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Recent assaults on N.Y. nurses bring healthcare violence back to forefront

Monday April 7, 2014
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By Debra Anscombe Wood, RN

Media reports in February told of two incidents of violence against nurses in New York. One nurse suffered critical head injuries at a Brooklyn hospital and another was smacked in the face at a Manhattan facility. These incidents likely represent just a fraction of the assaults that occur in hospitals across the country.

“We are one of the most dangerous professions,” said Elizabeth Mizerek, RN, MSN, CEN, CPEN, FN-CSA, New Jersey State Council of the Emergency Nurses Association chairwoman for research and practice. ENA research has found significant underreporting of workplace violence. Its most recent study found nurses consider violence endemic to their workplace and suggest a culture of acceptance exists. Also, nurses said they feel unprepared to recognize cues indicating a person has a high potential for violence.

“You need to be able to recognize when things are starting to escalate,” said ENA President Deena Brecher, RN, MSN, APN, ACNS-BC, CEN, CPEN. “We know our behaviors can help escalate a situation, not intentionally.”

Laura A. Giles, RN, BS, president of the Manhattan/Bronx Chapter of ENA, reported educational programs can prove helpful in identifying risks and recognizing when a patient is likely to lash out.

ENA research has found 80% of ED nurses had taken such a course, but hospitals did not provide the training in half of the cases, Brecher said. The Centers for Disease Control and Prevention offers a free continuing education program to prevent violence against nurses.

Assaults on nurses can have lasting repercussions, Brecher said. According to an ENA study, 36.7% of ED nurses reported to have considered leaving the field because of a fear of violence.

Virginia Hebda, RN, MS, CEN, NE-BC, president of the New York State Council of ENA, said newer nurses are less accepting of intense threatening behavior. “People are more willing to say, ‘This isn’t right,’” Hebda said. “That’s a change I have seen in the last year or so.”

Elizabeth McFarland, RN, CEN, president of the New Jersey ENA, agreed things are getting better.

“But we have a lot more work to do, both with the culture of acceptance and breaking the barriers down with a culture of acceptance in hospitals and with the law enforcement community,” McFarland said.

What can be done?
Brecher suggested employing the ENA Toolkit as a guide to assess the status of the ED and hospital policies, prioritizing gaps and moving forward with a plan. The New Jersey Council of ENA helped to develop the toolkit and partnered with the state hospital association to implement it, Mizerek said.

“The ERs that have been successful in addressing the issue have been hospitals that put a multidisciplinary team together [to address the issue] and have a zero-tolerance policy,” Brecher said.

Nurses are advised to constantly scan the environment, watching for high-risk situations. Brecher reported that mounting frustration associated with long ED wait times, intoxication and drug-seeking behavior increase the risk.

Environmental interventions, such as controlled access, managing the number of visitors at the bedside, panic buttons and installing bullet-proof glass, can make it safer for nurses, Mizerek said.

Sheila Wilson, RN, MPH, co-founder of the StopHealthcareViolence.org website, suggested flagging health records of patients who have acted violently in the past and communicating that to the healthcare team, never turning one’s back toward a patient, staying a safe distance from the bedside and not wearing jewelry. All incidents should be reported, she said, and the victim fully supported, including counseling, medical care and time off to go to court.

However, many hospitals fear the public-relations repercussions associated with pressing charges, said Sandra L. Tetler, RN, BSN, president-elect, New York State ENA, which plans to talk with hospital associations about the issue.

Pressing charges, according to Giles, may be a tough sell to nurses who do not want the perpetrator to know their address or to appear in court.

“Some hospitals discourage nurses from reporting,” Giles said. “If you feel your hospital is behind you, you are in a better place.”

By reporting, hospital leaders can learn from the episode and possibly make changes. But with inaction, nurses often think there’s no point in reporting, Mizerek said. Visibility of guards may deter some people from acting out, Hebda said.
While more security guards may help, Giles said guards cannot be everywhere.

Tougher problems to solve
Some factors associated with healthcare workplace violence, such as cultural acceptance, are more difficult to solve.

Tetler pointed out the acceptance of some portions of society of domestic and child violence, road rage and youth bullying.

“Society has to change,” Tetler said. “But I don’t know if that will change.”
Giles suggested the lack of psychiatric resources, with mental health patients waiting days or weeks in the ED for a psych bed, contributes to the violence problem.

“We have so many patients who need care for behavioral health issues, and it’s just not available for them,” Mizerek said.

Legislative actions
Both New York and New Jersey have enacted legislation to address the problem of violence against healthcare workers.

New York has made assault on ED workers a felony, yet the problem persists. Brecher called felony legislation part of the solution, but the laws are too new to have data of their success as a deterrent.

Both alleged perpetrators in the February New York cases were arrested.

Mount Sinai Beth Israel, where the nurse reportedly was slapped, declined comment for this story. Brookdale Hospital, where the assault on the nurse who was critically injured happened, did not respond for requests for information about the incident or its safety program. McFarland and Giles have witnessed assaults in which the police would not take action. The New York Council of ENA met with several district attorneys from across the state to discuss the issue, and Giles found them supportive. The council also has met with the New York State Law Enforcement Council.

For change to occur, hospital leadership must support legal action, law enforcement must make the arrest, district attorneys must move the case forward and judges must hold people accountable, Brecher said.
“Everybody,” she said, “has to recognize this is unacceptable behavior.”

Debra Anscombe Wood, RN, is a freelance writer.

LEARN MORE: Take the Nurse.com CE course “Preventing Violence in the Healthcare Setting” at CE.Nurse.com/CE130-60.


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Workplace violence resources

Emergency Nurses Association
Workplace Violence Toolkit
ENA.org - search “workplace violence toolkit”

Centers for Disease Control and Prevention
Workplace Violence Prevention for Nurses course
CDC.gov/niosh/topics/violence/training_nurses.html

Stop Healthcare Violence
StopHealthcareViolence.org

NYS ENA Setting the Pace Conference
Preconference session
about preventing workplace violence
NYSENA.org/conference.html

80%
Nurses who have taken a course about violence in the workplace, according to Emergency Nurses
Association research.