After a required small business review, the Occupational Safety and Health Administration, (OSHA) recently reopened comments on its proposed draft standard to prevent violence in healthcare.
A state hospital association said the violence prevention standard “will result in unnecessary regulatory burden, substandard care practices, and additional expense without impacting the incidence and prevalence of violent events.”1
A national association for disability service providers said an OSHA violence prevention standard could have “a devastating impact” and add to their burden to a “harrowing degree.”2
Then, on July 22, a security guard at Legacy Good Samaritan Hospital in Portland, OR, was shot dead by a visitor who was angry and armed. Another healthcare worker was wounded but is expected to recover. Hospital security called police at mid-morning that day, saying a visitor of a patient was threatening healthcare workers. The shooter fled the hospital by the time authorities arrived, but police tracked down and killed the accused shooter. The security guard died protecting patients and fellow employees, the hospital said in a statement.3,4
The shooting follows the May 5 attack in Atlanta when a man who was denied a medication he requested became enraged and shot five patients in a waiting room. One died, a 38-year-old mother of two who worked at the CDC.5
The reams of research, news reports, and first-hand accounts continue to accumulate, revealing rampant danger in healthcare that grew worse during the pandemic. Yet there remains resistance to an OSHA standard, with few denying there is a problem while others argue a regulation would be duplicative of recommendations that are not working.
OSHA reopened comments after the agency’s Small Business Advocacy Review (SBAR) Panel finished their review of the draft standard and issued a report on May 1. The panel recommended the violence prevention standard be flexible, allowing employers to tailor their approach depending on the size and complexity of their facilities.
Several comments in response to the report agreed with this, but also questioned the need for a standard that duplicates other requirements or recommendations by The Joint Commission and other groups.
The SBAR report recommended that “OSHA review existing regulations, guidance, and accreditation standards on [workplace violence] prevention in determining the need for a rule, avoid duplication unless necessary to mitigate risks associated with workplace violence, and ensure any OSHA requirements do not conflict with other governing bodies or standards-setting organizations.”6
Concurrently, the small business panel underscored that healthcare workers are in danger of occupational violence from patients and visitors. “These workers face an increased risk of workplace violence (WPV) — nearly six times that of workers in all other industries averaged — resulting primarily from violent behavior of patients, clients, residents, or visitors in their workplaces,” the SBAR report states. “OSHA has also heard first-hand accounts of the extent and severity of WPV in the healthcare and social assistance sector.”
For this potential standard, OSHA focused solely on Type II WPV, which are violent acts committed by patients, clients, and visitors on workers. As outlined in the small business report, the framework for the draft standard includes addressing the following:
• Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff;
• Poor environmental design of the workplace that may block employees’ vision or interfere with their escape from a violent incident;
• Lack of means of emergency communication;
• Inadequate security;
• Unrestricted movement of the public in clinics and hospitals;
• Working alone in a facility or in patients’ homes.
Emergency Nurses Make Their Case
Arguing in favor of the rule, the Emergency Nurses Association (ENA) said disincentives to reporting violent incidents compound the problem. “A workplace assault is a defining moment in the lives of many emergency nurses, and their experience should not be overlooked because proper reporting or documentation requirements were not in place at the time of the assault,” the ENA said.7 “ENA fully supports reporting requirements that ensure all workplace violence incidents are appropriately documented. Without documentation, we will never fully understand the scope or severity of the workplace violence issue or have information that informs interventions.”
There are broadly inconsistent incident reporting protocols across healthcare facilities nationally, justifying the need for a “strong national standard that implements a reliable and consistent reporting protocol,” the ENA told OSHA.
Estimating that emergency department (ED) personnel experience a violent event about once every two months, the ENA said the situation is aggravating staff shortages, hastening the flight of about one-third of ED workers currently considering leaving the profession.
“We must do more to support and protect nurses at work; their lives and the lives of patients depend on it,” the emergency nurses said. “ENA strongly believes a rule that would require healthcare employers to develop and implement workplace violence prevention plans is necessary to address the pervasive issue of workplace violence in our nation’s healthcare facilities."
The letter authors described the ED as if it is a toxic environment. “[The] constant litany of verbal abuse and threats of violence from patients and visitors contributes to emotional strain and longer-range injuries like post-traumatic stress disorder (PTSD),” the ENA wrote. “Given the prevalence of PTSD in the emergency nursing workforce, it is also important to collect data on all types of violence, including lateral and organizational violence."
ENA cautioned OSHA against the overreliance on engineering controls and other technology to maintain the physical safety of nurses, given the lack of evidence indicating they are effective.
The Missouri Hospital Association (MHA) criticized OSHA for a lack of collaboration with other regulators. “While OSHA has sought feedback from small businesses, including hospitals, on the proposed standards, there still seems to be a lack of collaboration with other regulatory bodies on how the recommendations could impact patients and providers, result in regulatory contradictions and duplication, and increase cost,” the MHA commented to OSHA.1
The MHA reminded OSHA the small business panel recommended reviewing “existing regulations, guidance, and accreditation standards to determine the need for a rule and avoid duplication. To date, it does not appear that work has occurred.”
MHA believes OSHA has an opportunity to help alleviate regulatory burden and duplication by providing a framework for the suggested components of a plan, but leaving the specific contents up to the facility.
“The rule would require employers to perform regular hazard assessments based on their own injury records and identify and mitigate hazards,” the MHA commented to OSHA. “Comprehensive review of a facility related to workplace violence hazards annually is administratively burdensome, especially given the continual reporting and ongoing review of incidents.”
ACCSES, the national association for disability service providers, said they “are already subject to a plethora of regulatory requirements from a number of different state and federal agencies. [An OSHA standard] would create a new body of regulations that in many instances would be counterproductive, financially burdensome, and place the provider in a legal conflict between the OSHA regulations and numerous other laws.”2
REFERENCES
1. Missouri Hospital Association. Comments on OSHA drafted regulatory text regarding the potential standard on prevention of workplace violence. June 30, 2023.
2. ACCSES. Public comment on OSHA request for information and regulatory framework. July 3, 2023.
3. Bernstein M. Slain Good Samaritan hospital guard was a ‘dedicated’ employee, Legacy Health says. The Oregonian. July 23, 2023.
4. Portland Police Bureau. UPDATE #3: Victim of hospital shooting identified. July 24, 2023.
5. Young R, Tuchman G, Smart S, et al. Atlanta mass shooting led to a military vet in jail, an apology from his mother and trauma among hospital patients and staff. CNN. May 5, 2023.
6. Occupational Safety and Health Administration. Report of the Small Business Advocacy Review Panel on OSHA’s potential standard for prevention of workplace violence in healthcare and social assistance. May 1, 2023.
7. Emergency Nurses Association. Comment to OSHA. Potential standard to address prevention of workplace violence. June 30, 2023.
The reams of research, news reports, and first-hand accounts continue to accumulate, revealing rampant danger in healthcare that grew worse during the pandemic. Yet there remains resistance to an OSHA standard, with few denying there is a problem while others argue a regulation would be duplicative of recommendations that are not working.
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