For people in healthcare, violence is an occupational hazard

For paramedics, nurses and other health workers, being alert for assaults has become part of the job.

If you’re a barista, you might get a nasty burn from scalding-hot coffee. For office workers, carpal tunnel syndrome is a risk. But for paramedics, nurses and other health workers, being alert for assaults has become part of the job. 

Because of patient privacy concerns, the public rarely sees those incidents, but last year, surveillance video from a hospital in Minnesota showed a patient hitting nurses with a metal bedrail.

Among the incidents that force people to miss work, about 60 percent of them happen in health care. That’s according to the Bureau of Labor Statistics, which counts up non-fatal on-the-job assaults in the United States. It’s hard to know the scope of the problem, but health researchers are documenting stories.

Laurie Grover, a charge nurse at a locked psychiatric facility in Worcester, Massachusetts, was attacked at work in May.

“We just had a couple of patients who were acting up, they were kind of taunting us with these metal objects, so I grabbed the guy’s arm so he couldn’t stab me and the other mental health worker grabbed the other side and we’re trying to get him to ‘drop it, drop it.’ I was pulled up from the ground by my hair while one of them was punching me in the face,” Grover said.

She says the patient population at her hospital has grown to include not just chronically mentally ill patients, but a great number of ‘forensic patients’ — people facing criminal charges who are sent by the court to the mental health hospital for evaluation.

“I see a great deal of patients pretending to be psychotic to get out of jail. They just think, oh, crazy people hit people, so I’m going to hit people so they think I’m crazy,” Grover said.

“It shouldn’t hurt to be a nurse,” Grover said. “I been doing this for 32 years, I’ve had both thumbs broken, I’ve been bit, I’ve been spit on. I’ve been hurt a lot of different ways but this was just the worst beating I’ve ever taken in my life.”

She and other nurses from the Massachusetts Nurses Association union shared their stories with state lawmakers in a push for new legislation they say will protect health workers.

In an emailed statement, Pat Noga, vice president for clinical affairs with the Massachusetts Hospital Association, said the proposed legislation is redundant, and will not improve on recently passed rules designed to create safety for patients and employees.

“While our hospitals’ policies are strong and sound, no policy or set of policies is perfect, and so constant vigilance is required – and that is what Massachusetts hospitals are committed to,” Noga said.

Not part of the job

Lisa Wolf is an emergency room nurse in Northampton, Massachusetts. To take someone’s blood pressure or listen to a person’s lungs, sometimes she has to get within ‘swinging range’ of a combative patient. 

“The guy kicked across the bed and kicked me right in the head, I really kind of had my bells rung a little,” Wolf said.

Colleagues asked if she was alright and if she wanted to go home. “I said, ‘No, I’ve got this sick baby in the next room,’ and I just got up and went back to work,” Wolf said.

Many nurses don’t bother to report incidents to management because there’s a cultural assumption that a swat from a patient is “part of the job,” Wolf said.

In her research, Wolf says she’s been surprised how much nurses have internalized that attitude.

“You can’t change anything if nobody thinks it’s a problem,” she said.

“Nurses were actually told: this is an emergency room, what do you expect? This is part of your job. We don’t want to make a fuss. I think the feeling that a lot of nurses have is nothing is going to change. Why should I stay after my shift to fill out this paper that’s going to end up in a void?” said Wolf, who’s also the Director of the Institute for Emergency Nursing Research at the Emergency Nursing Association.

When her team surveyed 13,000 nurses, about 12 percent reported they had dealt with physical violence within the last week. Forty-three percent said they had experienced verbal abuse.

Wolf says attacks by patients are actually “reasonably predictable” but nurses need training to walk into a room and ‘size up’ the scene. Noise, poor lighting, not enough security—and long wait times in the E.R.–are all ingredients that can contribute to violence against health workers.

Wolf says hospitals are responding, but in most cases it’s not clear what prevention strategies are most effective, and there’s not been enough time to track and evaluate the efforts.

Jane Lipscomb, a professor in the schools of nursing and public health at the University of Maryland, co-authored a new guidebook, “Not Part of the Job: How to Take a Stand Against Violence in the Work Setting.”

She says training should include de-escalation techniques to help workers calm hostile patients or frustrated loved ones.

Lipscomb says the Veterans Administration has a “flagging” system that lets providers know when a patient with a history of violence is coming into the hospital. If the risk is great enough, the VA can limit the time and place where that veteran gets his or her care. But the VA is a “closed” system, it’s harder for a typical emergency room to know who’s going to walk through the door.

In her research, Lipscomb visited hospitals that gather staffers from across departments for a morning ‘huddle’ to discuss what happened yesterday and what needs to happen tomorrow. Those briefings weren’t designed for violence prevention, but have become a safety tool.

“It allows everybody to be in the know, and resources to be adjusted if need be,” Lipscomb said.

Paula Bussard, chief strategy officer for the Hospital and Healthsystem Association of Pennsylvania, says most hospitals have in-house policies to deal with violence.

“If you have an elderly, dementia patient that’s frightened and scared and flailing. Do you really want to call in law enforcement?

Bussard says the Joint Commission on Accreditation of Healthcare Organizations requires every medical center to have a plan that addresses worker safety and strategies to prevent violence. Hospital safety teams include staff members from across the health center, she said, and when there’s an incident, together they figure out what went wrong and what needs to change.

The Joint Commission says the number one factor in preventing workplace violence is hospital leaders who make safety a priority, according to Bussard. But nurses unions and other professional groups say for them the answer is more staffing. Bussard disagrees. 

“I don’t think numbers are necessarily going to make that difference as much as having the right staff, and having that staff trained, and having the right policies in place,” Bussard said.

In Philadelphia, injury researcher Jennifer Taylor and her team at the Dornsife School of Public Health at Drexel University are studying paramedics who’ve been assaulted. The health researchers asked the first-responders: What would make you feel safer?

Injury researcher Jennifer Taylor is studying workplace stress among paramedics who’ve been attacked by a patient. (Taunya English/WHYY)

“They said: ‘You can give us guns, body armor and mace.’ That to me is a response based on a very stressful work environment,” said Taylor, an associate professor in the Department of Environmental and Occupational Health.

If a medic reports for duty wary to do her job, that’s a concern, she said. When you’re a first-responder and you’re called to someone’s home to help and you become the victim, that changes how you do your work.

“I totally understand when people have said, it took everything in my power not to strike back, pick up an oxygen bottle and throw it at them, to say something disrespectful,” Taylor said.

The Drexel team is collaborating with firefighters and paramedics across the country to improve the work environment for emergency services workers.

“I think it’s good that people are taking it more seriously than we did 25 years ago,” said Chris Yates, a paramedic at Crozer Chester Medical Center outside of Philadelphia.

But he suspects that some of the surge in research on healthcare violence has more to do with protecting the patients than protecting the provider. In his decades on the job, occasional patient attacks have been the norm, he said. Violence from elderly people with dementia is particularly tough, he said.

“They’re biting, they’re grabbing and they are completely unpredictable,” Yates said. “This is grandma, and it’s kind of more difficult to deal with than the younger patient.”

The rate of serious workplace violence incidents was more than four times greater in healthcare than in private industry from 2002 to 2013. Psychiatry, pediatrics and the emergency department are among the settings where health workers are most vulnerable, and the government seems to be taking more notice. The Occupational Safety and Health Administration is the agency that looks out for Americans on the job, and this week it released a new prevention toolkit for hospital administrators and others.

In recent years, the agency has issued citations—and threatened to fine–a handful of hospitals that don’t have an adequate plan to protect workers.