stressed nurse
The tools & training they need
by Louis Kirby

One of the greatest limits on growth in the home health and hospice sector is the labor shortages that make it difficult to recruit and retain qualified nurses and home health workers. Registered nurses are retiring faster than new ones can be trained, according to the consulting firm Baker Tilly, and one of the primary causes of homecare nurse and aide burnout is workplace violence. Beyond the benefits of implementing a workforce safety plan, equipping your staff with the training and tools to mitigate safety risks has a direct impact on your ability to attract and keep employees.

Safety Is Important

Developing a robust safety program for your mobile workforce has been proven to reduce health care worker stress and turnover. A 2015 study published in BMC Public Health found that the threat of workplace violence was one of home health workers’ top concerns, ranking above transportation issues or environmental hazards. In addition, clearly communicating a commitment to workforce safety in your hiring materials allows your organization to distinguish itself as a caring and supportive place to work.

Because violent incidents are routinely underreported, many employers are unaware of the frequency and degree of the violence their employees face and the impact it has on employee retention. Only one-fifth of violent incidents “are ever reported in part due to embarrassment, organizational culture, tolerance or excusing the behavior of ‘ill’ clients,” according to an article in the Online Journal of Issues in Nursing. Nurses have cited fear of retribution from supervisors, the complexity of the legal system and disapproval from administrators as barriers to reporting workplace violence.

Alarming Statistics

But the violence is real. A review of health care worker safety in the New England Journal of Medicine found that 61% of homecare workers face violence each year, including verbal abuse and threats, sexual harassment, sexual abuse, rape, assault, shoving or displays of weapons. The home health industry carries unique risks and hazards compared to other health-related fields. Home health workers provide care in an uncontrolled environment without the protections offered in traditional health care facilities. Risk factors include drugs and alcohol, access to weapons, client dementia or mental illness and solo work without backup such as an onsite co-worker or panic button. Home health workers also face risks from the surrounding community, which can include robbery, travel after dark, car theft and vandalism, and violence from others involved the patient’s care.

Sending home health workers into the community has real consequences for both providers and organizations. The Occupational Safety and Health Administration (OSHA) fined Epic Healthcare $98,000 because it “failed to protect” two providers who were sexually assaulted in the same household on two separate occasions.

“Epic Health Services failed to protect its employees from life-threatening hazards of workplace violence and failed to provide an effective workplace violence prevention program,” OSHA’s regional administrator said in a news release, adding that the company had received numerous reports of assaults on employees. Companies have a responsibility to systematically address workplace violence prevention for their workers’ safety—and to mitigate the costs to the organization of a failure to do so.

This violence increases worker job dissatisfaction, which leads to staff members leaving the profession or employer. A 2009 study of home health care nurses found that 63% reported one or more violent incidents. Importantly, this study also looked at the intent to leave nursing or their employer and found that the violence inversely correlated with job satisfaction, the chief predictor of turnover.

Turnover is only one of the significant costs to an organization from workplace violence, but these costs—including damage done to the victim, loss of productivity and morale, and public relations impacts—are not fully recognized by management or
by accounting.

A violent incident can lead to:

  • The temporary or permanent absence of skilled employees
  • Psychological damage
  • Property damage, theft and sabotage
  • Productivity impediments
  • Diversion of management resources
  • Increased security costs
  • Increased workers’ compensation costs
  • Increased personnel costs

Some of these costs are manifested in employee turnover. Available research clearly establishes that unaddressed workplace violence and aggression against mobile health care workers leads to stress, depression, anxiety, sleep problems, post-traumatic stress disorder, worsened physical health and burnout. Burnout and stress can also adversely influence the quality of care, increasing the risk for medical or care administration errors. Violence and
the threat of violence may even lead employees to leave the employer or the industry altogether.

What Can Be Done?

The implementation of credible safety programs and tools geared to the specific needs of mobile homecare and hospice workers represents a significant and largely untapped opportunity to increase the safety of the home health workforce and enhance employee retention outcomes.

The California Division of Occupational Safety and Health (Cal/OSHA) health care regulations that went into effect in 2017 are the most comprehensive in the nation and serve as a model. Those regulations instruct organizations to develop and implement a written violence prevention plan. The elements of the plan include:

  1. Procedures for the active involvement of employees in developing, implementing and reviewing the plan
  2. Procedures for obtaining the assistance of law enforcement during all work shifts
  3. Procedures for accepting reports of workplace violence from employees and preventing retaliation against an employee who makes a report
  4. Procedures for communicating with employees about workplace violence matters, including:
    • a. How employees can report a violent incident, threat or other workplace violence concern
    • b. How employees can communicate workplace violence concerns without fear of reprisal 
    • c. How employee concerns will be investigated and how employees will be informed of the results and any corrective actions to be taken
  5. Procedures for training employees on workplace violence
  6. Assessment procedures to identify environmental risk factors for workplace violence
  7. Procedures to identify patient-specific risk factors, such as patient’s mental status, medications, history of violence, disruptive or threatening behavior
  8. Procedures for post-incident response and investigation
  9. Guidance to review and update the plan at least annually

Tools You Can Use

Reliance on safety training alone is likely to have limited effectiveness. OSHA’s “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers” recommends the use of specific tools to address home health worker concerns, including panic buttons, personal alarm devices and GPS devices. This can be illustrated by an experience shared by one of our hospice clients. At 1 a.m., the agitated and possibly inebriated husband of a patient aggressively approached a female hospice worker while brandishing a knife. She discretely pressed the SOS button on her AlertGPS device; police arrived minutes later and diffused the situation. In this case—and most likely the case of the Epic Healthcare workers who were sexually assaulted—pulling out a cellphone would actually have aggravated the situation rather than helped.

Cal/OSHA’s guidelines specify the careful appraisal of an organization’s requirement for and deployment of safety tools to ensure employees are not relying on a technology that fails to protect them. Alerting technology is especially critical when providers are working in patient’s homes at all hours of the day and night and do not have the luxury of assistance from inside a facility building.

Home health organizations should consider the additional benefits of any alerting solution they choose. They can offer advantages in terms of regulatory compliance, increased employee safety and long-term cost reduction.


Many in the home health industry do not believe there is a real danger to their mobile providers. This represents both a risk and an opportunity. Addressing the threats to home health providers in tangible ways through a well-designed safety plan that also incorporates robust alerting technology can pay significant dividends.

Consider adding alert technology to help keep your staff safe from violence. Before you choose, it’s best to have options that include:

  •  Worn on the body so the alarm is always within reach
  •  Accurate GPS location that does not rely on 911
  • Rapid dispatch of police and ambulance
  • Immediately notifies the organization of an incident (OSHA compliance)
  • Advance warning of known threats including registered sex offenders
  • Discrete, durable and easy to trigger an alarm without needing a phone at hand
  • Companion services when the provider feels in danger.

Louis Kirby, MD is a principal of AlertGPS, a provider of connected enterprise safety technology that offers companies the quickest way to locate, communicate and get help to their mobile workforce. Kirby is a board-certified neurologist and consultant to the pharmaceutical industry on diseases affecting the central nervous system.