Author: Lisa Stand

The American Nurses Association (ANA) has been hearing plenty from working nurses around the country that they deserve a better work environment in which to provide care to their patients. A common refrain, especially in the most recent year of COVID-19, is that their health care institutions are not doing enough to confront workplace violence.  As tensions have escalated during the pandemic, so too have the reports of bullying and assaults against nurses. Frustrations about the health care system, along with decreased staffing levels, very sick patients, and visitor restrictions, have contributed to this epidemic of violence in health care. 

Yet violence on the job is not a new concern for nurses. According to the 2019–2020 survey of 6,000 nurses, conducted by ANA’s Healthy Nurse, Healthy Nation, violence and bullying at work are two of the top 12 hazards that nurses consider a significant risk in the workplace.  That year, 23 percent of nurses said they experienced verbal or nonverbal aggression from a person of authority, 31 percent experienced verbal or nonverbal aggression from a peer, and 35 percent were verbally and/or physically threatened by a patient or patient’s family member. The US Department of Labor indicates that the rate of serious workplace violence incidents (those requiring days off to recuperate) was more than four times higher in health care than in private industry between 2002 and 2012. However, due in part to under-reporting, rates and incidents of workplace violence in health care are difficult to track. 

Given this dismal history, there is no reason to expect that workplace violence against health care personnel will go away when the pandemic recedes from their daily lives. That is, unless institutions make ending workplace violence a priority by ensuring accurate reporting, and implementing effective programs to reduce violence and supporttheir staff. 

Fortunately, health care leaders at the national level are taking note of the negative impact of violence on health care quality and patient safety. For the first time, beginning this year, the Joint Commission (JC) will examine hospital safety under new violence prevention standards. In a June 2021 publication about the new standard, the JC said, “Exposure to workplace violence can impair effective patient care and lead to psychological distress, job dissatisfaction, absenteeism, high turnover, and higher costs.” 

Hospitals are now required to have workplace-focused violence prevention programs, including reporting systems, data review, incident follow-up, and employee training. The language of the standards is general. To expand on the new expectations, the JC offers a Compendium of tools and resources to guide hospitals toward meeting the standards. 

ANA supports the JC’s efforts, and encourages hospital-based nurses to learn more about how their institutions are responding to the new standards. Some questions to ask include: 

• Are nurses and other healthcare personnel taking part in developing workplace violence prevention programs?
• What will leaders do to promote a culture where all personnel are comfortable reporting assaults and threats? 
• How can nurses have input into the design of training and education about workplace violence prevention? 
• How will the institution measure progress in reducing incidents of workplace violence? 

ANA also supports policies to hold all health care employers accountable if they do not take steps to prevent workplace violence. Congress and the Occupational Safety and Health Administration (OSHA) are working on solutions at the federal level. ANA strongly supports these efforts, and encourages nurses to advocate for policy changes. 

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COVID-19 protections for nurses and other health care personnel were long overdue on June 21, 2021, when the Occupational Safety and Health Administration (OSHA) published an Emergency Temporary Standard (ETS) in the Federal Register. In the notice, OSHA acknowledged that nearly a half million people working in health care had contracted COVID-19 by the end of May 2021, and more than 1,600 had died. It is reasonable to believe the standard is a little late, as some commenters have already responded to OSHA.

That said, the significance of OSHA’s action should not be overlooked. The ETS empowers nurses now to:

• Advocate for increased safety in their work site;
• Seek enforcement of concrete federal protections; and
• Voice a chorus of support for strong standards that will have force and effect during future pandemics.  

A cornerstone of the ETS is the requirement for health care employers to develop and implement a safety plan to minimize COVID-19 risks to personnel. The ETS also specifies a number of concrete steps employers must take to reduce COVID-19 transmission in all areas of health care facilities. The ETS includes particular requirements in areas where nurses and other personnel have or may have contact with COVID-19 cases. For instance, on the issue of personal protective equipment (PPE), the ETS is very clear that effective respiratory protection means an N95 face piece, elastomeric masks, or powered air-purifying respirators (PAPRs).

Consistent with OSHA’s stance throughout the coronavirus pandemic, the ETS allows for contingency and crisis strategies when PPE is in short supply, such as limited reuse or extended use of N95s. However, OSHA believes that adequate PPE is no longer in short supply, citing the Food and Drug Administration and the Centers for Disease Control and Prevention. In the event of N95 shortages, OSHA says that employers should provide elastomeric masks or PAPRs as the preferred mitigation strategy.

In addition to PPE, the ETS spells out requirements on a number of COVID-19 protections in health care, including:

• Screening for COVID-19 and appropriate management
• Access to vaccination
• PPE for aerosol-generating procedures with COVID-19 patients
• Physical distancing and physical barriers on premises
• Cleaning and disinfecting
• Ventilation and air filtration standards

With the exception of a few requirements, OSHA expects employers to comply with the ETS beginning July 6, 2021. Nurses with information about violations of specific ETS requirements can contact OSHA with complaints. Complaints can be filed online or by calling 800-321-6742 (OSHA). The ETS warns that under federal law, employers must not retaliate against an employee who complains to OSHA. The ETA also provides that employers must not take actions against an employee who exercises their rights under the ETA specifically.

Nurses understand that the pandemic is not over, and there will inevitably be more pandemics and other public health emergencies. Nurses must not be on the frontlines of failed preparedness in the future. A permanent standard with strong respiratory standards is a necessity. ANA has urged OSHA to build on the ETS and develop a permanent standard that will protect health care personnel specifically from threats involving infectious diseases.

Nurses can comment on the ETS, through July 21, 2021.

ANA members can access our Policy Brief on the ETS here.

OSHA’s materials on the ETS are available here.

As the coronavirus pandemic extends into a second year, nurses enter a second year of calling on Congress and the Administration to ensure an adequate supply of personal protective equipment (PPE) and prioritize COVID-19 vaccine distribution for health care providers. On these issues, the American Nurses Association (ANA) will remain a strong, clear voice until COVID-19 is no longer a threat to nurses on the job, wherever they provide care.

Throughout a challenging year of health emergency, though, nurses and their champions have not turned away from the serious workplace issues that pre-date and continue into the COVID-19 era. An example is workplace violence, which is shown to be highly prevalent in healthcare settings, causes harm to nurses and other health care providers, and undermines quality of care.

Violence and other abuses toward nurses are notably underreported. One reason that many nurses do not report incidents of violence is the belief that their experience will not be acted upon effectively by their facility’s leadership. Even so, the Government Accountability Office (GAO) reported in 2016 that violence against health care workers could be as much as 12 times higher than the overall workforce. This is a critical issue from ANA’s perspective, given that nurses are often the frontline providers in these settings.

The GAO concluded that more efforts are needed. Principally, federal workplace safety regulations should be strengthened. On February 22, 2021, Representative Joe Courtney of Connecticut introduced a bill, with bipartisan support, that would do just that. H.R. 1195, the Workplace Violence Prevention for Health Care and Social Service Workers Act, is almost identical to a measure that passed the House, but was not afforded a vote in the Senate, in 2019.

The bill would require the Occupational Safety and Health Administration (OSHA) to have and enforce specific standards for health care and social service employers. Specifically, OSHA could hold these employers accountable under new safety regulations. The regulations would require health care and social service employers to create violence prevention programs, take concrete steps to reduce the risk of on-site assaults, and employ best practices to encourage reporting and employee engagement in prevention.

ANA has endorsed H.R. 1195, and is working toward speedy passage in the House, followed by Senate action in this Congress. Future posts on Capitol Beat will explore the issue and the legislation in more depth.

For more information about the ANA’s advocacy on workplace violence, click here.