Chris Burchill, Ph.D., R.N., C.E.N., still remembers the evening he was attacked by a patient.

“I was on the phone with our social worker trying to help the patient obtain a ride home,” Burchill says. “Without any warning, he began pummeling me with his fists.”

Burchill, a clinical nurse in the emergency department (ED) at the Hospital of the University of Pennsylvania in Philadelphia, sustained facial lacerations and microfractures on his nose and near his eyes. He decided to press charges against the patient, and since the attack, which occurred last year, he has made it his mission to ensure that none of his nursing colleagues are attacked on the job.

“I put together an interdisciplinary group composed of nurses, doctors, ED techs, trauma surgeons, our COO, and director of human resources to look at how we can make the ED safer for staff,” Burchill says. “The hospital has put cameras in ED areas that previously weren’t covered by security cameras, and we also hope to secure training for staff on personal safety and de-escalation techniques.” The group is looking into personal communications badges that nurses and other staff can wear to alert security in the event of an emergency. “We’ve also trained staff to not enter a patient room alone if a patient isn’t acting rationally or is under the influence of drugs or alcohol,” he says.

Burchill is dedicated to improving nurse safety beyond his own hospital as well. He’s currently developing a survey on violence against nurses that he hopes will be approved for distribution at the UPenn Health System’s three hospitals, followed by distribution to the greater Delaware Valley, and ultimately made available to nurses on a national basis.

“Since I was attacked, I’ve learned that often nurses don’t report violence incidents to hospital administrators,” Burchill says. “But if violence isn’t reported, administrators aren’t aware of how pervasive the problem really is for nurses.”

The frequency with which hospital violence occurs is rather shocking. A 2010 study conducted by the Emergency Nurses Association (ENA) found that 8%–13% of emergency department nurses are victims of violence every week.

“I think people might have the misconception that violence goes hand-in-hand with working in the ED,” Burchill says. “Yet nowhere in a nurse’s job description does it say it’s okay to be assaulted.”

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Taking action

Violent acts against nurses are increasing around the country, according to the ENA’s research. In October 2010, nurse Cynthia Palomata was attacked and killed by an inmate she was caring for while working at the Contra Costa County Main Jail in Martinez, California. Another nurse was shot by a patient at Danbury Hospital in Connecticut last year. In yet another instance, a patient’s family member shot a doctor at Johns Hopkins Hospital before turning the gun on the patient and himself. Nurses have also reported being spit on, kicked, punched, and verbally abused.

Although many cases of hospital violence occur in the emergency department, it isn’t limited to that unit, as Theresa Brown, R.N., an oncology nurse in Pittsburgh, Pennsylvania, discovered when she was attacked by the wife of a patient.

“The patient and his wife, who I later learned was drunk, had been fighting, and when she lunged at him, I instinctively grabbed for her, hoping to keep him safe. Instead, she attacked me. I had no self-defense skills and I struggled with her until a male nurse and security arrived,” says Brown, author of the new book Critical Care: A New Nurse Faces Death, Life, and Everything in Between (HarperOne, 2010). “The experience made me feel scared for quite awhile afterwards, and I kept replaying it in my mind wondering what I could have done differently.”

According to the U.S. Bureau of Labor Statistics, 46% of all violent acts in the workplace that necessitated time off were against RNs. And in the 2011 HealthLeaders Media Industry Survey, just 40% of the responding health care professionals said nurse leaders have “effectively addressed” workplace hostility.

“There are many reasons that precipitate violence,” says Sharon Canariato, M.S.N., M.B.A., R.N., Deputy Executive Director for the Illinois Nurses Association. “I also don’t believe that the current state of the economy has helped. We’re seeing patients that are sicker and more stressed.”

Rather than wait for hospitals and other health care employers to implement antiviolence programs, some states have sought legislative solutions including mandatory comprehensive prevention programs for health care employers, as well as increased penalties for those convicted of an act of violence against a nurse. Last November, New York State’s Violence Against Nurses law took effect, making it a felony to assault an on-duty RN or LPN. Following Palomata’s death, the California Nurses Association worked with California assembly member Mary Hayashi to introduce a bill, AB 30, that would assure RNs have adequate staffing and safety measures at work.

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“Unfortunately, many hospitals don’t change their policies until an adverse event takes place,” Canariato says. “Hospitals are so extremely busy that the creation and implementation of a procedure that prevents a problem takes a back seat to immediate issues that need prompt resolution.”

That’s not to say nurses shouldn’t take action and push for workplace safety programs. “There’s a lot of information available on how to institute a zero tolerance program related to workplace violence,” Canariato says. “Nurses should also get involved with their state nurses’ association. These groups advocate for health care issues affecting nurses and the public through lobbying the state’s legislature and regulating bodies.” The Center for Occupational and Environmental Health of the American Nurses Association is currently working on a violence prevention-training module for nurses with the National Institute for Occupational Safety and Health (NIOSH).

Nurses also need to prepare themselves, taking steps to ensure their own safety on the job. “Never be alone with a potentially violent person. Always have an exit strategy,” Canariato says. “And always report violent occurrences to hospital administration. As nurses we tend not to make waves and will often dismiss or bury a problem.”

Shiphrah Williams-Evans, Ph.D., P.M.H.N.P., B.C., F.N.P., S.A.N.E.-A., an associate clinical professor at the University of South Alabama‘s College of Nursing in Mobile, says some of the red flags that precede violence among patients and their families include anger, hostility, paranoia, displaced aggression, and persistent voicing of unmet needs.

“I encourage all nurses to be vigilant, watch for warning signs of violence, and discuss with colleagues how to diffuse and prevent violent situations,” Williams-Evans says. 

Programs that promote safety

Some hospitals have begun taking steps to ensure their staff’s safety. Detroit’s Henry Ford Hospital has had success with metal detectors, confiscating 33 handguns, 1,324 knives, and 97 cans of pepper spray in the first six months of implementation. The American College of Emergency Physicians has recommended other safety measures, including 24-hour security guards, coded ID badges, bulletproof glass, and “panic buttons” medical staff can push.

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In the University of Wisconsin Hospitals and Clinics (UWHC) system, a new program utilizes a green-yellow-red color-coded alert system to show the current security status, with lights in strategic places in the department.

After having two employees injured in the ED in 2007, we put together a multidisciplinary team of physicians, nurses, and security to look at our current security processes and what we could do to improve safety,” says Tami Morin, an emergency department clinical nurse manager at UWHC. “We looked at past videos of incidents that had occurred and examined what we could do to prevent situations from escalating to the point of violence.”

UWHC nurses now go through a four-hour training program designed to teach them how to de-escalate situations and to protect themselves. If a situation starts to take a violent turn, nurses are encouraged to step back and call in a behavior response team, composed of ED techs and security trained to handle violent situations. Data shows the UWHC program, implemented last year, seems to be working. While there were several injuries reported by ED staff in the two-year period before the color-coded system, there was only one reported staff member injury and no injury-related staff absences after the safety program was introduced.

When incidents suggest a higher risk level for violence, such as patients exhibiting behavioral problems, the department’s status changes from green, business as usual, to yellow, potential for disruptive behavior. A red status signals the potential for loss of control in any part of the ED. During a “code red,” the ED restricts visitor access and goes into lockdown while security members cover all department entrances.

“The system helps staff to [be] better able to identify people at risk of individual violent behavior and know when to cue a potential change in security status,” Morin says. The hospital is now looking into personal communication badges that allow nurses to hit a button and obtain immediate assistance, and it is also examining the handling of verbal abuse in the ED.

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“It’s not okay to walk into a school or a grocery store, or any other public place, and verbally assault the person who is helping you,” Morin says. “It’s not okay to do that in the hospital either, and we’d like to see a policy in place noting that if you verbally assault a hospital staff member that there will be consequences.”

Training and solutions

At Seattle Children’s Hospital in Seattle, nurses are taught how to assess potentially violent situations as part of their new-hire orientation.

“Nurses are encouraged to ask patients and their families how they are doing and how to recognize and intervene in potentially escalating situations,” says Ann Moore, R.N., M.S., director of the hospital’s inpatient psychiatric unit. “People who are stressed often don’t cope well and it can come off as angry or hostile. If our nurses encounter someone like this, the best intervention may be to call in a social worker or pastoral care who can better help the person manage their emotions.”

In Seattle Children’s ED, a “code purple” has been established to identify incidences of aggression or high-risk events. Psych nurses and social workers are on call to help resolve potential conflicts. “If a nurse senses that a situation may be getting out of hand, we encourage them to call on the psych nurse or social worker rather than to try and handle the situation themselves,” Moore says.

The training also emphasizes listening skills and how to read patients’ body language. “It’s often easy to forget that what is just another day at work for us is actually their worst day,” Moore says. Often, it’s the little things that make a big difference, like having nurses and other staff members introduce themselves and ask patients and their families, “What can I do to help you right now?”

“All too often we get busy with our own agendas,” Moore says. “Sometimes we just need to pause and ask a family member what they need at that moment. It could just be someone to sit with them while their child is undergoing testing, or for us to call another family member or friend to come and be with them.”

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AnnMariePapa, D.N.P., R.N., C.E.N., N.E.-B.C., F.A.E.N., and President of the Emergency Nurses Association (ENA), says her organization’s new toolkit can help many nurses address on-the-job violence. (Visit www.ena.org/IENR and click on “Workplace Violence Toolkit” for more information.)

A recent ENA study found that over half of emergency department nurses experienced some form of verbal or physical abuse by patients or patients’ friends and relatives within the previous seven days. In three out of four cases, according to the survey, hospitals did not respond to nurses’ reports of violence.

“Our toolkit provides nurses with the resources to create a project plan that supports quality improvement in the ED through identification, evaluation, development, and implementation of a process towards decreasing and preventing workplace violence, thus working towards creating a safer environment for nurses and patients,” Papa says. “There are worksheets, sample forms, and more that help the nurse and the hospital develop an appropriate violence mitigation plan for their facility, and can be used in units other than the ED as well.”

Papa also cites MOAB Training International, Inc. (www.moabtraining.com) with teaching hospital staff to recognize, reduce, and manage violent and aggressive behavior. A cross-disciplinary corporate program, MOAB also trains workers in compassionate methods of dealing with aggressive people both in and out of the workplace.

“There are several different independent programs that can be brought in house for all staff training,” Papa says. “One of the key elements is partnering with the hospital security staff. Any training, in order to be effective, needs to complement the approach and mindset of the security personnel.”

Nurses should not be afraid to go to work. With a team-based approach to emergency preparedness, they won’t have to be.

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