Workplace Safety and Health: Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence
Published: 2016-03-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Workplace violence is a serious concern for the approximately 15 million health care workers in the United States. OSHA is the federal agency responsible for protecting the safety and health of the nation's workers, although states may assume responsibility under an OSHA-approved plan. OSHA does not require employers to implement workplace violence prevention programs, but it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards. GAO was asked to review efforts by OSHA to address workplace violence in health care.
GAO examined the degree to which workplace violence occurs in health care facilities and OSHA's efforts to address such violence.
GAO analyzed federal data on workplace violence incidents, reviewed information from the nine states GAO identified with workplace violence prevention requirements for health care employers, conducted a literature review, and interviewed OSHA and state officials.
section_title: What GAO Found
paragraphs: According to data from three federal datasets GAO reviewed, workers in health care facilities experience substantially higher estimated rates of nonfatal injury due to workplace violence compared to workers overall. However, the full extent of the problem and its associated costs are unknown. For example, in 2013, the most recent year that data were available, private-sector health care workers in in-patient facilities, such as hospitals, experienced workplace violence-related injuries requiring days off from work at an estimated rate at least five times higher than the rate for private-sector workers overall, according to data from the Department of Labor (DOL). The number of nonfatal workplace violence cases in health care facilities ranged from an estimated 22,250 to 80,710 cases for 2011, the most recent year that data were available from all three federal datasets that GAO reviewed. The most common types of reported assaults were hitting, kicking, and beating. The full extent of the problem and associated costs is unknown, however, because according to related studies GAO reviewed, health care workers may not always report such incidents, and there is limited research on the issue, among other reasons.
DOL's Occupational Safety and Health Administration (OSHA) increased its education and enforcement efforts to help employers address workplace violence in health care facilities, but GAO identified three areas for improvement in accordance with federal internal control standards.
Provide inspectors additional information on developing citations . OSHA has not issued a standard that requires employers to implement workplace violence prevention programs, but the agency issued voluntary guidelines and may cite employers for hazards identified during inspections—including violence in health care facilities—under the general duty clause of the Occupational Safety and Health Act of 1970. OSHA increased its yearly workplace violence inspections of health care employers from 11 in 2010 to 86 in 2014. OSHA issued general duty clause citations in about 5 percent of workplace violence inspections of health care employers. However, OSHA regional office staff said developing support to address the criteria for these citations is challenging and staff from 5 of OSHA's 10 regions said additional information, such as specific examples of issues that have been cited, is needed. Without such additional information, inspectors may continue to experience difficulties in addressing the challenges they reported facing.
Follow up on hazard alert letters . When the criteria for a citation are not met, inspectors may issue warnings, known as hazard alert letters. However, employers are not required to take corrective action in response to them, and OSHA does not require inspectors to follow up to see if employers have taken corrective actions. As a result, OSHA does not know whether identified hazards have been addressed and hazards may persist.
Assess the results of its efforts to determine whether additional action, such as development of a standard, may be needed . OSHA has not fully assessed the results of its efforts to address workplace violence in health care facilities. Without assessing these results, OSHA will not be in a position to know whether its efforts are effective or if additional action may be needed to address this hazard.
section_title: What GAO Recommends
paragraphs: GAO recommends 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 health care facilities, and assess its current efforts. OSHA agreed with GAO's recommendations and stated that it would take action to address them.

section_title: Letter
paragraphs: Workplace violence is a serious concern for the approximately 15 million  health care workers in the United States. At the federal level, the  Department of Labor’s (DOL) Occupational Safety and Health  Administration (OSHA) is the agency that has primary responsibility for  protecting the safety and health of the nation’s workers, and though  OSHA does not require employers to have workplace violence prevention  programs, the agency issued guidelines to help employers establish such  programs. Furthermore, some states have enacted laws requiring health  care employers to develop and implement workplace violence prevention  programs.
You asked us to review efforts by OSHA and states to address workplace  violence in health care facilities. This report examines (1) what is known  about the degree to which workplace violence occurs in health care  facilities and its associated costs, (2) steps OSHA has taken to protect  health care workers from workplace violence and assess the usefulness  of its efforts, (3) how selected states have addressed workplace violence  in health care facilities, and (4) research on the effectiveness of  workplace violence prevention programs in health care facilities.
To describe what is known about the degree to which workplace violence  occurs in health care facilities and its associated costs, we reviewed  federal data sources used by three federal agencies to estimate injuries  and deaths related to workplace violence. To assess the reliability of the  data, we reviewed agency documentation, interviewed federal officials,  and performed electronic testing of required data elements. We  determined that the data were sufficiently reliable for purposes of  providing information about the number of cases and rates of workplace  violence in health care facilities.
To examine the steps OSHA has taken to protect health care workers  from such violence, we reviewed relevant federal laws and regulations;  analyzed OSHA’s guidance, inspection procedures, and enforcement  data from 1991 through April 2015; and interviewed OSHA officials. We  collected information from all 10 OSHA regional offices on inspector  training and how inspectors investigate workplace violence during  inspections of health care employers. To assess the reliability of the  OSHA enforcement data, we reviewed relevant agency documentation,  conducted electronic data testing, and interviewed agency officials. Based  on these reviews, we determined that the data were sufficiently reliable  for our purposes. We compared OSHA’s actions to federal internal control  standards.
To describe how selected states have addressed workplace violence in  health care facilities, we collected information from state officials in the  nine states we identified that have workplace violence prevention  requirements for health care employers and reviewed documents  provided by the officials. From our search of legal databases; review of  related studies; and interviews with federal officials, researchers, and  national labor organizations; we identified the following nine states:  California, Connecticut, Illinois, Maine, Maryland, New Jersey, New York,  Oregon, and Washington. We visited four of these states–California,  Maryland, New York, and Washington–which were selected for variation  in the length of time their state workplace violence prevention laws have  been in place. We did not conduct a nationwide review of state laws or  collect information from all 50 states; therefore, other states may also  have these types of requirements. During our site visits, we interviewed  state officials, visited health care facilities, and held five discussion  groups with health care workers. The information we obtained from the  states and our site visits is not generalizable.
To describe research on the effectiveness of workplace violence  prevention programs, we reviewed studies identified in a literature review  on the prevalence and costs of workplace violence in health care and the  effectiveness of workplace violence prevention programs. Specifically, we  identified studies published in government reports and peer-reviewed  journals from January 2004 to June 2015 that were (1) based on original  data collection, (2) provided quantitative evidence related to our  objectives, (3) provided information related to physical violence against  health care workers, and (4) that were sufficiently reliable and  methodologically rigorous to include in our review. For further details  regarding our scope and methodology, see appendix I.
We conducted this performance audit from August 2014 to March 2016 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: OSHA and State Responsibilities for Worker Safety and Health
paragraphs: OSHA is responsible for protecting the safety and health of the nation’s  workers under the Occupational Safety and Health Act of 1970 (OSH  Act). OSHA sets and directly enforces occupational safety and health  standards for the private sector in about half the states. Occupational  safety and health standards are a type of regulation and are defined as  standards that require “conditions, or the adoption or use of one or more  practices, means, methods, operations, or processes, reasonably  necessary or appropriate to provide safe or healthful employment and  places of employment.” OSHA carries out its enforcement activities  through its 10 regional offices and 90 area offices. The remaining states  set and enforce their own workplace safety and health standards for  employers under a state plan approved by OSHA. In these states, the  state agency typically responsible for enforcing workplace safety and  health standards is the state department of labor. OSHA conducts two  types of inspections to enforce the OSH Act and its standards:  unprogrammed and programmed inspections. Unprogrammed  inspections are unplanned and conducted in response to certain events,  such as investigating employee complaints, including claims of imminent  danger and serious accidents involving fatalities, amputations, and in- patient hospitalizations. Programmed inspections are planned and target  industries or individual workplaces based on predetermined criteria, such  as those that have experienced relatively high rates of workplace injuries  and illnesses. Among states with OSHA-approved state plans,  enforcement practices may vary, but states generally are expected to use  a similar approach to performing planned and unplanned inspections.
The states with OSHA-approved state plans cover different types of  employers in their state. Twenty-one of the states with OSHA-approved  state plans are responsible for enforcing workplace safety and health  laws and standards at private-sector and state and local government  workplaces. Five of the states with OSHA-approved state plans cover  state and local government workplaces only, with OSHA providing  enforcement for the private sector (see fig. 1).
Four of the nine states we reviewed–California, Maryland, Oregon, and  Washington–are responsible for enforcement for the private sector and  the state and local public sector under an OSHA-approved state plan. In  the remaining five states–Connecticut, Illinois, Maine, New Jersey, and  New York–OSHA provides enforcement for the private sector, while the  state is responsible for the state and local public sector.
In addition to workplace safety and health regulation by OSHA and state  departments of labor, other federal and state government agencies  regulate health care employers in various ways and may have  requirements related to workplace violence prevention. For example,  states may impose certain licensing requirements on hospitals or other  health care facilities. In addition, the Joint Commission on Accreditation of  Healthcare Organizations (Joint Commission), a nonprofit corporation that  accredits and certifies health care organizations and programs, also has  its own requirements for accreditation purposes.
section_title: OSHA Enforcement and Guidelines Related to Workplace Violence Prevention
paragraphs: OSHA does not require employers to have workplace violence prevention  programs; however, the agency issued voluntary guidelines in 1996 to  help employers establish them. Although there is no federal  occupational safety and health standard for workplace violence  prevention, OSHA may issue citations to employers for violating a certain  provision of the OSH Act–referred to as the general duty clause–which  requires employers to provide a workplace free from recognized hazards  likely to cause death or serious physical harm. To cite an employer  under the general duty clause, OSHA must have evidence that (1) a  condition or activity in the workplace presents a hazard to an employee,  (2) the condition or activity is recognized as a hazard by the employer or  within the industry, (3) the hazard is causing or is likely to cause death or  serious physical harm, and (4) a feasible means exists to eliminate or  materially reduce the hazard. When OSHA does not have enough  evidence to support a citation, it can issue hazard alert letters that warn  employers about the dangers of specific industry hazards and provide  information on how to protect workers.
OSHA has recordkeeping regulations that require employers to record  certain workplace injuries and illnesses. For each work-related injury  and 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, 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.
section_title: Federal Data on Nonfatal Workplace Violence
paragraphs: Three federal agencies collect national data on nonfatal workplace  violence in health care facilities: BLS, within DOL; NIOSH, within the  Department of Health and Human Services (HHS); and BJS, within the  Department of Justice (DOJ). The three agencies collect data on different  types of workplace violence cases from different sources (see table 1).
section_title: Workers in Health Care Facilities Experience Higher Estimated Rates of Nonfatal Workplace Violence than Workers Overall, though the Full Extent of the Problem and Its Costs Are Unknown
subsections: section_title: Federal Data Show That Workers in Health Care Facilities Have Higher Estimated Rates of Nonfatal Injury Due to Workplace Violence than Workers Overall
paragraphs: Workers in health care facilities experience substantially higher estimated  rates of nonfatal injury due to workplace violence compared to workers  overall, according to data from three federal data sets we reviewed (see  fig. 2). BLS’s Survey of Occupational Injuries and Illnesses (SOII) data  for 2013 show that the estimated rates of nonfatal workplace violence  against health care workers in private-sector and state in-patient  facilities–including hospitals and nursing and residential care facilities–are  from 5 to 12 times higher than the estimated rates for workers overall,  depending on the type of health care facility. More specifically, in 2013  the estimated rate of injuries for all private-sector workers due to such  violence that resulted in days away from work was 2.8 per 10,000  workers. In contrast, the estimated rate for private-sector hospital  workers was 14.7 per 10,000 workers, and for nursing and residential  care workers the rate was 35.3 per 10,000 workers. The estimated rates  of nonfatal injury due to workplace violence were highest in state  hospitals and nursing and residential care facilities, according to BLS’s  SOII data. Workers in these state facilities may have higher rates of  workplace violence because they work with patient populations that are  more likely to become violent, such as patients with severe mental illness  who are involuntarily committed to state psychiatric hospitals, according  to BLS research. Data from HHS’s National Electronic Injury  Surveillance System-Work Supplement (NEISS-Work) data set show that  in 2011 the estimated rate of nonfatal workplace violence injuries for  workers in health care facilities was statistically greater than the  estimated rate for all workers. Data from the National Crime Victimization  Survey (NCVS) data set show that from 2009 through 2013 health care  workers experienced workplace violence at more than twice the estimated  rate for all workers (after accounting for the sampling error).
Research also suggests that nonfatal workplace violence is prevalent in  in-patient health care facilities. Although their results are not  generalizable, three studies that surveyed hospital workers found that 19  to 30 percent of workers in a general hospital setting who completed the  surveys reported being physically assaulted at work sometime within the  year prior to each study (see app. II for more information on these  studies). In addition, a study that surveyed staff in a psychiatric hospital  found that 70 percent of staff reported being physically assaulted within  the last year.
Moreover, BLS data indicate that reported nonfatal workplace violence  against health care workers has increased in recent years. Such cases  reported by employers in BLS’s SOII increased by about 12 percent over  2 years, from an estimated 22,250 reported cases in 2011 to an  estimated 24,880 in 2013. We also examined the estimated rates of  workplace violence reported by employers in BLS’s SOII by the type of  facility and found that there was relatively little change from 2011 through  2013, with the exception of a 70 incidents per 10,000 workers increase in  the rate for state nursing and residential care facilities. The estimated  number of health care workers reporting at least one workplace violence- related assault in BJS’s NCVS survey from 2009 through 2013 varied  from year to year with no clear statistical trend (see fig. 3).
Nonfatal and fatal workplace violence against health care workers  involves different types of perpetrators and violence. For nonfatal  violence, patients are the primary perpetrators, according to federal data  and studies we reviewed. More specifically, patients were the  perpetrators of an estimated 63 percent of the NEISS-Work cases where  workers in health care facilities came to the emergency department for  treatment after experiencing workplace violence-related injuries in 2011.  Several of the studies we reviewed also found that patients were the  primary perpetrators of nonfatal violence against health care workers,  followed by the patient’s relatives and visitors (see app. II for more  information on these studies). According to NEISS-Work data from 2011,  hitting, kicking, and beating were the most common types of nonfatal  physical violence reported by workers in health care facilities. As for fatal  violence, the BLS Census of Fatal Occupational Injuries reported 38  workers in health care facilities died as a result of workplace violence  assaults from 2011 through 2013, representing about 3 percent of all  worker deaths due to workplace violence across all industries during  those years. Many of the deaths in a health care setting involved a  shooting, with many perpetrated by someone the worker knew, such as a  domestic partner or co-worker.
Health care workers we interviewed described a range of violent  encounters with patients that resulted in injuries ranging from broken  limbs to concussions (see table 2).
section_title: Patient and Work-Related Factors Can Increase a Health Care Worker’s Risk of Being Assaulted at Work
paragraphs: Research suggests that patient-related factors can increase the risk of  workplace violence. A study that surveyed over 5,000 workers in six  hospitals in two states found that patient mental health or behavioral  issues were contributing factors in about 64 percent of the patient- perpetrated violent events reported by health care workers who  completed the survey, followed by medication withdrawal, pain, illicit  drug/alcohol use, and being unhappy with care.  In three of our  discussion groups, health care workers said working with patients with  severe mental illness or who are under the influence of drugs or alcohol  contributed to workplace violence in health care facilities.
Certain types of health care workers are more often the victims of  workplace violence. According to BLS data from 2013, health care  occupations like psychiatric aides, psychiatric technicians, and nursing  assistants experienced high rates of workplace violence compared to  other health care occupations and workers overall (see fig. 4).  Furthermore, one study that surveyed over 5,000 workers in six hospitals  in two states found that workers in jobs typically involving direct patient  care had a higher percentage of physical assaults compared with other  types of workers. For example, a higher percentage of nurse’s aides  reported being physically assaulted within the last year (14 percent) than  nurse managers (4.7 percent). 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.
section_title: The Full Extent of Workplace Violence against Health Care Workers and Its Associated Costs Are Unknown
paragraphs: While the three national datasets we analyzed shed some light on the  level of workplace violence committed against health care workers, the  full extent of the problem is unknown for three main reasons: 1)  differences in the criteria used to record workplace violence cases in the  data sets, 2) health care workers not reporting all cases of workplace  violence, and 3) employer inaccuracies in reporting cases of workplace  violence.
subsections: section_title: Differences in Criteria Used in the Data Sets
paragraphs: Not all workplace violence cases are included in the three national data  sets we reviewed because of the criteria used by each of the data sets.  With regard to the first two data sets (SOII and NEISS-Work), workplace  violence that does not result in injuries severe enough to require days off  from work or an emergency room visit are not included. For the NCVS  data, cases that are not considered to be crimes are not included. Table 3  describes the number and types of workplace violence cases recorded in  each of these datasets in 2011, the most recent year in which data were  available from all three sources.
Health care workers do not formally report all incidents of workplace  violence for various reasons. Although the results are not generalizable,  estimates of the percentage of cases that are formally reported ranged  from 7 to 42 percent in the studies we reviewed (see app. II for more  information on these studies). The health care workers surveyed in four  of the five studies we reviewed most often reported the violence  informally to their supervisors or co-workers. A study that surveyed 762  nurses from one hospital system found that the reasons health care  workers provided for not formally reporting the violence included (1) not  sustaining serious injuries, (2) inconvenience, and (3) the perception that  violence comes with the job. Health care workers in all five of our  discussion groups said that they do not report all cases of workplace  violence unless they result in a severe injury. Health care workers in four  discussion groups also said that they do not report all cases of workplace  violence because the reporting process is too burdensome and because  management discouraged reporting. Health care workers in two of our  discussion groups reported fear of being blamed for causing the attack,  losing their job, as well as financial hardships associated with their  inability to work due to injury, as reasons for not formally reporting all  cases of workplace violence.
section_title: Inaccurate Reporting
paragraphs: OSHA and BLS research indicate that employers do not always record or  accurately record workplace injuries in general. Specifically, in a 2012  report OSHA found that for calendar years 2007 and 2008, approximately  20 percent of injury cases reconstructed by inspectors during a review of  employee records were either not recorded or incorrectly recorded by the  employer. OSHA is working on improving reporting by conducting  additional outreach and training for employers on their reporting  obligations. BLS research has also found that employers do not report  all workplace injury cases in the SOII, and 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.
section_title: Limited Information on the Costs Associated with Workplace Violence
paragraphs: There is limited information available on the associated costs of injuries  due to workplace violence in health care. While DOL and HHS collect  information on occupational injuries and illnesses due to violence in  health care, they do not collect data on the costs. The BJS NCVS  survey asks individuals about the medical expenses they incurred as a  result of workplace violence; however, our analysis of the data did not  identify enough cases to produce a national estimate of the costs. One of  the states we reviewed, Washington, provided us with a report about the  cost the state incurred due to workplace violence over a 5 year period.  The state estimates between $4 million and $8 million each year from  2010 through 2014 in workers’ compensation costs for health care  workers who were injured from workplace violence and received medical  treatment for their injuries. Another state we reviewed, California,  analyzed worker’s compensation injury data for one of their hospitals from  2003 to 2013. According to state officials, 1,169 of the 4,449 injuries were  due to patient assaults and amounted to $16.6 million in worker’s  compensation costs over this time period. In another study, researchers  surveyed nurses from a hospital system in the mid-Atlantic region  regarding medical expenses related to work-related assaults against  them. They found that of the 106 nurses who reported injuries, the  collective costs of treatment and lost wages for the 30 nurses requiring  treatment was $94,156.
section_title: OSHA Increased Enforcement and Education Efforts, but Inspectors Face Challenges Taking Enforcement Actions and Following up on Hazard Alert Letters
subsections: section_title: OSHA Increased Its Workplace Violence Inspections of Health Care Employers
paragraphs: OSHA increased its inspections of health care employers for workplace  violence from 11 in 2010 to 86 in 2014 (see fig. 5). OSHA officials  attribute this increase to a rise in employee complaints and programmed  inspections following implementation of a 3-year National Emphasis  Program (NEP) targeting nursing and residential care facilities, which  began in April 2012. Workplace violence was one of the hazards  included as part of the NEP, which required each OSHA region to inspect  a minimum number of facilities from a list developed by OSHA’s national  office of those facilities meeting or exceeding certain injury and illness  rates.
OSHA conducted a total of 344 inspections involving workplace violence  in the health care sector from 1991 through April 2015. More than two- thirds of the 344 inspections since 1991 were unprogrammed, and over  70 percent of the unprogrammed inspections were conducted in response  to complaints (see fig. 6). Sixty percent (205 inspections) of the 344  inspections were conducted by 3 of OSHA’s 10 regions. OSHA officials  said that the higher number of inspections in certain regions could have  been due to them receiving a higher number of workplace violence  complaints than other regions. OSHA officials also said that the higher  number of inspections in certain regions could have been due to the  regions having more experienced workplace violence coordinators and  inspectors, which increased their comfort in pursuing workplace violence  cases.
In April 2015, OSHA announced the expiration of the nursing and  residential care facilities NEP. However, OSHA determined that the  results of the NEP indicated a need for continued focus on efforts to  reduce the identified hazards in those sectors, including workplace  violence. Consequently, in June of 2015, OSHA issued new inspection  guidance stating that all programmed and unprogrammed inspections of  in-patient health care facilities–including hospitals and nursing and  residential care facilities–are to cover the hazards included in the recently  concluded NEP. This new inspection guidance applies to a broader  group of health care facilities by including hospitals, in addition to nursing  and residential care facilities, which were covered by the NEP. Unlike the  NEP, the guidance does not require OSHA area offices to inspect a  minimum number of facilities each year.
To determine whether workplace violence is a potential hazard in a  facility, OSHA inspectors are directed in an OSHA enforcement directive  to take certain steps during inspections, including a review of an  employer’s workplace injury and illness logs, interviews with employees,  and personal observations of potential workplace violence hazards. If  there are potential hazards, inspectors are expected to physically inspect  and identify any hazards that increase exposure to potential violence,  such as lack of appropriate lighting or the absence of security systems. In  addition, inspectors are instructed to interview all employees who have  observed or experienced any violent acts and review other records, such  as police and security reports and workers’ compensation records. In  addition, inspectors are instructed to determine the violence prevention  measures an employer has in place and whether it has provided any  related training to its employees. If inspectors determine that a general  duty clause or other citation is warranted, they will consult with their  regional office management, OSHA’s national office, and the Department  of Labor’s solicitor’s office to develop the citation, according to OSHA  officials.
OSHA has established various policies and procedures to support its  inspectors in conducting workplace violence inspections, including the  following:
Uniform inspection procedures. OSHA issued an enforcement  directive in 2011 to provide its inspectors with uniform procedures for  addressing workplace violence. This directive defines workplace  violence, describes the steps for conducting inspections, and outlines  the criteria for a general duty clause citation along with descriptions of  the types of evidence needed to support each criterion. The directive  also requires OSHA regional and area offices to ensure that OSHA  inspectors are trained in workplace violence prevention to assist them  in understanding specific workplace violence incidents, identify hazard  exposure, and assist the employer in abating the hazard.
Regional workplace violence coordinators. Every regional office  has a designated workplace violence coordinator who functions as an  in-house expert on workplace violence and provides advice and  consultation to inspection teams, according to OSHA officials. In  addition, according to OSHA officials, the coordinators hold bi-monthly  teleconferences with OSHA national office managers to exchange  information and discuss strategies for developing workplace violence  cases.
Inspector training. According to OSHA officials, all inspectors are  required to complete web-based training as part of their initial training  that includes four lessons related to workplace violence: (1) defining  workplace violence, (2) identifying solutions to the violence, (3)  conducting workplace violence inspections, and (4) protecting oneself  during an inspection. Three other optional webinars are offered: a 1.5- hour webinar on the 2011 workplace violence enforcement directive  that includes discussion of its purpose, procedures for conducting  inspections and issuing citations for workplace violence, and  resources available for workplace violence inspections. The second is  a 1.5-hour webinar that focuses on identifying risks for violence and  prevention strategies in health care and social services settings. The  third is a 2-hour webinar that includes information on how to conduct  inspections as part of the NEP targeting nursing and residential care  facilities. Out of 1,026 OSHA staff who were invited to take the  optional webinars, OSHA reports 652 staff have completed the  webinar on the 2011 directive, 1,023 have completed the one on  identifying risks and prevention strategies, and 713 have completed  the webinar on the NEP, as of June 2015.
section_title: OSHA Has Updated and Obtained Feedback on the Usefulness of Its Employer Guidelines for Preventing Workplace Violence
paragraphs: OSHA has developed and disseminated voluntary guidelines and a  variety of other informational materials to help educate health care and  other employers on preventing workplace violence. As previously  discussed, in 2015 OSHA issued an update of its written guidelines for  health care and social service employers on preventing and responding to  workplace violence. The guidelines identify the components that should  be incorporated in a workplace violence prevention program and include  checklists for employers to use in evaluating those programs. OSHA has  a workplace violence web page with links to the 2015 guidelines, other  publications, and resources and materials for employee training related to  workplace violence, along with links for obtaining consultation services  from OSHA and for filing complaints. In addition, OSHA launched a new  webpage in December of 2015 with resources that employers and  workers can use to address workplace violence in health care facilities.  For example, the webpage links to a new OSHA publication that presents  examples of health care facilities’ practices related to the five components  recommended in OSHA’s voluntary guidelines. OSHA also formed an  alliance with the Joint Commission to provide employers with information,  guidance, and access to training resources to protect their employees’  health and safety that includes addressing workplace violence. As part  of this alliance, OSHA has disseminated information on preventing  workplace violence in health care through publication of three articles in a  Joint Commission newsletter, with a fourth article planned.
OSHA officials told us they obtained feedback from stakeholders on the  workplace violence prevention guidelines and incorporated stakeholder  comments into the final publication of the 2015 guidelines. These  stakeholders confirmed the usefulness of OSHA’s revised guidelines,  according to OSHA officials. OSHA officials also told us the agency has  not conducted and does not plan to conduct any type of formal evaluation  of the usefulness of these materials due to insufficient resources.
OSHA also funds training on workplace violence prevention for employers  and workers. OSHA provided training grants in 2012 and 2013 totaling  $254,000 to three organizations that developed workplace violence  prevention curricula and trained 1,900 health care workers. Additional  training grants totaling over $514,000 were awarded to five organizations  in 2014 to be used for programs that include training health care workers  and employers in preventing and addressing workplace violence.
section_title: Inspectors Reported Facing Challenges Developing Citations and Ensuring That Actions Are Taken to Address Hazard Alert Letters
paragraphs: While the number of inspections involving workplace violence in health  care facilities has increased, a relatively small percentage of these  inspections resulted in general duty clause citations related to workplace  violence. From 1991 through October 2014, OSHA issued 18 general  duty clause citations to health care employers for failing to address  workplace violence. Seventeen of these citations were issued from 2010  through 2014 (see fig. 7). These citations were issued in about 5 percent  of the 344 workplace violence inspections of health care employers that  were conducted from 1991 to April 2015.
All 18 citations arose from unprogrammed inspections. Fourteen of the  citations arose from complaints—the most common type of  unprogrammed inspection among these cases. For example, in one case,  OSHA cited an employer for exposing employees working in a residential  habilitation home to the hazard of violent behavior and being physically  assaulted by patients with known histories of violence or the potential for  violence. OSHA determined that the company failed to identify and abate  existing and developing hazards associated with workplace violence. In  all 18 of these cases, health care workers had been injured or killed by  patients, clients, or residents. We found that the three regions that  conducted the highest number of workplace violence inspections also  issued the majority of workplace violence-related general duty citations to  health care employers. Collectively, the three regions issued 12 of the 18  general duty citations issued since 1991.
Staff from all 10 OSHA regional offices said it was challenging to cite  employers for violating the general duty clause when workplace violence  is identified as a hazard and staff from 4 OSHA regional offices said it  was challenging to develop these cases within the 6-month statutory time  frame required to develop a citation. As described in OSHA’s  enforcement directive, to cite an employer for violating the general duty  clause for a workplace violence hazard, OSHA inspectors must  demonstrate that (1) a serious workplace violence hazard exists and the  employer failed to keep its workplace free of hazards to which employees  were exposed, (2) the hazard is recognized by the employer or within the  industry, (3) the hazard caused or is likely to cause death or serious  physical harm, and (4) there are feasible abatement methods to address  the hazard. Some inspectors and other regional officials from 5 OSHA  regional offices said it is difficult to collect sufficient evidence to meet all  four criteria during an inspection. For example, two regional officials noted  that while injuries may have occurred as a result of workplace violence at  facilities they have inspected, the assaults may involve a single employee  or a very small number of employees, or the assaults may not be frequent  or serious enough to demonstrate a hazard that can cause serious  physical harm or death. Another inspector noted that an employer may  have a minimal workplace violence prevention program and that it is  sometimes difficult to prove that the employer has not done enough to  address the hazard.
Staff, including officials and inspectors, from 5 of OSHA’s 10 regional  offices said it would be helpful to have additional assistance to implement  the 2011 workplace violence enforcement directive. They suggested  having additional information on how to collect evidence and write up a  workplace violence citation, examples of workplace violence issues that  have been cited, examples of previously documented workplace violence  case files, and examples of citations that have been upheld in court would  be helpful. According to federal internal control standards, agency  management should share quality information throughout the agency to  enable personnel to perform key roles in achieving agency objectives.  While OSHA’s webinar on the 2011 workplace violence enforcement  directive provides general guidance on the types of evidence needed to  develop a general duty clause citation, it does not provide the types of  detailed information proposed by staff. For example, officials from one  region said that although the training they received was helpful, assessing  workplace violence hazards is new to many inspectors, and additional  information would help inspectors fully understand how to inspect, collect  evidence, and write up a workplace violence citation. Inspectors from  another region suggested the national office provide an updated webinar  with lessons learned and examples of what has been cited so inspectors  can be consistent in how they develop these cases. Officials from  OSHA’s national office told us they have considered developing additional  training for inspectors on conducting workplace violence inspections and  are planning to revise the 2011 enforcement directive. For example, they  said that they would like to provide inspectors more specific guidance on  developing a workplace violence case in different environments and  additional information about the hazards and abatement measures  applicable to different health care facilities. OSHA officials said the  training would be developed and the directive would be revised by the  end of 2016. Without this additional information, inspectors may continue  to face challenges in conducting workplace violence inspections and  developing citations.
When inspectors identify workplace violence hazards during an  inspection, but all the criteria for issuing a general duty clause citation are  not met and a specific standard does not apply, inspectors have the  option of issuing warning letters to employers, known as Hazard Alert  Letters (HAL). These letters recommend that the employer voluntarily  take steps to eliminate or reduce workers’ exposure to the hazard. The  letters describe the specific hazardous conditions identified in an  inspection, list corrective actions that can be taken to address them, and  provide contact information to seek advice and consultation on  addressing the hazards. From 2012 through May 2015, OSHA issued 48  HALs to health care employers recommending actions to address factors  contributing to workplace violence. Several of the HALs we reviewed  stated that workers had been assaulted, notified the employers that they  failed to implement adequate measures to protect their workers from  assaults, and recommended the employers take specific steps to better  protect their workers.
Agency officials informed us OSHA inspectors are not required to  routinely conduct follow-up inspections after issuing HALs, and the  uniform inspection procedures from the 2011 enforcement directive do  not specify a process for contacting employers to determine whether  hazards and deficiencies have been addressed. They explained,  however, that a follow-up inspection would not normally be conducted if  the employer or employer representative provides evidence that the  hazard has been addressed. According to OSHA officials, if OSHA  decides to conduct a follow-up inspection, OSHA’s recommended time  period for a follow-up with employers is 12 months following employer  receipt of the HAL, although this is not required in the inspection  procedures from the 2011 enforcement directive. OSHA established a  policy in 2007 to follow up on HALs related to ergonomics issues, but this  policy does not apply to HALs related to workplace violence issues.   OSHA established the ergonomics HAL policy after its ergonomics  standard was invalidated under the Congressional Review Act in 2001.  The ergonomics HAL follow-up policy outlines a process for contacting  employers to determine whether ergonomic hazards and deficiencies  identified in the letters have been addressed. OSHA inspectors are  directed to schedule a follow-up inspection to determine if the hazards are  being addressed if the employer does not respond or responds  inadequately.
In addition, OSHA was not able to tell us how many of the 48 health care  employers who received HALs for workplace violence issues had follow- up inspections because the follow-up status of HALs is not centrally  maintained. Each regional office workplace violence coordinator would  have to be contacted to find out the status of each HAL. OSHA has a  centralized information system, but has not systematically used it for  tracking the status of HALs. While OSHA’s information system is capable  of tracking the status of HALs, OSHA officials are not sure if regional  offices are consistently entering updated information. According to federal  internal control standards, agency management should perform ongoing  monitoring as part of the normal course of operations. Without a uniform  process to follow up on these HALs, OSHA will not know whether the  hazards that placed employees at risk for workplace violence at these  facilities continue to exist. In addition, without routine follow up on these  cases, OSHA may not obtain the information needed to determine  whether a follow-up inspection or other enforcement actions are needed.
OSHA officials acknowledged that it can be challenging to develop a  general duty clause citation for workplace violence and cited some  potential benefits of having a workplace violence prevention standard.  However, officials stated that OSHA is not planning at this time to develop  a workplace violence prevention standard because it has identified other  workplace hazards that are higher priorities for regulatory action.  According to OSHA officials, the potential benefits of having a specific  standard include setting clearer expectations for employers, increasing  employer implementation of workplace violence prevention programs, and  simplifying the process for determining when citations could be issued.  Rather than pursuing a standard on workplace violence, the officials  stated that OSHA has focused its efforts on increased enforcement using  the general duty clause, issuing new guidance, and developing a new  webpage for employers and workers with resources for addressing  workplace violence in health care facilities.
OSHA officials also highlighted other efforts the agency has taken to  reduce workplace violence in health care facilities. These efforts included  obtaining feedback from stakeholders on the employer guidelines,  establishing a task force to develop a long term agency plan for  workplace violence prevention and resources for OSHA staff and the  public, and issuing publications on workplace violence prevention  strategies. In addition, OSHA officials reported conducting a qualitative  and quantitative review of data from its NEP for Nursing and Residential  Care Facilities. However, OSHA’s review of the NEP entailed  summarizing data collected from the regions 6 months after the program  began on inspections that resulted in the issuance of ergonomics hazard  alert letters. OSHA officials said they did not complete an overall  evaluation of the program even though the NEP procedures provided that  the agency do so. The NEP procedures stated that the national office was  to collect data relevant to the effectiveness of the program from the  regions and complete an evaluation. Additionally, the procedures  specified that the evaluation should address the program’s role in meeting  OSHA’s goals, such as the reduction in the number of injuries and  abatement measures implemented. An OSHA official we spoke with could  not provide a reason why OSHA did not conduct an evaluation of the NEP  and was not aware of any plans for the agency to conduct such an  evaluation. According to information provided by agency officials, they  have not assessed how well OSHA’s approach to helping prevent  workplace violence is working. According to federal internal control  standards, agency management should assess the quality of agency  performance over time and correct identified deficiencies. Such  assessments involve analyzing data to determine whether the intended  outcomes were achieved and identifying any changes that may improve  results. Because OSHA has not assessed the results of its education and  enforcement efforts, it is not in a position to know whether they have  helped, for example, to increase employer awareness and  implementation of abatement measures. Assessing how well OSHA’s  approach is working could inform future efforts to address workplace  violence in health care facilities. For example, completing the evaluation  of the NEP results could provide OSHA with information to decide  whether further action may be needed to address workplace violence  hazards. OSHA could also consider cost-effective ways to conduct such  assessments, such as reviewing a sample of workplace violence  inspections that resulted in hazard alert letters to determine the extent to  which employers implemented recommended abatement measures.
section_title: Selected States Have Workplace Violence Prevention Requirements Similar to OSHA’s Voluntary Guidelines and Have Some Additional Efforts to Address Workplace Violence
paragraphs: All of the nine states we reviewed have enacted laws that require health  care employers to establish a plan or program to protect workers from  workplace violence. According to our review of information provided by  state officials, these states have requirements, either in law or  regulation, similar to the components of an effective workplace violence  prevention program identified in OSHA’s voluntary guidelines (see table  4). Specifically, seven of the nine states require management and  worker participation in workplace violence prevention efforts, such as  through a committee or other means. Eight of the nine states require  health care employers to analyze or assess worksites to identify hazards  that may lead to violent incidents. All nine states require health care  employers to take steps to prevent or control the hazards, such as  changing policies, security features, or the physical layout of the facility.  Eight of the nine states also require health care employers to train  workers on workplace violence prevention, such as how workers can  protect themselves and report incidents. All nine states require health  care employers to record incidents of violence against workers, and eight  of the states require health care employers to periodically evaluate or  review their workplace violence prevention plan or program.
According to state officials in the nine states we reviewed, the department  of labor is responsible for ensuring compliance with these workplace  violence prevention requirements, although in some states the  department of health also has oversight responsibilities. In addition, under  their OSHA-approved state plans, the state departments of labor in our  selected states may issue citations to employers under their jurisdiction  for violations of an applicable state standard or the state’s equivalent to  the general duty clause. Similar to OSHA, state agency oversight  activities included investigating complaints and reports of violent  incidents, as well as conducting planned inspections. The departments of  labor in the states we reviewed conducted varying numbers of inspections  of health care employers involving workplace violence issues and in some  cases cited employers for violations of their requirements. From 2010  through 2014, state officials from eight of the nine states reported  conducting from 2 to 75 inspections of health care employers related to  workplace violence. One state did not conduct inspections of health  care employers regarding workplace violence. The completed  inspections resulted in 0 to 74 reported citations.
In addition to their workplace violence prevention laws, officials in some of  the states we reviewed described other efforts to further address  workplace violence against health care workers. For example, California,  New York, and Oregon have a NIOSH-funded program for tracking and  investigating work-related fatalities called the Fatality Assessment and  Control Evaluation Program. The purpose of this program is to identify  risk factors for work-related fatalities and disseminate prevention  recommendations. Also, the state of Washington has an independent  research program called the Safety and Health Assessment and  Research for Prevention Program that conducts research projects on  occupational health and safety. In addition, California department of labor  officials stated that they are developing a workplace violence prevention  standard that will be adopted by July 2016, which officials said would  make it easier for inspectors to cite employers for workplace violence  issues.
section_title: Research on the Effectiveness of Workplace Violence Prevention Programs Is Limited, but a Few Studies Show Positive Results
paragraphs: Relatively few studies have been conducted on the effectiveness of  workplace violence prevention programs, limiting what is known about the  extent to which such programs or their components reduce workplace  violence. After conducting a literature review, we identified five studies  that evaluated the effectiveness of workplace violence prevention  programs and met our criteria, such as having original data collection and  quantitative evidence.
Four of the five studies we reviewed suggest that workplace violence  prevention programs can contribute to reduced rates of assault.
Three Studies of the Veterans Health Administration system. In  one study, researchers surveyed workers from 142 Department of  Veterans Affairs (VA) hospitals in 2002 and identified facility-level  characteristics associated with higher and lower rates of assaults. The  researchers found that facility-wide implementation of alternate  dispute resolution training was associated with reduced assault  rates. In a separate study of the VA system, researchers examined  the relationship between the implementation of a comprehensive  workplace violence prevention program at 138 VA health care  facilities and changes in assault rates from 2004 through 2009. The  workplace violence prevention program included training, workplace  practices, environmental controls, and security. The researchers  found that facilities that fully implemented a number of training  practices experienced a modest decline in assault rates. The training  practices included assessing staff needs for training, having trainers  present in the facility and actively training, and providing staff training  on prevention and management of disruptive behavior and reporting  disruptive behavior, among other things. In a third study, researchers  described the processes that VA’s Veterans Health Administration  (VHA) uses to evaluate and manage the risk of assaultive patients.  The study stated that VHA’s approach included the use of committees  made up of various stakeholders to assess threatening patients, and  recommendations flagged in veterans’ electronic medical records to  notify staff of individuals who may pose a threat to the safety of  others. Researchers surveyed Chiefs of Staff at 140 VHA hospitals  and found that committee processes and perceptions of effectiveness  were associated with a reduction in assault rates. For example,  facilities that rated their committees as “very effective” were the only  facilities that experienced a significant decrease in assault rates from  2009 to 2010.
Emergency departments study. In a fourth study, researchers found  mixed results regarding the effect that a workplace violence  prevention program had on the rate of assaults. The study was  conducted with three emergency departments that implemented the  program (intervention sites) and three emergency departments that  did not implement the program (comparison sites). Implementation of  the program took place in 2010 and included environmental changes,  changes in policies and procedures, and staff training. Researchers  measured assault rates in the intervention and comparison sites  before and after the workplace violence program was implemented by  surveying on a monthly basis over an 18-month period 209 health  care workers who volunteered to participate in the study. The  researchers found that workers at the intervention sites and the  comparison sites reported significantly fewer assaults over the study  period. Therefore, the researchers could not conclude that workers at  the intervention sites experienced a significantly greater decrease in  violence compared with workers at the comparison sites. However, at  the facility level, the researchers found that two of the intervention  sites experienced a significant decrease in violence, and no individual  comparison site had any significant change in assaults.
In-patient mental health facilities study. A fifth study we reviewed  found that implementation of a workplace violence prevention  program improved staff perceptions of the safety climate in the facility  but did not result in an overall change in assault rates. This study  evaluated a comprehensive workplace violence prevention program  that New York implemented in three state-run, in-patient mental health  facilities from 2000 through 2004. The study compared these  facilities that implemented the program (intervention sites) with three  state-run, in-patient mental health facilities that did not implement the  program (comparison sites). Researchers surveyed 319 staff at the  intervention sites and found that staff perceptions of management’s  commitment to violence prevention and employee involvement in the  program was significantly improved after the program was  implemented. However, an analysis of the change in staff-reported  physical assaults did not indicate a statistically significant reduction in  assaults at the facility level in either the intervention or comparison  sites.
Research also suggests that workplace violence prevention legislation  may increase employer adoption of workplace violence prevention  programs. Two studies compared the workplace violence prevention  programs reported by hospitals and psychiatric facilities in California— which enacted a workplace violence prevention law for hospitals in  1993—to facilities in New Jersey, where a similar law did not exist at the  time of the study, according to the authors. Information was collected  through interviews; facility walk-throughs; and a review of written policies,  procedures, and training material. In the first study, researchers  compared 116 California hospital emergency departments to 50 New  Jersey hospital emergency departments and found that a significantly  higher percentage of the California hospitals had written policies and  procedures on workplace violence prevention compared to hospitals in  New Jersey. In the second study, researchers compared 53 psychiatric  units and facilities in California to 30 psychiatric units and facilities in New  Jersey and found a higher percentage of California facilities that  participated in the study had written workplace violence prevention  policies compared to facilities in New Jersey. While New Jersey had a  smaller percentage of facilities with written workplace violence prevention  policies compared to California, the study found that New Jersey had a  higher proportion of facilities (17 of 30 or 71 percent) than in California  (25 of 53 or 61 percent) with workplace violence policies that address  violence against personnel, patients, and visitors. In a third study,  researchers found that rates of assault against employees in selected  California hospital emergency departments decreased after enactment of  the California law (from 1996 to 2001), whereas the assault rates in  selected New Jersey hospital emergency departments increased over this  same time period. However, the researchers could not conclude that  these differences were attributable to the California law.
section_title: Conclusions
paragraphs: Compared to workers overall, health care workers face an increased risk  of being assaulted at work, often by the patients in their care. Given the  high rate of violence committed against health care workers, particularly  in in-patient facilities, there is an increasing need to help ensure that  health care workers are safe as they perform their work duties. OSHA  may issue general duty clause citations to employers who fail to protect  their workers from hazardous conditions. While OSHA has increased the  number of inspections of workplace violence in health care facilities in  recent years, relatively few general duty clause citations resulted from  these inspections. Inspectors reported facing challenges in developing  the evidence needed to issue these citations, and officials and inspectors  from 5 of OSHA’s 10 regions said it would be helpful to have additional  information to assist them in implementing the 2011 enforcement  directive. Without this additional information, inspectors may continue to  experience difficulties in addressing challenges they reported facing in  developing these citations.
When inspectors do not have enough evidence to issue a general duty  clause citation, OSHA inspectors can issue nonbinding hazard alert  letters warning employers of a serious safety concern. However, without a  policy requiring inspectors to follow-up on hazard alert letters, OSHA will  not know whether employers have taken steps to address the safety  hazards identified in these letters or whether a follow up inspection is  needed. If the situations identified in the letters are left unchecked, health  care workers may continue to be exposed to unsafe working conditions  that could place them at an increased risk of workplace violence.
OSHA has increased its education and enforcement efforts in recent  years to raise awareness of the hazard of workplace violence and to help  employers make changes that could reduce the risk of violence at their  worksites. However, OSHA has done little to assess the results of its  efforts. Without assessing the results of these efforts, OSHA is not in a  position to know whether the efforts are effective or if additional action,  such as development of a specific workplace violence prevention  standard, may be needed.
section_title: Recommendations for Executive Action
paragraphs: To help reduce the risk of violence against health care workers, we  recommend that the Secretary of Labor direct the Assistant Secretary for  Occupational Safety and Health to take the following actions:
Provide additional information to assist inspectors in developing  general duty clause citations in cases involving workplace violence.
Establish a policy that outlines a process for following up on health  care workplace violence-related hazard alert letters.
To help determine whether current efforts are effective or if additional  action may be needed, such as development of a workplace violence  prevention standard for health care employers, the Secretary of Labor  should direct the Assistant Secretary for Occupational Safety and Health  to:
Develop and implement cost-effective ways to assess the results of  the agency’s efforts to address workplace violence.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Departments of Labor (DOL),  Health and Human Services (HHS), Justice (DOJ), and Veterans Affairs  (VA) for review and comment. We received formal written comments from  the DOL and VA, which are reproduced in appendices III and IV. In  addition, DOL’s Bureau of Labor Statistics, HHS, and DOJ provided  technical comments, which we incorporated as appropriate.
In its written comments, DOL’s Occupational Safety and Health  Administration (OSHA) said it agreed with all three of our  recommendations. With regard to our first recommendation, OSHA stated  that the agency is in the process of revising its enforcement directive and  developing a training course to further assist inspectors. With regard to  our second recommendation, OSHA stated that the agency plans to  include standardized procedures for following up on hazard alert letters in  its revised enforcement directive. With regard to our third  recommendation, OSHA stated that it intends to find a cost effective way  to gauge its enforcement efforts to determine whether additional  measures, such as developing a workplace violence prevention standard  for health care workers, is necessary. In addition, OSHA stated that the  agency is reviewing past inspections that resulted in citations or hazard  alert letters to evaluate how these cases were developed and what  measures may improve the process.
In its written comments, VA said it agreed with our findings and three  recommendations to OSHA, but suggested the recommendations could  be more specific regarding the tools and processes necessary to support  OSHA inspectors. For example, VA suggested that OSHA should develop  measurable and performance based criteria for workplace violence  prevention programs in the unique health care environment. We believe  that our recommendations appropriately address our findings. VA also  stated that our report did not fully describe the specific processes that the  Veterans Health Administration uses to protect employees and patients  from dangerous patient behaviors and provided a reference to a study  about these processes. In response, we reviewed the study and  incorporated its findings in the section of our report on research on the  effectiveness of workplace violence prevention programs.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretaries of Labor,  Health and Human Services, Justice, and Veterans Affairs, appropriate  congressional committees, and other interested parties. In addition, the  report will be available at no charge on the GAO website at  http://www.gao.gov. Please contact me on (202) 512-7215 or at  sherrilla@gao.gov if you or your staff have any questions about this  report. Contact points for our Offices of Congressional Relations and  Public Affairs may be found on the last page of this report. Key  contributors to this report are listed in appendix VII.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: This report examines: (1) what is known about the degree to which  workplace violence occurs in health care facilities and its associated  costs, (2) steps OSHA has taken to protect health care workers from  workplace violence and assess the usefulness of its efforts, (3) how  selected states have addressed workplace violence in health care  facilities, and (4) research on the effectiveness of workplace violence  prevention programs in health care facilities.
For the purposes of this report, we focused on workplace violence against  health care workers. We used the National Institute for Occupational  Safety and Health’s (NIOSH) definition of workplace violence, which is  “violent acts (including physical assaults and threats of assaults) directed  toward persons at work or on duty.” We did not focus on other types of  violence, such as self-inflicted violence, bullying, or incivility among health  care workers.
To address these objectives, we: analyzed federal data used by three federal agencies to estimate  workplace violence-related injuries and deaths in health care facilities; reviewed related studies identified in a literature review; interviewed federal officials, analyzed enforcement data, and  reviewed relevant federal laws, regulations, inspection procedures,  and guidelines; reviewed selected state workplace violence prevention laws from nine  selected states and visited four of the states where we interviewed  state officials, health care employers, and workers; and  interviewed researchers and others knowledgeable about workplace  violence prevention in health care facilities.
We conducted this performance audit from August 2014 to March 2016 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Analysis of Federal Data on Workplace Violence- Related Injuries
paragraphs: To identify what is known about the degree to which workplace violence  occurs in health care facilities and its associated costs, we reviewed  federal data sources used by three federal agencies to estimate  workplace violence-related injuries and deaths. The four national datasets  we analyzed collect data on different types of workplace violence  incidents from different sources (see table 5). The years of data we  analyzed varied by data source, depending on the availability of data and  the number of cases needed to develop national estimates, but the dates  generally were from 2009 through 2013.
We reported the estimated rates of nonfatal workplace violence against  workers in health care facilities compared to workers overall (all industries  combined) for each relevant data source. The rates of nonfatal workplace  violence were calculated so that the base (denominator) was the same  across all three data sources (the rate per 10,000 workers). We also  reported information related to the health care occupations with high  nonfatal workplace violence-related injury rates, the type of violence, and  the perpetrator of the violence. For consistency purposes, we used 2011  as the common year of data from the three datasets with nonfatal injury  data–BLS’s SOII, NIOSH’s NEISS-Work, and BJS’s NCVS–to report the  number of nonfatal workplace violence cases in health care settings  recorded in each source.
The number of cases and rates of nonfatal workplace violence-related  injury we report includes violence perpetrated against health care workers  by other people. For the BLS SOII data, we reported cases where the  workplace violence was caused by another person–intentional,  unintentional, or unknown–and excluded cases where the violence was  self-inflicted or caused by animals or insects. We focused on the health  care industry and reported the BLS data for the three health care industry  categories BLS uses: ambulatory health care services, hospitals, and  nursing and residential care facilities.
The estimated rates and number of workplace violence cases we report  from the NCVS represent a subset of the workplace violence cases BJS  typically reports. BJS defines assaults as both simple and aggravated,  including threats. In addition, BJS defines violence to include all types of  physical harm, including sexual assault, robbery, and aggravated and  simple assault. We reported assaults, including rape and sexual assault,  aggravated assault, and simple assault. We focused on actual assaults  because these types of cases are more comparable to the cases we  reported from the other federal data sources. We did not include cases of  verbal threats of assault or robberies. Health care workers included  survey respondents who described their job as working in the medical  profession or mental health services field.
We did not report data on the costs of workplace violence or the  perpetrators of the violence from BJS’s NCVS because of data limitations.  The survey asks individuals about the medical expenses they incurred as  a result of workplace violence, but our analysis of the data identified 22  cases from 2009 through 2013 where dollar amounts were reported,  which was too few cases to produce a national estimate. We decided not  to report the perpetrator information from the survey data because BJS  officials said that due to a limitation of the survey, it underestimates the  number of workplace violence cases in which patients assault workers.  Specifically, the variables that describe the relationship of the victim to the  perpetrator in the survey are dependent on whether the victim knows the  perpetrator. Survey respondents who answer that the perpetrator is a  stranger are not subsequently asked if the perpetrator was a patient.  Therefore, it is possible that many perpetrators who are patients are  coded as strangers.
To assess the reliability of the federal data, we reviewed relevant agency  documentation, conducted electronic data testing, compared our results  to related information reported by the federal agencies, and interviewed  agency officials. Based on these reviews, we determined that the data  were sufficiently reliable for the purposes of providing information about  the number of cases and rates of workplace violence in the health care  industry.
All national estimates produced from our analysis of the federal data are  subject to sampling errors. We express our confidence in the precision of  our results as a 95 percent confidence interval. This is the interval that  would contain the actual population value for 95 percent of the samples  the respective agency could have drawn. For estimates derived from  BLS’s SOII data, we used the agency-provided relative standard errors to  estimate the associated confidence intervals. For estimates derived from  the NIOSH NEISS-Work supplement, we used the multi-stage cluster  sample variance estimation methodology detailed in the agency technical  documentation to estimate the associated confidence intervals. For  estimates derived from NCVS data, BJS provided us with generalized  variance function parameters for the 5 calendar years’ worth of survey  data, both individually and for all 5 calendar years combined. We used  these parameters with formulas for deriving the sampling error of  estimated totals and estimated ratios available in the NCVS technical  documentation to estimate the associated confidence intervals. The  tables below provide the estimates and 95 percent confidence intervals  for the data we present in the body of this report.
section_title: Review of Related Studies
paragraphs: We conducted a literature review to identify research related to the  prevalence of workplace violence and associated costs (objective 1) and  the effectiveness of workplace violence prevention programs (objective  4). We searched relevant platforms, such as ProQuest Research Library  and Social Services Abstracts, to identify studies published in government  reports and peer-reviewed journals from January 2004 to June 2015. We  also consulted with federal officials and researchers we interviewed to  identify related research. See appendix VIII for a bibliography of the  studies cited in this report.
We screened more than 170 articles and focused our review on U.S.  studies identified among this group that met the following additional  criteria. First, they were studies based on original data collection rather  than reviews of existing literature. Second, they provided quantitative  evidence directly related to our research objectives. Lastly, they provided  information related to physical violence against health care workers. For  example, we eliminated studies that focused solely on verbal abuse, such  as bullying or incivility among health care workers.
We conducted detailed reviews of the 32 studies that met these initial  screening criteria. Our reviews entailed an assessment of each study’s  research methodology, including its data quality, research design, and  analytic techniques, as well as a summary of each study’s major findings  and conclusions. We also assessed the extent to which each study’s data  and methods support its findings and conclusions. We eliminated studies  that were not sufficiently reliable and methodologically rigorous for  inclusion in our review. For example, we eliminated studies with low  survey response rates and studies whose findings were based on  information collected from a small number of health care workers. We  assessed the methodological sufficiency of each study using internal  guidance documents. We determined that 17 of the studies were  sufficiently reliable and methodologically rigorous for inclusion in our  review.
section_title: Review of OSHA’s Actions to Protect Health Care Workers from Workplace Violence
paragraphs: To examine the steps OSHA has taken to protect health care workers  from workplace violence, we reviewed relevant federal laws and  regulations; analyzed OSHA’s guidance, inspection procedures, and  enforcement data; and interviewed OSHA officials. We also collected  information from all 10 OSHA regional offices on inspector training and  how inspectors investigate workplace violence during inspections of  health care employers.
We analyzed enforcement data from two OSHA databases: the Integrated  Management Information System (IMIS) database and the Occupational  Safety and Health Information System (OIS) database, which replaced  the IMIS system. We analyzed enforcement data from 1991 through April  2015 on federal OSHA inspections, including data on the type of  inspection, inspection findings, citations, and penalties. To assess the  reliability of the OSHA enforcement data, we reviewed relevant agency  documentation, conducted electronic data testing, and interviewed  agency officials. Based on these reviews, we determined that the data  were sufficiently reliable for our purposes.
section_title: Review of Selected States’ Efforts to Address Workplace Violence in Health Care Facilities
paragraphs: To examine how selected states have addressed workplace violence in  health care settings, we analyzed selected state laws and other  information collected from state officials in nine states: California,  Connecticut, Illinois, Maine, Maryland, New Jersey, New York, Oregon,  and Washington. We focused our review on these nine states because  they were the ones we identified from our search of legal databases;  related studies; and interviews with federal officials, researchers, and  national labor organizations. We did not conduct a nationwide review of  state laws or collect information from all 50 states; therefore, other states  may have these types of requirements. For the nine states we identified,  we reviewed information provided by state officials on state requirements,  including laws and regulations, for workplace violence prevention  programs in health care settings. We confirmed our descriptions of the  selected state requirements with state officials as of December 2015. We  did not evaluate the quality or effectiveness of state requirements.
We visited four of these states–California, Maryland, New York, and  Washington–selected for variation in the length of time their state  workplace violence prevention laws have been in place. During our visits,  we interviewed state officials from the state’s department of labor and  department of health, visited one health care facility in each state, and  held discussion groups with health care workers. We visited four health  care facilities, including two state psychiatric hospitals, a nursing home,  and a hospital with an emergency department. We selected these types  of facilities because BLS data indicate that most workplace violence  incidents occur in hospitals and nursing and residential care facilities.  During each of the health care facility visits, we met with security,  management, and health care workers. We also participated in a guided  tour of the facility. The information we obtained from the states and our  site visits is not generalizable.
We conducted five nongeneralizable discussion groups with health care  workers to learn about their experience with workplace violence. These  discussion groups were organized by labor organization officials that  represent health care workers. The discussions occurred in Baltimore,  Maryland; Los Angeles, California; New York, New York; Seattle,  Washington; and Washington, D.C. These locations were selected to  align with our selected site visit states. The labor organization officials  invited health care workers who had been verbally and/or physically  assaulted while performing their duties at work. A total of 54 health care  workers participated in the discussion groups. The participants worked in  various health care practice areas, including home health, acute care,  mental health, and residential care. We asked the health care workers  about their experience with workplace violence, whether they received  workplace violence prevention training, the factors they consider when  deciding whether to report an incident to their employer, the factors that  contribute to workplace violence, and what could be done to reduce these  incidents. We used their responses to identify themes and illustrative  examples. Methodologically, discussion groups are not designed to (1)  demonstrate the extent of a problem or to generalize results to a larger  population, (2) develop a consensus to arrive at an agreed-upon plan or  make decisions about what actions to take, or (3) provide statistically  representative samples or reliable quantitative estimates. Instead, they  are intended to generate in-depth information about the reasons for the  discussion group participants’ attitudes on specific topics and to offer  insights into their experiences. Because of these limitations, we did not  rely entirely on the information collected from the discussion groups, but  rather used several different methodologies to corroborate and support  our findings.
section_title: Appendix II: Summary of Findings from Research
section_title: Appendix III: Comments from the Department of Labor
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Mary Crenshaw (Assistant  Director), Cathy Roark (Analyst-in-Charge), Hiwotte Amare, Carl Barden,  James Bennett, Rachael Chamberlin, David Chrisinger, Sarah Cornetto,  Lauren Gilbertson, LaToya King, Linda Kohn, Joel Marus, Ashley McCall,  Jean McSween, Kathy Leslie, Terry Richardson, Stacy Spence, Walter  Vance, and Kate van Gelder made significant contributions to this report.
section_title: Appendix VI: B
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Gillespie, G. L., D.M. Gates, T. Kowalenko, S. Bresler, and P. Succop.  “Implementation of a Comprehensive Intervention to Reduce Physical  Assaults and Threats in the Emergency Department,” Journal of  Emergency Nursing, vol. 40, no. 6 (2014): 586-591.
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Hodgson, M. J., R. Reed, T. Craig, F. Murphy, L. Lehmann, L. Belton, and  N. Warren. “Violence in Healthcare Facilities: Lessons from the Veterans  Health Administration,” Journal of Occupational and Environmental  Medicine, vol. 46, no. 11 (2004): 1158-1165.
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Kelly, E. L., A.M. Subica, A. Fulginiti, J.S. Brekke, and R.W. Novaco. “A  cross-sectional survey of factors related to inpatient assault of staff in a  forensic psychiatric hospital,” Journal of Advanced Nursing, vol. 71, no. 5,  (2015): 1110-1122.
Kowalenko, T., D. Gates, G.L. Gillespie, P. Succop, and T.K. Mentzel.  “Prospective study of violence against ED workers,” American Journal of  Emergency Medicine, vol. 31 (2013): 197-205.
Lipscomb, J., K. McPhaul, J. Rosen, J. Geiger Brown, M. Choi, K.  Soeken, V. Vignola, D. Wagoner, J. Foley, and P. Porter. “Violence  Prevention in the Mental Health Setting: The New York State  Experience,” Canadian Journal of Nursing Research, vol. 38, no. 4  (2006): 96-117.
Mohr, D. C., N. Warren, M.J. Hodgson, and D.J. Drummond. “Assault  Rates and Implementation of a Workplace Violence Prevention Program  in the Veterans Health Care Administration,” Journal of Occupational and  Environmental Medicine, vol. 53, no. 5, (2011): 511-516.
Peek-Asa, C., C. Casteel, V. Allareddy, M. Nocera, S. Goldmacher, E.  O’Hagan, J. Blando, D. Valiante, M. Gillen, and R. Harrison. “Workplace  Violence Prevention Programs in Hospital Emergency Departments,”  Journal of Occupational and Environmental Medicine, vol. 49, no. 7  (2007): 756-763.
Peek-Asa, C. C. Casteel, V. Allareddy, M. Nocera, S. Goldmacher, E.  O’Hagan, J. Blando, D. Valiante, M. Gillen, and R. Harrison. “Workplace  Violence Prevention Programs in Psychiatric Units and Facilities,”  Archives of Psychiatric Nursing, vol. 23, no. 2 (2009): 166-176.
Pompeii, L. A., A.L. Schoenfisch, H.J. Lipscomb, J.M. Dement, C.D.  Smith, and M. Upadhyaya. “Physical Assault, Physical Threat, and Verbal  Abuse Perpetrated Against Hospital Workers by Patients or Visitors in Six  U.S. Hospitals,” American Journal of Industrial Medicine (2015): 1-11.
Speroni, K.G., T. Fitch, E. Dawson, L. Dugan, and M. Atherton.  “Incidence and Cost of Nurse Workplace Violence Perpetrated by  Hospital Patients or Patient Visitors,” Journal of Emergency Nursing, vol.  40, no. 3 (2014): 218-228.