By Gary Evans, Medical Writer

Hundreds of hospitals and other healthcare facilities in California are implementing a statewide workplace violence (WPV) law, with an April 1, 2018, deadline looming to have a written WPV prevention plan in place.

Implementing the requirements of the state law — California SB 1299 — are proving challenging at some facilities, according to various complaints and concerns received by one of the principle organizations behind the law, the California Nurses Association/National Nurses United.

“We experience this with all of our health and safety protections — there is an initial resistance and we have to overcome that,” says Bonnie Castillo, RN, director of health and safety for the nursing union, which lobbied for the law and supports similar requirements nationally.

Indeed, considering the historical struggles to convince hospitals to adopt needle safety devices or purchase safe patient handling equipment, it should come as little surprise that implementing violence prevention programs will require a similar diligence.

“Right now, we are actively engaged in all of the hospitals where we represent registered nurses,” she says. “We have found that there are some misinterpretations [of the requirements] by the employers and we are providing clarifications. The nurses are exercising their collective voice — which is really a protective voice — in ensuring that the employers ultimately comply with the full extent of the regulations. In the non-union settings, we are hearing of some blatant disregard of the requirements.”

As previously reported in Hospital Employee Health, California’s Occupational Health and Safety Administration (Cal/OSHA) adopted the WPV regulations in 2016, with implementation beginning last year and proceeding in 2018.1 (For more information, see the February 2017 issue of HEH.) Cal/OSHA is the first state OSHA plan — which must have requirements at least as stringent as the federal agency — to adopt a healthcare violence prevention regulation. For its part, federal OSHA announced in January 2017 that it will develop a national standard for violence prevention in healthcare, but the effort is in regulatory limbo in the current political climate.2

The California law requires healthcare employers to perform an environmental risk assessment of the facility, looking for things like poorly lit areas, isolated workstations, lack of escape routes, objects that can be used as weapons, and entryways vulnerable to unauthorized access. In addition, healthcare workers must be trained on violence prevention, including information gained from the risk assessment. The Cal/OSHA law states that training must include “workplace violence risks that employees are reasonably anticipated to encounter in their jobs. The employer shall have an effective procedure for obtaining the active involvement of employees and their representatives in developing training curricula and training materials, participating in training sessions, and reviewing and revising the training program.”1

The law calls for initial training on hire, when an employee is assigned new duties, and an annual in-service review.

“We are very concerned about training,” Castillo says. “We are ensuring that all of the training is given to all the employees and has to include all of the basic information specific to the workplace. Typically, [employers] may go to a cookie-cutter plan but the regulations require a plan specific to the facility and individual units.”

Healthcare workers at some facilities are reporting they have insufficient input into the violence prevention plans being set up at their facilities, though the regulation clearly states worker input should be part of the process, she adds.

“There are also complaints that some of the employers do not have a clear way to report incidents of workplace violence,” Castillo says. “That’s obviously critical to get a grasp of the severity of the problem.”

Whistleblower Protections

While such concerns may not be surprising as the law is phased in, healthcare worker advocates want to achieve voluntary compliance rather than seeking Cal/OSHA enforcement. The law requires employers to allow workers to express concerns about workplace violence without fear of reprisal.

“But if [employees] have questions about the regulations, they are concerned about being labeled as a whiner or complainer,” Castillo says.

Hospital implementation of all aspects of the law should improve as facilities come up to speed with the requirements, but the law has some nuances that will require culture change at some worksites. Part of this is the longstanding perception by many healthcare workers that violence comes with the territory, and if no injury results, the incident need not even be reported, explains Pidge Gooch, MSN, RN, CENP, executive director of regional patient care service operations at Kaiser Permanente in Oakland.

“Recently, I was made aware of an issue where a nurse was scratched by a patient with dementia while the nurse was attempting to reposition the patient,” she says. “The patient got upset and scratched the nurse. Neither the nurse nor the unit leadership recognized this as an act of workplace violence because the patient had dementia; they didn’t really know what they were doing. But the law makes no allowance for altered mental status as an acceptable reason why a patient may get violent, nor exempts that event from being reported. That is a really hard concept for staff and leaders alike to wrap their minds around, which is part of the culture change that is needed.”

Moreover, even if no injury occurs, an act of violence should be reported. SB 1299 defines WPV as “any act of violence or threat of violence that occurs at the worksite,” including incidents that cause physical or psychological harm or involve a firearm or other weapon.

“One of the most challenging aspects of the legislation will be educating our staff to view events where there is no physical contact or injury as an incident of workplace violence,” Gooch says. “The legislation is focused on the threat of violence as well as the act of violence. Typically, occupational health nurses are involved following an actual injury, not the threat of one. Because of this, I believe it will be of paramount importance for the occupational health nurse to become one of the faces of workplace violence prevention.”

According to Gooch, key roles for employee health professionals include:

• participation in worksite analyses to identify risks and mitigation strategies;

• lead staff education programs to raise awareness;

• establish workflows for the post-event period to provide care and counseling to employees;

• assist hospital leaders to promote the reporting of WPV events, even when no contact or injury takes place.

“In educating our staff, we need them to see the occupational health nurse outside of their usual response role — and one of more proactivity in assisting the hospitals to build effective workplace violence prevention plans,” Gooch says.

Hospitals must create a workplace violence log, gathering information on any incident even if the healthcare worker was not injured. Absent of personal identifiers, the log is designed to highlight risk settings and behaviors that can be addressed in the WPV prevention plan.

“The log also must include post-incident responses and the resulting investigation into causes,” Gooch says. “Hospital leadership across the continuum, occupational health nurses, security personnel, behavioral health experts, and frontline staff are just some of the people on the multidisciplinary teams working on this.”

A Daily Risk

The essential facts are not in dispute; healthcare is a hazardous job. For example, federal OSHA was prompted to pursue rulemaking by a government watchdog report3 that cited a disturbing level of assaults in hospitals, with attacks resulting in lost work days five times higher than the private sector as a whole. Efforts to use the OSHA General Duty Clause to enforce existing protections have been minimal and ineffective, the Government Accountability Office found.

Healthcare workers are at daily risk of violence, primarily from patients and visitors. Gooch recently published an article4 on the California law which cited some sobering statistics, with approximately 24,000 assaults reported in healthcare settings between 2010 and 2013. Hospitals in the U.S. have reported increasing violent crime, up from two events per 100 beds in 2012 to 2.8 events per 100 beds in 2015.

Contributing factors that have been cited in the rising tide of violence in healthcare include the loss of mental health facilities nationally, and the staggering scale of the opioid epidemic. This may finally be changing to some degree, but another contributing factor is that violence awareness and prevention strategies have traditionally not been strongly emphasized in medical and nursing schools. However, more nurses are being taught concepts like situational awareness and de-escalation techniques to prevent and defuse potentially violent incidents. (For more information, see related article in this issue.)

While there are common requirements, themes and issues, it is expected that violence prevention plans in California will vary somewhat by facility and patient population, Gooch says.

“While a hospital system could have a standardized template, the very nature of a hazard risk assessment is that it is highly specific to the facility being evaluated,” she says. “Factors such as hospital services, patient demographics, and population served are just some of the elements that can vary by facility. While the specific subject matter is focused on WPV, most hospitals have a hazard vulnerability assessment, so the concept is not entirely new. I believe hospitals are up for the challenge.”

Besides creating and maintaining a log of all WPV instances, leaders must develop an effective response plan for potential events like an active shooter. As part of this preparation, evacuation and sheltering plans should be in place. Employee health professionals may be involved in providing care for victims, ensuring all involved are identified and providing trauma counseling in the aftermath, Gooch notes.

Such major events present a planning challenge, but the day-to-day struggle will be convincing healthcare workers to report individual acts of violence as defined by the new law.

“One of the greatest challenges occupational health nurses face is an awareness of incidents that are not reported,” Gooch concludes. “Collaboration with hospital safety officers, security, and other key leaders is necessary to integrate the occupational health team into the WPV prevention plan and increase staff awareness of the issues.”


1. Cal-OSHA. Workplace Violence Prevention in Healthcare. 2016. Available at: Accessed Dec. 28, 2017.

2. OSHA. Prevention of Workplace Violence in Healthcare and Social Assistance. Fed Reg 2016-29197, Dec. 7, 2016. Available at: Accessed Dec. 28, 2017.

3. Government Accountability Office. Workplace Safety and Health: Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence. April 14, 2016. Available at: Accessed Dec. 28, 2017.

4. Gooch, P. Hospital Workplace Violence Prevention in California: New Regulations. October 2017: DOI: 10.1177/2165079917731791.