OSHA has formally initiated rulemaking for a regulation to protect healthcare workers from rampant violence perpetuated by patients and visitors. As a result, healthcare workers are coming forth with horrific accounts of violent attacks.
Consider one story, that of Gena Deck, MSN, RN, assistant professor of nursing at the University of Alaska, who conducted the following interview with Hospital Employee Health.
HEH: To the degree you are comfortable, can you provide more detail on the patient attack you experienced?
Deck: The patient was known to the department and hospital, although I had never tended to him in terms of nursing care. I was new to the hospital within the previous few months. It was an emergency room environment. The patient was brought in by EMS for altered mental status secondary to diabetes. The patient has many medical and psychosocial issues — which I now know. He was placed in a trauma bay, in view of the healthcare provider’s station. He was calm and cooperative while receiving services for about four hours.
Because he had a history of not wanting to leave the hospital at discharge, security was called to the bedside to assist. I did not know this information prior to this event. The patient presented many obstacles as to why he could not be discharged, including having no transportation, no place to go, and threatening to harm himself if we discharged him. A physician evaluated the patient and stated he was still to be discharged. He was offered a ride to the shelter, who had already agreed to accept him. The patient then stated he had no appropriate footwear. A security guard stated he would grab some temporary footwear from the storage closet.
In a flash, as soon as the guard was gone, the patient stood, grabbing the cording from the overhead Phillips monitor, wrapping all three cords around my neck, shouting, “Here, bitch, you try it” — in reference to his saying earlier he would hurt himself. In the next 10 seconds, hearing the screams and commotion, the guard and physician who had been assessing him returned to the room, freeing me from the situation.
HEH: Can you describe some the physical and emotional aftermath of this incident and a little more detail on the assaults you suffered previously?
Deck: During the previous two events of overt violence I’ve experienced, there were breakdowns in procedures, security, and an atmosphere of “it just happens.” The first was an adult-sized autistic 15-year-old male who was in a guarded isolation room. I was asked to check on him to see if he needed anything. I was covering for a co-worker. The guard opened the door. The calm patient had his hand extended to me, showing me a penny in his hand. I reached for the penny, asking him about it. He closed his fist and punched me square in the face. There was no report filed. I was allowed to step into the break room “to calm down” and ice my face. I was then expected to return to work the remaining nine hours of my shift. There was no offer of support, apologies, forensic assessment of the circumstances, or concern for the emotional toll the situation took.
The second event, at the same hospital, was a woman who had been brought to the psychiatric isolation area in response to her expressing her helplessness with a chronically ill child being cared for in the same hospital in the pediatric unit. Reportedly, she “was out of control” and threatened to hurt herself in desperation, not realizing she would be put in this position and separated from her sick child. While taking her vital signs to do a basic assessment, she lifted the equipment and threw it at me in anger. I had no physical injuries, other than bruising, but was again, not supported. The only question was, “Are you hurt?’ To which I answered no, not wanting to appear weak.
In this situation, the police were called and a case made for assault. At the time, it was an automatic felony charge [for violence] against a healthcare worker in Pennsylvania. Alaska does not have the same law. At the very brief criminal hearing, it was ascertained that this person was a social service issue more than a violent criminal. I was asked what I wanted to have happen to her. I wanted for the woman to get the help she needed. I was never asked about how the hospital should have responded to the situation, nor did they offer any changes or discuss insight gained from the event.
This most recent issue has left me changed as a nurse and as a person. I believed that I would die. I physically had bruising, sore throat and scratches, all of which healed in a few days. The psychological impact was, and is, significant. I have sleeping difficulty, occasionally having nightmares that awaken my spouse, who then wakes me to calm me. I have anxiety when approaching some patients who are large, or loud. It changes who you are as a nurse. We are geared to go toward chaos and violence, not away from it. Professionally, I have had to become “that nurse” in the eyes of some co-workers. The one who was assaulted or is a victim, a title I bristle against. We have only one hospital in town, so sadly enough, the patient often frequents the same ER where I am employed. He now gets a security watch when he arrives and throughout his visit.
HEH: Many healthcare workers don’t pursue prosecution. Why did you decide to do so and what was the outcome? Do you think this needs to be done more often?
Deck: Yes, prosecution needs to be pursued. Violence against healthcare workers is increasing in my personal experience and from the stories I have heard from co-workers and colleagues. I have since learned that this patient had been violent in the past, had a known history of becoming agitated, and had committed verbal assaults, physical assaults, and threats in the same hospital — many not officially reported. The system for conveying that information succinctly and expediently does not currently exist, short of reading each previous visit’s nursing notes.
I did, in fact, pursue prosecution; however, I may not do it again in the future. It was far more abusive than the original circumstance. It took nearly a year to come to trial, with many delays. From start to finish, it took about nine days. Although I was compensated for my time, I received no support from our legal department or human resources while at the trial. In addition, the hospital management was warned not to appear, as it could look prejudicial against the assailant. Some co-workers defied the statement and came for parts of the trial for personal support. The man was charged with three felonies, and found guilty of two. Because of his history of felonies and misdemeanors, he was sentenced to three years in prison with no parole. While that sounds like a good ending, the patient is out on appeal, arguing that there was not enough evidence. He has 180 days to make the case. In the meantime, he has the ability to come to the ER.
The employee impact on me is that I don’t want to be forced to interact with the person — therefore, I have asked to be notified if he is in the department or request to be moved to another role when possible. Although supportive, management has recently suggested that I may be more comfortable in another department. OB is the only option, given that this patient will be in the ED, CCU, MHU and medical/surgical units at any given time.
HEH: You mention the event did not really transform your healthcare environment. Is that why it is important that OSHA enact regulation to standardize requirements and make hospitals accountable for protecting healthcare workers?
Deck: Yes. The environment is typical of emergency units and hospitals in general. The culture is one of expecting to be verbally yelled at, threatened, and treated poorly on a regular basis. Standing up to that is not the norm for the medical provider culture. Patients and their families in the healthcare environment or on mental health units are often in extraordinary acute distress. They are lashing out at anyone who may be in a position to keep them from what they want or need. For OSHA to enact regulation about work environments, reporting, supporting, and prevention would require healthcare employers to take the situations seriously.
Let us not forget the perpetrators themselves would also be protected when possible. I have witnessed patients being wrestled to the ground with multiple staff, and in one circumstance had a patient who was tasered by police in his hospital room when things escalated.
As a result of my personal situation, there were some internal meetings for the root cause analysis of what went wrong. There was question of the physician’s choices, or security’s decision to leave the bedside. A psychiatrist who had treated the patient in the past actually said, “You’re a nurse. There is some expectation of danger and violence in your job by its very nature.” The changes suggested, some of which never happened, included having a computerized in-house flagging system for known violent patients in order to protect caregivers before close interactions, increasing security personnel numbers, having a no-weapons policy, purchasing personnel emergency alarms, and metal detectors.
Perhaps most importantly would be creating an environment for nurses that includes open discussion of violence, threatening patients, and reinforcing a zero-tolerance policy in support of medical staff. Positively, the support from co-workers has been very good, applauding the effort of prosecuting the criminal behavior and sticking together as a group of people who could be victimized at any time.
HEH: The scale of the problem of violence in healthcare has reached staggering proportions, but the incoming presidential administration is not considered pro-regulation. OSHA has taken the first step — are you hopeful of eventual regulation to protect healthcare workers?
Deck: I am hopeful, but doubtful in the short term. I would wonder what the actual objections to the regulations are. I have read in the comments of others that employers feel that this is a situation that can’t be regulated and that violence is often random and unpredictable. I disagree. That may be true in many locations in our country where violence is exploding, but in the hospital setting, there are many areas of possible or anticipated violence where early interventions would work if incorporated into a comprehensive plan.
If the cost of implementation of regulations is perceived to be too expensive, I would suggest the cost of injuries, loss of life, and inability to protect other patients is also a very expensive alternative. Interestingly enough, outside of my professional environment as a nurse and a professor, I have told few people the story of any of these incidents, including family. It’s almost like battered wife syndrome: It happens more than we will admit to, but it’s “easier” to just let it go.