Wednesday, July 09, 2008


In the last seven years, Mercy Jaiswal has been physically assaulted three times. She was beaten with pots filled with hot coffee. She was kicked so powerfully that her leg was covered with a massive bruise that would linger for months. Most recently, she was thrown "like a rag doll," sustaining a fractured arm that required surgery and six months of recovery time. Mercy Jaiswal is a registered nurse. All of her injuries, says New York State Nurses Association, occurred when she was at work in a Long Island healthcare facility, delivering professional nursing care to the patients that she "loves so dearly."

What are nurses looking for when they head to work each day? A chance to care for fellow human beings in their time of need, to exercise state-of-the-art skills, to bring meaning to their own lives and to earn a paycheck.

What are nurses not looking for? To be elbowed, slapped, punched, kicked, verbally abused, even shot or raped.

There's no question that nurses face big risks: according to the U.S. Bureau of Labor Statistics, nurses and other personal care workers suffer 25 injuries annually resulting in days off from work for every 10,000 full-time workers. That's 12 times the rate of the overall private sector.

Fifty percent of nurses surveyed by the Massachusetts Nurses Association (MNA) and the University of Massachusetts said they had been punched at least once in a two-year period. Some reported being strangled, sexually assaulted or stuck with contaminated needles.

Nurses understand that they have a tough job, but getting attacked and abused is not what former Boston area emergency room nurse Ellen MacInnis says she signed up for.

"It was very frightening," the 18-year veteran told CNN. An angry and frustrated patient had grabbed MacInnis' hand, dug her nails in and made a chilling threat. "If you have children, I'll find them and I'll kill them."

Nurses are often on the receiving end of physical assaults, because they are typically the first and most frequent medical personnel by the bedside of ill and sometimes angry or frustrated patients.

A recent study by the Emergency Nurses Association (ENA) showed that 86 percent of all ER nurses who responded to the survey had some form of violence committed against them while on duty over the past three years.

"Those are astronomical numbers," said ENA president Donna Mason, who is in Salt Lake City this week for the group's annual conference.

Mason told the Deseret Times last fall, "The public needs to know this is not OK. You would never kick a cop or a firefighter for putting out a fire. Nursing is a very trusted profession. We want to take care of people."

Those who are committing violence in emergency rooms are not typically gang members who are brought to the hospital after a violent confrontation with a rival gang and are looking for payback, Mason said. Rather, it's citizens who are sometimes intoxicated, and many times upset with having to sit for hours in the waiting room.

Violence is most frequent in psychiatric wards, emergency rooms, waiting rooms and geriatric units, according to a National Institute for Occupational Safety and Health report. However, no nurses are immune from workplace violence.

“Factors contributing to workplace violence include stress, poor staffing levels, long working hours, improper training of personnel, and power and control issues,” writes author John Murray, Colonel, USAF, NC, RN, PhD, CPNP, CS, FAAN, who is Director of Education, Training & Research for Joint Task Force National Capital Region Medical in Bethesda, MD and President of the Federal Nurses Association. Murray encourages workplaces to create a healthy work environment by adopting principles from organizations such as the American Organization of Nurse Executives and the Nursing Organizations Alliance.

“We must send a clear message that intimidation and abuse will not be tolerated in the workplace,” says Pamela Cipriano, PhD, RN, FAAN, CNAA-BC, Editor-in-Chief of American Nurse Today. “And, we have to provide nurses with the skills they need to respond appropriately.”

The American Hospital Association says executives are very aware of the problem and are taking steps to address it, including expanding security staffing, increasing the use of surveillance cameras and providing training on how to deal with violent situations. However, nurses say that while some hospitals are supportive, far too many discourage nurses from discussing these assaults and do little to prevent them.

And in fact 80% of actual incidents go unreported.

"Nurses need to know that violence against them will be fully prosecuted," said Tina Gerardi, RN, chief executive officer for the Nurses Association. "And their potential attackers need to know the same thing."

"Each year thousands of nurses are attacked in the workplace," said Assemblyman David Koon (D-Perinton), sponsor of a New York State bill which would make assaulting a nurse a Class C felony. "Violence should not be 'just part of the job' for nurses. It is important for the state to establish that violent or abusive acts against nurses will have severe consequences, as they do for attacks on police, firefighters, and emergency service personnel."

New York State Assemblyman Marc Molinaro while discussing the above proposal said, “As a volunteer fireman and the husband of a nurse, I understand the importance of protecting those who protect us. With the growing crisis over nurse shortages, it is all the more important we send a message that assaulting our nursing professionals will not be tolerated and that we support the tireless work that nurses dedicate themselves to.”

The following is from the New York Times (you don't see that very often).

Nurses Step Up Efforts to Protect Against Attacks

Karen Coughlin, a psychiatric nurse in Taunton, Mass., remembers the evening four years ago when her 14-year-old son asked her if any patients had tried to kill her that day.

“I was astounded, but he was serious because he’d heard about co-workers going to the hospital for injuries,” Ms. Coughlin said. “I’ve been hit, I’ve been kicked and spit on. I’ve had a knife pulled on me. I love what I do and many of the patients I work with, but I don’t love the conditions I work in.”

Three years ago, an enraged patient — 6 feet 4 inches and 275 pounds — smacked another patient, bit a health aide, threatened to kill Ms. Coughlin and lunged forward to strike her. He was restrained before he reached her.

“I really thought that my life was in danger,” she said. “It was probably the most terrified I’ve been in my 24 years of nursing.”

In recent years, nurses like Ms. Coughlin have sounded the alarm about workplace violence, most of it committed by patients. According to the federal Bureau of Labor Statistics, half of all nonfatal injuries resulting from workplace assaults occur in health care and social service settings.

Nurses and other personal care workers bear the brunt of such attacks, with 25 injuries annually resulting in days off from work for every 10,000 full-time workers — 12 times the rate of the overall private sector, according to the bureau. The most dangerous settings are psychiatric units and nursing homes, where patients are often confused, disoriented or suffering from mental ailments, as well as emergency rooms, where long waits for care can anger patients, and the people with them.

The level of violence may well be higher, since the government figures include only the most serious incidents. A booklet published by the Occupational Safety and Health Administration in 2004 noted that violence in health facilities was “likely to be underreported, perhaps due in part to the persistent perception within the health care industry that assaults are part of the job.”

Nurses say the persistent nationwide nursing shortage is making matters worse, because understaffing increases the risk of violent incidents. And nurses cite the fear of assault as a reason for low morale, especially if they feel that management does not share their concern.

“Many nurses who are the victims of violence will actually leave their position rather than fight the system,” said Evelyn Bain, coordinator of the health and safety division of the Massachusetts Nurses Association, a union that represents more than 20,000 nurses.

It is hard to tell whether the problem has grown more serious in recent years or is simply receiving more attention, because researchers differ in their study methods and their definitions of violence. But, either way, advocates for nurses have stepped up efforts to fight it. They are demanding that employers provide greater protections and security for staff members, lobbying state legislatures to increase penalties for assaults on health care workers and urging nurses to report all incidents rather than shrug them off.

“It’s much more on the radar screen than it ever was, absolutely,” said Diana Mason, editor in chief of The American Journal of Nursing. “Nurses are just starting to get to the place where they’re saying, ‘I don’t have to put up with this.’ ” She added that the problem was international in scope.

One of the largest studies on the issue was a 2004 survey of 6,300 randomly selected nurses in Minnesota, in which 13 percent of respondents reported having been physically attacked during the previous year and 39 percent reported having been threatened, verbally abused or sexually harassed. Patients committed almost all of the physical assaults and two-thirds of the verbal ones, with visitors as well as physicians and other staff members responsible for the rest. The study appeared in the journal Occupational and Environmental Medicine.

Its lead author, Susan G. Gerberich, a professor of public health at the University of Minnesota, said nurses frequently felt pressure not to report violence incidents. “Nurses find different kinds of responses from their administrations and different levels of support,” she said. “Everything from ‘This is not tolerated at our institution’ all the way to ‘If you don’t like it, people, you can leave your job.’ ”

In a 2006 survey by the Emergency Nurses Association, a national group, 86 percent of respondents said they had experienced violence in the previous three years, and a fifth said they encountered it frequently.

Emergency room nurses say they also face the potential for violence from patients’ family members. “If you have families come in and their loved one has been in a traumatic accident, and their anxiety levels are so high, it can overwhelm their coping skills,” said Nancy Hughes, the director for occupational and environmental health at the American Nurses Association, another professional organization.

Ms. Hughes recalled an emergency room incident in which she escorted a woman who was high on drugs to the bathroom. Although the two women had a security escort, the patient managed to punch her so hard in the chest that she needed surgery.

“It was quite a traumatic event, but I didn’t get much support where I worked,” she said. “The doctor I was working with said don’t be a wimp, sort of take your lumps and don’t worry about it.”

Richard Wade, a spokesman for the American Hospital Association, said health care facilities should not necessarily be blamed for patient violence. “These things don’t happen because of breaches of security,” he said, “but because something happens that you can’t predict, and nurses are on the front lines.”

But Mr. Wade added that hospitals were very much aware of the issue and were addressing safety concerns in a variety of ways, among them increasing camera surveillance, expanding the security staff and training employees to deal with potentially violent situations.

“You want to have good security, but you don’t want it to feel like going through an airport screening or like a place in lockdown,” he said. “Hospitals are by their very nature supposed to be open, caring places where patients and families feel safe and don’t feel imprisoned.”

Tammy Peterman, the chief operating officer at University of Kansas Hospital in Kansas City, said it had stepped up its security efforts in recent years. It now keeps certain units locked at all times, funnels late-night visitors through a single entrance with a metal detector and mandates violence prevention training for all staff members.

The state Highway Patrol maintains a round-the-clock post at the hospital, and officers make rounds to enhance their visibility and reduce the risk of violence, Ms. Peterman said, adding, “When you’re driving down the interstate and you see the police, you don’t speed.”

Nursing organizations and unions have been the most active in drawing public attention to the issue. The Massachusetts Nurses Association, for example, has conducted member surveys on violence and lobbied for legislation to increase penalties against perpetrators and require employers to improve worker protections. (Ms. Coughlin, the Boston-area nurse, testified before the State Legislature on violence against nurses.)

The organization has dubbed Brockton Hospital, in the suburbs south of Boston, the “poster child” for workplace violence. Last year, in response to complaints, OSHA investigated the hospital and found, according to its report, that “the types of physical assaults include, but are not limited to, punching, kicking, biting, scratching and pulling hair.”

The agency recommended that the hospital analyze the workplace hazards, solicit extensive comments from employees, and develop a comprehensive violence-protection plan. The nurses’ association says the hospital has done little to carry out the recommendations, which are voluntary.

Rob Brogna, a spokesman for Signature Healthcare, which owns the hospital, said that even before the investigation, the company had an “ongoing initiative” for workplace safety. “Many of the suggestions raised by OSHA had already been put in place at the hospital before they even came out,” he said, declining to comment further about the union’s complaints.

Other states are also looking at legislative fixes. Last year New Jersey and Oregon passed legislation that requires health care facilities to assess the dangers of workplace assault and develop programs to address it. Liz Jacobs, a spokeswoman for the California Nurses Association, said improved nurse-to-patient ratios mandated by the State Legislature had helped reduce violence.

“Staffing levels really affect what happens in terms of safety on the unit,” said Barbara Williams, a psychiatric and emergency room nurse who retired last year from Dominican Hospital in Santa Cruz, Calif. “If people’s needs don’t get met in a timely manner, that level of frustration builds. When people become angry, the nurses become the focus of the anger when they really had nothing to do with it.”

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