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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