OSHA Violence Prevention Draft Reg Gathers Momentum
AOHP conference: Violence in healthcare an ‘outrage’
By Gary Evans, Medical Writer
Making slow but steady progress on an intractable problem, the Occupational Safety and Health Administration (OSHA) is expected to issue a violence prevention draft standard for healthcare in 2023, Hospital Employee Health has learned.
The need for regulation is compelling, particularly since violence in healthcare is notoriously underreported. But consider the available numbers. Excluding healthcare, the average number of workplace violence incidents per 10,000 workers in all other industries is 0.6. By the same measure, violent incidents for healthcare and social service settings per 10,000 workers is 17.3, said Ryan Tremain, MPH, a health scientist at OSHA.
“Healthcare violence is about 30 times greater than all other industries, which is pretty ridiculous if you think about it,” he said at the annual conference of the Association of Occupational Health Professionals in Healthcare (AOHP) in Austin.
Moreover, the American College of Emergency Physicians (ACEP) released a survey showing violence is worsening and that EDs are virtually under siege.1 (For more information, see the related story in this issue.)
Attacks on healthcare workers have triggered a mix of state laws, often named after the victims who were killed by the patients they were trying to help. Lynne Truxillo, RN, came to aid of a co-worker under attack by a patient at Baton Rouge (LA) Hospital on April 4, 2022. The patient turned on her, chasing her and slamming her head on a desk. She initially survived as other healthcare workers came to the scene and subdued the patient. However, less than a week later, Truxillo died of blot clots directly linked to the attack. Louisiana Gov. John Bel Edwards recently signed a bill into law bearing Truxillo’s name, making any attack on a healthcare worker a felony. Officials are posting signs warning of legal consequences in healthcare facilities across the state.2
Several states have enacted various laws to protect healthcare workers and discourage patient attacks, but anti-violence advocates like Lynda Enos, RN, MS, COHN-S, CPE, say a comprehensive OSHA regulation would be preferable to a patchwork of state legislation.
“If we have a standardized law as we do with bloodborne pathogens, at least we are all on the same page,” Enos tells HEH. “It does sound like we have a chance to get this through, or at least OSHA will do it without the Congress.”
Move Forward with Best Practices
Although passage is an open question, two major anti-violence bills are in various stages of the legislative process in Congress. One is HR 7961, the Safety from Violence for Healthcare Employees (SAVE) Act.3 The other is the Workplace Violence Prevention for Healthcare and Social Service Workers Act, SB 4182 and HR 1195. The bill calls on OSHA to issue enforceable standards requiring healthcare and social service employees to implement workplace violence prevention plans.4
An occupational health consultant in Oregon, Enos joined Tremain and several other speakers at a keynote panel discussion on violence at the AOHP conference. As different approaches and tactics were discussed, Enos warned there is little peer-reviewed research on any of them.
“There is very little evidence about which intervention or which group of interventions will prevent and control violence in healthcare,” she told AOHP attendees. “We have to rely on each other and best practices. We can’t wait 20 years for the research to be published.”
In that regard, an OSHA regulation on violence should not be overly prescriptive, but Enos tells HEH the drafts she has seen seem to be striking the right balance.
“It looks pretty programmatic and would not violate what we have to do for The Joint Commission,” Enos says. “I think we absolutely need it. My concern is that it will take the spotlight away from musculoskeletal disorders and slips, trips, and falls because a lot of resources are going to be directed at this.”
A chronic problem in preventing healthcare violence is underreporting of incidents, with a slew of barriers from the patient’s condition to the complexity — and often futility — of going through the legal system to press charges. According to research by Enos, other factors include fear reporting will reflect poorly on the healthcare worker, pressure not to undermine “patient satisfaction,” fear of retaliation from the patient or their family, and that reporting will result in no action by the hospital.5 Perhaps as big an issue as any of these is the ingrained old-school perception that occasional violence is an unavoidable consequence of delivering healthcare.
William Buchta, MD, MS, MPH, of the American College of Occupational and Environmental Medicine, conceded he held this old-school mindset until a series of incidents turned his attitude to “outrage.” The emerging link between patient violence and nurse resignations has driven the point home, as administrators look at an ongoing exodus of staff due to the pandemic.
“We have got to stop this,” said Buchta, who moderated the AOHP discussion. “Do we really need another reason for healthcare workers to leave the field?”
There is an emotional harm that resonates beyond a physical attack, he said, describing a woman who had worked as a psychiatric nurse for 30 years until a patient pulled her hair and punched her.
“That just snapped her — that was it,” Buchta said. “She was done with psych nursing. She was reassigned, and I think she left nursing soon after that. It wasn’t the physical injuries. It was, ‘Why do my patients do this to me?’”
Similarly, a nurse working in internal medicine was intentionally tripped by a patient in a wheelchair. “As she walked past the patient, this guy intentionally stuck out his leg and tripped her, and she fell and hit her face on a sink,” Buchta recalled. “It was pretty serious injury, but it was also the emotional injury again of, ‘Why would my patient do this to me?’ She didn’t go back [to work].”
Another nurse, in her third trimester of pregnancy, was kicked in the stomach by a patient and delivered prematurely. Her infant was in the NICU for weeks. As a result, the nurse faced financial problems and had to move to another state.
“While this was going on, one of her [colleague] nurses was raped by a patient during a third shift. What was my reaction? Outrage,” said Buchta, who directed employee health at the Mayo Clinic for 15 years.
AOHP panelists also discussed cases when dissatisfied patients return with a weapon. On June 1, 2022, a patient in Tulsa, OK, complaining of post-surgical back pain shot and killed his orthopedic surgeon and three others before turning the gun on himself.6 While there was no indication the physician was at fault, liability concerns may deter clinicians from recognizing the pain and apologizing to the patient.
“If more of my colleagues were allowed to say, ‘I’m sorry this happened to you’ when things go wrong, I think a lot of these things wouldn’t happen,” Buchta said. “Unfortunately, we are told, ‘Don’t talk to them, don’t bring it up.’ That makes you look callous and uncaring, and I don’t think that is really the case. We need to communicate properly without necessarily admitting guilt but showing some empathy. Some of these people simply want to be acknowledged — the patient got hurt and you were part of this process.”
OSHA Reg Gaining Momentum
Citing the bills in Congress and The Joint Commission’s antiviolence standards effective this year,7 Tremain said there is some momentum as OSHA awaits sign-off as required by the Small Business Regulatory Enforcement Fairness Act (SBREFA). This process will be completed in the fall or winter, with the completion of the draft standard to follow in the ensuing months.
“OSHA is ready to go through with the SBREFA process and is currently drafting text in all of the various supporting [areas] — hundreds of pages of the document that we need to move forward with the process,” Tremain noted.
One reason OSHA is seeking a standard is it can currently only enforce measures to prevent violence against healthcare workers with its General Duty Clause, which states employers must provide workers with a job site “free from recognized hazards that are causing or are likely to cause death or serious physical harm to employees.”
OSHA has been working on a violence prevention standard for years, but the effort stalled with the anti-regulatory stance of the previous presidential administration. Still, OSHA requested information and comment on workplace violence and published a book of guidelines and resources in 2016.8
The OSHA draft standard will apply to hospitals, EDs, psychiatric hospitals, residential behavioral health facilities, ambulatory mental health and substance abuse treatment centers, residential care facilities, and home healthcare.
As proposed in the draft standard, healthcare employers must establish a workplace violence prevention program and regularly assess and mitigate potential violence hazards. “Employers and employees would jointly conduct workplace violence hazard assessment,” Tremain said. “Employers will implement control measures. There will be pretty extensive workforce training as well as violent incident investigation and recordkeeping”
The proposed standard will address only Type II violence, which are attacks by patients and visitors on healthcare workers. “There are a lot of important considerations that we have to navigate in going forward with this,” Tremain said. “That’s what we went to the Office of Management and Budget with, and it was approved for rulemaking. This would not cover cases of nurse bullying or perhaps assaults from a healthcare worker’s intimate partner.”
Another issue is sensitivity to patients and families who do not want their loved ones placed in a facility that treats them as if they are a hazard. “Particularly in the behavioral settings, [families] have expressed concerns that might be the way we are leaning without seeing the draft text,” Tremain noted. “We are certainly keeping that in mind and are navigating around such issues.”
Healthcare workers who believe leaders are ignoring violent incidents at their facilities can call OSHA’s whistleblower hotline and their identity will be protected, Tremain added.
The Varieties of Violence
In a free-ranging discussion that included questions submitted by AOHP attendees, multiple reasons were given for patient violence, including improper or lack of medication, dementia, and fall prevention attempts by healthcare workers. In the latter situation, healthcare workers sometimes are hit and kicked when they are attempting to stabilize a patient who is a fall risk. Dementia patients may lash out because they cannot see who is touching them.
“That person does not remember that you told them to stay in bed,” said Bobbi Jo Hurst, RN, BSN, COHN-S, AOHP community liaison. “That patient has limited vision. They are just protecting themselves. We need training in how to properly have them see us and talk to us. We did a pilot program on this, and the nurses that went through did so well with these patients.”
Nursing and other medical schools may not prepare students for such situations, so it often must be handled at the clinical level. “Dementia, post-anesthesia patients — they are not intending to hurt, but it still hurts, right?” Buchta asked. “Enter their field of vision, engage with the patient before you touch them. It’s really simple things like that.”
Many incidents have been traced to the politicization of COVID-19 and crowded EDs, as people with other conditions delayed care during the height of the pandemic. Some random incidents, like the ones Buchta mentioned, remain somewhat inexplicable. Although they were “healthcare heroes” early in the pandemic, it is possible the acceptance of violence in healthcare for years has become part of the public/patient psyche. Of course, violence in general is a mainstay of the entertainment industry. A study in Scotland hypothesized media reports of violence against nurses were exacerbating the problem. Studying press coverage of workplace violence in healthcare from 2006-2016, the authors reported nurses were frequently depicted as “helpless.”9
“We concluded that media coverage of violence and aggression was overwhelmingly negative and reductionist,” the authors wrote. “Normalization of violence and aggression was an accepted and acceptable part of the nursing role.”
A Surreal Discussion
There were open questions during the AOHP panel about whether nurses should wear panic buttons, or even arm themselves with pepper spray or guns. This seemed a surreal area of discussion for healthcare, but it highlighted how deeply ingrained patient violence has become. Nurses with guns was a bridge too far, with panelists citing the need for training and the likelihood a weapon could be taken and used against healthcare staff.
“What scares me about that is if you are a nurse doing patient care and you are carrying a weapon, what would happen if a patient got hold of it?” Hurst asked. “I would not know the [nurse’s] level of training. Our security officers carry weapons, and they went through training to use them.”
The evidence base shows that in 10% to 20% of gun-related incidents in hospitals, the perpetrator took the gun from a security guard, Enos said. “We had a nurse in Oregon who took a gun to work,” she added. “It’s a carry-concealed permit state. She dropped her purse, and the gun discharged in the nurses station. No one was injured, but she was terminated.”
Some hospitals are using body alarms or panic buttons staff can use to alert colleagues of a dangerous situation. There also is the abiding perception that using panic buttons too often will lead to lead to alarm fatigue and unfavorable views of staff who call “too many” codes.
“We need to encourage healthcare workers to call the code when they feel threatened or afraid,” Hurst said. “If the de-escalation doesn’t work, you need to be getting people there. If you continue trying to de-escalate and it is not working, you may be in trouble. We put the panic buttons there for a reason — to be used. I don’t know that they can be used too often.”
Metal detectors and the use of body cams also were discussed. “I think we might have a HIPAA problem with body cams,” Enos said. “Is it going to prevent violence, or just catch the perpetrator after the fact? I don’t know. We have a couple of hospitals in the Northwest who tried metal detectors. It’s a very expensive proposition, and there are so many entrances they couldn’t put a metal detector everywhere. They went to the [metal detector] wands, which are more cost beneficial. Because of COVID and the violence we have seen, we have just put in a metal detector in our ED. Gang members were coming in to retaliate against an injured person in a rival gang.”
- American College of Emergency Physicians. Poll: ED violence is on the rise. August 2022.
- Carver MC. New Louisiana law aims to prevent health care facility violence. New Orleans City Business. Sept. 19, 2022.
- 117th Congress. H.R.7961 — SAVE Act. June 7, 2022.
- 117th Congress. H.R.1195 — Workplace Violence Prevention for Health Care and Social Service Workers Act. Feb. 22, 2021.
- Enos L. Workplace violence in hospitals: A toolkit for prevention and management. Oregon Association of Hospitals Research & Education Foundation. December 2017.
- Bella T, Knowles H, Bever L, Kornfield M. Tulsa gunman angry over pain after back surgery, police say. The Washington Post. June 2, 2022.
- The Joint Commission. R3 Report: Workplace violence prevention standards. June 18, 2021.
- Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 2016.
- Hoyle LP, Smith E, Mahoney C, Kyle RG. Media depictions of “unacceptable” workplace violence toward nurses. Policy Polit Nurs Pract 2018;19:57-71.
Making slow but steady progress on an intractable problem, OSHA is expected to issue a violence prevention draft standard for healthcare in 2023. The need for regulation is compelling, particularly since violence in healthcare is notoriously underreported.
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