OSHA targets workplace violence at hospitals

Assaults on HCWs remain a top problem

Hospitals are places of high emotion and drama, of pain and fear, of last resort, and sometimes of desperation. In this patient-centered world, there has been a high tolerance of aggressive or explosive behavior. But not anymore.

For the first time, the U.S. Occupational Safety and Health Administration has provided specific instructions to its inspectors about using the general duty clause to address incidents of workplace violence. Health care is included among the industries identified as "susceptible to workplace violence."

"Employers may be found in violation of the general duty clause if they fail to reduce or eliminate serious recognized hazards," OSHA's compliance directive says. "Furthermore, investigations should focus on the availability to employers of feasible means of preventing or minimizing such hazards."

The OSHA directive comes in the wake of two high-profile enforcement actions in Bangor, ME, and Danbury, CT, where hospitals were cited for failing to implement a comprehensive violence prevention program despite numerous violent incidents. Meanwhile, violence in hospitals has gained increasing attention with new state laws and pressure from unions and professional organizations.

Connecticut recently passed a law requiring hospitals to implement violence prevention programs, joining New Jersey, California, Illinois, Oregon and Washington, which have similar laws. Other states have raised the penalties for assaulting a health care worker.

While the OSHA directive doesn't require specific steps for employers to take, "it clearly identifies, from an enforcement perspective, your industry as one that has a recognized hazard," says Brad Hammock, an attorney with Jackson Lewis in Reston, VA, who specializes in occupational health law.

'An important step'

A single random act of violence wouldn't necessarily trigger any action by OSHA. But the compliance directive is raising awareness of the hazard. (Hospitals already were put on notice by the Joint Commission accrediting body in 2010 with a Sentinel Event Alert: http://bit.ly/rtT5rn)

"We specifically identified the health care industry as having a history of problems in this area," says an OSHA spokesperson. "We just wanted to ensure that the compliance officers recognized this and understood the proper procedures not only for finding violations, but in terms of general education of employers."

Inspectors may ask about hazard assessments, incident reviews, employee training, and a workplace violence prevention plan, according to the directive. They will interview employees and look at a variety of records, including security and police reports.

The OSHA directive is an important step, says AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, president of the Emergency Nurses Association and clinical director of emergency nursing at the Hospital of the University of Pennsylvania.

"While we are certainly pleased that OSHA has issued this compliance directive, like any other tool, it must be used," she says. "This directive, along with the tools available through ENA and elsewhere, leave few excuses for health care organizations who fail to provide a safe work environment.

"While violence cannot be eliminated, it can certainly be reduced from the unacceptable levels we are currently seeing," she says. "It is now up to the health care organizations to take a more proactive approach to keeping nurses and other health care workers safe from violence."

A stream of abuse from patients

Violence has become endemic in the nation's hospitals. Acute care hospitals account for almost one in 10 of all workplace assaults that lead to lost workdays. In surveys, nurses reveal a constant stream of lesser assaults.

An online survey of 3,211 nurses by the Emergency Nurses Association found that more than half (54.8%) had experienced physical violence or verbal abuse within the past week.1 A New Jersey survey of registered nurses found that one third had experienced violence in their hospital or nursing home.2 (A sample survey tool, which can be used to assess workplace violence in the ER, has been inserted into this issue.)

"People come into the ER in a state of crisis, so you know they're going to be more angered – but that's doesn't mean it's right," says Papa. "I think now people are saying, 'What can we do and how can we stop it?'"

A shooting at Danbury Hospital in 2010 spurred the recent passage of the Connecticut workplace violence law. The injured nurse, who was shot three times by an elderly cardiac patient, eventually returned to work in nursing education and still is impacted by the injuries, says Mary Consoli, RN, BSN, president of the Danbury Nurses Union, an affiliate of the American Federation of Teachers. He previously was an assistant nurse manager working at the bedside.

Connecticut's law was designed to require hospitals to follow best practices, Consoli says. But the state laws also send a message throughout health care, she says.

"It's not part of the job to be abused," she says. "It's not part of the job to be attacked by patients. It's not part of the job to risk your life. You shouldn't have to go to work and worry if you're going to come home in one piece."

The New Jersey law was passed in 2007 in the wake of a report sponsored by the National Institute for Occupational Health and Safety (NIOSH) that highlighted gaps in reporting and training at hospitals. Now New Jersey hospitals and nursing homes are required to have a committee that develops and maintains a workplace violence prevention plan. The facilities must conduct annual workplace violence risk assessments, provide annual training, and keep a record of violent acts against employees.

"With the workplace violence committee, issues get addressed, whereas they might not have been in the past," says Bernie Gerard Jr., RN, BSN, vice president of Health Professionals and Allied Employees in Emerson, NJ, a union that represents nurses and other health care workers in New Jersey and Pennsylvania.

NIOSH has launched a study of the impact of the New Jersey law. "Our central hypothesis is that the hospitals that have a high compliance with the regulation will have low rates of violence-related injury," says Marilyn Ridenour, RN, BSN, MBA, MPH, CPH, nurse epidemiologist with NIOSH's Division of Safety Research in Morgantown, WV.

The study may lead to a compilation of best practices that can help reduce violent incidents, she says.

Shootings are random, violence is not

Shootings at hospitals make the headlines with regularity: In Orlando, a transplant surgeon was shot and killed by a patient. A man opened fire after arguing with another man in the lobby of a medical center in Omaha. A former soldier with a small arsenal of weapons took hostages at a Savannah hospital.

In September 2010, a man upset about the care his mother, a cancer patient, had received, shot his mother's surgeon at Johns Hopkins Hospital in Baltimore, then killed his mother and himself. In the wake of that shooting, two Johns Hopkins physicians reflected on the problem of violence in America's hospitals in an opinion piece in the Journal of the American Medical Association.3

"The perception that health care facilities located in high-crime neighborhoods are at particular risk because of local gun violence is not well supported by data," they wrote. "Health facility shootings have tended to be random, at smaller centers, and unrelated to local violence. To underscore, the shooter at our institution was 50 years old, lived out of state (with his mother), had no criminal background, held a responsible job, and had a license to carry a firearm in his home state."

Rather than installing magnetometers to detect weapons, hospitals should focus on efforts to address the more common assaults, the authors said.

Hospitals also should make sure they address the stress that results from both physical and verbal assaults by providing counseling to employees, says Papa. Nurses may feel conflicted about reporting incidents because of their concern for patients, and they often face logistical barriers to reporting incidents if they don't have an OSHA-recordable injury, says Papa.

"I would challenge organizations to be creative so they can make it easy for the nurses to report this," she says.


1. Emergency Nurses Association. Emergency department violence surveillance study. August 2010, Des Plaines, IL. Available at http://bit.ly/nOy9xK

2. Peek-Asa C, Casteel C, Allareddy V, et al. Workplace violence and prevention in New Jersey hospital emergency departments. J Occup Environ Med 2007; 49:756-763..Available at http://1.usa.gov/otI7iZ

3. Kelen GD and Catlett CL. Violence in the health care setting. JAMA 2011; 304:1-2.