When being hit is 'just part of the job'

HCWs often don't report violent assaults

Health care workers rarely report workplace assaults, according to a review of two community hospitals and two nursing homes as part of a five-year study of health care workplace safety.

A series of focus groups with 50 nurses found that nurses are reluctant to report incidents that don't result in serious injury. This is especially true for physical assaults by patients, researchers found. When they did report incidents to their managers, the managers often discouraged them from taking further action and the events often weren't reported to employee health, the study found.

Nurses often are concerned about income loss and low reimbursement in workers' compensation, as well. But they also may view assaults by patients as simply "part of the job," especially if the patient is cognitively impaired, according to a summary of findings.

The five-year PHASE (Promoting Healthy and Safe Employment in Healthcare) study was conducted by researchers at the University of Massachusetts Lowell and sponsored by the National Institute for Occupational Safety and Health. In addition to focus groups, the study included surveys of workers, an analysis of U.S. Occupational Safety and Health Administration and workers' compensation injury reports, and interviews with managers and hospital leadership.

The study examined various types of injuries, including patient handling injuries, at two hospitals and two long-term care centers.

Concerns about reporting injuries were especially apparent in the handling of violent incidents. "We kept being told by managers, by workers, by supervisors that it's just part of the job," says principal investigator Craig Slatin, ScD, MPH, co-director of the Center for Public Health Research and Health Promotion at the University of Massachusetts Lowell. "'Of course, if you work with people who have Alzheimer's, they might flail and you're going to get hit."

That attitude prevents hospitals from taking measures that would improve safety and security and leaves nurses feeling that they are not supported, notes co-investigator Lee Ann Hoff, PhD, RN, a nurse anthropologist who specializes in crisis and violence issues. Hoff was team leader of the focus group research and analyzed almost 500 transcribed pages of remarks.

"The power of the nurses stories' speak for themselves," she says. "The nurses feel they get blamed for what happens to them."

For example, one nurse reported that her nurse manager would "rip up the incident reports" and verbally attack nurses for "trying to cause trouble." She would ask them, "Why are you making out these incident reports just because someone got punched in the face?"

Nurses 'frequently' threatened, pinched

Nurses may not be reporting assaults to employee health, but other measures reveal the extent of the workplace violence problem.

On average, nurses suffer assaults 74% more often than all other occupations, and mental health workers experience more than four times as many assaults, according to the U.S. Department of Justice National Crime Victimization Survey.

About 30% of nurses reported being "regularly or frequently" physically threatened, pinched, scratched, spit on, or having their hand or wrist twisted in a 2004 survey of 172 Massachusetts nurses conducted by the Massachusetts Nurses Association (MNA) and the University of Massachusetts at Amherst. ("Regularly" was defined as nine or more times in the past two years; "frequently" referred to incidents that occurred four to eight times in the past two years.)

Almost half the nurses in the survey said they had been punched at least once. Seven had been strangled in the past two years, eight were sexually assaulted, and two were intentionally stuck with a contaminated needle, the survey found. Patients committed the majority of violent acts.

Only 20% of the nurses said they felt their employers were very concerned about their health and safety, including the problem of workplace violence.

The MNA learned from Norfolk County (MA) District Attorney William R. Keating that by ignoring the smaller acts of violence, hospitals allow a climate that increases the risk of more serious incidents, says Evelyn Bain, MEd, RN, COHN-S, associate director/health and safety coordinator of the Massachusetts Nurses Association in Canton, MA.

"If you don't address the very basic and frequent levels of violence of any kind, then it tends to escalate to a greater degree of violence," she says.

Employee health professionals may not even be aware of violent events because they may be reported only to the frontline supervisor, says Bain. "Workplace violence is not necessarily [formally] reported until it gets to a level of major injury," she says.

Violence prevention policies lacking

Most hospitals have a written policy on workplace violence. Unfortunately, many do not act on those policies.

For example, nurses said they found it difficult to report incidents when they faced time pressures and heavy workloads, a cumbersome reporting process, and unsupportive supervisors, Slatin says. Although facilities offered training on workplace violence at orientation and annual competency days, the training was often minimal, he says.

"Only one facility had a comprehensive violence prevention program in place," he says. "It was primarily put in place to protect patients from being harmed by each other or by the workers."

The U.S. Bureau of Labor Statistics recently conducted a survey of employers related to their violence prevention programs. Almost all of the larger employers in health care and social assistance, which would include hospitals, had violence prevention policies.

But less than half of those employers had a method for identifying a history of violence among patients or visitors, the survey showed. Less than half of all health care and social assistance employers provided training on risk factors and strategies to reduce violence.

Sometimes a serious incident can lead to change at a hospital. One hospital included in the PHASE study had implemented tighter security in the emergency department after an incident in another part of the facility.

Employees received training on techniques to calm agitated patients and visitors and to prevent escalation of tense situations. Security was beefed up in the unit, and employees were able call for more security personnel.

"The emergency department staff was protected from the risk of being harmed from someone coming in who was deranged or very angry or on drugs," Slatin says.

Prevention Strategies for Employers

The National Institute for Occupational Safety and Health (NIOSH) offers this advice for hospital employers to prevent violent incidents:

To prevent violence in hospitals, employers should develop a safety and health program that includes management commitment, employee participation, hazard identification, safety and health training, and hazard prevention, control, and reporting. Employers should evaluate this program periodically. Although risk factors for violence are specific for each hospital and its work scenarios, employers can follow general prevention strategies:

Environmental Designs

  • Develop emergency signaling, alarms, and monitoring systems.
  • Install security devices such as metal detectors to prevent armed persons from entering the hospital.
  • Install other security devices, such as cameras and good lighting, in hallways.
  • Provide security escorts to the parking lots at night.
  • Design waiting areas to accommodate and assist visitors and patients who may have a delay in service.
  • Design the triage area and other public areas to minimize the risk of assault.
  • Provide staff restrooms and emergency exits.
  • Install enclosed nurses' stations.
  • Install deep service counters or bullet-resistant and shatterproof glass enclosures in reception areas.
  • Arrange furniture and other objects to minimize their use as weapons.

Administrative Controls

  • Design staffing patterns to prevent personnel from working alone and to minimize patient waiting time.
  • Restrict the movement of the public in hospitals by card-controlled access.
  • Develop a system for alerting security personnel when violence is threatened.

Behavior Modifications

  • Provide all workers with training in recognizing and managing assaults, resolving conflicts, and maintaining hazard awareness.

Source: NIOSH, Violence: Occupational hazards in hospitals, April 2002 (Publication No. 2002-101). Available at http://www.cdc.gov/niosh/2002-101.html.