Protecting margins by protecting staff

Most rural hospital leaders don’t need a consultant to tell them staffing is hard. They’re already living it — covering shifts with team members who are already stretched to capacity, watching their valued nurses contemplate departure, and knowing that losing even one person can send a ripple cascading through their entire organization.

What gets talked about less is the direct connection between workforce safety and staff satisfaction, turnover, and financial distress. This was the situation I was in as CEO of a health system with several critical access hospitals (CAHs). Despite my primary interest in patient and staff safety, I never realized how pervasive workplace violence was in our facilities. 

Safety incidents are often hidden, showing up intermittently in incident reports, HR conversations, and compliance reviews. But for staff, they are an active topic of conversation in hallways and break rooms. Understandably, workplace violence isn’t typically framed as a financial issue, but the associated downstream costs land squarely on the income statement — manifesting in elevated turnover, recruiting fees, overtime, and agency fees. The tragic human toll doesn’t get its own line item, instead manifesting as declining morale, accelerated burnout, and crucial institutional knowledge, trust, and relationships lost when a valued team member decides they’ve finally had enough.

The problem is magnified in small teams

For CAHs, the math is particularly unforgiving. Having run both large quaternary centers and rural CAHs, I know it’s far easier for large systems to absorb patient or family behavioral challenges through dedicated security teams, layered staffing, rapid response teams, and other backup resources. Small rural hospitals simply don’t have that cushion.

When a staff member in a high-risk area such as an emergency department, a behavioral health unit, or an overnight shift faces a patient or family member who is escalating toward violence, backup may not be close or even available at all. In environments where every team member already carries a broader scope of responsibility, the expectation that nurses and clinicians will simply manage these moments on their own isn’t just unsafe — it’s totally unrealistic.

This is how safety gaps compound. When an incident occurs, all team members experience trauma even if not directly involved. They feel unsettled, unsupported, and unsafe, and they tell their coworkers about it. Trust and morale erode – first quietly, then quickly – and turnover escalates.

What staff are actually saying

Leaders who have invested in workforce safety tools hear a consistent theme from their clinical staff: the technology is used only if it’s incredibly simple and always reliable.

One nursing director put it plainly: “If it isn’t quick, easy, and foolproof, it just won’t get used.”

When you’re mid-interaction with a frustrated or angry patient or family member, you need a simple and reliable way to call for help without further escalating the situation. The tools that work are the ones staff don’t have to think about: discrete, one-touch activation, no workflow interruption, and a highly reliable response on the other end. Anything more complicated than that just stays at home or in the locker.

Staff who feel safe and supported stay in place

Not surprisingly, staff who feel safe and supported stay in their roles longer.¹ In rural health care, where teams are small and relationships run deep, the signal that leadership is paying attention carries extra weight.

When a hospital makes a visible investment in staff safety, it demonstrates something important to team members: you matter here, we care about you, and we’re not leaving you to handle this alone. That message carries significant weight in recruitment and retention, and that value increases as your culture of safety is fostered and team morale improves.

The numbers behind the narrative

Beyond the obvious human toll, the financial exposure from unsafe work environments is also very real, and it compounds quickly.

Let’s start with turnover. According to the 2025 NSI National Health Care Retention & RN Staffing Report,² the average cost of replacing a single staff RN has now reached $61,110 — and that figure doesn’t fully account for overtime coverage, agency fees, or productivity loss while a replacement gets up to speed. In a rural hospital running lean, losing two or three nurses in a year becomes a budget-busting, six-figure hit that places patient safety at risk.

Now let’s consider regulatory risk. OSHA has become increasingly aggressive about workplace violence in health care settings.³ In 2024, Circles of Care Inc., a Florida behavioral health organization, was cited for failing to protect staff from patient assaults and as a result faced penalties of $101,397. Beyond regulatory concerns, the financial exposure escalates sharply when cases are litigated. Research by Papa and Venella (2013) found the average jury award in workplace violence liability cases was $3.1 million per person per incident.⁴

All of these costs — turnover, overtime, agency spend, workers’ comp claims, fines, and potential litigation — are typically hidden deep within financial statements where they accumulate quietly, quarter by quarter. That’s what makes this problem so easy to underestimate and so expensive to ignore.

Bottom line: protecting staff also protects margins

As leaders, our first imperative is to keep our patients and team members safe. Investing in staff safety meets that imperative and is the right thing to do, but it also generates significant financial returns. 

Rural hospitals don’t have the reserves to absorb what large systems can shrug off. A single serious incident — one that triggers an OSHA investigation, a legal claim, or a wave of departures from an already thin team — can destabilize an organization that was otherwise healthy.

Importantly, the inverse is also true. Hospitals that make visible investments in effective staff safety solutions will see their commitment reflected in retention, improved morale, and ability to recruit in markets where word travels fast. Returns from a well-designed safety program are measurable.

In the end, the math is straightforward: staff who feel safe stay where they are. When staff stay in place, it eliminates one of the largest controllable cost drivers for any rural hospital. Hospital leaders who take that seriously aren’t just doing the right thing for their people — they’re making the right financial decision for the sustainability of their organization and communities they serve.

NRHA adapted the above piece from VersaBadge, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.
 

Ronald A. Paulus, MD, is President and CEO of RAPMD Strategic Advisors, providing advisory services to health system Boards, CEOs, technology companies and others. Dr. Paulus also is the immediate past President and CEO of Mission Health, a $2 billion integrated health system serving all of western North Carolina.

Sources

¹ Press Ganey. (2018). Optimizing the nursing workforce: Key drivers of intent to stay for newly licensed and experienced nurses (2018 Press Ganey Nursing Special Report). https://www.njha.com/media/569363/2018Press-GaneyNursingSpecialReport.pdf

² NSI Nursing Solutions. (2025). NSI national health care retention & RN staffing report. https://www.nsinursingsolutions.com/documents/library/nsi_national_health_care_retention_report.pdf

³ U.S. Department of Labor, Occupational Safety and Health Administration. (2024). Department of Labor investigation into worker's serious injuries finds healthcare facility's operator again failed to protect employees from patient violence. https://www.osha.gov/news/newsreleases/region4/05092024

⁴ Papa, A., & Venella, J. (2013). Workplace violence in healthcare: Strategies for advocacy. OJIN: The Online Journal of Issues in Nursing, 18(1), Manuscript 5. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No1-Jan-2013/Workplace-Violence-Strategies-for-Advocacy.html