This report originally appeared in the July 2010 issue of DOTmed Business News

The woman came to the emergency room in an ambulance. She had overdosed on medication while driving her car. An emergency room nurse at a community hospital in Pennsylvania fed the patient, who was still under the influence of drugs, a drink referred to as charcoal. Thick and black, it's used to soak up all the toxins in the body.

It was at this point the woman decided she wanted to leave the facility. The nurse told her she wasn't able to leave; hospital policy forbids letting patients go who are still under the influence or are a threat to themselves or others. The woman, as she stood up to get out, threatened to sue the hospital.

Then things got ugly

Sherry Casey, 41, heard her colleague yell for help. She and other ER staff hurried to find the patient's face covered in the charcoal drink, struggling to get out of the stretcher.

"It just escalated from there," recalls Casey, an 11-year veteran in ER nursing.

The woman, swearing, spitting and thrashing out, managed to rip the IV out of her arm.

"There was blood everywhere," Casey says.

The woman went berserk. It took 10 ER staff members to restrain the woman, who kicked Casey and continued flailing, cursing and throwing punches. A staff member stuffed gauze in the woman's mouth to quiet her, and she was then restrained to the hospital's only stretcher that has leather straps, says Casey.

Finally, the woman was calmed with a sedative injection to her left deltoid. By the time the local police showed up, the woman was sleeping. She was still sleeping when Casey left hours later.

"That was just one isolated incident," she says.

Events like these are not uncommon nowadays. Nurses face a growing pattern of violence, whether in an ER, psychiatric ward or even just patrolling the floors.

All health care workers, nurses especially, face workplace hazards every day in a hospital setting. In fact, hospital workers suffered more than 275,000 injuries and illnesses in 2008, according to data from the Bureau of Labor Statistics (BLS). An unsettling number of the injuries resulted from patient attacks.

According to 2006 data from the BLS, health care patients were the leading source of injury among nursing, psychiatric and home health aides; they accounted for 59 percent of health care worker injuries from 1995 to 2004. These injuries generally were suffered by employees straining themselves lifting a patient or through patient assault.

A 2009 workplace violence survey found that nearly half of all non-fatal assaults in the United States were caused by health care patients.

"Nurses have always had to deal with inappropriate behavior from patients for years," says Christine Pontus, associate director of the health and safety division of the Massachusetts Nurses Association (MNA). "We're getting many more episodes and much more deviance. It's a matter of both frequency and severity."

A recent Canadian survey of ER staff in an inner-city tertiary care center found that 68 percent reported an increased frequency in violence, and 60 percent reported an increase in violence severity.

The law fights back

The numbers are so bad when it comes to patients attacking those in health care that Massachusetts passed legislation through the Senate in April to further protect health care workers. The employee safety law currently on the books makes it a specific crime to commit assault and battery on emergency medical technicians, ambulance operators and ambulance attendants. Currently awaiting House action, the law would extend protection to doctors, dentists, nurses, social workers, chiropractors and psychologists.

The extended version of the law, entitled An Act Relative to Assault on Health Care Providers, comes after the state saw a spike in attacks against health care workers; half of Massachusetts nurses have at least been punched within the last two years, according to data from the Beacon Hill Roll Call. And 25 to 30 percent of nurses are regularly pinched, spit on, scratched or have their wrists or hands twisted, according to a 2004 MNA Task Force and Congress on Health and Safety survey.

The bill would extend the existing penalties - a mandatory 90-day minimum sentence in prison or at least a $500 fine for anyone who assaults a worker who is responsible for treating or transporting them - to those convicted of assault on these newly included health care workers.

Massachusetts Sen. Michael Morrissey (D-Mass.), who backs the legislation, says he hopes it will send the message that assault "won't be tolerated."

His move to extend protection to nurses comes after finding they "also experience similar problems," as emergency responders when it comes to violence.

The senator quotes a survey from a Massachusetts hospital that found there were three 911 calls a day from within the hospital as a result of dangerous situations.

"A lot of jobs aren't what they used to be," Morrissey says. "There's a nursing shortage, a staffing shortage. We can't have people getting away with assault of people who are doing the right thing. The increased penalties send a strong message...People should be responsible for their actions."

Massachusetts is also working to implement laws confronting the issues tackled by violence prevention programs such as assault and battery. The programs currently exist as law in eight states. Massachusetts is also looking into the creation of a "difficult-to-manage" unit, which would put certain patients under stricter supervision.

Nationally, the American Nurses Association's (ANA) House of Delegates (HOD) released an action report this year, focusing on hostility, abuse and bullying in the workplace. The report followed a 2006 resolution, which addressed workplace abuse and harassment of nurses. In June, HOD resolved to "reaffirm and fully support principles from the 2006 resolution" and work with Congress to promote the growing problem of violence against nurses, according to the organization.

"ANA is dedicated to raising awareness of this problem and working on solutions, which include an emphasis on prevention and reporting," said ANA President Karen Daley in a statement.

Emergencies outside of the emergency room

ER and psychiatric ward nurses aren't the only ones at risk for patient-inflicted violence.

"With these kinds of behavior problems, dealing with people who are mentally unstable with violent tendencies, you can be a staff nurse in a hospital just walking by," says Pontus.

Pontus recalls an instance when a staff nurse was walking by a patient's room, who was calling for help with his urinal pan. The nurse went to help him, and he smashed the pan on her head.

"The nurse was going to help somebody," Pontus says. "She had no idea; she was just helping a patient."

A similar situation happened to Rita Anderson, then an assistant manager of a New York hospital's night shift. Due to the large volume of emergency department patients, some were laying in stretchers in the hallways.

As Anderson approached one stretcher, the female patient asked if she could use the bathroom. Because Anderson did not know the patient's history or current status, she went to ask the patient's nurse. After receiving the okay from the nurse, Anderson, a 115-pound woman in her early 50s at the time, returned and told the patient she could use the bathroom. The patient, a 16-year-old, 300-pound girl, said she couldn't get off of the stretcher and asked for some privacy to use a bed pan.

Anderson went to find an open slot - a partitioned section of a room - where the patient could use the bed pan. When Anderson returned to the stretcher, she leaned over to lower the rails. Out of nowhere came a blinding punch to Anderson's jaw. She fell back onto the nurses' station, trying to steady herself.

Later, when the patient was wheeled into a private room, Anderson was called in: the girl wanted to apologize. Anderson hung in the doorway, not wanting to get any closer and the girl said, "I'm sorry, but I was just tired of waiting."

It wasn't until the next afternoon when Anderson was eating dinner with her husband did she notice something was wrong.

"I bit down, and my husband said, 'What's wrong with your jaw, Rita?'" Anderson, now 62, recalls.

It turns out her jaw was broken. It took Anderson eight weeks to recover - eight weeks of lost work days.

She pressed charges, but the assistant district attorney dropped the case. The girl was never prosecuted.

Anderson eventually left the New York hospital for an ER position in Arizona, although not because of this incident.

In some cases, nurses who treat patients coming out of surgery are at risk for drug-induced violence from patients who, under normal circumstances, are "nice as pie," says Pontus.

She remembers a nurse who was treating a patient who had just awoken from surgery. The patient bit the nurse's hand so hard the ligament was torn off the bone.

"There was no malice on the patient's part," says Pontus. "But how do you represent that? That's tough."

ER nurse Casey used to think violent patients calmed down once admitted. She's come to realize the violence is a snowball effect, reaching all the way to floor nurses.

But the ER and the psychiatric units get the brunt of the problem.

Pontus explains that due to the mental health "crisis," in which more and more mental health facilities are closing down, ERs have a lot of homeless, mentally ill patients wandering in off the street.

"[Some of the] patients getting into psychiatric wards should be in prison," she says. "There's an inappropriate placement of patients."

Diane Gurney, president of the Emergency Nurses Association (ENA), agrees, pointing out that as ERs become more crowded, the violence problem is "exacerbated."

"The issues and risks have always been there," she says.

Police who find people under the influence of drugs or alcohol - those who cannot be arrested but need medical attention - drop them off at the ER, where they pass the buck to on-staff nurses, who then become responsible for wayward patients.

Casey calls this the "dump syndrome."

As an ER nurse, she experiences violence firsthand. Once, she saw two to three violent incidents in just a 24-hour period. She attributes the increases in severity and frequency of violence to the growing number of ER patients.

According to a 2009 ENA survey, 27 percent of ER nurses reported experiencing a "high frequency" (more than 20 incidents) of physical violence in the past three years, and 4 percent reported incidents of physical abuse during every shift.

Violence "is swept under the rug"

The MNA notes that the issue of workplace violence is often overlooked and underreported. The association points out that it's a "managers-do-not-ask, workers-do-not-tell" atmosphere, and nurses may fear retaliation, blame or poor performance reviews if they bring the issue to light.

"The reason that [violence] gets underreported is because for so many years, nurses just took care of patients; they had to take [violence], it was part of the job," explains Pontus. "We always understood that. We went along with it."




The thought that this concept is dated is unanimous throughout the nursing profession.

"[The myth was] you signed up for this type of work, you should know," says Kathleen McPhaul, assistant professor at University of Maryland's School of Nursing. "That's a dated concept, and we don't agree with that at all."

And because in many cases, underlying conditions such as drugs or mental instability lead to violent outbursts, nurses generally don't think attacks are a "reportable thing," Pontus says.

But now, she urges her nurses to report these incidents and press charges.

"We've always been somewhat alert, but now we're looking to be more proactive," she says.




In order to face the issue of nursing violence head-on, Pontus advises members of MNA to inform other nurses of their own reports, flagging certain patient behaviors.

"We, as a profession, have to learn to recognize who needs to be watched, who needs to be taken care of in a more intense manner to prevent [violence]," she says.

Nancy Hughes, ANA director of the Center of Occupational and Environmental Health, says that reporting incidents will help shed light on the situation, which in some cases, hospitals are oblivious to.

"Employers need to have a policy and encourage people to report so they get an accurate picture," she says. "If [incidents are] not being reported, employers may not realize they have the problem that they have."

But in some cases, reporting is pretty much impossible. MNA reported that many health care settings don't even have a reporting process - a 2005 BLS survey found 9 percent of private industry establishments had no policy. Processes that do exist tend to be extremely time-consuming. And even those employees who go through the timely process of reporting an adverse event, research has found nothing changes anyway, according to MNA. Ninety percent of establishments did nothing to change the work environment or protect workers from violence.

"We need to develop very clear procedures for reporting violent incidents," says ENA's Gurney. "Nurses can't be made to feel intimidated or ridiculed by other staff because we report it."

According McPhaul, there is a multitude of factors that prevent hospitals from implementing or changing policies, largely related to regulation issues.

"I think another reason [for underreporting] is when you do get a health care worker who reports an incident, nothing is done. You pretty much get the sense that nothing is going to be done. It's a vicious cycle," she explains.

"Sometimes hospitals don't have great systems for reporting incidents," McPhaul says. "Hospitals traditionally lump all of these kinds of events [together in an incident report]. Risk management folks who review the report tend to be more concerned with patient safety rather than employee safety...Patients can sue, workers can't."

Arizona nurse Anderson attributes the lack of reporting and the oversight of this problem to the fact that nurses are not given the respect they deserve.

"It's often that a patient will yell and scream and carry on, but when the physician walks in, everything is fine," she says. "They feel that nurses can be yelled at, can be pushed."

Despite the fact that hospitals are highly regulated facilities, workplace violence is not anything that hospitals "absolutely" have to focus on when it comes to regulation and enforcement, explains McPhaul.

Hospitals are asked to comply with the Occupational Safety and Health Administration (OSHA) guidelines, but that compliance is not enforced at all.

"In the last 15 years, OSHA hasn't regulated much of anything," she says. "What's probably a higher priority to OSHA and to workers who work in the health care industry is safe lifting and safe patient-handling standards...Violence continues to be one of those hazards that even OSHA tends to think maybe is a criminal justice [issue]."

OSHA did not respond to calls or e-mail requests for an interview.

Any workplace safety regulations fall under OSHA's broad general duty clause, which states that employees have the right to work in a safe and healthy environment, says McPhaul. She says that workers have gone to OSHA to file complaints under this clause, stating that their work place is not safe or healthy.

"When you make a complaint, there's a high burden of proof [for the person filing the complaint]," she says. "People have done it, but it's very, very difficult."

Incidents that are reported, explains ANA's Hughes, can be filed as workers' compensation claims, though that's often not the case.

"A lot of times nurses don't report the incident and think they're too minor to report," she says.

Despite Casey's advice for nurses to be proactive and report violent events in an effort to seek help, she has never reported an incident, nor does she know of any colleagues who have reported events.

"Why haven't I? I don't know," she says. "It's such an everyday occurrence; it's not anything new. It's not shocking, not alarming. It's the same old drunk or addict peeing on the floor. Just when you think you've seen everything and nothing shocks you, you see something that shocks you and then that [becomes] the norm."

"There is a fear of repercussions from management," Casey says. "[Management] may interpret [an incident] as 'I must have done something wrong.'"

The battle over restraints

If nurses are the subject of so much violence in the workplace, isn't it their right to defend themselves?

That's where everything gets gray.

Because nurses are dealing with patients, many who are mentally ill or under the influence of either street or medical drugs, some feel it's not ethical to fight back as one would under normal circumstances.

"In the past, we were able to get more support dealing with dementia and delirium [patients] through restraints," says MNA's Pontus. "Nurses are trying to follow restraint orders. New regulations are talking about restraining - when you can and cannot restrain."

While the Substance Abuse and Mental Health Services Administration (SAMSHA) - a sector of the Department of Health and Human Services - advocates health professionals move away from all types of restraints, the group doesn't expect a nurse to subject herself or himself to assault.

"Our focus is to prevent the use of restraints, only using them when the safety of staff, the patient or another patient is at risk," says Larke Huang, a SAMSHA senior adviser.

Restraints, Huang points out, can be harmful to both patients and staff members; physical restraints kill between 50 and 150 psychiatric patients a year, according to a SAMSHA report. And studies have found that staff can suffer more injuries when attempting to use restraints than workers in high-risk industries such as lumber, construction and mining suffer carrying out their tasks.

Chemical and mechanical restraints are primarily found in psychiatric care facilities and psychiatric units, where staff members generally have a crisis care plan mapped out before a situation escalates. But that doesn't mean nurses in the ER or in hospital psychiatric units don't run into problems.

Huang says that nurses who aren't trained to properly handle psychotic patients or drug-induced psychotic patients tend to use restraints as the first line of defense.

"[Nurses] don't really like to use restraints, but if they're not given other skills to know what they can do instead of restraining patients, they don't know what else to do," says Huang. "You really need to have these training strategies to prevent the use of [restraints]."

In general, nurses are trying to move away from restraints, says ENA's Gurney.

"Many hospitals are trying to get to zero use of physical restraints because those also can harm patients," she says. "There's a fine line between therapeutic treatment and having to employ a process that's going to be harmful to patients."

Other strategies, Huang suggests, include calming a patient in a comfort room or offering sensory calming devices like a blanket. Of course, it takes training and working closely with patients to understand how best to deal with them, and that is generally found in psychiatric care centers.

According to a study by Kevin Huckshorn, a nurse and director of the Office of Technical Assistance at the National Association of State Mental Health Program Directors, it is possible to reduce restraint, which ultimately reduces violence in the workplace.

Fixing the situation

Plain and simple, nurses want their employers to take notice of the rapidly growing problem of workplace violence.

"It's swept under the table," Casey says. "Nobody wants to talk about it."

Once recognized as a problem, nurses seek proper training programs, adequate support and equipment.

Casey says her hospital needs surveillance cameras, metal detectors, security staff - the hospital has just one security officer - a panic button that calls the police directly and an overall awareness of what the ER atmosphere is like. She points out that ER greenhorns don't realize what actually goes on in the ER until they get there, usually unprepared.

"Nobody knows what goes on behind the doors," she says.

But ultimately, it comes down to training, nurses agree, and most importantly, informing a nurse to keep herself between the patient and the door in case a situation escalates toward violence.

ANA's Hughes feels there should be training, so nurses can recognize when a situation may be escalating into dangerous territory. According to an ENA survey, 68 percent of nurses reported that training was not required for their ER department.

Casey recommends nurses take self-defense courses.

"Is it ever going to get to the point where we, as nurses, feel like we have to carry mace?" says Casey. "That we have to keep ourselves safe during our work hours? I don't feel safe going to work."

Casey is not alone. According to the ENA survey, 72 percent of ER nurses reported feeling unsafe in their workplace.

What needs to happen, nurses say, is for hospitals to follow OSHA guidelines, or even better, make those guidelines become federal standards. The ENA is in talks with OSHA's director about possibly making that dream a reality.

"OSHA has some guidelines, but we want to see them as standards," says ENA's Gurney. "I'm thrilled [the director] agreed to meet with us."




Nurses also want their employers to implement a zero-tolerance policy when it comes to violence in the workplace.

"Perpetrators need to be prosecuted," Casey says. "It should be posted all over the hospital that violence is not tolerated. Violators will be prosecuted."

"I'd like to see a zero-tolerance policy developed," says Gurney. "That's going to start with changing the culture, even with nurses themselves, because a good number of them feel [violence] comes with the job. It's the whole culture that needs to be changed."

Why stay?

Alarming numbers indicate plenty of nurses don't want to put their safety at risk anymore and they leave their job or the profession altogether. A 2005 survey from the Maryland Nurses Association found that 18 percent of nurses said they left a job in fear of their safety, and 15 percent said they wanted to leave but hadn't yet. A 1999 survey found that 67 percent of nurses no longer worked in the ER due to violence.

But many nurses stay.

"Why stay?" Casey says. "Do I have thoughts of leaving? Absolutely. But you know there is that person that is really ill and really needs your help and is really thankful. My decisions play a role in their outcome...You take the good with the bad."

And there's the excitement factor. Casey says part of the appeal of the ER the uncertainty of what's coming through the door.

"You see so many different things," she says. "It increases your nursing knowledge...yet I know as I get older I am not going to keep up with that fast pace."

Deep down, Casey also knows her days as an ER nurse are numbered. In just another year or so she'll finish her master's program and become a full-time nursing educator.

"I'm at the point where I feel, as a nurse, I don't need to take this," she says.

Even after Anderson, who's been a nurse for 43 years, had her jaw broken by a violent patient, she hasn't turned her back on the profession.

"It's what I do. I'm a nurse," she says. "I can't separate that from me. I can't not be a nurse."

Heather Mayer can be reached by e-mail at hmayer@dotmed.com.