Safe at Home

Home health clinicians and social service providers are at risk of personal injury due to violence on the job. Violence on the job is workplace violence and can come from community crime or from patients and their household members.

Home care employers are generally aware of the possible risks and many offer safety strategies such as escort services for high-crime areas. The federal Occupational Safety and Health Administration (OSHA) provides recommendations for employers to protect home care employees and, increasingly, states are strengthening laws that protect health care clinicians who visit patients’ homes. The essential elements of a framework to protect home visiting staff are outlined here.

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Employer/Employee involvement

Both clinicians and employers can use the OSHA framework to assess the need for safety services and benchmark the effectiveness of safety strategies. A comprehensive approach begins with a policy that defines workplace violence and states the approach for dealing with it at your agency. This represents one aspect of “management commitment,” which is an essential component of a strong workplace violence program. Management also demonstrates commitment by endorsing and resourcing the remaining elements of a comprehensive program described in this article.

The next feature of a strong program is “employee involvement.” The evidence for best practices suggests programs are most effective when direct care staff and management work together. Typically, an organization will convene a task force or empower the safety committee to develop and implement a workplace violence program. The task force or committee should be comprised of managers, direct care staff, security (if available), EAP, human resources and union representatives (if applicable). There should be representation from all the important categories of staff such as therapists, aides and nurses.

Employee involvement also involves mechanisms for every employee to be involved via structured communication such as presentations at staff meetings.

Risk assessment

Once a formal task force or committee exists, then a risk assessment or hazard analysis can be performed. This phase is extremely important to understand the incident history of the agency and its customers, the crime patterns of the geographic territory served by the agency, the willingness of law enforcement to assist, the impressions of staff about their risk and the types of environments encountered on visits, e.g., apartment buildings, homes, shelters, etc.

The risk assessment involves reviewing as many data sources as possible. This will include past incidents and their specific features:

• time of day;

• type of service;

• previous history of violence of client or household members;

• quality of information about client and household available to agency;

• type of medical service being provided;

• emotional and behavioral issues;

• environment of home environment; and

• crime patterns in the neighborhood.

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For example, in a study conducted by the University of Maryland, it was learned via staff focus groups that there were concerns about animals and rodents and also that household members put both patients and providers at risk by conducting illegal activities in the home. We also learned patients and household members who are under the influence when the provider arrives greatly increase the risk of problems during the visit. Finally, it was determined occasionally guns and weapons were in plain sight in the home.

From the risk assessment, a hazard control plan is developed. This plan may involve engineering or technological controls such a crime mapping, cell phones with GIS locating capability, or other specialized technology to call for assistance. Administrative controls include devising policies for security escorts for high-risk visits or creating check-in policies for staff and behavioral contracts with clients and patients and their households.

Violence training

Each of these elements must be communicated to staff in the form of ongoing workplace violence training. Training can cover all aspects of the employer policy, including the definition of a high-risk patient or household and when to bring along an escort. The training should also address when to enter a home, when to leave a visit early and how to report suspicious behavior.

Periodic safety meetings and debriefing can ensure the annual training is frequently refreshed and updated depending on incidents. Home care personnel are by definition very independent and generally work alone, but for safety’s sake the agency must create opportunities for information sharing and supervisory monitoring of staff safety behavior in the community.

The final elements of strong and effective workplace violence programs involve post-incident counseling and management of the trauma and stress when an incident does occur. Injured and frightened staff may have difficulty returning to the community and work after a particularly traumatic injury. Employers and supervisors must make every effort to stay in touch with affected staff without appearing punitive. In some cases, the employer must support a nurse who wishes to press charges. Many states have upgraded the assault of a nurse from a misdemeanor to a felony creating both a stronger deterrent and a more effective avenue for assaulted staff to seek a legal remedy.

Identifying high-risk visits

Research has shown certain patient and environmental features increase the risk of violence to home visiting staff. The strongest risk factor for violence is past violent behavior. Therefore, the intake assessment of the patient and the household members is crucial to determining is the visit will be a high-risk visit. Crime-mapping of communities as well as strong relationships with law enforcement can also inform whether precautions such as escorts should be considered.

Visiting patients with active substance abuse disorders; behavioral, cognitive or mental health disorders that involve dementia; or agitation or impulsive behavior should also be considered high risk. In some cases, the communication skill of the provider combined with the quality of the relationship of the provider to the patient can mitigate the risk. Some unstable households such as those where the children are at high risk for abuse and are being considered for removal from the home are very high risk. In these situations, social workers and clinicians must take extra precautions and bring a security escort or another provider on the visit

Total commitment

As indicated above, following the OSHA framework will ensure safety resources are utilized in an evidence-based manner and linked to the hazard analysis. Of course, meticulous recordkeeping and documentation is in both the staff and employer’s best interest (see Employer Workplace Violence Checklist).

Employers and staff working together can develop effective workplace violence prevention programs, but it requires vigilance and consistency, along with frequent safety meetings and debriefings.

Kate McPhaul is assistant professor at the Work and Health Research Center, University of Maryland School of Nursing, Baltimore.