Workplace Safety for Nurses in Healthcare Settings

WORKPLACE SAFETY FOR NURSES IN HEALTHCARE SETTINGS

Our presidential election is only days away. 48 million people in America are uninsured and healthcare costs are rising 2 to3 times faster than our nation’s GDP. Where will America’s healthcare system be in 5 years? Welcome to ReachMD’s monthly series focused on public health policy. This month we explore the many questions facing healthcare today.

Workplace violence in healthcare settings is a significant, yet often underreported public health problem. Patients are most likely to commit these crimes. Nurses and mental health professionals are the most common victims. Where does workplace violence occur most frequently? What are the key risk factors we can look for in working to put a stop to it?

You are listening to ReachMD XM157, the channel for medical professionals. Welcome to a special segment focused on healthcare policy. I am your host, Dr. Jennifer Shu, practicing general pediatrician in office. Our guests are Dr. Diana Mason, registered nurse and Editor-in-Chief of the American Journal of Nursing and Charlene Richardson, registered nurse and advocate for workplace safety. Welcome, Dr. Mason and Ms. Richardson.

DR. MASON:

Thank you.

MS. RICHARDSON:

Thank you.

DR. JENNIFER SHU:

Today we are discussing workplace safety for nurses in healthcare settings. Dr. Mason, why don't we start off just with a definition of workplace violence, what is it?

DR. MASON:

While most people think of workplace violence as entailing physical violence, hitting, punching, throwing things at nurses; even murder, killing, but it also entails emotional abuse and harassment, and sometimes that is also included bullying, which is pretty rampid in healthcare including from nurse to nurse as well as between physicians and nurses as well as with families, everybody involves everybody. We need to not just think of the physical violence and one reason we do not want to think just of physical violence is because that physical violence takes place within a context that condones abuse often. Our healthcare settings are very stressful settings. There is often not enough support from administration for respectful communications among everybody in that expectation and the joint commission on the accreditation of hospitals that accredits hospitals and healthcare facilities has become so concerned about this problem that in January, they are now expecting accredited facilities to have a written policy that is a code of conduct on respectful communication and behavior in the workplace that everyone will be held to.

DR. JENNIFER SHU:

Ms. Richardson, can you give us an idea of how common workplace violence is, is it increasing, is it decreasing, staying the same?

MS. RICHARDSON:

It is definitely increasing and not just physical, I have to concur with Dr. Mason completely, particularly, you know there is a lot of lateral violence between medical professionals; unsafe staffing creates increase in already stressful working conditions. Definitely a physical component and strong verbal component with regard to not just from the level of the patient, but families, visitors, they are so big on a hotel environment now and creating a hotel environment that even, you know, with regard to visitors, the visiting hours are out of control and there just is not any limit and with that, the nurses are not able to do their job the way they need to do their job.

DR. JENNIFER SHU:

Now nearly half of all occupational violence occurs in healthcare settings with more than 200,000 assaults taking place on hospital workers each year. Dr. Mason, why are healthcare facilities at such risk for this violence?

DR. MASON:

I think there are a number of reasons why healthcare facilities and environments are at such risk. I think one is that we know that psychiatry is a high-risk environment. Certainly people with severe psychiatric disorders may be hallucinating or otherwise be reacting violently to a disturbed state of mind, but this also applies to people with severe dementia and for instance, we know now that bathing somebody with dementia can be a combative situation and there are best practices to try to avoid escalating the abusive nature of that experience because a person, you know you are taking their clothes off, they are cold, they may be, think as a stranger and it all feels very uncomfortable and dangerous and so they may start hitting and certainly nurse’s aides have been victims of abuse in many situations, particularly in long-term care. I think the other is emergency departments. Often trauma is coming in the door, trauma cases, that are the results of violence and we did publish a couple of papers in the American Journal of Nursing on family presence letting family members to be present during <_____> and invasive procedures and we got a couple of letters from nurses in emergency departments who said “You know what, I cannot let the family and/or people who say that the family because we have had instances where whoever was the perpetrator of that gunshot wound is now coming into the emergency department to finish the job and we are put at risk. So emergency departments are also high-risk environments, but I think that there is also the fact that we live in a violent society. If you look at the games and you as the pediatrician know this, if you look at some of the games that our children are playing, they are about violence. Violence is in films, it is all around us and so I am not sure why we are expecting people to deal with, you know, difficult situations in their lives in non-violent ways when the messages they get is violence is the way to respond, and if you think given a difficult diagnosis or if you are in a situation in a healthcare environment where the systems has failed you, which very well may have these days because of problems with staffing and other issues, you may react in ways that are not usual are you. So I think we have got a number of factors that are contributing to violence being a way of expression in healthcare facilities.

DR. JENNIFER SHU:

Ms. Richardson, you mentioned the whole hotel mentality and administrators may be warranting the hospital to feel like an open caring place or even a haven as opposed to a prison, what would happen if the image changes to a more of a locked down area?

MS. RICHARDSON:

I do not think it so much needs to be, I am not looking for a response that we do not involve family. What I am saying is we have gone too much in the other way, in that it has become out of control now and we are allowing people to be in settings all the time without any limitation and it puts nursing at risk and it is actually a barrier to the patient’s care.

DR. JENNIFER SHU:

So it is interesting a lack of boundary now becomes a barrier. Dr. Mason, you also mentioned staffing issues, it is clear that that poor staffing ratios for nurses and patients can affect medical care, but how would that affect workplace violence?

DR. MASON:

Well, when you have a nurse with too many patients to stress one on the nurse, the ability of that nurse to react calmly and evenly to difficult situations becomes jeopardized plus imagine, you know, the family member in particular who is angry because their mother has not had her pain medication even though she asked for it quite some time ago and so it just escalates this feeling amongst family and patients that the staff do not really care and it is not that the staff do not really care, it is that hospitals and other facilities are not staffing adequately to meet the needs of patients and I do want to add that one of the reasons I am really glad to see you do this program, and I am really glad to see the attention that is being paid for violence against nurses and violence in healthcare settings in general, this has been going on for a very long time, but nurses are no longer putting up with it. One of the reasons that nurses are not putting up with it is because the spotlight is being shown on it and that has come about because of the nursing shortage as we started to look at why do not we retain nurses as much as we ought to, one of the reasons is because of violence in the workplace and we have got a couple of studies that bear that out one of which suggested that nurses were looking to leave because of the violence and so it is a problem that we need to address and that is the physical violence that I am talking about, but even with the emotional abuse, there are nurses who leave because there are disrespectful communications in the facilities all the time and so our workplaces really need a lot of healing and shining a lens on this problem can help that healing to occur. I think when you walk into a hospital where there is respect among the staff, where there really is true concern, I agree with what Charlene Richardson is saying that this hotel mentality is not where the focus ought to be, it ought to be focused on how do we meet the needs that this patient has and if you really care about that, you staff adequately first and foremost and so if we are doing all the things that we think are important to meet the needs of patients and what comes across is that we really care about you, that violence is not going to be at the level that it is in some institutions.

DR. JENNIFER SHU:

Now, we have mentioned that nurses are very aware of the problem of workplace violence, what about the people committing the violent crimes, the patients? Ms. Richardson, do you know of any patient education effort or ways to engage the patients to make them more aware of the issue?

MS. RICHARDSON:

This all started back in 1999 where a nurse actually took her challenge to court and was told by the judge that it was part of her job and the mass nurses went into action and formed a task force on the workplace violence to develop a significant amount of resources enough to address this crisis and secondary to that we have done a lot of education and we are out there, we are out there with District Attorney’s office, we have their full support, we do lots of seminars. To our nurses we try to ask nurses, educate families and patients and try to get rid of this – there is a misconception out there that assault is part of our job and you know, our listeners need to understand it is not part of the job, it is a risk of the job and we have really been focused on education with that and have done lots of work with OSHA and as I said District Attorney’s office has been trying to turn this around.

DR. JENNIFER SHU:

Do you think patients are aware Ms. Richardson that assault is a criminal act?

MS. RICHARDSON:

No, I do not. I think that patients who are daring enough and in my experience, the types of patients that I have dealt with, there are patients that are above the law and you know, at the end of the day the majority of hospitals protect the patient because the patient is the customer and the customer is always right.

DR. JENNIFER SHU:

Dr. Mason, let us talk a little bit more about patients. One of the OSHA guidelines I saw recommended flagging the charts of patients with a history of violent behavior yet trying to do this in a confidential manner. Do you have any experience with that kind of identification of high-risk patients?

DR. MASON:

I do not have personal experience with it, but there is another report in a 2006 paper in the Journal of Neuroscience Nursing, it was actually a survey of some nurses who are working with brain injured patients and what they found was that when nurses can identify patients who are most likely to be abusive, preventive interventions can be planned. So you might do something like if you know that this patient becomes violent when he gets an injection that you have another worker accompany you, it may be just trying to be very mindful of how you are talking to and approaching this patient, are you using a soothing gentle voice and this I mentioned earlier about patients who have dementia being also some of the perpetrators of the violence, but you cannot really blame them and you have to be very thoughtful about how to not escalate their fear and their anxieties and the combative behavior that kind of accompany that.

DR. JENNIFER SHU:

I would like to thank our guests, Dr. Diana Mason and Charlene Richardson. We have been discussing workplace safety for nurses in healthcare settings. I am Dr. Jennifer Shu.

You have been listening to a special segment focused on healthcare policy on ReachMD XM157, the channel for medical professionals. Be sure to visit our website at ReachMD.com featuring on-demand podcasts of our entire library. For comments and questions, please call us toll free at 888MD XM157 and thank you for listening.

You have been listening to public health policy in America, a special ReachMD XM157 interview series with our nation’s top thought leaders in public health. This month ReachMD XM157 will be discussing the many issues challenging public health policy in America. For a complete schedule of guests and programming information, visit us at ReachMD.com.