[Federal Register Volume 81, Number 235 (Wednesday, December 7, 2016)]
[Proposed Rules]
[Pages 88147-88167]
[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:<PHONE_NUMBER>. (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

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_ADDRESS>    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:<PHONE_NUMBER>;
email<EMAIL_ADDRESS>
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).

   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

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

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

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

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

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.

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.

 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....................................

        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.

    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

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

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

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

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

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

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

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