course going forward and inform OSHA's 
approach to this hazard, OSHA has posed a number of detailed questions 
for comment throughout the RFI. To make the best decisions about OSHA's 
next steps in this area, the questions posed are designed to better 
elucidate these general subjects:
     The scope of the problem in healthcare and social 
assistance--frequency of incidents of workplace violence, where those 
incidents most commonly occur, and who is most often the victim in 
those incidents;
     The common risk factors that could be addressed;
     Interventions and controls that data show are working 
already in the field;
     The efficacy, feasibility and cost of different options.
    The remainder of the RFI is organized as follows. Section II 
provides

[[Page 88150]]

background on the growing awareness of the problem of workplace 
violence in health care and social assistance, and steps taken to date 
by OSHA, states, and the private sector. Section III discusses and 
seeks information on definitional issues. Section IV provides an 
overview of current data on the problem of workplace violence in the 
health care and social assistance sectors, and seeks input on a 
potential scope for a standard. Using OSHA's workplace violence 
guidelines as a starting point, Section V discusses the elements of a 
workplace violence prevention program that might be included in a 
standard, and asks for public input on these elements. Finally, Section 
VI seeks input on costs and economic impacts, and Section VII contains 
the references relied on by OSHA in preparing this RFI.

II. Background

A. OSHA's Prior Actions To Protect Healthcare and Social Assistance 
Workers From Workplace Violence

1. Guidelines for Preventing Workplace Violence for Healthcare and 
Social Assistance
    Protecting healthcare and social assistance workers from workplace 
violence is not a new focus for OSHA. In 1996, OSHA published the first 
version of its ``Guidelines for Preventing Workplace Violence for 
Healthcare and Social Service Workers.'' The same year, NIOSH published 
and broadly disseminated its document describing violence as an 
occupational hazard in the healthcare workplace, as well as risk 
factors and prevention strategies for mitigating the hazard (NIOSH, 
1996). In 2002, NIOSH published a report entitled ``Violence: 
Occupational Hazards in Hospitals'' (NIOSH, 2002). The current revision 
of OSHA's violence prevention guidelines (2015) is at: http://www.osha.gov/Publications/osha3148.pdf.
    OSHA's Guidelines are based on industry best practices and feedback 
from stakeholders, and provides recommendations for policies and 
procedures to eliminate or reduce workplace violence in a range of 
healthcare and social services settings. Information on five settings 
was included in the updated guidelines: Hospital settings, residential 
treatment settings, non-residential treatment/services settings, 
community care settings, and field work settings. In addition, the 
updated 2015 version covers a broader spectrum of workers in comparison 
with previously published guidelines because healthcare is increasingly 
being provided in other settings such as nursing homes, free-standing 
surgical and outpatient centers, emergency care clinics, patients' 
homes, and pre-hospitalization emergency care settings.
    The Guidelines recommend a comprehensive violence prevention 
program that consists of five core elements or ``building blocks'': (1) 
Management commitment and employee participation; (2) worksite 
analysis; (3) hazard prevention and control; (4) safety and health 
training; and (5) recordkeeping and program evaluation. These elements 
are discussed further in Section V below. While these guidelines 
provide much detailed, research-based information on specific controls 
and strategies for various healthcare and social assistance settings to 
help employers and employees prevent violence, they are recommendations 
and therefore non-mandatory.
    Lipscomb and colleagues (2006) report the results of a 
participatory intervention study that implemented and then evaluated 
violence prevention programs that were based on the 1996 OSHA 
Guidelines in three New York state mental health facilities. The New 
York State Office of Mental Health (OMH), working through its labor-
management health and safety committee established a policy requiring 
all 26 in-patient OMH facilities to develop and implement a proactive 
violence-prevention program. Recognizing the opportunity for a 
``natural'' experiment, the study investigators chose three 
``intervention'' and ``comparison'' sites, with the intervention sites 
benefitting from consultation with the study team and with the 
project's New York State-based violence-prevention coordinator. The 
intervention had three main components: (1) Implementation of a 
facility-specific violence prevention program; (2) conducting a risk 
assessment; and (3) designing and implementing feasible recommendations 
evolving from the risk assessment. The OSHA elements of management 
commitment and employee involvement, worksite analysis, hazard control 
and prevention, and training were operationalized within the project. 
The authors stated that the guideline's emphasis on management 
commitment and employee involvement was critical to the successful 
implementation of the program. Program impact was evaluated through 
focus groups and surveys. A comparison of pre- and post-intervention 
survey data indicate an improvement in staff perception of the quality 
of the facility's violence-prevention program (i.e., OSHA elements) in 
both intervention and comparison facilities.
    In 2015, OSHA also published a complementary Web page, ``Caring for 
Our Caregivers: Strategies and Tools for Workplace Violence Prevention 
in Healthcare'' containing resources and tools to help healthcare 
facilities develop and implement a workplace violence prevention 
program, located at: https://www.osha.gov/dsg/hospitals/workplace_violence.html. The focus of this guidance is primarily 
hospitals and behavioral health facilities, and the content was 
developed from examples shared with OSHA by healthcare facilities with 
various components of successful violence prevention programs.
2. Enforcement Directive
    Although OSHA has no standard specific to the prevention of 
workplace violence, the Agency currently enforces Section 5(a)(1) 
(General Duty Clause) of the OSH Act against employers that expose 
their workers to this recognized hazard. Section 5(a)(1) states that 
employers have a general duty to furnish to each of its employees 
employment and a place of employment which are free from recognized 
hazards that are causing or are likely to cause death or serious 
physical harm to its employees (29 U.S.C. 654(a)(1)). Section 5(a)(1) 
does not specifically prescribe how employers are to eliminate or 
reduce their employees' exposure to workplace violence. A standard on 
workplace violence would help clarify employer obligations and the 
measures necessary to protect employees from such violence.
    To prove a violation of the General Duty Clause, OSHA must provide 
evidence that: (1) the employer failed to keep the workplace free of a 
hazard to which its employees were exposed; (2) the hazard was 
recognized; (3) the hazard was causing or likely to cause death or 
serious injury; and (4) a feasible and useful method was available to 
correct the hazard.
    Prior to 2011, federal OSHA rarely used the General Duty Clause to 
inspect and cite healthcare and social assistance facilities for the 
hazard of workplace violence, in part because no guidance existed on 
how to conduct such an inspection. In September 2011, OSHA took an 
important step toward beginning to address workplace violence in 
healthcare and other high-risk settings by publishing a compliance 
Directive CPL 02-01-052 (https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-052.pdf), detailing potential hazards in those settings and 
providing OSHA compliance officers with

[[Page 88151]]

enforcement guidance to respond to complaints regarding the hazard of 
workplace violence. The Directive provides guidance on how a workplace 
violence enforcement case should be developed and what steps Area 
Offices should take to assist employers in addressing this hazard. The 
Agency is currently in the process of updating and revising its 
Directive.
    A relatively small percentage of the inspections related to 
workplace violence in health care facilities resulted in general duty 
clause citations. From 2011 through 2015, OSHA inspected 107 hospitals 
(NAICS code 622) and nursing and residential care facilities (NAICS 
code 623) and issued 17 general duty clause citations to healthcare 
employers for failing to address workplace violence (OSHA Enforcement 
Data).
B. State Laws
    As of August 2015, nine states had enacted laws that require 
employers who employ healthcare and/or social assistance workers to 
establish a plan or program to protect those workers from workplace 
violence: California, Connecticut, Illinois, Maine, Maryland, New 
Jersey, New York, Oregon, and Washington (US GAO, 2016). State laws 
differ widely in definitions of workplace violence, requirements and 
scopes of facilities covered. For example, Washington and New Jersey 
cover the healthcare sector broadly, while Maine covers only hospitals 
and Illinois covers only developmental disabilities and mental health 
centers. Eight state laws require worksite risk assessment to identify 
hazards that may lead to violent incidents; however, not all state 
regulations specify how to conduct a risk assessment. Only Maine does 
not have a requirement for a risk assessment. All the states but Maine 
also require violence prevention training, although requirements differ 
in frequency and format of training, as well as the occupations of the 
employees required to be trained. All nine states require healthcare 
employers to record incidents of violence against workers. Some laws 
apply specifically to healthcare settings (e.g., Washington Labor and 
Industries' RCW 49.19), while others apply more broadly to cover 
additional industries or sectors. New York is the only state that 
operates its own OSHA program that has a standard that specifically 
requires a violence prevention program; however, coverage is limited to 
public employees. California law requires hospitals to conduct security 
and safety assessments, and to use the assessment to develop and update 
a security plan (California Health and Safety Code Section 1257.7). 
Also, as of 1991, Cal/OSHA's Workplace Injury and Illness Prevention 
standard requires a program to address and prevent known occupational 
hazards, including violence.
    Tragic events are often the impetus for legislation. Such was the 
case when a psychiatric technician was strangled on the Napa State 
Hospital grounds by a patient in November 2010. (http://articles.latimes.com/2010/nov/03/local/la-me-hospital-violence-20101103). In February 2014, two healthcare worker unions, the Service 
Employees International Union (SEIU) and SEIU Nurse Alliance of 
California, filed petitions requesting the California Occupational 
Safety and Health Standards Board to adopt a new standard that would 
provide more protections to healthcare workers, specifically against 
workplace violence.
    In June 2014, California's Board requested the Division of 
Occupational Safety and Health to convene an advisory committee and 
develop a proposal for workplace violence protection standards. In 
September 2014, the governor signed Senate Bill (SB) 1299, requiring 
the Board to adopt standards developed by the Division that would 
require facilities to adopt a workplace violence prevention plan as 
part of their injury and illness prevention plan. On October 20, 2016, 
California announced the adoption of those standards, and became the 
first state to promulgate an occupational health and safety standard 
requiring healthcare facilities to take certain specific steps to 
establish, implement and maintain an effective workplace violence 
prevention plan. Implementation will begin in 2017.
    Some studies in the published literature evaluated whether 
healthcare facilities located in states with state laws have higher 
quality violence prevention programs than in states with no 
requirements, as a measure of the value or efficacy of state laws 
(Peek-Asa et al., 2007; Peek-Asa et al., 2009, Casteel et al., 2009). 
Peek-Asa et al. (2007) compared workplace violence programs in high-
risk emergency departments among a representative sample of hospitals 
in California (a state with a violence prevention law) and New Jersey 
(which at the time of the study did not have such a law). California 
had significantly higher scores for training, policies and procedures, 
but there was no difference in the scoring for security and 
environmental approaches. Program component scores were not highly 
correlated. For example, hospitals with a strong training program were 
not more likely to have strong policies and procedures. The authors 
concluded that a comprehensive approach that coordinates the components 
of training, policies, procedures, environmental approaches, and 
security is likely to be achieved only through multidisciplinary and 
representative input from the staff and management (Peek-Asa et al., 
2007).
    Two years later, the same authors (Peek-Asa et al., 2009) conducted 
studies that compared workplace violence programs in a representative 
sample of psychiatric units and facilities in California and New 
Jersey. The researchers found that a similar proportion of hospitals in 
both states had workplace violence prevention training programs. A 
higher proportion of hospitals in California had written workplace 
violence policies and a higher proportion of New Jersey hospitals had 
implemented environmental and security modifications to reduce 
violence.
    One study examined the effects of a state law on workers' 
compensation costs, and supports the conclusion that Washington State's 
efforts to reduce workplace violence in the healthcare industry have 
led to lower injury rates and workers' compensation costs. From 1997 to 
2007, the state's average annual rate of workers' compensation claims 
associated with workplace violence in the healthcare and social 
assistance industry was 75.5 per 10,000 full-time equivalent workers 
(FTEs). From 2007 to 2013, the rate had fallen to 54.5 claims per 
10,000 FTEs, a decrease of 28 percent. This improvement coincides with 
Washington's 2009 rule that required hazard assessments, training, and 
incident tracking for workplace violence (Foley, and Rauser, 2012).

C. Recommendations From Governmental, Professional and Public Interest 
Organizations

    In response to a request from members of Congress, the GAO 
conducted an investigation of OSHA's efforts to protect healthcare 
workers from workplace violence in healthcare. The investigation 
focused on healthcare, and included residential care facilities and 
home health care services.
    During its investigation, GAO identified nine states with workplace 
violence prevention requirements for healthcare employers, examined 
workplace violence incidents, conducted a literature review, and 
interviewed OSHA and state officials. The final report, published in 
April 2016, included a summary of interviews of healthcare workers, who 
described a

[[Page 88152]]

range of violent encounters with patients. See the table below for 
details.

Table 2--Examples of Workplace Violence Incidents Reported by the Health
                      Care Workers GAO Interviewed
------------------------------------------------------------------------
                                         Examples of reported workplace
        Health care facilities                 violence incidents
------------------------------------------------------------------------
Hospitals with emergency rooms.......   Worker hit in the head
                                        by a patient when drawing the
                                        patient's blood and suffered a
                                        concussion and a permanent
                                        injury to the neck.
                                        Worker knocked
                                        unconscious by a patient when
                                        starting intravenous therapy on
                                        the patient.
Psychiatric hospitals................   Worker punched and
                                        thrown against a wall by a
                                        patient and had to have several
                                        surgeries. As a result of the
                                        injuries, the worker was unable
                                        to return to work.
                                        Patient put worker in a
                                        head-lock, and worker suffered
                                        neck pain and headaches and was
                                        unable to carry out regular
                                        workload.
                                        Patient broke healthcare
                                        worker's hand when the
                                        healthcare worker intervened in
                                        a conflict between two patients.
Residential care facilities..........   Patient became upset
                                        after being deemed unfit to
                                        return home and attacked the
                                        worker.
                                        Worker hit in the head
                                        by a patient and suffered both
                                        physical and emotional problems
                                        as a result of the incident.
Home health care services............   Worker attacked by
                                        patient with dementia and had to
                                        defend self.
                                        Worker was sexually
                                        harassed by a patient when the
                                        patient grabbed the worker while
                                        rendering care.
------------------------------------------------------------------------
Source: GAO, Workplace Safety and Health: Additional Efforts Needed to
  Help Protect Healthcare Workers from Workplace Violence, 2016.

    In its final report, the GAO recommended that OSHA provide 
additional information to assist inspectors in developing citations, 
develop a policy for following up on hazard alert letters concerning 
workplace violence hazards in healthcare facilities, and assess the 
results of its efforts to determine whether additional action, such as 
development of a standard, may be needed. OSHA agreed with the GAO's 
recommendations and stated that it would take action to address them. 
Since then, OSHA's Training Institute in the Directorate of Training 
and Education developed a course on Workplace Violence Investigations 
for its Compliance Safety and Health Officers (CSHOs) and other staff 
with responsibilities in this area. In June 2016, approximately 30 
CSHOs, Area Directors, Acting Area Directors, and other OSHA staff, 
participated in the first offering of the 3-day course on workplace 
violence, which included exercises using actual scenarios encountered 
by investigators. The Agency's publication of this RFI is in part a 
response to the GAO's recommendation to consider issuance of a standard 
addressing workplace violence. OSHA will review the record developed as 
a result of the information received and decide on the appropriate 
course of action regarding a standard.
    In July 2016, a coalition of unions representing healthcare 
workers, including SEIU, AFL-CIO, and the American Federation of 
Governmental Employees, petitioned the Agency for a Workplace Violence 
Prevention Standard. National Nurses United (NNU) filed a similar 
petition. While NNU petitioned the Agency for a standard covering its 
membership only (healthcare workers), the broader coalition of labor 
unions requested a standard covering all workers in healthcare and 
social assistance. By this time, the Agency had already made the public 
aware about the publication of an RFI by November 2016, via the Unified 
Regulatory Agenda.
    In recent years, several nursing professional associations have 
published statements on workplace violence (ANA, 2015; APNA, 2008; ENA, 
2010). In addition, the ANA has published a model state law, ``The 
Violence Prevention in Health Care Facilities Act,'' recommending that 
healthcare facilities establish violence prevention programs to protect 
healthcare workers from acts of violence (ANA, 2011).
    Some organizations have recommended specific programmatic elements, 
policies, procedures and processes to reduce and prevent workplace 
violence. In 2008, APNA published recommendations for addressing 
workplace violence. In 2011, it published a report that included 
recommendations for adequate staffing, increased security, video 
monitoring, and safe areas for nurses (Cafaro, 2012; http://www.apna.org/i4a/pages/index.cfm?pageID=4912#sthash.2JKbjy3w.dpuf). The 
American Association of Occupational Health Nurses, Inc. has published 
strategies for preventing workplace violence. It also noted the problem 
of underreporting of workplace violence events, which it recommended 
should be addressed so that ``the scope of non-fatal violence in the 
workplace'' is adequately measured and in turn ``informed targeted 
prevention strategies'' are developed (AAOHN, 2015).
    In 2013, Public Citizen published ``Health Care Workers 
Unprotected; Insufficient Inspections and Standards Leave Safety Risks 
Unaddressed,'' which recommended that OSHA promulgate a standard to 
address the hazardous situations of workplace violence. Based on their 
analysis of data from the Bureau of Labor Statistics, the U.S. Census 
Bureau, OSHA, the AFL-CIO, and The Kaiser Family Foundation, they 
recommended that such a standard should require employers to create a 
policy of zero tolerance for workplace violence, including verbal and 
nonverbal threats; require workplace policies that encourage employees 
to promptly report incidents and suggest ways to reduce or eliminate 
risks; provide protections to employees to deter employers from 
retaliating against those who report workplace-violence incidents; and 
require employers to develop a comprehensive plan for maintaining 
security in the workplace (Public Citizen, 2013).
    The Society for Human Resource Management's (SHRM) Workplace 
Violence Policy provides guidance on prohibited conduct, reporting 
procedures, risk reduction measures, employees at risk, dangerous/
emergency situations, and enforcement for human resource professionals.
D. Questions for Section II
    The following questions are intended to solicit information on the 
topics covered in this section. In general, OSHA is interested in 
hearing about healthcare facilities' experiences with

[[Page 88153]]

provisions of state laws that have been shown to be effective in some 
way. Wherever possible, please indicate the title of the person 
completing the question and the type and the number of employees at 
your facility. OSHA is also interested in hearing from employers and 
managers in public sector facilities in New York State about their 
experiences with the Public Employees Safety and Health workplace 
violence prevention regulations.
    Question II.1: What state are you employed in or where is your 
facility located? If your state has a workplace violence law, what has 
been your experience complying with these requirements? Are there any 
specific provisions included in your workplace violence law that you 
think should or should not be included in an OSHA standard? If so, what 
provisions and why?
    Question II.2: For employers and managers: If your state has a 
workplace violence prevention law, have you or are you conducting an 
evaluation of the effectiveness of its programs or policies? If you are 
conducting such an analysis, how are you doing it? Have you been able 
to demonstrate improved tracking of workplace violence incidents and/or 
a change in the frequency or severity of violent incidents? If you 
think it is effective, please explain why. If you think it is 
ineffective, please explain why.
    Question II.3: If your state has workplace violence prevention 
laws, how many hours do you spend each year (month) complying with 
these laws?
    Question II.4: Please specify the number or percentage of staff 
participating in workplace violence prevention activities required 
under your state laws.
    Question II.5: Do you have experience implementing any of the 
workplace violence prevention practices recommended by the American 
Psychiatric Nurses Association (APNA), American Association of 
Occupational Health Nurses (AAOHN), or similar organizations? If so, 
please discuss the resources it took to implement the practice, and 
whether you think the practice was effective. Please provide any data 
you have to support your conclusions.

III. Defining Workplace Violence

A. Definition and Types of Events Under Consideration

    As discussed in the overview above, the data show that injuries and 
fatalities in the health care and social assistance sector due to 
workplace violence are substantially elevated compared to the private 
sector overall. This section addresses the question of how to define 
the universe of workplace violence that OSHA might cover in a standard. 
This involves at least two issues: (1) What events constitute 
``violence'' (i.e., should physical assaults be covered only, or should 
threats be considered as well?); and (2) should there be consideration 
of the type of injury (physical, psychological) and a threshold for 
harm that could be sustained as a result of the activity.
    The National Institute of Occupational Safety and Health (NIOSH) 
defines workplace violence as ``violent acts (including physical 
assaults and threats of assaults) directed toward persons at work or on 
duty'' (https://www.cdc.gov/niosh/docs/2002-101/). Examples of violence 
include threats (expressions of intent to cause harm, including verbal 
threats, threatening body language, and written threats), physical 
assaults (attacks ranging from slapping and beating to rape, homicide, 
and the use of weapons such as firearms, bombs, or knives), and 
muggings (aggravated assaults, usually conducted by surprise and with 
intent to rob) (NIOSH at: http://www.cdc.gov/niosh/docs/2002-101/default.html). OSHA's Web page refers to ``workplace violence'' as any 
act or threat of physical violence, harassment, intimidation, or other 
threatening disruptive behavior that occurs at the work site. Both the 
NIOSH definition and the general one on OSHA's Web site include 
harassment and intimidation; however, OSHA's focus has been solely on 
physical injuries resulting in serious harm. The effects of violence on 
individuals represent a range in intensity and include minor physical 
injuries; serious physical injuries; temporary and permanent physical 
disability; psychological trauma; and death. Healthcare and social 
assistance workers involved in workplace violence incidents can suffer 
physical injury, disability, and chronic pain; employees who experience 
violence also suffer psychological problems such as loss of sleep, 
nightmares, and flashbacks (Gerberich et al., 2004).
    Further, workplace violence can be classified into the following 
four categories, based on the relationship between the perpetrator and 
the victim/worker: Type I (criminal intent; the perpetrator has no 
legitimate relationship to the business), Type II (customer/client/
patient), Type III (worker-on-worker), and Type IV (personal 
relationship) (UIIPRC, 2001). Type II events occur most commonly in 
healthcare and social assistance and these events are the type 
addressed by this RFI. Type III (sometimes referred to as ``lateral 
violence'') is also commonly reported in the literature, especially 
when taking verbal abuse into account.
    OSHA intends to address only Type II, or customer/client/patient 
violence in this RFI. Type I, or criminal intent, perpetrated by 
criminals with no connection to the workplace other than to commit a 
crime, typically does not apply the healthcare environment. OSHA does 
not intend to seek information specific to Type I or Type III 
incidents, ``lateral'' or ``worker-on-worker'' violence. In addition, 
OSHA does not intend to cover Type IV incidents or violence that happen 
to be carried out in a healthcare workplace but are based on personal 
relationships. Although such incidents often garner media attention, 
they are not the typical foreseeable workplace violence incidents that 
are associated with predictable risk factors in the workplace that 
employers can reduce or eliminate. OSHA has determined that Type I, III 
and IV incidents are generally outside the scope of any potential 
rulemaking activity stemming from this RFI.

B. Questions for Section III

    The following questions are intended to solicit information on the 
topics covered in this section. Wherever possible, please indicate the 
title of the person providing the information and the type and number 
of employees of your healthcare and/or social assistance facility or 
facilities.
    Question III.1: CDC/NIOSH defines workplace violence as ``violent 
acts (including physical assaults and threats of assaults) directed 
toward persons at work or on duty'' (CDC/NIOSH, 2002). Is this the most 
appropriate definition for OSHA to use if the Agency proceeds with a 
regulation?
    Question III. 2: Do employers encourage reporting and evaluation of 
verbal threats? If so, are verbal threats reported and evaluated? If 
evaluated, how do employers currently evaluate verbal threats (i.e., 
who conducts the evaluation, how long does such an evaluation take, 
what criteria are used to evaluate verbal threats, are such 
investigations/evaluations effective)?
    Question III.3: Though OSHA has no intention of including violence 
that is solely verbal in a potential regulation, what approach might 
the Agency take regarding those threats, which may include verbal, 
threatening body language, and written, that could reasonably be 
expected to result in violent acts?
    Question III.4: Employers covered by OSHA's recordkeeping 
regulation must

[[Page 88154]]

record each fatality, injury or illness that is work-related, that is a 
new case and not a continuation of an old case, and meets one or more 
of the general recording criteria in section 1904.7 or the additional 
criteria for specific cases found in section 1904.8 through 1904.11. A 
case meets the general recording criteria in section 1904.7 if it 
results in death, loss of consciousness, days away from work or 
restricted work or job transfer, or medical treatment beyond first aid. 
What types of injuries have occurred from workplace violence incidents? 
Do these types of injuries typically meet the OSHA criteria for 
recording the injury on the 300 Log?
    Question III.5: Currently, a mental illness sustained as a result 
of an assault in the workplace, e.g., Posttraumatic Stress Disorder 
(PTSD), is not required to be recorded on the OSHA 300 Log ``unless the 
employee voluntarily provides the employer with an opinion from a 
physician or other licensed healthcare professional with appropriate 
training and experience (psychiatrist, psychologist, psychiatric nurse 
practitioner, etc.) stating that the employee has a mental illness that 
is work-related (1904.5(b)(2)(ix)).'' Although protecting the 
confidentiality of the victim is important, an unintended consequence 
of omitting these incidents from the 300 Log is that the extent of the 
problem is likely underestimated. In a workplace violence prevention 
standard, should this exclusion be maintained or be removed? Is there a 
way to capture the information about cases, while still protecting 
confidentiality?
    Question III.6: Are you aware of cases of PTSD or psychological 
trauma related to workplace violence in your facility? If so, was it 
captured in the recordkeeping system and how? Please provide examples, 
omitting personal data and information.
    Question III.7: Are there other indicators of the extent and 
severity of workplace violence in healthcare or social assistance that 
OSHA has not captured here? Please provide any additional data that you 
are aware of, or any indicators you have used in your workplace to 
address workplace violence.

IV. Scope

A. Health Care and Social Assistance

    The Health Care and Social Assistance sector is composed of a wide 
range of establishments providing varying levels of healthcare and 
social assistance services, from general medical-surgical hospitals to 
at-home patient care to treatment facilities for substance abuse 
disorders, and different types of establishments providing social 
assistance, such as child day care services, vocational rehabilitation 
and food to the needy. In 2015 the healthcare industry had a total of 
1,432,801 establishments and employed 18,738,870 workers in both 
healthcare and non-healthcare occupations (BLS, Census of Employment 
and Wages, 2016 and Occupational Employment Statistics, 2015). The 
Health Care and Social Assistance sector provides a range of services 
employing a diverse group of occupations at places such as: Nursing 
homes, free-standing surgical and outpatient centers, emergency care 
clinics, patients' homes, and pre-hospitalization emergency care 
settings. The largest occupational group employed in the Health Care 
and Social Assistance industry are healthcare practitioners (defined as 
healthcare professionals, technicians, and healthcare support workers), 
which included 6,288,040 workers in 2015, an increase of 1.2 million 
workers over the past 10 years (BLS, Occupational Employment 
Statistics, 2016). Healthcare practitioners are employed across various 
industries, but the industry with the largest concentration of 
healthcare practitioners is General Medical and Surgical Hospitals, 
which employed 2,926,350 workers in 2015.

 Table 3--Top 5 Occupations in Healthcare and Social Assistance Industry
                          Between 2005 and 2015
------------------------------------------------------------------------
                                          2005 (million)  2015 (million)
------------------------------------------------------------------------
Healthcare and social assistance                    15.2            18.7
 industry...............................
    Healthcare practitioners and                     5.1             6.3
     technical occupations..............
    Healthcare support occupations......             2.9             3.5
    Office and administrative support                2.5             2.7
     occupations........................
    Personal care and service                        1.0             1.9
     occupations........................
    Community and social services                    0.8            1.0
     occupations........................
------------------------------------------------------------------------
BLS, Occupational Employment Statistics, April 2016.

    Across all industries there were 8.0 million Health Care 
Practitioners and Technical workers employed in 2015 and can be found 
in various parts of the private sector outside of the Health Care and 
Social Assistance sector, for example in Air Transportation, 
Accommodations, Recreation, and Retail Trade. Of the almost 8.0 million 
Healthcare Practitioners and Technical workers, 515,970 are employed at 
retail trade facilities, the majority are specifically at Health and 
Personal Care Stores.
    For purposes of assessing workplace violence risk, OSHA has used 
the BLS category of Intentional Injury by Other Person. OSHA has not 
included here the BLS category of Injury by Person--Unintentional or 
Intent Unknown. That category may include some incidents classifiable 
as workplace violence, but also includes large numbers of injuries 
resulting from such causes like attempting to lift patients. 
Unintentional injuries resembling workplace violence may also be common 
in mental health services. Of the almost 16,000 cases of Intentional 
Injury by Other Persons in the private sector in 2014, 11,100 were in 
the Healthcare and Social Assistance sector (BLS Table R4, November 
2015).
    The rate of intentional injury in the Healthcare and Social 
Assistance sector as a whole was 8.2 per 10,000 full time workers, over 
four times the rate across all private industry, 1.7 per 10,000 full-
time workers in 2014 (BLS Table R8, November 2015). Within the 
Healthcare and Social Assistance sector, the incident rates for 
Intentional Injury by Other Person(s) ranges from a low of 0.4 per 
10,000 full-time workers in Offices of Physicians (lower than private 
industry as a whole) to a high of 109.5 per 10,000 full-time workers in 
Psychiatric and Substance Abuse Hospitals \2\ (BLS Table R8, November 
2015). Of the four major subsectors within Health Care and Social 
Assistance in 2014, the highest incident rate of Intentional Injury by 
Other Person(s) was 18.7 per 10,000 in Nursing and Residential Care 
Facilities.

[[Page 88155]]

The incident rates for the next two highest subsectors, Hospitals, and 
Social Assistance were half that of Nursing and Residential Care 
Facilities, 8.9 and 9.8 respectively. The subsector of Nursing and 
Residential Care Facilities includes establishments providing services 
to a diverse population of patients, many of whom need a higher level 
of care at these facilities. In contrast, the services provided in the 
other areas of the Health Care and Social Assistance sector may 
typically involve more routine health care services requiring less 
physically demanding care from staff. This wide range reflects the 
diversity of workplace conditions and patient interactions faced by 
workers in the Health Care and Social Assistance economic sector.
---------------------------------------------------------------------------

    \2\ The term ``Substance Abuse Hospital'' is used because it is 
the official designation in the NAICS code manual for such 
facilities.

    Table 4--Incident Rate for Violence and Other Injuries by Private
   Industry in the United States per 10,000 Full Time Workers in 2014
------------------------------------------------------------------------
                                                            Intentional
                                                             injury by
                                                           other person
------------------------------------------------------------------------
All Private Industry....................................             1.7
Health care and social assistance.......................             8.2
    Ambulatory health care services.....................             1.9
        Offices of physicians...........................             0.4
            Offices of physicians except mental health..             0.3
            Offices of mental health physicians.........             8.5
        Offices of other health practitioners...........              --
        Outpatient care centers.........................             4.1
        Medical and diagnostic laboratories.............             5.6
        Home health care services.......................             5.0
        Other ambulatory health care services...........             3.1
            Ambulance services..........................             5.3
            All other ambulatory health care services...              --
    Hospitals...........................................             8.9
        General medical and surgical hospitals..........             6.7
        Psychiatric and substance abuse hospitals.......           109.5
        Other hospitals.................................             7.3
    Nursing and residential care facilities.............            18.7
        Nursing care facilities.........................            15.8
        Residential mental health facilities............            34.9
        Community care facilities for the elderly.......             7.2
        Other residential care facilities...............            39.9
    Social assistance...................................             9.8
        Individual and family services..................            10.2
            Child and youth services....................             4.0
            Services for the elderly and disabled.......            11.0
        Emergency and other relief services.............              --
            Community housing services..................              --
        Vocational rehabilitation services..............            20.8
        Child day care services.........................             6.5
------------------------------------------------------------------------
(BLS Table R8, November 2015).
Note: Dash indicates data do not meet BLS publication guidelines for
  their Survey of Occupational Injuries and Illnesses.

    The industries in the Social Assistance subsector provide a wide 
variety of services directly to clients, and include industries with 
incident rates of intentional injury that are higher than those in the 
Ambulatory Health Care sector. The highest incident rate within this 
sector for intentional injury by other person was in Vocational 
Rehabilitation Services with 20.8 per 10,000 full time workers in 2014. 
The next highest industry in this sector was Services for the Elderly 
and Disabled with an incident rate of 11 per 10,000 full time workers. 
This sector includes, among other industries, services for children and 
youth, the elderly, and persons with disabilities; community food and 
housing services; vocational rehabilitation; and day care centers. 
Consequently, the risk of workplace violence to healthcare workers 
differs depending on the nature of the setting and the level of 
interaction with patients.
    The severity of workplace violence in the Health Care and Social 
Assistance sector is even greater in state government entities where 
the incident rate for intentional injury by other person(s) in 2014 was 
79.3 per 10,000 full time workers. Across state government sectors the 
incident rate for intentional injury by other persons in the Health 
Care and Social Assistance sector is the highest even compared to the 
sector for Public Administration at 10.5 per 10,000 full time workers, 
which includes Police Protection and Correctional Institutions. State-
run healthcare facilities often serve individuals with fewer available 
heath care options and populations with fewer preventive healthcare 
services. State- run healthcare and social assistance facilities may 
face unique challenges compared to the private sector.

[[Page 88156]]



 Table 5--Incident Rate for Violence and Other Injuries by Select State
  Industries in the United States per 10,000 Full Time Workers in 2014
------------------------------------------------------------------------
                                                            Intentional
                                                             injury by
                                                           other person
------------------------------------------------------------------------
ALL STATE GOVERNMENT....................................            15.8
SERVICE PROVIDING.......................................            16.2
Healthcare and Social Assistance........................            79.3
    Hospitals...........................................            97.4
    Nursing and Residential Care Facilities.............           116.8
Public Administration...................................            10.5
    Justice, Public Order, and Safety Activities........            23.1
        Police Protection...............................             8.7
        Correctional Institutions.......................            37.2
------------------------------------------------------------------------
BLS Table S8, April 2016.

    Locally-run health care and social assistance facilities, on the 
other hand, appear to present risks that are comparable to private 
facilities, the incident rate of intentional injury by other persons in 
sector of Healthcare and Social Assistance was 13.1 per 10,000 full 
time workers. The overall incident rate for the Public Administration 
sector in local governments is not much lower at 11.1 per 10,000 full 
time workers.

 Table 6--Incident Rate for Violence and Other Injuries by Select Local
 Government Industries in the United States per 10,000 Full Time Workers
                                 in 2014
------------------------------------------------------------------------
                                                            Intentional
                                                             injury by
                                                           other person
------------------------------------------------------------------------
ALL LOCAL GOVERNMENT....................................             8.7
SERVICE PROVIDING.......................................             8.8
Healthcare and Social Assistance........................            13.1
    Hospitals...........................................            13.0
    Nursing and Residential Care Facilities.............            39.9
Public Administration...................................            11.1
    Justice, Public Order, and Safety Activities........            22.5
        Police Protection...............................            36.8
        Fire Protection.................................             7.1
------------------------------------------------------------------------
BLS Table L8, April 2016.

    Another way to consider the data is by occupation. Nursing-
Psychiatric and Home Health Aides (which includes Psychiatric Aids and 
Nursing Assistants) had the highest rates of violence in 2014 across 
three of the four sectors. Out of the 4,690 injury cases in Nursing and 
Residential Care Facilities (based on data from BLS provided upon 
request), 2,640 of the cases of workplace violence were perpetrated 
against Nursing-Psychiatric and Home Health Aides in 2014 (BLS SOII 
2014 Data, requested June 2016). Across all private industries, the 
highest rates of incidents for Intentional Injury by Other Person(s) 
were for Psychiatric Aides at 426.4 per 10,000 full time workers, 
followed by Psychiatric Technicians at 206.8 per 10,000 full time 
workers in 2014 (BLS Table R100, November 2015). These two occupations 
reflect the highest rates of intentional injury by other person(s) that 
occurs in the major sector of healthcare practitioners and technical 
occupations.

 Table 7--Cases of Intentional Injury by Other Person(s) by Industry and
                           Occupation in 2014
------------------------------------------------------------------------
                                                               2014
------------------------------------------------------------------------
All Private Sector Industries...........................          15,980
    Goods Producing.....................................             260
    Service Producing...................................          15,710
Healthcare and Social Assistance........................          11,100
    Ambulatory Healthcare Services......................             960
        Counselors- Social Workers- and Other Community              100
         and Social Service Specialists.................
        Health Diagnosing and Treating Practitioners....             150
        Health Technologists and Technicians............             230
        Nursing- Psychiatric- and Home Health Aides.....             290
        Occupational Therapy and Physical Therapist                   --
         Assistants and Aides...........................
        Other Personal Care and Service Workers.........             100
    Hospitals...........................................           3,410
        Counselors- Social Workers- and Other Community              180
         and Social Service Specialists.................
        Health Diagnosing and Treating Practitioners....           1,110
        Health Technologists and Technicians............             610
        Other Healthcare Practitioners and Technical                  20
         Occupations....................................

[[Page 88157]]

 
        Nursing- Psychiatric- and Home Health Aides.....           1,030
        Occupational Therapy and Physical Therapist                   --
         Assistants and Aides...........................
        Other Personal Care and Service Workers.........             100
    Nursing and Residential Care Facilities.............           4,690
        Counselors- Social Workers- and Other Community              370
         and Social Service Specialists.................
        Health Diagnosing and Treating Practitioners....             170
        Health Technologists and Technicians............             310
        Nursing- Psychiatric- and Home Health Aides.....           2,640
        Occupational Therapy and Physical Therapist                   --
         Assistants and Aides...........................
        Other Personal Care and Service Workers.........             770
    Social Assistance...................................           2,050
        Counselors- Social Workers- and Other Community              190
         and Social Service Specialists.................
        Health Diagnosing and Treating Practitioners....              30
        Health Technologists and Technicians............              --
        Nursing- Psychiatric- and Home Health Aides.....             150
        Other Personal Care and Service Workers.........           1,060
------------------------------------------------------------------------
BLS SOII 2014 Data, requested June 2016.
Note: Dash indicates data do not meet BLS publication guidelines for
  their Survey of Occupational Injuries and Illnesses.

    Violence in the workplace is a topic that has been studied heavily 
using different data sources such as workers' compensation data, and 
occupation specific surveys. The results from these studies highlight 
similar findings to that of BLS's SOII data by industry, both showing 
that workplace injury rates of workers in the healthcare industry rank 
among the highest across private sector industries. In one study, 
Washington State workers compensation data was evaluated for the period 
between 1997 and 2007 (Foley, and Rauser, 2012). The results showed 
that the industry sectors with the highest rates of workplace violence 
were Health Care and Social Assistance (75.5 claims per 10, 000 FTEs), 
Public Administration (29.9 per 10,000 FTEs), and Educational Services 
(15.0 claims per 10,000 FTEs). Within the Health Care and Social 
Assistance sector, the industry groups with the highest estimated claim 
rates were Psychiatric and Substance Abuse Hospitals \3\ at 875 per 
10,000 FTEs, and Residential Mental Retardation, Mental Health and 
Substance Abuse Facilities at 749 per 10,000 FTEs. The rates of these 
two Health Care and Social Assistance groups are 65 times and 56 times 
the overall claim rate of 13.4 per 10,000 FTEs for workplace violence 
in all industries. A study that surveyed staff in a psychiatric 
hospital (Phillips, 2016) found that 70 percent of staff reported being 
physically assaulted within the last year. Another study that surveyed 
over 300 staff in a psychiatric hospital found that ward staff, which 
had the highest levels of patient contact, were more likely than 
clinical care and supervisory workers to report being physically 
assaulted by patients (Kelly and Subica, 2015; as reported in US GAO, 
2016). Data from HHS' NEISS-Work data set showed that in 2011 the 
estimated rate of nonfatal workplace violence injuries for workers in 
healthcare facilities was statistically greater than the estimated rate 
for all workers. The Department of Justice's National Crime 
Victimization Survey (NCVS) data set showed that from 2009 through 2013 
healthcare workers experienced workplace violence at more than twice 
the estimated rate for all workers (after accounting for the sampling 
error). These results consistently point to the healthcare industry and 
occupations within the healthcare field as having the highest risks to 
workplace violence compared to other private sector industries.
---------------------------------------------------------------------------

    \3\ The term ``Substance Abuse Hospital'' is used because it is 
the official designation in the NAICS code manual for such 
facilities.
---------------------------------------------------------------------------

    The four subsectors that make up the Health Care and Social 
Assistance sector include a wide range of establishments providing 
varying types of services to the general public, and placing workers at 
elevated levels of exposure to workplace violence relative to other 
economic sectors. The Health Care and Social Assistance sector includes 
industries with the highest rates for Intentional Injury by Other 
Persons exceeding all other private sector industries.

B. Questions for Section IV

    The following questions are intended to solicit information on the 
topics covered in this section. Wherever possible, please indicate the 
title of the person completing the question and the type and employee 
size of your healthcare and/or social assistance facility.
    Question IV.1: Rates of workplace violence vary widely within the 
healthcare and social assistance sector, ranging from extremely high to 
below private industry averages. How would you suggest OSHA approach 
the issue of whom should be included in a possible standard? For 
example, should the criteria for consideration under the standard be 
certain occupations (e.g., nurses), regardless of where they work? Or 
is it more appropriate to include all healthcare and social assistance 
workers who work in certain types of facilities (e.g., in-patient 
hospitals and long-term care facilities)? Another approach could be to 
extend coverage to include all employees who provide direct patient 
care, without regard to occupation or type of facility. If OSHA were to 
take this approach, should home healthcare be covered?
    Question IV.2: If OSHA issues a standard on workplace violence in 
healthcare, should it include all or portions of the Social Assistance 
subsector? Are the appropriate preventive measures in this subsector 
sufficiently similar to those appropriate to healthcare for a single 
standard addressing both to make sense?
    Question IV.3: The only comparative quantitative data provided by 
BLS is for lost workday injuries. OSHA is particularly interested in 
data that could help to quantitatively estimate the extent of all kinds 
of workplace violence problems and not just those caused by lost 
workday injuries. For that reason, OSHA requests information and data 
on both workplace violence incidents that resulted in days away from 
work needed to recover from the injury as well as those that did not 
require days away from work, but may have required only first aid 
treatment.

[[Page 88158]]

    Question IV.4: OSHA requests information on which occupations are 
at a higher risk of workplace violence at your facility and what about 
these occupations cause them to be at higher risk. Please provide the 
job titles and duties of these occupations. Please provide estimates on 
how many of your workers are providing direct patient care and the 
proportion of your workforce this represents.
    Question IV.5: The GAO Report relied on BLS SOII data, HHS NEISS 
data and DOJ NCVS data. Are there any other data sets or data sources 
OSHA should obtain for better estimating the extent of workplace 
violence?
    Question IV.6: The data provided by BLS are for relatively 
aggregated industries. Instance of high risk of workplace violence can 
be found aggregated with industries with low average risk, and low risk 
of workplace violence within industries with high risk. Please describe 
if your establishment's experience with workplace violence is 
consistent with the relative risks reported by BLS in the tables found 
in this section? If you are in an industry with high rates, are there 
places within your industry where establishments or kinds of 
establishments have lower rates than the industry as a whole? If you 
are in an industry with relatively low rates, are there work stations 
within establishments or within the industry that have higher rates?
    Question IV.7: Are there special circumstances in your industry or 
establishment that OSHA should take into account when considering a 
need for a workplace violence prevention standard?
    Question IV.8: Please comment if the workplace violence prevention 
efforts put in place at your establishments are specific to certain 
settings or activities within the facility, and how they are triggered.
    Question IV.9: OSHA has focused on the Health Care and Social 
Assistance sectors in this RFI. However, workers who provide healthcare 
and social assistance are frequently found in other industries. Should 
a potential OSHA standard cover workers who provide healthcare or 
social assistance in whatever industries they work?

V. Workplace Violence Prevention Programs; Risk Factors and Controls/
Interventions

A. Elements of Violence Prevention Programs

    OSHA has recognized the unique challenges of workplace violence in 
healthcare and social assistance for decades. OSHA's ``Guidelines for 
Preventing Workplace Violence for Healthcare and Social Service 
Workers,'' which was last updated in 2015 is based on industry best 
practices and feedback from stakeholders, provides recommendations for 
policies and procedures to eliminate or reduce workplace violence in a 
range of healthcare and social assistance settings. The guidelines 
recommend a comprehensive violence prevention program that covers the 
following five core elements: (1) Management commitment and worker 
participation; (2) worksite analysis and hazard identification; (3) 
hazard prevention and control; (4) safety and health training; and (5) 
recordkeeping and program evaluation. Below, OSHA uses this framework 
in discussing and seeking information on the elements that might be 
included in a workplace violence standard. In addition, because there 
are particular concerns with underreporting of workplace violence in 
the healthcare and social assistance sector, below OSHA also discusses 
and seeks information on effectiveness of its whistleblower protection 
requirements in these sectors.
1. Management Commitment and Employee Participation
    OSHA's Guidelines for Preventing Workplace Violence for Healthcare 
and Social Service Workers highlight the benefits of commitment by 
management and establishment of a joint management-employee committee, 
whether the committee is focused on workplace violence prevention or 
worker safety more broadly. The structure of the management-employee 
teams will differ based on the facility's size and the availability of 
personnel to staff it.
    OSHA is interested in hearing from employers and individuals 
working in healthcare and social assistance about their experiences 
with management commitment and employee participation. Specific 
questions regarding these topics are at the end of Section V.
2. Worksite Analysis and Hazard Identification
    OSHA's guidelines emphasize worksite analysis and hazard 
identification. A worksite analysis involves a mutual step-by-step 
assessment of the workplace to find existing or potential hazards that 
may lead to incidents of workplace violence.
    Healthcare and social assistance workers face a number of risk 
factors that are known to contribute to violence in the workplace. 
Common risk factors (or factors that have been shown to increase the 
risk of harm if one is exposed to a hazard) for workplace violence 
generally fall into two groups: (1) Patient, client and setting-related 
and (2) organizational-related (OSHA, 2015a, p. 4-5). The patient/
client and setting-related group includes: (a) Working directly with 
people who have a history of violence, especially if they are under the 
influence of drugs or alcohol or a diagnosis of dementia; (b) lifting, 
moving and transporting patients and clients; (c) working alone in a 
facility or in patients' homes; (d) poor environmental design of the 
workplace that may block employee vision or interfere with escape from 
a violent incident; poor lighting in hallways, corridors, rooms, 
parking lots and other exterior areas; (e) lack of means of emergency 
communication; (f) long waiting periods for service; or (g) working in 
neighborhoods with high crime rates.
    Organizational risks (the second group) arise from workplace 
policies, or the lack thereof. Examples include a lack of facility 
policies and staff training for recognizing and managing escalating 
hostile and assaultive behaviors from patients, clients, visitors, or 
staff; working when understaffed, especially during mealtimes and 
visiting hours; inadequate security and mental health personnel on 
site; not permitting smoking; allowing unrestricted movement of the 
public in clinics and hospitals; allowing a perception that violence is 
tolerated and victims will not be able to report the incident to police 
and/or press charges; and an overemphasis on customer satisfaction over 
staff safety (OSHA, 2015a).
    Studies show that staff working in some hospital units or areas are 
at greater risks than others. High-risk areas include emergency 
departments (EDs), admission areas, long-term care and geriatrics 
settings, behavioral health, waiting rooms, and obstetrics and 
pediatrics, among others (DeSanto et al., 2013).
    Assault rates for nurses, physicians and other staff working in EDs 
have been shown to be among the highest (Crilly et al., 2004; Gerberich 
et al., 2005; Gates et al., 2006; Gacki-Smith et al., 2009). In high 
volume urban emergency departments and residential day facilities, 
staff are in frequent contact with patients or family members who may 
have a history of violence, and/or a history of substance abuse 
disorders. Also, an increasing number of patients are in possession of 
handguns and weapons (Stokowski, 2010).
    Workers in the healthcare occupations of psychiatric aides, 
psychiatric

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technicians, and nursing assistants experienced higher rates of 
workplace violence compared to other healthcare occupations and workers 
overall (BLS Table R100, 2015; Pompeii et al., 2015). Some studies have 
found that nursing assistants in long-term care have the highest 
incidence of assaults among all workers in the U.S. (Gates et al., 
2005).
    Surveys of nurses have identified risk factors including patient 
mental health or behavioral issues, medication withdrawal, pain, 
history of a substance abuse disorder, and being unhappy with care 
(Pompeii et al., 2015).
    OSHA is interested in hearing from employers and individuals 
working in healthcare and social assistance about their experiences 
with worksite analysis and hazard identification, including how they 
use risk factors. Specific questions regarding these topics are at the 
end of Section V.
3. Hazard Prevention and Control
    Once workplace violence hazards are identified, controls can be 
designed and implemented to prevent and control them. OSHA's hierarchy 
of controls includes: elimination, substitution, engineering controls, 
administrative controls, and work practices, and personal protective 
equipment (PPE) in that order. Engineering controls for workplace 
violence prevention are permanent changes to the work environment. 
Administrative controls are policies and procedures that reduce or 
prevent exposure to risk factors. Administrative strategies include 
modification of job rules and procedures, training and education, 
scheduling, or modifying assigned duties.
a. Engineering Controls
    Engineering controls attempt to remove the hazard from the 
workplace or create a barrier between the worker and the hazard. 
Examples of engineering controls include the installation of alarm 
systems, panic buttons, hand-held alarms, or noise devices, 
installation of door locks and increased lighting or use of closed-
circuit video monitoring on a 24-hour basis (Haynes, 2013). Other 
examples include improvements to the layout of the admission area, 
nurses' stations and rooms. Where appropriate, some hospitals may have 
metal detectors installed to detect for guns, knives, box cutters, 
razors, and other weapons.
    Effective interventions that have been described in the literature 
include K-9 security dog teams, metal detectors, and the installation 
of a security system, that includes metal detectors, cameras, and 
security personnel (Stirling et al., 2001) and increased lighting 
(Gerberich et al. 2005).
b. Administrative Controls
    Administrative controls, sometimes referred to as management 
policies, include organizational factors and can have a major impact on 
day-to-day operations in healthcare and social assistance, for both 
staff and patients/residents. For example, staffing issues, such as 
mandatory overtime and inadequate staffing levels can lead to increased 
and unscheduled absences, high turnover, low morale and increased risk 
of violence for both healthcare and social assistance workers and their 
patients. Adequate numbers of well-trained staff can help ensure that 
situations with the potential for violence can be diffused before they 
escalate into full-blown violent incidents, resulting in fewer 
injuries. Adequate numbers of staff to address the needs of the 
patients can result in a higher level of safety and comfort for both 
patients and staff. Effective training can increase staff confidence 
and control in preventing, managing and de-escalating these incidents, 
resulting in a greater sense of safety for both staff and patients.
    Employer policies often include security measures to prevent 
workplace violence, including policies for monitoring and maintaining 
premises security (e.g., access control systems, video monitoring 
security systems) and data security (e.g., measures to prevent 
unauthorized use of employer computer systems and other forms of 
electronic communication by a patient with a history of violence to 
obtain personal information about a staff member). Many organizations 
also have policies that limit or monitor access of nonemployees to the 
premises. Emergency departments (EDs), because they are typically open 
24 hours a day, expose hospitals to the community at large and can pose 
unique safety and security concerns. If the hospital is located in a 
community or area with a high crime rate, the crime can spill into the 
ED.
    Zero Tolerance policies are policy statements from employers/
management that state that any violence to employees and patients/
customers will not be tolerated. In general, zero tolerance policies 
require and encourage staff to report all assaults or threats to a 
supervisor or manager. Supervisors and managers keep a log of 
incidents, and all reports of workplace violence are investigated to 
help determine what actions to take to prevent future incidents. Some 
studies in the literature describe and discuss the effectiveness of 
zero-tolerance policies (Nachreiner et al., 2005; Lipscomb and London, 
2015).
    Policies that encourage employees to report incidents help ensure 
that hazards are addressed; however, the current evidence shows that 
many assaults go unreported (Snyder et al., 2007; Bensley et al., 1997; 
Gillespie et al., 2014; Kowalenko et al., 2013; Arnetz et al., 2015; 
Speroni et al., 2014; Pompeii et al., 2015).
    Research has shown that injured healthcare and social assistance 
workers and their employers are reluctant to report violent incidents 
and resulting injuries out of fear of stigmatizing the patients or 
residents who are the perpetrators of the violence, particularly when 
they are mentally ill, developmentally disabled, or cognitively 
impaired elderly. There is also an attitude among many that violence 
toward those working with the public, especially with individuals with 
cognitive impairment, mental illness, or brain injury, is part of the 
job (Lipscomb and London, 2015; Speroni et al., 2014). Confusion on the 
part of nurses and other staff about what to report, and what legally 
constitutes ``assault'' and ``abuse'' as well as the lack of 
institutional support for reporting incidents can contribute to under-
reporting (May and Grubbs, 2002).
c. Personal Protective Equipment
    In OSHA's hierarchy of controls, personal protective equipment is 
the least-preferred type of control because these methods rely on the 
compliance of all individuals, and often places a burden on the 
individual worker rather than on the organization as a whole. However, 
there may be circumstances where the use of personal protective 
equipment (PPE) is appropriate for preventing workplace violence. For 
example, the ANA identified the use of gloves, sleeves, and blocking 
mats as a barrier method to protect staff from bites and scratches when 
caring for individuals with certain developmental disabilities and 
where other types of controls are infeasible (Lipscomb and London, 
2015).
d. Innovative Strategies
    In addition to controls that fall into the traditional OSHA 
hierarchical approach previously described here, OSHA is also very 
interested in hearing about strategies and innovations that have been 
developed from the clinical experience of health professionals, 
particularly if they have been shown to be effective. The Agency is 
interested in how existing operations tools, such as electronic 
infrastructure and work practices, can be modified to support

[[Page 88160]]

violence prevention in specific healthcare and social assistance 
settings. In addition, the Agency seeks information on cross-
disciplinary tools and strategies that merge techniques from different 
disciplines (such as threat assessment, education, and clinical 
practice) to improve workplace safety and health. Examples of 
innovative approaches include soliciting information from patients and 
their families about risk factors and effective solutions through 
informal surveys or focus groups. One behavioral health facility that 
hires and employs ``milieu officers,'' typically corrections officers 
with mental health training whose job is to be visible and accessible 
on the unit and maintain control over the unit environment as a whole, 
has reduced violent incidents on some patient units.
    New Hampshire Hospital, a state-run behavioral health facility, 
serves as a teaching hospital through its affiliation with the Geisel 
School of Medicine at Dartmouth College. This connection allows New 
Hampshire Hospital to serve as a living laboratory for ongoing research 
to identify precursors to violence and test new practices. Physicians 
engage patients as partners in their research, which is part of the 
hospital's drive for continual improvement. This connection to academic 
studies also helps to raise awareness of other new research and 
encourage staff members to adopt the best available evidence-based 
approaches.
    OSHA is interested in hearing from employers and individuals 
working in healthcare and social assistance about their experiences 
with hazard prevention and control. Specific questions regarding these 
topics are at the end of Section V.
4. Safety and Health Training
    OSHA's Guidelines for Preventing Workplace Violence for Healthcare 
and Social Service Workers highlight education and training as an 
essential element of a workplace violence prevention program. Safety 
and health training helps ensure that all staff members are aware of 
potential safety hazards and how to protect themselves, their coworkers 
and patients through established policies and procedures. The content 
and frequency of training can vary, as well as the staff eligible for 
training. In general, training covers policies and procedures specific 
to the facility and perhaps the unit, as well as de-escalation and 
self-defense techniques. De-escalation of aggressive behavior and 
managing aggressive behavior when it occurs are very important 
components of the training (Nonviolent Crisis Intervention Training, 
2014).
    Training provides opportunities to learn and practice strategies to 
improve both patient safety and worker safety. The nationwide movement 
toward reducing the use of restraints (physical and medication) and 
seclusion in behavioral health--which is mandated in some states--along 
with the movement toward ``trauma-informed care,'' means that workers 
are relying more on approaches that minimize physical contact with 
patients, intervening with verbal de-escalation strategies before an 
incident turns into a physical assault thereby reducing injuries. 
Trauma-informed care is a strengths-based approach that is grounded in 
an understanding of and responsiveness to the impact of trauma, that 
emphasizes physical, psychological, and emotional safety for both 
providers and survivors, and that creates opportunities for survivors 
to rebuild a sense of control and empowerment (SAMHSA). The results can 
be a ``win-win'' for patient and worker safety (OSHA, 2015b). Training 
ensures consistent dissemination of information about policies and 
procedures, as well as an opportunity to practice and develop 
confidence with newly-learned skills and techniques, such as de-
escalation. In particular, when implementing a zero tolerance policy, 
training staff on what and when to report is essential to changing the 
expectation that violence will not be tolerated.
    Staff training on policies and procedures is usually conducted at 
orientation and periodically (e.g., annually or semi-annually) 
afterward. A number of studies show that training can be effective in 
reducing workplace violence (Swain, 2014; Martin, 1995; Allen, 2013).
    Because duties, work locations, and patient interactions vary by 
job, violence prevention training can be customized to address the 
needs of different groups of healthcare personnel, particularly: Nurses 
and other direct caregivers; emergency department (ED) staff; support 
staff (e.g., dietary, housekeeping, maintenance); security personnel; 
and supervisors and managers (Greene, 2008). The Joint Commission 
(formerly the Joint Commission on Accreditation of Healthcare 
Organizations (JCAHO)) emphasizes that security personnel need specific 
training on the unique needs of providing security in the healthcare 
environment, including the psychological components of handling 
aggressive and abusive behavior, and ways to handle aggression and 
defuse hostile situations (The Joint Commission, 2009).
    OSHA is interested in hearing from employers and individuals 
working in healthcare and social assistance about their experiences 
with the various types of training and their effectiveness. Specific 
questions regarding training are at the end of Section V.
5. Recordkeeping and Program Evaluation
a. Recordkeeping
    OSHA's recordkeeping regulations require employers to record 
certain workplace injuries and illnesses. The OSHA 300 Log can be a 
valuable source of evaluation metrics data for establishing baseline 
injury and illness rates and benchmarks for success. Information from 
the OSHA 300 Log, 300A Annual Summary, and the 301 Incident Report can 
be used to identify tasks and jobs with higher risks of injury or 
illness, and to monitor trends. Under OSHA's recordkeeping regulation, 
an employer must record each fatality, injury, and illness that is 
work-related, a new case, and meets one or more of the general 
recording criteria in section 1904.7 or the application to specific 
cases of section 1904.8 through 1904.11. The general recording criteria 
in section 1904.7 is triggered by an injury or illness that results in 
death, days away from work, restricted work or transfer to another job, 
loss of consciousness, or medical treatment beyond first aid. For each 
such injury, the employer is required to record the worker's name; the 
date; a brief description of the injury or illness; and, when relevant, 
the number of days the worker was away from work, assigned to 
restricted duties, or transferred to another job as a result of the 
injury or illness. Employers with 10 or fewer employees at all times 
during the previous calendar year and employers in certain low-hazard 
industries are partially exempt from routinely keeping OSHA injury and 
illness records (29 CFR 1904.1, 1904.2). Accurate records of injuries, 
illnesses, incidents, assaults, hazards, corrective actions, patient 
histories, and training can help employers evaluate methods of hazard 
control, identify training needs, and develop solutions for an 
effective program.
    All employers, including those who are partially exempt from 
keeping records, must report any work-related fatality to OSHA within 8 
hours of learning of the incident, and must report all work-related 
inpatient hospitalizations, amputations, and losses of an eye to OSHA 
within 24 hours of learning of the incident (29

[[Page 88161]]

CFR 1904.39). These events can be reported to OSHA in person, by phone, 
or by using the reporting application on OSHA's public Web site at 
www.osha.gov/recordkeeping. See https://www.osha.gov/recordkeeping2014/.
    Employers do not always record or accurately record workplace 
injuries and illnesses in general. Specifically, in a 2012 report OSHA 
found that for calendar years 2007 and 2008, approximately 20 percent 
of injury and illness cases reconstructed by inspectors during a review 
of employee records were either not recorded or incorrectly recorded by 
the employer (OSHA, 2012). BLS is working on improving reporting by 
conducting additional research on the extent to which cases are 
undercounted in the SOII and exploring whether computer-assisted coding 
can improve reporting (BLS, 2014). Further, as discussed above in 
Section V.A.3.b, there are a number of published studies that show that 
employees substantially underreport workplace violence cases.
    OSHA is interested in hearing from employers and individuals in 
healthcare and social assistance facilities about their experiences 
with both recordkeeping to comply with OSHA requirements as well as 
reporting of incidents at the facility or unit level. Specific 
questions regarding recordkeeping are at the end of Section V.
b. Program Evaluation
    Programs are evaluated to identify deficiencies and opportunities 
for improvement. Accurate records of injuries and illnesses can help 
employers gauge the effectiveness of intervention efforts. The 
evaluation of a comprehensive workplace violence prevention program 
typically includes, but is not limited to, measuring improvement based 
on lowering the frequency and severity of workplace violence incidents; 
keeping up-to-date records of administrative and work practice changes 
implemented to prevent workplace violence (to evaluate how well they 
work); surveying workers before and after making job or worksite 
changes or installing security measures or new systems to evaluate 
their effectiveness; tracking recommendations through to completion; 
keeping abreast of new strategies available to prevent and respond to 
violence as they develop; and establishing an ongoing relationship with 
local law enforcement and educating them about the nature and 
challenges of working with potentially violent patients. The quality 
and effectiveness of training is particularly important to assess.
    OSHA is interested in hearing from employers and individuals in 
healthcare and social assistance facilities about their experiences 
with program evaluation. Specific questions regarding program 
evaluation are located in section V.3. below.

B. Questions for Section V

    OSHA is interested in hearing from employers and individuals in 
facilities that provide healthcare and social assistance about their 
experiences with the various components of workplace violence 
prevention programs that are currently being implemented by their 
facilities. Wherever possible, please indicate the title of the person 
completing the question and the type and employee size of your 
facility. In particular, the Agency appreciates respondents addressing 
the following:
1. Questions on the Overall Program, Management Commitment and Employee 
Participation
    Question V.1: Does your facility have a workplace violence 
prevention program or policy? If so, what are the details of the 
program or policy? Please describe the requirements of your program, or 
submit a copy, if feasible. When and how did you implement the program 
or policy? How many hours did it take to develop the requirements? Did 
you consult your workers through union representatives?
    Question V.2: How is your program or policy communicated to 
workers? (e.g., Web site, employee meetings, signage, etc.) How are 
employees involved in the design or implementation of the program or 
policy?
    Question V.3: In your experience, what are the important factors to 
consider when implementing a workplace violence prevention program or 
policy?
    Question V.4: At what level in your organization was the workplace 
violence prevention program or policy implemented? Who has 
responsibility for implementation? What are the qualifications of the 
person responsible for its implementation?
    Question V.5: How well is your program or policy followed? Have you 
received sufficient support from management? Employees? The union, if 
there is one?
    Question V.6: How did you select the approach to workplace violence 
prevention outlined in your facility program or policy (e.g., triggered 
by an incident, following existing guidelines, listening to staff 
needs, complying with state laws)?
    Question V.7: Do you have a safety and health program in place in 
your facility? If so, what is the relationship between the workplace 
violence prevention program and the safety and health management 
system?
    Question V.8: Does your facility subscribe to a management 
philosophy that encompasses quality measures, e.g., lean sigma, high 
reliability? If so, are metrics for worker safety included?
    Question V.9: Does your facility have a safety and health 
committee? Does your facility also have a workplace violence committee? 
If so, what is the function of these committees? How are they held 
accountable? How is progress measured?
    Question V.10: Does your facility have a workplace violence 
prevention committee that is separate from the general safety committee 
or part of it? If separate, how do the two committees communicate and 
share information? How many hours do they spend meeting or doing 
committee work? How many hours of employee time does this require per 
year?
    Question V.11: If the facility does not have a committee, are there 
reasons for that?
    Question V.12: What is the make-up of the committee? How are the 
committee members selected? What is the highest level of management 
that participates? Are worker/union representatives included in a 
committee? Is there a rotation for the committee members?
    Question V.13: What does the decision making process look like? Do 
the committee members play an equal role in the decision making? Is 
there a meeting agenda? Does the committee keep minutes and records of 
decisions made?
    Question V.14: How are the workplace violence prevention 
committee's decisions disseminated to the staff and management? Does 
the committee address employees' safety concerns in a timely manner?
    Question V.15: If OSHA were to require management commitment, how 
should the Agency determine compliance?
    Question V.16: If OSHA were to issue a standard that included a 
requirement for employee participation, how might compliance be 
determined?
2. Questions on Worksite Analysis and Hazard Identification
    Question V.17: Are workplace analysis and hazard identification 
performed regularly? If so, what is the frequency or triggers for these 
activities? Are there any assessment tools or overall approaches that 
you have found

[[Page 88162]]

to be successful and would recommend? Please describe the types of 
successes or problems your facility encountered with reviewing records, 
administering employee surveys to identify violence-related risk 
factors, and conducting regular walkthrough assessments.
    Question V.18: Who is involved in workplace analysis? How are the 
individuals selected and trained to conduct the workplace analysis and 
hazard identification? How long does it take to perform the workplace 
analysis?
    Question V.19: What areas of the facility are covered during the 
routine workplace assessment? Please specify why these areas are 
included in the assessment and how many of these areas are part of the 
assessment.
    Question V.20: What records do you find most useful for identifying 
trends and risk factors with regards to workplace violence? How many of 
these records are collected per year?
    Question V.21: What screening tools do you use for the worksite 
analysis? Are these screening tools designed specifically to meet your 
facility's needs? Are questionnaires and surveys an effective way to 
collect information about the potential and existing workplace violence 
hazards? Why or why not?
    Question V.22: Who provides post-assessment feedback? Is it shared 
with other employees and if so, how is it shared with the other 
employees?
    Question V.23: Does your facility use patient threat assessment? If 
so, do you use an existing tool or did you develop your own? If you 
develop your own, what criteria do you use?
    Question V.24: Does your facility conduct accident/incident 
investigations? If so, who conducts them? How are follow-ups conducted 
and changes implemented?
    Question V.25: How much time is required to conduct your patient 
assessments? What is the occupational background of persons who do 
these assessments?
    Question V.26: If OSHA were to implement a standard with a 
requirement for hazard identification and worksite analysis, how might 
compliance be determined?
    Question V.27: What do you know or perceive to be risk factors for 
violence in the facilities you are familiar with?
3. Questions on Hazard Prevention and Controls
    Question V.28: Are you aware of any specific controls or 
interventions that have been found to be effective in reducing 
workplace violence in an ED environment? How was effectiveness 
determined? If so, can you provide cost information?
    Question V.29: Are you aware of any specific controls or 
interventions that have been found to be effective in reducing 
workplace violence in a behavioral health, psychiatric or forensic 
mental health setting? How was effectiveness determined? If so, can you 
provide cost information?
    Question V.30: Are you aware of any specific controls or 
interventions that have been found to be effective in reducing 
workplace violence in a nursing home or long-term care environment? How 
was effectiveness determined? If so, can you provide cost information?
    Question V.31: Are you aware of any specific controls or 
interventions that have been found to be effective in reducing 
workplace violence in a hospital environment? How was effectiveness 
determined? If so, can you provide cost information?
    Question V.32: Are you aware of any specific controls or 
interventions that have been found to be effective in reducing 
workplace violence in a home health environment? How was effectiveness 
determined? If so, can you provide cost information?
    Question V.33: Are you aware of any specific controls or 
interventions that have been found to be effective in reducing 
workplace violence of any other environments where healthcare and/or 
social assistance workers are employed? How was effectiveness 
determined? If so, can you provide cost information?
    Question V.34: Are you aware of any existing or modified 
infrastructure and work practices, or cross-disciplinary tools and 
strategies that have been found to be effective in reducing violence?
    Question V.35: Have you made modifications of your facility to 
reduce risks of workplace violence? If so, what were they and how 
effective have those modifications been? Please provide cost for each 
modification made. Please specify the type of impact the modification 
made and whether the modification resulted in a safer workplace.
    Question V.36: Does your facility have controls for workplace 
violence prevention (security equipment, alarms, or other devices)? If 
so, what kind of equipment does your facility use to prevent workplace 
violence? Where is the equipment located? Are there any barriers that 
prevent using the equipment? What labor requirements or other operating 
costs does this equipment have (e.g., have you hired security guards to 
monitor video cameras)?
    Question V.37: Who is usually involved in selecting the equipment? 
If a committee, please list the titles of the committee members. Is new 
equipment tested before purchase, and if so, by whom? Are there any 
pieces of equipment purchased that are rarely used? If so, why?
    Question V.38: Is there a process for evaluating the effectiveness 
of controls once they are implemented? What are the evaluation 
criteria?
    Question V.39: What best practices are in use in your facility for 
workplace violence prevention?
    Question V.40: How do you assure that the program is followed and 
controls are used? What are the ramifications for not following the 
program or using the equipment? If OSHA were to issue a standard, how 
might compliance with hazard prevention and control be determined?
    Question V.41: Do you have information on changes in work practices 
or administrative controls (other than engineering controls and 
devices) that have been shown to reduce or prevent workplace violence 
either in your facility or elsewhere?
    Question V.42: Do you have a zero tolerance policy? If so please 
share it. Do you think it has been successful in reducing workplace 
violence incidents? Why or why not?
    Question V.43: If you have a policy for reporting workplace 
violence incidents, what steps have you taken to assure that all 
incidents are reported? What requirements do you have to ensure that 
adequate information about the incident is shared with coworkers? Do 
you think these policies have been effective in improving the reporting 
and communication about workplace violence incidents? Why or why not?
    Question V.44: What factors do you consider in staffing your 
security department? What are the responsibilities of your security 
staff?
    Question V.45: Have you instituted policies or procedures to 
identify patients with a history of violence, either before they are 
admitted or upon admission? If so, what costs are associated with this? 
How is this information used and conveyed to staff? Whose 
responsibility is it and what is the process? Has it been effective?
4. Questions on Safety and Health Training
    Question V.46: What kind of training on workplace violence 
prevention is provided to the healthcare and/or social assistance 
workers at your facility? If

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this is copyrighted/branded training, please provide the name.
    Question V.47: What is the scope and format of the training, and 
how often is workplace violence prevention training conducted?
    Question V.48: What occupations (e.g., registered nurses, nursing 
assistants, etc.) attend the training sessions? Are the staff members 
required to attend the training sessions or is attendance voluntary? 
Are staff paid for the time they spend in training? Who administers the 
training sessions? Are they in-house training staff or a contractor? 
How is the effectiveness of the training measured? What is the duration 
of the training sessions or cost of the contractor?
    Question V.49: Do all employees have education or training on 
hazard recognition and controls?
    Question: V.50: Are contract and per diem employees trained?
    Question V.51: Are patients educated on the workplace violence 
prevention program and, if so, how?
    Question V.52: Does training cover workers' rights (including non-
retaliation) and incident reporting procedures?
    Question V.54: If OSHA were to require workplace violence 
prevention training, how might compliance be assessed?
5. Questions on Recordkeeping and Program Evaluation
    Question V.55: Does your facility have an injury and illness 
recordkeeping policy and/or standard operating procedures? Please 
describe how it works. How are records maintained; online, paper, in 
person?
    Question V.56: Who is responsible for injury and illness 
recordkeeping in your facility?
    Question V.57: Does your facility use a workers' compensation form, 
the OSHA 301 or another form to collect detailed information on injury 
and illness cases?
    Question V.58: Where are the OSHA 300 log(s) kept at your facility? 
Are they kept on each unit, each floor, or are they centrally located 
for the entire facility?
    Question V.59: Would the OSHA 300 Log alone serve as a valuable or 
sufficient tool for evaluating workplace violence prevention programs? 
Why or why not?
    Question V.60: Are you aware of any issues with reporting (either 
underreporting or overreporting) of OSHA recordables and/or 
``accidents'' or other incidents related to workplace violence in your 
facility and if so, what types of issues? If you have addressed them, 
how did you address them?
    Question V.61: Do you regularly evaluate your program? If so, how 
often? Is there an additional assessment after a violent event or a 
near miss? If so, how do you measure the success of your program? How 
many hours does the evaluation take to complete?
    Question V.62: Who is involved in a program evaluation at your 
facility? Is this the same committee that conducted the workplace 
analysis and hazard identification?
    Question V.63: If you have or are conducting an evaluation of the 
effectiveness of your workplace violence prevention program, have you 
been able to demonstrate improved tracking of workplace violence 
incidents and/or a reduction in the frequency or severity of violent 
incidents?
    Question V.64: What are the most effective parts of your program? 
What elements of your program need improvement and why?
    Question V.65: When conducting program evaluations, do you use the 
same tools and metrics you used for the initial worksite assessment? If 
not, please explain.
    Question V.66: If OSHA were to develop a standard to prevent 
workplace violence and included a requirement for program or policy 
evaluation, how might compliance be determined?
    Question V.67: Could you provide information characterizing the 
nature and extent of the difficulties in implementing your facility's 
program or policy?
    Question V.68: What actions are taken based on the results of the 
program evaluation at your facility?
VI. Costs, Economic Impacts, and Benefits
    As part of the Agency's consideration of a possible workplace 
violence standard, OSHA is interested in the costs, economic impacts, 
and benefits of related practices. OSHA is also interested in the 
benefits of such practices in terms of reduced injuries, deaths, and 
compromised operations (i.e., emotional distress, staffing turnover, 
and unexpected reallocation of resources).
    Workplace violence exacts a high cost today. It harms workers often 
both physically and emotionally, and employers also bear several costs. 
A single serious injury can lead to workers' compensation losses of 
thousands of dollars, along with thousands of dollars in additional 
costs for overtime, temporary staffing, or recruiting and training a 
replacement. Even if a worker does not have to miss work, violence can 
still lead to ``hidden costs'' such as higher turnover and 
deterioration of productivity and morale. In the study of Washington 
state's workers' compensation data (1997-2007), the average cost claim 
per time-lost was $32,963, with an annual average of at least 2,247 
claims related to workplace violence in Washington State for the period 
from 1997-2007. Similar costs were cited by McGovern et al. (2000) who 
found costs per case for assaults was $31,643 for registered nurse and 
$17,585 for licensed practical nurses. These costs included medical 
expenses, lost wages, legal fees insurance administrative costs, lost 
fringe benefits, and household production costs.
    In addition to the out-of-pocket costs by the employer and 
employee, healthcare workers who experience workplace violence have 
reported short term and long term emotional effects which can 
negatively impact productivity. It was found by Gates et al. (2003; 
2006) that nursing assistants employed in long term care, who had been 
assaulted suffered a range of occupational stressors including job 
dissatisfaction, decreased safety, and fear of future assaults. 
Caldwell (1992) and Gerberich et al. (2004) found emergency department 
(ED) workers to have post-traumatic stress disorder or symptom of the 
disorder at rates between 12 percent to 20 percent; the 12-month 
prevalence rate for the general U.S. adult population is about 3.5 
percent (http://www.nimh.nih.gov/health/statistics/prevalence/post-traumatic-stress-disorder-among-adults.shtml). The impact of PTSD 
caused by workplace violence on productivity was studied by Gates, 
Gillespie and Succop (2011), where they found those who suffered from 
PTSD symptoms or experienced emotional distress reported difficulty 
thinking, withdrawal from patients, absenteeism, and higher job 
turnover. The results also found that, although emergency department 
nurses with PTSD symptoms continued to work, they had trouble remaining 
cognitively focused, and had ``difficulty managing higher level work 
demands that required attention to detail or communication skills.''
    OSHA requests any workers' compensation data related to workplace 
violence. Any other information on your facility's experience would 
also be appreciated.
    Several studies have evaluated the effectiveness of various 
engineering and administrative workplace violence controls in a variety 
of settings (e.g., hospitals, nursing homes). The implementation of a 
comprehensive

[[Page 88164]]

workplace violence prevention program that includes administrative and 
engineering controls has been shown to lead to lower injury rates and 
workers' compensation costs (Foley and Rauser, 2012, updated data 
provided to OSHA by the authors in 2015).

A. Questions for Costs, Economic Impacts, and Benefits

    The following questions are intended to solicit information on the 
topics covered in this section. Wherever possible, please indicate the 
title of the person providing the information and the type and number 
of employees at your healthcare and/or social assistance facility.
    Question VI.1: Are there additional data (other than workers' 
compensation data) from published or unpublished sources that describe 
or inform about the incidence or prevalence of workplace violence in 
healthcare occupations or settings?
    Question VI.2: As the Agency considers possible actions to address 
the prevention and control of workplace violence, what are the 
potential economic impacts associated with the promulgation of a 
standard specific to the risk of workplace violence? Describe these 
impacts in terms of benefits from the reduction of incidents; effects 
on revenue and profit; and any other relevant impact measure.
    Question VI.3: If you have implemented a workplace violence 
prevention program or policy, what was the cost of implementing the 
program or policy, in terms of both time and expenditures for supplies 
and equipment? Please describe in detail the resource requirements and 
associated costs expended to initiate the program(s) and to conduct the 
program(s) annually. If you have any other estimates of the costs of 
preventing or mitigating workplace violence, please provide them. It 
would be helpful to OSHA to learn both overall totals and specific 
components of the program (e.g., cost of equipment, equipment 
installation, equipment maintenance, training programs, staff time, 
facility redesign).
    Question VI.4: What are the ongoing operating and maintenance costs 
for the program?
    Question VI.5: Has your program reduced incidents of workplace 
violence and by how much? Can you identify which elements of your 
program most reduced incidents? Which elements did not seem effective?
    Question VI.6: Has your program reduced costs for your facility 
(e.g., reduced insurance premiums, workers' compensation costs, fewer 
lost workdays)? Please quantify these reductions, if applicable.
    Question VI.7: Has your program reduced indirect costs for your 
facility (e.g., reductions in absenteeism and worker turnover; 
increases in reported productivity, satisfaction, and level of safety 
in the workplace)?
    Question VI.8: If you are in a state with standards requiring 
programs and/or policies to reduce workplace violence, how did 
implementing the program and/or policy affect the facility's budget and 
finances?
    Question VI.9: What changes, if any, in market conditions would 
reasonably be expected to result from issuing a standard on workplace 
violence prevention? Describe any changes in market structure or 
concentration, and any effects on services, that would reasonably be 
expected from issuing such a standard.

B. Impacts on Small Entities

    As part of the Agency's consideration of a workplace violence 
prevention standard, OSHA is concerned whether its actions will have a 
significant economic impact on a substantial number of small 
businesses. Injury and illness incident rates are known to vary by 
establishment size in the healthcare industry, where establishments 
between 50 and 999 employees had a rate of 5.4 per 10,000 full time 
workers, while establishments under 50 employees had a rate of 2.8 and 
lower in 2014 (BLS Table Q1, October 2015).
    If the Agency pursues development of a standard that would have 
such impacts on small businesses, OSHA is required to develop a 
regulatory flexibility analysis and convene a Small Business Advocacy 
Review (SBAR) under the Small Business Regulatory Enforcement Fairness 
Act (SBREFA) Panel prior to publishing a proposal. Regardless of the 
significance of the impacts, OSHA seeks ways of minimizing the burdens 
on small businesses consistent with OSHA's statutory and regulatory 
requirements and objectives (Regulatory Flexibility Act, 5 U.S.C. 601 
et seq.).

C. Questions for Impacts on Small Entities

    Question VI.10: How many, and what type of small firms, or other 
small entities, have a workplace violence prevention training, or a 
program, and what percentage of their industry (NAICS code) do these 
entities comprise? Please specify the types of workplace violence risks 
you face.
    Question VI.11: How, and to what extent, would small entities in 
your industry be affected by a potential OSHA standard to prevent 
workplace violence? Do special circumstances exist that make preventing 
workplace violence more difficult or more costly for small entities 
than for large entities? Describe these circumstances.
    Question VI.12: How many, and in what type of small healthcare 
entities, is workplace violence a threat, and what percentage of their 
industry (NAICS code 622) do these entities comprise?
    Question VI.13: How, and to what extent, would small entities in 
your industry be affected by an OSHA standard regulating workplace 
violence? Are there conditions that make controlling workplace violence 
more difficult for small entities than for large entities? Describe 
these circumstances.
    Question VI.14: Are there alternative approaches OSHA could use to 
mitigate possible impacts on small entities?
    Question VI.15: For very small entities, what types of workplace 
violence threats are faced by workers? Does your experience with 
workplace violence reflect the lower rates reported by BLS?
    Question VI.16: For very small entities, what are the unique 
challenges establishments face in addressing workplace violence, 
including very small non-profit healthcare facilities and at small 
jurisdictions?

VI. References

I. Overview

American Nurses Association. 2014. American Nurses Association 
Health Risk Appraisal (HRA): Preliminary Findings October 2013-
October 2014.
Bureau of Labor Statistics [BLS]. (2015). Table R3. Number of 
nonfatal occupational injuries and illnesses involving days away 
from work by industry and selected sources of injury or illness, 
private industry, 2014. Accessed July 26, 2016 at: http://www.bls.gov/iif/oshwc/osh/case/ostb4369.pdf.
Bureau of Labor Statistics [BLS]. (2015). Table R4. Number of 
nonfatal occupational injuries and illnesses involving days away 
from work by industry and selected events or exposures leading to 
injury or illness, private industry, 2014. Accessed July 26, 2016 at 
http://www.bls.gov/iif/oshwc/osh/case/ostb4370.pdf.
Bureau of Labor Statistics [BLS]. (2015). Table R100. Incidence 
rates for nonfatal occupational injuries and illnesses involving 
days away from work2 per 10,000 full-time workers by occupation and 
selected events or exposures leading to injury or illness, private 
industry, 2014. Accessed July 26, 2016 from http://www.bls.gov/iif/oshwc/osh/case/ostb4466.pdf.
Bureau of Labor Statistics [BLS]. Injuries, Illnesses, and 
Fatalities for 2014 and 2013, by selected worker characteristics

[[Page 88165]]

and selected industry (IIF) database. Accessed on July 26, 2016 at 
http://data.bls.gov/gqt/InitialPage.
Bureau of Labor Statistics [BLS]. (2015). Table R8. Incidence rates 
for nonfatal occupational injuries and illnesses involving days away 
from work per 10,000 full-time workers by industry and selected 
events or exposures leading to injury or illness, private industry, 
2014. Accessed July 26, 2016 at: http://www.bls.gov/iif/oshwc/osh/case/ostb4374.pdf.
Jayaratne, S.,Vinokur-Kaplan, D., Nagda, B.A; Chess, W.A. (1996). A 
national study on violence and harassment of social workers by 
clients. Journal of Applied Social Sciences, Vol 20(1):1-14.
McPhaul, K, and Lipscomb, J. (2004). Workplace Violence in Health 
Care: Recognized but not Regulated, The Online Journal of Issues in 
Nursing. Vol. 9, No. 3.
Occupational Safety and Health Administration [OSHA] (2011). 
Enforcement Procedures for Investigating or Inspecting Workplace 
Violence Incidents. Directive CPL 02-01-052 (https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-052.pdf.).
Occupational Safety and Health Administration [OSHA] (2011-2015). 
Table 1. Inspections and citations related to workplace violence in 
healthcare in 2011-2015.
Pompeii L.A., Dement J., Schoenfisch, A.L., Lavery A. (2013). 
Perpetrator, worker and workplace characteristics associated with 
patient and visitor perpetrated violence (Type II) on hospital 
workers: a review of the literature and existing occupational injury 
data. Journal of Safety Research, 44: 57-64.
Rey L. (1996) What Social Workers Need to Know About Client 
Violence. Families in Society: The Journal of Contemporary Social 
Services: 1996, Vol. 77, No. 1, pp. 33-39.
Robinson, T. A. (2014). New study points to significant under 
reporting of injuries to bureau of labor statistics. Retrieved from 
https://www.lexisnexis.com/legalnewsroom/workers-compensation/b/recent-cases-news-trends-developments/archive/2014/08/29/new-study-points-to-significant-underreporting-of-injuries-to-bureau-of-labor-statistics.aspx.
Ruser, J. (2008). Examining evidence on whether BLS undercounts 
workplace injuries and illnesses. Monthly Labor Review. Retrieved 
from: http://www.bls.gov/opub/mlr/2008/08/art2full.pdf.
United States Government Accountability Office [GAO]. (2016). 
Workplace safety and health: Additional efforts needed to help 
protect health care workers from workplace violence. Retrieved from 
http://www.gao.gov/assets/680/675858.pdf.

II. Background

American Association of Occupational Health Nurses, Inc. [AAOHN] 
(2015) Position Statement: Preventing Workplace Violence: The 
Occupational and Environmental Health Nurse Role. Retrieved on 
August 10, 2016 at http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwie3dSDjNXOAhXCkx4KHf8yAY0QFgghMAA&url=http%3A%2F%2Faaohn.org%2Fd%2Fdo%2F41&usg=AFQjCNFbnfdAms9REGlNcgeU15lo8zfmvA&sig2=FlFAqgRWochSWXnm1PLn7A.
American Nurses Association [ANA] (2015). American Nurses 
Association Position Statement on Incivility, Bullying, and 
Workplace Violence. Retrieved from http://www.nursingworld.org/Bullying-Workplace-Violence.
American Nurses Association [ANA]. (2011). Model ``state'' bill: 
``The violence prevention in health care facilities act''. Retrieved 
on August 10, 2016 from http://nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-Reports/State-WorkplaceViolence/ModelWorkplaceViolenceBill.pdf.
American Psychiatric Nurses Association [APNA]. (2008). Workplace 
violence position statement. Retrieved on July 8, 2016 from: http://www.apna.org/files/public/APNA_Workplace_Violence_Position_Paper.pdf.
California Health and Safety Code Section 1257.7. Retrieved from 
http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-09-49.pdf.
Cal/OSHA's Workplace Injury and Illness Prevention standard, 1991 
http://www.dir.ca.gov/title8/3203.html.
Cafaro, T., Jolley, C., LaValla, A., Schroeder, R. (2012). Workplace 
violence workgoup report. http://www.apna.org/i4a/pages/index.cfm?pageID=4912#sthash.2JKbjy3w.OAOGuO2N.dpuf.
Casteel, C., Peek-Asa, C., and Nocera, M. (2009). Hospital employee 
assault rates before and after enactment of the California Hospital 
Safety and Security Act. Annals of Epidemiology, 19, 125-133.
Center for Disease Control and Prevention [CDC], National Institute 
for Occupational Health [NIOSH) (2002). Violence: Occupational 
Hazards in Hospitals. DHH (NIOSH) Pub. No. 2001-101. http://www.cdc.gov/niosh/docs/2002-101/#5
Emergency Nurses Association [ENA] (September 28, 2010). Rates of 
violence against Emergency Department Nurses are high. 
HealthNewsDigest.com. Retrieved from: http://www.healthnewsdigest.com/news/Research_270/Rates_of_Violence_against_Emergency_Department_Nurses_Are_High_printer.shtml.
Foley, M., and Rauser, E. 2012. Evaluating progress in reducing 
workplace violence: Trends in Washington State workers' compensation 
claims rates, 1997-2007. Work. 42: 67-81.
Lipscomb. J., McPhaul, K., Rosen. J., Brown, J. G., Soeken, K., 
Vignola, V., Foley, J. & Porter, P. (2006). Violence prevention in 
the mental health setting: the New York state experience. CJNR 2006, 
38(4), 96-117.
National Institute of Occupational Safety and Health [NIOSH]. 
(1996). Current Intelligence Bulletin 57: violence in the workplace; 
risk factors and prevention strategies. Cincinnati, OH: U.S. 
Department of Health and Human Services, Public Health Service, 
Centers for Disease Control and Prevention, National Institute for 
Occupational Safety and Health, DHHS (NIOSH) Publication No. 96-100.
Occupational Safety & Health Administration [OSHA] (1970). OSH Act. 
Retrieved from https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=2743.
Occupational Safety and Health Administration [OSHA] (2015a). 3148-
04R Guidelines for Preventing Workplace Violence for Healthcare and 
Social Service Workers. https://www.osha.gov/Publications/osha3148.pdf.
Occupational Safety and Health Administration [OSHA] (2015b). Caring 
for our Caregivers: Strategies and Tools for Workplace Violence 
Prevention in Healthcare. Accessed on August 1, 2016 at https://www.osha.gov/dsg/hospitals/workplace_violence.html.
Occupational Safety and Health Administration [OSHA] (2011). 
Enforcement Procedures for Investigating or Inspecting Workplace 
Violence Incidents. Directive CPL 02-01-052 (https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-052.pdf).
Peek-Asa, C., Casteel, C., Allareddy, V., Nocera, M., Goldmacher, 
S., & O'Hagan, E. (2007). Workplace violence prevention programs in 
hospital emergency departments. Journal of Occupational & 
Environmental Medicine, 49(7), 757-763.
Peek-Asa, C., Casteel, C., Allareddy, V., Nocera, M., Goldmacher, 
S., O'Hagan, E., Harrison, R. (2009). Workplace violence prevention 
programs in psychiatric units and facilities. Archives of 
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j.apnu.2008.05.008.
Public Citizen. (2013). Health care workers unprotected: 
Insufficient inspections and standards leave safety risks 
unaddressed. Retrieved from https://www.citizen.org/documents/health-care-workers-unprotected-2013-report.pdf.
Romney, L., (2010) Patient aggression intensifies at Napa State 
Hospital. Los Angeles Times, November 3, 2010. Retrieved from: 
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SEIU Nurse Alliance in California. (February 10, 2014). Petition 
538. Petition for a Workplace Violence Prevention Standard for 
Healthcare Workers. Retrieved from https://www.dir.ca.gov/oshsb/petition_538.pdf.
Senate Bill No. 1299, Chapter 842, An act to add Section 6401.8 to 
the Labor Code, relating to Occupational Safety and Health. 
September 29, 2014.
State of California--Department of Industrial Relations. Occupation 
Safety and Health Standards Board. Title 8. California Code of 
Regulations. New Section 3342,

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General Industry Safety Orders. Workplace Violence Prevention in 
Health Care. October 30, 2015.
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Workplace safety and health: Additional efforts needed to help 
protect health care workers from workplace violence. Retrieved from 
http://www.gao.gov/assets/680/675858.pdf.

III. Defining Workplace Violence

Center for Disease Control and Prevention [CDC], National Institute 
for Occupational Health [NIOSH) (2002). Violence: Occupational 
Hazards in Hospitals. DHH (NIOSH) Pub. No. 2001-101. http://www.cdc.gov/niosh/docs/2002-101/#5.
Gerberich, S.G., Church T.R., McGoven, P.M., Hasen, H. (2004). An 
epidemiological study of the magnitude and consequence of work 
related violence: the Minnesota nurses' study. Occupational and 
Environmental Medicine, 61, 495-503.
Lipscomb J., and London, M. (2015). Not part of the job: How to take 
a stand against violence in the work setting. Silver Spring, MD: 
American Nurses Association.
University of Iowa Injury Prevention Center [UIIPRC]. (2001). 
Workplace Violence--A report to the nation. Accessed July 8, 2016 
at: http://docplayer.net/8506391-A-report-to-the-nation-february-2001.html.

IV. Scope

Bureau of Labor Statistics [BLS]. (April 2016). Occupational 
Employment Statistics OES Data, National Industry Specific Tables, 
May 2015 and May 2005. Accessed July 26, 2016 from http://www.bls.gov/oes/tables.htm.
Bureau of Labor Statistics [BLS]. (2015). Table R8. Incidence rates 
for nonfatal occupational injuries and illnesses involving days away 
from work per 10,000 full-time workers by industry and selected 
events or exposures leading to injury or illness, private industry, 
2014. Accessed July 26, 2016 from http://www.bls.gov/iif/oshwc/osh/case/ostb4374.pdf.
Bureau of Labor Statistics [BLS]. (2015). Table R4. Number of 
nonfatal occupational injuries and illnesses involving days away 
from work by industry and selected events or exposures leading to 
injury or illness, private industry, 2014. Accessed July 26, 2016 
from http://www.bls.gov/iif/oshwc/osh/case/ostb4370.pdf.
Bureau of Labor Statistics [BLS]. (2015). Table R100. Incidence 
rates for nonfatal occupational injuries and illnesses involving 
days away from work2 per 10,000 full-time workers by occupation and 
selected events or exposures leading to injury or illness, private 
industry, 2014. Accessed July 26, 2016 from http://www.bls.gov/iif/oshwc/osh/case/ostb4466.pdf.
Bureau of Labor Statistics [BLS]. (2015). Table L8. Incidence rates 
for nonfatal occupational injuries and illnesses involving days away 
from work per 10,000 full-time workers by industry and selected 
events or exposures leading to injury or illness, local government, 
2014. Accessed July 26, 2016 from http://www.bls.gov/iif/oshwc/osh/case/ostb4606.pdf.
Bureau of Labor Statistics [BLS]. (2015). Table S8. Incidence rates 
for nonfatal occupational injuries and illnesses involving days away 
from work per 10,000 full-time workers by industry and selected 
events or exposures leading to injury or illness, state government, 
2014. Accessed July 26, 2016 from http://www.bls.gov/iif/oshwc/osh/case/ostb4490.pdf.
Foley, M., and Rauser, E. (2012). Evaluating progress in reducing 
workplace violence: trends in Washington State workers' compensation 
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the authors in 2015).
Kelly, E.L., A.M. Subica, A.M., Fulginiti, A., Brekke, J.S., and 
Novaco R.W. (2015). ``A cross-sectional survey of factors related to 
inpatient assault of staff in a forensic psychiatric hospital.'' 
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to Congressional Requesters-Workplace Safety and Health--Additional 
Efforts Needed to Help Protect Health Care Workers from Workplace 
Violence. Accessed July 26, 2016 from http://www.gao.gov/assets/680/675858.pdf.

V. Workplace Violence Prevention Programs; Risk Factors and Controls/
Interventions

Allen D. (2013). Staying safe: re-examining workplace violence in 
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injury and illness recordkeeping and reporting requirements. 
Retrieved from http://www.osha.gov/recordkeeping.
Occupational Safety and Health Administration [OSHA]. (2015). OSHA 
forms for recording work-related injuries and illnesses. Retrieved 
from  https://www.osha.gov/recordkeeping/new-osha300form1-1-04.pdf.
Occupational Safety and Health Administration [OSHA] (2015a). 3148-
04R Guidelines for Preventing Workplace Violence for Healthcare and 
Social Service Workers. https://www.osha.gov/Publications/osha3148.pdf.
Occupational Safety and Health Administration [OSHA]. (2015b). 
Caring for our caregivers: Strategies and tools for workplace 
violence prevention in healthcare. Retrieved on August 1, 2016 at 
https://www.osha.gov/dsg/hospitals/workplace_violence.html.
Occupational Safety and Health Act, Section 11(c)(1) (1970). https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=336529 CFR 
1904.35(b)(1)(iii) and 29 CFR 1904.35(b)(1)(iv) Other OSHA injury 
and Illness Recordkeeping Requirements. Retrieved from: https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12779#1904.35(b)(1).
Pompeii L.A., Schoenfisch A.L., Lipscomb H.J., Dement J.M., Smith 
C.D., and Upadhyaya M. (2015). Physical assault, physical threat, 
and verbal abuse perpetrated against hospital workers by patients or 
visitors in six U.S. hospitals. American Journal of Industrial 
Medicine. 1-11.
Snyder, L.A., Chen, P.Y., and Vacha-Haase, T. (2007). The 
underreporting gap in aggressive incidents from geriatric patients 
against certified nursing assistants Violence and Victims, 22(3), 
367-379.
Speroni, K.G., Fitch, T., Dawson, E., Dugan, L., and. Atherton, M. 
(2014) Incidence and cost of nurse workplace violence perpetrated by 
hospital patients or patient visitors. Journal of Emergency Nursing, 
40(3), 218-228.
Stirling. G., Higgins. J.E., Cooke, M.W. (2001). Violence in A and E 
departments: a systematic review of the literature. Accident and 
Emergency Nursing, 9, 77-85.
Stokowski, L.A. (2010). Violence: Not in My Job Description. 
Retrieved from http://www.medscape.com/viewarticle/727144_4.
Swain, N., Gale, C. (2014). A communication skills intervention for 
community healthcare workers reduces perceived patient aggression: a 
pretest-posttest study. International Journal of Nursing Studies, 
5:1241-1245.

VI. Costs, Economic Impacts, and Benefits

Bureau of Labor Statistics [BLS]. (October 2015). Table Q1. 
Incidence rates of total recordable cases of nonfatal occupational 
injuries and illnesses, by quartile distribution and employment 
size, 2014. Accessed July 26, 2016 from http://www.bls.gov/iif/oshwc/osh/os/ostb4359.pdf.
Caldwell, M.F. (1992). Incidence of PTSD among staff victims of 
patient violence. Hospital & Community Psychiatry: A Journal of the 
American Psychiatric Association, 43(8), 838-839.
Foley, M., and Rauser, E. (2012). Evaluating progress in reducing 
workplace violence: trends in Washington State workers' compensation 
claims rates 1997-2007. Work. 42, 67-81. (Updated data provided by 
the authors in 2015).
McGovern, P., Kochevar, L., Lohman, W., Zaidman, B., Gerberich, 
S.G., Nyman, J., & Findorff-Dennis, M. (2000). The cost of work-
related physical assaults in Minnesota. Health Services Research, 
35(3), 663-686.
Gates, D., Gillespie, G., & Succop, P. (2011). Violence Against 
Nurses and its Impact on Stress and Productivity. Nursing Economics, 
29(2), 59-66.
Gates, D., Ross, C.S., McQueen, L. (2006). Violence against 
emergency department workers. Journal of Emergency Medicine. 31(3), 
331-337.
Gates, D., Fitzwater, E., & Succop, P. (2003). Relationship of 
stressors, strain and anger to caregiver assaults. Issues in Mental 
Health Nursing, 24(8), 775-793.
Gerberich, S.G., Church T.R., McGoven, P.M., Hasen, H. (2004). An 
epidemiological study of the magnitude and consequence of work 
related violence: the Minnesota nurses' study. Occupational and 
Environmental Medicine, 61, 495-503.


    Authority and Signature:  Dr. David Michaels, Assistant 
Secretary of Labor for Occupational Safety and Health, authorized 
the preparation of this notice pursuant to 29 U.S.C. 653, 655, and 
657, Secretary's Order 1-2012 (77 FR 3912; Jan. 25, 2012), and 29 
CFR part 1911.

    Signed at Washington, DC, on December 1, 2016.
David Michaels,
Assistant Secretary of Labor for Occupational Safety and Health.
[FR Doc. 2016-29197 Filed 12-6-16; 8:45 am]
 BILLING CODE 4510-26-P