Uniting to Stop Violence Against Employees in Health Care

M. L. Hopkins

Health care employees – including occupational health providers who evaluate workers’ compensation claims and deliver health services to injured workers – are in the grip of a disturbing trend: workplace violence that leads to injury, even death. In August 2023, the Associated Press reported, “Data shows that American health care workers now suffer more nonfatal injuries from workplace violence than workers in any other profession, including law enforcement.”¹

A clearer picture of the aggression against health care employees emerges from a small survey in February to April 2023. Of the survey’s 672 respondents – ranging from clinical to administrative to security personnel – 40% said they had experienced workplace violence in the last two years. More than half of violent incidents involved combative patients interacting with nursing staff. In more than 60% of the cases, the attack involved scratching, hitting, and biting and, in 20%, an object was thrown. Sexual assault or harassment was alleged in 14% of cases and a firearm was involved in 1 of every 100 violent interactions.²

Workplace violence, a sign of trying times?

According to the U.S. Bureau of Labor Statistics, the rate of injuries from violent attacks against medical professionals grew by 63% from 2011 to 2018, and hospital safety directors say that aggression against staff escalated as the COVID-19 pandemic intensified in 2020. Among more than 2,000 nurses who responded to an April 2022 survey, 48% reported an increase in workplace violence – more than double the percentage from a year earlier.³

Many industries can relate to what health care is experiencing. In 2020, service occupations led in “nonfatal intentional injuries by another person” in the workplace with 18,690 injuries, or over half of the total of 37,060. In second place, with 8,590 nonfatal intentional injuries by another person were health care practitioners and technical employees. They were followed by employees in educational instruction and libraries (5,470), transportation and material moving (1,560), and management, business, and financial occupations (1,360).⁴

There were 392 workplace homicides in 2020; of these, 23.5% were in sales/sales-related occupations (92), followed by transportation and material moving (51), management (29), construction and excavation (20), and production (18).

Signs that a violent outburst may be coming

Being aware of the warning signs of workplace violence is everyone’s business because, as the National Safety Council says, “most every ‘place’ is somebody’s workplace,” and violence can affect anyone – patron, employee, or bystander.

Behavioral signs may include appearance of excessive use of alcohol or drugs, unexplained absenteeism, depression or withdrawal, perceptions of unfair treatment, emotional responses to criticism, mood swings, and paranoia.⁵

In health care specifically, “The reasons for aggression vary: patients’ anger and confusion about their medical conditions and care; grief over the decline of hospitalized loved ones; frustration while trying to get attention amid staffing shortages, especially in nursing; delirium and dementia; mental health disorders; political and social issues; and gender and race (issues).”⁶

Response to health care violence is multifaceted, serious

Now that health care facilities – a refuge of caring for people in vulnerable conditions – are themselves becoming vulnerable, administrators are tightening the security and safety net. More facilities are flagging the records of patients who have shown aggression in the past, restricting where visitors can go, installing more cameras, providing panic alarms, training staff how to respond to aggression and spot the early signs of violence, and forming interdisciplinary teams to rapidly respond to incidents.⁷

After a man stabbed an emergency department nurse in June, Heywood Healthcare in Massachusetts reacted with additional security measures, including a zero-tolerance policy for weapons.⁸ A zero-tolerance policy is one of the best protections employers can offer their employees, the Occupational Safety and Health Administration (OSHA) has said. OSHA also recommends a well-written and well-implemented workplace violence prevention program.⁹

The General Duty Clause that OSHA enforces requires all employers to provide a work environment that is “free from recognized hazards that are causing or likely to cause death or serious physical harm.” Because “workplace violence is a recognized hazard within the health care industry, (health care employers) have the responsibility to abate the hazard.”¹⁰

Occupational health presents an opportunity for employers and health care providers to ensure employees understand their joint expectation that employees’ behavior in medical centers and clinics must mirror the safe conduct required when performing their jobs. On occasion, employees may feel nervous about the results of certain health services, particularly when a work impact is possible. However, these services – drug testing, injury care, physical therapy, physical exams, and various screenings and tests – must proceed calmly and professionally; indeed, this is the expectation for employees’ behavior their entire time in occupational health facilities. Clinicians, administrators, and other staff are empowered to call in law enforcement at the first signs of disruption.

Lawmakers support protection, penalties

Some states have enacted or increased penalties for attacks on health care employees.^11,12 Nationally, legislation to protect health care employees from workplace violence has been introduced or considered by committees every year since at least 2018.^{13,14,15,16,17,18}

Three bills have been introduced so far in the 118th Congress (2023-2024):

S. 1176 (Workplace Violence Prevention for Health Care and Social Service Workers Act), introduced by lead sponsor Tammy Baldwin of Wisconsin in mid-April; it has 36 co-sponsors and was referred to the Committee on Health, Education, Labor, and Pensions;
HR 2663 (also the Workplace Violence Prevention for Health Care and Social Services Workers Act). This companion bill was introduced in the House by lead sponsor Joe Courtney of Connecticut, also in mid-April, and referred to the Committee on Education and Workforce, as well as the Committees on Energy and Commerce, and Ways and Means to a period to be determined by the Speaker;
S. 2768 (the SAVE Act or Safety from Violence for Healthcare Employees Act) was introduced by Joe Manchin of West Virginia and Marco Rubio of Florida in September and referred to the Committee on the Judiciary.

S. 1176 and HR 2663 would direct the Secretary of Labor to issue an occupational safety and health standard requiring covered employers in health care and social service industries to develop and implement a comprehensive workplace violence plan. This interim final standard is to be issued not later than one year after the law’s enactment with required employers plans to be based on the Occupational Safety and Health Administration’s (OSHA’s) Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.^19,20,21

S. 2768 would prohibit anyone from interfering with hospital personnel performing their jobs and enact penalties and/or a term of imprisonment. An assault of a hospital employee could receive fines and up to 10 years in prison. If dangerous weapons are involved or if there is bodily injury, term of imprisonment is up to 20 years.²² The higher penalties and imprisonment apply when violence occurs during a public emergency or major disaster. The bill applies to “hospitals,” as defined as a hospital under the Social Security Act, as well as a long-term care hospital, a rehabilitation facility, a children’s hospital, a cancer hospital, a critical access hospital, a rural hospital.²³

OSHA: Years spent on workplace violence in health care

Employers who want to understand the direction OSHA may take on workplace violence in health care can get a sense of the agency’s top priorities from a couple of resources. The first is its Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. The current version, updated in 2016, is 60 pages long and addresses risks and hazard prevention/control for five types of health care settings: hospitals, residential treatment centers, such as nursing homes, non-residential treatment centers, such as clinics and mental health centers, community care residential facilities and group homes, and home health care workers.²⁴

Of particular interest to employers may be OSHA’s identification of “organizational risk factors,” because they could represent aspects on which field compliance officers might focus their attention under a new standard if one is approved. These organization risk factors include:

Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff
Working when understaffed, especially during mealtimes and visiting hours
High worker turnover
Inadequate security and mental health personnel on site
Long wait times and uncomfortable waiting rooms
Unrestricted movement of the public in clinics and hospitals
Perception that violence is tolerated and victims will not be able to report the incident to police and/or press charges

As is often the case, OSHA is interested in employers developing a written program for workplace violence prevention and lists five essential building blocks for incorporation into these programs: management commitment and employee participation; worksite analysis; hazard prevention and control; safety and health training; and recordkeeping and program evaluation.

OSHA’s Guidelines document also includes appendices on workers’ rights, OSHA assistance, services, and programs, NIOSH Health Hazard Evaluation Program, and OSHA contact information.

A second resource: SBREFA panel report

In March 2023, OSHA convened a Small Business Advocacy Review (SBAR) panel on the prevention of workplace violence in healthcare and social assistance. A panel like this is part of OSHA’s procedures when investigating the need for a new standard. The Small Business Regulatory Enforcement Act (SBREFA) requires that OSHA assess how a draft rule could potentially affect small entity representatives, or SERs.²⁵

In their testimony, the SERs raised several points of interest to all employers, especially smaller organizations, such as:

Cost of compliance should not be unduly burdensome
A “one-size-fits-all” approach should be discouraged
What is the definition of “workplace violence”? Only physical harm? Or verbal threats?

The panel recommended moving forward to develop a new standard and agreed the approach should be flexible. Also, the panel said, OSHA should first review existing regulations, available guidance, and accreditation standards to ensure that any OSHA rule is consistent, but not duplicative, with existing requirements.

Uniting against workplace violence in health care

Concentra® is committed to the protection of health care employees. Verbal and physical abuse, violence of any kind, and weapons are prohibited at all times at all Concentra facilities, in compliance with Concentra’s zero-tolerance policy. Any and all incidents will be reported to law enforcement and charges will be pursued. With the goal of preventing workplace violence, Concentra looks forward to continued collaboration and cooperation with the companies we serve and to whom we provide the highest quality occupational health care services.

NOTES

“Attacks at U.S. medical centers show why health care is one of the nation’s most violent fields,” by Rebecca Boone. Associated Press. August 7, 2023.
“Forty percent of healthcare workers experienced workplace violence in the last two years,” by Jeff Lagasse. HealthcareFinance. June 7, 2023.
“Threats against health care workers are rising. Here’s now hospitals are protecting their staffs,” by Patrick Boyle. Association of American Medical Colleges. August 18, 2022.
Workplace violence: homicides and nonfatal intentional injuries by another person in 2020. TED: The Economics Daily. U.S. Bureau of Labor Statistics. November 21, 2022.
“Assault Fifth Leading Cause of Workplace Deaths.” National Safety Council. Accessed: October 9, 2023.
“Threats against health care workers are rising. Here’s now hospitals are protecting their staffs,” by Patrick Boyle. Association of American Medical Colleges. August 18, 2022.
“Threats against health care workers are rising. Here’s now hospitals are protecting their staffs,” by Patrick Boyle. Association of American Medical Colleges. August 18, 2022.
“Massachusetts hospital increases security measures after New Hampshire man accused of attacking nurse,” by Ray Brewer. WMUR9 ABC, Manchester, New Hampshire. June 19, 2023.
“OSHA & Worker Safety: Guidelines for Zero Tolerance.” The Joint Commission Environment of Care News. August 2015;18(8):8-11.
OSHA’s General Duty Clause. Centers for Disease Control and Prevention. Last reviewed: February 7, 2020.
“Protecting Health-care Workers: A Summary of Laws in Our Members’ States,” by Justin Steiner, JD. Physicians Insurance.
“Lawmakers in these 6 states move to combat violence against healthcare workers,” by Kelly Gooch and Marissa Plescia. Becker’s Hospital Review. March 9, 2022
“Bill to address health care workplace violence introduced in Congress.” Industrial Safety and Hygiene News. November 26, 2018.
“Congress Bill Works to Protect Health Care Workers from Violence.” Occupational Health and Safety. November 25, 2019.
“Workplace Violence: The Congressional Vote on HR 1309,” by Dan Morhaim, MD. Annals of Emergency Medicine. July 2020.
“House passes bill to prevent violence in health care workplaces,” by Cristina Marcos. The Hill. April 16, 2021.
“Workplace Violence Prevention for Health Care and Social Services Act Introduced in the Senate.” Safety+Health. May 12, 2022.
“Workplace violence prevention bill aimed at health care and social services,” Safety+Health. April 20, 2023.
S. 1176: Workplace Violence Prevention for Health Care and Social Service Workers Act. GovTrack. Accessed: October 9, 2023.
H.R. 2663: Workplace Violence Prevention for Health Care and Social Service Workers Act. GovInfo. PDF. Accessed: October 9, 2023.
“Workplace violence prevention bill aimed at health care and social services,” Safety+Health. April 20, 2023.
“Workplace violence in health care: Lawmakers seek stiffer penalties.” Safety+Health. September 15, 2023.
S. 2768: The SAVE Act (Safety from Violence for Healthcare Employees Act). Congress.gov. Accessed: October 9, 2023.
“Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.” Occupational Health and Safety Administration. 2016.
“Report on the Small Business Advocacy Review Panel on OSHA’s Potential Standard for Prevention of Workplace Violence in Healthcare and Social Assistance.” Final Report. Occupational Safety and Health Administration. July 2023.