With recently finalized regulations in California serving as a possible template, OSHA is considering a national standard to protect healthcare workers, primarily from assaults by patients.

OSHA issued a request for information (RFI) and comment on Dec. 7, 2016, announcing that it is considering promulgating a federal standard to prevent workplace violence in healthcare settings.1

As previously reported in Hospital Employee Health, a Government Accountability Office (GAO) report2 last year took OSHA to task for not doing more to prevent violence against healthcare workers. (For more information, see the August 2016 issue of HEH.) Efforts to use the OSHA General Duty Clause to enforce existing protections have been minimal and ineffective, the GAO found, pushing OSHA to the conclusion that a separate violence prevention standard may be needed. As a result, OSHA took the initial step toward rulemaking, asking for comments and suggestions as to how to best proceed. The comment deadline is April 6, 2017.

“Evidence indicates that the rate of workplace violence in the industry is substantially higher than private industry as a whole,” OSHA states in the document. “OSHA is considering whether a standard is needed to protect healthcare and social assistance employees from workplace violence. [OSHA] is interested in obtaining information about the extent and nature of workplace violence in the industry and the nature and effectiveness of interventions and controls used to prevent such violence.”

In issuing the RFI, OSHA cited the recent passage of healthcare violence prevention regulations by its state-based program in California. The Cal-OSHA program adopted the new standards3 on Oct. 20, 2016, with implementation beginning this year. In doing so, Cal-OSHA became the first state OSHA plan — which must have requirements at least as stringent as the federal agency — to adopt a healthcare violence prevention regulation.

The California regulation could serve as a template for a national OSHA standard, says Bonnie Castillo, RN, director of health and safety for the California Nurses Association/National Nurses United, which has been lobbying for the law for several years.

“We believe that the California workplace regulations are a model for the nation, and we intend to work to ensure that these protections [are extended nationally] for all nurses, healthcare workers, and the public,” she tells HEH. “These are the most robust workplace violence regulations in the nation. We are very pleased, but any law or regulation is only as good as its enforcement. We will be involved every step of the way to make sure that [the regulations] are actually followed and enforced.”

The Cal-OSHA regulation requires hospitals to establish a written Workplace Violence Prevention Plan that would include a risk assessment of all hospital areas. Some of the risks noted by Cal-OSHA that employee health professionals and their colleagues should identify are summarized as follows:

  • healthcare workers assigned to isolated or remote work stations where they may work alone at night or early in the morning,
  • poor lighting or blocked visibility in areas where assailants may not be seen,
  • lack of effective escape routes,
  • obstacles or impediments to accessing alarm systems, which should be periodically checked to ensure they are operational,
  • entrances to buildings where unauthorized access may occur, such as doors designated for staff or emergency exits, and
  • presence of furnishings or objects that can be used as weapons in patient care areas.

“It’s important every area of the hospital — every unit where you have patients and healthcare workers interfacing — is assessed for risk factors that contribute to violence,” Castillo says. “[This would include the structural] layout, engineering controls such as lighting and alarm systems. The plan needs to include every single area.”

While the California regulation allows flexibility with some specifics at the local level, a common theme is that healthcare workers must be involved in identifying the risks, creating the plan, and conducting subsequent reviews of its effectiveness. Likewise, frontline healthcare workers should be involved in designing and implementing training, reporting, and investigating workplace violence incidents. (For more information, see story on additional provisions of the California law in this issue.)

“It is important that nurses and healthcare workers are involved in that process,” Castillo says. “In the case of registered nurses, they are there 24/7. There is no better person to be involved in assessing every single work area, and ensuring there is training and [adequate] staffing. Make sure that everybody is aware of how to handle a situation, should it arise, in order to mitigate the risk. [Risk factors can vary] from unit to unit. Some are designed with centralized workplaces where nurses are working closely together. Some are dispersed where they may be working in a pod by themselves and have limited access to other personnel for help should a situation arise. All of these things have to be taken into consideration.”

In comments submitted before the regulation was finalized, the California Hospital Association expressed concern that the Cal-OSHA regulations do not “fully recognize the complexity of hospital operations and healthcare at large and that, as a result, the current version of the proposed regulations are likely to cause significant confusion and operational challenges without furthering the goal of mitigating and/or preventing workplace violence.”

For example, the California standard calls for awareness of patient risk factors for violence caused by mental health problems or other conditions that may contribute to unpredictable, disruptive, or aggressive behavior. Contributing factors could include medication status and any history of violence known to the healthcare facility or employees. While that seems reasonable enough, the CHA noted in its comments on the rule that “scientific literature is unclear on how to predict whether a patient may be at increased risk for violence.”

Though not stated directly in the CHA comments, hospital groups and administrators may have concerns about increased liability for incidents and the creation of burdensome regulations that offer no additional protection for workers. Similar concerns have been expressed at the national level in comments submitted to the federal OSHA public docket after it issued the request for information.

For example, regulations are a large cost factor for employers to address rare incidents, placing employers “in a position of liability over situations in which they have no control,” a healthcare administrator told federal OSHA.

“I do not believe any federal or state regulation can do anything more than penalize an employer for an uncontrollable situation,” commented Michael Van Sickle, administrator of Bethany Lutheran Home in Council Bluffs, IA. “While we can tell our staff to ‘run, hide, or fight,’ that is realistically the best an employer can do without the police or courts being involved. We already have laws for assault that would cover family assaults on healthcare workers. We have laws about domestic violence that would cover family internal struggles. We have laws and regulations that address patient assaults on caregivers.”

Other comments submitted to the federal OSHA docket foreshadow what a national debate on the issue may look like.

“Since the vast majority of the violent incidents and injuries to caregivers are caused by the very persons that we are trying to help, healthcare professionals must be supported in the adoption of strategies to better understand the circumstances and events leading up to these types of behaviors,” commented Bryan Warren, CHPA, safety director of corporate security for Carolinas HealthCare System in Gastonia, NC.

A good foundation is the creation of rules and standards with which to better prevent and respond to incidents of workplace violence when they occur, Warren wrote. “Healthcare facilities are no longer safe havens, and have joined other previously sacrosanct settings such as houses of worship and schools as prime venues for acts of violence,” he told OSHA. “I feel it is of paramount importance that concrete steps be taken to help to mitigate this growing issue and to better equip healthcare workers to detect, prevent, and recover from such incidents when they occur.”

Another commenter told OSHA the “status quo” of ongoing violence in healthcare is no longer acceptable.

“I am a registered nurse and a clinical educator,” Zachary Fink, RN, told OSHA. “While I understand that it is difficult to control the behaviors of those suffering from delirium, confusion, or psychosis, the frightening reality is that many of the perpetrators are completely aware of what they’re doing and are capable of making decisions. Currently, healthcare workers are afraid to contact law enforcement on their own for fear that they will suffer repercussions as a representative of their institution, and organizations do little to act on the behalf of the employees in all but the most extreme of situations.”

Fink suggested a “clear and purposeful” rule that requires employers to train staff in violence prevention and makes it clear to patients and visitors that aggressive behavior will not be tolerated.

“I feel that these rules will have additional benefit by improving the environment in which healthcare employees work,” Fink told OSHA. “Currently, healthcare workers often feel ‘trapped’ and feel that their rights are infringed upon when they work long hours, are unable to take sufficient breaks, and unable to ‘simply walk away’ when it would result in patient abandonment. The resulting stress, anxiety, and fatigue all contribute to burnout, compassion fatigue, and an overall reduction of the quality of care that patients receive.”

Nancy Bork of Central DuPage Hospital in Winfield, IL, recommended zero tolerance for disruptive behaviors that could escalate into violent attacks.

“Granted, it is a small percentage, but there are many patients and visitors that have become terrible bullies toward heathcare workers,” Bork said in her comments. “These behaviors have, unfortunately, been tolerated in healthcare, but you don’t see the same behaviors in airports or on planes. Please examine and address the upstream behaviors that precede violence.”

While federal OSHA said it would not likely include verbal incidents in an antiviolence rule, the agency did request more information on the issue.

“What approach might the agency take regarding those threats, which may include verbal, threatening body language, and written, that could reasonably be expected to result in violent acts?” OSHA asked in the RFI.

While the Cal-OSHA regulations are in the books, the national effort could run straight into political headwinds with an incoming administration that may not look too favorably on existing regulations, let alone new ones.

“We know at the federal level OSHA [rulemaking] has historically been a much slower process,” Castillo says. “However, we know that workplace violence is an acute problem that nurses, healthcare workers, and the public are faced with. We believe that when it comes to ensuring that hospitals are safe havens for patients to make a full recovery, we intend to advocate that every hospital is safe. We are going to be there at the federal level and we will continue to work with various states for state regulations as well.”

In a sense, the threat of violence is among the many occupational threats — from needlesticks to patient handling — that require advocacy and action by healthcare workers if protections are to be put in place.

“None of these health and safety regulations came about on their own,” Castillo says. “Nurses must engage in education, advocating, and working collectively to take the healthcare industry on. The healthcare industry is privatized and they have concerns primarily with their profit margin. For us, when lives are at risk, we believe that health and safety comes before profits. We are not dealing with inanimate objects, we are dealing with human lives.”


  1. OSHA. Prevention of Workplace Violence in Healthcare and Social Assistance. Fed Reg. 2016-29197. Dec. 7, 2016: http://bit.ly/2hB5gL5.
  2. GAO. Workplace Safety and Health: Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence. April 14, 2016: http://bit.ly/1Nzd8Ti.
  3. Cal-OSHA. Workplace Violence Prevention in Healthcare. 2016: http://bit.ly/2ia1xF4.