Workplace violence continues to rear its ugly head

Nurse safety remains an issue in healthcare

By Marcia Frellick

EDITOR'S NOTE: Marcia Frellick is a freelance writer.

Allison Boreham, RN, a charge nurse in an emergency department at an Omaha, Neb., hospital was six weeks pregnant in October last year when she took a kick to the stomach from a drunk and violent patient.

Nineteen weeks later in the pregnancy, Boreham, who asked that her hospital not be named, was punched in the face by an unstable mentally ill teenage patient. She was knocked unconscious, had two bones broken and wasn’t able to work for a week. Both incidents happened in the ED, but workplace violence against nurses can happen in a variety of settings and can come from patients, patients’ family members and even co-workers. The incidents include everything from verbal assaults, spitting, hitting, hair pulling, shoving and throwing, to gun violence and killing. Nurses are the largest sector of the healthcare workforce and interact with patients more than other providers. Healthcare workers have a much higher risk for serious workplace violence (resulting in workers taking time off to recuperate) than workers in other sectors. According to an Occupational Health and Safety Administration report, from 2002 to 2013, serious workplace violence was four times more common in healthcare settings than in private industry on average.

In 2013, the healthcare and social assistance sector had 7.8 cases of serious violence per 10,000 full-time employees. In comparison, construction and manufacturing each had fewer than 2 cases per 10,000 employees, according to OSHA. And the numbers showed an uptick in recent years, with a report from the CDC showing violence against nurses increased steadily between 2012 and 2014. In a study published in 2014 in the Journal of Emergency Nurses, in a community/urban hospital system with more than 5,000 nurses, 76% of nurses reported they experienced violence in the previous year (verbal abuse by patients, 54.2%; physical abuse by patients, 29.9%; verbal abuse by visitors, 32.9%; and physical abuse by visitors, 3.5%.) “Emergency nurses experienced a significantly greater number of incidents,” the study found.

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Prevention instead of prosecution

Despite the incidents she endured, Allison Boreham, who has been a nurse for 12 years, said it hasn’t changed the way she feels about patients or her work. “I love being able to help people,” she said. “They still need help. Some are not themselves; they’re off their medication and they don’t know what they’re doing.” She said she calls security for backup more these days and feels nervous when entering certain rooms. But she doesn’t see an easy fix for workplace violence. “I can’t see that any steps would have prevented my attacks,” she said. “If you do more to protect nurses, you’re going to take more rights away from the patients.” She said many of the problems in her experience stem from mentally ill patients off their medication. “They still have rights to refuse medication,” she said. “We can’t hold them down and force it on them. Nobody wants to restrain a patient, because that won’t help the situation.”

Laws and regulations that protect healthcare workers

The following list includes some of the laws and other measures passed or proposed to help protect nurses and other healthcare workers from workplace violence:

OSHA requested public comment this year on its Request for Information: Preventing Workplace Violence in Healthcare and Social Assistance, which addresses whether a national standard is needed to protect healthcare and social-assistance workers from workplace violence.

An Ohio law authorizes hospitals to post a warning sign that could include communicating that abuse or assault of staff will not be tolerated and could result in a felony charge.

According to legislation passed in April of 2017, OSHA California Section 3342 of Title 8 of the California Code of Regulations, Cal/OSHA Violence Prevention in Health Care requires that by April 2018 healthcare employers create and implement, with direct-care staff input, comprehensive facility- and unit-specific workplace violence prevention plans. The following healthcare employers are covered by the standard: All health facilities that admit patients for 24 hours or longer including all clinics and other operations located in the same facility, home healthcare and home-based hospice, emergency medical services and medical transport, drug treatment programs and outpatient medical services to the incarcerated.

Read more about new legislation in the story, "Take a stand against workplace violence".

A law in Utah increased the penalty for knowingly attacking a healthcare provider and causing substantial injury from a misdemeanor to a third-degree felony, the same penalty as attacking a police officer.

Nurses still love helping people despite the violence

Gerard Brogan, RN, lead nursing practice representative for the California Nurses Association and National Nurses United, said he senses as he talks with nurses and nurses’ aides throughout the country that “nurses are at the end of their rope with this.”

Meanwhile, more people are seeking regular care in the ED and most healthcare systems lack comprehensive care for mentally ill patients. “People who would normally be stabilized if we had a better mental health system — they end up in crisis” and then in the emergency room, Brogan said.

His organizations are pushing for “prevention, not prosecution,” he said. That can include better staffing, panic buttons, bulletproof glass or better security protocols. Workplace training on how to intervene is also crucial, he said.

But it also requires a change in the culture of hospitals and nursing to make prevention a priority. “This is not part of the job,” he emphasized, though he said many nurses have received that response when they report assaults.

It’s a problem many facilities don’t want to talk about, he said. “It’s like a dysfunctional family. People will still defend the family, rather than shining a light on the problem,” he said.

Gordon Lee Gillespie, PhD, DNP, RN, CEN, CNE, CPEN, PHCNS-BC, FAEN, FAAN, an associate professor in the College of Nursing at the University of Cincinnati, Ohio, and a former emergency nurse with more than 20 years of experience, said he has experienced two serious assaults and “at least 100” incidents that included spitting, pushing, grabbing or verbal assaults when he was an ED nurse.

Gillespie said he has experienced a high number of incidents because male nurses often are called in to help in case of physical assault.

When he trains nurses now in avoiding assault, one thing he emphasizes on the prevention side is that the goal is not to win an argument. If the patient is persistently argumentative, nurses can offer to bring in someone else or quietly back down. “I tell them, ‘You can either win an argument or come home without being assaulted. Sometimes those are mutually exclusive,’ ” Gillespie said.

He added that as patients are admitted to the hospital and receiving introductory information, they should be informed that nurses are committed to their safety and acts of violence will not be tolerated.