OSHA`s Workplace Violence Standard and the Fire Service
BY STEVEN S. WILDER
It is expected that in late 1998 or early 1999, the Occupational Safety and Health Administration (OSHA) will pass the proposed Workplace Violence Standard. When this standard passes, fire departments that provide prehospital service–either in the form of ambulance response or other related responses, such as EMS (emergency medical services), engine company, or truck company–will be faced with a new challenge: how to comply with a standard designed primarily for hospitals and social service agencies.
OSHA 3148, titled “Guidelines for the Prevention of Workplace Violence for Healthcare and Social Workers,” appears on first glance to be intended for just that–healthcare and social workers. But when you read into the opening paragraphs, it clearly states that the act is intended to include those individuals involved in providing emergency medical care, which would include firefighters and EMS providers.
Complying with the act is not easy, but it need not be made overly difficult either. In a nutshell, OSHA expects the employer to provide adequate training and equipment so that the workers can recognize potentially violent behavior before it becomes violent, know how to diffuse potential violence, and have the means and resources to protect themselves.
BACKGROUND
“Going postal” is a phrase that has been used jokingly and loosely in recent years, following a rash of violent incidents in post offices. Most people think of workplace violence and automatically equate it with the post office, which is unfair to the postal service. “Going medical” would be more appropriate, since healthcare is now the second leading industry for workplace violence. Each year, more than one million healthcare workers nationally are injured in the workplace as a direct result of violence, according to U.S. Department of Labor statistics. More than half will lose at least one day of work as a direct result of their injuries. Many of these incidents occur in the prehospital setting, and some have resulted in death or permanent injury to firefighters and EMS providers.
OSHA recognizes these statistics and has set out to implement programs designed to curb this increasing phenomenon. In doing so, however, it has categorized every form of healthcare, including prehospital, into one major category. Anyone who has spent any time in the healthcare field will agree that the challenges faced in the prehospital setting are much different from those in the emergency room, psychiatric units, medical/surgical units, nursing homes, and the home-care setting–the list can go on and on. Unfortunately, OSHA has decided that the same standards can apply for all of us and has created somewhat of an albatross in the process.
COMMON RISK FACTORS
When you think about it, it really isn`t surprising that we are at risk from violence. Consider the environment into which we are often called. Domestic violence, gang violence, crime scenes, accidents, drunken altercations–we see violence in just about every form imaginable. It only stands to reason that as emergency service providers we could easily find ourselves in the middle.
One study referenced in the OSHA standard suggests that as many as 25 percent of Americans own or carry handguns. We see them in homes, in cars, and on people we have contact with on the street.
Another growing concern to emergency service providers is the increasing number of mentally ill patients who are on the streets. Changes in laws now allow these individuals to refuse medication unless (or until) they become a risk to others. Unfortunately, when this happens, we are usually the ones with the first contact.
THE OSHA PROGRAM
OSHA has used the same basic approach in designing this program as it has in most other programs. There are basically four key areas to a successful program: (a) management commitment and employee involvement, (b) a worksite analysis, (c) development of hazard prevention and controls, and (d) proper training.
To better understand these and to appreciate how they fit into the program, let`s look at them in detail.
Management Commitment. Management commitment, including the endorsement and involvement of the administration of the department, provides the motivation and resources to deal with the issue and to make the program successful.
At minimum, management commitment should include the following:
a) demonstrated concern for employee physical and emotional health and safety,
b) assigned responsibilities in the workplace violence prevention program to ensure that all officers and employees understand their roles and obligations,
c) appropriate allocation of authority and resources to responsible parties,
d) a system of accountability for all officers and employees of the department,
e) a program of counseling and debriefing for all employees witnessing or experiencing assaults or violent behaviors, and
f) commitment to supporting and implementing appropriate recommendations from safety or health committees within the department.
Employee involvement should include
a) understanding and complying with the department`s workplace violence prevention program and all other safety policies,
b) prompt and accurate reporting of violent incidents,
c) participation in health and safety committees addressing the issue of workplace violence, and
d) participating in continuing education programs that address the topic of aggression management.
For the program to be successful, it must be defined in writing. How basic or elaborate it is will be up to the department. At minimum, the written program should include
a) a “zero-tolerance” policy created and disseminated throughout the department. The policy should include physical violence, verbal abuse, nonverbal abuse, and other related actions;
b) assurance that no reprisals will be taken against any employee who reports experiencing or witnessing incidents of workplace violence;
c) encouragement for employees to report experiencing or witnessing any form of workplace violence as soon as it happens;
d) a comprehensive plan for dealing with known conditions that have a greater likelihood of risk of violence than other scenarios commonly encountered; and
e) assigned responsibility and authority to individuals or teams.
The Worksite Analysis. A workplace analysis is a common-sense, step-by-step risk assessment of what we do and where the potential for violence is greatest. Some may argue that we can never be sure when we may face a violent scenario, which is true. Still, we can often recognize the potential for violence just by the message received from dispatch.
Consider each of these dispatches, and figure out which ones clue you in on a potentially violent situation:
* Dispatch A: Engine 11, assist Ambulance 64 at The Red Dog Saloon, 1221 Broadway, for a combative patron.
* Dispatch B: Rescue 12, Engine 14, Ambulance 8: Respond to a traffic accident at 102nd and Terrace Blvd. Police on the scene advise subject has a severe head injury.
* Dispatch C: Truck 110, EMS response with Butterfield Ambulance at the Butterfield Medical Clinic, 9151 Portage Road. Caller advised that there was a mental health patient acting inappropriately. Police are en route.
Hopefully, you can appreciate how each of these scenarios waves a red flag. One component of your worksite analysis will be to identify common ways in which emergency responders can be tipped off to potentially violent conditions before arriving on the scene.
Many organizations have enjoyed success in the use of “Threat Assessment Teams,” using a multidisciplinary approach. Participants may include fire department administration, a training representative, the safety officer, an EMS officer, and perhaps even a union representative, if applicable.
To be successful, the individual or group performing the worksite analysis should have access to injury records, documented incidents of violence, safety records, and other related assessments. The goal of the analysis is to identify where vulnerabilities exist and to assist in providing recommendations on how the risk may be lowered.
Hazard Prevention and Control. Once a comprehensive worksite analysis is completed, take that information and use it productively to lessen the risks. Usually, this is accomplished through engineering controls and work practice controls.
Engineering controls are steps taken to remove the hazard or to create a barrier between the employee and the hazard. This is not a new concept to the fire service. Much of what we routinely do places a barrier between us and the hazard; it may be something as simple as an SCBA.
To be used effectively as a tool to prevent workplace violence, these engineering controls must be used in tandem with the results of the worksite analysis. After the analysis is complete, it can be reviewed to determine what type of controls can be implemented. Some of the more common ones include the following:
–the use of bulletproof vests on ambulances and engine companies in high-risk areas,
–minimal personnel response to calls known to be violent before responding, and
–limited accessibility to the patient compartment by family or friends of the patient.
Work practice controls are those practices we implement to control how people do their jobs. Some examples follow:
–the development of a police department liaison to communicate to fire department personnel areas where the risk of violence is substantially higher;
–policies or guidelines requiring employees to report all acts of violence, no matter how insignificant they may seem;
–provide proper training in aggression management to all staff; and
–ascertain behavioral traits of patients and contacts before being placed in an area alone with them.
Training and Education. Training and education ensure that all staff members are aware of potential risks before they find themselves in a potentially violent situation. Every emergency service employee involved in “public contacts” should be aware of the “Universal Precautions for Violence,” which means that violence should be expected but can be avoided or mitigated through preparation.
Training also instructs staff to avoid physical intervention whenever possible and to engage in it only as a last resort to protect themselves from injury. Topics to add to the training curriculum should include Techniques of Aggression Management, Personal Self-Defense Training, Verbal Deescalation Techniques, Preplanning for Violent Behavior, and Team Response Protocols.
Annual training should be provided to all employees who are deemed at greater risk for violent situations. At minimum, these programs should include the following:
–review of the department`s workplace violence prevention policy,
–risk factors that cause or contribute to violent episodes,
–early recognition of progressive aggressive behavior,
–stages of aggression,
–deescalation techniques,
–cultural diversity awareness,
–dealing with hostile bystanders,
–behavior control methods,
–safe application of restraint devices,
–use of the “buddy system” for personal protection,
–escapes from grabs and holds,*
–blocking techniques,*
–basic take-down techniques,*
–basic holds,*
–reporting requirements, and
–procedures for obtaining physical or emotional assistance after an incident.
* These techniques should be learned only from a qualified self-defense instructor and be used only in cases where the use of force can be justified to protect oneself from injury or death.
Recordkeeping. Recordkeeping is an essential element in a successful program. Along with mandated recordkeeping requirements, the data we collect from our own documentation will provide us with ample information to evaluate the efficacy of our program and to continuously improve it.
The following records are important:
OSHA Log of Injury or Illness (OSHA 200 Log). OSHA requires an entry on the OSHA 200 log when an injury occurs and any of the following conditions are met:
* requires treatment greater than first aid,
* results in lost time,
* results in restricted or modified duty,
* causes death, or
* results in loss of consciousness.
In addition, if the injury results in a fatality or in the hospitalization of three or more employees (including ER treatment), then the regional OSHA office must be called within eight hours of the incident. This applies to all occupations in OSHA-regulated states, including firefighting, and encompasses incidents of workplace violence.
Medical Reports. Maintain medical reports of work injuries and supervisors` investigation reports on recorded assaults. The records should reflect the circumstances leading up to the assault, the injuries sustained, the action taken, and any other circumstances related to the incident.
Incident Reports. The department or organization should develop a form that documents the incident and becomes an administrative tool for the department. This form should be completed only when a firefighter or other department employee is involved in an incident of aggression. The safety committee or other discipline within the department should review these reports regularly to identify trends and patterns so that the program can be modified and enhanced to improve efficacy.
Dealing with violent and aggressive behavior is not a new concept to the fire service. At the same time, the societal changes of the 1990s have brought on a new breed of violence, with much more severe outcomes. Regardless, the fire service will continue to be the one facet of the emergency services that people will confidently call on, knowing that an immediate response is ensured.
The OSHA program, while noble in nature, fails to recognize that not all areas of healthcare are alike and ends up treating the fire service in much the same way as it does an ER or a psychiatric unit.
An effective Workplace Violence Prevention Program is geared to one outcome: keeping our people safe. Like any other safety program, its effectiveness will be equal to the commitment of the department leaders. By making our program “performance oriented” instead of “paper oriented,” we give our members the opportunity to perform their duties in hazardous environments with a new and improved degree of safety.
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STEVEN S. WILDER is a 20-year veteran of the Bradley (IL) Fire Department, where he is a captain and director of training. He is a field instructor with the Fire Service Institute at the University of Illinois and an instructor in the Bachelor of Arts in Fire Service Administration for Southern Illinois University, teaching courses in fire service risk management at both institutions. Wilder is a partner in the consulting firm of Sorensen, Wilder, and Associates in Bradley, Illinois, which provides risk and safety management services to fire departments, law enforcement agencies, and EMS organizations. He is the author of Risk Management in the Fire Service (Fire Engineering, 1997) and has written extensively on the topic for numerous fire service-related publications.
