Workplace violence is a persistent and worsening problem in healthcare. According to the Bureau of Labor Statistics, healthcare workers are five times more likely to experience workplace violence than those in other professions and account for nearly half of all reported workplace assaults despite comprising roughly 10% of the workforce. The nonfatal injury rate due to intentional injury in the private healthcare and social assistance industry rose from 10.4 per 10,000 full-time workers in 2018 to 15.2 per 10,000 in 2020. Between 2011 and 2018, approximately 156 healthcare workers were killed at their workplaces, averaging about 20 deaths annually.
Underreporting compounds the problem. Studies indicate that only 20% to 50% of incidents are reported, with some research finding underreporting rates exceeding 89%. Barriers include organizational culture, time constraints, fear of retaliation, and a perception that reporting leads to no meaningful change.
The federal regulatory landscape
OSHA has acknowledged workplace violence as “a serious and longstanding concern.” The agency first issued “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers” in 1996 and updated them in 2004 and 2016. In 2016, OSHA published a Request for Information on the extent and nature of workplace violence and the effectiveness of existing interventions. 81 FR 88147 (Federal Register, Dec. 7, 2016). In 2017, following petitions from labor unions, including National Nurses United, OSHA granted requests to develop a formal standard. A Small Business Advocacy Review panel convened in March 2023 issued its report in May 2023, advancing the rulemaking process.
Now, the Department of Labor is auditing OSHA on workplace violence prevention for the first time in 25 years.
According to the Spring 2025 regulatory agenda released in September 2025, OSHA moved its proposed rule on “Workplace Violence in Health Care and Social Assistance” to Long-Term Action status. This designation means regulatory action is not expected within twelve months — any federal standard remains at least a year away. The agency had previously planned to publish a proposed rule in June 2025, but now it appears employers will have time to appropriately prepare.
Federal legislation also remains pending. The Workplace Violence Prevention for Health Care and Social Service Workers Act, introduced in the 119th Congress, would direct the Secretary of Labor to issue a standard requiring covered employers to develop and implement comprehensive workplace violence prevention plans based, at minimum, on OSHA’s 2015 guidelines.
State-level developments: California leads the way
While federal action remains pending, states have continued to move forward. True to form – California is at the forefront. California Senate Bill 553, signed on September 30, 2023, created California Labor Code section 6401.9, enforceable as of July 1, 2024. Cal/OSHA is developing a workplace violence prevention standard due to the Occupational Safety and Health Standards Board by December 31, 2025, with adoption required by December 31, 2026. Other states often follow California’s lead on workplace safety, so healthcare organizations nationwide should monitor these developments.
Under California’s requirements, employers must establish, implement, and maintain an effective written Workplace Violence Prevention Plan that includes identifying responsible parties, involving employees in development and implementation, accepting and responding to reports of workplace violence, prohibiting retaliation, providing effective training, identifying and correcting workplace violence hazards, and performing post-incident response and investigations.
California’s framework recognizes four types of workplace violence: Type 1, involving criminal intent by persons with no legitimate business relationship; Type 2, violence directed at employees by patients, clients, or visitors; Type 3, violence by current or former employees; and Type 4, violence by persons with personal relationships to employees. Healthcare workplaces often face multiple types simultaneously, requiring comprehensive prevention strategies when they develop their Workplace Violence Prevention Plans.
The Joint Commission’s role
Beyond governmental regulation, the Joint Commission implemented new and revised consensus-based standards in 2022, establishing a framework for effective hospital workplace violence prevention systems. These standards require hospitals to have a workplace violence prevention program led by a designated individual and developed by a multidisciplinary team, provide training and education at hire and regularly, establish policies for preventing and responding to violence, report incidents to analyze trends, support victims and witnesses, and complete worksite analyses with corrective actions.
The Joint Commission adopted a broader definition of workplace violence encompassing not only physical violence but also “covert” forms, including verbal, nonverbal, and written aggression, threatening or intimidating words or actions, bullying, sabotage, sexual harassment, and other behaviors of concern.
Practical strategies for healthcare leaders
Given the regulatory uncertainty at the federal level, healthcare leaders should take proactive steps now. OSHA and NIOSH recommend that all hospitals develop comprehensive violence prevention programs, recognizing that risk factors vary from facility to facility and unit to unit. The following action items provide a framework for building a legally defensible program.
Governance and policy development
- Establish a written zero-tolerance policy that explicitly covers all workers, patients, clients, visitors, contractors, and anyone else who may come into contact with facility personnel.
- Designate a responsible individual to lead the workplace violence prevention program and ensure accountability at the leadership level.
- Form a multidisciplinary safety committee that includes direct-care staff, management representatives, and union representatives where applicable to identify unit-specific risk factors and develop tailored reduction strategies.
- Document all policies and procedures in a formal Workplace Violence Prevention Plan that can be produced upon regulatory inspection or in litigation.
Hazard assessment and risk identification
- Conduct comprehensive worksite assessments to identify environmental and operational hazards that contribute to violence risk, including factors such as working alone, working at night, exchanging money, and interacting with individuals known to have histories of violence.
- Perform unit-by-unit risk analyses recognizing that emergency departments, psychiatric units, and other high-acuity settings may require enhanced controls.
- Review incident data and near-miss reports to identify patterns and emerging risks before serious incidents occur.
- Reassess hazards periodically and following any significant incident to ensure controls remain adequate.
Controls and mitigation measures
- Implement engineering controls such as panic buttons, security cameras, controlled access points, safe rooms, and improved lighting in parking areas and isolated work locations.
- Establish administrative controls, including adequate staffing levels, visitor management protocols, patient flagging systems for individuals with known violence history, and clear escalation procedures.
- Address systemic triggers such as long wait times, inadequate staffing, and poor communication between clinicians and patients that can precipitate violent incidents.
Training and education
- Provide initial and recurring training on recognizing warning signs, de-escalation techniques, emergency response procedures, and proper incident reporting.
- Incorporate communication skills and mindfulness training, as well as patient handover tools that focus on managing aggressive patients.
- Train staff in self-awareness and de-escalation, which research has associated with improved safety outcomes.
- Document all training with attendance records, content summaries, and competency assessments to demonstrate compliance.
Reporting, response, and continuous improvement
- Create accessible and confidential reporting mechanisms that encourage employees to report all incidents, including near-misses and verbal threats, without fear of retaliation.
- Investigate all reported incidents promptly and document findings, corrective actions, and follow-up measures.
- Provide post-incident support for victims and witnesses, including access to employee assistance programs and trauma-informed care.
- Analyze incident trends on a regular basis and use findings to update prevention strategies and demonstrate a commitment to continuous improvement.
Looking ahead
Healthcare leaders cannot afford to wait for federal mandates. The legal risks under existing frameworks — including OSHA’s General Duty Clause and state-specific requirements — already create compliance obligations. By implementing comprehensive violence prevention programs now, healthcare organizations can protect their workforce, maintain quality of care, and position themselves for compliance with forthcoming regulatory requirements.
Photo: s-c-s, Getty Images
Robert Rodriguez, Stefan Borovina, and Savannah McDonald are licensed attorneys and members of the Workplace Violence Prevention Practice Group at Ogletree Deakins, one of the largest labor and employment law firms representing management. The Workplace Violence Prevention Practice Group is a cross-disciplinary team of attorneys with experience advising and counseling employers on a broad cross-section of workplace violence and threat assessments and response. When needed, they coordinate and collaborate with internal and external experts, including security and law enforcement professionals, threat assessment psychologists, and public relations professionals, to provide advice and litigation support for a variety of workplace violence-related disputes and issues. Robert is co-chair of the practice group and a Sacramento shareholder. Stefan is of counsel in New York, and Savannah is an associate in Washington, D.C.
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