Zero tolerance

For nurses, abuse at work comes in many forms, from name-calling and yelling to spitting, kicking, punching and even choking. Often, the perpetrator is a patient and the scene is a hospital room.

“They curse, they call your mother all kinds of names,” said AnnMarie Papa, president of the Des Plaines, IL-based Emergency Nurses Association and clinical director of emergency nursing at the Hospital of the University of Pennsylvania. “And it’s really tough to try to stay disconnected when you’re really in there trying to help someone.”

While progress has been made in protecting nurses and nursing aides from needlesticks and musculoskeletal injuries, advocates such as Papa say many hospitals lack effective policies to address verbal and physical abuse.

In November, ENA released the results of an ongoing survey of more than 7,000 nurses in which more than half reported verbal abuse and almost 13 percent said they had experienced physical violence between January 2010 and January 2011. These results were consistent with the survey’s previous findings.

A recent American Nurses Association survey of 4,614 registered nurses found that respondents reported their work environment has become safer in the past 10 years; however, problems remain. OSHA announced last year it would launch a National Emphasis Program for nursing home and residential care facilities with inspections targeting workplace violence; back injuries; exposure to bloodborne pathogens and other infectious diseases; and slips, trips and falls. The NEP was spurred by recent data from the Bureau of Labor Statistics indicating that among health care support workers, the rate of injury and illness cases requiring days away from work increased 6 percent in 2010, while the MSD incidence rate for nursing aides, orderlies and attendants rose 10 percent.

Papa said she appreciates the focus on health care, but questioned whether employers and the public recognize how damaging verbal abuse and physical violence can be to nurses.

“Unfortunately, not speaking respectfully is sometimes tolerated by some organizations,” she said.

Although issues can happen anywhere in a hospital, ENA’s survey indicated that physical violence usually occurred in a patient’s room. Papa said emergency departments are a common location for problems because incoming patients often are stressed and have to deal with long waits and crowded waiting areas.

Collaboration between nursing and security

ENA has found that zero-tolerance policies go a long way toward making the environment safer for health care workers. These policies anticipate aggressive behaviors and spell out appropriate responses, such as a verbal reprimand or removing the person from the premises.

“It’s not just a policy that sits there and gets dust. It’s a policy that is living, breathing, that people are utilizing,” Papa said.

Laws protecting health care workers vary by state. In Washington state, assaulting a health care worker is a felony. That seriousness is reflected in new security precautions at Tacoma General Hospital in Tacoma, WA. In April 2010, Tacoma General and the adjoining Mary Bridge Children’s Hospital debuted a new emergency department featuring several lines of security, including a metal detector, multiple checkpoints and card access to treatment areas.

“It’s a very controlled atmosphere,” said Gary Barth, director of security, safety and transportation for both facilities.

Every treatment room has a panic switch for nurses and physicians. The switch sets off an alarm at the nurse’s station and triggers cameras inside and near the entrance of the patient’s room.

“[The switch is] fairly big, and we made it big so that if their hands are tied up, they can reach out with their foot and kick it,” Barth said.

He noted that nurses had full input on the changes, and training is available on self-defense and how to approach agitated patients.

From 2007 to 2010, the number of incidents at the two hospitals decreased to 157 from 252, according to Marce Edwards, media relations manager for MultiCare Health System, which runs Tacoma General and Mary Bridge.

However, for hospital design and procedures to work, nurses have to formally report incidents, and ENA data indicates that many choose not to. Papa said the main reason for this is nurses view reporting as a challenge. The form is typically found online, and some nurses feel they do not have time to fill it out. Others may think the police will not take the complaint seriously. The thought of having to make repeat court appearances if the perpetrator is prosecuted also may discourage nurses from reporting incidents, Papa said.

Making the reporting process easier may help. After being assaulted, a nurse at the University of Pennsylvania created a paper form that Papa said nurses preferred because they could fill it out at their convenience.

In addition, Papa emphasized the importance of collaboration between nurses and security. “The security guards want to help us,” she said. “Sometimes they don’t know how.”

Papa advised conducting drills to learn how to work together to manage aggressive behavior. At a hospital she visited in Wisconsin, the policy for dealing with an active shooter involved police telling everyone to get on the ground and put their hands up. Papa said nurses might naturally ignore such directions and continue helping patients. But after discussing the matter with security, they understood their participation was crucial to helping ensure the safety of the scene.