Healthcare facilities have long been among the most dangerous workplaces in the country. Infectious diseases, workplace violence, hazardous chemicals, and musculoskeletal (e.g., back) injuries all contribute to healthcare workers having among the highest rates of injury and illness of any occupation.1 This problem has only grown worse during the COVID-19 pandemic, when healthcare facilities have been at or over capacity, staffing levels have been dangerously low, and anxieties and stresses for both healthcare workers and patients have been greater than ever.2
The data from 2020 (the most recent year for which annual data are available) illustrate how much worse the conditions for healthcare workers have become. The number of injuries and illnesses reported to the Bureau of Labor Statistics (BLS) by all private employers dropped by 5.7 percent in 2020, even with the dramatic rise in cases of respiratory illness—but the number of injuries and illnesses reported by private healthcare and social service employers rose by a whopping 40.1 percent. The total incidence rate for the healthcare and social service sector was 5.5 cases per 100 full-time employees in 2020 (compared to 3.8 in 2019). In comparison, the incidence rate for all private industry workers in 2020 was 2.7, and even industries considered dangerous fared better than healthcare: mining had a rate of 1.2, construction had a rate of 2.5, and manufacturing had a rate of 3.1.3
It isn’t just the number of injuries and illnesses among healthcare workers that has increased—it’s the severity. Well over half of the healthcare and social service sector’s 806,200 injury and illness cases in 2020 were serious enough to result in at least one day away from work. Nursing assistants, registered nurses, and licensed practical and licensed vocational nurses all had notable increases over 2019 in their days away from work and in the number of serious cases. Nursing assistants had particularly shocking increases, going from 27,590 to 96,480 serious injuries and illnesses, with their median days away from work jumping from 6 to 12. Registered nurses were not far behind; serious injury and illness grew from 20,150 to 78,740 and days away from 8 to 13.4
And although it is difficult to obtain a comprehensive and accurate count, we know that thousands of healthcare workers died from COVID-19 acquired on the job in 2020. As healthcare workers have undertaken greater and greater risks just to do their jobs, in many cases with insufficient support from their employers, they—and their unions—have increasingly turned to the Occupational Safety and Health Administration (OSHA) to demand that it fulfill its duty and protect them from harm in their workplaces.5
In 1970, after many years of organizing and lobbying by the labor movement and public health community, the Occupational Safety and Health Act was passed with the goal of ensuring safe and healthful workplaces for all American workers.6 The law requires employers to provide safe working conditions for their employees, and employers can be penalized for failure to comply with federal safety standards; OSHA was created to establish and enforce those standards.
There was very little unionization in the service sector or in the healthcare sector when the Occupational Safety and Health Act passed;7 most of the union activity related to health and safety was concentrated on conditions in the manufacturing and construction sectors that dominated the American economy and the American labor movement in the 1950s and ’60s.8 In part because of that history, OSHA has struggled to provide adequate protection for healthcare workers.
The successes OSHA has had in issuing standards and enforcing laws, supporting its budget, and defending the agency from endless attacks from the healthcare industry (and the business community in general) have been the result of union activism.
OSHA, Unions, and the Health of Healthcare Workers
The first OSHA standard that focused primarily on the healthcare industry was the ethylene oxide (EtO) standard, issued in 1984.9 EtO is used mainly as a sterilant for reusable and single-use medical equipment and supplies. The gas is highly flammable, and emerging evidence had begun to show that chronic exposure is associated with the occurrence of cancer, reproductive effects, mutagenic changes, neurotoxicity, and sensitization. The Reagan administration refused to update its antiquated standard until labor unions and public health groups successfully sued to force the agency to issue a standard.
At that time, OSHA estimated that more than 62,000 healthcare workers were directly exposed to the carcinogen and 25,000 were indirectly exposed. The agency set an exposure limit over an 8-hour workday, but it took an additional lawsuit to compel OSHA to set a short-term (15-minute) exposure limit in 1988.10
Bloodborne Pathogens: Healthcare Workers Are Not Immune
OSHA had not yet touched the issue of infectious diseases when a new and little understood disease, eventually known as human immunodeficiency virus or acquired immune deficiency syndrome (HIV/AIDS), began to take a devastating toll in the early 1980s. As HIV/AIDS patients inevitably ended up in the hospital, healthcare workers became increasingly concerned about contracting the disease. While it was eventually learned that HIV/AIDS was a bloodborne pathogen, it was initially not clear how it was transmitted.11
There were no legal requirements covering worker exposure to infectious diseases at that time. OSHA had no standards covering infectious disease, and while the Centers for Disease Control and Prevention (CDC) had a voluntary “Guideline for Isolation Precautions in Hospitals” designed to prevent healthcare worker exposure to infectious diseases (such as hepatitis B, which at that time posed a more significant risk than HIV/AIDS), CDC guidance was not enforceable if healthcare institutions chose not to comply.
Unions representing healthcare workers were hearing from members who were becoming increasingly alarmed at the lack of protective measures taken by hospitals. Many reported that managers refused to allow them to wear gloves because gloves might make the patients nervous or because they didn’t have gloves that fit. Sharps were commonly recapped, infectious waste was frequently discarded along with regular trash, and overflowing incinerators spilled untreated waste on hospital floors.12
In 1986, several unions representing healthcare workers petitioned OSHA for better protections against bloodborne pathogens for their members.13 They encountered resistance from both OSHA leadership and the hospital industry. Healthcare workers were seen as somehow immune from infectious diseases, and if they were not immune, then choosing to work in the healthcare field meant they were assuming the risk of contracting infectious diseases. The hospital industry, led by the American Hospital Association (AHA), argued that hospitals were already adequately protecting their employees and there was nothing for OSHA to worry about.
In late 1989 and early 1990, OSHA held weeks of regulatory hearings across the country where workers testified about the exposures they routinely experienced—the largest public response to a proposed rule to that point in OSHA’s history.14 In the hearings, the AHA and the American Dental Association warned that the standard would cause crippling increases in the cost of healthcare and attempted to scare patients with visions of ignorant OSHA inspectors bursting into operating rooms in muddy boots to write reams of citations. Healthcare “experts” testified that it would be impossible to practice medicine while wearing gloves, and dentists warned that masks would scare off children.15
Despite industry opposition and the George H. W. Bush administration’s reluctance to break new ground in worker protection, pressure from unions, Congress, and the public health community spurred OSHA forward, and the Bloodborne Pathogens Standard (BPS) was issued in December 1991.16
The new standard fundamentally changed the way healthcare was performed in the United States. OSHA required “universal precautions” for all potentially infectious materials. Before the BPS, workers routinely resheathed syringes, often sticking themselves in the process. The BPS forbade that practice and required that needles and sharps be disposed of in puncture-proof containers present in every room (instead of the overflowing containers out in hallways, as had been common). Gloves were required to be provided in all sizes for all workers whenever there was risk of exposure to infectious materials. The BPS also required hospitals to provide hepatitis B vaccinations to all potentially exposed workers at no cost to the workers.
But the BPS didn’t go far enough. Large numbers of healthcare workers were still getting stuck by syringes. As a result of strong union lobbying, in 2000 Congress passed the Needlestick Safety and Prevention Act, which directed OSHA to revise the BPS to include requirements for inherently safer sharps.* Until COVID-19, the BPS was the end of OSHA activity around infectious diseases. Other attempts (e.g., to add infectious diseases to the Hazard Communication Standard or to issue a tuberculosis standard) were not successful.
Ergonomics: On the Backs of Healthcare Workers
The next major healthcare-worker hazard unions attempted to address was the epidemic of back injuries that healthcare workers suffered from lifting and moving patients. OSHA began work on an ergonomics standard in 1992 under a Republican administration, in response to a union petition. After years of fierce opposition from the business community and Republicans in Congress, OSHA finally issued an ergonomics standard in November 2000 (under a Democratic administration).
OSHA estimated that almost 7 million hospital and nursing home workers were covered by the standard, which required employers to establish a program to reduce musculoskeletal injuries, such as back injuries, and required hospitals to use patient lifts. Unfortunately for those 7 million workers, the Republican-controlled Congress and President George W. Bush repealed the standard shortly after Bush took office in 2001.17
Workplace Violence: Mixed Martial Arts on the Hospital Floor
Assault is one of the leading causes of injury in healthcare settings. A 2021 House of Representatives report summed up the issue:
In 2019, hospital workers were nearly five times as likely to suffer a serious workplace violence injury than all other workers, while workers in psychiatric hospitals are at 34 times greater risk of workplace violence injuries compared with all other workers. BLS reports 20,870 health and social service workers had injuries so severe they lost workdays from injuries due to workplace violence in 2019, amounting to 70 percent of all workplace violence injuries across all industries. The total number of the most severe workplace violence injuries in the health care and social service industry, which are those requiring days away from work, has nearly doubled since 2011.18
Workplace violence afflicts healthcare workers with more than just serious physical injuries. During a congressional hearing in 2019, AFT member Patricia Moon-Updike described the trauma she suffered after being seriously injured by a patient in 2015 while working as a nurse in the Milwaukee County Behavioral Health Division’s child and adolescent treatment unit:
After I went home, the nightmares started. I couldn’t sleep. I figured this was normal and it would pass.… However, this was a different kind of “feeling” than I had ever experienced before.… As days passed, I became more “scared” of people … being unpredictable.… Since June 2015, I have been diagnosed with moderate to severe post-traumatic stress disorder, moderate anxiety, insomnia, depressive disorder and social phobia related to this incident…. I suffer from terrible memory problems. I cannot wear a seat belt properly because it comes too close to my neck; I have to wear both belts around my waist. I have not been to a mall, a concert or a sporting event since the assault because of my fear of crowds.19†
Although labor unions have pressed OSHA and state health departments on workplace violence for decades, progress has been hard and slow. In the 1980s and early 1990s, most healthcare administrators and federal OSHA leaders refused to consider workplace violence an appropriate issue to be addressed by an agency that dealt primarily with falls, machine guarding, and chemical issues. Assaults on mental health workers, social workers, and emergency room workers were seen as “just part of the job.” Employers often discouraged workers from reporting incidents, and many workers reported that they were disciplined after an attack because an assault meant they had failed to keep the patient under control.20
By the mid-1990s, following the murder of a social worker by one of her clients, CalOSHA had issued guidance to prevent violence in healthcare and social service establishments; US Department of Labor solicitors also gave federal OSHA permission to cite workplace violence under OSHA’s General Duty Clause, a legally burdensome enforcement tool that can be used to cite employers for unsafe conditions where there is no relevant standard.21 In 1996, federal OSHA finally issued guidance for workplace violence against healthcare and social service workers and began limited enforcement under the General Duty Clause. That guidance was updated in 2012.22
In late 2016, at the end of the Obama administration, OSHA began work on an enforceable standard to protect workers from workplace violence in healthcare and social services.23 To speed up the process, the US House of Representatives passed bipartisan legislation in 2019 and in 2021 that would have required OSHA to issue a workplace violence standard within 24 months.24 Passage of the legislation came over the objections of the AHA, which argued that hospitals were already doing a great job protecting workers and an OSHA standard would impose burdensome unfunded mandates and prohibitive costs on hospitals.25 At the time this article was finalized for print (August 2022), the bill had not come to a vote in the Senate.
COVID-19: Sacrificing Our “Heroes”
The COVID-19 pandemic has put OSHA—its responsibilities to workers, its weaknesses, and the importance of healthcare unions—in the spotlight. Healthcare workers have been on the frontlines of the pandemic since the beginning, and the severity of the physical and mental toll they are bearing is still unknown. Even their death toll from workplace-acquired COVID-19 infections is essentially unknown because it has likely been significantly underreported.26
The threat to healthcare workers was not a surprise. In 2009, early in the Obama administration, the country faced a potentially serious H1N1 flu pandemic. OSHA realized that it did not have the enforcement tools to address a major disease outbreak and began work on a comprehensive infectious disease standard that would supplement the Bloodborne Pathogens Standard.27 OSHA also became aware in 2009 of a potential critical shortage of N95 respirators. While a national stockpile had been created during the George W. Bush administration to protect healthcare workers in a major airborne disease pandemic, in 2009 it contained only a tiny fraction of the billions of N95 respirators that would likely have been needed had H1N1 reached pandemic levels in the United States.28
In January 2020, when the United States had only a handful of COVID-19 cases and no deaths, Rep. Bobby Scott (D-VA), chair of the House Education and Labor Committee, and Rep. Alma Adams (D-NC), chair of the Workforce Protections Subcommittee, sent an urgent letter to OSHA. Their letter warned the agency of the threat healthcare workers were likely to face and asked OSHA to start work on an emergency temporary standard (ETS) to protect healthcare workers.29
The Trump administration ignored this request, leaving healthcare workers vulnerable to whatever precautions their employers voluntarily chose to take. In response, representatives Scott and Adams introduced legislation to require OSHA to issue an ETS within a short timeframe, but it was defeated through scare tactics by the AHA. Indeed, an ETS that would have offered healthcare workers critical protections was never issued during Trump’s presidency.
Meanwhile, the predicted shortage of N95 respirators came to pass. While the national stockpile contained only around 30,000 N95s, government infectious disease experts estimated that the country would need 5 to 7 billion to adequately protect healthcare workers. This severe shortage led the CDC to ignore what we were learning about COVID-19 transmission and change its healthcare worker guidance. At the beginning of the pandemic, the CDC recommended healthcare workers use N95 (or more effective) respirators if they might be in contact with patients infected with COVID-19. However, the CDC weakened its guidance in March 2020, despite growing evidence that aerosol transmission was a major mode of infection that could only be blocked by N95s or more effective respirators.30
In contrast, the Biden administration began well. On the first day of the new administration, President Biden issued an executive order that directed OSHA to issue an ETS that would protect all potentially exposed workers by March 15.31 Unfortunately, March 15—and then April 15 and May 15—came and went. Finally on June 21, 2021, OSHA issued an ETS covering only healthcare workers, hoping that the COVID-19 vaccine would take care of everyone else.32
Soon afterward, the combination of the Delta variant, increasing evidence that vaccine protection against infection deteriorated over time, and growing political resistance from anti-vaxxers made it clear that workers needed more protection than just the hope that everyone would get vaccinated. OSHA instead doubled down on the vaccine, requiring all unvaccinated workers (outside of healthcare) to wear masks and get tested weekly. (The Centers for Medicare and Medicaid Services separately issued a regulation requiring all healthcare workers to be vaccinated.) The OSHA mandate was later blocked from going into effect by the Supreme Court.33
According to the Occupational Safety and Health Act, an ETS should be followed by a permanent standard within six months. While it is unclear to legal experts whether the six-month deadline is mandatory, in December 2021, as the ETS reached the six-month point, OSHA nevertheless announced its intention to withdraw all but the recordkeeping portions of the ETS, leaving healthcare workers with coverage only under the General Duty Clause. In response, the AFT joined with other national healthcare unions in suing OSHA, asking that the emergency standard remain in place until a permanent standard can be finalized.34 Now, despite ongoing resistance from the AHA,35 OSHA is working on a permanent COVID-19 standard for healthcare workers, which it hopes to finish this year.
Lessons from OSHA History
The last 50 years have taught three important lessons about protecting healthcare workers from workplace hazards:
- Progress on worker protection only happens as a result of pressure from labor unions and public health advocates. From the earliest days of OSHA, unions representing healthcare workers pressured OSHA through lawsuits, petitions, and congressional lobbying to protect healthcare workers from hazardous chemicals, infectious diseases, musculoskeletal injuries, and workplace violence. While progress has been slow, it would have been nonexistent without union activity.
- Hazards to healthcare workers are not well covered by OSHA. Adequate health and safety coverage continues to be a struggle because of the agency’s initial and continuing focus on manufacturing and construction, the glacially slow pace of rulemaking, OSHA’s small budget, the strength of employer organizations like the AHA, and the persistent belief that healthcare workers somehow voluntarily assume hazards in their jobs (almost all of which are preventable with appropriate investments in engineering controls, staffing, personal protective equipment, and other protections).
- OSHA is severely underfunded and understaffed, and the agency has few standards that address healthcare worker hazards. This means that while OSHA serves as an important backstop to prevent healthcare worker injuries, illnesses, and deaths, workers have to take action on their own—through forming unions, writing protections into contract language, and enforcing those contracts.
Congressional action is crucial to improving OSHA’s coverage of healthcare workplaces: every year, Congress has the ability to increase OSHA’s budget. Therefore, it is also important for all legislators to hear from healthcare workers and their union representatives about legislation and budget increases that would empower OSHA to better ensure worker safety. The Protecting America’s Workers Act would address many of the problems in the antiquated Occupational Safety and Health Act.36 It would require coverage of all public employees (who are not currently covered by OSHA in 23 states), strengthen weak anti-discrimination protections, increase OSHA penalties, and expand workers’ rights. Other pending legislation would require OSHA to issue standards addressing workplace violence, heat, and other hazards.
But OSHA standards are the bare minimum needed to help workers come home healthy at the end of each workday. Strong contract language and robust enforcement of that language are the best protection. Passage of legislation such as the Protecting the Right to Organize Act (PRO Act)37 that will help workers organize unions is ultimately one of the best protections that healthcare workers can achieve.
Jordan Barab is the former senior labor policy advisor for the US House Education and Labor Committee and served as deputy assistant secretary of labor for the Occupational Safety and Health Administration (OSHA). For 16 years, he was also assistant director of research for health and safety for the American Federation of State, County and Municipal Employees (AFSCME). Since 2003, he has authored Confined Space, an online newsletter focusing on workplace safety and labor issues.
1. See, for example, M. Dressner, “Hospital Workers: An Assessment of Occupational Injuries and Illnesses,” Monthly Labor Review, US Bureau of Labor Statistics, June 2017; and K. Wrightson and T. Lincoln, Health Care Workers Unprotected: Insufficient Inspections and Standards Leave Safety Risks Unaddressed (Washington, DC: Public Citizen’s Congress Watch, July 17, 2013).
2. B. Sable-Smith and A. Miller, “’Are You Going to Keep Me Safe?’: Hospital Workers Sound Alarm on Rising Violence,” KHN, October 11, 2021.
3. “Employer-Reported Workplace Injuries and Illnesses (Annual) News Release,” Economic News Release USDL-21-1927, US Bureau of Labor Statistics, November 3, 2021.
4. “Employer-Reported Workplace Injuries.”
5. See, for example, A. Coles, “AFT’s Health Professionals Push OSHA for a COVID Standard,” American Federation of Teachers, May 4, 2021.
6. R. Asher, “Organized Labor and the Origins of the Occupational Safety and Health Act,” New Solutions 24, no. 3 (2014): 279–301.
7. E. Becker, F. Sloan, and B. Steinwald, “Union Activity in Hospitals: Past, Present, and Future,” Health Care Financing Review 3, no. 4 (June 1982): 1–13.
8. Asher, “Organized Labor”; and Becker, Sloan, and Steinwald, “Union Activity.”
9. Federal Register 49, no. 122 (June 22, 1984): 25609–832.
10. D. Weinstock and T. Failey, “The Labor Movement’s Role in Gaining Federal Safety and Health Standards to Protect America’s Workers,” New Solutions 24, no. 3 (2014): 409–34.
11. R. Nall, “The History of HIV and AIDS in the United States,” Healthline, October 21, 2021.
12. W. Muraskin, “The Role of Organized Labor in Combating the Hepatitis B and AIDS Epidemics: The Fight for an OSHA Bloodborne Pathogens Standard,” International Journal of Health Services 25, no. 1 (1995): 129–52.
13. Weinstock and Failey, “The Labor Movement’s Role.”
14. B. Roup, “OSHA’s New Standard: Exposure to Bloodborne Pathogens,” AAOHN Journal 41, no. 3 (March 1993): 136–142.
15. Author’s personal experience as assistant director of research for health and safety at AFSCME, 1982–98.
16. Muraskin, “The Role of Organized Labor”; and Occupational Safety and Health Administration, “Bloodborne Pathogens and Needlestick Prevention,” US Department of Labor.
17. V. Sutcliffe, “Bush Repeals Ergonomics Rules,” EHS Today, March 20, 2001.
18. B. Scott, “Workplace Violence Prevention for Health Care and Social Service Workers Act: Report Together with Minority Views,” US House Committee on Education and Labor, 117th Congress, First Session, Rept. 117–14, Part 1, April 5, 2021.
19. P. Moon-Updike, “Statement of Patricia Moon-Updike, RN, Wisconsin Federation of Nurses and Health Professionals,” US House of Representatives, Committee on Education and Labor, Subcommittee on Workforce Protections, February 27, 2019.
20. Author’s personal experience as assistant director of research for health and safety at AFSCME, 1982–98.
21. K. McPhaul and J. Lipscomb, “Workplace Violence in Health Care: Recognized but Not Regulated,” Online Journal of Issues in Nursing 9, no. 6 (September 30, 2004): manuscript 6.
22. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (Washington, DC: US Department of Labor, Occupational Safety and Health Administration, 2016).
23. “Prevention of Workplace Violence in Health Care and Social Assistance,” US Department of Labor, RIN 1218-AD08.
24. US Congress, House, Workplace Violence Prevention for Health Care and Social Service Workers Act, HR 1195, 117th Congress, 1st session, March 24, 2021.
25. T. P. Nickels to J. Courtney, March 23, 2021.
26. C. Jewett and L. Szabo, “Coronavirus Is Killing Far More US Health Workers Than Official Data Suggests,” The Guardian, April 15, 2020.
27. D. Michaels and G. Wagner, “Occupational Safety and Health Administration (OSHA) and Worker Safety During the COVID-19 Pandemic,” JAMA 324, no. 14 (2020): 1389–90.
28. G. Busenberg, “Policy Lessons from the History of Pandemic Preparedness,” COVID-19 Rapid Response Impact Initiative white paper 23, September 3, 2020.
29. Office of US Congresswoman Alma Adams, “Adams Leads Committee Hearing on OSHA’s COVID-19 Failures,” press release, May 28, 2020.
30. E. Baumgaertner and S. Karlamangla, “Healthcare Workers Fear Greater Coronavirus Risk Due to Safety Gear Shortage,” Los Angeles Times, March 15, 2020.
31. J. Biden, “Executive Order on Protecting Worker Health and Safety,” White House, January 21, 2021.
32. Occupational Safety and Health Administration, “Statement on the Status of the OSHA COVID-19 Healthcare ETS,” US Department of Labor, December 27, 2021.
33. E. Parasidis, “COVID-19 Vaccine Mandates at the Supreme Court: Scope and Limits of Federal Authority,” Health Affairs Forefront, March 8, 2022.
34. A. Coles, “AFT Among a Coalition of Unions Calling for Permanent COVID Protections,” American Federation of Teachers, January 6, 2022.
35. S. Hughes to D. Parker, “AHA Urges OSHA Not to Finalize COVID-19 Emergency Temporary Standard,” April 22, 2022.
36. US Congress, House, Protecting America’s Workers Act, HR 2876, 117th Congress, 1st session, April 28, 2021.
37. US Congress, House, Protecting the Right to Organize Act of 2021, HR 842, 117th Congress, 1st session, March 11, 2021.
[Illustrations by Lucy Naland]