Workplace Violence in Healthcare: When Being A Punching Bag Isn't Your Life's Calling

While there are explicit statutory protections for patients who are subject to abuse or inappropriate behavior by medical personnel,⁴ there are few protections for medical personnel outside of standard criminal penalties.  Of the statutory protections that do exist, typically only emergency medical services personnel are protected.⁵  Because of the increase in the frequency and severity of attacks by patients and their families upon medical personnel, additional legislative protections are needed.⁶  Likewise, better education of available courses of action are necessary so clinicians are made aware of their options when they are subjected to assault and abuse.  “A 2001 U.S. Bureau of Justice Statistics (BJS) document reported an annual incidence of 16.2 assaults per 1,000 physicians, 21.9 assaults per 1,000 nurses . . . In 2011 the incidence of assaults on nurses nearly doubled the 2001 rate.”⁷ Since 2011, the rates of workplace violence against healthcare workers has further increased.  For example, in 2016, 40.8 percent of RN injuries resulted from healthcare patients.⁸ 

Medical personnel often do not have knowledge of their legal options, such as their ability to press criminal charges against a patient who has assaulted them.⁹ This is in large part because of an unfortunate lack of communication between the fields of medicine and law.  Other contributors to this issue include employer failure to support and educate staff of their options and facility and cultural pressure to not report instances of patient violence.

Some patients who harm medical staff are legally incapacitated.  In these situations, there should be supports implemented by facilities, such as greater staffing, to diminish the magnitude of violence.  The use of restraints or seclusion as recommended by The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission should also be implemented by facilities to reduce violent patient attacks on clinicians.¹⁰ This article focuses primarily on the instances where patients have the capacity to understand their harmful and violent actions.

This article will discuss how the issues of supervisory retaliation for reporting¹¹ and burnout¹² are related to workplace violence, some of the costs incurred by facilities as a result of this violence,¹³ and an overview of the law and current regulations.

Problem: Issues with Reporting Violence

There is a common sentiment that violent patients are just part of the job, and some clinicians fear retaliation if they report a physical attack by a patient.¹⁴  The National Advisory Council on Nurse Education and Practice has explained that, “an accepting attitude toward violence in the workplace is commonplace . . . . Often, customer service initiatives (encouraging nurses to “be nice” to customers) take priority over facilities’ focus on keeping the staff safe from aggressive patients.”¹⁵

Nurse managers have been involved in perpetrating or being unresponsive to nurse complaints.¹⁶  In a survey of nurses, over half agreed with a statement saying that a nurse who takes legal action against a patient is in danger of losing his/her job.¹⁷  Because of the fear of supervisory retaliation and uncertainty of what constitutes violence, there is underreporting of workplace violence in healthcare.¹⁸  “According to the Bureau of Labor Statistics, the incidence of injury from nonfatal assaults of health service workers is significantly higher than that of other workers; The actual incidence of violence is likely higher than reported for various reasons, including inadequate reporting mechanisms and because victims under-report incidents out of fear of reprisal, isolation and embarrassment.”¹⁹  These factors and the current healthcare culture discourage internal reporting and external reporting, such as pressing charges against violent patients.

One nurse described being kicked in the pelvis by a patient with such force that she was slammed against a wall when she was two months pregnant.²⁰  When she reported it to her supervisor, her supervisor was surprised the nurse reported the incident and refused to honor the complaint.²¹ “There’s also a pervasive notion that dealing with unruly patients is just part of a nurse’s job.  ‘We always feel discouraged from reporting it.’ One nurse reported that she was punished by a past employer for calling 9-1-1 after a patient attacked her. Only 29 percent of the surveyed nurses who were physically attacked actually reported it to their supervisors.  About 18 percent said they feared retaliation if they reported violence.”²²

A main reason for this discouragement and retaliation is hospitals’ fear of angering or alienating patients.²³ Two percent of hospitals’ total annual CMS funding is variable; 30 percent of that determination is based upon patient satisfaction, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems).²⁴  Attaining more funding is a primary motivation for nurse managers and hospital administrators, leading some of them to compromise the safety of their employees and placing a priority on customer perceived service.²⁵  The focus on funding stems in part from facilities lacking equipment and the decentralized uncoordinated nature of healthcare.²⁶  Hospitals also focus on funding because some federal funding has been decreasing, such as the HPP (Hospital Preparedness Program).²⁷ “HPP funding has dropped by half from $515 million in 2003 to $255 million in fiscal 2017, according to an American Journal of Public Health study. . . Funding has dropped over the past three years.”²⁸

Since the introduction of HCAHPS in 2006,²⁹ violence in hospitals has increased steadily over the years, causing increased deaths, decreased productivity, decreased quality of care and increased burnout of clinicians.³⁰

Problem: The Effects of Workplace Violence and Burnout

Interestingly, addressing workplace violence may help resolve another problem facilities are facing: clinician burnout.  Burnout has negative effects on healthcare practitioners.³¹  The psychological toll of workplace violence is a large factor of burnout and causes a high turnover rate in the medical profession.³²  Between 2012 and 2014, for nurses and nurse assistants alone, the rates of reported workplace violence injuries rose by 65 percent nationally.³³  “When subjected to physical violence, physicians can lose work time for recovery.  They may also have mental trauma and often experience fear, anxiety, and loss of concentration at work.  This has an adverse effect on patient care . . . 77% of ACEP-surveyed physicians feel that violence in the emergency department has affected patient care because it leads to loss of productivity, emotional stress, and increased waiting times.”³⁴  Violence against healthcare workers “exacts a significant toll on victims, their co-workers, patients, families and visitors.”³⁵  As a result, people are putting years and thousands of dollars into professional training and then trained workers are leaving the profession.³⁶  Abuses by patients and their families are decreasing the retention of trained medical staff in hospitals and other healthcare facilities.³⁷ 

Staff resignations due to violent outbursts by patients cost hospitals and other healthcare facilities in many ways, such as the need to recruit, hire, and train new staff more often and at a greater frequency (which can cost $500,000 - $1 million for one clinician),³⁸ the cost of paid medical leave when a staff member is harmed, and paying more to incentivize staff to work overtime or come in on a day off because they are short staffed.³⁹  Eighty-one percent of hospital organizations have said that retention is a “key strategic imperative.”⁴⁰  “In 2016, 51.0 percent of all injuries and illnesses to RNs . . . required a median of 7 days away from work.”⁴¹

One of the reasons for increased violence by patients and families is that there is less staff available, which results in slower responses to situations and fewer people available to help deescalate the situation when a patient does turn violent.⁴²  This is a self-perpetuating problem; when hospitals and other facilities are continually understaffed, both practitioners and patients suffer.⁴³   Not only do staff burn out at an increased rate when they are subject to violent outbursts by patients, but facilities are also subject to costs.⁴⁴ “Insurance claims, lost productivity, disruptions to operations, legal expenses and property damage are only a few of the negative effects that workplace violence has on health care facilities.”⁴⁵ Higher acuity adds to the burnout experienced by clinicians as they work greater patient loads with less staff, pushing the ratios to unsafe numbers.⁴⁶  “When there are not enough nurses at hospitals, and those who are there feel stressed and unsafe, patients and staff all wind up suffering.”⁴⁷

Current Law and Trends in the Law

Approximately seven states have recognized the issue of violence in healthcare facilities and have passed laws providing greater legal protections to first responders and emergency room personnel, specifically by implementing increased criminal penalties for assaults.⁴⁸ Some have also begun passing greater legal protections for non-emergency healthcare staff, such as greater penalties for assaults on nurses.⁴⁹  There is growing recognition of this problem, called an “epidemic” by some states and federal agencies, and that additional steps need to be taken to prevent further violence and protect clinicians.⁵⁰  In 2019, “at least 16 states have introduced more than 30 bills to address workplace violence in health care settings.  To date, NV [Nevada], OR [Oregon] and WA [Washington] have adopted legislation.”⁵¹

In addition, some states have passed or proposed statutes and regulations requiring hospitals and other healthcare facilities to begin prevention and increase awareness of workplace violence by trainings, increased reporting of incidents, and investigations by facilities into the causes of the incidents.⁵²  These statutes are enacted because, as noted in New Jersey’s statute, “[v]iolence is an escalating problem in many health care settings in the State and across the nation . . .  health care workers are at a particularly high risk.”⁵³  In some states these investigations will be used to determine further action by the facility and state legislature to prevent workplace violence.⁵⁴  For example, to resolve issues of workplace violence and better protect staff, California has enacted a statute to allow a temporary restraining order to be placed by an employer against someone threatening or enacting unlawful violence against an employee.⁵⁵  There are also various clinician groups who advocate for legislative reform in various states.⁵⁶

While these state initiatives are steps in the right direction, federal bills have been historically unfruitful.⁵⁷  Over the past two years, federal bills for workplace violence prevention have failed to be enacted into law; however, legislators have again reintroduced bills for the prevention of workplace violence in healthcare in 2019.⁵⁸  The newly introduced Workplace Violence Prevention for Health Care and Social Service Workers Act would be beneficial to clinicians, as it would require healthcare employers to implement workplace violence prevention plans based upon the Occupational Safety and Health Administration’s (OSHA) 2016 guidelines, require employers to investigate reported incidents of workplace violence, and take action to prevent further violence.⁵⁹

Despite this legislative inaction, the Department of Labor is evaluating regulations to prevent workplace violence in healthcare settings.⁶⁰ In addition, OSHA has recommended that medical professionals bring criminal charges against patients if a crime such as rape, assault, a lesser offense, or homicide occurs.⁶¹  A significant issue is that many medical professionals do not know what constitutes an assault and that they are able to press charges.⁶²  The pending federal legislation would require healthcare facilities to educate clinicians about this option.⁶³

There have been a few incidents where criminal charges were brought against patients by or on behalf of a medical professional; unfortunately, this often only occurs in the most extreme circumstances, despite OSHA’s recommendation.  For instance, a patient in Louisiana was arrested in 2019 for manslaughter;⁶⁴ a nurse in Louisiana died from the injuries she received when interrupting the patient’s attack on another nurse.⁶⁵ A defendant received a 12-year prison sentence for killing a nurse with a lamp in California in 2014.⁶⁶  In Pennsylvania, criminal charges were brought against a man who attempted to rape a nurse in his hospital room in 2018; the trial is scheduled to be held in December 2019.⁶⁷  Also in Pennsylvania, in 2017 a nurse pressed criminal charges when he was stabbed in the neck by a former patient, and had a doctor not been standing in the hallway as this occurred, the nurse would have died. The patient entered into a plea deal with the district attorney’s office.⁶⁸  

Conclusion

Workplace violence by patients against medical professionals is of growing concern.  Reducing such violence would not only improve clinicians’ lives and workplace conditions; facilities would likely experience increased staff retention, fewer workers’ compensation claims, and reduced paid medical leave. This would also likely result in better care for the patient population.  As this area of law is gaining recognition, the legal industry should take active steps to get involved and observe how the administrative and legislative branches are affecting this developing area of law.

1. The Joint Commission, Physical and Verbal Violence Against Health Care Workers, 59 Sentinel Event Alert, at 3 (April 2018), https://www.jointcommission.org/assets/1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf.
2. Abbot, A. & Brinkmann, J.T., Workplace Violence Against Healthcare Providers, The O&P Edge (October 2017), https://opedge.com/Articles/ViewArticle/2017-10-01/workplace-violence-against-healthcare-providers.
3. ECRI Institute, Violence in Healthcare Facilities, Healthcare Risk Control (May 2017), https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?PF=1%3Fsource=print.
4. 18 Pa.C.S.A. § 2713.1 (a); 16 Del.C. § 1134; 210 IL.C.S. § 85/9.6.
5. 18 Pa.C.S.A. § 2702 (c)(21); Auxiliary Police Officer Protection Act, 2007 N.Y. S.B. 6643.
6. Wenner, D. Nurses fear increasing attacks by patients: ‘We need safe environments,’ Penn Live (August 2018), https://www.pennlive.com/news/2018/08/hospital_nurses_increasingly_u.html; Tedeschi, B., As Patients Turn Violent, Doctors and Nurses Try to Protect Themselves, STAT News (November 2015), https://www.statnews.com/2015/11/20/patients-violence-hospitals/; 405 IL C.S.A. § 90/5 (1).
7. Abbot & Brinkmann, Workplace Violence Against Healthcare Providers, supra n. 2.; Speroni, K.G., Fitch, T., Dawson, E.  Dugan, L., & Atherton, M., Incidence and Cost of Nurse Workplace Violence Perpetrated by Hospital Patients or Patient Visitors, 40 Journal of Emergency Nursing 3, 218-28 (May 2014), https://www.ncbi.nlm.nih.gov/pubmed/24054728; Gillespie, G.L., Gates, D.M., Miller, M. & Howard, P.K., Workplace Violence in Healthcare Settings: Risk Factors and Protective Strategies, 35 Rehabilitation Nursing: The Official Journal of the Association of Rehabilitation Nurses 5, 177-84 (September-October 2010),  https://www.ncbi.nlm.nih.gov/pubmed/20836482.
8. Dressner, M. & Kissinger, S.P., Occupational Injuries and Illnesses Among Registered Nurses, U.S. Bureau of Labor Statistics: Monthly Labor Review (November 2018), https://www.bls.gov/opub/mlr/2018/article/occupational-injuries-and-illnesses-among-registered-nurses.htm.
9. 18 Pa.C.S.A. § 3124.1; 18 Pa.C.S.A. § 2701 (a); 18 Pa.C.S.A. § 2702, supra n. 5.
10. Hazardous to Your Health: Violence in the Health-Care Workplace, ASH Clinical News (December 2018), https://www.ashclinicalnews.org/features/hazardous-health-violence-health-care-workplace/; Joint Commission Standards on Restraint and Seclusion/Nonviolent Crisis Intervention Training Program, CPI, at 2 (2010), https://www.crisisprevention.com/CPI/media/Media/Resources/alignments/Joint-Commission-Restraint-Seclusion-Alignment-2011.pdf; § 482.13(e) Standard: Restraint or Seclusion, Department of Health & Human Services Centers for Medicare & Medicaid Services Manual System, at 90 (October 2008), https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf.
11. Campbell, A.F., Why Violence Against Nurses Has Spiked in the Last Decade, The Atlantic (June 2017), https://www.theatlantic.com/business/archive/2016/12/violence-against-nurses/509309/.
12. Kapoor, M.C., Violence Against the Medical Profession, 33 J. Anesthesiology Clinical Pharmacology, 145-147 (April-June 2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520583/; Meyer, K., Nurses push for staff changes, against wishes of nurse and hospital associations, WHYY (2018), https://whyy.org/articles/nurses-push-for-staff-changes-against-wishes-of-nurse-and-hospital-associations/; Myers, J., NEPA Healthcare Workers, Advocates, and Officials Convene Round Table on Future of Healthcare in Their Region, SEIU Healthcare Pennsylvania (May 2019), http://www.seiuhcpa.org/2019/05/31/nepa-healthcare-workers-advocates-and-officials-convene-round-table-on-future-of-healthcare-in-their-region/; Adler, E.L., Abusive Patient Behavior: Physicians Have ‘Rights’ Too, Physicians Practice (August 2012), https://www.physicianspractice.com/abusive-patient-behavior-physicians-have-rights-too.
13. First Healthcare Compliance Staff, The Cost of Workplace Violence Under OSHA, First Healthcare Compliance (March 2019), https://1sthcc.com/the-cost-of-workplace-violence-under-osha/.
14. Gacki-Smith et al., Violence Against Nurses Working in US Emergency Departments, 36 Journal of Nursing Administration, no. 7/8, 340-49 (July/August 2009), https://www.ncbi.nlm.nih.gov/pubmed/19641432.
15. Violence Against Nurses: An Assessment of the Causes and Impacts of Violence in Nursing Education and Practices, NACNEP, at 12 (December 2007), (citing Homeyer, C.L., Violence: The battle zone of acute care, presented at the annual meeting of the National Advisory Council on Nurse Education and Practice, Rockville, MD, (April 2005)), https://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/reports/fifthreport.pdf.
16. Jackson, D., Clare, J., & Mannix, J., Who Would Want to be a Nurse? Violence in the Workplace – A Factor in Recruitment and Retention, Journal of Nursing Management (2002), https://psycnet.apa.org/record/2002-18767-003.
17. Violence Against Nurses, supra n. 15, at 10.
18. The Joint Commission, Physical and Verbal Violence Against Health Care Workers, supra n. 1, at 2; Health Care Workplace Violence Prevention Act, 2005 ILL. Laws 347, § 5 (2); Stephens, W., Violence Against Healthcare Workers: A Rising Epidemic, The American Journal of Managed Care (May 2019), https://www.ajmc.com/focus-of-the-week/violence-against-healthcare-workers-a-rising-epidemic///?p=2.
19. Violence Prevention in Health Care Facilities Act, 2006 N.J. Laws 3027 (2)(b)-(c).
20. Campbell, Why Violence Against Nurses Has Spiked in the Last Decade, supra n. 11.
21. Id.
22. Id.
23. Additional factors that could discourage reporting include: a hospital culture of accepting the violence, clinicians feeling it is their duty to care for patients however violent they may be, clinicians’ worry it would be burdensome on their coworkers to have to work with the violent patients instead; and clinicians not wanting to blame patients if they are mentally incapacitated to some degree.
24. Centers for Medicare & Medicaid Services, CAHPS Hospital Survey (HCAHPS): Quality Assurance Guidelines Version 13.0, at 10 (March 2018), https://www.hcahpsonline.org/globalassets/hcahps/quality-assurance/2018_qag_v13.0.pdf; Mehta, S.J., Patient Satisfaction Reporting and Its Implications for Patient Care, AMA Journal of Ethics (July 2015), https://journalofethics.ama-assn.org/article/patient-satisfaction-reporting-and-its-implications-patient-care/2015-07; Letourneau, R., Better HCAHPS Scores Protect Revenue, HEALTHLEADERS (September 2016), https://www.healthleadersmedia.com/finance/better-hcahps-scores-protect-revenue; Carta, J., How Does Patient Satisfaction Impact Reimbursement?, Access (March 2018) https://www.accessefm.com/blog/how-does-patient-satisfaction-impact-reimbursement; CMS, Hospital Value-Based Purchasing (HVBP) Program – Scoring, Centers for Medicare & Medicaid Services, https://www.qualitynet.org/inpatient/hvbp/participation#tab4; CMS, The Latest Hospital VBP Update, Centers for Medicare & Medicaid Services (October 2019), https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Hospital-Value-Based-Purchasing-.html.
25. Robbins, A., The Problem With Satisfied Patients, The Atlantic (April 2015), https://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684/; Geiger, N., On Tying Medicare Reimbursement to Patient Satisfaction Surveys, American Journal of Nursing 112-7, at 11 (July 2012), https://journals.lww.com/ajnonline/Fulltext/2012/07000/On_Tying_Medicare_Reimbursement_to_Patient.2.aspx#O2-2; Kroning, M., Viewpoint: Putting Money at the Bedside, American Nurse Today, 10 Journal of American Nurses Association, no. 10 (October 2015), https://www.americannursetoday.com/viewpoint-putting-money-bedside/.
26. Johnson, S.R., Federal Funding Doesn’t Fully Support Hospitals Facing Large-Scale Emergencies like Flu, Modern Healthcare (January 2018), https://www.modernhealthcare.com/article/20180123/NEWS/180129963/federal-funding-doesn-t-fully-support-hospitals-facing-large-scale-emergencies-like-flu.  The focus on funding is also in part because of the push for value-based care, the potential loss of reimbursements, resources to hire and maintain staff, and new obligations of non-profit hospitals to financially assist patients.
27. Watson, C., Watson, M. & Sell, T.K., Public Health Preparedness Funding; Key Programs and Trends From 2001 to 2017, American Journal of Public Health (September 2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594397/#bib1; Johnson, Federal Funding Doesn’t Fully Support Hospitals, supra n. 26.
28. Johnson, Federal Funding Doesn’t Fully Support Hospitals, supra n. 26.
29. CMS, HCAHPS: Patients’ Perspectives of Care Survey, Centers for Medicare & Medicaid Services (October 2019), https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html.
30. Arnetz, Hamblin, Russell, Upfal, Luborsky, Janisse, & Essencacher, Preventing Patient-to-worker Violence in Hospitals: Outcome of a Randomized Controlled Intervention, Journal of Occupational and Environmental Medicine (January 2017), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214512/; Kelen, Catlett, Kubit, & Hsieh, Hospital-Based Shootings in the United States: 2000 to 2011, American College of Emergency Physicians, at 3, 6 (August 2012), https://www.hasc.org/sites/main/files/03-hos1_0.pdf; Patient Safety Advisory Group, Preventing Violence in the Health Care Setting, 45 The Joint Commission, at 1 (June 2010), https://www.jointcommission.org/assets/1/18/SEA_45.pdf.
31. Dr. Jannenga, H., Why Burnout is the Norm in Healthcare – And How We Can Beat It, Becker’s Hospital Review (October 2018), https://www.beckershospitalreview.com/human-capital-and-risk/why-burnout-is-the-norm-in-healthcare-and-how-we-can-beat-it.html.
32. The Joint Commission, Physical and Verbal Violence Against Health Care Workers, supra n. 1, at 3; Workplace Violence in Healthcare, OSHA at 4 (December 2015), https://www.osha.gov/Publications/OSHA3826.pdf.
33. Gomaa, A. et al., Occupational Traumatic Injuries Among Workers in Health Care Facilities – United States, 2012-2014, 64 Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report, no. 15, 405-410 (April 2015), https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6415a2.htm.
34. Dr. Phillips, J.P., Workplace Violence Against Health Care Workers in the United States, New England Journal of Medicine (April 2016), https://www.nejm.org/doi/full/10.1056/NEJMra1501998 ; Davis, N., Addressing Workplace Violence Against Physicians, Medical Bag (December 2018), https://www.medicalbag.com/home/business/addressing-workplace-violence-against-physicians/; Marketing General Incorporation, ACEP Emergency Department Violence Poll Research Results,  American College of Emergency Physicians, at 18 (September 2018), https://www.wpr.org/sites/default/files/2018ACEP%20Emergency%20Department%20Violence%20PollResults.pdf. 
35. Violence Prevention in Health Care Facilities Act, 2006 N.J. Laws 3027 (2)(d), supra n. 19.
36. Breaking Point: Pennsylvania’s Patient Care Crisis, Nurses of Pennsylvania: United for Quality Patient Care, at 9 (2017), https://www.nursesofpa.org/wp-content/uploads/2017/09/Nurses-of-Pa-Patient-Care-Crisis-Report.pdf.
37. Wenner, supra n. 6; Myers, J., Nurses Join Legislators to Introduce Safe Patient Limit Bills to Save Lives, SEIU Healthcare Pennsylvania (March 2019), http://www.seiuhcpa.org/2019/03/29/nurses-join-legislators-to-introduce-safe-patient-limit-bills-to-save-lives/; Kapoor, supra n. 12; The Joint Commission, Physical and Verbal Violence Against Health Care Workers, supra n. 1, at 3; Violence Against Nurses: An Assessment of the Causes and Impacts of Violence in Nursing Education and Practice, supra n. 15, at 2, 3.
38. Rossheim, J., Recognition a Key Driver for Healthcare Worker Engagement, HCAHPS Scores, Workhuman (March 2018), https://www.workhuman.com/resources/globoforce-blog/recognition-a-key-driver-for-healthcare-worker-engagement-hcahps-scores.
39. 2019 National Health Care Retention & RN Staffing Report, NSI Nursing Solutions Inc., at 11, http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/2019%20National%20Health%20Care%20Retention%20Report.pdf; see also The Joint Commission, Physical and Verbal Violence Against Health Care Workers, supra n. 1, at 3; U.S. Department of Labor: Occupational Safety and Health Administration, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (OSHA, 3148), at 3 (2016), https://www.osha.gov/Publications/osha3148.pdf; Abbot & Brinkmann, Workplace Violence Against Healthcare Providers; Workplace Violence in Healthcare, supra n. 2, at 4.
40. 2019 National Health Care Retention & RN Staffing Report, supra n. 39, at 4.
41. Dressner, Occupational Injuries and Illnesses Among Registered Nurses, supra n. 8.
42. Breaking Point: Pennsylvania’s Patient Care Crisis, supra n. 36, at 7; Joint Commission, Physical and Verbal Violence Against Health Care Workers, supra n. 1, at 3.
43. Walmer, D., Are Low Nurse Staffing Levels Putting Central Pennsylvania Hospital Patients at Risk?, Lebanon Daily News (2017), https://www.ldnews.com/story/news/local/2017/09/14/low-nurse-staffing-levels-putting-central-pennsylvania-hospital-patients-risk/658401001/; Rosseter, R., Nursing Shortage, American Association of Colleges of Nursing at 3-5 (2019), https://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet.pdf; DPE, Safe Staffing: Critical for Patients and Nurses, Department for Professional Employees: Fact Sheet 2019, at 2-3 (April 2019), https://dpeaflcio.org/wp-content/uploads/Safe-Staffing-2019.pdf.
44. DPE, Safe Staffing, at 4-5, supra n. 43.
45. Violence Prevention in Health Care Facilities Act, 2006 N.J. Laws 3027 (2)(e), supra n. 19.
46. Paulsen, R., Taking Nurse Staffing Research to the Unit Level, Nursing Management, vol. 49, no. 7 (July 2018), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039374/; Blitchok, A., Proposed Federal RN Ratios – What You Can Do About It, Nurse.org, (January 2018), https://nurse.org/articles/federal-staffing-ratios/.
47. Magrath, P., Over the Last 10 Years Violence Against Nurses Has Increased, DiversityNursing Blog (December 2016), http://blog.diversitynursing.com/blog/over-the-last-10-years-violence-against-nurses-has-increased.
48. Workplace Violence, American Nurses Association: Practice & Policy (June 2019), https://www.nursingworld.org/practice-policy/advocacy/state/workplace-violence2/.
49. Cal. Civ. Code § 1714.9 (a); Conn. Gen. Stat. § 53a-167c, (a)-(b); W. Va. Code § 61-2-10b (b)-(e);  A.C.A. § 5-13-202 (a), (e); Workplace Violence, American Nurses Association: Practice & Policy, supra n. 48.
50. Coutre, L., Healthcare Workers Face Violence ‘Epidemic,’ Modern Healthcare (March 2019), https://www.modernhealthcare.com/providers/healthcare-workers-face-violence-epidemic.
51. Workplace Violence Legislation Introduced Across the Country, Association of periOperative Registered Nurses: 2019 Health and Policy News (June 2019), https://www.aorn.org/about-aorn/aorn-newsroom/health-policy-news/2019-health-policy-news/workplace-violence.
52. Conn. Gen. Stat. § 19a-490q (c), (e); Rev. Code Wash. (ARCW) § 49.19.020 (1), (2); N.Y. C.L.S. Labor § 27-b (1), (3)-(5); Cal. Labor Code § 6401.8 (a), (b); Conn. Gen. Stat § 4a-2a (a), (b); 8 C.C.R. § 3342 (c), (d), (f), (g);  2018 TX Reg. 35241, 25 TAC 1.13.G.13.81-.87 (13.81) (June 2018).
53. Violence Prevention in Health Care Facilities Act, 2006 N.J. Law 3027 (2)(a), supra n. 19.
54. Rev. Code Wash. (ARCW) § 49.19.020 (2), supra n. 52; 8 C.C.R. § 3342 (c)(9)-(11), (e), (g), supra n. 52.
55. Cal. Code Civ. P. § 527.8 (a).
56. Dickinson, Virgil, Clinician Groups Welcome Joint Commission’s Guidance On Addressing Hospital Violence, Modern Healthcare (April 2018), https://www.jointcommission.org/assets/1/9/Modern_Healthcare_Workplace_Violence_SEA_18_0423.pdf; Incivility, Bullying, and Workplace Violence, American Nurses Association (July 2015), https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/incivility-bullying-and-workplace-violence/; Bill to Protect Health Care, Social Service Workers from Epidemic of Workplace Violence Poised for Historic House Committee Vote, National Nurses United (June 2019), https://www.nationalnursesunited.org/press/bill-protect-health-care-social-service-workers-epidemic-workplace-violence-poised-historic; Hospitals Against Violence, American Hospital Association (2019), https://www.aha.org/hospitals-against-violence/human-trafficking/workplace-violence.
57. Health Care Workplace Violence Prevention Act, 116 H.R. 1309 (February 2019).
58. Workplace Violence Prevention for Health Care and Social Service Workers Act, 115 S. 851 (March 2019); Health Care Workplace Violence Prevention Act. 115 H.R. 5223 (March 2018.
59. Workplace Violence Prevention for Health Care and Social Service Workers Act, supra n. 58; OSHA, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, supra n. 39.
60. Department of Labor, Semiannual Agenda of Regulations, 83 Fed. Reg. 58046, vol. 83, no. 222 (November 2018); Department of Labor, Semiannual Agenda of Regulations, 84 Fed. Reg. 29653, vol. 84, no. 121 (June 2019).
61. Wilson, T.H., Confronting Violence in the Workplace, OSHA Guide for Health Care Facilities, ¶812.1 (July 2015) citing Joint Commission Sentinel Event Alert, Preventing Violence in the Health Care Setting, 45 (June 2010).
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About the Author

Mimi Miller is in her second year of law school at Penn State’s Dickinson School of Law.  She began working as a Certified Nursing Assistant during her senior year of high school and continued through the summer after her first year of college.  Ms. Miller also worked as a volunteer and then as assistant director of a homeless outreach in Portland, OR during her second and third summers of university.  Her first summer work in law school was as the Head Research Assistant for a team of 17 law students who are researching and creating online educational modules for new and prospective guardians in Pennsylvania, and interviewing experts such as judges, attorneys, legal services providers, disability rights workers, medical professionals, and guardians, which will be hosted on the Pennsylvania Court’s website.  Ms. Miller has also recently joined a workgroup with the ABA International Human Rights committee to draft a policy on universal jurisdiction.  She is interning with the Pennsylvania Department of State’s Office of General Counsel’s Prosecution Division for the fall 2019 semester. She can be reached at [email protected].