Taking the first step in what is likely to be a protracted political struggle, OSHA recently announced it will promulgate a federal regulation to protect healthcare workers from a shocking epidemic of violence.

The decision came at a Jan. 10, 2017, public meeting in Washington, DC at which the standard litany of assault rates and statistics was devastatingly humanized by first-person accounts of healthcare workers.

In the current political environment, any new regulation could face stiff resistance, but after hearing such stories it may be hard to argue pros and cons, as academic discussions give way to a growing sense of outrage.

“I’ve been bitten, kicked, punched, pushed, pinched, shoved, scratched, and spat upon,” said Lisa Tenney, RN, of the Maryland Emergency Nurses Association. “I have been bullied and called very ugly names. I’ve had my life, the life of my unborn child, and of my other family members threatened, requiring security escort to my car.”

Unfortunately, such stories are not uncommon. (For more information, see related story in this issue.)

“It is clear that workplace violence is a serious occupational hazard that presents a significant risk for healthcare and social assistance workers, and I believe that a standard protecting healthcare and social assistance workers against workplace violence is necessary,” said David Michaels, PhD, MPH, the outgoing assistant secretary of labor for OSHA. “I am pleased to announce, as one of my last actions, that OSHA will grant [HCW/union] petitions and will commence rulemaking to address the hazards of workplace violence in the healthcare and social assistance industries.”

OSHA issued a request for information1 on Dec. 7, 2016, asking for comments and suggestions as to how to best proceed with violence prevention strategies in healthcare. The comment deadline is April 6, 2017.

OSHA was prompted to pursue rulemaking by a recent GAO watchdog report2 that cited staggering levels of assaults in hospitals, with attacks resulting in lost work days “at least” five times higher than private sector industries overall. Efforts to use the OSHA General Duty Clause to enforce existing protections have been minimal and ineffective, the GAO found.

“The collapse of America’s mental health system has resulted in emergency rooms and hospitals being filled with patients in need of scarce inpatient psychiatric facilities, outpatient psychiatric facilities, and especially medical psych beds and medical geriatric psych beds,” Tenney said. “This has resulted in ER psych orders, frustrated patients and family members, and it has increased violence. We ask that the OSHA [regulations] be coordinated with and complimentary to any efforts being undertaken by other federal agencies who are addressing the mental health crisis. While it’s important that workplaces internally mitigate violence, it’s also important for us to get to the root cause of the violence. As a nation, we need to have zero tolerance for anyone who hurts a healthcare worker, a patient, or a visitor.”

While that level of violence is disturbing in any context, it actually represents an undercount because many assaults go unreported by healthcare workers.3 The attacks are primarily made by patients or their family members, and healthcare workers that do not report incidents may fear reprisals or think that no action will be taken by administration. However, the grim prevailing dogma that violence “is just part of the job” is starting to be roundly rejected.

“We know that workplace violence could be dramatically reduced if employers respond to our concerns and develop comprehensive prevention plans to protect workers,” said Jean Ross, RN, co-president of National Nurses United, the largest union of registered nurses in the country. “OSHA cannot stand by and watch one more injury, one more threat of violence, or one more death to healthcare workers that serve patients across this country. The well-being of nurses, healthcare workers, and their patients must be safeguarded, and it’s past time for OSHA to mandate these protections.”

Mental Anguish

The psychological effect of an assault may linger beyond the physical pain, becoming a traumatic echo that remains with the worker long after the incident.

“Aside from sustaining a physical injury, being a victim of assault from a patient is vastly different from any other type of healthcare-related injury,” said Erin Johnson, RN, of the Massachusetts Nurses Association. “Workplace violence has a psychological component that vastly affects one’s mental ability to feel safe and secure when returning to work, and it takes support from employers to regain these feelings.”

An RN for seven years, Johnson was recently attacked while working on a child and adolescent inpatient psychiatric unit at Providence Behavioral Health Hospital.

“Working with children ranging from ages 5 to 12 years old, I am more likely to be hit or kicked than I would be if I were working with older adolescents or adults, due to the higher tendencies of their impulsive behaviors,” she said. “Recently, I was a victim of workplace violence, and although my experience may not seem horrific, it is one of the many examples occurring across the country.”

Two patients broke through a secure door and escaped the unit last Christmas Eve.

“As these patients were being safely returned, I was punched in the back twice and bit on the inner portion of my upper right arm,” Johnson said. “After my shift ended, I cried for what felt like hours, because I was in such a state of shock. I felt hurt, frustrated, sad, and most of all, angry.”

The frustration may be widely felt when healthcare worker advocates are faced with the long slog it will take to pass an OSHA regulation under an administration that is moving to deregulate federal government.

While the recent passage of a California law4 to prevent violence in healthcare certainly adds momentum to enactment of a national standard, hospital ownership and healthcare administrators will certainly raise the issue of costs, staffing, and warn against stigmatizing patients by “criminalizing” them, said Katherine Hughes, RN, with the SEIU Nurse Alliance of California.

“I don’t want to criminalize the patient,” she said. “I’m a nurse. I’ve taken care of white supremacists. I’ve taken care of gang members. I’ve taken care of murderers. I’ve taken care of the homeless. I’ve taken care of the hospital CEO. I’ve taken care of someone’s grandma. We were able to show [in California] that healthcare workers don’t really care where people came from. We treat them all the same, most of us.”

Hughes also takes exception to the common argument that violence is unpredictable and regulations cannot effectively prevent incidents.

“But you can predict it,” she said. “You know patients coming out of anesthesia might act up. So, do some training for people in the recovery room on what those things might be, right? I think it’s really important that we can show our employers that if we had a little bit more time and a little bit more staff, we might actually be able to prevent some of the stuff that they say is unpreventable.”

Yet, as urgent as the problem is, the OSHA process to enact regulation takes years of hearings, stakeholder meetings, and various and sundry bureaucratic and political requirements.

“I think the GAO assessed that generally, it takes on average about seven years,” said Jordan Barab, deputy assistant secretary of labor at OSHA. “But again, it is a process. It will require constant vigilance on your part to move the process forward, and if the crowd here is any indication, I’m sure constant vigilance will not be a problem. I think the evidence is clear in terms of the significant risk that workplace violence poses, in terms of the cost that workplace violence imposes upon employers, and particularly workers — not just in terms of money, but in terms of their physical and mental health.”

Without Warning

While expressing disappointment at the projected timeline for OSHA regulation, James Phillips, MD, of the American College of Emergency Physicians, said there are some positive signs of progress and the medical community should not be discouraged.

“We can’t just rely on our government representatives and our organizations in Washington to make those decisions for us,” he said. “As not only victims and healthcare providers, but as the research experts and those of us who are affiliated with them, it’s our job to develop consensus, expert guidelines to help guide hospitals and other facilities going forward.”

Having published a recent review article5 on violence in healthcare, Phillips said he was, in part, motivated by attacks by patients in his work in emergency medicine and surgery.

“I’ve had a patient convicted of felony assault against me,” he says. “But even worse was the fact that during my surgical residency, I actually had an intoxicated patient intentionally spit hepatitis C-positive blood in my eyes. I had no idea it was a crime. It was witnessed by the police, who didn’t make mention of it. My attending said nothing. I visited occupational health, getting tested for the next six months.”

One reason healthcare workers are not prepared for occupational violence is that the threat is not emphasized in medical school, he added.

“There’s no training in medical schools to tell you, ‘Hey, you are about to enter into the most violent industry outside of law enforcement in the United States. Be prepared,’” Phillips said. “Never — not one time in four years of medical school, nine years of residency, and a year of fellowship. I’m not qualified to speak about nursing school, but I certainly can say that the vast majority, if not all, medical schools do not discuss workplace violence or what you’re entering into."

REFERENCES

  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. Pompeii LA, Schoenfisch A, Lipscomb HJ, et al. Hospital Workers Bypass Traditional Occupational Injury Reporting Systems When Reporting Patient and Visitor Perpetrated (Type II) Violence. Am J Ind Med 2016;59(10):853-865.
  4. Cal-OSHA. Workplace Violence Prevention in Healthcare. 2016: http://bit.ly/2ia1xF4.
  5. Phillips, JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med 2016; 374:1661-1669.