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The video is chilling to anyone, but especially to nurses who can imagine being in exactly the same vulnerable position. A man’s brutal attack on unit nurses at St. John’s Hospital in Maplewood, MN, is putting the spotlight on violence in healthcare facilities and the potential harm facing the victims and the hospital.
The Minnesota incident was a graphic reminder of the risk faced by healthcare employees. A hospitalized patient suddenly went on a rampage. He rushed to the nurses’ station on his unit and attacked four nurses with a metal pole. Four nurses were injured. Security cameras recorded the attack. Police caught the assailant three blocks away, and he died soon after being handcuffed.
Not long after that attack, a patient attacked staff members at a hospital in Oklahoma City. He cut a security guard, bit a nurse, and injured another.
Workplace violence is a recognized hazard in the healthcare industry. The International Healthcare Security and Safety foundation reports that 60% of workplace assaults occur in healthcare facilities. The United States Department of Labor defines workplace violence as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It can range from threats and verbal abuse to physical assaults and even homicide.
In 2010, the Bureau of Labor Statistics (BLS) data reported healthcare and social assistance workers were the victims of approximately 11,370 assaults by persons, which was a greater than 13% increase over the number of such assaults reported in 2009. Almost 19% of these assaults occurred in nursing and residential care facilities alone. The Department of Labor believes many more incidents probably go unreported. (For more statistics and guidance on addressing workplace violence, see the Department of Labor web site at http://tinyurl.com/oht557f.)
Addressing the risk starts with knowing what forms workplace violence can take, what violence is occurring across all industries, and what violence already has occurred at your own facility, says Maureen McGovern, RN, CPHRM, director of risk management and patient safety officer at South Nassau Communities Hospital (SNCH) in Oceanside, NY. She and her colleagues at SNCH watch the media for trends in workplace violence and track all incidents at their facility.
SNCH also uses a specially trained team that responds to reports of a patient or other person exhibiting signs of potentially violent behavior. When healthcare workers recognize signs of agitation and a buildup toward violence, they call a ]Code Grey” on the hospital intercom system. Employees with special training in de-escalating behavior and containment of violent subjects respond. ]All employees are trained in recognizing potential workplace violence and the availability of the Code Grey team,” McGovern says. ]They team is called out most often for situations that do not result in violence, but we’re OK with that. There is no penalty for calling the Code Grey team.”
Also, the presence of the Code Grey team often defuses a person who otherwise might have become violent, McGovern explains. A nurse may call the team for a disruptive patient who refuses to take medications, for example, and seeing the team there and ready to intervene might make the patient think twice about lashing out.
All nurse managers are trained for the Code Grey team, along with nursing supervisors, and many are certified in crisis intervention through the Crisis Prevention Institute in Milwaukee, WI. (See the resource at the end of this article for more information on the certification.) Some members of the hospital’s security department also are certified in crisis intervention.
]They have been trained on what might trigger the situation to become violent and what techniques to utilize to calm the patient and avoid violence,” McGovern says. ]For instance, they are trained to always speak in a calm, clear voice, always be polite, be aware of their own body language, listen to the person, and show confidence and compassion. They learn what the patient’s complaint is and restate it to ensure they understand, apologize if appropriate, and give the person options for how to resolve the situation.”
The team members also calmly but firmly outline the limits of what can be done to address the person’s concerns. At SNCH the Grey Team is usually called out between 20 and 30 times per month.
Understanding what typically prompts a patient to threaten violence or act violently is important, McGovern says. In healthcare, the motivation might be pain, alcohol or drug withdrawal; a reaction to a medication; disregard of the person’s personal space; slow response to the patient’s needs; delirium and dementia; or a number of other causes.
Every Code Grey call is debriefed to determine how the process worked in defusing or containing the violence, and any injuries are studied closely to see if improvements in the process would reduce them. Very few Code Grey calls result in injuries, McGovern says.
SNCH also has developed an ]active shooter” protocol on the off chance that a gunman would attack in the hospital. That protocol was tested in a full-scale drill with the local police department more than a year ago, but tabletop drills are done more frequently because they are less disruptive.
The risk of violence can be affected by the type of patients being treated, notes Nan Jordan, RN, senior clinical consultant at Compliagent, a compliance consulting firm in Los Angeles. She is writing a guidance statement for a large national long-term care provider chain on the specific issue of preventing violence by long-term care facility residents against the medical staff. The violence guidance is part of a larger engagement about dealing with sex offenders who are facility residents.
]We have a population that is aging, and aging criminal offenders are being released after long prison sentences. So we’re seeing some of these people with past offenses who are now requiring long-term care,” Jordan says. ]This is difficult to handle when you are dealing with a clientele that is primarily old, fragile, and vulnerable.”
Some healthcare providers, such as long-term care facilities, can screen patients for the potential to reoffend or act violently, Jordan says. A criminal history or violent past does not necessarily mean the patient will repeat those actions, so Jordan says it more appropriate to screen for the potential to reoffend. To that end, she advises her long-term care clients to look for antisocial personality traits, lack of bonding, and persons who blame others and refuse to accept responsibility for their actions.
Violence at healthcare facilities, or the threat of it, can significantly affect patients and nurses psychologically. Christine Tenley, JD, an attorney at the Atlanta law firm of Taylor English Duma, has worked closely on the issue with a company managing healthcare facilities, and she says employers must be aware of the potential for liability from violence and threats.
]The healthcare environment is often a hectic one, and once something is done everyone moves on, with no more thought to the verbal abuse that took place,” Tenley says. ]If you want to prevent workplace violence and retain your nurses, you have to look at the verbal abuse as part of the problem and not just accept that as part of the job.”
Another wrinkle in healthcare settings is physicians and other superiors who scream, threaten, throw things, and otherwise terrorize their coworkers, Tenley notes. Nurses are getting it from all sides: patients, families, doctors. The day-to-day abuse from people that doesn’t rise to the level of actually hitting someone still can be enough to cause damage to the nurse that might be compensable,” Tenley says. ]Policies and training could be significantly improved at most hospitals, and a zero tolerance policy is the way to start.”
Hospitals should have a standalone workplace violence policy that defines violence and has a clear reporting mechanism, Tenley says. Training is imperative, she says, and administration often resists the expense.
Insurance coverage is available to mitigate the damages from workplace violence, notes Rich Kosinski, president of Specialty Insurance Advisors (SIA) in North Andover, MA. SIA offers Needle Stick and Workplace Violence coverage. In the event of unexpected medical fees and a potential sudden inability to work, Essential Professionals Insurance Coverage (EPIC) pays up to a $200,000 lump sum if an employee suffers an injury at the workplace as a result of an assault or accidental infection. ]For employers, this provides the additional indemnity coverage if there is an assault at work or even off premises if they are doing the normal course of work for the employer,” Kosinski says. ]There also is the benefit of psychological and trauma counseling, which can help the healthcare employer comply with the federal guidelines that require post-incident response treatment and therapy.”
Additional coverage such as EPIC provides a better safety net from employees than simply relying on workers’ compensation, Kosinski says. Victims such as the nurses attacked in Minnesota can use the funds to cope with sometimes debilitating injuries from assaults. (See the story on p. 5 for more details on EPIC coverage.)
]Workers’ comp helps the employee, but there is nothing there for the employee who can’t continue to work and still needs to pay the mortgage and get the kids through college,” Kosinski says. ]The nature of a workplace assault, unfortunately, is that people can be left with severe disabilities, and adequate coverage helps a hospital do its best to look after its employees.”
Nan Jordan, RN, Senior Clinical Consultant, Compliagent, Los Angeles. Telephone: (310) 996-8952. Email: firstname.lastname@example.org.
Rich Kosinski, President, Specialty Insurance Advisors, North Andover, MA. Telephone: (800) 828-3742. Email::email@example.com.
Maureen McGovern, RN, CPHRM, Director of Risk Management and Patient Safety Officer, South Nassau Communities Hospital, Oceanside, NY. Telephone: (516) 632-4963. Email:firstname.lastname@example.org
Christine Tenley, JD, Taylor English Duma, Atlanta. Telephone: (678) 336-7240. Email:email@example.com.
Certification in crisis intervention is available through the Crisis Prevention Institute in Milwaukee, WI. Options include a one-day introductory seminar, a two-day comprehensive workshop, and four-day instructor certification. Costs are determined by the type of training and the number of attendees. For more information, go to crisisprevention.com or call (888) 426-2184.