At Kaiser Permanente South Bay Medical Center in Los Angeles, registered nurse Kimberly Mullen is not unaccustomed to being kicked, scratched, shoved, or threatened while on duty in the telemetry unit. She says it's considered part of the job when dealing with patients who are sometimes confused, frustrated, and feel a loss of control in an unfamiliar hospital setting. Still, she is grateful she hasn't suffered more serious injuries, such as a colleague who was attacked by a patient's family member.

Mullen and millions of healthcare workers across the country are gradually becoming accustomed to workplace violence, which ranges from verbal abuse and threats to physical assault and even homicide. The extent to which the pandemic has exacerbated this issue is not entirely clear, but multiple attacks have occurred this year.

At HCA Mission Hospital in Asheville, North Carolina, registered nurse Hannah Drummond says yelling, insults, and loud profanity now happen daily, whereas "that wasn't the case in the past."

According to data from the U.S. Bureau of Labor Statistics, workers in healthcare and social services industries have the highest rates of injuries due to workplace violence, being five times more likely to suffer such injuries than all workers combined. These incidents have risen almost every year since the BLS began tracking them in 2011. Sometimes these events are fatal. According to BLS data, between 2016 and 2020, private healthcare workers experienced an average of 44 workplace homicides per year.

Currently, there is no federal requirement mandating that healthcare employers protect employees from workplace violence, although the Occupational Safety and Health Administration (OSHA) provides voluntary guidelines. A few states have rules or laws penalizing perpetrators, which leaves most of the responsibility on individual hospitals.

Some nurses say their hospitals effectively protected them during the pandemic, such as through sustained visitor restrictions and workplace violence prevention programs often pushed by unions or mandated by state laws. Others disagree, arguing that a lack of security, training, and staffing issues worsened by the pandemic hindered their ability to provide timely, adequate care for every patient, causing frustration among patients and families that sometimes escalated into violence.

"Fewer and fewer resources to care for patients"

Meanwhile, hospitals face unprecedented staffing shortages. With widespread stress and burnout prompting healthcare workers, especially nurses, to consider leaving, this issue is unlikely to ease in the short term. According to data from the Department of Health and Human Services, in early January, one in four U.S. hospitals reporting data faced severe staffing shortages.

Drummond of HCA Mission Hospital said a patient recently attacked her colleague because staff did not deliver medication in time. "A lot of the frustration nurses face is justified because every year we have fewer and fewer resources to care for patients," Drummond said.

So far this year, there have been multiple attacks against healthcare workers. For example, in late January, according to a statement from the system's CEO, Warner Thomas, a patient's family member attacked an ICU nurse at Ochsner Medical Center's West Bank Campus in New Orleans. Thomas now advocates for state legislation to make violence against healthcare workers a felony, because "hospitals are responding to an increase in disruptive or violent incidents within their walls—many involving hostile visitors—which adds additional strain to the healthcare workplace."

In some states like Utah, lawmakers are currently considering legislation to strengthen penalties for assaulting healthcare workers. Wisconsin already has a law making battery against certain healthcare workers a felony, but a bill under consideration in its legislature would extend that penalty to anyone who threatens violence against healthcare workers—similar to laws covering police and other government employees.

Meanwhile, no federal law directly addresses violence against healthcare workers, although the U.S. House of Representatives passed the Workplace Violence Prevention for Health Care and Social Service Workers Act last April, but the Senate has not yet passed it. The legislation would require healthcare employers to develop and implement comprehensive workplace violence prevention plans based on OSHA's voluntary guidelines, and would also require annual training for employees, detailed records of violent incidents, and an annual summary submitted to the federal Department of Labor.

Currently, California has similar laws, with guidance and enforcement carried out through the state's OSHA division. California and a few other states, such as Connecticut, Illinois, Maryland, Minnesota, New Jersey, Oregon, and Washington, also have laws requiring healthcare employers to run workplace violence prevention programs, according to the American Nurses Association.

Some provider groups, such as the American Hospital Association, oppose the federal bill, saying hospitals already have targeted policies to address workplace violence and that a one-size-fits-all OSHA standard is unnecessary.

Verbal attacks rise amid pandemic frustrations

Nevertheless, labor groups like National Nurses United argue that unified, consistent, and enforceable rules are needed. NNU opposes state laws aimed at criminalizing violence against healthcare workers because perpetrators are often vulnerable patients, and imprisoning them does more harm than good, the union said in an email statement.

Nurses like Drummond say better staffing would allow nurses to give patients their full attention, provide the best care, and address many of the issues that lead to violence. She added that increasing support staff, such as nursing assistants and security guards, would also help. Early in her career, Drummond felt she had more time for therapeutic conversations with patients and their families. "Now, I can't devote the same time and attention to patient care as I would like," said Drummond, a registered nurse with eight years of experience.

The extent to which the pandemic has affected violence against healthcare workers, in its various forms, remains unclear because the Labor Department's most recent data is from 2020, and the agency tracks workplace injuries and illnesses by examining incidents that result in days away from work. According to BLS data, nursing assistants, registered nurses, licensed practical nurses, and vocational nurses all saw increases in days away from work in 2020. Nursing assistants had the highest number of days away from work among all occupations, increasing 2.5 times from 2019 to 2020.

While some nurses missed work due to contracting COVID-19, others had to take time off due to workplace violence incidents. Meanwhile, nurses say frustrations and misinformation surrounding COVID-19 and the pandemic have particularly intensified verbal attacks beyond previous levels.

At South Bay Medical Center where Mullen works, "frequent flyers"—patients who return to the hospital frequently for chronic conditions—are often the most prone to frustration, with one patient known for repeatedly hurling racial slurs at staff during shifts, Mullen said. However, the limited visitor policy during the pandemic has helped curb physical attacks, Mullen said. The hospital still allows visitors for patients who are confused or near death.

Her hospital is covered by the state's workplace violence prevention law, but it is also part of Kaiser Permanente, which has unionized nurses and a unique labor-management partnership with the hospital system. Her hospital also has a dedicated workplace violence prevention committee that develops new techniques to ensure employee safety. One technique employees now use is placing a green card on the window of patients who have exhibited violence, or placing a green blanket on the patient. This signals to other staff, such as those delivering meals or environmental services, to be extra cautious if they have not yet interacted with that patient.

The green blanket program started at one location and then expanded to all other medical centers in Southern California, said Charmaine Morales, executive vice president of the United Nurses Associations of California/Union of Health Care Professionals. The union represents more than 32,000 healthcare workers. Additionally, emergency buttons are installed on every computer in these facilities, Morales said.

However, hospitals in other states without workplace violence laws or unions pushing for more protections typically do not have emergency buttons or committees to establish new prevention methods. Morales said national regulations like the Workplace Violence Prevention for Health Care and Social Service Workers Act would help "rather than leaving each state to decide on its own." However, "even without a law, it doesn't mean you shouldn't do the right thing to protect workers' physical and mental well-being," she said.