By Gary Evans, Medical Writer

With a national wave of violence in healthcare resulting in little substantive federal action, states are moving to enact laws to protect nurses and their colleagues from workplace violence. Effective Jan. 1, 2019, Illinois has passed a sweeping state law to protect healthcare workers from violence after a horrific assault on two nurses last year by a prisoner who had disarmed a guard.

“We spent over a year crafting the law and got true input from nurses on the ground that are experiencing these acts of violence every day,” says the bill’s sponsor, State Rep. Stephanie Kifowit (84th District). “We made it as all-encompassing as possible. Other states may want to use this at least as a base.”

The state law requires hospitals in Illinois to have violence prevention protocols in place and includes specific requirements for handling of inmates under medical treatment. The law also provides whistleblower protections for workers who report violent incidents and requires specific action by healthcare facilities in response.1 (See requirements in this issue.)

The 2017 incident that led to the law occurred at a hospital in Geneva, IL. An inmate brought in for treatment stole his guard’s gun and took two nurses hostage, sexually assaulting one before being shot by police.

“I have heard from a lot of nurses that were very happy that this law passed, from the nurses that were engaged in the incident and nurses in general,” Kifowit says. “It’s tragic that such a horrific thing had to happen for us to take a long look at the procedures, but I think we’ve made a safer environment for all nurses — we extended this to all healthcare workers.”

Though violence in healthcare is a longstanding problem, there are signs that it is getting worse. In a study published this year, the National Institute for Occupational Safety and Health (NIOSH) analyzed workplace violence injury surveillance data from 2012 to 2015.2

Overall, 105 participating hospitals reported an increase in the rate of workplace violence injuries by 72% over the time period. The rate went from 4.4 injuries per 1,000 full-time equivalent (FTE) workers in 2012 to a high of 7.6 per 1,000 FTE before declining to 7.2 in 2015.

At the federal level, the Occupational Safety and Health Administration (OSHA) announced last year that it would develop a standard to protect healthcare workers from violence. But so far, the OSHA action has been a nonstarter.

And the Health Care Workplace Violence Prevention Act (H.R. 5223), a bill introduced at the federal level in March of this year, also is facing opposition. If passed, it would essentially require OSHA to develop a violence prevention standard for healthcare.

States Take Action

Given these circumstances, individual states have acted with a wide variety of antiviolence laws and regulations. According to the American Nurses Association (ANA), California, Connecticut, Maryland, Minnesota, New Jersey, and New York also require workplace violence programs in healthcare. New York’s law is limited to public healthcare employers, and Washington requires reporting of violent incidents. Many other states have established specific penalties for assaulting nurses and other healthcare workers beyond existing statutes.

The ANA does not lobby at the state level but has continued to push for national action to prevent violence in healthcare. More than laws alone — at any level — will be needed to stem the tide of violence in healthcare, says Janet Haebler, MSN, RN, senior associate director of policy and state government affairs at the ANA.

“Illinois and other states have passed laws, but it’s just one tool in the toolkit,” she says. “Legislation alone will not reduce workplace violence. Additionally, with any law, the details captured in the regulations and whether there is a provision for enforcement make a difference as to the effectiveness.”

While many healthcare employers may have zero-tolerance policies on the books, the reality is that healthcare workers can be reluctant to report violence. That means the current high level of incidents actually underestimates the problem.

“ANA convened a large group of nurses from across the country to identify why zero-tolerance workplace policies are insufficient,” Haebler tells Hospital Employee Health. “Not surprisingly, we are hearing that underreporting is based on a fear of retaliation by the employer and/or a belief that no action will be taken.”

Discouraged From Reporting

This has become a common theme and was specifically cited in support of the Illinois law at an April 10, 2018, hearing. Alice Johnson, RN, of the Illinois Nurses Association (INA) said only 15% of roughly 200 state nurses recently surveyed said when they reported violence, management was supportive and tried to find solutions. Thirty-four percent said management was supportive, but nothing was done to solve the problem. Another 27% said that management was not supportive of reporting, she testified.

“And 6% said that management was intimidating or discouraged them from reporting the incident,” Johnson said. “Another 6% said that management harassed or blamed them when they reported the incident.”

Based on such reports, whistleblower protections were put into the bill, Kifowit says.

“We heard that individuals feared for their job if they reported violence,” she said. “We put some protections in so they can feel they are working in a safe environment.”

While providing such protections, the law assigns some responsibility to healthcare workers. The law requires that those who contact law enforcement about a workplace violence incident must notify their facility management within three days of filing the report.

The law also requires healthcare employers provide immediate post-incident care for assaulted workers, including medical treatment and access to psychological evaluation.

“What is the impact of this pervasive violence on our members?” Johnson said. “They experience difficulty concentrating on the job, psychological symptoms such as anxiety and sleeplessness, and physical symptoms such as headache and stomachaches.”

Interim results from the unpublished INA study show that three-quarters of the nurses responding said violence and abuse have been “serious problems” in their workplace in the last 12 months, she said.

A similar percentage of respondents said they “feared or anticipated violence” over the last year, and 41% said in general, they do not feel safe at work, Johnson testified.

Workers Experience PTSD

The psychological effects may be more difficult to quantify than physical injuries, but some reports are suggestive of a kind of post-traumatic stress disorder.

For example, Sonja McCarthy, RN, an ED nurse in a Level I trauma center in Chicago, said a co-worker who was attacked by a patient required months of counseling before she could return to work.

“I worked a shift last night and drove straight here because I feel like this is an important bill to support,” McCarthy testified at the hearing. “Every night in the ER, I am caring for patients that are verbally and physically aggressive toward our staff.”

A former Marine, McCarthy said she can take care of herself, but said a younger nurse who looks up to her as her “work mother” was attacked.

“She was violently attacked by a patient — slammed into a wall and beaten on her head,” McCarthy said. “She missed work because of her injury. When she came back after she was cleared of her injury, she could not stay at work. She had to leave and seek counseling to continue working in her chosen profession.”

Several months of counseling were necessary before she returned to work in the ED. “To this day, if we have a violent patient, she is reluctant to provide care,” she said. “Without a bill like this that provides some protection and guidelines, I don’t have a means to protect her if I am not there.”

The attack on the nurse was traced to a violent offender brought to the ER and left with little collaboration or communication with law enforcement, McCarthy said. The new law calls for protocols and communication between the hospital and law enforcement if someone is brought in that could be potentially violent.

“They have to have prior notice,” Kifowit says. “There is an enhanced protocol and understanding. The original [2017] incident involved a guard that was not properly trained, so we put in training as a mandate. They have to know how to handle these inmates and how to de-escalate a situation to ensure safety is a top priority.”

An initial proposal that two officers be required to bring in a prisoner for care received some pushback from budget-strapped state law enforcement agencies. With training for appropriate use of restraints and shackling, only one officer is required to be present, she said.

“We addressed their concerns, and they eventually came around,” Kifowit says. “The state hospital association was at the table from day one. They were very cooperative and had very good insights.”

Although the 2017 incident was the catalyst of the law, as they got into hammering out a bill, Kifowit and other lawmakers realized the issue goes beyond policies for prisoners and nurses.

“We realized there was a whole other avenue with regard to safety during [all] patient interactions that we needed to address as well,” she says. “So we also put in language for mandatory guidelines for general workplace safety.”

The lawmakers in Illinois looked at laws in other states and held a series of stakeholder meetings, sometimes including 14 people around the table, Kifowit says.

“We looked at California and some other states,” she says. “In the end, we worked together to craft a law that is very comprehensive, includes all healthcare workers, and sets protocols for prosecution of violent patients and those in custody if they seek medical treatment. I think ours is one of the better laws.”

The law essentially codifies some OSHA recommendations and requirements, which in the absence of a specific standard, the agency can only enforce through its general duty clause.

As the bill was proposed and hearings began, many nurses came forward with stories to tell. At one point during the discussions, a nurse showed Kifowit a photo that had been taken after the nurse was punched in the the face by a patient.

“We need to hold patients accountable for their violence against nurses,” the legislator says. “We need to be able to prosecute them.”

Those calling for action in support of the law included Paul Pater, RN, a nurse who works in Chicago. Providing an unusual perspective to the issue, Pater submitted written testimony describing himself as an unlikely victim, being 6’2” tall, weighing 250 pounds, and having a full beard.

“As a registered nurse, working at two different emergency departments in my short career, I have been placed in a number of dangerous situations that have put my physical safety in danger,” Pater stated. “I have been punched, kicked, had my genitals grabbed, been threatened at knifepoint, [and] been threatened to be shot. I want you to imagine the terrors my fellow nurses have had to endure, who do not share my physical features.”

Noting he has been advised by management that such threats “are part of the job,” Pater said nurses will remain in danger until healthcare systems accept accountability and encourage reporting of such incidents.

“This bill is the first step in making that happen,” he said.

Various studies and surveys have cited factors contributing to the rising wave of healthcare violence, including the opioid epidemic and the lack of mental health treatment resources. In addition, workplace factors such as understaffing, high turnover, crowded conditions, and long patient wait times can contribute to violence. Until these variables are understood, laws can punish behavior but not always change it.

“Beyond reporting, there should be a process of analysis to identify the contributing factors,” Haebler says. “This will happen when there is a culture change and a true commitment to improving the safety of the environment for everyone. And that can’t be legislated.”


  1. Illinois General Assembly. Health Care Violence Prevention Act. Public Act 100-1051 (HB4100). Effective date Jan. 1, 2019. Available at:
  2. Groenewold MR, Sarmiento RFR, Vanoli K, et al. Workplace violence injury in 106 US hospitals participating in the Occupational Health Safety Network (OHSN), 2012-2015. Am J Ind Med 2018;61:157–166.