| | The role of surveillance and evaluation research in the reduction of violence against workers1Abstract Background: Violence against workers is garnering increased attention as awareness grows of the toll violent events have on workers and work environments. Methods: In this review, we summarize information about surveillance of violent events in the workplace and summarize evaluations of intervention programs to reduce such violence. We describe surveillance programs that nationally collect data, and we compare some data. We summarize two systematic studies of workplace violence–prevention programs: The first study examined evaluations of the Crime Prevention Through Environmental Design approach to prevention, and the second examined evaluations of behavioral and administrative interventions. Results: Reliable national data sets of worker homicides exist, but case identification and coding problems have yet to be solved. Although the number of workplace homicides has decreased since the mid-1990s, much less is known about the incidence of nonfatal events. The role that prevention programs have played in reducing workplace homicide remains largely unknown because so few evaluations have been conducted. Conclusions: Information about effective methods to reduce violence against workers is needed. Research that evaluates existing prevention programs, especially efforts conducted in a collaborative manner, will be invaluable to shaping effective programs in the future.
Introduction  Violence prevention is a relatively new topic of study for occupational safety and health professionals. Although research efforts in surveillance, risk factor assessment, and evaluation of preventive measures have increased, great need remains for improved information in each of these areas. Workplace homicide rates have fallen along with rates of overall violent crime since the mid-1990s, but we do not know the extent to which we can attribute these decreases to industry-based prevention programs. The growing economy, increased law-enforcement activities, and anticrime legislation have all been cited as causes for recent decreases in violent crime, and demographic factors may also play a role.1 Whatever the contributors to these decreases, businesses must be aware of the risk factors for various types of violence in their work environments and take measures to prevent violent events. Evidenced-based prevention is the most-effective approach and requires several organized steps. The first of these steps is surveillance, in which populations at risk and the scope of the problem are identified. In the second step, factors that place certain workers at higher risk than others are defined, and employers use this information to target segments of the workforce. The third step involves the design and application of intervention programs, followed by scientific evaluations of these efforts. This manuscript describes research contributions to these prevention steps. Categorizing workplace violent events By focusing on the perpetrator’s relationship with the business in which the victim was injured, we can identify four categories of violence to workers:2, 3
•Criminal intent: The perpetrator has no legitimate relationship to the business or its employees and is usually committing a criminal act before the violence. Criminal acts include robbery, shoplifting, and loitering (Type I).
•Customer/client: The perpetrator has a legitimate relationship with the business and becomes violent during a business transaction. This category includes customers, clients, patients, students, inmates, and any other group to which the business provides services (Type II).
•Worker on worker: The perpetrator is an employee or past employee of the business who attacks or threatens another employee(s) or past employee(s) (Type III).
•Personal relationship: The perpetrator does not have a relationship with the business but has a personal relationship with the intended victim. This category includes victims of domestic violence who are assaulted while at work (Type IV).
These events, although occurring at work, may not be directly work-related. Surveillance Surveillance of violent injuries to workers has advanced in the past 10 years, but many procedural and reporting problems persist. Although data that enumerate fatal events have been available for many years, we lack information about nonfatal events and the economic costs and other losses associated with both fatal and nonfatal events. The lack of such data makes it difficult to conduct time-series studies or ecologic evaluations of interventions. Surveillance information is an important component of program design and evaluation because researchers can use it to identify high-risk segments of the workforce, to describe the scope of the problem, and to conduct outcome evaluations. Data sources Fatal event surveillance Census of Fatal Occupational Injuries (CFOI) The Bureau of Labor Statistics (BLS), Department of Labor, collects CFOI data. The CFOI surveillance began as a pilot effort in 1991, and national data are currently available from 1992 through 1998. State Departments of Labor or their equivalents identify cases and report these to the BLS. The CFOI uses a broad definition of “work” and includes events in which the decedent was receiving compensation or profit for a legal activity or was present at the site of the event as a requirement of his or her job.4 The CFOI excludes commuting. It includes all deaths caused by physical trauma. Sources of case information include death certificates, workers’ compensation reports and claims, reports to regulatory agencies such as the Occupational Safety and Health Administration (OSHA), medical examiner reports, police reports, and media stories. At least two of these sources must corroborate the information. National Traumatic Occupational Fatality Database (NTOF) The National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, collects the NTOF. Established in 1980, the NTOF was the first national database of occupational deaths. Data are available through 1995. The NTOF uses the same reporting units as the CFOI, but ascertains cases differently. The NTOF relies solely on death certificates reported through Vital Statistics Offices and uses the death certificate designation of “injury at work.” Thus, case identification becomes the judgment of individual agencies that fill out the death certificates, which might not systematically or consistently define “injury at work.” National Safety Council (NSC) The NSC reports annual numbers and rates of workplace death and injury in their Injury Facts series. The database identifies cases through the National Center for Health Statistics, state vital statistics departments, and state industrial commissions. Case identification for fatal events relies on the death certificate “injury at work” designation. Uniform Crime Reports (UCR) The UCR is a database of all homicides assembled by the Department of Justice, Federal Bureau of Investigation. Although some information about work relatedness exists, such cases are very difficult to identify and are usually not reported. Workplace homicides can be identified through a link with the CFOI.5 Nonfatal event surveillance National Crime Victimization Survey (NCVS) The NCVS is a weighted annual household survey of approximately 46,000 households and 95,000 people. The survey includes questions about victimization of all types of violent events, including those that occur while working. The survey asks participants to describe their experiences as victims of crime, and ascertaining work relatedness depends on participants’ self-reporting. The NCVS classifies perpetrators based on law enforcement standards, and this information does not directly correlate with the categories of workplace violence events reviewed above. Survey of occupational illnesses and injuries The Bureau of Labor Statistics conducts a survey of 169,000 private industry establishments in collaboration with state agencies. Participating employers report events to their state Department of Labor, and the BLS accumulates reports. Survey results are weighted to estimate annual incidence rates by industry and occupation. Only events that lead to lost working days are included. Case identification and determination of which events are work-related depends on the individual reporting establishment. Workers’ compensation data Although workers’ compensation data are not collected at the national level, these reports can be excellent sources of information for specific studies. Limitations of workers’ compensation data include the numerous providers that cover various populations, differing definitions of assault, differing responses to claims submitted, and the fact that many high-risk workers are not covered. Challenges to surveillance efforts Case identification Definitional ambiguities complicate surveillance of occupational injuries and violent events. Definitions of “work” and “workplace activities” differ among agencies, and sometimes even within the same agency.6, 7 Ambiguities include activities such as commuting and travel; individuals who participate as volunteers or students; workplaces not always associated with work, i.e., farms and home offices; and jobs that require ongoing involvement, i.e., law enforcement and armed services. Although guidelines exist to assess work relatedness of an event, the guidelines do not help in situations without sufficient information or in which circumstances fall into an ambiguous category. Because surveillance systems use different methods to identify work relatedness, we cannot compare reported estimates. Reporting Although all deaths in the United States are recorded, the challenge persists in fatal event surveillance to identify which violent deaths are work related. Although case identification issues also apply to nonfatal events, the absence of a central reporting mechanism presents further challenges to surveillance of nonfatal events. Traditional sources of information about nonfatal illness and injury—workers’ compensation records, physicians’ records, or employees’ reports—often fail to capture events related to violent crime. Police reports, which capture information about violent crime, may miss events not linked to criminal activity. Police records can also fail to identify victims as employees, and therefore the relationship of the violent event to the workplace becomes difficult to determine. Furthermore, many nonfatal events may not be reported to any authority, especially when they occur in small or independent businesses or when events are less severe. Linkage of OSHA data with law enforcement data offers a promising approach for studying nonfatal events. Rates Rates are an essential element in understanding time trends and in identifying risk by industry and occupation. Changes in the labor force overall and within individual sectors will influence exposure and its measurement as the rate denominator. Unfortunately, inter–census year, denominator data are often inaccurate and may greatly influence reported rates. The most commonly used source of denominator data is the Current Population Survey (CPS), conducted annually by the Bureau of the Census. The CPS is a weighted survey of approximately 57,000 households that includes questions about occupation and demographics. The survey is standardized to the 10-year census to create annual estimates of the labor force. Estimates of the population by occupation have high error margins, especially when applied to small geographic areas. Results from surveillance data Homicides Since surveillance of occupational homicide began, homicide has been the second leading cause of occupational death and has accounted for approximately 17% of workers’ deaths. Figure 1 shows the number of worker homicides as reported by NTOF and CFOI from 1980 through 1998. Each year, CFOI reports more cases than does NTOF because it uses more reporting sources and because CFOI surveillance is conducted at the state level. The high degree of agreement, however, suggests that most workplace homicides are identified through death certificates. Since CFOI was established, homicides peaked at 1080 in 1994 and then fell to their lowest level of 711 in 1998. Between 1997 and 1998, workplace homicides decreased 18%, more than the 8% decrease in homicides overall.8 Decreases in homicides accounted for most of the 3% decrease in workplace deaths that CFOI reported from 1997 to 1998. Deaths in the retail industry decreased 27.5%, which was the largest decrease of all industries. These decreases are likely due in large part to successful robbery- and injury-prevention programs. Approximately 85% of workplace homicides reported through CFOI are related to robbery (Type I), with less than 10% of deaths attributable to each of the other types of violence (Figure 2). 4 Retail and service industries consistently suffer the highest risk. The occupations of taxicab driver, sales clerk, and security professional are high-risk, as is work in liquor stores, gas stations/convenience stores, and bars. Minorities and new immigrants of any ethnicity have an elevated risk of workplace homicide compared with their proportion of the workforce.9, 10 Reasons for this elevated risk may include work in high-risk occupations and high-crime areas. In 1995, CFOI reported 780 workplace homicides for men and 244 for women, with corresponding rates of 1.30 per 100,000 male workers and 0.45 per 100,000 female workers. Although rates for men are higher, homicides comprised only 13.7% of all male occupational deaths but 45.7% of female occupational deaths. Nonfatal violent victimizations According to the NCVS, more than 2 million workers were victims of violence each year between 1992 and 1996.5 This total includes 1.5 million simple assaults, 396,000 aggravated assaults, 51,000 rapes and sexual assaults, and 84,000 robberies. Nonfatal violent victimizations decreased 21% between 1994 and 1996. In the NCVS, strangers (Type I) perpetrated 59.6% of events and acquaintances perpetrated 35.3% of events. Other research reports that, depending on the reporting source, criminal acts (Type I) accounted for 46% to 67% of nonfatal violent injuries and customers, clients, patients, or inmates (Type II) accounted for 18% to 48% of events (Figure 3). 11 Worker-on-worker violence (Type III) accounted for less than 6% of events, and events based on personal or intimate relationships (Type IV) account for less than 2%. In 1997, the BLS Survey of Occupational Injury and Illness reported 21,300 events that led to days away from work because of assaults and violent acts by other people.12 The assault rate was 2.5 per 10,000 full-time workers and accounted for 1.2% of all reported illnesses and injuries. The median number of days away from work was 5, and 17.8% of events led to 31 or more days away from work. Occupations reporting the highest number of nonfatal workplace violence victimizations include retail sales, law enforcement, teaching, health care, mental health care, transportation, and private security.5, 11 The Survey of Occupational Injury and Illness reported the highest rates among the service industry (6.3 per 10,000 full-time workers), the retail industry (1.8 per 10,000 full-time workers), and transportation and public utilities (1.3 per 10,000 full-time workers). In the NCVS, male victims outnumbered female victims by a factor of two. Men were more likely to be victims of robbery and assault, whereas women were victims in the majority of rapes and sexual assaults. Nearly 90% of the respondents who reported nonfatal workplace victimization were white. Other outcomes As we learn more about the effects of violence in businesses, it becomes more clear that injury is just one of many adverse outcomes. In a survey of bank clerks who had experienced robbery, 80% reported that their productivity was negatively impacted, 67% reported debilitating anger and stress, and more than 40% reported desire to change jobs.13 An evaluation of workers’ compensation claims from workplace violence in a large insurance carrier identified 28,692 claims for nonfatal violent events, which together exceeded $84 million dollars in claims.14 Only 15.5% received compensation for lost working days, with the majority of costs devoted to medical attention. However, in banks, which comprised a large proportion of the claims, 93% of lost working days were caused by stress after robberies. These findings indicate that homicide is just one of many types of losses associated with robbery and that preventive efforts are needed in all business settings. Prevention The classification of workplace violence into four distinct categories and the ability to examine surveillance data to help prioritize these types has aided prevention activities. Although underlying tenets of prevention apply to all businesses and all risk profiles, specific components of an intervention program vary for each type of event. The fundamental step in an individual prevention program is therefore the characterization of the hazard within the specific type of workplace. The California Occupational Safety and Health Administration requires all businesses in California to implement an Injury and Illness Prevention Program (IIPP). In the IIPP approach, which has been integrated into the California Code of Regulations, the essential elements of an effective workplace security plan are defined as the following:
1.Commitment from management.
2.Compliance: a system to ensure that employees comply with safe work practices.
3.Communication: mechanisms by which employees can inform employers of hazards and vice versa.
4.Hazard assessment: procedures for identifying workplace security hazards.
5.Event investigation: procedures for investigating events.
6.Hazard correction: procedures for correcting unsafe conditions.
7.Training: methods to teach employees to recognize hazards, prevent events, and respond when an event does occur.
Although these guidelines present a comprehensive approach to implementing a security program, they include no recommendations about specific intervention measures. The absence of evaluation data to support intervention components is responsible in large part for this omission, along with the realization that no single, defined strategy can be effective in all work environments. Although intervention programs must be designed to fit the specific work environment, a comprehensive approach should involve several components. These general components apply to all types of violence, but specific modifications will vary by the type of hazard identified in the business. These components include environmental approaches, behavioral/training approaches, and management approaches. Environmental approaches include control of entry/exits, lighting, and general maintenance for a positive and controlled physical work environment. Environmental modifications are especially important in crime-related events (Type I), but are an important part of addressing all types of events. Lighting has been cited as an important part of reducing customer/client (Type II) events, as has control of physical space to avoid isolated areas and maintaining control over all entrances.15 Behavioral approaches focus on training, which is a crucial element in any prevention program. Training should include information about violence policies and procedures as well as recognizing hazardous situations and people and how to respond and report such events. Management approaches are based on the need for businesswide commitment to maintaining a safe working environment. The IIPP program described above identifies the steps that management should take to implement a workplace violence–prevention program. In the absence of data to make evidence-based recommendations, government agencies have released several guidelines for businesses to use in prevention. Although many of the recommended measures are becoming widespread in various industries, the effectiveness or cost-benefit of most remains unknown. Two reviews of existing evaluations have been conducted, and we describe them below. Research evaluations Evaluations of prevention programs are the key to understanding which programs are effective and in which environments. Although information about intervention effectiveness is growing, controlled, scientific evaluations are uncommon. The available literature is scattered across many disciplines, and many evaluations have not been published. To help bring together some of this knowledge, researchers conducted two comprehensive reviews of the research that evaluates workplace violence–prevention strategies. These reviews have been published in a separate supplemental issue of this journal. One of these reviews focused on environmental changes and the other on behavioral modifications, and we summarize below the basic findings of these reviews. Critical review of environmental approaches Environmental modifications to reduce workplace violence are based on an approach defined in the 1970s called Crime Prevention Through Environmental Design (CPTED).16 This approach has been applied and evaluated only in the retail setting and only in its role of decreasing robbery and related injury. A thorough review of this approach identified 26 evaluations.17 Convenience stores made up the settings for 15 evaluations and general retail accounted for another 7. Four of the twenty-six studies evaluated a series of Florida ordinances that included security measures such as limiting cash in registers, increasing lighting and visibility, staffing and hour changes, and employee training.18, 19, 20, 21, 22 These studies had no information about which stores complied with the ordinances or whether the stores with low or no compliance had higher robbery rates. Excluding evaluations of ordinances, the median sample size of businesses in the evaluation was 105. The longest follow-up periods occurred in the studies that evaluated ordinances, the longest of which was 5 years.22 Follow-up for studies that examined individual stores did not exceed 1 year. Thus, the body of studies that evaluate CPTED prevention programs have either small sample sizes, short follow-up periods, lack evidence about compliance to the program, or use restricted business settings. Despite the limitations to individual evaluations, the body of evidence clearly indicates that these programs are highly effective in reducing robbery and related injury. For programs that introduced a comprehensive security program, robberies decreased between 30% and 84% compared with control stores.23, 24 The CPTED-based ordinances led to robbery decreases of between 12% and 65%,19, 20, 22 with only one study not observing a significant decrease.18 These studies do not provide information about which components are most successful or which intervention components work best in different business settings. Critical review of behavioral and administrative approaches Runyan et al.25 undertook a similar review to evaluate the efficacy of behavioral and administrative approaches in reducing violence against workers. These interventions were directed at altering management (e.g., preplacement screening, staffing patterns) or worker practices (e.g., conflict management, restraint and control strategies). The authors included only articles that reported on interventions targeting the victim, assailant, or social/environmental interventions and that measured cognitive, behavioral, or injury-related outcomes. Using 17 different databases, only nine evaluations met these criteria. All of these evaluations were carried out in health care facilities, six of them in psychiatric facilities. All the interventions were aimed at preventing assaults between patients and employees (Type II). Two papers studied post-event strategies to reduce negative psychological outcomes among staff assaulted in psychiatric facilities.26, 27 One suggested that a peer-help program for staff resulted in declines in the frequency of assaults.26 Another reported that unavailability of debriefing counseling was associated with increased reports of post-traumatic stress among employees, yet found no differences between those who had received counseling and those who had access to counseling but chose not to enroll.27 Five papers evaluated training programs aimed at teaching hospital employees how to manage patients’ assaultive behaviors.28, 29, 30, 31, 32 They included an ecologic study attempting to compare wards with trained versus untrained employees,28 a 1-day workshop on preventing abuse by patients,29 aggression-control training,30 and training staff to appropriately use patient-restraint techniques.32 Another study, although not attempting to measure injury or involvement in assaults, documented in detail the process by which training on managing violent behavior was delivered to personnel in a Veterans’ Administration hospital. Finally, two studies evaluated administrative strategies in hospital settings: Drummond et al.33 investigated an administrative attempt to identify violent patients on admission, and Hunter and Love34 evaluated a total quality management approach to decreasing patient violence. Taken together, these studies underline the dearth of quality research on the efficacy of administrative and behavioral efforts to prevent workplace violence and point to no single, effective strategy. Only two studies27, 30 used nonrandomized control groups, and none used randomized control groups. Most of the studies used a before–after comparison with no control group. Although randomized controlled trials can be problematic because of both practical constraints and ethical concerns, better evaluation studies are needed to guide the use of administrative and behavioral interventions to prevent violence at work. Potential routes for future research Many of the evaluations of workplace violence–prevention programs were not subject to the peer-review process, and many serious weaknesses were present. The majority of studies used pre- and post-intervention evaluations without control groups, which presents a number of limitations. Many of the outcome measures were ecologic and, therefore, it is difficult to attribute changes to the program itself. Few of the studies controlled for confounders, including adjustments for changing crime rates over study periods. Although several corporations have conducted evaluations of their programs, many of these evaluations were not publicly available or lacked detailed information on methods or quantitative results. However, some of the most-valuable information to direct future intervention activities lies within businesses that implement prevention programs. Collaborative research to conduct controlled scientific evaluations of these programs would significantly advance the current state of knowledge. Although clear reasons exist for a business to be reticent to publicly evaluate their programs, the ultimate costs and consequences of implementing an ineffective program far outweigh these disadvantages. Funding for evaluation studies needs to increase. Prospective, controlled evaluations are expensive, but their findings carry more scientific weight than do a series of less rigorous studies. Potential to conduct parallel evaluations in different businesses and at several sites is a promising and cost-effective approach that will help identify overall program effectiveness as well as differential effects in various work environments. References 1.
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Psychiatr Serv. 1996;47:751–754. MEDLINE a Southern California Injury Prevention Research Center, UCLA School of Public Health (Peek-Asa), Los Angeles, California, USA b University of North Carolina, Injury Prevention Research Center (Runyan), Chapel Hill, North Carolina, USA c Injury Prevention Research Center, University of Iowa (Zwerling), Iowa City, Iowa, USA  Address correspondence and reprint requests to: Corinne Peek-Asa, PhD, UCLA School of Public Health, 10911 Weyburn Ave, Suite 200, Los Angeles, CA 90024
PII: S0749-3797(00)00290-7 © 2001 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved. | |
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