Sunday September 25th 2016

Not ‘part of the job’

Nurses seek an end to workplace violence

When registered nurse Kelly McLean graduated from nursing school last May, she was fortunate to land a job that allowed her to pursue one of her clinical passions: working with psychiatric-mental health patients. But what happened to her three months later was shocking.

While reviewing discharge paperwork with one patient at the nurses’ station of an acute inpatient psychiatric unit, another patient brutally attacked her — punching, kicking, and choking her until she was unconscious. He then grabbed the wall phone from a charge nurse who was calling for help and used it to continue his assault.

McLean now is among the hundreds of thousands of nurses who are victims of workplace violence each year. And although she is still recovering, she wants to help raise awareness about workplace violence and advocate for strategies to prevent it.

She said that neither her psych clinical rotation nor her job orientation prepared her to confront such incredible violence.

“I’ve always known there’s potential for danger, but it was always talked about more as ‘unfortunate accidents,’ like twisting an ankle or slipping when putting patients in restraints,” said McLean, a New York State Nurses Association (NYSNA) member. “I never heard stories of people getting assaulted. Now I know that nurses are far more likely than other health care professionals to be a victim of assault.”

The attacks on McLean and a nurse at another New York facility in less than a month prompted NYSNA to issue calls for action to end workplace violence and to hold vigils for the seriously injured nurses. The American Nurses Association (ANA), NYSNA, and other nurses associations are continuing their efforts to ensure that nurses, policymakers, and the public know that verbal or physical violence should never be viewed as “just part of the job.”

“ANA believes nurses have a right to work in a healthy environment,” said Nancy Hughes, MS, RN, director of ANA’s Center for Occupational and Environmental Health. “And there are strategies to prevent it, from having adequate staff to safer building designs to policies that promote a culture of safety.” (See related story on strategies, page 7.)

Barbara Crane, RN, CCRN, an ANA board member and NYSNA member said, “Employers and others must know that nurses are not going to take workplace violence anymore.

“We’ve seen a dramatic increase in the number of patients coming into our hospitals who are on drugs, who have gone without needed care because the mental health system has been broken down, and who have an intent to harm. Many nurses are not prepared to deal with violence, and it’s ingrained in them to ‘not touch a patient’ [in an attempt to defend themselves].”

Illinois Nurses Association Deputy Executive Director Sharon Canariato, MSN, MBA, RN, concurred, adding that hospitals in her state also have seen an increasing influx of patients from jails and prisons for care that used to be provided within the penal system. Many are detoxing and potentially more violent.

“Nurses need to be more mindful of their safety in this case,” said Canariato, also a member of ANA’s Congress on Nursing Practice and Economics (CNPE). “And I’ve been hearing from more nurses about visitor aggression.”

Reports and reporting

The U.S. Occupational Safety and Health Administration estimated that two million American workers experience workplace violence annually, with health care and social services workers at particularly high risk. The U.S. Department of Justice reported that nearly 500,000 nurses are victims of violence in their work sites each year. Further, nurses in emergency departments (EDs) and psychiatric-mental health facilities are common targets.

Government agencies and nurse experts also suggest that workplace violence incidents are underreported.

“Nurses still are reluctant to report,” said Bill Briggs, MSN, RN, CEN, FAEN, immediate past president of the Emergency Nurses Association (ENA) and its representative on ANA’s CNPE. “They are either afraid to report or feel that nothing will be done. In some cases, employers blame the victim — making it seem as if the reason it happened is because of a nurse’s ‘weakness.’”

Cindy Balkstra, MS, RN, CNS-BC, immediate past president of the Georgia Nurses Association and ANA board member, however, did file a police report against a patient who assaulted her, and she had the full support of her employer.

Recalling the incident, Balkstra said that she was getting ready to draw blood from the patient’s dialysis line as part of the discharge protocol when he started cursing and swinging at her. Although she managed to protect her face, he did strike her shoulder.

“I started yelling, and then he tried to fight with staff that came to help me,” Balkstra said. “It took a half hour for him to calm down — and not completely until the police came.

“It was upsetting to me that a patient would go to that extreme, and that my colleagues were putting up with that behavior for a month. Some staff had simply refused to take care of him, but others would, and then leave work in tears. They kept making excuses for him, saying he was very debilitated.

“But that doesn’t justify patients cursing, throwing things, and hitting nurses and other staff.”

Nurses in some states have convinced legislators that laws should be enacted to protect them — given the rising incidence of workplace violence. ANA also created a “model” state bill on violence prevention in health care facilities that its member associations can use to craft their own legislation. It’s available, along with other materials, on ANA’s website at

In New York, NYSNA was instrumental in getting a law on the books that makes it a felony to assault nurses who are on duty. It took effect this November.

“It shouldn’t hurt to be a nurse,” said Karen Ballard, MA, RN, FAAN, NYSNA president and ANA board member. “It must not hurt to be a nurse.”

ANA reports that nine states in addition to New York have enacted legislation to strengthen or increase penalties for acts of workplace violence affecting nurses. They are: Alabama, Arizona, Colorado, Hawaii, Illinois, Nevada, North Carolina, New Mexico, and West Virginia. Some states have measures that address workplace violence in other ways.

In terms of other New York efforts, NYSNA currently is developing a comprehensive toolkit and plans to hold workshops on the implications of the new law and how nurses can keep themselves safe, Ballard said.

NYSNA also has been calling for facilities, including the upstate Erie County Medical Center, where McLean was attacked, and Franklin Hospital in Long Island, where another nurse was viciously beaten, to implement a range of worker safety strategies.

Franklin Hospital management is investigating the attack and has promised to work with NYSNA to ensure a safe working environment. And after years of trying to get Erie County Medical Center to improve its safety and security procedures, including increasing its staff, hospital management this summer assured NYSNA that it was ready to take new steps to improve worker safety, according to NYSNA.

McLean noted that she has received tremendous support from Erie’s CEO and staff, as well as from nurses throughout her state and around the country.

And although Crane fully backs the felony assault laws, she too wants prevention programs implemented so nurses don’t ever have to use them [the laws].

“We want to keep nurses safe now,” she said.

‘Just plain wrong’

“Students and new nurses tend to first think of nursing in terms of its clinical, caring, and treatment aspects,” Canariato said. “Once they are more exposed to nursing [in their work settings], they do start to think more of their safety. And unfortunately it often takes an event before we learn or take action to protect people.”

McLean believes patients deserve to be in a safe environment, and she can still talk about the rewards of psychiatric-mental health nursing.

But the young nurse and mother — who is undergoing physical therapy and counseling and is dealing with constant headaches, eye pain, and peripheral vision problems — truly believes that the 22-year-old patient who attacked her had all intentions of carrying out earlier threats of killing her. (She had sought and received a standing order for prn medication from a physician after she witnessed the patient’s increasing agitation over the previous days.)

“Nurses and the general public need to know it’s a problem, and that no one should come to work and accept that they can be beaten. It’s just plain wrong, and the effects are devastating — to the person assaulted, to families, and to staff.

“Nurses also should know that choosing to press changes doesn’t make you a bad person or not compassionate. Many psychiatric patients know the difference between right and wrong, and they should be held responsible for their actions.”

The patient, who earlier pleaded guilty to assaulting McLean, was sentenced Nov. 15 to up to two years in prison, according to The Buffalo News. He faced up to seven years.

Spotlight on safety: emergency nursing

The Emergency Nurses Association (ENA), an organizational affiliate of ANA, is closely tracking workplace violence in the nation’s EDs and developing a toolkit to help nurses remain safe based on information gleaned from ongoing quarterly surveys.

Bill Briggs, MSN, RN, CEN, FAEN, immediate past president of ENA and its representative on ANA’s Congress on Nursing Practice and Economics said that the rate of violence against nurses within EDs has remained high.

“There is a significant amount of physical violence and verbal abuse, and it’s happening pretty consistently,” he said.

Specifically, the new ENA study released in August finds that every week, between eight and 13 percent of ED nurses are victims of physical violence. More than half the nurses reported experiencing physical or verbal abuse at work in the seven days prior to being surveyed.

The Emergency Department Violence Surveillance Study also found that 15 percent of nurses who reported experiencing physical violence said they sustained a physical injury as a result of the incident, and in almost half the cases no action was taken against the perpetrator.

Three in four nurses who experienced physical violence reported that their hospitals did not respond to the incident.

The study is based on quarterly surveys of 3,211 emergency nurses across the country from May 2009 to February 2010. ENA collected the data at three-month intervals to assess whether there were fluctuations over the course of a year.

The study also found:

•   Patients and their relatives were the perpetrators of nearly all incidents of physical violence (97 percent) and verbal abuse (91 percent).

•   The majority of incidents of physical violence occurred in patient rooms
(81 percent).

•   Physical violence occurred most frequently when nurses were triaging patients (38 percent), restraining or subduing a patient (34 percent), and performing an invasive procedure (31 percent). Briggs added that triaging is a high-risk activity because the nurse is assessing an unknown patient. For the report, go to

“The survey also drives home the point that for nurses who work in facilities with zero-tolerance programs that require reporting of violence and that have prevention strategies in place, like panic buttons or silent alarms, the amount of violence they experience goes down,” Briggs said. “And that indicates to me that it is preventable.”

He added that ENA is working hard to get OSHA to make its voluntary guidelines regarding worker safety into enforceable, required standards.

Spotlight on safety: the mental health setting

Safety in the workplace is a major concern for psychiatric-mental health nurses, said Michele Valentino, CNS, NP, who co-chaired an expert taskforce on workplace violence at the American Psychiatric Nurses Association (APNA). It subsequently created a 2008 position statement that addresses the scope of the problem, defines workplace violence and its consequences, and offers a set of detailed recommendations to address it. (The position statement is available at

The APNA statement cites two studies from 1992 and 2007 showing that 75 to 100 percent of nurses on acute psychiatric units have been assaulted during their careers.

“We try to be as safe as we can in our work,” Valentino said. “But it’s very stressful to try to pay attention to every small detail at all times.”

She also explained that there are no current national, evidence-based standards to keep nurses and other psychiatric-mental health staff safe.

“For example, I don’t know why a facility would have one nurse do rounds alone, yet this practice continues,” Valentino said. “And in the outpatient setting, there often is no communication protocol between departments, like nursing, pharmacy, or the lab. So if one department receives a threatening phone call, staff in other departments don’t know about it and can’t prepare to act on it.”

The position statement includes broad (and more defined) recommendations, such as:

•   Professional nursing organizations must advocate for safe work environments; more research; education about risk management and prevention; and stricter laws and mandatory regulations enforcing safe work practices.

•   Health organizations must implement a comprehensive program that includes the prevention, reporting, and management of all types of workplace violence (verbal, physical, sexual, and lateral, such as bullying by peers or managers).

•   Nursing educators must include all aspects of workplace violence prevention and conflict management in school curriculum and ongoing professional education.

Valentino said another key message is the importance of determining best practices when it comes to intervention strategies and tools, training, policies, and other key factors.

“How do we know one type of de-escalation strategy is better than another?” she said. “Would implementing zero-tolerance programs actually decrease reporting to prevent facilities from not looking good? Is incident debriefing effective?”

Valentino speaks nationally on workplace violence, and what her audiences really want to know is, “What can I do in my workplace?”

She added, “Back in the ’70s and ’80s we used to think of patients as being violent or not. But really they are a very heterogeneous group so it’s not simple at all. But there are some good scales out there to predict violence. And we owe it to nursing staff and others to keep them safe.”

— Susan Trossman is the senior reporter for The American Nurse.

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