No one should go to work expecting to get hurt. And certainly no one should go to work expecting to get assaulted. Unfortunately, assault at work is a common occurrence for this country’s care givers — health care workers and especially nurses. And unlike many workplace injuries, violence is often accompanied by serious psychological trauma, including Post Traumatic Stress disorder, that prevents health care workers from returning to work.
In a recent article, Modern Healthcare writer Elizabeth Whitman “Quelling a storm of violence in healthcare settings,” does a comprehensive and sensitive job describing the causes, frequency, physical and mental toll workplace violence takes on nurses in this country.
Last December, at about 2 a.m. in the intensive-care unit, Allysha Shin’s patient attacked her.
Shin, a neuroscience nurse, was carefully monitoring the patient, a woman in her 20s who’d suffered a hemorrhagic stroke. She’d begun her usual overnight shift accompanied by a sitter, a person who helps supervise or care for high-need patients.
The sitter was called away after two hours to attend to another patient. Later that night, Shin’s patient, whose stroke had likely affected her behavior, grew agitated. She twisted in the restraints that bound her wrists, kicked Shin in the face and punched her. Then, she ripped away the restraints.
Shin yelled for help. It took four nurses, a nurse’s aide and other staff to wrestle the patient into a chair. In the process, she kicked Shin several more times in the chest and stomach. Shin, who works at Keck Medicine at USC in Los Angeles, took the next two nights off, her body aching from the attack.
In my 35 years in this field, from AFSCME to OSHA to the House of Representative and back to OSHA again, workplace violence — against health care workers, social service workers, taxi drivers, late night retail employees, teachers, prison employees and others — has been the greatest challenge I’ve faced. I wrote a lot about workplace violence in the previous version of Confined Space. Three and a half decades later, we’ve made an enormous amount of progress, but we still have a long way to go to make sure workers are protected.
How big a problem?
According to the Bureau of Labor Statistics, in 2015, 417 worker deaths were workplace homicides and violence was responsible for 26,540 lost-time injuries. Women workers suffered 66% of the lost-time injuries related to workplace violence. The AFL-CIO summarizes the problem in their latest Death on the Job report which notes that African America, Asian and Hispanic workers bear a disproportionate share of workplace violence fatalities. Whitman describes the problem in health care:
Violence in healthcare settings is measured poorly. Less than half of incidents are recorded—one survey estimated just 19%—and official accounting by government agencies such as the Bureau of Labor Statistics, the U.S. Justice Department and the Occupational Safety and Health Administration vary widely.
Studies and surveys often classify violent incidents differently, which leads to discrepancies in quantifying the problem. In 2011, the number of nonfatal violent incidents in healthcare facilities ranged from 22,250 to 80,710, the Government Accountability Office estimated last year..
What is known is that healthcare workers, especially direct care providers, face far higher risk of being injured on the job than workers in other industries. In 2014, 52% of workplace violence incidents reported to the BLS occurred in healthcare.
More than half of nurses and nursing students have been verbally abused and more than 20% physically assaulted, according to a 2014 survey of 3,765 registered nurses and students conducted by the American Nurses Association. Homecare workers face similar perils, with 18% to 59% reporting verbal aggression and 2% to 11% reporting physical assaults. Physicians, especially in emergency medicine, are targets, too.
One of the biggest contributing factors to workplace violence in health care institutions is staffing shortages. There are several reasons:
The more patients that nurses and other providers must care for, the less time they can spend with each. And the more overworked they become, the harder it is for them to catch warning signs and stave off brewing violence.
“It is the time that (nurses) are spending with (patients) that’s allowing them to assess the degree to which the behavior they’re seeing could be problematic,” said Pam Cipriano, president of the American Nurses Association. “If there’s not sufficient staffing, that’s a missed opportunity to catch something before it’s a problem.”
When frontline providers are stretched thin, there are also fewer of them to respond to violent incidents. They could be in another room attending to another patient—as was Shin’s sitter the night Shin was attacked.
I first started hearing horrific stories from health care workers and social service workers about being assaulted in the early 1980’s. Management was rarely responsive to these incidents, and often disciplined workers after they were assaulted for not maintaining control of the situation, despite low staffing levels and poor training. Back in the 1980’s we couldn’t get OSHA to consider workplace violence to be a real workplace hazard under their authority. In the early 1990’s, the Department of Labor’s Solicitors finally determined that workplace violence could be addressed through OSHA’s General Duty Clause. OSHA can use the General Duty Clause to cite employers for hazards even where there is no specific standard. In 1996, responding to injury numbers that couldn’t be ignored, and strong pressure from labor unions that represented health care workers, OSHA issued guidance for health care and social service workers, and shortly thereafter, guidelines for violence in late night retail establishments. OSHA also began using the General Duty Clause in a few enforcement cases, a practice that was discontinued during the Bush administration.
Addressing workplace violence issues was a special focus of OSHA under the Obama administration. OSHA stepped up enforcement of workplace violence, mostly in health care, but also in prisons and late night retail establishments. The agency issued a compliance directive to guide Compliance Officers in issuing General Duty Clause violations (or Hazard Alert Letters when there wasn’t enough evidence for a citation), and modernized the Guidelines for Health Care and Social Service Workers, information in OSHA’s Caring for Caregivers program, and a recent update of the compliance directive. OSHA also held a week-long training seminar for its compliance officers. Since 2012, OSHA has conducted 169 workplace violence inspections and issued 28 workplace citations, 21 of which have been in health care. These included hospital settings, residential treatment, community care and field work. Even though the penalties for most of the cases were low, OSHA issued press releases on almost all of them to ensure that the health care industry understood that the agency considered workplace violence a major problem and employers had a legal responsibility to keep their employees safe.
In 2016, the Government Accountability Office issued a report calling on OSHA to OSHA to assess its work to see “whether its efforts are effective or if additional action may be needed to address this hazard.” Last Fall, CalOSHA issued a standard to protect health care workers against workplace violence. Finally, faced with a growing problem, petitions from health care worker unions and members of Congress for regulatory action, and the GAO report, OSHA put workplace violence on the regulatory agenda and issued a Request for Information with comments due in April 2017. In January 2017, the agency held a stakeholder meeting attended by health care workers who had been assaulted on the job, union representatives and health care associations. At that meeting, OSHA’s Assistant Secretary David Michaels stated that OSHA had officially accepted the union petitions and would move forward with a standard to protect health care and social service unions. The fate of those protections now lie in the hands of the Trump administration.
What is to be done
Under the Obama administration, OSHA committed to move forward on a workplace violence standard protecting health care and social service workers. Under the best of circumstances, this is a multi year project. The chances of moving this forward will depend on what kind of evidence is in the record and how much political pressure can be applied. OSHA is in the middle of gathering information through a request for information. The next step after analyzing that information is a SBREFA (small business review) panel, followed by a proposal, pre-hearing comments, a public hearing, post hearing comments and briefs, analysis of those comments and eventually a final standard. The Trump administration can slow or stop that process at any point, and, of course, their recent executive order, requiring two regulations to be removed for every one that’s added would be a major impediment.
In order to pressure the Trump Administration to move forward on workplace violence, and ensure that there is sufficient evidence in the RFI record, the AFL-CIO has set up a site for workers to sign a petition and to record their stories. OSHA is currently preparing its Spring Regulatory Agenda which sets forth the agency’s regulatory priorities and timetables. Labor Secretary nominee Alexander Acosta’s confirmation hearing is next week, and assuming he is confirmed, he will testify at Fiscal Year 2018 budget hearings in the Senate and House of Representatives. All of these hearings will provide opportunities to ask him questions about OSHA’s progress on a workplace violence standard. Make sure you Congresspersons and Senators hear from you, especially those who sit on the relevant committees. Finally, workers at risk of workplace violence need to keep filing complaints and making sure OSHA follows up on them. (And if you file a workplace violence complaint with OSHA and receive an unsatisfactory response, let me know.)