In this article, we look at workplace violence data in healthcare and in nursing and the steady increase in violence seen across the nation. There is an overview of healthcare workplace violence laws and regulations with a focus on the specifics of the 2019 Washington state workplace violence law. Included are opportunities to reflect upon safety in your own professional practice environment. We conclude with actions to consider when faced with a workplace violence on-the-job injury.

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In Spokane, Washington on Dec. 1, 2022, three shots rang out and a fourth shot followed. Tragically, an event of workplace violence ended the life of a visiting registered nurse. Two months earlier, a deadly shooting in a Dallas hospital claimed the lives of a nurse and social worker on a Labor and Delivery Unit. Just days earlier, a nurse practitioner died of stab wounds inflicted by a patient in North Carolina.

Shootings, stabbings, threats, and violent attacks are increasingly common in hospitals and healthcare settings. Results from a 2022 survey of American College of Emergency Physicians found that workplace violence has steadily increased over the past five years, with the vast majority of assaults committed by patients.

According to the American Nurses Association, Washington is one of eight states to require employers to implement a workplace violence prevention program. Further, RCW 9A.36.031 states that assault of a nurse, physician, or healthcare provider who is performing nursing or other healthcare duties (at the time of the assault) is a class C felony. This, combined with legislation passed in 2019, strengthens healthcare workplace violence prevention in Washington state. But is it enough?

Violence by the numbers

Workplace violence occurrences continue to rise, posing a daily threat to the safety of healthcare workers. Widely recognized as a hazard, events of workplace violence date back decades. Today, healthcare workplace violence has reached alarming numbers across the nation. According to a recent Press Ganey report, more than two nurses were assaulted every hour between April 1 and June 30, 2022. That is approximately 57 occurrences per day and over 1,700 assaults per month. Press Ganey’s National Database of Nursing Quality Indicators (NDNQI) reveals that patients cause the highest number of assaults.

The 2020 U.S. Bureau of Labor Statistics (BLS) fact sheet indicates that workplace violence in healthcare is both a public health issue and an increasing concern. In 2018, healthcare and social workers accounted for 73% of all nonfatal workplace violence injuries/illnesses, and this group was five times more likely to experience workplace violence than all other workers.

The BLS reports that compared to other professions, healthcare workers — particularly nurses — are at greater risk for workplace violence than other professions. There were 207 workplace violence deaths in healthcare between 2016-2020 in the nursing/social assistance industry. In a 2020 comparison of healthcare and social assistance workers, findings showed a violence and assault incidence rate of 10.3 (out of 10,000 full-time workers), far less than a rate of 21.8 for nursing and personal-care facility workers.

Incidence rates for nonfatal assaults and violent acts by industry, 2020

Incidence rate per 10,000 full-time workers 

In examining data specific to Washington state, the Washington Department of Labor and Industries accident claims data reveals that healthcare job classes incur the highest total costs for accidents related to workplace violence. In the category designated as “assaults by violent acts by person(s),” the registered nurse job class ranked No. 1 in 2021, followed by psychiatric technicians, personal/home care aides, and nurse aides/orderlies. Total cost of accident claims for workers in these four job classes topped $13 million in 2021 alone.

2021 “Assaults and Violent Acts by Person(s)” Category⁷

Washington Department of Labor and Industries accident claims data

Classifications of workplace violence

The National Institute for Occupational Safety and Health (NIOSH) identifies four types of workplace violence in the context of healthcare:

• Criminal violence: An individual that does not have a relationship with the healthcare entity or its healthcare workers initiates an event of workplace violence.
• Customer / patient-to-healthcare worker violence: Workplace violence involves a patient or client that has a business relationship with the entity and may be receiving healthcare services. This is reportedly the most common type of workplace violence in healthcare settings.
• Healthcare worker-to-healthcare worker violence: Workplace violence involves a healthcare worker that is violent toward another healthcare worker.
• Personal relationship violence: An individual that has no relationship with the healthcare entity but has a personal relationship with a healthcare worker (that is the target of workplace violence) initiates an event of violence.

Workplace violence law and regulation

There are a variety of laws and regulations to prevent violence in the workplace. These originate from federal and state government and from regulatory and other agencies.

Federal: At the federal level, the Occupational Safety and Health Act of 1970 addresses worker safety using a General Duty Clause. Employers must provide a work environment that is “free from recognized hazards that are causing or likely to cause death or serious physical harm.” Since this clause is general in nature, it does not provide specific direction to address workplace violence.

In 1996, the Occupational Safety and Health Administration (OSHA) authored the first of two (unenforceable) advisory guidelines to address workplace violence prevention for healthcare and social workers. Recently, federal legislators proposed H.R. 1195, the “Workplace Violence Prevention for Health Care and Social Service Workers Act.” This directs the Department of Labor to establish workplace violence prevention standards for healthcare. The House passed this bill in April 2021. To date, the Senate has not voted on this bill.

Centers of Medicare and Medicaid (CMS): On Nov. 28, 2022, the Centers for Medicare and Medicaid issued a memo addressing workplace violence in hospitals. The memo describes the risks of workplace violence in healthcare and the steady growth of violence since 2011. The document emphasizes the need to prioritize patient and staff safety and reinforces the expectation that healthcare facilities must provide a safe environment. Of note, CMS intends to enforce workplace safety expectations, including a safe environment for both patients and staff.

The Joint Commission (TJC): In response to the increase in workplace violence and the threat to the health and safety of healthcare workers, TJC adopted new accreditation requirements effective Jan. 1, 2022. These focus on the development of effective hospital Workplace Violence Prevention Plans that include an annual workplace analysis to address workplace violence safety and security risks. TJC expects workplace analysis and best practices to drive improvements including review of policies, procedures, training, and education.

American Nurses Association (ANA): At the 2022 ANA Membership Assembly, the association adopted a motion to address verbal abuse and workplace violence across the continuum of care. This focus seeks to advance strategies and public policy to support a culture of safety and zero tolerance for violence in nursing practice and in healthcare settings. Read the full text of the ANA membership assembly summary at bit.ly/3neJbWm.

Washington state: In 2019, an updated workplace violence prevention bill unanimously passed both houses of the state legislature and went into effect January 1, 2020. This improved upon prior law related to workplace violence prevention in healthcare with increased focus on workplace violence prevention planning, monitoring, and training. Read the full text of the law at bit.ly/2019ViolenceLaw.

2019 Washington workplace violence law

There were a variety of changes to the Washington State Workplace Violence Prevention Law that went into effect in 2020. It is important for healthcare workers and healthcare consumers to be familiar with the current law and the obligations to address escalating violence in healthcare settings in Washington state.

Change in definition

The 2019 law updates the workplace violence definition to include “any physical assault or verbal threat of physical assault against an employee of a healthcare setting on the property of the healthcare setting.” This addresses physical assault or verbal threat of assault with a weapon, including a firearm or any object used as a weapon.

Applicable workplace settings

The workplace violence prevention law applies to the following healthcare settings. The related RCW or chapter provides further reference.

• Hospitals (RCW 70.41.020)
• Home health, hospice, and home-care agencies (chapter 70.127)
• Evaluation and treatment facilities (RCW 71.05.020)
• Behavioral health programs (RCW 71.24.025)
• Ambulatory surgical facilities (RCW 70.230.010)

Workplace Violence Prevention Plan – updated every three years

An important change in current law relates to the Workplace Violence Prevention Plan. While past versions of the Washington Workplace Violence Law required a prevention plan, the recent change requires periodic updates to the plan. Every three years, applicable healthcare settings must develop and implement a plan focused on prevention and protection of employees from workplace violence. In plan development, the healthcare setting must consider guidelines on violence in the workplace and/or in the healthcare setting issued by the Department of Health, the Department of Social and Health Services, the Department of Labor and Industries, the federal Occupational Safety and Health Administration, Medicare, and relevant accrediting organizations.

Oversight committee and Workplace Violence Prevention Plan content

An established safety committee (RCW 49.17.050) or a workplace violence prevention committee (comprised of 50% employee members and 50% employer-selected members) must develop, implement, and monitor progress on the Workplace Violence Prevention Plan. At minimum, the plan includes strategies to address security considerations and factors contributing to, or preventing, the risk of workplace violence:

• Physical layout and characteristics, (i.e., security systems, alarms, emergency response, security personnel available).
• Staffing, including staffing patterns, patient classifications, and procedures to mitigate employee time spent working alone in areas at risk for workplace violence.
• Job design, equipment, and facilities.
• First aid and emergency procedures.
• Reporting of violent acts.
• Employee education and training requirements, and the plan for implementation.
• Security risks in specific units / areas, areas of the uncontrolled access, late night or early morning shifts, and employee areas around the facility, (e.g., parking).
• Processes and expected interventions to assist an employee victim of a violent act.

Incident review frequency

Annually, each healthcare setting must conduct a review of workplace violence incidents that occurred in their facility or locations served. The review includes the frequency of incidents, identification of incident cause, result of the violent act, and issues that contributed to events of workplace violence. Using this information, the healthcare setting must improve the Workplace Violence Prevention Plan to address and mitigate events of violence specific to their healthcare setting.

Violence prevention training

By July 1, 2020, and on a regular basis thereafter, healthcare settings must provide workplace violence prevention training to all applicable employees, volunteers, and contracted security personnel. For new hires, workplace violence prevention training must occur within 90 days of the employee’s initial hire date unless the worker is a temporary employee.

The method and frequency of training may vary according to the information and strategies identified in the Workplace Violence Prevention Plan. Training may include, but is not limited to, classes that provide interactive opportunities, hands-on training, video training, brochures, verbal training, or other verbal or written training deemed appropriate under the Workplace Violence Prevention Plan.

Trainings must address the following topics as appropriate to setting and employee duties / responsibilities based on hazards identified by the healthcare setting in the Workplace Violence Prevention Plan:

• Review of the entity’s Workplace Violence Prevention Plan.
• General safety procedures.
• Violence predicting behaviors and factors.
• The violence escalation cycle.
• De-escalation techniques to minimize violent behavior.
• Strategies to prevent physical harm with hands-on practice or role play.
• Response team processes.
• Proper application and use of restraints, (physical and chemical).
• Documentation and reporting of incidents.
• The debrief process for affected employees following violent acts.
• Resources available to employees for coping with the effects of violence.

Tracking violent acts

Each healthcare setting must keep a record of violent acts against an employee, a patient, or a visitor occurring at the setting for a minimum of five years following the reported act. The record will be available for inspection by the WA DOH upon request, and, at minimum, records will include:

• The healthcare setting’s name and address.
• The date, time, and specific location at the healthcare setting where the act occurred.
• The name, job title, department or ward assignment, and staff identification or social security number of the victim if an employee.
• A description of the person against whom the violent act was committed as a patient, visitor, an employee, or other.
• A description of the person committing the violent act as a patient, visitor, an employee, or other.
• A description of the type of violent act, (e.g., threat of assault, physical assault, etc.).
• An identification of any body part injured.
• A description of any weapon used.
• The number of employees in the vicinity of the act when it occurred.
• A description of actions taken by employees and the healthcare setting in response to the act.

For additional information, please access Chapter 49.19 RCW at bit.ly/RCW49-19 ¹².

As is evident, there are a variety of requirements associated with the Washington State Workplace Violence Prevention Law. When fully implemented, applicable healthcare settings will undertake important measures to prevent workplace violence in Washington state. The 2019 law underscores that workplace violence necessitates a systems approach to address this occupational hazard and to change the belief that workplace violence is part of the job.