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Original Contribution |

Violence and Threats of Violence Experienced by Public Health Field-Workers FREE

Joann M. Schulte, DO; Beverly J. Nolt; Robert L. Williams; Cynthia L. Spinks; James J. Hellsten, PhD
[+] Author Affiliations

From the Bureau of HIV/STD Prevention, Texas Department of Health, Austin.


JAMA. 1998;280(5):439-442. doi:10.1001/jama.280.5.439.
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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.15

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 settings915 and has been well documented as an occupational hazard for health care workers and social workers.1618 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.

The questionnaire was jointly developed by the STD and HIV/AIDS programs and reviewed by STD or TB program managers in Dallas, Houston, and Austin. Pilot testing of the questionnaire was done with 10 Florida public health workers who had worked with one of us (J.M.S.) on prior outbreak investigations. Program managers in 48 regional and local health departments in Texas identified a total number of 381 public health field-workers employed in HIV/AIDS, STD, and TB programs; they did not provide workers' names.

During a 6-week period beginning in late 1994, we did 1 mailing of 381 questionnaires for return by February 28, 1995. Each questionnaire included a cover sheet outlining reasons for the study, describing the Austin attack, and asking each worker to complete the anonymous, self-administered questionnaire. Participation was not mandatory, and no attempt was made to recontact nonresponders. The questionnaire was part of an evaluation of ongoing program operations in STD, HIV/AIDS, and TB programs and was exempt from review by the health department's institutional review board.

We asked about workers' demographics, the types of clients with whom they worked, work hours and environment, job duties, 4 different types of violent incidents ever experienced during their fieldwork, and safety precautions routinely taken at the time of the survey. We asked public health workers to provide yes/no responses as to whether they planned their route ahead of time, did fieldwork early in the day, sent 2-person teams to the field, carried a protective weapon (gun and/or knife), used a beeper and/or cellular phone, and did not complete paperwork in the field. With the exception of carrying a weapon, all those safety precautions are common in public health programs.

We defined 4 violent outcomes: verbal threat, weapon threat, physical attack, and rape. We asked if the worker had ever experienced those events while doing public health fieldwork and when the last occurrence was. A verbal threat was defined as a client's vocalization of intent to harm or injure the worker. A weapon threat was one made to the worker while a client displayed a weapon; we asked what weapon was shown. We defined a physical attack as a punch, kick, hit, or slap to the worker's body. We specifically asked if workers were raped or sexually assaulted while doing fieldwork. Descriptive statistics were used to characterize the workers' demographics and potential risk factors associated with violent outcomes. Univariate analyses were done to measure the association between the individual risk factors and each of the 4 outcomes. Stepwise multiple logistic regression using maximum likelihood estimates was used to create 4 multivariate models using each of the outcome variables. Epi Info version 6 was used for data entry, descriptive statistics, and univariate analyses19; SAS version 6.11 was used for multiple logistic regression.20 In the logistic regression models, 22 risk factors were eligible to enter into each model using a P value of .10 as the significance level for entry. Results of univariate analyses and logistic regression are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Preliminary analyses showed that black and Hispanic ethnicity did not have significant associations with any of the 4 violent outcomes, and race/ethnicity was used as a dichotomous white/nonwhite variable in the models. Safety precautions taken by workers were not associated with any of the 4 violent outcomes and were excluded from the final models presented in this article.

Overall, more than half the workers were men with a mean age of 38.7 years, and approximately equal proportions of the workers were white, black, and Hispanic. The workers had a mean of 4.8 years of experience, and most worked in urban locations (Table 1). The public health workers worked in 43 Texas counties, and 165 (45%) were assigned to the state's 3 most populous counties (Harris, Dallas, and Bexar) where Houston, Dallas, and San Antonio are located.

Table Graphic Jump LocationTable 1.—Characteristics of Public Health Workers*

Respondents to the questionnaire totaled 364 workers (95.5%); 139 (38%) reported 611 violent incidents, an average of 4.4 incidents per worker exposed to violence. Verbal threats were reported by 136 workers (37%); weapon threats by 45 workers (12%), physical attacks by 14 workers (4%), and rapes by 3 workers (1%). The 45 workers experiencing weapon threats reported the weapon last used was a gun (28 threats [62%]) or knife (14 threats [31%]); unspecified weapons were used 3 times (7%). The median number of verbal threats was 1 (range, 1-30); weapon threats, 1 (range, 1-10); and physical attacks, 1 (range, 1-3). No worker reported more than 1 rape. The year that workers last reported the most recent occurrence of violent incidents is shown in Table 2.

Table Graphic Jump LocationTable 2.—Reported Year of Most Recent Violent Incident Experienced by Workers*

These 611 incidents included 489 verbal threats, 94 weapon threats, 25 physical assaults, and 3 rapes. Of the 139 workers experiencing violent events, 90 (65%) reported only 1 type of violent incident, 39 (28%) reported 2 different violent incidents, and 10 (7%) reported 3 different violent incidents. No worker reported all 4 types of violent incidents. The types of violent incidents that workers reported are in Table 3.

Table Graphic Jump LocationTable 3.—Types and Combinations of Violent Incidents Reported by Public Health Field-Workers

Reported regular safety precautions included mapping a route ahead of time (277/364 [76%]), not doing paperwork in the field (108/364 [30%]), always working as a 2-person team (67/364 [18%]), carrying a weapon (gun and/or knife) (5/364 [1%]), carrying a beeper (137/364 [38%]), carrying a cellular phone (68/364 [19%]), and doing fieldwork early in the day (197/364 [54%]). No safety precautions were associated with any violent outcome. Of the 5 workers who carried a weapon for protection, 3 reported only verbal threats; 1 reported both a verbal threat and a weapon threat; and 1 reported a combination of a verbal threat, a weapon threat, and rape.

In univariate analysis (Table 4), verbal threats were associated with worker's male sex; white ethnicity; experience of 5 years or longer; STD work; patient transport; being alone with the opposite sex; contact with certain clients (pimps, homeless persons, alcoholics, gang members, and intoxicated drug users); visits to specific establishments (flophouses, bars, and crack houses); and client behavior (asking for needles, making sexual remarks to the worker). Weapon threats (Table 4) were associated with worker's male sex; white ethnicity; age of 40 years or older; experience of 5 years or longer; work with STD clients; rural work; contact with certain clients (pimps, homeless persons, alcoholics, gang members, and intoxicated drug users); visits to specific sites (flophouses, bars, and crack houses); and contact with clients who asked for needles. Physical attacks (Table 5) were associated with sexual remarks that clients made to public health workers. No risk factors were associated with rape in univariate analysis.

Table Graphic Jump LocationTable 4.—Factors Associated With 3 Violent Outcomes Among Public Health Workers: Univariate Analysis*
Table Graphic Jump LocationTable 5.—Factors Associated With Violent Incidents Among Public Health Workers: Multivariate Analysis*

In multiple logistic regression (Table 5), verbal threats were associated with worker's male sex, white ethnicity, experience of 5 years or longer, weekend work, and sexual remarks that clients made to the worker. Receipt of weapon threats was associated with worker's male sex, white ethnicity, age of 40 years or older, experience of 5 years or longer, rural work, being alone with the opposite sex, and contact with homeless clients. Physical attacks were associated with sexual remarks clients made to the worker. No risk factors predicting rape were identified.

Violence was declared a public health emergency in 1992,21 and we have found that violent threats and incidents are commonly made by clients to public health field-workers. Almost 40% of Texas public health workers reported 1 incident, and more than one third of those workers had experienced 2 or more types of violent threats or incidents. The years in which violent incidents last occurred were reported for 142 violent incidents; 47% were in the year preceding the study. One percent of the workers carried weapons as protection while working and did so before Texas passed a concealed weapons law in 1996. The frequency of such incidents may be underestimated because we surveyed only current employees and did not reach former workers, who could have resigned because of actual or potential violence.

Violence and its consequences are already documented occupational hazards for social workers and health care workers employed in emergency departments and psychiatric care facilities. Between 42% and 100% of nurses, psychiatrists, and other therapists in selected US psychiatric care facilities have been assaulted at least once.1114 In a survey of 127 emergency departments in US teaching hospitals, 43% reported at least 1 physical attack on a staff member each month.17 During 2 years, 1 Canadian teaching hospital reported 242 injuries related to physical abuse and 646 incidents of verbal abuse or physically threatening behavior.9 In published studies, social workers have reported that verbal threats (23%-83%), weapon threats (18%), and physical attacks (3%-40%) are common.1618 Whether public health workers have occupational rates of violence that equal or exceed those of social workers or other health care workers is uncertain; 1 study of minority workers in Los Angeles found that psychiatric hospital workers had an assault rate 38 times higher than that of public health workers.22

The violence that public health workers experienced in Texas differs from that found in emergency departments and psychiatric care facilities, which are fixed locations where guards, metal detectors, and other security devices can provide some protection to health care workers. Guidelines to protect health care workers and social service workers in fixed locations have been published.23,24 Such measures are not completely applicable to mobile public health workers who must visit sites that include crack houses, housing projects, and bars where activities can include prostitution, drug sales, and violent crime. In addition, results from Texas may differ from the experience of workers in other states. The challenge facing public health field-workers is working safely in communities where they must visit repeatedly while imparting and seeking information that clients may not want to hear or reveal. Clearly, public health workers have duties that the National Institute for Occupational Safety and Health25 characterizes as increasing a worker's chance of workplace assault. These duties include delivery of services to clients, working alone or in small numbers, working in high-crime areas, and working in community-based situations.25

This study provides a preliminary look at the occupational violence experienced by public health workers and identifies risk factors possibly associated with violence. For example, we found that workers who were male and of white ethnicity and who had 5 years' or more experience are more likely to experience verbal and weapon threats. We also found that sexual remarks made by a client to a public health worker are associated with verbal threats and physical attacks. However, these findings do not provide the complete context of the violence. We did not collect detailed information about the triad of setting, client, and public health worker as related to specific incidents. In addition, since we asked whether public health workers had ever experienced violent incidents during their fieldwork, those with longer work experience would have greater exposure.

Given the work that a public health worker performs, verbal threats may not be unexpected. In an STD or HIV interview, for example, a public health worker attempts to learn the client's sexual orientation (heterosexual, homosexual, or bisexual), the types of sexual behavior (vaginal, anal, and/or oral intercourse), and numbers of partners (regular, casual, and/or anonymous) in specific time periods. The TB workers administering directly observed therapy, a technique important in preventing emergence of drug-resistant strains, may face hostility from patients during their biweekly visits that continue for months. For confidentiality purposes, public health workers are often alone when such interviews are done, and fieldwork in Texas is not assigned on the basis of the worker's or client's sex or ethnicity. In addition, public health workers looking for a client or exposed person cannot tell anyone except that individual why he or she is being sought and cannot tell the individual who named them as being potentially exposed to STD, HIV/AIDS, or TB.

We did not find any safety measures routinely used by public health workers to be protective or predictive of any of the 4 violent outcomes studied. More information is needed about the dynamics involved in violent threats and incidents. For example, it is possible that sexual remarks that a male client makes to a female public health worker may differ from those a female client would make or those made when both client and field-worker are of the same sex.

Whether these preliminary findings mean that public health workers should more closely resemble the communities they serve is debatable. Our limited analysis suggests that some types of workers (white, male, with 5 years' or more experience) may be more likely to experience verbal and weapon threats. We did not assess the types of clients associated with violent threats and incidents. In addition, public health dollars are limited, and it may not be realistic to match workers and communities when the public health workers in Texas include broad representation of both sexes and the state's 3 major ethnic groups (white, black, and Hispanic).

Public health workers should not have to accept occupational violence as part of the job.21 Education of public health workers is important so that they are capable of assessing or managing a given situation, place, or client that may escalate into violence. Public health researchers studying injury and violence22,23 should collaborate with their counterparts in STD, HIV/AIDS, and TB programs to conduct research that will help ensure safer working conditions for public health workers.

Chirgwin K, DeHovitz JA, Dillon S, McCormack WM. HIV infection, genital ulcer disease, and crack cocaine use among patients attending a clinic for sexually transmitted diseases.  Am J Public Health.1991;81:1576-1579.
Booth RE, Watters JK, Chitwood DD. HIV risk-related sex behaviors among injection drug users, crack smokers and injection drug users who smoke crack.  Am J Public Health.1993;83:1144-1148.
Gunn RA, Montes JM, Toomey KE.  et al.  Syphilis in San Diego County 1983-1992: crack cocaine, prostitution and the limitations of partner notification.  Sex Transm Dis.1995;22:60-66.
Leonhardt KK, Gentile F, Gilbert BP, Aiken M. A cluster of tuberculosis among crack house contacts in San Mateo County, California.  Am J Public Health.1994;84:1834-1836.
Perlman DC, Perkins MP, Paone D.  et al.  Shotgunning as an illicit drug smoking practice.  J Subst Abuse Treat.1997;14:3-9.
Benowitz NL. Clinical pharmacology and toxicology of cocaine.  Pharmacol Toxicol.1993;72:3-12.
Das G. Cocaine abuse in North America: a milestone in history.  J Clin Pharmacol.1993;33:296-310.
Marzuk PM, Tardiff K, Leon AC.  et al.  Fatal injuries after cocaine use as a leading cause of death among young adults in New York City.  N Engl J Med.1995;332:1753-1757.
Yassi A. Assault and abuse of health care workers in a large teaching hospital.  CMAJ.1994;151:1273-1279.
Goodman RA, Jenkins EL, Mercy JA. Workplace-related homicide among health care workers, United States, 1980 through 1990.  JAMA.1994;272:1686-1688.
Lanza HL. The reactions of nursing staff to physical assault by a patient.  Hosp Community Psychiatry.1985;34:44-47.
Bernstein HA. Survey of threats and assaults directed toward psychotherapists.  Am J Psychother.1981;35:542-549.
Madden DJ, Lio JR, Penn MW. Assaults on psychiatrists by patients.  Am J Psychiatry.1976;133:422-425.
Poster EC, Ryan JA. Nurses' attitudes toward physical assaults by patients.  Arch Psychiatr Nurs.1989;3:315-322.
Lavoie FW, Carter GL, Danzl DF, Berg LG. Emergency department violence in United States teaching hospitals.  Ann Emerg Med.1988;17:1227-1233.
Rey LD. What social workers need to know about client violence.  Fam Soc.1996;77:33-39.
Newhill CE. Prevalence and risk factors for client violence toward social workers.  Fam Soc.1996;77:488-495.
Jayaratne S, Vinokur-Kaplan D, Nagda BA, Chess WA. A national study on violence and harassment of social workers by clients. J Appl Soc Sci. 1995-1996;20:1-14.
Dean AG, Dean JA, Coulombier D.  et al.  Epi Info, Version 6: A Word-Processing, Database, and Statistics Program for Public Health on IBM-Compatible Microcomputers . Atlanta, Ga: Centers for Disease Control and Prevention; 1994.
SAS Institute.  Principles of Regression Analysis . Cary, NC: SAS Institute; 1994.
Koop CE, Lundberg GD. Violence in America: a public health emergency: time to bite the bullet back.  JAMA.1992;267:3075-3076. [published corrections appear in JAMA. 1992;268:3074, and JAMA. 1994;271:1404]
Sullivan C, Yuan C. Workplace assaults on minority health and mental health care workers in Los Angeles.  Am J Public Health.1995;85:1011-1014.
State of California.  Guidelines for Security and Safety of Health Care and Community Service Workers . Sacramento: Division of Occupational Safety and Health, Dept of Industrial Relations; 1993.
US Department of Labor.  Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers . Washington, DC: Occupational Safety and Health Administration; 1996. OSHA bulletin 3148.
National Institute for Occupational Safety and Health.  Violence in the Workplace: Risk Factors and Prevention Strategies . Cincinnati, Ohio: National Institute for Occupational Safety and Health; June 1996. Publication 96-100.

Figures

Tables

Table Graphic Jump LocationTable 1.—Characteristics of Public Health Workers*
Table Graphic Jump LocationTable 2.—Reported Year of Most Recent Violent Incident Experienced by Workers*
Table Graphic Jump LocationTable 3.—Types and Combinations of Violent Incidents Reported by Public Health Field-Workers
Table Graphic Jump LocationTable 4.—Factors Associated With 3 Violent Outcomes Among Public Health Workers: Univariate Analysis*
Table Graphic Jump LocationTable 5.—Factors Associated With Violent Incidents Among Public Health Workers: Multivariate Analysis*

References

Chirgwin K, DeHovitz JA, Dillon S, McCormack WM. HIV infection, genital ulcer disease, and crack cocaine use among patients attending a clinic for sexually transmitted diseases.  Am J Public Health.1991;81:1576-1579.
Booth RE, Watters JK, Chitwood DD. HIV risk-related sex behaviors among injection drug users, crack smokers and injection drug users who smoke crack.  Am J Public Health.1993;83:1144-1148.
Gunn RA, Montes JM, Toomey KE.  et al.  Syphilis in San Diego County 1983-1992: crack cocaine, prostitution and the limitations of partner notification.  Sex Transm Dis.1995;22:60-66.
Leonhardt KK, Gentile F, Gilbert BP, Aiken M. A cluster of tuberculosis among crack house contacts in San Mateo County, California.  Am J Public Health.1994;84:1834-1836.
Perlman DC, Perkins MP, Paone D.  et al.  Shotgunning as an illicit drug smoking practice.  J Subst Abuse Treat.1997;14:3-9.
Benowitz NL. Clinical pharmacology and toxicology of cocaine.  Pharmacol Toxicol.1993;72:3-12.
Das G. Cocaine abuse in North America: a milestone in history.  J Clin Pharmacol.1993;33:296-310.
Marzuk PM, Tardiff K, Leon AC.  et al.  Fatal injuries after cocaine use as a leading cause of death among young adults in New York City.  N Engl J Med.1995;332:1753-1757.
Yassi A. Assault and abuse of health care workers in a large teaching hospital.  CMAJ.1994;151:1273-1279.
Goodman RA, Jenkins EL, Mercy JA. Workplace-related homicide among health care workers, United States, 1980 through 1990.  JAMA.1994;272:1686-1688.
Lanza HL. The reactions of nursing staff to physical assault by a patient.  Hosp Community Psychiatry.1985;34:44-47.
Bernstein HA. Survey of threats and assaults directed toward psychotherapists.  Am J Psychother.1981;35:542-549.
Madden DJ, Lio JR, Penn MW. Assaults on psychiatrists by patients.  Am J Psychiatry.1976;133:422-425.
Poster EC, Ryan JA. Nurses' attitudes toward physical assaults by patients.  Arch Psychiatr Nurs.1989;3:315-322.
Lavoie FW, Carter GL, Danzl DF, Berg LG. Emergency department violence in United States teaching hospitals.  Ann Emerg Med.1988;17:1227-1233.
Rey LD. What social workers need to know about client violence.  Fam Soc.1996;77:33-39.
Newhill CE. Prevalence and risk factors for client violence toward social workers.  Fam Soc.1996;77:488-495.
Jayaratne S, Vinokur-Kaplan D, Nagda BA, Chess WA. A national study on violence and harassment of social workers by clients. J Appl Soc Sci. 1995-1996;20:1-14.
Dean AG, Dean JA, Coulombier D.  et al.  Epi Info, Version 6: A Word-Processing, Database, and Statistics Program for Public Health on IBM-Compatible Microcomputers . Atlanta, Ga: Centers for Disease Control and Prevention; 1994.
SAS Institute.  Principles of Regression Analysis . Cary, NC: SAS Institute; 1994.
Koop CE, Lundberg GD. Violence in America: a public health emergency: time to bite the bullet back.  JAMA.1992;267:3075-3076. [published corrections appear in JAMA. 1992;268:3074, and JAMA. 1994;271:1404]
Sullivan C, Yuan C. Workplace assaults on minority health and mental health care workers in Los Angeles.  Am J Public Health.1995;85:1011-1014.
State of California.  Guidelines for Security and Safety of Health Care and Community Service Workers . Sacramento: Division of Occupational Safety and Health, Dept of Industrial Relations; 1993.
US Department of Labor.  Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers . Washington, DC: Occupational Safety and Health Administration; 1996. OSHA bulletin 3148.
National Institute for Occupational Safety and Health.  Violence in the Workplace: Risk Factors and Prevention Strategies . Cincinnati, Ohio: National Institute for Occupational Safety and Health; June 1996. Publication 96-100.
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