Assessing Workplace Violence Against Lone Workers In The HealthCare Sector

By Dr. Joshua Sinai

On December 4, 2024, Luigi Nicholas Mangione, 26, of Towson, Maryland, allegedly intentionally killed UnitedHealthcare executive Brian Thompson, in Midtown Manhattan. The killing sparked a wave of complaints in social media about the U.S. healthcare system, whether justified or not. It highlighted this sector’s vulnerability to being targeted by some patients/customers who feel aggrieved about the service and reimbursement they receive or are psychologically troubled to begin with and express their disorders by lashing out against their healthcare providers.

This article focuses on the vulnerability of a specific component of the healthcare sector, those who work remotely from their companies’ main facilities as they provide medical-related services to patients at their homes or other facilities.
 
The risk of workplace violence against a company’s or organization’s lone workers who perform their healthcare jobs outside their primary workplace facility, particularly in a client’s home, is categorized as Workplace Violence, Type II: Patient/Customer-on-Worker. In this type of workplace violence, an employee is attacked by a hostile patient at their home or by violent assailants while enroute to or upon return from such a remote site. The other four types of workplace violence are: Type I: Criminal (in which there is no direct relation between the attacker, such as a robber, and the employee), Type III: Worker-on-Worker (or ex-Worker-on-Worker (where the attackers are known to at least some of the targets), Type IV: Personal Relationship (in which a self-aggrieved person attacks a former romantic partner at their place of employment), and Type V: Political (in which the violent assailant targets employees at an organization for extremist ideological objectives).

With the pervasiveness of the lone workforce (also termed field workers or mobile workers) in the healthcare sector, many of these mobile workers work alone continuously with one patient or at various times treating several patients at their homes. This type of employment has been accompanied by threat challenges to their safety and security. These threats are presented by difficult customers and patients who might be upset with the levels of service they receive from their care-givers or who experience a psychological disorder that propels them to strike against anyone in their midst.

In response, government and industry security regulations and standards mandate that healthcare companies must ensure they comply with duty of care responsibilities. This requires implementing all necessary measures to ensure the safety and security required for their mobile lone employees who are subject to potential security-related issues as part of their employment outside their companies’ facilities.

Developing overall workforce security policies, communicating with lone workers while they are in the field, and deploying security technologies to track worker locations and movements are some of the measures required to ensure lone workers do not find themselves alone when threats to their safety occur. Such security measures will empower lone workers to know they are directly connected to their employers who are heavily invested and prepared to ensure their security and safety. This will provide the employees a sense of well-being while performing their regular work duties, thereby increasing their work productivity and retention.

Lone Workers

Lone workers are employees who work on behalf of their organizations at locations outside of their organizations’ facilities, who work alone or with little assistance from others due to the type, time, or location of their work, while providing services to their organizations’ clients or patients at their homes. Such locations can include remote locations or other work areas where employees are not in close proximity to their fellow employees. Lone workers are, thus, usually physically alone with their clients or patients. They are also usually part of a team whose members also likely are lone workers, led by a manager, so there is some degree of direct or indirect supervision over their work. Because of the nature of their work, particularly in the healthcare sector, they may also work at such remote locations in the early mornings or late at night.  

Workplace Violence

Workplace violence in the healthcare sector is defined as any act or threat of harassment, intimidation, physical violence or other types of disruptive and abusive behavior by a client or patient in a workplace-related environment that threatens an employee. For home care health workers, in particular, these workplaces are generally patients’ homes, including in sometimes unfamiliar or unsafe neighborhoods.

As discussed earlier, there are five types of potential workplace violence that might threaten lone workers. For the purposes of this article, the primary focus is on Type II: client/patient on employee, although the other types of violence may be relevant, as well, for instance, a mobile worker might be robbed (Type I), attacked by a fellow employee (Type III), an aggrieved romantic partner might attack a lone worker while they are in a remote worksite (Type IV), or a lone worker might be perceived by a political adversary as a soft target for a symbolic attack (Type V).

Within these five types of workplace violence, three levels of threat might target mobile workers: level 1: verbal abuse, level 2: threat of physical violence (such as raising a fist in anger), and level 3: physical violence. It is possible that what starts as verbal abuse will quickly escalate into physical violence, so these three levels are viewed as a dynamic continuum.

Although authoritative statistical breakdowns are unavailable, it can be assumed that level 1: verbal abuse is the most pervasive type of workplace violence likely to threaten an employee. Although it may not be accompanied by physical violence, it is still likely to cause trauma to the targeted worker because of the possibility it could escalate into physical violence. Physical violence might be a rare event, but its consequences are tremendously severe and damaging to the employee, with significant post-incident financial, insurance, and legal liability damages against the affected employing company, as well.

Another form of workplace violence experienced by lone workers is sexual harassment, and so all types and levels of such violence should be incorporated into an organization’s emergency prevention program.

Size Of Lone Workers In The U.S.

In 2021, it was estimated there were approximately 25 million lone workers in the United States, which represented around 15 percent of the overall workforce. Lone workers in the healthcare sector constitute a significant proportion of this workforce, although updated precise figures are not available. In some of the available figures, in 2010 3.4 million Medicare and Medicaid beneficiaries were provided with home healthcare service of some type. A 2013 National Workforce Survey of Registered Nurses that found six percent of nurses in the United States worked in home care. With the demand for home healthcare services rising as the population in America grows older and more healthcare-related services are delivered outside acute-care hospital or social services settings, the trend in the usage of lone workers is expected to rise, especially with some patients complaining they are not receiving the full health care coverage they expect.

Case Studies

Two cases illustrate the types of workplace violent types of threats facing lone worker healthcare employees.


Integra

On December 10, 2012, Stephanie Ross, a social service worker was stabbed to death during a home visit to an agency client in Dade City, Florida. When Integra Health Management, Inc. hired her as a service coordinator, she was a recent college graduate with no prior experience in social work or working with the mentally ill. After a three-month period of providing her training on in-home and community safety, as well as how to identify potentially dangerous clients, Integra assigned her to complete a mandatory home assessment with a client who suffered from schizophrenia. Later, OSHA stated that Integra was aware of the workplace violence hazards Ross and other social workers faced, including that Ross’s client had a history of violence and criminal behavior, along with schizophrenia and paranoia, but it failed to take action to protect them.

During their investigation, OSHA inspectors found other instances where Integra workers suffered verbal and physical assaults from clients, yet the company failed to conduct a hazard assessment for service coordinators or implement a workplace violence prevention plan.
The client also had a prior criminal record that included multiple convictions for aggravated assault with a deadly weapon, of which Integra was unaware because they did not perform background checks on their clients. Following several home visits, the employee submitted multiple reports to her supervisors in which she described disturbing behavior from the client and stated that she was uncomfortable being alone with him inside his house without another service coordinator to accompany her. Despite these concerns, she was assigned to return alone to conduct another home visit with the client, during which the client fatally stabbed her.

Integra was subsequently cited with multiple safety violations for violating the general duty clause of the OSHA’s regulations by exposing its worker to “the hazard of being physically assaulted by members [clients] with a history of violent behavior.” In 2015, two citations against Integra were upheld by an OSHA administrative law judge. Integra appealed the ruling. On March 4, 2019, the Occupational Safety and Health Review Commission (OSHRC) upheld the original citations, which included $10,500 in proposed penalties and a requirement that Integra implement a workplace violence prevention program.

Conclusion

Healthcare workers, whether at their facilities or as lone workers in remote locations with patients, are at a higher risk of violence than employees in other employment sectors. With a comprehensive WVPP the risk challenging lone workers can be mitigated with this article’s recommendation of ten best practices in securing their safety.

About the Author

Dr. Joshua Sinai is Professor of Practice, Intelligence and Global Security Studies, at Capitol Technology University, Laurel, MD. He is the author of the best-selling “Active Shooter – A Handbook on Prevention” (ASIS International, June 2016)

 

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