Environmental Evaluation for Workplace Violence in Healthcare and Social Services

Transcription

1 Journal of Safety Research 39 (2008) Environmental Evaluation for Workplace Violence Healthc Social Services Kathleen M. McPhaul a,, Matw London a,b, Kev Murrett c, Kelly Flannery a, Jonathan Rosen b, Jane Lipscomb a a University of Maryl School of Nursg, USA b Public Employees Federation, USA c Architectural Resources, Inc., USA Available onle 26 March 2008 Abstract Problem: Federal policy recommends environmental strategies as part of a comprehensive workplace violence program healthc social services. The purpose of this project was to contribute specific, evidence based guidance to healthc social services employer communities regardg use of environmental design to prevent violence. Method: A retrospective record review was conducted of environmental evaluations that were performed by an architect two Participatory Action Research (PAR) projects for workplace violence prevention 2000, second project Ten facility environmental evaluation reports along with staff focus group reports from se facilities were analyzed to categorize environmental risk factors for Type II workplace violence. Results: Fdgs were grouped accordg to ir impact on access control, ability to observe patients (natural surveillance), patient worker safety (territoriality), activity support. Discussion: The environmental assessment fdgs reveal design security issues that, if corrected, would improve safety security of staff, patients, visitors reduce fear unpredictability. Impact on dustry: Healthc social assistance employers can improve effectiveness of violence prevention efforts by cludg an environmental assessment with complementary hazard controls National Safety Council Elsevier Ltd. All rights reserved. Keywords: Workplace violence prevention; Participatory action research; Environmental assessment; Healthc workers; Occupational jury 1. Problem purpose Risk factors for Type II workplace violence, defed as violence toward employees perpetrated by a client or customer, clude overcrowded waitg as healthc, workg isolation from coworkers, workg a high crime a, havg a mobile workplace, transportg patients, poor environmental design, access to firearms, workg with volatile patients. Environmental approaches to reducg risk of violence toward healthc social assistance workers recommended (National Institute for Occupational Safety Health [NIOSH], 1996), but have yet to be evaluated for ir impact on violence prevention. Ideally, violence prevention would be Correspondg author. addresses: kf@drexel.edu, mcphaul@son.umaryl.edu (K.M. McPhaul). an important consideration addressed design of a new facility advance of a major renovation project. The U.S. Occupational Safety Health Admistration (OSHA) recommends environmental design security technologies for violence prevention healthc context of a comprehensive program (OSHA, 1996, 2004, 2008). A comprehensive workplace violence prevention program as outled OSHA guideles cludes hazard assessment control elements, along with management commitment/employee volvement, recordkeepg evaluation, employee trag. Evaluation of impact of environmental design security technology toward reducg Type II workplace violence has been limited. Furrmore, process by which employers select, implement, evaluate environmental design security technology has not been adequately described or tested. To contribute specific, evidence based guidance to healthc social services communities regardg use /$ - see front matter 2008 National Safety Council Elsevier Ltd. All rights reserved. doi: /j.jsr

2 238 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) of environmental design to prevent violence, we examed environmental survey reports from two workplace violence prevention research projects to accomplish followg: 1. Identify security technology /or architectural design risk factors for violence public mental health addiction treatment facilities. 2. Exame staff perception of those hazards of potential control measures to reduce violence ir workplace. 3. Describe process by which environmental hazard assessment fdgs cluded hazard assessment control phases of a comprehensive workplace violence program. 4. Propose a workg paradigm for volvg direct c staff design security assessment procurement decisions ir facilities. 2. Background Reducg jury through environmental design, an approach long promoted by jury epidemiologists (Haddon, 1972, 1974) appeals to public health practitioners because this approach does not depend on changg personal behavior because controls can be broadly applied to protect a large population (e.g., troduction of airbags to automobile design production; Haddon, 1974; Peek-Asa & Zwerlg, 2003). Preventg exposure to occupational hazards through engeerg controls is a parallel concept. Engeerg out job hazards via elimation of, substitution of, or enclosure of a hazard or redesigng a job improves job safety without dependg on permanently consistently changg workers' behavior (Harris, 2000). In a of workplace violence prevention, examples exist for successful use of environmental design to control community, residential, retail crime (Mair & Mair, 2003; Peek-Asa & Zwerlg, 2003). In addition, field of crimal justice can form efforts of preventg workplace violence. Some research has been conducted assessg environmental design controls for workplace violence, cludg a study by Gates, Ross, McQueen (2006) who examed workplace violence five facilities with emergency departments a mid western U.S. city. Facilities cluded a Level 1 Trauma hospital with separate medical, psychiatric, air c, four facilities with a general emergency department. They found that 32% of surveyed staff (n =115) worked facilities where patient triage as were open to public; 25% reported that weapons were easily brought to ir facilities; 22% noted a lack of metal detectors or alarms ir emergency department. Sixty percent felt that long waitg times contributed to violence ir facilities (Gates, Ross, & McQueen). The Bureau of Labor Statistics recently completed a representative survey of U.S. employers, both private sector public sector, lookg at prevalence of security environmental design features American workplaces. This survey also examed risk factors, experiences of workplace violence, workplace violence prevention programs. The survey represents 7.4 million U.S. establishments that employ over 128 million workers. Remarkably, a key fdg of study noted that nearly 5% of workplaces had experienced at least one episode of workplace violence past year, but most reported that this experience did not prompt any changes programmg or procedures. Healthc social assistance workplaces were more likely to experience Type II violence; however, state government workplaces reported highest percentages of workplace violence episodes overall (32%) past year. Forty three percent of private sector healthc social service employers 80% of state government healthc social assistance workplaces control or limit access to workplace compd to 31% of all establishments. In terms of measures such as surveillance cameras, metal detectors, personal alarms, private sector healthc social assistance workplaces less likely than state government settgs to utilize surveillance cameras (12.1% vs. 50.7%), metal detectors (0.2% vs. 20.6%), employee personal alarms (2.0% vs. 15.4%). These fdgs provide national basele data for benchmarkg improvements workplace violence prevention programmg (Bureau of Labor Statistics [BLS], 2006) Crime Prevention Through Environmental Design (CPTED) Security design ory terventions that have been applied to retail environment (Casteel, Peek-Asa, Howard, & Kraus, 2004; Peek-Asa, Casteel, Meschian, Erickson, & Kraus, 2004) may have application to healthc environment. One such paradigm is an approach known as Crime Prevention Through Environmental Design (CPTED; Crowe, 1991; Jeffery, 1971; Peek-Asa & Zwerlg, 2003; Smith, 2004). The elements of CPTED clude natural surveillance, access control, territoriality, activity support. Applied to healthc environment, natural surveillance is ability for c providers to view a patient population ward, recreation, or program environment to be viewed by patients or staff. Access control addresses entry to facility, as well as ward entrances, sleepg as, offices, program as, medication storeroom. This also cludes door type traffic floor patterns to control patient movement. Territoriality is a concept that connotes an effort to empower legitimate occupants of a space over crimal elements who would occupy a space. In healthc, this might apply to nurses station, rapists offices, medication as, program as, parkg lots. Ideally, legitimate occupants of a space (staff patients alike) develop a sense of proprietorship that discourages crime violence. An element cluded later CPTED work addresses activity support. For example, environmental design may encourage safe behavior impact quality of c when program as clean, have adequate temperature control, well lit, not excessively noisy, comfortable for activities such as recreation, rest, group rapy, or private examation Ecological approach Anor approach that is used to study crime or sectors that may have application to healthc is an ecologic approach that cludes community crime data to underst dustry specific crime. For example, a study of liquor stores

3 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) California researchers used crime data for all liquor stores one city to calculate crime trends by liquor store location. Applyg this approach to healthc, regional crime rates could be used as a covariate to studies of violence emergency rooms rar than relyg on crude categories of location such as urban vs. suburban or level of complexity of services such as trauma center (Casteel et al., 2004) Workplace violence legislation environmental design A growg number of states have adopted workplace violence regulations (Michigan Department of Human Services, 2007; Speier, Killea, & Watson, 1993; State of New Jersey 212th legislature, 2006; Washgton State Department of Labor Industries, 2002; New York State Department of Labor, 2007). One of first state laws, California's Hospital Security Act (Speier et al.) requirg hospitals to provide security to reduce violence, prompted a study that is one of earliest efforts to describe presence or absence of specific environmental security technology healthc (Peek-Asa, Cubb, & Hubbell, 2002). The study found an crease proportion of hospital emergency departments with security at entrances (from 49% to 95.6%) surveillance cameras (from 26% to 69.5%) over a 10 year period California. The fdgs suggest that law resulted reduced violence California emergency departments, but also apped to result creased attention to environmental design security technology emergency departments. The relationship between environmental design or security technology reduced violence is difficult to exame highly dynamic healthc environment, but documentg presence of environmental design security technology represents an advance science of understg role environmental design security technology may play Type II workplace violence prevention (Peek-Asa et al., 2002). A later study examed a representative sample of hospitals two states categorizg hospitals as follows: Trauma I II, Trauma III IV, Acute C facilityn 300 beds, Acute cb 300, Rural Acuteb 300, Rural Trauma II IV. This categorization scheme represents a potentially important variable when considerg impact of design security technology on workplace violence healthc facilities. This study also cluded use of on site visits to assess architectural design features (environmental components of workplace violence programs). A scorg system identified presence of specific violence prevention strategies required by law that were place one of two states participatg study. Environmental components of workplace violence program cluded surveillance cameras, elimation of places that employees work alone, dividual alarm system, good lightg visibility, control of access exit, elimation of as where staff can be isolated overcome. The most common environmental feature hospitals both states was surveillance cameras (88.8% 90%). Elimatg as where employees work alone or can become isolated was much less commonly achieved (8.8% 0%); controlled access was surprisgly low as well, 40% state with workplace violence law 22% comparison state (Peek-Asa et al., 2007) Trag for Development of Innovative Control Technologies (TDICT) Collaboration with field of product design has led to highly successful Trag for Development of Innovative Control Technologies (TDICT) project, which has brought toger occupational health product design fields, as well as frontle healthc workers to develop evaluate safe needles or sharp devices for use healthc (Fisher, 1999; Fisher & Wilburn, 2000; Fisher, 2008a; Haiduven et al., 2006). The TDICT project utilizes a health safety committee structure to identify select safe sharp devices. Where devices limited or do not exist, TDICT facilitates product designers dustrial hygienists to observe clicians at work combation with trag healthc workers prciples of product design evaluation. The notion of volvg front le workers environmental walk through evaluations for violence assessment is not new (Lipscomb et al., 2006; Rosen, 1999); however, volvg frontle staff evaluation procurement of security technology environmental design services is an novative, but logical extension of TDICT paradigm. The TDICT process recommends focus group studies of healthc workers to exame design implications of engeered sharps. Fally, TDICT suggests an depth product evaluation of selected engeered devices structural failure analyses by product designers. While TDICT methodology has been tegrated to trag curricula (American Nurses Association, 2002; Fisher, 1999), an -depth evaluation of its feasibility, effectiveness, cost has not been done. OSHA has corporated pieces of process requires clusion of frontle staff selection of engeered sharps healthc (OSHA, 2006). The science of workplace violence prevention can be advanced by an approach that is formed by distct, yet overlappg ories practices of jury control, public health, dustrial hygiene, product design, crimal justice. The clusion of environmental design workplace violence prevention terventions is based on notion that such programs should be based on site specific risk assessments that consider environment, organizational, clical practices, terpersonal teractions delivery of c. 3. Methods 3.1. Design The context of environmental surveys described this report was two large federally funded tervention effectiveness research projects. These projects used a participatory action research approach, where management, labor, direct c staff representatives worked closely with researchers design implementation of project (Isreal, Eng, Schulz, Parker, & Satcher, 2005). A statewide advisory group provided guidance oversight for overall project. The tervention cluded three ma components: (a) developg supportg a facility level Project Advisory Groups (PAG) to design implement a facility specific program; (b) conductg a comprehensive risk assessment, (c) designg implementg

4 240 Table 1 Environmental Assessments of Four Public Inpatient Psychiatric Facilities # of beds Wards Assessed Access Control Territoriality Natural Surveillance Facility A Facility B Facility C Facility D Adult Adult Adult Forensic Childrens wards Sally ports not visibly secure wards wards 1st floor visitg a unsupervised/ The open to secretarial a. dg room has only one exit Night shift feels unsafe walkg to Night shift safety office had Old closed circuit television system Need bus add security escorts, improved concerns with parkg lot security should be replaced with system with lightg, blue light station cler images Need personal alarm system Need personal alarm system Therapist's office locks with dividual keys should have master keys Provide emergency communications lk to nurses station Cluster day as to facilitate monitorg Secluded alcoves: dg room Nurses station is fully enclosed, poor visibility offices Cluster night as to facilitate monitorg Some not able to see well at night The exam / treatment / medication / chart room is a remote location Nurses station / med room is isolated at Peep holes dorm doors Dorms need night light for better supervision end of hall covered Need separate spaces for meds/ exams Fish eye mirrors used not sufficient for chartg remote as alcoves Program space at one end of ward is isolated Most bedrooms do not have night lights No visibility to office program rooms Visitg a is remote from control pot; unable to supervise There is poor visibility to seclusion room Elimate hidden as behd greenhouse 55 3 livg units personal alarm system K.M. McPhaul et al. / Journal of Safety Research 39 (2008)

5 241 ActivitySupport Layout/Design Materials Matenance Dg rooms too small furniture is condensed Staff could be cornered large 16 bed wards In seclusion room door can be blocked by a foam mattress No natural light corridors Lack of light combed with unstimulatg terior is depressg Easy to pull pictures frames from wall Wardrobe units not anchored can be used altercations to block doors. Open hged doors replace with contuous hges Acoustics very poor. All fishes non absorbent reflect sounds In seclusion room grille blades removable can be used as weapons Locks on cabets syrge drawers missg or broken Exposed screws seclusion room In dg room rewere complats of unbearable noise. Picture frames potential weapons Suspended acoustic ceilg tiles can hide contrab weapons Alumum door guards have sharp edges/corners Bedroom furniture is not bolted place Alumum framed display cabets have sharp corners. Valism poor matenance bathroom The dg room has poor acoustics; allow high levels of noise Dorms overcrowded Patients can barricade corridor door usg hampers/shower bench Wdow air conditioners effective Wall fans scavenged for weapons Some program rooms closed on cold days because of poor heatg Limited opportunities for activities outdoor recreation a Metal acoustic ceilg frames can be easily removed used as weapon Bedroom door latches old asylum type with pch hges Activity room tables have removable fasteners hidg as base Program room wdows allow little light replace with Lexan Visitg a vestibule offers little comfort or privacy Better separation of age groups would reduce fear of timidation Very poor ventilation, odors quite obvious Hot water is limited; promptg arguments Heatg, ventilation air conditiong system needsmatenance upgradg Improve lightg throughout Provide exped outdoor recreation as Bedroomwardrobes can be tipped Dg room acoustics very poor with all surfaces hard Lots of graffiti, much appntly gang related K.M. McPhaul et al. / Journal of Safety Research 39 (2008)

6 242 Table 2 Environmental Assessments of Six Inpatients Addiction Treatment Facilities ATC1 ATC2 ATC3 ATC4 ATC5 ATC6 Year built Origal use Transitional residence for Nurses' residence ATC Psychiatric Hospital Nurses' residenceatc Mental Health patients Ward Year became ATC Number of beds Settg Grounds of PC Grounds of PC Free stg 11th floor ofpcgrounds of prison Grounds ofpc Number of floors Access Control No secure staff a for No visitor reception a Bedroom wdows open, Must enter thru No visitorreplace panic monitorg of cameras easy to get contrab psych center reception a bars on doors Staff need discrete Wdows old, poor Poor layout for safe med Slam locks can No dedicated secure work as condition, resultg distribution poor security accidentally isolate admissions a on bedroom floors security problems of meds nurses staff Install Dutch door Nurse a is congested nursg a where multi purpose meds dispensed Territoriality Outdoor surveillance limited Outdoor lightg surveillance cameras limited Natural Surveillance Sgle bedrooms configured No central a to observe Corridors with turns, Slide bar locks can Central corridorwith as suites alcove not visible patient movement bedroom alcoves result prevent entrance to bedrooms offices to staff, patients can move ability to observe office or bedroom on both sides room to room patients supervision is difficult Doors to program rooms Nurses located at end Doors to program offices need view wdows of long corridor no rooms offices ability to monitor patients need view wdows Increase visibility to program rooms by replacg part of wall with Lexan K.M. McPhaul et al. / Journal of Safety Research 39 (2008)

7 ActivitySupport Layout/Design Materials Matenance Outdoor recreation as limited Dg a limited Poor separation of male female sleepg as Indoor recreation space limited Program as limited Hard fishes corridors common as lead to noisy environment Replace glass wdows with Lexan or tempered glass Survey for elimate sharp corners/edges Bedroom doors can be barricaded Replace chairs that have sharp angular frames Outdoor recreation as very limited Dg a very limited congested. Should be replaced No dedicated admissions a Program as limited Hard fishes corridors common as lead to noisy environment Replace glass wdows with Lexan or tempered glass Survey for elimate sharp corners/edges Elimate leaks properly remediate mold No outdoor recreation as Replace glass wdows with Lexan or tempered glass Bedroom wardrobes can barricade doors Drywall shower as kitchen leads to mold/pests Distegratg façade, scaffoldg Limited outdoor recreation as Hard fishes corridors common as lead to noisy environment Replace glass wdows with Lexan or tempered glass Survey for elimate sharp corners/edges Open hges can cause pch jury Outdoor recreation asok, but could be improved Dg a very limited congested. Should be replaced Lack of air conditiong makes buildg hot summer Hard fishes corridors common as lead to noisy environment Survey for elimate sharp corners/edges Well designed mataed buildg Virtually no recommendations made K.M. McPhaul et al. / Journal of Safety Research 39 (2008)

8 244 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) feasible recommendations evolvg from risk assessment (Lipscomb et al., 2006). The settgs for se studies were selected based on state government agencies' terest enhancg ir existg violence prevention programmg because of strong labor management cooperation with agencies. The state employees represented by labor unions that have negotiated for agency local labor/management health safety committees ir collective bargag agreements. Furrmore, occupational health safety is addressed by an active labor management health safety committee with each agency. The environmental surveys focus groups described this report a part of overall violence prevention tervention projects were undertaken to identify environmental risk factors for violence, cludg staff perceptions of how physical work environment contributes to safety at work. The fdgs from staff surveys determed enhancement of each facility's violence prevention program. The overall study design, implementation, program evaluation was guided by a state wide project advisory (PAG) for each agency as well as local advisory groups facility level (FPAG's). The groups met regularly throughout project. The data described this report were a critical part of risk analysis step overall violence prevention program. The fdgs from se environmental surveys served as a basele environmental assessment led to development, implementation, evaluation of feasible terventions. For each of two studies, a critical component was conductg a robust multifaceted risk assessment each worksite. There were a total of 10 study sites, four psychiatric hospitals (two adult, one adult forensic, one children's) six patient addiction treatment centers. Risk assessment activities cluded a review of available data (jury, staffg, overtime), key formant terviews with managers union representatives, focus groups with frontle staff, written questionnaire surveys, a comprehensive evaluation of physical environment. The fdgs from each phase of risk assessment were reviewed by facility project advisory groups for opportunities to enhance facility violence prevention programs Focus groups The focus groups were of mutes duration cluded 6 12 front le staff with no managers. The psychiatric center focus groups were facilitated by a psychiatric nurse consultant with project's violence prevention coordator as note taker. The Addiction Treatment Center (ATC) groups were facilitated by two of authors were tape recorded transcribed. Summaries of transcripts were prepd shd with Facility Project Advisory Groups (FPAGs) at each of respective agencies Environmental evaluation The comprehensive evaluations of physical environment were conducted by one of authors, a licensed architect specializg evaluatg designg secure semi secure facilities. The architect took unique approach of mergg his knowledge of materials design with safety rapeutic needs on each ward he reviewed. Prior to each visit, architect was briefed about facility. Each visit began with a meetg with facility managers union representatives to obta a relevant history for facility. The architect was accompanied on each walkthrough by a small group of managers union representatives as well as by a member of buildg's matenance staff. In course of walkthrough, architect frequently spoke with staff that he encountered to learn more about ir jobs, ir concerns, facility itself. The walkthroughs typically took 2 3 hours. At conclusion of each walkthrough, a debriefg with managers union representatives was held. A comprehensive written report was later prepd shd with relevant FPAGs PAG. The four psychiatric hospital surveys were conducted The six addiction treatment center surveys were conducted Results The fdgs from environmental surveys largely organized usg categories that constitute CPTED approach (Crowe, 1991; Jeffery, 1971): Access Control, Natural Surveillance, Activity Support, Territoriality. With Activity Support, we have created three sub categories: Layout/ Design, Materials, Matenance. At psychiatric centers, clearly issues of access control had been already considered, as very few fdgs were made durg our visits (Table 1). Territoriality, meang ability of space users to work habit space safely, was noted as a concern all four facilities. These were prcipally related to exitg buildg at night, need for a personal alarm system while with facility. Suggestions related to natural surveillance (i.e., ability to observe be observed) were noted three of four facilities. Many of se suggestions focused on poor visibility to specific offices or work as or isolated as. The architect evaluated activity support issues such as layout/design features that encouraged safe behavior, use of safe materials, proper matenance of facility. There were numerous fdgs from all four psychiatric centers. Some of design problems cluded poor lightg, ventilation, layout of space. Materials related issues cluded open hged doors providg pch pots, sharp objects (cludg picture frames), furniture that could be used as a weapon, so forth. There were only a few matenance issues, maly related to evidence of valism that had not yet been repaired. Some of clical design issues were location of nurses station to patient day room relative strength or weakness of ward design for promotg patient/staff teraction staff observation of patient activity. Fdgs from ATC environmental surveys summarized Table 2. A number of access control issues were noted, cludg security of medication distribution lack of separate visitor reception as. The territorial issues that were raised related to surveillance of outdoor as. With category of natural surveillance, many offices program as lacked view wdows, some of bedrooms were

9 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) Table 3 Focus Groups Psychiatric Centers: Staff Perceptions of Environmental Design Risk for Violence Center Focus group fdgs Adult A No personal alarm system No pagg system Mix of forensic non forensic patients on secure wards Escortg patient to treatment mall on different floor on elevators is risky No escort support: 1 staff on elevator with 10 patients Open nursg station on some wards perceived as dangerous by staff Many unsafe objects Renovation progress, but staff not consulted about physical changes to environment TV room has restricted visibility requirg more staff Night checks of dorm rooms dangerous; visibility is poor; staffg is low There no route searches Hallways have bld spots alcoves where patients can hide Offices isolated from or staff Areas without phone or emergency call button, such as laundry a Visitors to facility packages not searched Adult B Consider radical environment re design to crease visibility; reduce risk Concern about objects beg used as weapons Staff not consulted about ways to make physical environment safer Patients use drop ceilgs to hide contrab There no searches Metal frames from drop ceilgs can be used as a weapon Dng room tables/chairs lightweight; easy to pick up throw Chairs have parts that can be broken off used as weapons Photo frames can be ripped off wall easily used as weapons Patients use balloon valances to hide contrab There bld spots alcoves Personal alarms systems not effective due to: dead zones, battery failure re is no systems to check ensure sure y workg Smokg policies promote violence; must escort patients to smokg as Concerned about visitg contrab policies, visitors brg weapons, such as knives gun parts Visitors to facility packages not searched Client's property cannot be checked Forensic There is no secure unit to send violent patients no way to separate violent patients from or patients Often too many patients elevators; opportunities to pass weapons; Elevators slow; lengthy waits; patients arrive late to program Problems with key pad entry system; Staff occasionally forget to lock doors Small treatment rooms; furniture or objects can be weaponized Tool crib frame shop concerns staff; tools can be stolen Children's Physical layout of facility is not ideal accordg to staff Visitor patient search policies should be revised/applied consistently Patients get toger form gangs agast or patients /or staff No good way to separate violent patients from ors Day room is used as a safe a but was not designed for this purpose Must leave nurses station open when usg day a to watch one patient (contued on next page) Table 3 (contued ) Center Focus group fdgs Children's Calm patients lose ir social space when day a use as safe a Secure units have a mix of secure non secure patients; not safe for all Some staff work alone with limited knowledge of patient history (of violence) Teachers alone classrooms with 12 students Art room has lots of loose items that can become weapons; Art room is isolated at end of hall Furniture, electric wire, light bulbs weaponized frequently by children Patients can access nurses a when day room beg used as safe a Many dead zones make personal alarms systems unreliable Motion detectors easy for patients to defeat Broken phone brgs patients to nurses station to use phone Many arguments much tension over phones no phone use rules Install surveillance cameras to reduce allegations of abuse Increase space per child configured so as to make observation of access to patients difficult. Fally, with regard to activity support, a number of issues were noted. These cluded adequate recreation as, congested dg as, limited program as, a couple of ATCs. Numerous materials related items were noted, cludg noisy environments due to use of hard surfaces, need to replace glass with Lexan or tempered glass, elimation of sharp corners/edges that could result serious jury if someone were pushed. Matenance was considered to be generally quite good, though moisture related mold was identified two ATCs. While staff focus groups did not center on risk factors related to physical environment, a number of issues were raised. Fdgs from four psychiatric centers summarized Table 3. Staff voiced concerns about natural surveillance such as bld spots alcoves, which give patients an opportunity to hide. Additionally staff reported poor lightg, which makes night checks dangerous related to poor visibility. One facility described broken phones, which caused many arguments tension brought agitated patients to nurses' station to use phone re. Staff also described congested slow elevators; which resulted large groups of patients congregatg hallways. These crowded situations often unruly provide opportunities for patients to pass contrab (if present). Also, numerous concerns were mentioned about existg furniture, decoration, or architectural structure beg used to make weapons or hide contrab. All four facilities reported concerns with technology; eir lack reof or faulty existg technology. Lastly, at least two facilities voiced frustration about not beg consulted when physical changes were made to ir unit/wards environment. Table 4 summarizes focus group fdgs from ATC's. Focus groups were conducted five of six ATCs. One facility decled to participate stard focus group, refore only five facilities presented here. Compd to psychiatric centers, addictions treatment facilities much

10 246 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) Table 4 Focus Groups Addictions Treatment Centers: Staff Perceptions of Environmental Design Risk for Violence ATC ATC2 ATC3 ATC4 ATC5 ATC6 Focus group fdgs Unsecure parkg, domestic violence cident occurred Staff escort peers to parkg lot Staff person trapped behd desk by angry patient Property destruction, especially bedrooms Staff often isolated from peers when with group of patients Staff can be alone on sleepg floor with 30 patients No ability to communicate between floors Staff suggest panic buttons /or walkie talkies Staff often alone with patients on nights weekends No access control to basement filg a Little/no recreation outside of facility There numerous security cameras Security guards slow to respond 6-story facility Neighborhood violence Patient fist fights over phone use Suggested soundproof enclosure for patients' phone Suggested have phone cut off after five mutes A patient stashed razor blades throughout facility Violence gang activity outside buildg Must walk gauntlet of psychiatric patients to enter buildg Staff desire to move ATC to own facility Many patients waitg durg take process leads to volatility Staff suggest walkie talkies Staff suggest more break space for patients Overcrowded dg a is source of tension Poor environmental conditions, especially summer heat Suggest panic buttons offices Suggest PA system that reaches all as of facility Suggest red phone 911 on each floor Suggest surveillance cameras Suggest alarm system nurses station Staff feel isolated offices with patients Staff suggest view wdows for office doors Poor access to outside recreation as due to proximal correctional facility Staff happy with physical environment Suggest everyone ensure office setup precludes beg cornered smaller with fewer staff clients. Many of ATC buildgs were origally used for some or purpose before beg commissioned for an ATC. While issues were myriad, y cluded concerns about beg isolated, beg unable to get prompt help when needed, office layout visibility. Dependg on facility, staff described secure parkg as, feelg isolated ir offices, possibility of beg trapped behd ir desk by a hostile patient. Two facilities reported neighborhood violence directly outside buildg. Natural surveillance, or ability to observe teract with clients, was also noted as a problem. For stance, one facility suggested viewg wdows be placed office doors. Additionally, at least three of facilities staff suggested updatg or addg technology to improve safety, communication, visibility. 5. Discussion In 10 stitutional psychiatric addiction treatment centers that participated se participatory action research projects, a robust environmental hazard evaluation was successfully completed as part of a comprehensive workplace violence prevention program. The fdgs cluded items relatg to access control, safety of premises (territoriality), ability to observe patients (natural surveillance), activity support. It is important to note that se environmental assessments were used by facility's management union representatives as part of a multifaceted risk assessment, lookg at environmental, organizational, clical risk factors as well. The risk assessment fdgs were used to develop an extensive list of potential control measures. Some of environmental fdgs were easily quickly remediated; some were more amenable to resolution mid term; some were clearly more long term as y would require significant capital expenditures. While not subject of this paper, it is important to note that many control measures were implemented as a result of projects. While se environmental assessments certaly benefited from volvement of a certified, experienced architect, we believe that volvement of managers, union representatives, frontle staff, buildg matenance staff of equal importance. When contemplatg conductg an environmental assessment, first step is to assemble such a team. The attached checklist (Fig. 1 Kev's checklist) was developed for project provides a useful template, both for walkthrough itself for process as well. The checklist should be modified to reflect particular environment which it will be used. As described items 1 2 of checklist, assessment should also reflect formation that is gared from cident jury reports, focus groups, staff surveys, or activities that help identify as of concern. The healthc social service communities need additional guidance, stronger evidence, more detailed tools processes before environmental assessment application of cost effective environmental controls becomes norm. Anecdotally focus groups we hear frustrated managers staff alike complag about ir work spaces wasteful renovations that do nothg to improve safety or productively. At a mimum, we suggest that volvg direct c workforce design renovation projects represents enlightened management. In addition, we have seen effective collaboration between architects, direct c staff, security, management that improve overall workg conditions with subsequent benefit to patient c environment as well. Our categorization of fdgs usg CPTED approach may not be as simple as identifyg an environmental concern, deleatg specific safety issue associated with staff or patient concern, listg environmental /or operational approach to mitigatg problem. But it does provide a framework for examg environment with larger context of patient c work. 6. Impact on dustry 6.1. Prevention through design At recent NIOSH Prevention through Design meetg attendees challenged healthc social assistance sectors

11 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) to transform current fragmented vision of safety (which focuses almost solely on patient safety) by tegratg patient, staff, environment safety (NIOSH, 2007). This work group of national leaders also felt that management culture leadership must shift to facilitate this transformation that frontle workers must be engaged processes that improve safety. They also called for a renewed emphasis on applied research to provide necessary evidence. While not focused on workplace violence, this Prevention through Design Workshop Breakout Session provided useful guidance for practice, education, policy, research that will benefit Type II workplace violence prevention efforts (Fisher, 2008b; McPhaul, 2008). The evolvg science known as Evidence Based Design (Berry et al., 2004) also holds promise for promotg Fig. 1.

12 248 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) Fig. 1 (contued ). evaluatg healg environments. While this field has not focused on testg novative healthc designs for staff safety, re is evidence for improved patient outcomes associated with natural light, wdows allowg views of nature, noise reduction. What is needed is tegration of design sciences with occupational safety science to better underst impact of ward facility design toger with security technology on effectiveness of workplace violence programs. Ideally, violence prevention or occupational safety considerations become part of design of every new renovated buildg healthc social services dustry. 7. Summary This retrospective review of environmental survey fdgs from two participatory action research projects illustrates nature type of environmental risk present 10 public facilities. This work demonstrates that engagement of direct c workforce understg evaluatg security design issues volved ir day to day safety is an tegral aspect of workplace violence prevention. Much like successful paradigm used to control regulate exposure to blood

13 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) borne pathogens healthc, existg state workplace violence prevention regulations federal OSHA guideles call for comprehensive programs volvement of frontle workers (OSHA, 1996, 2004). In addition, practical guidance to healthc social assistance employers is emergg from lessons from crime prevention, dustrial hygiene, public health, product buildg design, security technology. References American Nurses Association. (2002). Needlestick prevention guide. Retrieved January 16, 2008, 2008, from needleguide.pdf Berry, L. L., Parker, D., Coile, R. C., Jr., Hamilton, D. K., O'Neill, D. D., Sadler, B. L., et al. (2004). The busess case for better buildgs. Frontiers of health services management, 21(1), Bureau of Labor Statistics. (2006). Survey of workplace violence prevention, Retrieved January 19, 2008, 2008, from osh_wpvs.htm Casteel, C., Peek-Asa, C., Howard, J., & Kraus, J. (2004). Effectiveness of crime prevention through environmental design reducg crimal activity liquor stores: A pilot study. Journal of Occupational Environmental Medice, 46, 450. Crowe, T. D. (1991). Crime prevention through environmental design: Applications of architectural design space management concepts. Boston, MA: Butterworth Heemann. Fisher, J. (1999). Strategies for tegratg health c workers to process of design, selection use of control technology. In W. Charney (Ed.), Hbook of modern hospital safety. Boca Raton, FL: CRC Press. Fisher, J. (2008a). TDICT. Retrieved January 11, 2008, from org/materiali/doc/tdict.htm.htm Fisher, J. (2008b). User-based design: A case study prevention of occupational exposure to blood. PTD Motion, 1, gov/niosh/topics/ptd/#motion Fisher, J., & Wilburn, S. (2000). Don't get stuck with unsafe needles. American Journal of Nursg, 100(10), 139. Gates, D., Ross, C., & McQueen, L. (2006). Violence agast emergency department workers. Journal of Emergency Medice, 31(3), Haddon, W. (1972). A logical framework for categorizg highway safety phenomena activity. Infection & Critical C, 12(3), Haddon, W. (1974). Strategy preventive medice: Passive vs. active approaches to reducg human wastage. Journal of Trauma Injury Infection & Critical C, 14(4), Haiduven, D., Applegarth, S., DiSalvo, H., Mangipudy, S., Konopack, J., & Fisher, J. (2006). A pilot study to measure compressive tensile forces required to use retractable tramuscular safety syrges. American Journal of Infection Control, 34(10), Harris, R. L. (Ed.). (2000). Patty's dustrial hygiene (5th edition) volumes 1 4 (5th ed.). Chichester, West Sussex, UK: John Wiley & Sons. Isreal, B. A., Eng, E., Schulz, A. J., Parker, E. A., & Satcher, D. (2005). Methods Community Based Participatory Research for Health. San Francisco: John Wiley & Sons. Jeffery, C. R. (1971). Crime prevention through environmental design. Beverly Hills, CA: Sage Publications. Lipscomb, J., McPhaul, K., Rosen, J., Geiger Brown, J., Choi, M., Soeken, K., et al. (2006). Violence prevention mental health settg: The New York state experience. Canadian Journal of Nursg Research, 38(4), Mair, J. S., & Mair, M. (2003). Violence prevention control through environmental modifications. Annual Review of Public Health, 24, McPhaul, K. (2008). Comprehensive workplace violence programs clude attention to environmental design. PTD Motion, 1, gov/niosh/topics/ptd/#motion Michigan Department of Human Services (2007). Worker's safety: Lisa's law. (Retrieved August 24, 2007, from _ ,00.html). National Institute for Occupational Safety Health [NIOSH]. (1996). Violence workplace: Risk factors prevention strategies. Ccnati, OH: Author No. CIB #57. National Institute for Occupational Safety Health [NIOSH]. (2007). Prevention through design. 2007, July 9 11, New York State Department of Labor (2007). Workplace violence prevention requirements for New York state public employers. Retrieved March 5, 2008, from Workplace%20Violence%20FlyerNov3.pdf Occupational Safety Health Admistration [OSHA]. (1996). Guideles for preventg workplace violence for healthc social service workers. Washgton, DC: Author No. OSHA # Occupational Safety Health Admistration [OSHA]. (2004). Guideles for preventg workplace violence for health c & social service workers. Washgton, DC: Author No. OSHA R Occupational Safety Health Admistration [OSHA]. (2006). Regulations (stards 29 CFR) bloodborne pathogens Washgton, DC: Author No Occupational Safety Health Admistration [OSHA]. (2008). Hospital etool healthc wide hazards module workplace violence. Retrieved January 16, 2008, 2008, from hazards/workplaceviolence/viol.html Peek-Asa,C., Casteel, C.,Allddy, V.,Nocera, M., Goldmacher, S., OHagan, E.,et al. (2007). Workplace violence prevention programs hospital emergency departments. Journal of Occupational & Environmental Medice, 49(7), Peek-Asa, C., Casteel, C., Meschian, L., Erickson, R. J., & Kraus, J. F. (2004). Compliance to a workplace violence prevention program small busesses. American Journal of Preventive Medice, 26(4), Peek-Asa, C., Cubb, L., & Hubbell, K. (2002). Violent events security programs california emergency departments before after 1993 hospital security act. Journal of Emergency Nursg: JEN: Official Publication of Emergency Department Nurses Association, 28(5), Peek-Asa, C., & Zwerlg, C. (2003). Role of environmental terventions jury control prevention. Epidemiologic Reviews, 25, Rosen, J. (1999). A jot labor/management experience implementg OSHA's violence prevention guideles NYS office of mental health. In W. Charney (Ed.), Hbook of modern hospital safety. Boca Raton, FL: CRC Press. Smith, K. (2004). Environmental hazards: Assessg risks reducg disaster (4th ed.). New York: Routledge. Speier, Killea, & Watson. (1993). AB 508. Retrieved January 20, 2008, 2008, from ab_508_bill_931008_chaptered State of New Jersey 212th legislature. (2006). Senate no No. Senate No Washgton State Department of Labor Industries. (2002). Violence Washgton workplaces, No Kathleen M. McPhaul PhD, MPH, BSN, RN., is Assistant Professor core faculty member of University of Maryl Work Health Research Center. She is a co-vestigator on several on-gog completed workplace violence research projects. She is an occupational health nurse specialist with over 20 years experience occupational health services, program development, policy research. She has authored co-authored several publications on workplace violence has presented widely on topic at scientific, clical, public meetgs. She provides consultation to health c systems facilities on workplace violence prevention. She teaches courses on leadership safety healthc work environment. Matw London MS has worked occupational health safety for 25 years. He earned an M.S. dustrial hygiene from University of Ccnati, received epidemiologic trag as a member of CDC's Epidemic Intelligence Service (EIS), n worked from at National Institute for Occupational Safety Health (NIOSH) conductg Health Hazard Evaluations. Begng 1987, Matt worked at NYS Department of Health (DOH), helpg to develop New York's statewide Occupational Health Clic Network overseeg DOH's dustrial hygiene activities. Sce May 2004, Matt has worked as project coordator for two NIOSH funded workplace violence prevention projects beg conducted with NYS government.

14 250 K.M. McPhaul et al. / Journal of Safety Research 39 (2008) Kev Murrett is an architect with experience designg renovatg secure buildgs for patient or populations. He participated two federally funded workplace violence tervention studies conductg environmental assessments providg reports for use by staff management. He has participatg educational scientific conferences presentg aspects of his strategies for environmental assessments for workplace violence. Jonathan Rosen MPH, CIH has served as Director of Occupational Health & Safety Department for NYS Public Employees Federation, AFL CIO sce In this capacity he has facilitated PEF's 130 jot health & safety committees developed programs addressg fectious disease, chemical, ergonomic, safety hazards, cludg workplace violence prevention. Jonathan has conducted workshops on workplace violence for George Meany Institute, Albany Law Center, SUNY School of Public Health, American Psychiatric Association, Oregon Industrial Relations Research Association, 1999 Montreal International Conference on Occupational Health for Healthc Workers, University of Iowa Workplace Violence Intervention Research Workshop, Veteran's Health Admistration. He is a contributg author to Lewis Publishers Volume 4, Essentials of Modern Hospital Safety: A Jot Labor/ Management Experience Implementg OSHA's Violence Prevention Guideles NYS Office of Mental Health author of A Labor Perspective of Workplace Violence Prevention, published February 2001 American Journal of Preventive Medice. He is currently co-vestigator on a federal NIOSH tervention research grant studyg workplace violence tervention New York State Social Service Agencies also a NIOSH grant evaluatg TYPE III Violence. Jonathan has completed a Master's Degree Industrial Health at University of Michigan is a Certified Industrial Hygienist. Kelly Flannery R.N., B.S.N. has been a registered nurse for five years. She earned her bachelors of science nursg from Drexel University. She has worked critical c, operation room research. Currently she is a graduate research assistant on two workplace violence projects at University of Maryl. She completed an ternship at Public Employees Federation conductg a study on impact of a state workplace violence law. Her terests public health epidemiology. Jane Lipscomb RN, PhD, FAAN, is Professor Director of School of Nursg's Center of Excellence, Work Health Research Center. She is Prcipal Investigator on three NIOSH funded tervention evaluation R01s. She has recently completed a NIOSH funded study entitled Effects of OSHA Guideles on Violence Prevention Mental Health." In each of se projects, Dr. Lipscomb has successfully led a team of researchers, union, management partners development, implementation, evaluation of workplace terventions. Dr. Lipscomb is an epidemiologist with over 25 years of experience conductg research focusg on health c or groups of workers. She has conducted tervention effectiveness research on workplace violence for past 10 years.