Unprotected: Healthcare Workers and the Federal Safety Gap Nobody Has Closed

Healthcare workers across the United States are being assaulted at rates that exceed nearly every other industry, and the federal government has yet to give them a rule designed specifically to protect them.

The Occupational Safety and Health Administration has the authority to set workplace safety standards. It has received decades of warnings about violence in hospitals, clinics, and care facilities. It has not acted on them with a dedicated regulation. What exists instead is a general requirement that employers provide a safe working environment, a provision broad enough to cover almost any hazard and specific enough to address almost none of them directly.

That gap has consequences. A nurse in California works under a state law that requires her hospital to maintain a formal violence prevention program, conduct annual security assessments, and document incidents. A nurse doing the same job in a state without such a law works under no equivalent requirement. Her protection depends on whether federal OSHA chooses to enforce the general provision and whether her employer has chosen, on its own, to take the issue seriously.

That is not a safety system. It is a geography problem.

The patchwork has been building for years. California and New York are among the states that have moved ahead with their own workplace violence requirements for hospitals and healthcare facilities. New York Governor Kathy Hochul signed legislation requiring hospitals and nursing homes to establish prevention programs that include annual site-specific assessments, incident reporting, employee training, and security procedures. These are meaningful requirements. They are also requirements that workers in dozens of other states do not have.

A recent federal court decision has clarified the boundaries of existing authority without filling the hole at the center of the problem. The Tenth Circuit Court of Appeals, in UHS of Delaware v. Occupational Safety and Health Review Commission, upheld OSHA's ability to use the General Duty Clause to enforce safety standards in the absence of a specific rule. That is a significant legal affirmation. It confirms that employers cannot simply point to the absence of a dedicated regulation as a reason to do nothing. But it does not create the uniform baseline that a specific federal rule would establish.

The decision carries a particular warning for healthcare employers who have begun but not finished the work of violence prevention. The court found that an employer's own written policies can be used as evidence of what safety measures are feasible. A risk assessment that sits in a drawer, or a violence prevention plan that was drafted and never fully implemented, can become a liability. The message is direct: starting the process and stopping halfway may be worse than not starting at all.

The factors driving violence in healthcare settings are not mysterious. Long wait times create frustration that can turn hostile. Patients experiencing mental health crises or substance use emergencies may be unpredictable. Facilities operating with reduced staff have fewer people available to de-escalate a situation or call for help. Emergency departments, psychiatric units, and long-term care facilities carry the highest risk, and workers in those settings often have the least institutional support.

The Biden administration moved to address this with a proposed rule covering the healthcare and social assistance sectors. That rule has since been placed on the long-term action list in the federal regulatory agenda, a designation that signals it is not a near-term priority. Whether the current administration will revive it, modify it, or let it recede further is not yet clear. What is clear is that while the regulatory process stalls, the conditions that produce violence in healthcare settings have not improved.

For employers trying to navigate this environment, the practical guidance is consistent across legal contexts. Comprehensive violence prevention programs, including security assessments, staff training, clear incident reporting systems, limits on patient access to certain areas, and adequate security personnel, reduce risk and demonstrate good faith under both state laws and the General Duty Clause. Employers who have not yet built these programs face legal exposure. Employers who have built them only on paper face a different kind.

The broader question is whether a national problem can be managed through a collection of state solutions. Some states have strong laws. Some have weak ones. Some have none. The result is that a healthcare worker's level of protection is determined less by the nature of her job than by the state in which she performs it.

A federal rule would not solve every dimension of workplace violence in healthcare. It would not eliminate the underlying pressures that make these settings dangerous. But it would establish a floor, a minimum set of expectations that apply regardless of location, and it would give workers and employers alike a clear standard to meet.

That standard does not yet exist. And every day it remains absent, the workers providing care to the sick and vulnerable are doing so without the specific federal protection that workers in other high-risk industries have long been able to take for granted.

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