In 2010, Donna Gross, a psychiatric technician at Napa State Hospital for more than a decade, was strangled to death at work by a mentally ill patient. While on-the-job violence in the health care sector was certainly nothing new at the time, the shocking and preventable circumstances surrounding Gross’ death helped ignite a new and coordinated movement for change. Now, just a handful of years later, California is set to become the only state with an enforceable occupational standard aimed at preventing workplace violence against health care workers.

“Honestly, this (proposed rule) wouldn’t have happened if it weren’t for two things: the prevalence of the problem and the fact that our health care workers aren’t afraid to speak up any longer,” said Kathy Hughes, who’s been a registered nurse for 20 years and works as a labor specialist with Service Employees International Union (SEIU) Local 121RN, which represents about 8,000 nurses and health workers in southern California. “It really is a big deal. It’s one of those things where you think ‘I can’t believe I’m a part of this.’”

In early 2014, Hughes, along with fellow labor and professional nursing advocates, petitioned the California Division of Occupational Safety and Health (Cal/OSHA) to promulgate a comprehensive workplace violence prevention standard to protect health care workers. A few months later, the Cal/OSHA Standards Board unanimously voted to accept the petition and move forward. Today, public comments on the proposed standard, “Workplace Violence Prevention in Health Care,” are being accepted through Dec. 17, when the Standards Board will hold a public hearing on the rule. If the violence prevention rule is adopted, as is expected and required by state statute, it will join two other major health worker protections enforced by Cal/OSHA: a safe patient handling standard as well as a standard designed to protect workers from aerosol transmissible disease. With the three standards on the books, California will arguably have the most comprehensive framework of occupational protections for health care workers in the nation.

“A lot of the regulations have been spearheaded by nurses who are organized in California,” said Mark Catlin, health and safety director for SEIU. “Now, workers across the country can point to California and say ‘Look, they have these standards on the books, they haven’t destroyed the industry and they work.”

‘It’s just so pervasive’

While Gross’ death represents the most horrific consequence of an employer’s failure to protect workers against known hazards, violence in the health care sector has become so common that many nurses simply see it as a part of the job, Hughes told me.

According to the U.S. Occupational Safety and Health Administration (OSHA), more than 70 percent of the thousands of violence-related workplace injuries that occur every year happen in health care and social service settings. In fact, health care workers are nearly four times as likely to be injured as a result of violence than the average private-sector worker. A study published earlier this year in CDC’s Morbidity and Mortality Weekly Report found that nurses and nurse assistants experienced higher rates of violence-related injuries at work than other health care workers. And another recent study published in the Journal of Emergency Nursing found that more than three-quarters of nurses surveyed experienced either physical or verbal abuse in the past year.

Currently, there is no federal occupational standard on workplace violence in health care, though federal OSHA recently released new guidelines and materials on the topic.

“It’s just so pervasive,” Hughes said. “One of our goals is to change that mindset and help all health workers recognize that violence shouldn’t be part of the job.”

In the wake of Gross’ death in 2010, Hughes and her colleagues, including Ingela Dahlgren, executive director of the SEIU Nurse Alliance of California, traveled to rallies organized in Gross’ memory and began talking with workers about conditions at Napa State Hospital. Dahlgren, herself a trauma and critical care nurse, said she couldn’t believe the circumstances under which Gross lost her life. For instance, the hospital staff wore personal alarms to call for help, but the alarms only worked inside the buildings, not between buildings where Gross was killed. Also, patients who had a history of aggressive behavior and stalking were allowed to freely roam about the facility. (Cal/OSHA ultimately fined Napa State Hospital more than $100,000 for failures to safeguard workers that were uncovered during an investigation following Gross’ murder.)

Hughes and Dahlgren soon expanded their inquiry throughout the state and even began talking to nurses across the country, collecting first-person stories of the violence that too often comes with caring for the sick and injured. Dahlgren told me she was “just flabbergasted” at the amount of violence that nurses were experiencing. And compounding the problem was a culture of silence around violence at work — “nurses were experiencing an enormous amount of violence that they never even spoke about,” Dahlgren said.

“We have hundreds of stories about violent incidents,” Dahlgren said. “But you can’t sit down and read all of them. It’s just too heart breaking.”

Catlin, at the national SEIU office, said health care workers are increasingly speaking up about violence and recognizing all forms of violence at work. For example, he said, when you ask a room of health care workers how many have experienced violence at work, about half raise their hands. But when you ask how many have been threatened, spit on, bit or hit, every hand in the room goes up.

“The public doesn’t see workplace violence as it sees other health and safety issues,” he told me. “And when you do hear about an incident, it’s usually something like a disgruntled person who walks in and shoots his co-workers. But that’s actually the least common form of workplace violence.”

In her own career as a nurse, Dahlgren told me the story of a John Doe patient who had been found in a trash bin, badly beaten and suffering from massive head injuries. Dahlgren was sitting at a desk working on the patient’s chart when a tall man walked in wearing a heavy coat in the middle of summer. He asked for the John Doe patient. Dahlgren could see a gun under his coat. All she could do was look him sternly in the eye, tell him to leave and hope that he would. Thankfully, the man left. But Dahlgren told me there was little she could have done had the armed man not heeded her instructions.

The proposed Cal/OSHA violence prevention rule likely won’t prevent all people with dangerous intentions from attempting to enter a health care facility with a weapon. And it may not change the behavior of patients and their families. But it will put in place standards to keep many health care workers safer than they are today. Among its many measures, the rule would require employers to establish a plan with the input of employees, regularly train workers, and assess the environmental factors that make workers more vulnerable to violence. For example, in Dahlgren’s experience, an electronic badging system could have prevented the armed man from entering the unit in the first place.

“There’s a lot of violence in this society and Cal/OSHA isn’t going to fix all the factors that cause violence,” said Deborah Gold, who recently retired as deputy chief for health and engineering services at Cal/OSHA and who was involved in the early development of the proposed violence standard. “But what Cal/OSHA can do is ask employers to take reasonable measures to protect employees and enable them to provide care without fearing for their lives. That’s what this regulation has the potential to do.”

‘This isn’t a patient problem. It’s a system problem.’

While the proposed Cal/OSHA rule will be a first for the nation, it’s not the state’s only attempt at violence prevention in health care settings.

In 2009, California passed a law requiring general acute care hospitals to develop a workplace violence prevention plan, but that requirement falls under the state’s licensing codes, not its labor protections. Similarly, many hospital and health care systems have their own violence prevention efforts in place. For example, some hospitals may use a certain color of blanket for patients with an aggressive history — the color is a signal to nurses to take protective actions around the patient, such as working in pairs. Other hospitals, especially those that regularly care for community victims of violence, provide employees with de-escalation training. And many large health care employers likely have some type of violence prevention program or plan. But nothing comes close to the scope and comprehensiveness of the proposed Cal/OSHA protections.

“There’s a whole workplace culture that contributes to this problem,” Hughes told me. “This isn’t a patient problem. It’s a system problem.”

The proposed Cal/OSHA rule standardizes violence prevention requirements across health care settings in California, but it’s in no way a “cookie cutter” approach, Hughes said. Instead of handing down step-by-step instructions, the rule recognizes that each employer has different needs — in other words, a 300-bed hospital will require a different plan than an outpatient clinic. But the rule does require that employers take certain actions, such as establishing a written workplace violence prevention plan with the input and involvement of employees. Employers will also be required to assess the workplace for environmental factors that heighten workers’ vulnerability, such as having employees work in isolated areas, poor lighting, cumbersome alarm systems, and a lack of escape routes. Other requirements include annual employee education and training; developing systems to respond to and investigate violent incidents; and correcting hazards related to workplace violence in a timely manner.

And not only will the proposed rule apply to every health care facility in the state, from general acute care and psychiatric hospitals to correctional treatment centers and hospice facilities, but it will protect all workers in such facilities, from doctors and nurses to custodial staff and temporary workers. The rule would also require covered facilities to report violent incidents to Cal/OSHA within specific time frames.

“We’ll be able to hold management accountable,” Dahlgren said. “That’s one of the most important parts — we can enforce the law and hold everyone accountable.”

Both Hughes and Dahlgren said the movement toward enforceable violence prevention standards wouldn’t have been possible without the help of nurses and other health care workers who decided to speak up about experiencing violence at work. Dozens of health workers have attended Cal/OSHA hearings to share their stories in person.

“It’s really become a grassroots member movement,” Hughes said. “We’re changing the dialogue and the culture. …Workers are taking ownership of this issue and becoming advocates in their own facilities around violence prevention.”

According to state statute, Cal/OSHA must adopt a health care worker violence prevention standard by July 2016. The rule would go into effect in October 2016. The public comment period on the proposed rule ends Dec. 17 — submit your comments to oshsb@dir.ca.gov. To learn more about violence in health care and the need for worker protections, visit California Health Care Workers’ Safe Care Standard.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for nearly 15 years.