Violence against health care workers — particularly nurse assistants and nurses — is increasing at an alarming rate that warrants immediate action. Accordingly, there has been a surge of recent activity by a variety of federal agencies and other organizations that reach consensus on one point: The level of violence in health care has become unacceptable.

“There’s absolutely a lot of momentum on this issue,” says Jaime Dawson, MPH, senior policy advisor with the American Nurses Association in Silver Spring, MD. “I think the culture is changing. Nurses are not accepting violence as a part of their job.”

The Occupational Health Safety Network (OHSN) — a Web-based portal that collects data about injury and incident reports in hospitals and other settings — reports that from Jan. 1, 2012 to Sept. 30, 2014, workplace violence injury rates increased for all non-physician job classifications and nearly doubled for nurse assistants and nurses.1

Given that level of increase, is it possible some kind of a surveillance artifact could be occurring through increased reporting or other factors? Unfortunately, that is not the case, explained Ahmed Gomaa, MD, ScD, MSPH, a medical officer in the surveillance hazard evaluation branch of the National Institute for Occupational Safety and Health (NIOSH).

“This finding is an actual increase representing the data collected from the 112 participating facilities located in 19 states,” he says. “A similar workplace violence increase is also documented by a Bureau of Labor Statistics report — a national survey which showed a 16% increase from 2012 to 2013.”

The OHSN collected data on OSHA-reportable injuries related to violence for the period, finding that the hospitals reported a total of 2,034 incidents. OSHA reported violent injuries were defined as incidents that result in at least one of the following: loss of consciousness, days away from work, restricted work activity or job transfer, medical treatment beyond first aid, a diagnosis by a physician, and death. Incident reports that provided details suggests that virtually all of the injuries resulted from physical assaults by patients.

“Patients at risk for committing violent acts [include] those with mental illness, behavioral disorders, and cognitive dysfunction,” Gomaa says.

Numb to violence?

Given the surge of incidents it is fair to ask whether health care is becoming numb to violence, as it seems much of the nation has after one mass casualty event after another. Consider the glaring contrast of the Ebola outbreak: Two nurses became infected with the Ebola virus last year and there were nursing protests in the streets and government officials saying they would protect health care workers at all costs. Two cases and both survived. Strange that so little is said about health care workers dying every year due to workplace homicide. For the last decade, an average of 15 health care workers a year have been the victims of workplace homicide, according to Dan Hartley, EdD, workplace violence prevention coordinator at NIOSH.

Though the murder rate has seemingly plateaued at that grim level, overall violent incidents in health care are on the rise and are disproportionate to the level occurring in other work sites. In 2013, health care workers reported an estimated 9,200 workplace violence incidents requiring time away from work to recover, with the majority of these perpetrated by patients or their family members, Harley noted in a recent NIOSH blog post.2

“That represents 67% of all nonfatal violence-related injuries from an industry that only represents 11.5% of all workers,” he emphasized.

The situation is serious enough that the Department of Health and Human Services (HHS) is advising hospitals and other health care settings to incorporate “active shooter” scenarios into their emergency operations plans. In April, the Occupational Safety and Health Administration released updated workplace violence guidelines. “This is the first update in over a decade and it could not have come sooner,” Jordan Barab, deputy assistant Secretary of Labor, said in an OSHA blog post accompanying the release of the guidelines.3

OSHA has issued 18 citations and 57 “hazard alert” letters to health care employers since October 2012 for failing to have an adequate program to prevent workplace violence. During this period, the agency has conducted 148 inspections in response to workplace violence complaints. Of those, 101 were in healthcare or social service settings.

In addition to the actions by OSHA and the HHS, other groups are sounding the alarm on violence in health care. For example, a major patient safety organization — ECRI Institute of Plymouth Meeting, PA — named “managing patient violence” as a top patient safety concern. The American Nurses Association is drafting a position statement on “incivility, bullying and workplace violence,” and nurses continue to rank “on the job assault” as one of their top workplace concerns. The California Occupational Safety & Health Standards Board is drafting a rule that would require health care employers to have a comprehensive workplace violence prevention program. Five other states require workplace violence prevention programs in hospitals.

Active shooter incidents in hospitals are much less common than the day-to-day verbal and physical assaults. But they have focused national attention on the overall problem, says Jane Lipscomb, PhD, RN, FAAN, professor in the University of Maryland School of Nursing and Medicine in Baltimore and an expert on workplace violence.

“I think employers are waking up to this,” says Lipscomb, co-author of Not Part of the Job: How to Take a Stand Against Violence in the Work Setting (ANA, 2015). “There are some hospitals that are really stepping forward and it’s reassuring.”

While most physical assaults never make the headlines, they are “none-the-less severe and life-changing,” notes Dee Tyler, RN, COHN-S, FAAOHN, executive president of the Association of Occupational Health Professionals in Healthcare (AOHP). The new OSHA guidelines provide strategies to help manage the situations that lead to violence, she says.

Violence a hazard OSHA ‘takes seriously’

OSHA has been emboldened to use the “general duty clause” of the Occupational Safety and Health Act and will likely issue more citations for workplace violence in hospitals, says Valerie Butera, a partner with Epstein Becker Green in Washington, DC, who specializes in occupational safety and health law.

In its budget justification for Fiscal Year 2016, OSHA noted that it plans to hire more compliance officers and focus on more complex inspections. OSHA specifically highlighted its efforts related to workplace violence: “Novel hazards, such as workplace violence, are important to pursue to put the employer and employee communities on notice that these are hazards that OSHA takes seriously.”

In August 2014, OSHA cited Brookdale University Hospital and Medical Center in Brooklyn, NY, for a “willful violation” — defined as one that the employer either knowingly commits or commits with indifference to the Occupational Safety and Health Act — related to about 40 incidents that occurred earlier in the year. Nurses had been kicked, hit, and punched, causing various injuries, OSHA said. In the most egregious incident, a patient attacked a nurse and stomped and kicked her repeatedly in the head, leading to severe brain damage.

“Brookdale management was aware of these incidents and did not take effective measures to prevent assaults against its employees. The facility’s workplace violence program was ineffective, with many employees unaware of its purpose, specifics or existence,” said Kay Gee, OSHA’s area director for Brooklyn, Manhattan, and Queens.4 As a result, OSHA cited Brookdale for one willful violation, with fines totaling $78,000 for failing to “develop and implement adequate measures to reduce or eliminate the likelihood of physical violence and assaults against employees by patients or visitors.”

Brookdale contested the citations, issuing a statement that said: “The safety and security of our employees, patients and visitors is and has been our highest priority. Workplace violence is a challenge that all health care institutions around New York City and the country face, and it is completely unacceptable any time a staff member is assaulted while simply doing his or her job to help others. While we have fully cooperated with OSHA during its investigation and on our own have strengthened our already robust security procedures, we absolutely disagree with OSHA’s finding that the Hospital willfully violated any regulatory requirement.”5

Robert Kulick, OSHA’s regional administrator in New York, said in a statement as the citations were issued, “The hazard of violence against employees is well-recognized in the health care industry and known to this employer. Brookdale must actively and effectively implement a Workplace Violence Prevention Program immediately to ensure the safety and well-being of its workers.”

To Butera, such pronouncements indicate that OSHA’s voluntary workplace violence guidelines are more than mere suggestions. In March, Wal-Mart withdrew its appeal of a general-duty clause citation related to the 2008 trampling death of a worker — which provides further encouragement for OSHA to use the tactic to address injuries for which there is no standard, she says.

“You should do all that you can to have a program that is similar to what they’re setting out in the [workplace violence] guidelines,” she advises.

Expect OSHA to scrutinize injury reports, especially those involving inpatient hospitalization, which must be reported to OSHA within 24 hours of an incident, she says. OSHA also has said it plans to focus on high-risk industries, which includes health care.

“I think it’s a powerful time for OSHA,” says Butera. “They’re probably going to be extremely active for the rest of this administration.”

Guide to keeping workers safe

The updated OSHA workplace violence guidelines are structured around the basic components of a comprehensive injury and illness prevention program: management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation.6

The guidelines provide charts with suggested safety measures and strategies for different types of health care settings, such as hospitals, residential treatment centers and community care. OSHA also provides checklists for issues such as security measures, staffing, training and work procedures.

“It helps employers understand how to fulfill their responsibility to keep workers safe,” says Lipscomb.

OSHA notes that 50% of all reported workplace assaults involve health care workers. Assaults are the cause of about 10% of all health care worker injuries that require days away from work, compared with just 3% of such injuries among all private industry employees.

Changing that dynamic may require more than voluntary guidelines, says Jonathan Rosen, MS, CIH, of AJ Rosen & Associates LLC, who was instrumental in advocating for a New York law covering public employees when he was with the Public Employees Federation.

“In health care, there are all kinds of written programs that look impressive, but do they really reflect the practices day to day on the ward in terms of dealing with people before they become violent?” he says.

California is drafting a standard that will become the strongest in the nation, says Mark Catlin, health and safety director of Service Employees International Union in Washington, DC. It will require site-specific hazard analysis and monitoring of threats as well as injuries. It will cover non-clinical as well as clinical employees and the public and private sectors, he says.

Health care workers have flocked to hearings to tell their stories of workplace assaults, giving the rule-making grass-roots energy, he says. “Our ultimate goal would be an enforceable national standard along the lines of what we’re seeing in California,” Catlin says.

Violence also a patient safety concern

ECRI Institute, a leading patient safety organization, gave hospitals another reason to implement violence prevention: It threatens to erode patient care, as well as worker safety. ECRI named “managing patient violence” as No. 3 of the top 10 patient safety concerns in 2015.

Health care workers who don’t have adequate training may try to minimize contact with patients who are known to be verbally abusive or to act out violently, says Cindy Wallace, CPHRM, an ECRI risk management analyst. “It becomes a patient safety issue if staff are hesitant to manage someone who has acute care needs,” she says.

ECRI advises hospitals to require reporting of incidents, train staff in de-escalation strategies, and implement and monitor security measures, including having a rapid-response team to respond to emergencies, if appropriate. “The hospital should have a facility-wide safety plan that considers all levels of risk, from the single acute episode of threatening behavior to an active shooter situation anywhere in the facility or on campus,” ECRI said.

Hospital leadership should address factors that could be precursors to aggression and violence, says Ruth Ison, MDiv, STM, ECRI Institute PSO patient safety analyst and consultant. For example, a delay in finding a bed for a psychiatric patient in the emergency room may create unnecessary stress. Problems with staffing levels, staffing mix and team coordination can raise the potential for patient aggression, and patients under the influence of drugs or alcohol are likely to be more emotionally volatile, she says.

“It’s the underlying risks that are going unrecognized in the health care environment,” she says. “That’s where the problem lies.”

Meanwhile, the ANA issued a draft position statement on “incivility, bullying and workplace violence.” The association is addressing worker-on-worker and patient-on-worker aggression as part of a “larger complex phenomenon.”

“They are not separate issues. They all relate to a work environment where these risks exist,” says Dawson.

The ANA is recommending a zero tolerance policy for bullying and violence, mentors for new nurses, and even a Code Pink or similar code to provide support for someone who is being bullied on the job. Linking the different forms of violence is important, says Dawson.

“Nurses want to work in healthy environments where they feel safe and in environments that support the best patient care,” she says.


  1. Centers for Disease Control and Prevention. Occupational Traumatic Injuries Among Workers in Health Care Facilities — United States, 2012–2014. MMWR 2015:64(15);405-410
  2. Hartley, D. Violence in Healthcare. NIOSH Science Blog March 27th, 2015
  3. Borab J. If Work Came With a High Risk for Assault, Would You Go? OSHA Blog April 2, 2015
  4. OSHA. Brooklyn medical facility cited by US Department of Labor’s OSHA for inadequate workplace violence safeguards. Aug. 11, 2014.
  5. Goldberg G. Brookdale Hospital fined $78,000 by OSHA. Capitol Aug. 11, 2014
  6. Occupational Health and Safety Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 2015