Federal legislation that would require healthcare facilities to create comprehensive violence prevention programs is at a tipping point in Congress. The bill cleared the House with enough bipartisan support to raise hopes it will pass in the Senate.
The longstanding problem of patients and visitors attacking and verbally abusing healthcare workers has been worsened by the chaos and cultural divisiveness of the pandemic.1 Which raises the question: If not now, when?
“The abusive nature of the ED was bad before COVID, but I feel like COVID has made some people even meaner,” said Todd Haines, RN, BSN, president of the Tennessee state chapter of the Emergency Nurses Association (ENA).
A man of no small stature, Haines was a police officer for a decade before embarking on a second career as an ED nurse. After 12 years as an ED nurse, Haines left the bedside, he said at a May 4 rally2 for passage of the bill in Washington, DC.
“I’ve been verbally and physically assaulted more times in my 12-year career as a nurse than in my 10 years in law enforcement. That’s sad,” Haines recalled. “I’ve been threatened, my family has been threatened, by patients and also by their family members. It was so bad that it got to the point to where the first chance I got to leave the bedside, I did. Please understand that I love ED nursing at the bedside; it’s just gotten to a point to where I had to leave it, and I’m not alone.”
The Right Thing to Do
Haines spoke at a rally outside the Capitol building to support the Workplace Violence Prevention for Health Care and Social Service Workers Act,3 which has cleared the House and has been introduced in the Senate by Sen. Tammy Baldwin (D-WI).
“The bill would ensure that the healthcare and social service workplaces adopt proven prevention techniques and are prepared to respond in the tragic event of a violent incident,” Baldwin told the crowd. “As time is of the essence in this fight, I am excited to announce that this afternoon, I will go to the Senate floor and call for unanimous consent to fast-track this legislation. We have waited long enough for this important legislation. If my colleagues want to oppose this bill, they are going to have to come to the Senate floor and explain why.”
Citing government data that show acts of violence are 12 times higher against healthcare workers than other occupations, Baldwin called continued inaction as caregivers risk their lives on the frontlines of a pandemic “unacceptable.”
Although the Senate may be a tough hurdle to clear, the bill passed the House with 38 Republicans joining all Democrats in a vote of 254-166.
With physicians and nurses leaving their fields, and more shortages projected in the future, a “long-term systemic change” is needed in healthcare culture, said Jennifer Schmitz, MSN, EMT-P, CEN, president of the ENA.
“Protecting nurses and physicians is the right thing to do,” Schmitz said at the rally. “In what other service industry is it acceptable to spit on people, yell at them, or treat them poorly without really any repercussions? Police reports and prosecutors who charge offenders should be the norm and not the exception. Healthcare systems should see workplace violence prevention programs and initiatives as vital to staff, and not a burden.”
Within one year of passage, the legislation calls for healthcare employers to implement a comprehensive workplace violence prevention plan. At a minimum, the plans would include provisions previously published by OSHA. In 2016, the agency proposed a rule4 for preventing healthcare violence, but it was never finalized. If the federal law passes, it could be cited and enforced by OSHA and other federal agencies with healthcare oversight.
Law Requirements
Among other things, that congressional bill calls for annual training, reporting and investigation procedures, and workplace policies like staffing and working in teams. Violence prevention measures could include:
- barrier protection;
- monitoring systems;
- exit routes;
- security and alarm systems;
- adequate lighting;
- entry procedures;
- established areas for patients and clients;
- systems to identify and flag patients with a history of violence.
The law would require a risk assessment to identify workplace violence hazards. Any violent incidents would be subject to established reporting procedures, recordkeeping requirements, and anti-retaliation policies to protect employees who report incidents.
“Employers must correct, in a timely manner, hazards identified in any violent incident investigation and any annual report,” the bill states.
The bill could be a “game-changer” on an issue that been perceived too long as the risk healthcare workers take to administer care, Haines said. “It’s not a part of my job,” he emphasized.
If passed, the legislation would create an atmosphere of transparency and a supportive environment to report incidents of violence.
“This bill will help put protocols in place to provide investigative outlets when something like this does happen,” Haines said. “It will ensure that employees get the training and education for identifying and dealing with violent patients and families.
Several speakers concurred the perception of the problem is worsening. “I’ve never seen or heard as much worry and anxiety over safety in the emergency department,” said Ron Kraus, RN, immediate past president of the ENA. “The nurses I’ve talked to have told me heart-wrenching stories [about] concussions, broken bones, and the overall psychological scarring that comes with being attacked in the emergency department. Livelihoods have been disrupted. Passionate, dedicated care providers have become depressed and lost.”
Physicians’ Tales
Aisha Terry, MD, MPH, FACEP, practices at George Washington University Hospital. She spoke at the rally as a member of the American College of Emergency Physicians (ACEP).
“I think one of the issues is that many people don’t realize how bad it really is,” Terry said. “We think about it, and you assume you can go to work and feel safe. You assume you can serve as the safety net of this country, taking care of patients — certainly in the context of a pandemic — and not have to be worried about your safety. But the reality is that it really is a problem. It’s becoming more of a problem. Seven out of 10 emergency physicians say that they’ve noticed over the past five years an increase in workplace violence.”5
Terry recalled a violent incident she experienced. “I knew there was a patient behind me, in the patient room, and I knew that one of our nurses was caring for that patient at the time,” she said. “I was working on the computer, putting orders in and the like, and suddenly, I heard a really loud thump. I’ll never forget it. I can hear it to this day. Just a thump. I was like, ‘What in the world was that?’ It was followed by a second thump.”
Terry quickly turned around, seeing a nurse lying on the floor. “The first thump was from a patient having punched a nurse in the face who was taking care of him and trying to medicate him,” she said. “The second thump that I heard was her hitting the floor. Her body fell to the floor, and she was unconscious. We immediately scurried to her side to make sure that she was OK, to check on the patient as well to see what was going on with him. To this day, it has impacted her career. She’s developed some PTSD from it.”
Jennifer Casaletto, MD, an emergency physician and president of the North Carolina chapter of ACEP, also recalled serious incidents from her ED. “I was disheartened to be notified by colleagues of back-to-back assaults in two of our emergency departments over a holiday weekend this past January that resulted in severe injuries and at least one fatality,” she said. “Listening to my colleagues report these incidents, I know the terror that they felt in the moment — for themselves, for their colleagues, and for their patients. I know that raw fear of being attacked and the complex emotions that follow that fear.”
One of those is to stay, hoping the situation will improve — or bail from your chosen career.
“Hospital culture and law enforcement too often see workplace violence in healthcare as just part of the job,” Casaletto said. “We had several incidents at our community emergency department that followed in the next three to four months before my husband gave me an ultimatum — wear a Kevlar vest, or don’t go back to work at that emergency department. Our boys need a mother more than you need that job.”
REFERENCES
- McGuire SS, Gazley B, Majerus AC, et al. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med 2022;53:285.e1-285.e5.
- Emergency Nurses Association. ENA, ACEP push for swift passage of workplace violence legislation. May 4, 2022.
- 117th Congress. H.R.1195 - Workplace Violence Prevention for Health Care and Social Service Workers Act. April 19, 2021.
- Occupational Safety and Health Administration. Prevention of workplace violence in healthcare and social assistance. Federal Register 81:88147-88167. Dec. 7, 2016.
- American College of Emergency Physicians. Violence in emergency departments is increasing, harming patients, new research finds. Oct. 2, 2018.
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