The end of summer is quickly approaching. This year Labor Day does not just signify kids are headed back to, or in many cases, already back in, school. It also means that healthcare facilities in Texas (hospitals, nursing facilities, ambulatory surgery centers, home health and hospice, and freestanding emergency medical care facilities) must have a workplace violence prevention program in place.

On May 15, 2023, Governor Abbot signed SB 240, relating to workplace violence prevention in certain healthcare facilities. The new law became effective on September 15, 2023, and was incorporated into Chapter 331 of the Texas Health & Safety Code. Texas healthcare facilities must meet Chapter 331 workplace violence prevention requirements by September 1, 2024.

Most acute care and mental hospitals already have a workplace violence prevention program in place due to The Joint Commission workplace violence standards adopted in 2022. But in addition to hospitals, the Texas workplace violence prevention law applies to:

• Ambulatory Surgery Centers;
• Freestanding Emergency Medical Care Facilities;
• Nursing Facilities (licensed under Chapter 242 of the Texas Health & Safety Code); and
• Home and Community Support Services Agencies (i.e., Home Health Service, Hospice)

Covered facilities must establish a workplace violence prevention committee, prevention plan, and policy. The workplace violence prevention committee must include at least one registered nurse and one physician licensed to practice medicine in Texas (unless the facility does not employ a physician), both of whom must provide direct care to patients of the facility. The committee also must include one facility employee who provides security services. After the committee is formed, the committee must also develop a workplace violence prevention plan and policy.

At a minimum, the prevention plan must: (i) be tailored to the practice setting; (ii) define “workplace violence”; (iii) provide for annual training; (iv) review physical security and safety; (v) create a reporting system; and (vi) adjust the care assignments (if possible) of employees and providers who have been assaulted or threatened. The prevention plan must be evaluated annually, and the results of the evaluation must be reported to the facility’s governing body. An electronic or printed copy of the prevention plan must be made available upon request of a provider or employee. The prevention plan may be redacted if disclosure of the full plan is determined to be a security threat.

The policy must: (i) require the facility to consider the committee’s recommendations; (ii) allow providers and employees to provide confidential workplace violence information; (iii) protect providers and employees who report workplace violence information from retaliation; and (iv) comply with the Texas Department of Health and Human Services’ rules relating to workplace violence (new rules were proposed as of May 16, 2024).

The new law also requires that following a workplace violence incident, a facility must at a minimum offer immediate post-incident services to the healthcare provider or employee, including any necessary acute medical treatment for those directly involved in the incident. Facilities may not discourage providers or employees from contacting law enforcement or disciplining an employee for reporting a workplace violence incident. Failure to follow the requirements of the workplace violence prevention program law may result in a facility’s licensing agency taking disciplinary action.

Over the past decade, a handful of states^[1] have established laws and regulations requiring healthcare employers to have workplace violence prevention programs.^[2] Texas healthcare facilities can implement an effective and successful workplace violence prevention program by understanding lessons learned by facilities in other states that already require the adoption of workplace violence prevention programs.

In 2016, California passed a law, similar to the Texas law, requiring that a wide range of healthcare facilities establish and adopt workplace violence prevention programs.^[3] I spoke with the Director of a Workplace Violence Prevention Program for a large health system in California about the lessons he has learned over the last seven years. Initially, the Program Director was focused on ensuring compliance with regulatory requirements. Once a compliant program was in place, his goal shifted to transforming the prevention plan to be the best in class at keeping healthcare workers safe.

Key elements driving this transformation have been: (i) setting patient expectations and boundaries through new signage at entry points; (ii) developing in-person employee training with enhancements on de-escalation techniques; (iii) optimizing the reporting process and incident data analytics; and (iv) focusing on post-incident care with employees who have been victims of workplace violence.

Entry communication, such as signage, can assist in establishing parameters around actions that will not be tolerated within the facility. The system has found that having large posters at the point of patient access and a care covenant agreement among patients and visitors with clinical staff were effective in helping patients to self-regulate, de-escalate, or act in a more normal manner for nurses and other staff. The system’s “Care Covenant” is an agreement for both patients and visitors to refrain from violent or threatening conduct that is changing the culture so that workplace violence is not part of any healthcare worker’s job. Signage does not just stop at the front entries. If a patient is exhibiting aggression, system staff will place an orange check mark on the door, or the room may be branded with a caution sign, that states to check with a nurse before entering. Clinical staff are trained to be aware that these signs indicate a person has shown aggression at some point since entering the facility, and they should have a heightened sense of caution while providing care for those patients. The system also uses posters in the break room and flyers at nursing symposiums to effectively communicate with clinical teams on various topics of workplace violence.

Investing in employee training is a key component in creating an effective workplace violence program. Originally, in order to meet compliance requirements, the system added a required workplace violence training module to their employee online training platform. The system discovered that investing in live in-person training tailored to the environment in which employees provide care (i.e., acute hospitals, ambulatory clinics, home health) not only created better prepared employees but also increased employee job satisfaction around the training they received. In-person training also allows the employer to gauge employees’ readiness and receive feedback from employees to identify areas that may need further training. For example, through the training and data, it became apparent that nurses needed more effective training around patient restraints. Once deficiencies are identified, the employer can further develop the tailored training necessary to strengthen the employees’ knowledge of preventing workplace violence and injuries associated with those events.

Robust reporting and analytics tools are the cornerstones of an effective workplace violence prevention program. The system recently consolidated their reporting of workplace violence incidents and injuries into one application, so an employee affected by a violent incident does not have to fill out multiple reports. Security teams and administration should be constantly asking, “What do I need to know to determine what actions need to be taken to help mitigate and prevent future violence and injuries?” The California Prevention Program Director reviews reports weekly to not only see the data points but also to determine the root causes of workplace violence. For example, some of the information he wants to know is whether the patient was in the process of being restrained, was the patient on a hold due to a mental health crisis, or was there a behavioral cause for the violent act (e.g., aggression, intoxication, pain reaction, anesthesia, etc.). The Program Director has found that the more he refines what information is collected, the better he can analyze workplace violence incidents in aggregate and make improvements to employee safety and the program.

How the system treats employees impacted by workplace violence or threatening conduct is a crucial part of the Program Director’s evaluation of the prevention plan. Local workplace violence administrators often consider the following as part of post-incident care:

• Are employees receiving the necessary physical and behavioral health treatment following a workplace violence incident?
• Do the employee communications reflect the system’s concern, alarm, and compassion for the employee? (If an employee reports a workplace violence incident, the communication back to the employee should not be sterile and stoic.).
• Do employees know that, when allowed by the law, their employer is willing to take the necessary steps with the employee to press charges, when applicable, against the patient or visitor?

The Program Director’s focus is on building an easy-to-use program that reflects the system’s concern for its employees’ welfare and its compassion for their violent experiences. The purpose of building a comprehensive program is to make the system one of the safest healthcare networks for workers.

Based on the lessons learned in California, when Texas healthcare facilities adopt workplace violence prevention plans to comply with the new requirements of the Texas Health & Safety Code, they should consider:

• Developing or utilizing a checklist to ensure their prevention plan meets all of the requirements of Texas law.
• Assessing their employees’ knowledge related to workplace violence (e., identification, de-escalation, avoidance, proper and appropriate use of restraints, physical maneuvers).
• Tailor training, preferably in-person, to the healthcare environment (ER vs. home health) and ensure the training meets the employees’ knowledge gaps.
• Building a reporting tool that collects the information that will be necessary to analyze workplace violence incidents, and continually asking what additional information would help to further provide better analysis.
• Continually looking to make changes to improve employee safety based on the analysis of the workplace violence data and tracking whether such changes were effective.
• Ensuring that the top priority after an incident is getting the employee the necessary treatment.
• Remembering that the employee is a victim, the facility’s communications with its employees should reflect the same or even more compassion and concern than the administration would have for an employee who was the victim of a violent crime at home.
• Investing in a robust and effective workplace violence prevention program will not only help keep employees safe but will also improve employee satisfaction and help differentiate the facility from other healthcare employers.

[1] California, Connecticut, Illinois, Maryland, Minnesota, New Jersey, Oregon and Washington

[2] Workplace Violence – Types of Violence & State Laws | ANA (nursingworld.org)

[3] California Code of Regulations, Title 8, Section 3342. Violence Prevention in Health Care.