With the COVID-19 standard moving through the final stages toward finalization, OSHA is expected to next issue a violence prevention draft standard for healthcare in 2023.
The need for action is scrawled in blood. On Dec. 30, 2022, a 40-year-old female healthcare worker was fatally shot in the employee parking lot at Geisinger Hospital in Danville, PA.1 No suspect was apprehended as this report was filed. The incident follows the Oct. 18, 2022, stabbing death of a behavioral health nurse by a patient in a facility in Durham, NC. She was well liked and was readying to pursue a doctorate, prompting a statement from the NC Nurses Association.
“Her loss has shaken the nursing profession throughout North Carolina,” said Meka Ingram, RN, the association’s president.2 “Violence in the workplace is one of the greatest challenges facing nurses, and the problem has grown exponentially over the last few years.”
Earlier in 2022, six healthcare workers were killed by patients in two separate incidents in Tulsa, OK, and Dallas. (For more information, see the story in the January 2023 issue of Hospital Employee Health.)
Although seemingly paralyzed by political divisions, 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
Meanwhile, OSHA is moving independently. As described by Ryan Tremain, MPH, a health scientist at OSHA, the draft standard would require healthcare employers to create workplace violence prevention programs and regularly assess and mitigate potential violence hazards.
“Employers and employees would jointly conduct workplace violence hazard assessments,” he said at the 2022 conference of the Association of Occupational Healthcare Professionals in Health. “Employers will implement control measures. There will be pretty extensive workforce training as well as violent incident investigation and recordkeeping” (For more information, see the story in the November 2022 issue of Hospital Employee Health.)
The OSHA draft standard will apply to hospitals, residential behavioral health facilities, ambulatory mental health and substance abuse treatment centers, residential care facilities, and home healthcare. The proposed standard will address only Type II violence, which are attacks by patients and visitors on healthcare workers.
Point Blank
A comprehensive OSHA regulation would be preferable to a patchwork of state antiviolence legislation, said researcher and occupational health expert Lynda Enos, RN, MS, COHN-S, CPE, ergonomics/human factors consultant with HumanFit, LLC.
A leading proponent and frequent speaker on healthcare violence prevention, Enos has looked down the barrel of a gun in a healthcare setting — literally.
“I’ve been in a situation where the father of one of the children in our ICU brought a gun to the unit and threatened all of us,” Enos recalled at a recent American Nurses Association webinar. “We were fortunate enough that a staff member was able to do a silent alert for our security. They were able to subdue the father until the police arrived. No one was hurt, but we were all scared. Hopefully you never have to be exposed to that, but you have to be prepared, unfortunately.”
The author of a workplace violence prevention toolkit5 for Oregon hospitals, Enos said healthcare violence can cause PTSD and, somewhat surprisingly, presenteeism.
“You’re working in physical, psychological pain and cannot perform your job 100% and provide the best care for patients,” Enos said.
Healthcare violence is another key driver of staff shortages, which ECRI identified in 2022 as the greatest threat to patient safety.6 The second-greatest threat was the mental health of healthcare workers. Factor in the enduring pandemic — during which violence has increased7 — and you have the makings of a vicious cycle.
“Overall, exposure to violence leads to higher rates of turnover,” Enos said. “If we look at the research overall, we know that as the workload increases for our nurses, there’s more fatigue and error, and the likelihood of patient death increases significantly.”
The risk to healthcare workers increases when they are working with patients in pain, with cognitive impairment, substance abuse problems, and mental illness.
“There are many different reasons why they may become aggressive or act out,” Enos said. “They may want to leave, and you don’t want them to leave. They might be frightened of needles, medical devices, or you are trying to redirect them back to their room.”
Proactively addressing these risk factors to the degree possible may prevent severity of incidents and injury to staff and other patients. Violence prevention training and minimizing situations where staff are isolated or working alone with patients can help. Also address community risk, including gang violence and drug use in areas surrounding the hospital.
“As your workplace violence committee works on the program internally, you want to partner with your behavioral health partners in the community,” Enos said. “Emergency medical services, law enforcement — all of them should be working with you to improve communication.”
For example, EMS can advise staff they are bringing in a patient who is verbally aggressive and potentially violent. “If you have a heads up from EMS, you can be prepared to control that situation,” Enos said.
Leadership Must Be Engaged
It is unlikely violence prevention programs will succeed in facilities where administrative leadership is not actively engaged in the problem and does not follow up timely on reported incidents.
“I was working with a behavioral health nurse with 20 years of experience,” Enos said. “She was nearly strangled one night on the job by a psychotic patient.”
A co-worker pulled the patient off the nurse and the situation was brought under control. “She went to the emergency room with a lot of bruising around her neck, and then had to wait there for four hours before she got treatment,” Enos said. “She then went home and heard nothing from her employer. She said, ‘You know, this was traumatic in itself. I nearly died. But the fact my employer didn’t care about me, I now want to leave nursing.’ After 20 years.”
REFERENCES
- CBS3 Staff. Pa. hospital employee gunned down in parking lot: Police. CBS News Philadelphia. Dec. 31, 2022.
- Hoggard D. “It’s very painful’: Raleigh family mourns loss of loved one killed while working at recovery center. ABC 11 Eyewitness News. Oct. 20, 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.
- Oregon Association of Hospitals and Health Systems. Workplace violence prevention toolkit. Content last reviewed March 2020.
- ECRI. ECRI reports staffing shortages and clinician mental health are top threats to patient safety. March 14, 2022.
- 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.
With the COVID-19 standard moving through the final stages toward finalization, OSHA is expected to next issue a violence prevention draft standard for healthcare in 2023.
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