“The young lady was nice to me the whole eight hours, and at the last 30 minutes she just walked up to me and said, ‘I don’t like you. I’ll kick your ass,’” the patient “sitter” recalled. “I looked back. Was she looking at somebody else but me? Because we were cool. She said she wanted popcorn, and I went and got her popcorn out of the vending machine, bought her sodas, and washed her hair, and when I turned around she was standing in my face and she is like, ‘I’ll knock you out,’ and she actually swung, and she hit me.”

This and other harrowing accounts of violence and abuse suffered by healthcare sitters — who are assigned to watch patients for a variety of reasons — are detailed in a landmark new study1 that found that 76% of respondents experienced at least one event of patient threats and violence in the prior year. Among sitter respondents, 61% reported physical assault, 63% cited physical threat, and 73% experienced verbal abuse. The small study, which appears to be the first to document and specifically describe threats of violence against healthcare sitters, was bolstered by extensive interviews and focus groups.

“We did a lot of intense focus groups, and it was really disturbing and overwhelming — it is incredible what they are dealing with,” says co-author Lisa A. Pompeii, PhD, a former employee health professional who is now a professor and researcher in the school of public health at the University of Texas Health Sciences Center in Houston. “[Hospitals] need someone in this sitter role but they need to get up to speed and really train these workers on what is expected, when do they call for help, how do they leave the patient. This is something that is just beneath the radar and I suspect others will start to study this work group as well.” (For comments from sitters, see story in this issue.)

Sitters appear to be a shadow work force — generally undefined in both duties and qualifications — that has fallen between the margins of occupational health and patient safety. They may be asked to prevent patients likely to fall from getting out of bed, watch a patient with dementia, stay with someone who is suicidal, or sit with patients who are disoriented but have not been put in restraints.

“There is just a real range of the type of patient they are going to monitor,” Pompeii says. “The other thing is that nurse managers are really at kind of a loss in how to train them — what do they need? It’s really kind of this loose workplace [role] right now that is really needed by the hospitals, but isn’t formally defined like a nurse’s aide, a nurse, or a physician. There seems to be a greater need for this role, but a nurse sitter comes in and she weighs 102 pounds and she is sitting next to a guy who is suicidal and she has to stay within five feet of him or arm’s reach. Some of it doesn’t make sense and it’s really dangerous.”

Indeed, a manager commented in one of the study interviews: “The sitters are the least-trained individuals in this hospital. And they are the ones who are really, really on the front lines. There are times when I will go in, and I will see a [psychiatric] patient who is really scary, and I’m like, ‘If this guy decides to go for [the sitter’s] throat, [the sitter’s] not going to get out of the room. They’re not going to be able to call for help. They’re going to be dead.”

PROTECT PATIENTS AT OWN RISK

Despite ambiguity in the details of sitters’ job responsibilities and training, there was “consistency across study participants that sitters’ overarching role was to protect the patient — even without adequate tools, training, and resources to do so,” the authors found. “Protection of the patient sometimes came at the expense of sitters’ own safety and well-being, as well as that of their personal belongings.” Although constant observation may be carried out by a variety of provider types (e.g., nurses, security personnel, nurses’ aides, other paid employees, volunteers, family members), it is generally the unskilled or untrained hospital worker who fills this role, they note.

A hospital security report recommended that sitters be trained in violence prevention and de-escalation techniques, but agreed with the current general approach of not using security guards for sitting duties. “The presence of a uniformed officer may give the impression that the patient is in custody and may actually escalate fear, especially in a semi-private room,” the report noted.2 (See related story in this issue.)

Currently, there are no consensus national guidelines or regulations on the role of sitters or protecting their health and safety on the job. There is considerable variability in sitters’ job descriptions, their purpose (i.e., custodial versus therapeutic) and the definition of patients needing observation, the researchers report. “Particularly striking is the absence of research focused on the occupational safety, health, and well-being of sitters,” they found.

The Occupational Safety and Health Administration (OSHA) issued a healthcare violence prevention report last year that in general calls for risk assessments, worker surveys, and a job hazard analysis that prioritizes workers “with high assault rates due to workplace violence.”3 It appears there are no specific new regulatory requirements in the emphasis on violence prevention, but OSHA inspectors have some leeway under their General Duty clause requirement that employers provide a workplace that is “free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”

Employee health professionals should help establish clear policies and guidelines to define and protect the sitter work group, says lead author Ashley Schoenfisch, PhD, MSPH, assistant professor at Duke University School of Nursing in Durham, NC.

“Constant observation is an essential and integral part of patient care practice in hospitals across the US,” she says. “Employee health professionals should be knowledgeable about the roles and responsibilities of sitters in their institutions when developing, implementing, and evaluating occupational safety and health policies and procedures — including training.”

When providing care to sitters who have experienced an adverse work-related event, employee health professionals should be cognizant of both the physical and mental demands placed on sitters, she adds.

“Employee health may serve as an important liaison between sitter managers and managers of patient care units to ensure a safe work environment,” Schoenfisch says.

Comments made by sitters and unit managers in the study’s focus groups include a lack of clarity about their role and responsibilities.

“They tell you, ‘Go sit with this patient,’” one sitter said. “Is it ok to talk to them? Should I be ignoring them? Am I like the security?”

Another sitter told the researchers that they are told to keep the patient safe, “but most of them don’t understand why they’re there, what actions to take and not take if you are in a situation. I mean, if the patient’s becoming combative to the point that they’re hitting, then kicking, then spitting, what actions do you take?”

In the study, sometimes other hospital workers were required to sit with a patient in the event a sitter was not available. This so-called “warm body” affect is often seen with patient fall concerns, but may occur with many other situations, Pompeii says.

A nurse manager recounted in a focus group, “I have a new unit secretary who has been pulled to sit. One of the first things she said to me is, ‘I have not been trained on how to handle this patient if they decide to get up. If they start falling, what do I do?’ So I had to make some phone calls to figure out [the protocol].”

During the course of a larger study focused on type II violent events in the hospital setting (HCWs threatened by patients or visitors), sitters emerged as an occupational group that warranted further examination. (See related story in this issue.)

The study took place in two large healthcare systems in North Carolina and Texas, with each comprised of one large medical center and two smaller community hospitals. The hospitals vary by size, location, and types of communities they serve. Combined, they employ approximately 11,000 workers who likely interact with patients or visitors as part of their job. According to the policies at the study hospitals, sitters are responsible for providing a safe environment for a patient (or patients) requiring continuous observation, performing required patient care within their scope, and reporting observations to the appropriate direct patient care provider.

The policies surrounding sitter assignment, skill set, and expectations vary across the health systems, they reported. In one of the study health systems, sitters were primarily certified nurses’ aides who come from the hospitals’ internal float pools or external contract services. In the other health system, sitters typically do not have training as a certified nurses’ aide. Rather, they attend an orientation session on patient safety maintenance. In both health systems, other staff may function as a sitter as needed, including unit secretaries, dietary workers, housekeeping staff, or light duty staff, the authors note.

“Just as we saw in this study, we anticipate hospitals across the US will vary in their processes of sitter management and assignment, as well [the] required skill set and job expectations,” Schoenfisch tells Hospital Employee Health. “However, concerns surrounding sitters’ occupational safety and health are applicable to hospitals across the U.S., given the need for constant observation practices.”

In general, an RN is responsible for assigning a sitter, establishing the responsibilities, and a lunch/restroom break schedule, they reported. Sitters are responsible for completing patient “handoff” forms as a way of communicating with the unit nursing staff various elements of their shift, including the number of times they prevented patients from pulling on tubes or falling, as well any linen change, bathing, oral care, vital signs, etc. Sitters’ shifts are typically eight or 12 hours long.

THE 'OTHERS'

In the aforementioned larger study,4 researchers identified a small number identifying themselves as sitters in the “other” job description category. The researchers followed up with focus groups and interviews after 41 sitters were identified. They gathered additional data from sitters, nurses, sitter managers, and nurse managers. Although this group was small, they observed a significantly higher proportion — relative to other occupational groups — of patient-to-worker violence in the previous 12 months. Between April 2012 and December 2013, 21 focus groups and seven key informant interviews were conducted with a total of 110 participants.

Among the survey respondents who worked as a sitter (41), 24% were less than 30 years old, 88% were female, and 80% were non-white, they reported. One-fifth of sitter participants spent less than a year working in their profession. Overall, 80% of sitters said they had experienced some form of patient violence in their careers. Among the 31 sitters who experienced patient violence in the previous 12 months, the number of events by sub-type was 69 physical assaults, 77 physical threats, and 119 events of verbal abuse. These were not mutually exclusive events.

When asked to describe their most serious event in the previous 12 months, sitters indicated the perpetrator was often a patient (94%), with whom the sitter was alone in two-thirds of the incidents. Threatening patients were often disoriented (66%), had behavioral issues (45%), were sundowning (34%), or drunk and/or on drugs (31%). Nearly three-fourths of sitters’ events involved an object used against the sitter, commonly a body part(s) (e.g., fist, nails) or bodily fluids.

Sitters and managers described “the need for support and respect from staff” on the patient care units, the authors note. Sitters’ efforts to seek assistance from unit-level staff — for crisis situations as well as for required lunch and restroom breaks — were not always effective. “They described being left alone to deal with challenging situations, disregarded after voicing concerns — related to both personal and patient safety — and disrespected as an occupational group by patients, visitors, and hospital staff,” the researchers concluded.

Yet even in this work environment, hospital sitters are an essential part of ensuring safe patient care at the bedside. “Institutionally-supported policies that focus on sitters’ safety, well-being, and human rights are crucial,” Schoenfisch and Pompeii argue. “Such policies will provide guidance to sitters, as well as to the managers who supervise them and managers of patient care units where sitters work.”

At a minimum, they recommend, policies should do the following:

  • clearly define the role of the sitter;
  • recognize sitters as an integral part of a patient care unit;
  • provide education to sitters on identifying, managing, and preventing events of violent behavior, as well as remaining safe during such events.

REFERENCES

  1. Schoenfisch, AL, Pompeii, LA, Lipscomb, HJ, et al. An urgent need to understand and address the safety and well-being of hospital “sitters.” Am J Ind Med 2015;58:1278–1287.
  2. Richman CM, Sarnese PM. Patient Sitter Use Within Hospitals: A Cross-Sectional Study Final Report to the International Healthcare Security and Safety Foundation. December 2014. http://ihssf.org/PDF/patientsitterusewithinhospitals.pdf.
  3. Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. U.S. Department of Labor OSHA 3148-04R 2015: http://1.usa.gov/1NlEvig.
  4. Pompeii, LA, Schoenfisch AL, Lipscomb, HJ, et al. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med 2015; 58: 1194–1204.