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Chapter 51 - Violence

VIOLENCE IN THE WORKPLACE

Leon J. Warshaw

Violence is pervasive in modern society and appears to be escalating. Entirely apart from repression, wars and terrorist activities, the media daily report in banner headlines on the mayhem inflicted by humans upon each other in “civilized” as well as more primitive communities. Whether there has been a real increase or this simply represents more thorough reporting is arguable. After all, violence has been a feature of human interaction since prehistoric ages. Nevertheless, violence has become one of the leading causes of death in modern industrial societies—in some segments of the community it is the leading cause of death—and it is increasingly being recognized as a public health problem.

Inescapably, it finds its way into the workplace. From 1980 to 1989, homicide was the third leading cause of death from injury in North American workplaces, according to data compiled by the National Traumatic Occupational Facilities Surveillance System (NIOSH 1993a). During this period, occupational homicides accounted for 12% of deaths from injury in the workplace; only motor vehicles and machines accounted for more. By 1993, that figure had risen to 17%, a rate of 0.9 per 100,000 workers, now second only to motor vehicle deaths (Toscano and Windau 1994). For  women  workers,  it  remained  the  leading  cause  of  work-related death, although the rate (0.4 deaths per 100,000) was lower than that for men (1.2 deaths per 100,000) (Jenkins 1995).

These deaths, however, represent only the “tip of the iceberg”. For example, in 1992, about 22,400 American workers were injured seriously enough in non-fatal assaults in the workplace to require days away from work to recuperate (Toscano and Windau 1994). Reliable and complete data are lacking, but it is estimated that for every death there have been many thousands—perhaps, even hundreds of thousands—of instances of violence in the workplace.

In its newsletter, Unison, the large British union of health care and governmental service workers, has labelled violence as “the most threatening risk faced by members at work. It is the risk which is most likely to lead to injury. It can bring unmanageable levels of occupational stress which damages personal esteem and threatens people’s ability to continue on the job” (Unison 1992).

This article will summarize the characteristics of violence in the workplace, the kinds of people involved, its effects on them and their employers, and the steps that may be taken to prevent or control such effects.

Definition of Violence

There is no consensus on the definition of violence. For example, Rosenberg and Mercy (1991) include in the definition both fatal and nonfatal interpersonal violence where physical force or other means is used by one person with the intent of causing harm, injury or death to another. The Panel on the Understanding and Control of Violent Behavior convened by the US National Academy of Sciences adopted the definition of violence as: behaviours by individuals that intentionally threaten, attempt or inflict physical harm on others (Reiss and Roth 1993).

These definitions focus on threatening or causing physical harm. However, they exclude instances in which verbal abuse, harassment or humiliation and other forms of psychological trauma may be the sole harm to the victim and which may be no less devastating. They also exclude sexual harassment, which may be physical but which is usually entirely non-physical. In the national survey of American workers conducted by the Northwestern National Life Insurance Company, the researchers separated violent acts into: harassment (the act of creating a hostile environment through unwelcome words, actions or physical contacts not resulting in physical harm), threats (expressions of an intent to cause physical harm), and physical attacks (aggression resulting in a physical assault with or without the use of a weapon) (Lawless, 1993).

In the UK, the Health and Safety Executive’s working definition of workplace violence is: any incident in which an employee is abused, threatened or assaulted by a member of the public in circumstances arising out of the course of his or her employment. Assailants may be patients, clients or co-workers (MSF 1993).

In this article, the term violence will be used in its broadest sense to include all forms of aggressive or abusive behaviour that may cause physical or psychological harm or discomfort to its victims, whether they be intentional targets or innocent bystanders involved only impersonally or incidentally. While workplaces may be targets of terrorist attacks or may become involved in riots and mob violence, such instances will not be discussed.

Prevalence of Violence in the Workplace

Accurate information on the prevalence of violence in the workplace is lacking. Most of the literature focuses on cases that are formally reported: homicides which get tallied in the obligatory death registries, cases that get enmeshed in the criminal justice system, or cases involving time off the job that generate workers’ compensation claims. Yet, for every one of these, there is an untold number of instances in which workers are victims of aggressive, abusive behaviour. For example, according to a survey conducted by the Bureau of Justice Statistics in the US Department of Justice, over half the victimizations sustained at work were not reported to the police. About 40% of the respondents said they did not report the incident because they considered it to be a minor or a personal matter, while another 27% said they did report it to a manager or a company security officer but, apparently, the report was not relayed to the police (Bachman 1994). In addition to the lack of a consensus on a taxonomy of violence, other reasons for under-reporting include:

·     Cultural acceptance of violence. There is in many communities a widespread tolerance for violence among or against certain groups (Rosenberg and Mercy 1991). Although frowned upon by many, violence is often rationalized and tolerated as a “normal” response to competition. Violence among minority and ethnic groups is often condoned as a righteous response to discrimination, poverty and lack of access to social or economic equity resulting in low self-esteem and low valuations of human life. As a result, the assault is seen as a consequence of living in a violent society rather than working in an unsafe workplace. Finally, there is the “on-the-job syndrome”, in which workers in certain jobs are expected to put up with verbal abuse, threats and, even, physical attacks (SEIU 1995; Unison 1992).

·     Lack of a reporting system. Only a small proportion of organizations have articulated an explicit policy on violence or have designed procedures for reporting and investigating instances of alleged violence in the workplace. Even where such a system has been installed, the trouble of obtaining, completing and filing the required report form is a deterrent to reporting all but the most outrageous incidents.

·     Fear of blame or reprisal. Workers may fear being held responsible when they have been attacked by a client or a patient. Fear of reprisal by the assailant is also a potent deterrent to reporting, especially when that person is the worker’s superior and in a position to affect his or her job status.

·     Lack of interest on the part of the employer. The employer’s lack of interest in investigating and reacting to prior incidents will certainly discourage reporting. Also, supervisors, concerned that workplace violence might reflect unfavourably on their managerial capabilities may actually discourage or even block the filing of reports by workers in their units.

To determine the prevalence of violence in the workplace in the absence of reliable data, attempts have been made to extrapolate both from available statistics (e.g., death certificates, crime reports and workers’ compensation systems) and from specially designed surveys. Thus, the US National Crime Victimization Survey estimated that about 1 million American workers (out of a workforce of 110 million) are assaulted at work each year (Bachman 1994). And, a 1993 telephone survey of a national sample of 600 American full-time workers (excluding self-employed and military personnel) found that one in four said that he or she had been a victim of workplace violence during the study year: 19% were harassed, 7% were threatened, and 3% were attacked physically. The researchers reported further that 68% of the harassment victims, 43% of the threat victims and 24% of the attack victims had not reported the incident (Lawless 1993).

A similar survey of workers in the UK employed by the National Health Service revealed that, during the previous year, 0.5% had required medical treatment following an on-the-job physical assault; 11% had suffered a minor injury requiring only first aid, 4 to 6% had been threatened by persons wielding a deadly weapon, and 17% had received verbal threats. Violence was a special problem for emergency staff in ambulances and accident departments, nurses, and workers involved in the care of psychologically disturbed patients (Health Services Advisory Committee 1987). The risk of health workers being confronted by violence has been labelled a feature of everyday work in primary care and in accident/emergency departments (Shepherd 1994).

Homicide in the Workplace

Although workplace homicides are only a small proportion of all homicides, their substantial contribution to work-related deaths, at least in the United States, their unique features, and the possibility of preventive interventions by employers earn them special attention. For example, while most homicides in the community involve people who know each other, many of them close relatives, and only 13% were reported to have been associated with another felony, these proportions were reversed in the workplace, where more than three-fourths of the homicides were committed in the course of a robbery (NIOSH 1992). Further, while persons aged 65 and older in the general population have the lowest rates of being victims of homicide, this age group has the highest rates of such involvement in workplace homicides (Castillo and Jenkins 1994).

American workplaces with the highest rates of homicide are listed in table 51.1 . Over 50% are accounted for by only two industries: retail trade and services. The latter includes taxi driving, which has nearly 40 times the average workplace homicide rate, followed by liquor/convenience stores and gas stations, prime targets for robberies, and by detective/protective services (Castillo and Jenkins 1994).

Table 51.1 US workplaces with the highest rates of occupational homicide, 1980-1989

Workplaces

No. of homicides

Rate1

Taxicab establishments

287

26.9

Liquor stores

115

8.0

Gas stations

304

5.6

Detective/protective services

152

5.0

Justice/public order establishments

640

3.4

Grocery stores

806

3.2

Jewellery stores

56

3.2

Hotels/motels

153

3.2

Eating/drinking places

754

1.5

1 Number per 100,000 workers per year.

Source: NIOSH 1993b.

Table 51.2  lists the occupations with the highest rates of workplace homicides. Again, reflecting the likelihood of involvement in attempted felonies, taxi drivers head the list, followed by law-enforcement personnel, hotel clerks and workers in various types of retail establishments. Commenting on similar data from the UK, Drever (1995) noted that most of the occupations with the highest mortality from homicides had high rates of drug dependence (scaffolders, literary and artistic occupations, painters and decorators) or alcohol abuse (cooks and kitchen porters, publicans, bartenders and caterers).

Table 51.2 US occupations with the highest rates of occupational homicide, 1980-1989

Occupations

No. of homicides

Rate1

Taxicab drivers/chauffeurs

289

15.1

Law enforcement officers

520

9.3

Hotel clerks

40

5.1

Gas station workers

164

4.5

Security guards

253

3.6

Stock handlers/baggers

260

3.1

Store owners/managers

1,065

2.8

Bartenders

84

2.1

1 Number per 100,000 workers per year.

Source: NIOSH 1993b.

As noted above, the vast majority of work-related homicides occur during the course of a robbery or other crime committed by a person or persons usually not known to the victim. Risk factors associated with such incidents are listed in table 51.3 .

Table 51.3 Risk factors for workplace homicides

Working alone or in small numbers

Exchange of money with the public

Working late night or early morning hours

Working in high crime areas

Guarding valuable property or possessions

Working in community settings (e.g. taxi drivers and police)

Source: NIOSH 1993b.

About 4% of workplace homicides occur during confrontations with family members or acquaintances who have followed the victim into the workplace. About 21% arise out of a confrontation related to the workplace: about two-thirds of these are perpetrated by workers or former employees with a grudge against a manager or a co-worker, while angry customers or clients account for the rest (Toscano and Windau 1994). In these cases, the target may be the particular manager or worker whose actions provoked the assault or, where there is a grudge against the organization, the target may be the workplace itself, and any employees and visitors who just happen to be in it at the critical moment. Sometimes, the assailant may be emotionally disturbed, as in the case of Joseph T. Weisbecker, an employee on long-term disability leave from his employer in Louisville, Kentucky, because of mental illness, who killed eight co-workers and injured 12 others before taking his own life (Kuzmits 1990).

Causes of Violence

Current understanding of the causes and risk factors for assaultive violence is very rudimentary (Rosenberg and Mercy 1991). Clearly, it is a multifactorial problem in which each incident is shaped by the characteristics of the assailant, the characteristics of the victim(s) and the nature of the interplay between them. Reflecting such complexity, a number of theories of causation have been developed. Biological theories, for example, focus on such factors as gender (most of the assailants are male), age (involvement in violence in the community diminishes with age but, as noted above, this is not so in the workplace), and the influence of hormones such as testosterone, neurotransmitters such as serotonin, and other such biological agents. The psychological approach focuses on personality, holding that violence is engendered by deprivation of love during childhood, and childhood abuse, and is learned from role models, reinforced by rewards and punishments in early life. Sociological theories emphasize as breeders of violence such cultural and subcultural factors as poverty, discrimination and lack of economic and social equity. Finally, interactional theories converge on a sequence of actions and reactions that ultimately escalate into violence (Rosenberg and Mercy 1991).

A number of risk factors have been associated with violence. They include:

Mental illness

The vast majority of people who are violent are not mentally ill, and the vast proportion of individuals with mental illness are not violent (American Psychiatric Association 1994). However, mentally disordered individuals are sometimes frightened, irritable, suspicious, excitable, or angry, or a combination of these (Bullard 1994). The resultant behaviour poses a particular risk of violence to the physicians, nurses and staff members involved in their care in ambulances, emergency departments and both inpatient and outpatient psychiatric facilities.

Certain types of mental illness are associated with a greater propensity for violence. Persons with psychopathic personalities tend to have a low threshold for anger and frustration, which often generate violent behaviour (Marks 1992), while individuals with paranoia are suspicious and prone to attack individuals or entire organizations whom they blame when things do not go as they would wish. However, violence may be exhibited by persons with other forms of mental illness. Furthermore, some mentally ill individuals are prone to episodes of acute dementia in which they may inflict violence on themselves as well as on those trying to restrain them.

Alcohol and drug abuse

Alcohol abuse has a strong association with aggressive and violent behaviour. While drunkenness on the part of either assailants or victims, or both, often results in violence, there is disagreement as to whether alcohol is the cause of the violence or merely one of a number of factors involved in its causation (Pernanen 1993). Fagan (1993) emphasized that while alcohol affects neurobiological functions, perception and cognition, it is the immediate setting in which the drinking takes place that channels the disinhibiting responses to alcohol. This was confirmed by a study in Los Angeles County which found that violent incidents were much more frequent in some bars and relatively uncommon in others where just as much drinking was taking place, and concluded that violent behaviour was not related to the amount of alcohol being consumed but, rather, to the kinds of individuals attracted to a particular drinking establishment and the kinds of unwritten rules in effect there (Scribner, MacKinnon and Dwyer 1995).

Much the same may be said for abuse of illicit drugs. Except perhaps for crack cocaine and the amphetamines, drug use is more likely to be associated with sedation and withdrawal rather than aggressive, violent behaviour. Most of the violence associated with illegal drugs seems to be associated not with the drugs, but with the effort to obtain them or the wherewithal to purchase them, and from involvement in the illegal drug traffic.

Violence in the community

Violence in the community not only spills over into workplaces but is a particular risk factor for workers such as police and firefighters,  and  for  postal  workers  and  other  government employees, repair and service personnel, social workers and others whose jobs take them into neighbourhoods in which violence and crime are indigenous. Important factors in the frequency of violence, particularly in the United States, is the prevalence of firearms in the hands of the general public and, especially for young people, the amount of violence depicted in films and on television.

Work-Related Factors Associated with Violence

Instances of violence may occur in any and all workplaces. There are, however, certain jobs and work-related circumstances that are particularly associated with a risk of generating or being subjected to violence. They include:

Criminal activities

Perhaps the least complex of episodes of work-related violence are those associated with criminal violence, the major cause of worksite homicides. These fall into two categories: those involved with attempts at robbery or other felonies, and those related to traffic in illicit drugs. Police, security guards and other personnel with law-enforcement responsibilities face a constant risk of attack by felons attempting to enter the workplace and those resisting detection and arrest. Those working alone and field workers whose duties take them into high-crime neighbourhoods are frequent targets of robbery attempts. Health professionals making home visits to such areas are particularly at risk because they often carry drugs and drug paraphernalia such as hypodermic syringes and needles.

Dealing with the public

Workers in government and private community service agencies, banks and other institutions serving the public are frequently confronted by attacks from individuals who have been kept waiting unduly, have been greeted with disinterest and indifference (whether real or perceived), or were thwarted in obtaining the information or services they desired because of complicated bureaucratic procedures or technicalities that made them ineligible. Clerks in retail establishments receiving items being returned, workers staffing airport ticket counters when flights are overbooked, delayed or cancelled, urban bus or trolley drivers and conductors, and others who must deal with customers or clients whose wants cannot immediately be satisfied are often targets for verbal and sometimes even physical abuse. Then, there are also those who must contend with impatient and unruly crowds, such as police officers, security guards, ticket takers and ushers at popular sporting and entertainment events.

Violent attacks on government workers, particularly those in uniform, and on government buildings and offices in which workers and visitors may be indiscriminately injured or killed, may result from resentment and anger at laws and official policies which the perpetrators will not accept.

Work stress

High levels of work stress may precipitate violent behaviour, while violence in the workplace can, in turn, be a potent stressor. The elements of work stress are well known (see chapter Psychosocial and Organizational Factors [PSY00AE]). Their common denominator is a devaluation of the individual and/or the work he or she performs, resulting in fatigue, frustration and anger directed at managers and co-workers perceived to be inconsiderate, unfair and abusive. Several recent population studies have demonstrated an association  between  violence  and  job  loss,  one  of  the  most  potent job-related stressors (Catalano et al. 1993; Yancey et al. 1994).

Interpersonal environment in the workplace

The interpersonal environment in the workplace may be a breeding ground for violence. Discrimination and harassment, forms of violence in themselves as defined in this article, may provoke violent retaliation. For example, MSF, the British union of workers in management, science and finance, calls attention to workplace bullying (defined as persistent offensive, abusive, intimidating, malicious or insulting behaviour, abuse of power or unfair penal sanctions), as a characteristic of the management style in some organizations (MSF 1995).

Sexual harassment has been branded a form of assault on the job (SEIU 1995). It may involve unwelcome touching or patting, physical assault, suggestive remarks or other verbal abuse, staring or leering, requests for sexual favours, compromising invitations, or a work environment made offensive by pornography. It is illegal in the United States, having been declared a form of sexual discrimination under Title VII of the Civil Rights Act of 1964 when the worker feels that his or her job status depends on tolerating the advances or if the harassment creates an intimidating, hostile or offensive workplace environment. 

Although women are the usual targets, men have also been sexually harassed, albeit much less frequently. In a 1980 survey of US federal employees, 42% of female respondents and 15% of males said that they had been sexually harassed on the job, and a follow-up survey in 1987 yielded similar results (SEIU 1995). In the United States, extensive media coverage of the harassment of women who had “intruded” into jobs and workplaces traditionally filled by males, and the notoriety given to the involvement of prominent political and public figures in alleged harassment, have resulted in an increase in the number of complaints received by state and federal anti-discrimination agencies and the number of civil law suits filed.

Working in health care and social services

In addition to the attempted robberies as noted above, health care staff are often targets of violence from anxious and disturbed patients, especially in emergency and outpatient departments, where long waits and impersonal procedures are not uncommon and where anxiety and anger may boil over into verbal or physical assaults. They may also be victims of assault by family members or friends of patients who had unfavourable outcomes which they rightly or wrongfully attribute to denials, delays or errors in treatment. In such instances they may attack the particular health worker(s) whom they hold responsible, or the violence may be aimed randomly at any staff member(s) of the medical facility.

Effects of Violence on the Victim

The trauma caused by physical assault varies with the nature of the attack and the weapons employed. Bruises and cuts on the hands and forearms are common when the victim has tried to defend himself or herself. Since the face and head are frequent targets, bruises and fractures of the facial bones are common; these can be traumatic psychologically because the swelling and ecchymoses are so visible and may take weeks to disappear (Mezey and Shepherd 1994).

The psychological effects may be more troublesome than the physical trauma, especially when a health worker has been assaulted by a patient. The victims may experience a loss of composure and self-confidence in their professional competence accompanied by a sense of guilt at having provoked the attack or having failed to detect that it was coming. Unfocused or directed anger may persist at the apparent rejection of their well-intended professional efforts, and there may be a persistent loss of confidence in themselves as well as a lack of trust in their co-workers and supervisors that can interfere with work performance. All this may be accompanied by insomnia, nightmares, diminished or increased appetite, increased consumption of tobacco, alcohol and/or drugs, social withdrawal and absenteeism from the job (Mezey and Shepherd 1994).

Post-traumatic stress disorder is a specific psychological syndrome (PTSD) that may develop after major disasters and instances of violent assault, not only in those directly involved in the incident but also in those who have witnessed it. While usually associated with life-threatening or fatal incidents, PTSD may occur after relatively trivial attacks that are perceived as life-threatening (Foa and Rothbaum 1992). The symptoms include: re-experiencing the incident through recurrent and intrusive recollections (“flashbacks”) and nightmares, persistent feelings of arousal and anxiety including muscular tension, autonomic hyperactivity, loss of concentration, and exaggerated reactivity. There is often conscious or unconscious avoidance of circumstances that recall the incident. There may be a long period of disability but the symptoms usually respond to supportive psychotherapy. They can often be prevented by a post-incident debriefing conducted as soon as possible after the incident, followed, when needed, by short-term counselling (Foa and Rothbaum 1992).

After the Incident

Interventive measures to be taken immediately after the incident include:

Care of the victim

Appropriate first-aid and medical care should be provided as quickly as possible to all injured individuals. For possible medico-legal purposes (e.g., criminal or civil actions against the assailant) the injuries should be described in detail and, if possible, photographed.

Clean-up of the workplace

Any damage or debris in the workplace should be cleaned up, and any equipment that was involved should be checked to make sure that the safety and cleanliness of the workplace have been fully restored (SEIU 1995).

Post-incident debriefing

As soon as possible, all those involved in or witnessing the incident should participate in a post-incident debriefing or a “trauma-crisis counselling” session conducted by an appropriately qualified staff member or an outside consultant. This will not only provide emotional support and identify those for whom referral for one-on-one counselling may be advisable, but also enable the collection of details of exactly what has happened. Where necessary, the counselling may be supplemented by the formation of a peer support group (CAL/OSHA 1995).

Reporting

A standardized report form should be completed and submitted to the proper individual in the organization and, when appropriate, to the police in the community. A number of sample forms that may be adapted to the needs of a particular organization have been designed and published (Unison 1991, MSF 1993, SEIU 1995). Aggregating and analysing incident report forms will provide epidemiological information that may identify risk factors for violence in the particular workplace and point the way to suitable preventive interventions.

Investigating the incident

Each reported incident of alleged violence, however trivial it may seem, should be investigated by a designated properly trained individual. (Assignment for such investigations may be made by the joint labour/management safety and health committee, where one exists.) The investigation should be aimed at identifying the cause(s) of the incident, the person(s) involved, what, if any, disciplinary measures should be invoked, and what may be done to prevent recurrences. Failure to conduct an impartial and effective investigation is a signal of management’s disinterest and a lack of concern for employees’ health and welfare.

Employer support

Victims and observers of the incident should be assured that they will not be subject to discrimination or any other form of reprisal for reporting it. This is especially important when the alleged assailant is the worker’s superior.

Depending on the regulations extant in the particular jurisdiction, the nature and extent of any injuries, and the duration of any absence from work, the employee may be eligible for workers’ compensation benefits. In such cases, the appropriate claim forms should be filed promptly.

When appropriate, a report should be filed with the local law enforcement agency. When needed, the victim may be provided with legal advice on pressing charges against the assailant, and assistance in dealing with the media.

Union Involvement

A number of unions have been playing a prominent role in dealing with workplace violence, most notably those representing workers in the health care and service industries, such as the Service Employees International Union (SEIU) in the United States, and Management, Science and Finance (MSF) and Unison in the UK. Through the development of guidelines and the publication of fact sheets, bulletins and pamphlets, they have focused on the education of workers, their representatives and their employers about the importance of violence in the workplace, how to deal with it, and how to prevent it. They have acted as advocates for members who have been victims to ensure that their complaints and allegations of violence are given appropriate consideration without threats of reprisal, and that they receive all of the benefits to which they may be entitled. Unions also advocate with employers’ and trade associations and government agencies on behalf of policies, rules and regulations intended to reduce the prevalence of violence in the workplace.

Threats of Violence

All threats of violence should be taken seriously, whether aimed at particular individuals or at the organization as a whole. First, steps must be taken to protect the targeted individual(s). Then, where possible, the assailant should be identified. If that person is not in the workforce, the local law enforcement agencies should be notified. If he or she is in the organization, it may be desirable to consult a qualified mental health professional to guide the handling of the situation and/or deal directly with the assailant.

Preventive Strategies

Preventing violence in the workplace is fundamentally the employer’s responsibility. Ideally, a formal policy and programme will have been developed and implemented before victimization occurs. This is a process that should involve not only the appropriate individuals in human resources/personnel, security, legal affairs, and employee health and safety departments, but also line managers and shop stewards or other employee representatives. A number of guides for such an exercise have been published (see  table 51.4). They are generic and are intended to be tailored to the circumstances of a particular workplace or industry. Their common denominators include:

Establishing a policy

A policy explicitly outlawing discriminatory and abusive behaviour and the use of violence for dispute resolution, accompanied by specified disciplinary measures for infractions (up to and including dismissal), should be formulated and published.

Risk assessment

An inspection of the workplace, supplemented by analysis of prior incidents and/or information from employee surveys, will enable an expert to assess risk factors for violence and suggest preventive interventions. Examination of the prevailing style of management and supervision and the organization of work may disclose high levels of work stress that may precipitate violence. Study of interactions with clients, customers or patients may reveal features that may generate needless anxiety, frustration and anger, and precipitate violent reactions.

Table 51.4 Guides for programmes to prevent workplace violence

Date

Title

Source

1991

Violence in the Workplace:  NUPE Guidelines

Unison Health Care
1 Marbledon Place
London WC1H 9AJ, UK

1993

CAL/OSHA Guidelines for Security  and Safety of Health Care and  Community Service Workers

Division of Occupational Safety and Health
Department of Industrial Relations
45 Fremont Street
San Francisco, CA 94105, USA

1993

Prevention of Violence at Work:   An MSF Guide with Model   Agreement and Violence at Work  Questionnaire (MSF Health and  Safety Information No. 37)

MSF Health and Safety Office
Dane O’Coys Road
Bishops Stortford
Herts, CM23 2JN, UK

1995

Assault on the Job: We Can Do  Something About Workplace  Violence (2nd Edition)

Service Employees International Union
1313 L Street, NW
Washington, DC 20005, USA

1995

CAL/OSHA: Model Injury and  Illness Prevention Program for  Workplace Security

Division of Occupational Safety and Health
Department of Industrial Relations
45 Fremont Street
San Francisco, CA 94105, USA

1996

Guidelines for Preventing Work-  place Violence for Health Care  and Social Service Workers  (OSHA 3148)

OSHA Publications Office
P.O. Box 37535
Washington, DC 20013-7535, USA

Workplace modifications to reduce crime

Guidance from police or private security experts may suggest changes in work procedures and in the layout and furnishing of the workplace that will make it a less attractive target for robbery attempts. In the United States, the Virginia Department of Criminal Justice has been using Crime Prevention Through Environmental Design (CPTED), a model approach developed by a consortium of the schools of architecture in the state that includes: changes in interior and exterior lighting and landscaping with particular attention to parking areas, stairwells and restrooms; making sales and waiting areas visible from the street; use of drop safes or time-release safes to hold cash; alarm systems, television monitors and other security equipment (Malcan 1993). CPTED has been successfully applied in convenience stores, banks (particularly in relation to automatic teller machines which may be accessed around the clock), schools and universities, and in the Washington, DC, Metro subway system.

In New York City, where robbery and killing of taxi drivers is relatively frequent compared to other large cities, the Taxi and Limousine Commission issued regulations that mandated the insertion of a transparent, bullet-resistant partition between the driver and passengers in the rear seat, a bullet-proof plate in the back of the driver’s seat, and an external distress signal light that could be turned on by the driver while remaining invisible to those inside the cab (NYC/TLC 1994). (There has been a spate of head and facial injuries among rear seat passengers who were not wearing seat belts and were thrown forward against the partition when the cab stopped suddenly.)

Where work involves interaction with customers or patients, employee safety may be enhanced by interposing barriers such as counters, desks or tables, transparent, shatter-proof partitions, and locked doors with shatter-proof windows (CAL/OSHA 1993). Furniture and equipment can be arranged to avoid entrapment of the employee and, where privacy is important, it should not be maintained at the expense of isolating the employee with a potentially aggressive or violent individual in a closed or secluded area.

Security systems

Every workplace should have a well-designed security system. Intrusion of strangers may be reduced by limiting entry to a designated reception area where visitors may have an identity check and receive ID badges indicating the areas to be visited. In some situations, it may be advisable to use metal detectors to identify visitors carrying concealed weapons.

Electronic alarm systems triggered by strategically located “panic buttons” can provide audible and/or visual signals that can alert co-workers to danger and summon help from a nearby security station. Such alarm systems may also be rigged to summon local police. However, they are of little use if guards and co-workers have not been trained to respond promptly and properly. Television monitors can not only provide protective surveillance but also record any incidents as they occur, and may help identify the perpetrator. Needless to say, such electronic systems are of little use unless they are maintained properly and tested at frequent intervals to ensure that they are in working order.

Two-way radios and cellular telephones can provide a measure of security for field personnel and those who are working alone. They also provide a means of reporting their location and, when necessary, summoning medical and other forms of assistance.

Work practice controls

Work practices should be reviewed periodically and modified to minimize the build-up of work stress. This involves attention to work schedules, work load, job content, and monitoring of work performance. Adequate staffing levels should be maintained in high-risk work areas both to discourage violent behaviour and to deal with it when it occurs. Adjustment of staffing levels to cope with peak flows of clients or patients will help to minimize irritating delays and crowding of work areas.

Staff training

Workers and supervisors should be trained to recognize rising tension and anger and in non-violent methods of defusing them. Training involving role-playing exercises will help employees to cope with overly aggressive or abusive individuals without being confrontational. In  some  situations,  training  employees  in  self-defence may be indicated, but there is the danger that this will breed a level of self-confidence that will lead them to delay or entirely neglect calling for available help.

Security guards, staff in psychiatric or penal institutions, and others likely to be involved with physically violent individuals should be trained to subdue and restrain them with minimal risk of injury to others or to themselves (SEIU 1995). However, according to Unison (1991), training can never be a substitute for good work organization and the provision of adequate security.

Employee assistance programmes

Employee assistance programmes (EAPs—also known as member assistance programmes, or MAPs, when provided by a union) can be particularly helpful in crisis situations by providing counselling and support to victims and witnesses of violent incidents, referring them to outside mental health professionals when needed, monitoring their progress and overseeing any protective arrangements intended to facilitate their return to work.

EAPs can also counsel employees whose frustration and anger might culminate in violent behaviour because they are overburdened by work-related problems or those arising from life in the family and/or in the community, whose frustration and anger might culminate in violent behaviour. When they have several such clients from a particular area of the workplace, they can (without breaching the confidentiality of personal information essential to their operation) guide managers to making desirable work modifications that will defuse the potential “powder keg” before violence erupts.

Research

Because of the seriousness and complexity of the problem and the paucity of reliable information, research is needed in the epidemiology, causation, prevention and control of violence in society in general and in the workplace. This requires a multidisciplinary effort involving (in addition to experts in occupational safety and health), mental health professionals, social workers, architects and engineers, experts in management science, lawyers, judges and experts in the criminal justice system, authorities on public policy, and others. Urgently needed are expanded and improved systems for the collection and analysis of the relevant data and the development of a consensus on a taxonomy of violence so that information and ideas can be more easily transposed from one discipline to others.

Conclusion

Violence is endemic in the workplace. Homicides are a major cause of work-related deaths, but their impact and cost are considerably outweighed by the prevalence of near misses, non-fatal physical assaults, threats, harassment, aggressive behaviour and abuse, much of which remains undocumented and unreported. Although most of the homicides and many of the assaults occur in conjunction with criminal activities, workplace violence is not just a criminal justice problem. Nor is it solely a problem for mental health professionals and specialists in addictions, although much of it is associated with mental illness, alcoholism and drug abuse. It requires a coordinated effort by experts in a broad variety of disciplines, led by occupational health and safety professionals, and aimed at developing, validating and implementing a coherent set of strategies for intervention and prevention, keeping in mind that the diversity in workers, jobs and industries dictates an ability to tailor them to the unique characteristics of a particular workforce and the organization that employs it.

REFERENCES

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OTHER RELEVANT READINGS

MSF. Working Alone: Guidance for MSF Members and Safety Representatives.