A federal bill (HR-139) that would require an OSHA standard to prevent violence in healthcare passed the House Committee on Education and Labor, clearing the way for a possible vote by the full House.

“This bill enjoys bipartisan support, which is unique in these days,” says Michelle Mahon, RN, nursing practice representative for National Nurses United. “It is really encouraging to see that the public pressure and the outcry for protection of hospital worker safety has been heard.”

The Workplace Violence Prevention for Health Care and Social Service Workers Act was approved by the committee on June 11, 2019.

“Nurses across the nation hope that this bill will now be heard before the entire house,” Mahon says. “With continued public support, and people calling their legislators, this can happen. We have gotten this far.”

The issue has been subject to a protracted struggle for years, with OSHA finally agreeing in 2017 to promulgate a standard. Although still considered a political long shot, a similar bill has been introduced in the Senate (S.851) by Sen. Tammy Baldwin, D-WI. As of June 26, 2019, the bill’s 20 co-sponsors included the five Democratic senators who are running for president.

“We understand the nature of this struggle, and it is unfortunate,” Mahon says. “It should be a priority of the policymakers of this nation to protect healthcare workers from violence. These violent acts are preventable. We have been working on this a long time. We won this victory in California. We expect that this will move forward.”

While the California law is considered the model for national legislation, other states have not been quite as successful. For example, Nevada recently passed a healthcare violence bill (A.B. 348) after a series of compromises with state hospital groups.

“Unfortunately, the final version of A.B. 348 fell short of the strongest standard of protections, but we will continue to fight to win them in Nevada and nationally,” says Eleanor Godfrey, RN, director of health and safety at National Nurses United.

In what has become a depressing recurrence at state and federal hearings, several Nevada nurses testified about the occupational violence they face.

‘The Patient Was Right Behind Me’

Christy Tolotti, RN, an ED nurse in Reno, NV, testified that her hospital had already adopted some of the measures in the proposed bill, including alarms, improved environmental safety, and lockdown systems. The problem is that the measures were not implemented until after a violent incident occurred, and she expressed concern that other hospitals will be similarly reactive instead of proactive in preventing violence.

“About a year ago, one of my coworkers was stabbed while doing his job,” she said. “I was at work that day and responded to the incident.”

A patient had come in and registered, then stepped outside to smoke a cigarette. The patient was in violation of a hospital policy that prohibits smoking right outside a door, and a hospital tech stepped out and informed the patient. When the worker turned to re-enter the building, the patient stabbed him.

“The tech ran outside the door into the ambulance bay,” she said. “We have a camera in the ambulance bay, and I happened to see from the camera that the tech was running around. The tech then ran back inside and was stabbed a second time in the process.”

Tolotti assisted the tech, who was pale and going into shock, as codes were called and people were yelling.

“The patient was right behind me, yelling and screaming and waving the knife at the staff behind the registration desk, who were protected by a glass barrier,” Tolotti said. “The patient’s caregiver was trying to get the patient to drop the knife as security finally showed up and apprehended the patient.”

The ED tech survived — but, clearly, a worse outcome was entirely possible, she added.

“Our hospital was not ready for such an incident,” she said. “And even though there have been improvements in safety since the incident, it has all been reactionary. This is unacceptable.”

The staff carry personal alarms, but the onus is on workers to test them and ensure they are working, she said. Environmental improvements performed after the incident include garage-type doors that can be closed to block off equipment and other items that could be used as weapons if an aggressive, disoriented, or psychotic patient is in the ED, she said.

“Our hospital has a policy that whenever we have a shooting or stabbing victim come into the emergency department, we go on lockdown,” Tolotti said. “This is an important policy to protect everyone’s safety because there have been multiple times when a gang comes to the hospital to try to ‘finish off’ the victim.”

‘Categorically Different’

Such is the reality that healthcare workers face in a unique work environment, emphasizes Amy J. Behrman, MD, FACOEM, FACP, medical director of occupational medicine at the University of Pennsylvania in Philadelphia.

“It is categorically different,” she tells Hospital Employee Health. “The injuries that are incurred in healthcare settings are perpetrated by people that are delirious, in pain, out of control. Solutions that might be entirely appropriate for someone on an overnight retail shift are not going to work for a healthcare setting. I bring this up because there has been some discussion about whether this should be a more general OSHA mandate [on workplace violence].”

Berhman is the co-author of a letter supporting the federal legistlation recently issued by the American College of Occupational and Environmental Medicine (ACOEM).

“California has model legislation for this, but personally, I believe that a national mandate would be in the best interest of healthcare personnel rather than a state-by-state basis,” she says. “The numbers suggest that either there is more reporting, or there are more incidents of violence against healthcare personnel, or some mix of those two. It is certainly a severe and worsening problem. And the nurses bear the brunt of everything we are talking about.”

As previously reported in Hospital Employee Health, California’s Occupational Health and Safety Administration (Cal/OSHA), working with nurses in the state, adopted workplace violence regulations in 2016.

California nursing groups are ensuring that violent incidents in healthcare are reported under the new law, which is considered a first step in assessing its effectiveness, Mahon says.

“There is now some transparency and oversight in that regard,” she says. “We do know from the reports so far that the most common place for violence to occur is the patient room, followed by the emergency department and behavioral health units. We know now that specific units need further intervention and more prevention standards. The information [gained from reporting] will guide additional protection on these units.”

Citing the California law as the gold standard, National Nurses United wrote1 that the following elements should be included in a federal law:

• Broadly define workplace violence to include threats and the use of physical force, including incidents involving the use of firearms or dangerous weapons;

• Require employers to develop unit-specific and facility-specific prevention plans, instead of a general plan;

• Actively involve employees in developing, implementing, and reviewing the plan, and provide robust training programs for employees;

• Ensure that employers assess hazards and provide correction procedures, including staffing, trained security personnel, environmental risk factors, patient-specific risk factors, alarm systems, and job design and facilities;

• Require that employers establish effective reporting processes and policies to ensure that employees can report workplace violence without fear of retaliation; systems for communication between co-workers, shifts, emergency services, and law enforcement about risks for violence; and violent incident logs to track all incidents and threats;

• Mandate effective and prompt responses to all workplace violence incidents as well as appropriate follow-up, including providing prompt treatment to injured employees and investigating whether any measures could prevent similar incidents in the future.


  1. National Nurses United. Fact sheet: The Workplace Violence Prevention for Health Care and Social Service Workers Act. Available at: https://bit.ly/2RH7dW2.