State laws that address workplace violence in health care settings

Abstract

Introduction

Workplace violence (WPV) against health care workers is a longstanding challenge that impacts the well-being of workers and patients. State legislative efforts to address WPV against health care workers have accelerated in recent years, particularly following the COVID-19 pandemic.

Methods

This study conducted a review of WPV-related enacted laws in health care settings across all 50 states over the last 10 years.

Results

As of June 2024, 48 states had enacted at least 1 WPV law, and some states have enacted 2 or more laws. State laws were categorized into 3 types: penalties, prevention, and remediation. Forty-five states had laws that penalize perpetrators of WPV, 27 enacted prevention laws, and 23 had remediation laws. Ten states had laws combining penalties with either prevention or remediation, 17 states had laws covering all 3 categories, while 3 states had only prevention and remediation laws.

Conclusion

Understanding variation in state WPV laws is important to future efforts to evaluate the efficacy of different legislative approaches. This study provides a landscape for federal and state government to understand legislative trends, and can inform health systems on strategies that can be used to prevent and address WPV.

Introduction

Workplace violence (WPV) against health care professionals has garnered heightened attention as the COVID-19 pandemic illuminated the challenging conditions faced by health care workers. This increased attention builds upon a long-term trend of health care workers bearing the brunt of WPV in the United States, experiencing 73% of all nonfatal violent injuries in US work settings in 2018.¹ Additionally, recorded WPV incidents have grown over time, with WPV reported across health care facility types increasing by 30% from 2011 to 2021/2022.² Addressing WPV is critical not only to ensure the safety of health care workers but also to deter the adverse effects of WPV on psychological well-being and job satisfaction, turnover, and patient care quality.^3-6

Health systems and professional organizations in the United States have collectively worked to address WPV and protect workers. Health system approaches have commonly included violence risk assessments, enhanced staff training and education, changes in environmental design (including panic buttons and security systems), support for impacted staff, and improved reporting.⁷ Professional organizations have also dedicated attention to WPV prevention via the creation of toolkits, issue briefs, training webinars, and best-practice sharing.^7-13 Professional organizations have focused on mitigating community violence and health system risk, building prevention programs, developing a culture of safety, and providing trauma support.^7,11 Professional groups have also advocated for state and national policy change, through national awareness campaigns, legislative advocacy, and support for violence prevention standards.^7,12

At the same time, states have enacted legislation to address WPV against health care workers, perhaps in part as a response to the lack of enacted federal legislation. While limited evidence exists on the breadth and effectiveness of state laws to mitigate WPV, recent findings by Ninan et al¹⁴ concluded that WPV legislative efforts have reached almost all states. Legislation generally takes 2 forms: (1) increased penalties for perpetrators of WPV and (2) required actions for health care facilities. The vast majority of states have implemented punishments for perpetrators, and 20 states have introduced requirements for health care facilities to implement workplace risk assessments, violence prevention programs, or tracking of incidents.¹⁴

Despite these efforts, gaps persist in our understanding of legislative approaches to address WPV against health care workers, particularly related to understanding the types of interventions present in legislation, including efforts to target perpetrators of WPV or aimed at organizations to implement prevention, penalty, and remediation strategies. Workplace violence legislation has proliferated quickly, with significant variation in the types of health care settings and health professionals included in policies. Analyzing WPV legislative trends and archetypes as well as understanding variation in state-level WPV laws is important to evaluate the efficacy of different approaches and inform future legislation intended to protect health care workers. Additionally, to our knowledge, the literature to date has not comprehensively analyzed which types of health settings are being protected. Opportunities exist to understand trends in how state general assemblies' responses have changed over time. This understanding could help inform policymakers and researchers on the evolution in WPV legislation and which types have proliferated more recently. This study provides a comprehensive review of WPV-related enacted legislation in health care settings across all 50 states over the last 10 years.

Methods

We conducted a comparative analysis of state laws to address WPV towards health care workers. We aimed to understand (1) the focus of the legislation action (ie, penalty, prevention, remediation), (2) the type of health care setting protected, and (3) temporal trends in state WPV laws in the postpandemic period.

Data sources and collection methods

A literature review and a web-based search were used to develop an initial inventory of state WPV legislation, which served as a starting point to find additional legislation. With this preliminary information on WPV legislation, we created a protocol to systematically extract data on each state's WPV laws. With this extraction tool, state legislative archives, including the LegiScan Government Affairs Information Tracking System (GAITS) database,¹⁵ and additional web-based searches were conducted. Statute history was analyzed over time using state archives and the Justia US Law database¹⁶ to evaluate changes in legislative language. Both LegiScan and Justia are publicly available legal databases that provide real-time access to legislative tracking, statutory codes, and judicial opinions. Text and key characteristics of enacted laws were manually collected by 1 team member and reviewed by all authors (see Appendix S1 for data extraction guide).

Categorization of state laws

State laws were categorized based on the focus of legislative action. We drew upon the work of Ninan et al¹⁴ to initially identify 2 categories of WPV laws described: Penalty and Actions Health Care Facilities Must Take. However, after reviewing the enacted legislation text, the authors separated WPV laws in the second category, Actions Health Care Facilities Must Take, by those that aimed to prevent WPV and those that aimed to remediate the effects of WPV after an event has occurred. After these categories were identified, we further classified subtypes of prevention and remediation laws. The development of these categories and subcategories was made after reviewing the legislative text, creating a codebook and defining the categories, and team discussions.

The 3 categories include penalty, prevention, and remediation. Penalty legislation includes laws that increase punishment for perpetrators who commit violence towards health care workers; one common example is heightened penalties for assaults on health workers, including minimum sentencing, imprisonment, and/or monetary penalties.¹⁴ Prevention legislation pertains to laws aiming to head off violence before it occurs, including violence prevention planning, required training of staff, and required posted signage to raise awareness towards WPV. Remediation laws serve to support and protect health workers after a WPV incident, as well as requirements to collect WPV data in the state—for example, nonretaliation agreements for health workers who wish to press charges of a health setting–based WPV event.

Based on our review of the prevention and remediation laws, we further categorized prevention and remediation laws into subtypes. Prevention laws included 4 types: violence prevention plans for organizations, required training to develop staff skills, signage to display visual reminders about impermissible actions against staff, and other (eg, WPV awareness campaigns). Remediation laws involved victim supports and protections, which included counseling, nonretaliation, record keeping, data reporting, and evaluation. While 1 piece of legislation can include multiple categories and subcategories, historically enacted legislation often is either a penalty, targeting individual perpetrators, or targeting organization-level strategies.¹⁴

Analysis

Passed legislation was collected, categorized, and descriptively summarized. To examine changes in WPV legislation over time, we analyzed 3 periods: pre-2015 (all WPV legislation enacted prior to 2015), 2015–2019, and 2020–June 2024. This approach allowed for comparisons of two 5-year periods with earlier baseline data. Additionally, to understand geographical patterns, we created maps to observe possible state and regional differences in WPV laws.

Limitations

Data in this analysis are based on legislation as of June 2024, and 2 main factors may have limited our findings. First, the search may not have captured all existing laws available through state legislative websites; the LegiScan GAITS and Justia US Law were leveraged to minimize omissions. However, search limitations may be exacerbated by older laws that are less likely to be digitized or to be returned in search results. We utilized media articles as an additional way to identify the origins and histories of these bills and fill in gaps, where possible. Despite these measures, some state legislation may have been missed. Second, the study findings are limited to the time period of data collection and, due to WPV legislation's rapidly evolving nature, the study does not include information on pending legislation or legislation passed after June 2024 (eg, 21 laws were in progress as of June 2024). In addition, we use the term “victim” to refer to health workers; however, the laws could also potentially protect others such as patients and visitors in health settings.

Results

As of June 2024, 48 states had enacted legislation related to WPV in health care settings. Only South Carolina and Wyoming had not enacted WPV legislation. There were 112 WPV laws in place as of June 2024. Of the states that had WPV laws in place, states ranged from having 1 to 5 different laws in place, with a mean of 2.3.

Focus of legislative action

Forty-five states (90%) had enacted laws that aim to penalize individual perpetrators of WPV towards health care workers as of June 2024. Penalty laws include guidelines on sentencing, length of imprisonment, and monetary penalties. State examples include Rhode Island, with imprisonment of no more than 3 years or a fine of not more than 1500 dollars, or both, and Oklahoma, with an assault felony punishable by imprisonment not to exceed 2 years or by a fine not to exceed 1000 dollars, or both.

Twenty-seven states (56%) have passed prevention laws and 23 states (47%) have passed remediation laws (see Figure 1). Types of prevention and remediation laws varied. Prevention efforts that required health systems to implement violence prevention plans and training programs were most common—present in 36% and 34% of all states, respectively. Within remediation, requiring WPV incidents to be recorded and documented by the health setting was most prevalent (38% of states), followed by victim protections such as nonretaliation and personal information safeguards (28% of states). Only 1 state—Illinois—mentioned program evaluation in its law, requiring evaluation of the violence prevention programs.

Figure 1.

Focus of legislative action and types of laws states enacted to address workplace violence (WPV) towards health workers, June 2024. Sources: Authors’ analysis of state WPV towards health care workers legislation as of June 2024. Abbreviation: Org, organization.

Across the 48 states with WPV laws, 18 states only enacted penalty legislation, 3 states only enacted prevention and remediation but no penalties, while no states had only prevention or only remediation. States often have more than 1 type of legislative action to address violence towards health care workers. Our analysis identified 10 states with enacted legislation for penalty and either prevention or remediation and 17 states covering all 3 categories.

Setting protected by WPV legislation

State laws varied in defining the health care settings covered by WPV legislation (see Figure 2): 13% of states protect emergency services only (Emergency Medical Services [EMS] or emergency departments), 11% protect hospitals only, and 76% cover a broad range of health care facilities. Within prevention legislation, 4% of states cover emergency services, 22% protect hospitals only, 70% cover a broad range of health care facilities, and 4% cover other settings. Within remediation, 30% of states cover hospitals only, 65% cover a broad range health care facilities, and 4% protect other settings.

Figure 2.

Types of health care settings included in workplace violence (WPV) legislation, overall and by time period. Sources: Authors’ analysis of state WPV towards health care workers legislation. Abbreviations: ED, emergency department; HC, health care.

The types of health care settings included in WPV legislation changed over time. Prior to 2015, close to half (45%) of WPV legislation was targeted to emergency response services (EMS) or emergency departments exclusively, while 7% covered hospitals exclusively, and 45% covered health care settings broadly. As of June 2024, nearly three-quarters (72%) of WPV legislation broadly covered all health care settings, representing an increase in coverage across different settings.

Temporal trends in WPV legislation

Prior to 2020, 46 states enacted at least 1 type of WPV legislation, suggesting that WPV laws are not a new strategy to address violence against health care workers. Most legislation prior to 2015 focused on penalties for perpetrators of WPV (Figure 3). However, beginning in 2015, more states enacted legislation aimed at preventing and remediating WPV incidents. Prior to 2015, only 11 states had laws related to prevent WPV compared with 27 states that had laws related to prevention as of June 2024. Similarly, prior to 2015, only 8 states had remediation laws to address WPV as compared with 23 states as of June 2024.

Figure 3.

Number of states with enacted workplace violence (WPV) legislation towards health workers over time, by focus of legislative action. Sources: Authors’ analysis of state WPV towards health care workers legislation.

Figure 4 compares WPV type of legislation (penalty, prevention, and remediation) by state over two time periods. Prior to 2020, only 8 states had all 3 types of WPV legislation, 4 states had no WPV legislation (Nevada, New Hampshire, South Carolina, Wyoming) , 2 states (Maryland, Oregon) had only organization prevention and remediation laws, while the vast majority of states (32 states) had only penalty legislation. As of June 2024, 17 states had all 3 types of legislation, 2 states had no WPV legislation (South Carolina and Wyoming), 3 states (Maryland, Oregon, Rhode Island) had only prevention and remediation, and 18 states had only penalty laws. In addition, several states that only had penalty legislation prior to 2020 added either organization prevention laws (7 states) or remediation laws (3 states; Colorado, Missouri, Montana) by June 2024.

Figure 4.

States with enacted workplace violence (WPV) laws by category, prior to 2020 and 2024. Sources: Authors’ analysis of state WPV towards health care workers legislation.

Discussion

This article provides an overview of state laws that aim to prevent and address WPV in health care settings. The findings reveal that, while most states had already enacted WPV-related legislation prior to 2020, there has been a notable shift in the types of laws enacted from penalties to prevention and remediation coupled with a broadening of health care settings covered since 2020. This shift may reflect a growing recognition of the need for more organization-focused and preventive approaches to WPV. The increase in prevention laws, such as requiring health systems to implement violence prevention plans and staff training, indicates a shift toward proactive strategies that aim to reduce the incidence of WPV towards health care workers before it occurs. Similarly, the growth in remediation laws, including victim support and data-reporting requirements, reflects an emerging commitment to supporting affected health care workers and improving institutional accountability.

Although this study observed trends in increasing prevention and remediation strategies to address violence towards health care workers over time, it is unclear whether this shift was occurring as the result of a desire to utilize evidence-based strategies for WPV or that penalty-focused laws were ineffective in reducing WPV.^17-21 The majority of WPV research in health care has focused on prevalence and the impact of workplace violence on workers, with emerging study of interventions.^4,22 Presently, to our knowledge, no evidence conclusively supports one particular strategy to reduce the incidents of WPV,^4,23 and consensus on best practices is limited due to insufficient intervention design, mixed results, and violence underreporting.^4,22,23 For example, while training-focused WPV prevention programs are common and usually the first line of intervention and may increase knowledge and confidence, they often do not decrease the number of violence incidents.^24-26 Overall, the research points to using comprehensive interventions in lieu of singular interventions^23,27,28 and suggests using systems-based approaches that address the organization-level factors that may be driving WPV events, not just focusing on the individual worker-level strategies.^29,30

Further research is needed to evaluate the real-world impact of different legislative approaches, particularly in terms of reducing WPV incidents, improving worker well-being, and enhancing patient care. Although there is a need to study the effectiveness of different legislative approaches in reducing WPV incidents and improving outcomes for health care workers, only 1 state specifically included program evaluation in the enacted legislation. As of June 2024, 11 states require centralized data collection, which could create opportunities to evaluate the effectiveness of statewide strategies to reduce health care WPV. Future work would benefit from improving methodological design and analysis to assess the causal impact of environmental and organizational strategies to reduce WPV^{4,26,28,31,32} as well as examining the effectiveness of different strategies across different health care settings^24,31 and types of workers.^24,32 For example, how do enacted laws protect health workers delivering care outside of traditional health care settings that were specifically mentioned in the legislative text or, for instance, home health care. Comparing differences in WPV rates across states with different types of legislation (ie, penalty, prevention, remediation) could identify best practices and inform future policy development.

Supplementary material

Supplementary material is available at Health Affairs Scholar online.

Funding

This work was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Cooperative Agreement for a Regional Center for Health Workforce Studies #U81HP26495. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the US government.

Data availability

No original datasets were generated in this study. All legislative materials were obtained from two publicly accessible databases: LegiScan (https://legiscan.com/) and Justia US Law (https://law.justia.com/).