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An exploratory study of mandated safety measures for home visiting case managers

  • AJ Rosen & Associates LLC

Abstract and Figures

The purpose of this qualitative focus group study was to assess staff perceptions of the implementation and effectiveness of safety measures mandated for home visiting case managers. A participatory action research framework was used to conduct 5 focus groups of case managers employed by a state mental health system in the United States. The participants were employed by a program to provide case management for the severely and persistently mentally ill in the community. Safety measures instituted after the homicide of a visiting case manager were found to be effective in some agencies but not in others. There was variability between agencies in the strictness with which safety protocols, accountability procedures, accompanied visits for high-risk situations, and training were implemented. Contextual factors influenced perceptions of safety. Mandatory safety measures for home visiting health workers may be feasible but further research is necessary to explore risks and contextual factors.
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Étude exploratoire sur les mesures de
sécurité obligatoires imposées aux gestionnaires
de cas qui font des visites à domicile
Kathleen M. McPhaul, Jonathan Rosen, Shawn Bobb,
Cassandra Okechukwu, Jeanne Geiger-Brown,
Karen Kauffman, Jeffrey V. Johnson et Jane Lipscomb
Cette étude qualitative avait pour but d’évaluer les perceptions des gestionnaires
de cas à l’égard de la mise en œuvre et de l’efficaci de mesures de sécuri obli-
gatoires destinées à ceux et celles qui font des visites à domicile. Les chercheurs
se sont appuyés sur un cadre de recherche-action pour mener cinq groupes de
discussion formés de gestionnaires de cas employés au sein d’un programme de
services en santé mentale d’un État américain ces gestionnaires intervenant
auprès de personnes souffrant de maladie mentale grave et persistante. Les
mesures de sécurité adoptées à la suite de l’homicide d’un gestionnaire de cas en
visite sont jugées efficaces par certaines agences, mais pas par d’autres. La rigueur
avec laquelle on met en œuvre ces différentes mesures, dont les protocoles
de curité, méthodes de reddition des comptes, visites accompagnées dans les
situations à risque élevé et programmes de formation, varie d’un établissement
à l’autre. Par ailleurs, certains facteurs contextuels pourraient inuer sur la
perception quant à la sécurité. Imposer des mesures de sécurité à tous les presta-
teurs de soins à domicile est une solution envisageable, mais il faudra entre-
prendre d’autres recherches pour analyser les risques et les facteurs en jeu.
Mots clés : visites à domicile, gestionnaires de cas, personnes souffrant de maladie
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An Exploratory Study of
Mandated Safety Measures for
HomeVisiting Case Managers
Kathleen M. McPhaul, Jonathan Rosen, Shawn Bobb,
Cassandra Okechukwu, Jeanne Geiger-Brown,
Karen Kauffman, Jeffrey V. Johnson, and Jane Lipscomb
The purpose of this qualitative focus group study was to assess staff perceptions
of the implementation and effectiveness of safety measures mandated for home
visiting case managers.A participatory action research framework was used to
conduct 5 focus groups of case managers employed by a state mental health
system in the United States.The participants were employed by a program to
provide case management for the severely and persistently mentally ill in the
community. Safety measures instituted after the homicide of a visiting case
manager were found to be effective in some agencies but not in others.There
was variability between agencies in the strictness with which safety protocols,
accountability procedures, accompanied visits for high-risk situations, and
training were implemented. Contextual factors influenced perceptions of safety.
Mandatory safety measures for home visiting health workers may be feasible but
further research is necessary to explore risks and contextual factors.
Keywords:Workplace violence, home visiting, community health nursing, case
management, mentally ill persons
Visiting human service workers are at risk for injury and death while in
clients homes (Barling, Rogers, & Kelloway, 2001; Bussing & Hoge, 2004;
Department of Labor Statistics, 1997; Fazzone, Barloon, McConnell,
& Chitty, 2000; Fitzwater & Gates, 2000; Schulte, Nolt,Williams, Spinks,
& Hellsten, 1998).The home visiting workplace presents many of the
same care-related risks as institutional settings, such as clients with a
history of violence or with cognitive impairments, clients with mentally
illness and a co-occurring substance abuse disorder, working alone, and
exposure to weapons (Fazzone et al.; Fitzwater & Gates; Murphy, 2004;
Powell & Lloyd, 2001). Home visiting workers are also exposed to risk
factors associated with violent outcomes among workers in other occu-
pations such as taxi drivers and late-night retail workers.These factors
include working alone in the community, travel into crime-ridden areas,
and working late at night (Fitzwater & Gates; Kendra & George, 2001;
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Kendra,Weiker, Simon, Grant, & Shullick, 1996; Schulte et al.; US
Department of Labor & Occupational Safety and Health Administration,
There has been no rigorous research on the risks of violence towards
home visiting human service workers. However, case reports of homicide
and the results of limited studies specific to home visiting suggest broad
patterns of risk compatible with the literature on workplace homicide
and violence (Kendra, 1996; Schulte, 1998). Even though home visiting
human service workers are not identified in the literature as high risk for
homicide, they exhibit several risk factors for homicide, namely travel
into high-crime areas, working at night, exposure to rearms, and
working alone (National Institute for Occupational Safety and Health,
1996a, 1996b). Homicides of home visiting human service workers have
been reported in a number of US states, including Texas, Maryland,
Michigan, Kansas, NewYork, and Washington (Gillespie, 2001; Killing in
Texas, 2006; Ly, 2002; Martin, 2005; Newhill, 2003; Public Employee
Safety and Health, 1999; Sedensky, 2004). In response, at least three states
have introduced legislation to strengthen and/or require specific safety
measures for these at-risk workers (Lipscomb, Silverstein, Slavin, Cody, &
Jenkins, 2002). According to the Canadian Centre for Occupational
Safety and Health (2007), several Canadian provinces have also adopted
specific regulations or guidelines concerning workplace violence. In the
United States, however, regulatory agency investigations and citations for
workplace violence are rare, in spite of mounting evidence of violence as
an occupational hazard in such industry sectors as health care, law
enforcement, transportation, retail sales, and education (Bureau of Labor
Statistics, 2001, 2002; Duhart, 2001; Jenkins, 1996a, 1996b; McCall &
Horwitz, 2004; Moracco et al., 2000;Toscano, 1996;Toscano & Weber,
1995).An investigation was carried out in 1998 following the murder of a
community mental health nurse in a northeastern state. In this case, the
employer was cited by the state’s occupational safety agency for failure to
provide a safe and healthy workplace.The citation required the
employer (a state mental health agency) to institute five safety measures
as remediation for all visiting mental health workers employed
throughout the state:
regular training in the handling of potentially assaultive patients
a system to account for the whereabouts of all employees assigned to
the field
formal safety protocols to be followed by visiting mental health case
managers, and adequately communicated to all employees
accompanied visiting when the patient’s history indicates assaultive
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a means to summon assistance when necessary (Public Employee
Safety and Health, 1999)
This qualitative study was designed to assess whether the mandated
safety measures implemented in the wake of the homicide improve the
safety of home visiting case managers (HVCMs). In lieu of specic
instruments to assess home visiting risk, a qualitative approach was taken
in anticipation of developing measures for use in a future mixed-method
study of this population of workers.This article reports the findings of a
focus group study to assess the implementation and effectiveness of
mandated safety measures for HVCMs several years after their imple-
Conceptual Framework
A participatory action research (PAR) framework was employed in the
design and conduct of the study (Keith et al., 2001; Leung,Yen, &
Minkler, 2004; Schurman, 1996). In the aftermath of the visiting nurse’s
murder, her labour union played a pivotal role in crafting safety measures.
The PAR framework allowed for the workers and their union to be equal
partners and for the investigators to be “co-learners” in gathering infor-
mation on the effectiveness of the safety measures. University-based occu-
pational health researchers collaborated with the health and safety depart-
ment of the union that had represented the murdered nurse.The union
identified the primary research question: Are the required safety measures in
place and working? The union also advocated for the use of focus groups as
the data-collection method, in order to engage frontline staff in this safety
issue. Focus groups are an accepted method for PAR (Morgan, 2006) and
have been used in other exploratory occupational health studies
(Goldenhar et al., 1999; Keith et al.).The university-based investigator
secured funding for the project and collaborated with the union to
develop a plan for recruiting visiting mental health case managers for the
Sample and Recruitment
The union represented approximately 250 visiting mental health case
managers throughout 12 geographic regions of a northeastern state. In
2003, five focus groups, representing urban, rural, and suburban settings,
were conducted in 4 of the 12 regions.The union’s health and safety staff
publicized the project in their newsletter (circulation: 55,000).They
described the purpose of the focus groups, listed dates and locations, and
encouraged visiting case mental health case managers to register to
participate. One month prior to each scheduled focus group session, a
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memo was mailed to every visiting case manager listed in the union’s
database who lived in the targeted region.Additional efforts to reach out
to case managers were made through the union’s network of local union
leaders (council leaders and stewards). Focus group participants were not
compensated but were provided with food and reimbursed for travel
The focus groups were conducted either in a regional union office
(3 groups), in a hotel conference room (1 group), or at the worksite
(1 group, with the consent of management).All groups with the exception
of the worksite group were conducted in the evening after work.The
worksite group was conducted at midday. Each focus group was
conducted by a trained moderator (the PI) and a trained co-moderator.
Three of the five groups were also attended by a representative from the
unions health and safety department.The focus groups consisted of
between 4 and 12 persons currently working as visiting mental health case
managers for the state mental health system.The sessions lasted approxi-
mately 2 hours.A total of 42 visiting mental health workers participated
in the focus groups. Urban and suburban work settings were represented,
with half of the participants making visits in both urban and suburban
Focus Group Questions
The focus group questioning route was as follows: (1) Is a system in place
and working to ensure accounting of employees? (2) Are there established
safety and communication protocols? (3) Are accompanied visits available
upon need? (4) Is adequate training provided to deal with potentially
violent patients? (5) Are intensive case managers provided with a cell
phone or some other means to summon assistance? The sessions were
audiotaped and the tapes were transcribed by a professional medical tran-
scription service.
The transcriptions were analyzed and coded using Atlas.Ti, a qualitative
data analysis program.The PI and two of her co-authors coded tran-
scripts by searching for keywords reflecting any one of the ve safety
measures (visiting in pairs, cell phone, accountability system, etc.). Each
of the ve measures was analyzed and discussed in depth in order to
elucidate every aspect of the staff s perceptions. Additionally, themes
emerged that were not directly related to the safety measures but were,
in the opinion of the case managers, significant risk factors for violence.
These themes are discussed below.The study was approved by the univer-
sitys human subjects committee and written informed consent was
obtained from each participant.
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The availability and effectiveness of each of the five safety measures are
described. Contextual themes regarding the safety of HVCMs are also
Formal Safety Protocols
Most of the focus group participants were unable to describe formal
safety protocols. In the focus group for the HVCM unit that had expe-
rienced the tragic murder, however, the case managers were able to
consistently describe specific policies governing accompanied visits,
weapons in the home, household and family members under the
influence of alcohol or drugs, and use of police escorts:
If we were to send you our policy, you’d see that…calling in twice a day
identifying that you are safe, and knowing [that] if you dont call in
somebody is going to page you or call you to determine that you are safe
those things are in place and are working.
Case managers from other locations thought that formal safety
policies existed, especially for accompanied visits when a staff person felt
uneasy or when the client had a history of violence, but they were unable
to provide much detail about these policies:
My understanding is, if you’re not comfortable, dont [go]…take somebody
with you…you have a right to ask.
Some described policies governing accountability or check-in systems:
There’s a strict policy that actually the County developed as the result
of…it’s a policy… I’m not saying that we originated it, but if you’re out
in the community for more than 3 hours, you check in so that people know
that you’re safe.
Case managers generally agreed that safety protocols were in place but
believed that contextual issues at the societal and agency levels under-
mined their effectiveness.These contextual issues are described in the
following sections.
Accountability System
Each community case management program is required to have an
accountability system in place for visiting eld staff.A member of the
ofce staff is supposed to know the location and itinerary of case
managers at all times.The visiting case managers, for their part, are
supposed to communicate their itineraries in advance, provide current
contact information, and periodically check in to the office, especially if
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their itinerary changes. Staff itineraries change frequently throughout the
day due to emergencies and the changing needs of clients. Case managers
reported that some ofces did not have adequate staff to effectively
monitor field workers and their constantly changing itineraries. Further-
more, some ofces would call the eld worker if a check-in call had
been missed. Some visiting case managers disliked being interrupted by
a call from the office when they had failed to check in.Variations among
programs emerged:
I don’t know how well it’s adhered to… I know the main phone at [our
program], you call for hours there and won’t be able to get through…it’s
an automated system and it’ll just ring and ring and ring.
You’re supposed to call in…and schedules…things happen…the minute
you walk out the door youre getting calls from the police, the hospitals, this
client, that client, and, you know, youre always reassessing who youre
going to see, what the priority is…and you cant always convey back to
other people…
The comments of participants from units with efficient accountability
systems contrasted with those of participants who reported problems that
revealed inconsistencies in the structure, implementation, and effective-
ness of this abatement measure. Some units appeared to have an effective
accountability system, some to have no functional accountability system
at all, and others to have a system characterized by apathy and anger. For
some visiting case managers, the accountability system was a hot-button
issue, while for others it was an accepted part of their work life:
We have a system…where we all have to call in every day between 2:00
and 2:30…and the secretary, she takes the message or she takes your call
and she checks off who has called in… That’s one accountability system…
We also have a schedule that we read before we go out every day…in
terms of the client, the location, telephone number, what car we are
When case managers viewed the accountability system as ineffective
or as unnecessary for their own safety, they were less likely to adhere to
But the actual execution is problematic either for organizational reasons or,
in some cases, because the individual[s] themselves don’t view it as helping
with their safety.
Case managers had almost nothing positive to say about their training
experiences.When they were asked if safety training was required, they
gave conflicting responses:
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They cancelled it due to lack of interest.
We do have a mandatory training every year.
I know we don’t have it every year…that’s not mandated.
The larger issue appeared to be that it is difficult to engage experienced
case managers in meaningful training. Some case managers recalled a
training series at a local college with well-intended instructors and ample
opportunity for discussion:
It had a very good value…just the opportunity to ventilate and to brain-
storm among us.
According to the participants, this series of training sessions, which
covered more than just safety, was suspended.
The involvement of local law enforcement bodies in safety training
received mixed reviews:
There’s a local police officer that comes here and tells us to lock our car and
keep our purse in the trunk…that’s not cutting it.
We had brought in the police department, and that was effective…and
parole people who literally did what we did but in a different system.
Many case managers who had worked for the state mental health
system reported having received the same training as the inpatient mental
health staff.They found many of the same principles to be applicable,
though not the “takedown” and seclusion and restraint procedures, which
they could not and did not use in the community.
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Table 1 Frequently Cited Conditions Impacting on Safety of Staff
Ability to choose accompanied visiting
Quality of violence-prevention training
Effectiveness of accountability system
Assisted Outpatient Treatment Program requirement
(involuntary treatment)
Community environment
Safety and communication procedures
Role of representative payee
Ability to summon help
Erosion of resources for mental health care
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Some case managers reported viewing training videos that were
almost entirely without merit dated, redundant, and even offensive:
Yeah, but those are tapes…that’s inpatient.
It’s tapes from 1960 that they have you sit and watch.
Same training for the past 5 years.
Some HVCMs thought that they should be involved in the training
design, or at least in the needs assessment:
They develop this training without any kind of involvement from the case
managers themselves.
One HVCM felt that case managers could give the safety training them-
It’s the same training and, honest to God, it’s generic and we could teach
safety training.
A Means to Summon Assistance
Cell phones are now universally issued or available to case managers who
are state employees and union members.All participating case managers
reported having a cell phone for their professional use:“Everybody has
cell phones now. Staff in one program reported having to give up beepers
now that cell phones are available. Other staff reported that cell phone
service was inconsistent in rural areas. In NewYork State it is illegal to
make or receive a call on a cell phone while driving. In general, a means
to summon assistance from the eld appeared to be widely available to
case managers.Although one HVCM said,“Technology is probably not
going to save us, a communications device of some kind was considered
Cell phones allow HVCMs to report their whereabouts and alert the
office to any changes in their schedules. Most HVCMs agreed that cell
phones enhanced their therapeutic role by facilitating communication
with providers, social services, police, and others. Cell phones appear to
be a permanent addition to the safety armamentarium for case managers,
but this safety measure must be viewed in the context of overall risk and
hazard.A cell phone is a communications device, not an assault deterrent
or a substitute for the presence of another person in the event of an
Accompanied Visiting
The requirement that HVCMs visit high-risk clients in pairs is perhaps
the most challenging of the abatement measures.This safety measure
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forces case management programs to define a high-risk visit (usually, a
first visit or a visit to a client with a history of violent behaviour) and to
stretch already tight staff resources to accommodate pairing. Staff were
often conflicted about whether and when to request accompaniment.
HVCMs are aware of the risks but are also experienced mental health
providers who develop a therapeutic bond with their clients.They do not
want to jeopardize this therapeutic relationship by bringing in a stranger,
nor do they want to be injured by a client or to be the victim of violence
in a crime-ridden community. They are further conicted by the
knowledge that other HVCMs have a full caseload with no time to visit
someone else’s clients:
I’m quite sure the supervisor would have accompanied me… I know that,
but I also know that for her to come with me it’s an hour out, it’s an hour
there, and it’s an hour back, and then if she has a meeting and she can’t
come when I come, that’s a hassle, you know.
Some staff did not believe that accompanied visits were any safer:
Two is not safer.
I don’t always think going with someone else is necessarily any safer.
Two targets instead of one.
Most, however, felt that it had a “deterrent” and “assistive” effect “you
can pull the other individual [out].
The accompanied visit policy, though known and understood, is not
always easy to implement:
It’s kind of easier to go there even though you know maybe you shouldn’t,
so that piece of the safety policy is difficult, and…really, I wrestled with
this since [the murdered nurse] died, on how to cover that, and there is no
way to cover it other than [my colleague] and I, we try towe have
between us, you know, 27 people, 26, 27 people between us. If we did
double visits we’d need 80 hours a week to get all our work done and we
only have 40 hours a week to get it done, so you have to make a decision
at some point. But geographically its easier in the city and in the sur-
rounding suburbs to get a second person to go with you, much easier than
[for] somebody to drive 35 miles for a 20-minute visit.That’s a difficult
Accompaniment is more difcult to arrange for rural visits, yet
isolation from neighbours is common and in some areas cell phone
service is not available. One HVCM described the efforts of a new
colleague to visit a client in an isolated area.The client was considered
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high risk due to substance abuse problems. He lived without electricity,
telephone service, or running water:
He lives in a little hut that has no running water and no electricity…this
was where he was put…he was a known drug user, and the case manager
was instructed by the supervisor to go out and visit this client by herself
The first time she went to visit the client she took somebody with her.The
second time she arranged to take somebody with her and then the HVCM
coordinator pulled her aside and said,“You’ve got to learn to do this on
your own, leaving her to go out to…visit this client in the middle of
Staff who had experienced a threatening situation appeared to be
more confident when visiting in pairs:
After the knife incident, where I found the guy with the knife, I didn’t
make single visits any more.
Contextual Factors
Reduced resources for mental health care. Case managers described and
emphatically lamented the erosion of resources for intensive case
management programs.The original mission of the program was to
provide multiple supports, coordinated by the case manager, to enable the
high-risk mentally ill to thrive in the community. Staff were saddened
and demoralized by the inadequacy of the program. Case managers saw
the deterioration in services as contributing to the risk of violence
against staff. In their view, when the high-risk mentally ill have unmet
needs in the areas of housing, social support, employment, safety, medica-
tion, and treatment, they are more likely to become aggressive towards
case managers or others.The case managers across the state consistently
described feeling like a “last resort” or “safety net” for a society that does
not want to deal with the high-risk mentally ill while at the same time
wishing to be protected from the dangers they represent.
Involuntary treatment issues. Related to this theme was another
contextual nding specic to a state law providing for mandated
treatment of the mentally ill who present a security risk to the
community.The law was intended to reduce the risk to society when
high-risk mentally ill persons become dangerous because they refuse
treatment.The HCVMs reported that these “mandated” clients became
their responsibility, and most felt that they represented a higher risk for
violence because the mandatory nature of the provider-client relation-
ship is a barrier to the establishment of trust and to an optimal thera-
peutic relationship.The HCVMs felt that an optimal therapeutic rela-
tionship is protective (i.e., reduces the risk of violence towards the case
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manager) but that “mandated” relationships are less likely to achieve the
level of trust necessary for the therapeutic relationship to thrive. A
minority of the HVCMs, however, approved of one feature of the new
law: the ability to call in the sheriff when a client fails to comply with
treatment.They felt that, in general, it is better to force non-compliant
patients to take their medications than to watch them decompensate and
become violent.
Conflict of interest. In addition to the risks of dealing with mandated
clients, HCVMs reported that, in the absence of a suitable relative, the
case manager is often appointed representative payee for a client
(managing the clients nances). Many case managers said that this
responsibility creates the potential for tension and conflict over money
and increases the risk of violence towards the provider. Sometimes the
risk of violence comes from individuals in the community who prey on
the mentally ill and attempt to siphon their resources.This recurring
theme bears further exploration by the mental health system.The case
managers were practically unanimous in their view that representative
payee and therapeutic case manager are conflicting roles that increase the
risk of violence towards home visiting staff.
Home visiting human service workers and their employers use a variety
of safety strategies, none of which are supported specifically by clear
evidence.We evaluated staff perceptions of the effectiveness of required
safety measures in one state case management program.The results add
to our understanding of the factors associated with the effectiveness of
occupational safety measures for home visiting mental health programs.
The study found that the five required safety measures are generally
in place across the state but are inconsistently implemented. Notably, the
participants from the unit where the murdered nurse had been employed
did report strict compliance with all safety measures.This finding indi-
cates the feasibility of the measures.The reason for variable implemen-
tation of the safety protocols in other agencies is not clear; it could be a
training deficit, a communications breakdown, or inadequate manage-
ment commitment to safety issues.
HVCMs across the state were satised that they had a means to
summon assistance. Most participants reported having a cell phone and
many said they had a beeper provided by the employer. Some rural areas
do not have cell phone service. A review of possible technological
solutions in such areas is beyond the scope of this article; however, in the
absence of standard cell phone service, other technologies such as radios
or satellite phones may be available.
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Most staff reported some type of telephone check-in system and most
said it was their practice to leave a written itinerary in their field office.
Many HVCMs, however, were dissatisfied with the accountability proce-
dures in place in their home office/unit.These procedures were often
described as ineffective and many staff members were suspicious of the
accountability system.The reasons for the variability in accountability
systems throughout the system are not clear.
Most participants indicated that they felt they could request that a
colleague or supervisor accompany them on home visits, although some
case managers seemed to believe that doing so frequently was discour-
aged. In one unit it was the policy for a supervisor to accompany the
case manager on all new client visits and for 1 month thereafter, as well
as any time the case manager believed there was a risk. It appears that the
other jurisdictions allow HVCMs to visit in pairs when there is a specific
high-risk situation but do not provide the resources for frequent accom-
panied visits, nor, apparently, do they have an explicit denition for
“high-risk visit.
One focus group included staff of a pilot project, Assertive Com-
munity Treatment (ACT), which reportedly requires home visiting in pairs
or teams. According to the staff, the ACT model is newer than the
intensive case management model and is being piloted in one county
mental health department but is not widely used throughout the state.
The mandatory nature of the visiting-in-teams requirement is significant
because it eliminates possible tension between supervisor and case
manager over staff resources. It also eliminates the need for the case
manager or the supervisor to weigh staff resources against safety.This
nding suggests that visiting in pairs is feasible, but details about the
program and its resources are not available. Since only one of the focus
groups included ACT staff members, this finding did not reach saturation.
Models of care that provide community or home visitation by pairs or
teams of providers should be explored from the standpoint of patient and
staff safety outcomes.
Finally, violence-prevention training is an essential element of a
comprehensive violence-prevention program (US Department of Labor
& Occupational Safety and Health Administration, 1996). However,
training must be considered in the context of extra-training factors
(Cohen & Colligan, 1998), which include organizational attributes (such
as adequate staffing) and quality parameters (such as trainer competency
and a comfortable setting). It is useless to train staff for circumstances that
require visiting in pairs without providing sufficient staff for visiting in
pairs. Similarly, if staff are trained to check in at a set time during the day,
this behaviour must be monitored or the training will not be optimally
effective.A training method that insults the learner’s intelligence not only
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will be ineffective but will lower morale and foster resentment.
Furthermore, training should be geared to the experience and skill level
of the group.The training needs and requirements of seasoned mental
health professionals are different from those of newly assigned HVCM
staff.The murdered nurse was a veteran employee, which suggests that
training for more experienced staff may need to address different issues,
such as complacency or boundaries, and review data and risk factors.
Furthermore, seasoned providers will simply dismiss irrelevant or mean-
ingless training.
Strengths and Limitations
This project was a collaborative effort between the participants
(HVCMs), their union, and the research team.The PAR framework is
the most acceptable and appropriate means of studying an issue associ-
ated with severe trauma.The focus groups were well attended even
though most were conducted after working hours and none of the
participants was compensated beyond expenses. Contextual themes
reached saturation and were raised repeatedly in each group. Other
concerns were locally based or agency-based and reected the broad
theme of inconsistent application of safety measures. Furthermore, the
project offered a unique opportunity to evaluate staff perception of
mandated safety measures (which, to our knowledge, do not exist
The limitations of the project include the fact that it was carried out
in only one state, thus possibly affecting the applicability of the findings
to other states or other types of home visiting program.Also, information
on the demographics, work experience, and assault/injury experience of
the participants was not collected. Furthermore, the participants were
self-selected, thereby increasing the likelihood of bias. Finally, the partic-
ipants were all unionized HVCMs, restricting the applicability of the
findings to non-union workplaces.The study might have been strength-
ened by the addition of a state-wide survey assessing the impact of the
safety measures on the incidence of injury and violent assault since the
introduction of the new measures.
Implications for Practice, Policy, and Research
The implications of the findings include the need to direct attention to
the feasibility, effectiveness, and sustainability of ve specic safety
measures for visiting health and human service workers.To our knowl-
edge, even in the few North American jurisdictions that have safety regu-
lations regarding workplace violence and/or visiting human service and
health-care workers, no evaluation of these measures has taken place.The
findings of this study have direct implications for home visiting nurses and
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other human service practitioners. First, safety of the community/home
visiting workforce must be recognized as an essential element of opera-
tions. Workforce safety must be integrated into all aspects of patient care.
Systems need to be developed to evaluate new clients for a history of
violent behaviour and communicate this information to staff. Detailed
protocols for specific high-risk situations must be developed and regularly
reviewed with staff. Resources must be allocated to allow for visiting in
pairs in high-risk situations. Finally, staff training must be evaluated for
appropriateness and effectiveness.
The research implications of the findings include the need for explo-
ration of the various types of home visiting programs, clients, services,
and safety strategies, as well as the need for analytic research with respect
to risk factors specific to home visiting. Given the paucity of evaluation
data, a qualitative approach was considered the most appropriate for this
study; however, surveys of current safety practices would also be helpful.
Moreover, given the substantial risk even to experienced providers, more
research attention should be focused on differentiating the training needs
of novice and experienced home visiting staff. Ultimately, intervention
effectiveness research must be undertaken to determine the effectiveness
and sustainability of safety programs for home visiting health and human
service workers.
The focus groups employed in this study have given voice to a
workforce that is one of the chief supports for the mentally ill and other
vulnerable individuals living in communities rather than institutions.This
examination of mandated safety measures has implications for nurses,
who, along with members of other professional groups, may be at risk for
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Authors’ Note
This study was supported by funding from the Johns Hopkins
Bloomberg School of Public Health, NIOSH Educational Resource
Center Small Grant Program.
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Comments or queries may be directed to Kathleen M. McPhaul,
School of Nursing, University of Maryland, 655W. Lombard Street, Suite
655, Baltimore, Maryland 21201 USA. E-mail: mcphaul@son.
Kathleen M. McPhaul, PhD, MPH, is Assistant Professor, School of Nursing,
University of Maryland, Baltimore, United States. Jonathan Rosen, MS, CIH,
is Director of Safety, New York State Public Employees Federation, Albany,
United States. Shawn Bobb, MS, CIH, is Health and Safety Specialist, New
York State Public Employees Federation, NewYork City. Cassandra Okechukwu,
MS, MPH, is a doctoral student at the Harvard School of Public Health, Boston,
Massachusetts, United States. Jeanne Geiger-Brown, RN, PhD, is Assistant
Professor, School of Nursing, University of Maryland. Karen Kauffman, PhD,
RN, is Associate Professor, School of Nursing, University of Maryland. Jeffrey V.
Johnson, PhD, is Professor, School of Nursing, University of Maryland. Jane
Lipscomb, RN, PhD, is Professor, School of Nursing, University of Maryland.
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... However, an explanation of this result was insufficient due to the general limitations of survey research. In addition, previous focus group interviews with visiting nurses were outdated (e.g., pagers vs. smartphone) [25]. Thus, it is necessary to confirm to what extent the current organizational system contributes to the problem. ...
Full-text available
Visiting nurses are commonly exposed to workplace violence, but there is a lack of research on violence against these nurses. The purpose of this study was to identify visiting nurses’ workplace violence experiences during home visits. This study used a mixed method design. Survey data of 357 home visiting nurses from public health centers were collected for the quantitative data, and a focus group interview was conducted with six visiting nurses for the qualitative data. The quantitative data were analyzed using logistic regression, and the qualitative data were analyzed using content analysis. Younger, temporary visiting nurses and those who had previously been exposed to violent clients had a higher risk of workplace violence. The violence visiting nurses faced included not only violence during the visits but also unpredicted danger and harassment after the visit. After experiencing a violent event, visiting nurses’ attitudes and emotions changed toward nursing services. Visiting nurses were likely to deal with violence at the individual level given the insufficient organizational support system. An organizational-level safety management system should be established based on the characteristics of workplace violence risks and the nurses’ experiences in this study.
... 5,[25][26][33][34][35][36][37] Third, the literature review suggests conducting accurate and thorough risk assessment aid providers and agencies to develop programs more adequately preparing staff providing the in-home services. 9,17,19,[38][39][40][41] Each element will be examined independently in the following sections of this review. ...
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The problematic occurrence of client violence and patient aggression toward health care workers is pervasive, with studies and reports finding that home health care workers experience one of the highest rates of client violence than any other career field. With the recent passage of the Patient Protection and Affordable Care Act in 2010, traditional health care delivery in institutional care settings is increasingly shifted to service delivery venues in noninstitutional care settings. During this transition, greater numbers of health care workers are providing services in patients' private homes, increasing the potential risk to staff safety and well-being in these settings.
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In the United States, home health care (HHC) is a rapidly growing industry and home infusion therapy is a rapidly growing market. HHC can present substantial occupational safety and health (OSH) risks. This article summarizes major OSH risks relevant to home infusion therapy by illustrating them through real-life scenarios collected systematically using qualitative research methods by the National Institute for Occupational Safety and Health-funded research projects at the University of Massachusetts Lowell. The need for home infusion therapy will continue to grow in the future, and safety interventions to prevent or minimize OSH risks are essential.
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Background: The mental health knowledge gap challenges public health. The Alcohol Abuse Management in Primary Care (AAMPC) is an e-learning course designed to cover alcohol-related problems from the primary care perspective. The goal of this study was to verify if the AAMPC was able to enhance healthcare professionals' alcohol-related problems knowledge. Materials and methods: One hundred subscriptions for the AAMPC were offered through the federal telehealth program. The course was instructor-led and had nine weekly classes, delivered synchronously or asynchronously, at the students' convenience, using a varied array of learning tools. At the beginning, students took a test that provided a positive score, related to critical knowledge for clinical management, and a negative score, related to misconceptions about alcohol-related problems. The test was repeated 2 months after course completion. Results: Thirty-three students completed the course. The positive score improved significantly (p<0.001), but not the negative score. Students with previous experience with e-courses presented greater improvement on the positive score (p<0.036). Eighty-percent of the students thought the course excelled in meeting its objectives. Web conferences and video and audio recordings were the most appreciated learning tools. Course satisfaction was negatively related to frequency of Internet access (Spearman's rho=-0.455, p=0.022). Conclusions: E-learning was highly appreciated as a learning tool, especially by students with the least frequency of Internet use. Nonetheless, it worked better for those previously familiar with e-courses. The AAMPC e-course provided effective knowledge transmission and retention. Complementary strategies to reduce misconceptions about alcohol-related problems must be developed for the training of primary care staff.
The objective of this study was to develop and test measures for assessing risk of violence toward staff during home visits. Home visiting health workers from public and private home visiting programs in a Mid-Atlantic state (n = 130) were surveyed to assess exposure to risky home visits, verbal and physical violence, and workplace violence safety climate. Two measures demonstrated evidence of reliability and validity moving the safety research closer to developing tools and processes for protecting home care clinicians.
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This article describes the development of the Violence and Aggression in Health Care Questionnaire (VAQ) and the application of the measure in the field of home care. In a 1st sample of 361 German home care workers, the scales of the VAQ reached internal consistencies from .72 to .93. A confirmatory factor analysis gave evidence to the hypothesized factor structure. Significant correlation with indicators of psychophysical strain and health resulted in a 2nd sample of 180 home care workers. In multiple regression analysis based on a 3rd sample of 180 home care workers, verbal aggression by patients was a significant predictor of negative psychological outcomes. The relationship is completely mediated by negative emotional reactions after aggressive incidents.
Full-text available
Over the past decade, focus groups and group interviews have reemerged as a popular technique for gathering qualitative data, both among sociologists and across a wide range of academic and applied research areas. Focus groups are currently used as both a self-contained method and in combination with surveys and other research methods, most notably individual, in-depth interviews. Comparisons between focus groups and both surveys and individual interviews help to show the specific advantages and disadvantages of group interviews, concentrating on the role of the group in producing interaction and the role of the moderator in guiding this interaction. The advantages of focus groups can be maximized through careful attention to research design issues at both the project and the group level. Important future directions include: the development of standards for reporting focus group research, more methodological research on focus groups, more attention to data analysis issues, and more engagement with the con...
Context.— Public health workers may work with clients whose behaviors are risks for both infectious disease and violence.Objective.— To assess frequency of violent threats and incidents experienced by public health workers and risk factors associated with incidents.Design.— Anonymous, self-administered questionnaires.Setting.— Texas sexually transmitted disease (STD), human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS), and tuberculosis (TB) programs.Participants.— Questionnaires were completed by 364 (95.5%) of 381 public health workers assigned to the programs. The STD program employed 131 workers (36%), the HIV/AIDS program, 121 workers (33%), and the TB program, 112 workers (31%).Main Outcome Measures.— The frequencies with which workers had ever experienced (while on the job) verbal threats, weapon threats, physical attacks, and rape, and risk factors associated with those outcomes.Results.— A total of 139 (38%) of 364 workers reported 611 violent incidents. Verbal threats were reported by 136 workers (37%), weapon threats by 45 (12%), physical attacks by 14 (4%), and rape by 3 (1%). Five workers (1%) carried guns and/or knives while working. In multiple logistic regression, receipt of verbal threats was associated with worker's male sex (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.5-4.0), white ethnicity (OR, 2.4; 95% CI, 1.4-4.1), experience of 5 years or longer (OR, 2.2; 95% CI, 1.3-3.8), weekend work (OR, 1.8; 95% CI, 1.1-3.1), and sexual remarks made to the worker by clients (OR, 2.0; 95% CI, 1.2-3.5). Receipt of weapon threats was associated with worker's male sex (OR, 5.7; 95% CI, 2.4-15.3), white ethnicity (OR, 4.0; 95% CI, 1.8-9.3), age of 40 years or older (OR, 2.5; 95% CI, 1.1-5.8), work experience of 5 years or longer (OR, 2.7; 95% CI, 1.2-6.0), rural work (OR, 3.6; 95% CI, 1.3-10.1), being alone with the opposite sex (OR, 3.7; 95% CI, 1.6-9.7), and interaction with homeless clients (OR, 5.2; 95% CI, 1.7-18.8). Physical attacks were associated with sexual remarks made to the worker by clients (OR, 4.2; 95% CI, 1.4-13.9). No risk factors predicting rape were identified.Conclusions.— Violence directed toward public field-workers is a common occupational hazard. An assessment of what situations, clients, and locations pose the risk of violence to public health workers is needed. SOME CLIENTS seeking traditional public health services for sexually transmitted diseases (STDs), human immunodeficiency virus (HIV) infection, the acquired immunodeficiency syndrome (AIDS), and tuberculosis (TB) may engage in behaviors that are associated both with a risk of acquiring those diseases and with violence. For example, crack cocaine use and other illicit drug use are recognized risk factors for HIV infection, syphilis, and TB.1- 5 Crack cocaine use is also linked to violence. The drug's pharmacological effects include paranoid thinking and aggressive behavior.6- 7 Fatal injury after cocaine use, as measured by detection of cocaine metabolites in blood and urine, would rank as 1 of the 5 leading causes of death in New York City residents aged 15 to 44 years.8 Violence does spill into emergency departments and psychiatric care settings9- 15 and has been well documented as an occupational hazard for health care workers and social workers.16- 18 However, risks for on-the-job violence have not been studied among public health field-workers who routinely work outside clinics and in communities with patients and other persons who have been exposed to STDs, HIV/AIDS, and TB. The public health field-workers are not physicians or nurses, but their fieldwork is vital for patient follow-up and to stop disease transmission. Workers in STD, HIV/AIDS and TB programs notify patients of their exposure to disease, arrange disease-specific testing, schedule appointments, conduct interviews with patients and exposed persons, administer tuberculin skin tests, draw blood for HIV and STD testing, transport patients to the clinic, administer directly observed therapy for TB, and monitor outcomes for TB and STD therapy. Typically these workers have college degrees or some college and undergo training to work with patients with STDs, HIV/AIDS, and TB using training materials and classes developed by the Centers for Disease Control and Prevention. In 1994, an HIV outreach worker in Austin, Tex, was physically attacked during the late afternoon by a client who had received condoms from her. Two of us (J.M.S., R.L.W.) had prior experience with verbal threats and weapon threats (display of a gun) made by STD and TB patients to ourselves and to other public health workers conducting fieldwork or epidemiologic studies in other states. During follow-up of the Austin incident, 3 managers in Texas STD and HIV programs indicated 1 or more of their public health workers had experienced verbal threats or been kicked or hit while doing fieldwork. Because the exact number and frequency of such incidents were unknown, we decided to evaluate the frequency of the presence of violent incidents and risk factors associated with verbal threats, weapon threats, physical attacks, and rapes among public health workers in STD, HIV/AIDS, and TB programs.
Background Occupational scientists agree there are hazards associated with dry-cleaning, but do dry-cleaning owners and workers concur? Knowledge of owners' and workers' perceptions can help guide intervention efforts to reduce worker exposure. To better understand these issues, a qualitative study was conducted using focus group methodology and constant comparative analysis.Methods Two owner and four worker focus groups were held.ResultsFindings suggest that overall, health and safety issues were not of great concern. Owners were primarily concerned with the economic impact of regulations. Workers did express some anxiety about solvent exposure and burns, but most felt that these hazards were “just part of the job.” Also, other than the installation of air-conditioning in the shops and the provision of health benefits, workers could not think of ways health and safety on the job could be improved.Conclusions These findings will be used to develop comprehensive safety and health interventions (e.g., engineering plus education and training) in dry-cleaning shops. Am. J. Ind. Med. 35:112–123, 1999. Published 1999 Wiley-Liss, Inc.
Part of the community mental health nurse's (CMHN) role is the assessment of violence posed by clients. It explores factors such as the reduction of inpatient beds and the predictability of violent acts towards nursing staff. This study outlines how the risk of violence is assessed by generic CMHNs, by examining their awareness, understanding and perceptions of violence posed by their clients. The data were collected in one Trust, using questionnaire and focus groups. The findings emphasize the importance of historical evidence but also raise the issue of gut feelings of the nurse. They further identify that clinical judgement can be accurate in assessing for violence, and CMHNs relied upon experience and personal impressions of the presenting evidence, rather than through the use of a standardized instrument.
To examine the nature and magnitude of violence against women in the workplace. Data from the National Traumatic Occupational Fatalities surveillance system were analyzed for the 13-year period, 1980 to 1992. Employment information was coded from industry and occupation narratives taken from the death certificates. Rates were calculated using annual average employment data published by the Bureau of Labor Statistics. From 1980 to 1992, 2,001 women and 7,935 men were victims of work-related homicides, for rates of 0.32 and 1.01 per 100,000 female and male workers, respectively. The majority of female homicide victims were employed in two industries-retail trade (46%) and services (22%). The highest risk industry was grocery stores (1.74 per 100,000 workers), followed by eating and drinking establishments, hotels and motels, and justice and public order. The findings presented here are consistent with previous research indicating that homicide is the leading cause of occupational injury death for women, but that women are at lower risk than their male counterparts. Homicide played a major role in sales and service, sectors that have increased over the last several decades and in which future growth is predicted. Feasible and effective prevention strategies to reduce the risk of work-related homicides must be developed and implemented.
The American workplace is now in the midst of the most significant change since the advent of mass production. Whether these changes will lead to improvements in worker health and safety is not clear. This paper describes an approach to intervention and research-participatory action research (PAR)-that has the potential to redesign work organizations to improve performance while also improving health and safety. In the PAR method, researchers, managers, workers, and unions collaborate in a process of data-guided problem solving intended both to improve the system's performance and to contribute to general scientific knowledge. A case study example illustrates the use of a PAR approach in an automobile parts facility where labor, management, and researchers jointly conducted a longitudinal project aimed at reducing the major sources of stress and enhancing employee well-being. Results from the 6 year project suggest that, properly implemented, PAR has the potential to both lead to improved intervention and contribute to theoretical advances in occupational safety and health. The PAR approach to intervention research is contrasted with the total quality approach (TQA), and some suggestions are made for improving PAR research designs.
Information from the Bureau of Labor Statistics analyzed here reveals interesting findings related to injuries resulting from workplace violence. The data show which workers commonly sustain injuries as a result of violent acts, where the violence occurs, and how it happens. The circumstances differ markedly between workplace homicides and nonfatal assaults.
Homicide is to blame for 20 workplace deaths each week. Although no single intervention strategy will be appropriate in all situations, the author points out that interventions cannot be designed without knowledge of the demographic characteristics of victims and the distribution of workplace violence across industries and occupations. Such data are presented by gender, age, race, geographic distribution, method of homicide, and industry and occupation.
Factors influencing the remarkable growth of home health care include increased elderly population, decreased average length of hospital stay, and technological advancements that reduce the need for hospitalization. Societal changes have prompted increasing concern about personal risk to home care providers. The purpose of this pilot study was to: 1) ascertain factors related to perception of risk by home health care administrators and staff and to identify strategies used by home health care administrators to reduce risk to staff; and 2) determine whether quality of care is affected when home-visit situations present risk. A convenience sample of 36 home health care administrators and 62 staff was surveyed about risks and measures provided by the home health care agency to minimize risk. Factors associated with risk are geographic location, high incidence of crime, inappropriate patient or caregiver behavior, infectious diseases, and evening assignments. Strategies used to minimize risk include safety programs, preplanning of visits, personal protective equipment, escorts, and buddy systems. Perceived ability to refuse high-risk assignments, however, is questionable, as 66% of the staff stated that they leave a situation "as soon as possible." These findings will be used to strengthen inservice programs and to provide a basis for future studies.