QUELLING A STORM OF VI­O­LENCE

De­spite unan­i­mous agree­ment that health­care work­ers need to be pro­tected from vi­o­lence at work, there’s lit­tle con­sen­sus over how to ad­dress the prob­lem

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

Last De­cem­ber, at about 2 a.m. in the in­ten­sive-care unit, Allysha Shin’s pa­tient at­tacked her. Shin, a neu­ro­science nurse, was care­fully mon­i­tor­ing the pa­tient, a woman in her 20s who’d suf­fered a hem­or­rhagic stroke. She’d be­gun her usual overnight shift ac­com­pa­nied by a sit­ter, a per­son who helps su­per­vise or care for high-need pa­tients.

The sit­ter was called away after two hours to at­tend to an­other pa­tient. Later that night, Shin’s pa­tient, whose stroke had likely af­fected her be­hav­ior, grew ag­i­tated. She twisted in the re­straints that bound her wrists, kicked Shin in the face and punched her. Then, she ripped away the re­straints.

Shin yelled for help. It took four nurses, a nurse’s aide and other staff to wres­tle the pa­tient into a chair. In the process, she kicked Shin sev­eral more times in the chest and stom­ach. Shin, who works at Keck Medicine at USC in Los An­ge­les, took the next two nights off, her body aching from the at­tack.

In a state­ment, Anne Sy, Keck’s chief nurs­ing of­fi­cer, ac­knowl­edged the in­ci­dent but said she could not speak to the de­tails. “Keck Medicine of USC takes the safety of our staff and pa­tients very se­ri­ously,” Sy said. The med­i­cal cen­ter en­cour­ages all hospi­tal staff to speak up when vi­o­lence does oc­cur, she added.

Vi­o­lence in health­care set­tings has risen steadily in re­cent years. That has taken a grow­ing fi­nan­cial and hu­man toll on the na­tion’s 15 mil­lion health­care work­ers and on its hos­pi­tals and long-term care cen­ters, and has prompted ex­ec­u­tives, providers and pol­i­cy­mak­ers to take ac­tion in myr­iad ways.

Hos­pi­tals have de­buted tech­nolo­gies and launched aware­ness cam­paigns. States have pro­posed laws re­quir­ing work­places, in­clud­ing in health­care, to es­tab­lish an­tiv­i­o­lence pro­to­cols. Unions have pushed for min­i­mum nurse-to-pa­tient ra­tios.

The vi­o­lence is due to a con­flu­ence of fac­tors that defy easy solutions. In health­care set­tings, nurses, aides and other care­givers are of­ten shouted at, hit, kicked, beaten and shoved. The ma­jor­ity of the time, pa­tients mete out the abuse—some­times in­ten­tion­ally, some­times not. In other cases, it comes from vis­i­tors or other staff. In one no­to­ri­ous in­ci­dent, in 2015, the son of a for­mer pa­tient shot and killed a car­dio­vas­cu­lar sur­geon at Brigham and Women’s Hospi­tal in Bos­ton.

Such vi­o­lence not only poses a threat to peo­ple— nurses, physi­cians, health­care staff, pa­tients and vis­i­tors—but it also drives up costs and un­der­mines both the qual­ity of care and pa­tient out­comes. Yet fash­ion­ing an ef­fec­tive re­sponse to the vi­o­lence that rou­tinely oc­curs in clin­ics, hos­pi­tals, nurs­ing homes and other med­i­cal fa­cil­i­ties has long frus­trated providers and their ad­vo­cates.

“We’ve been work­ing on this for decades,” said Bon­nie Castillo, a reg­is­tered nurse and di­rec­tor of health and safety for the Cal­i­for­nia Nurses As­so­ci­a­tion-Na­tional Nurses United. “You can’t pre­dict ex­actly when they’re go­ing to hap­pen, but you know that they are go­ing to hap­pen.” Vi­o­lence in health­care set­tings is mea­sured poorly. Less than half of in­ci­dents are recorded— one sur­vey es­ti­mated just 19%—and of­fi­cial ac­count­ing by gov­ern­ment agen­cies such as the Bu­reau of La­bor Sta­tis­tics, the U.S. Jus­tice Depart­ment and the Oc­cu­pa­tional Safety and Health Ad­min­is­tra­tion vary widely.

Stud­ies and sur­veys of­ten clas­sify vi­o­lent in­ci­dents dif­fer­ently, which leads to dis­crep­an­cies in quan­ti­fy­ing the prob­lem. In 2011, the num­ber of non­fa­tal vi­o­lent in­ci­dents in health­care fa­cil­i­ties ranged from 22,250 to 80,710, the Gov­ern­ment Ac­count­abil­ity Of­fice es­ti­mated last year.

What is known is that health­care work­ers, es­pe­cially di­rect care providers, face far higher risk of be­ing in­jured on the job than work­ers in other in­dus­tries. In 2014, 52% of work­place vi­o­lence in­ci­dents re­ported to the BLS oc­curred in health­care.

More than half of nurses and nurs­ing stu­dents have been ver­bally abused and more than 20% phys­i­cally as­saulted, ac­cord­ing to a 2014 sur­vey of 3,765 reg­is­tered nurses and stu­dents con­ducted by the Amer­i­can Nurses As­so­ci­a­tion. Home­care work­ers face sim­i­lar per­ils, with 18% to 59% re­port­ing ver­bal ag­gres­sion and 2% to 11% re­port­ing phys­i­cal as­saults. Physi­cians, es­pe­cially in emer­gency medicine, are tar­gets, too.

These in­juries take their toll on both the wal­lets and psy­ches of the af­fected work­ers. In­jured em­ploy­ees might miss work or need med­i­cal care, which typ­i­cally comes out of work­ers’ com­pen­sa­tion in­surance. It also takes away from hos­pi­tals’ bot­tom lines. One hospi­tal spent just un­der $79,000 on med­i­cal treat­ment and $15,000 on in­dem­nity in one year, for 30 nurses in­jured by work­place vi­o­lence.

In some cases, vi­o­lence pushes work­ers to leave health­care al­to­gether, at a time when they are des­per­ately needed. From 2014 to 2024, the ranks of reg­is­tered nurses are pro­jected to grow from 2.75 mil­lion to 3.19 mil­lion, the Bu­reau of La­bor Sta­tis­tics has pro­jected. The num­ber of jobs for home health aides, to­tal­ing about 913,500 in 2014, is on track to grow a whop­ping 38% over the same pe­riod, adding 348,400 jobs.

The num­ber of ac­tual job open­ings is ex­pected to be even higher. Ac­cord­ing to a 2015 re­port by re­searchers at Ge­orge­town Univer­sity’s Cen­ter on Ed­u­ca­tion and the Work­force, 1.6 mil­lion jobs will open for nurses from 2015 through 2020—700,000 of them newly cre­ated and the rest to re­place re­tir­ing nurses. By 2020, the U.S. will have a short­age of 193,000 nurses, they pro­jected.

Nurses and hos­pi­tals are al­ready feel­ing the pinch.

“I’ve been do­ing this for 20 years, and I don’t re­mem­ber staffing lev­els this skele­tal,” said Lisa Wolf, a reg­is­tered nurse who is di­rec­tor of the In­sti­tute for Emer­gency Nurs­ing Re­search at the Emer­gency Nurses As­so­ci­a­tion.

When nurse-to-pa­tient ra­tios fall be­low a crit­i­cal level, the risk of vi­o­lence in­creases, ad­vo­cates for nurses say. The body of ev­i­dence show­ing that staffing lev­els di­rectly cor­re­late with vi­o­lence on wards is sparse, ac­cord­ing to Gor­don Gillespie, a nurse and as­so­ciate pro­fes­sor at the Univer­sity of Cincin­nati’s Col­lege of Nurs­ing.

Dur­ing his 21 years in nurs­ing, he has wit­nessed that vi­o­lence is most likely to erupt when staffing drops be­low a crit­i­cal level. Pa­tients some­times re­sort to vi­o­lence to catch nurses’ at­ten­tion, he said.

The more pa­tients that nurses and other providers must care for, the less time they can spend with each. And

the more over­worked they be­come, the harder it is for them to catch warn­ing signs and stave off brew­ing vi­o­lence.

“It is the time that (nurses) are spend­ing with (pa­tients) that’s al­low­ing them to as­sess the de­gree to which the be­hav­ior they’re see­ing could be prob­lem­atic,” said Pam Cipri­ano, pres­i­dent of the Amer­i­can Nurses As­so­ci­a­tion. “If there’s not suf­fi­cient staffing, that’s a missed op­por­tu­nity to catch some­thing be­fore it’s a prob­lem.”

When front­line providers are stretched thin, there are also fewer of them to re­spond to vi­o­lent in­ci­dents. They could be in an­other room at­tend­ing to an­other pa­tient—as was Shin’s sit­ter the night Shin was at­tacked.

“Many hospi­tal staff nurses will tell you there is def­i­nitely a short­age,” Cipri­ano said. The rea­sons vary, ac­cord­ing to Cipri­ano. Some hos­pi­tals try to cut costs by hir­ing fewer care providers. Oth­ers have stress­ful en­vi­ron­ments that re­sult in nurses’ burn­ing out and leav­ing. Still other hos­pi­tals strug­gle to hire nurses be­cause of ge­og­ra­phy—they might be in a ru­ral area, or their re­gion might have a dearth of nurs­ing grad­u­ates.

Many nurses con­sider vi­o­lence an un­wanted but in­evitable part of their jobs. To com­bat that no­tion and the com­pla­cency that ac­com­pa­nies it, the ANA has sought to ed­u­cate nurses. “We’ve put a stake in the ground and said, ‘No, you should have zero tol­er­ance. It is not OK for you to be mis­treated as a hu­man be­ing be­cause you’re tak­ing care of some­one else,” Cipri­ano said. “Par­tic­u­larly on the area of vi­o­lence, we’ve seen that ed­u­ca­tion is really fun­da­men­tal.”

Keck Medicine, where Shin is a nurse, trains staff to deal with pa­tients who might be deliri­ous or ag­i­tated, said Sy, the chief nurs­ing of­fi­cer. The train­ing in­cludes ap­proach­ing an ag­i­tated pa­tient, pre­vent­ing in­jury, de-es­ca­lat­ing sit­u­a­tions and get­ting help. “We’re con­fi­dent that our train­ing pro­gram helps pre­pare our staff for when these sit­u­a­tions arise,” Sy said.

Some hos­pi­tals and health sys­tems are turn­ing to tech­nol­ogy and aware­ness ini­tia­tives to curb vi­o­lence.

In Septem­ber 2015, the emer­gency depart­ment of Val­ley Hospi­tal, in Ridge­wood, N.J., dis­trib­uted a 10-ques­tion sur­vey about work­place safety to nurs­ing staff. The fol­low­ing month, the hospi­tal re­quired all ED staff to com­plete an on­line evac­u­a­tion train­ing pro­gram. The depart­ment also cre­ated a spe­cial team for deesca­lat­ing risky sit­u­a­tions with­out us­ing phys­i­cal force, spend­ing about $10,000 to train 90 staff mem­bers. It also gave nurses, physi­cians and other front­line staffers the op­tion of wear­ing a badge with a built-in alert button. If they feel threat­ened, they can dis­creetly press the button to no­tify se­cu­rity and the charge nurse.

As these ini­tia­tives were im­ple­mented, the num­ber of in­juries de­clined, from 45 and 55 in 2013 and 2014, re­spec­tively, to 26 in 2015. But in 2016 they rose again, reach­ing 27 by mid-Septem­ber, ac­cord­ing to the lat­est sta­tis­tics avail­able.

These ef­forts to cur­tail vi­o­lence by in­creas­ing aware­ness or de­ploy­ing new gad­gets may amount to no more than BandAids, es­pe­cially in the ab­sence of stricter reg­u­la­tory stan­dards and en­force­ment. “One of the chal­lenges is that we have no na­tional stan­dards,” said Gillespie, of the Univer­sity of Cincin­nati.

Since 1996, OSHA has of­fered vol­un­tary guide­lines for pre­vent­ing work­place vi­o­lence for health­care and so­cial ser­vice work­ers. Last up­dated in 2015, the guide­lines state that “a writ­ten pro­gram for work­place vi­o­lence pre­ven­tion, in­cor­po­rated into an or­ga­ni­za­tion’s over­all safety and health pro­gram, of­fers an ef­fec­tive ap­proach to re­duce or elim­i­nate the risk of vi­o­lence in the work­place.” They also list the build­ing blocks of such a pro­gram.

OSHA can’t en­force those guide­lines or re­quire em­ploy­ers to im­ple­ment pre­ven­tion pro­grams. What it can do is cite em­ploy­ers for vi­o­lence in health­care set­tings un­der the Oc­cu­pa­tional Safety and Health Act’s gen­eral duty clause, which re­quires em­ploy­ers to pro­vide a work­place free from haz­ards.

But OSHA in­spec­tors must meet a high bur­den of proof in or­der to is­sue ci­ta­tions un­der that clause. And even if they do, OSHA doesn’t re­quire em­ploy­ers to take cor­rec­tive ac­tion or re­quire in­spec­tors to fol­low up.

“There’s still a long way to go and a lot more we could have done,” said Jor­dan Barab, a for­mer deputy as­sis­tant sec­re­tary at OSHA dur­ing the Obama ad­min­is­tra­tion. “There’s a ma­jor prob­lem out there. It’s not be­ing ad­e­quately ad­dressed.”

The Gov­ern­ment Ac­count­abil­ity Of­fice, in a 2016 re­view of OSHA’s ef­forts to pro­tect health­care work­ers from vi­o­lence, rec­om­mended the agency give its in­spec­tors more in­for­ma­tion to de­velop ci­ta­tions and fol­low up on warn­ings. It also urged OSHA to as­sess its work to see “whether its ef­forts are ef­fec­tive or if ad­di­tional ac­tion may be needed to ad­dress this haz­ard.”

In re­cent years, OSHA had be­come in­creas­ingly de­pen-

dent upon the gen­eral duty clause to en­force com­pli­ance in health­care set­tings, Barab said. Mean­while, la­bor unions, Congress and pro­fes­sional as­so­ci­a­tions were high­light­ing the is­sue. Some called for OSHA to cre­ate a stan­dard to keep health­care work­ers safe from vi­o­lence.

In Jan­uary, OSHA be­gan rule­mak­ing to do so. It is gath­er­ing in­put from stake­hold­ers un­til April 2017—the early stages of a process that or­di­nar­ily takes five to seven years.

Un­der the ad­min­is­tra­tion of Pres­i­dent Don­ald Trump, who is­sued an ex­ec­u­tive or­der re­quir­ing the re­moval of two reg­u­la­tions for ev­ery new one ap­proved, the time­line for that rule­mak­ing is un­cer­tain. For now, OSHA can cite em­ploy­ers us­ing a process that Barab sees as highly bur­den­some.

In the ab­sence of fed­eral rules, nearly a dozen states have en­acted laws re­quir­ing health­care em­ploy­ers to cre­ate plans or pro­grams to pro­tect work­ers from vi­o­lence at work. Of­ten, vi­o­lent in­ci­dents are the trig­ger for such leg­is­la­tion. These laws vary con­sid­er­ably in sub­stance and scope. New Jer­sey’s law en­com­passes the health­care sec­tor, but Maine’s in­cludes only hos­pi­tals, for in­stance.

Forty-two states, ac­cord­ing to a com­pi­la­tion by the Amer­i­can Nurses As­so­ci­a­tion, have vary­ing penal­ties for as­sault­ing first-re­spon­ders. In a hand­ful of those states, the penalty ap­plies only to emer­gency or psy­chi­atric depart­ment staff. “That (penalty) does not seem to have been a sig­nif­i­cant de­ter­rent,” Cipri­ano said.

Nurses and their ad­vo­cates of­ten ar­gue that in­ad­e­quate staffing will un­der­mine tech­nolo­gies or ed­u­ca­tional ini­tia­tives de­signed to re­duce vi­o­lence. Dur­ing tes­ti­mony in Jan­uary, Jean Ross, co-pres­i­dent of Na­tional Nurses United, told OSHA, “We can­not down­play the im­por­tance of staffing lev­els in de­creas­ing work­place vi­o­lence in­ci­dents.”

One pro­posal to in­crease staffing is to set nurse-to-pa­tient ra­tios. So far, only Cal­i­for­nia has es­tab­lished a min­i­mum nurse-to-pa­tient ra­tio at all times, and Mas­sachusetts has set min­i­mum ra­tios in in­ten­sive-care units. One fed­eral re­quire­ment man­dates vaguely that hos­pi­tals par­tic­i­pat­ing in Medi­care have “ad­e­quate num­bers” of dif­fer­ent types of nurses “to pro­vide nurs­ing care to all pa­tients.”

The in­dus­try con­tends that nurse-to-pa­tient ra­tios add costs with­out im­prov­ing care and im­pose in­flex­i­ble re­quire­ments. In 2013, in a comment on a bill to man­date nurse-staffing ra­tios, the Amer­i­can Hospi­tal As­so­ci­a­tion said it op­posed “a cookie-cut­ter ap­proach to pa­tient care.” The as­so­ci­a­tion did not re­spond to queries for this story by dead­line.

Skilled-nurs­ing and as­sisted-liv­ing fa­cil­i­ties have lately re­ported in­creased vi­o­lence against em­ploy­ees, said Dr. David Gifford, se­nior vice pres­i­dent for qual­ity and reg­u­la­tory af­fairs at the Amer­i­can Health Care As­so­ci­a­tion/Na­tional Cen­ter for As­sisted Liv­ing. He at­trib­uted the uptick pri­mar­ily to grow­ing num­bers of pa­tients with men­tal health is­sues, de­men­tia or Alzheimer’s dis­ease. “In some cases, we are see­ing hos­pi­tals and other health­care providers look­ing to nurs­ing cen­ters as a place to dis­charge pa­tients who have be­hav­ior prob­lems,” Gifford said. “We are con­cerned that this prob­lem may grow as the pop­u­la­tion ages.” He called for “a na­tional di­a­logue around how to care for peo­ple with men­tal health and sub­stance abuse is­sues who are un­able to live in un­su­per­vised set­tings.”

De­spite the wide­spread recog­ni­tion that vi­o­lence in health­care work­places is a grow­ing prob­lem, there’s lit­tle agree­ment on how best to quell it. An April 2016 ed­i­to­rial in the New Eng­land Jour­nal of Medicine pointed out that most re­search is geared toward quan­ti­fy­ing the prob­lem rather than study­ing how to solve it.

“Prov­ing that pre­ven­tion pro­grams are ef­fi­ca­cious and cost­ef­fec­tive re­quires sci­en­tific ex­per­i­men­ta­tion, and de­sign­ing such ex­per­i­ments has proved to be chal­leng­ing,” Dr. James Phillips wrote. “With­out stan­dard­ized def­i­ni­tions, it will re­main dif­fi­cult for re­searchers to com­bine or com­pare data, as­sess in­ter­ven­tions, and de­tect tem­po­ral changes.”

The sit­ter as­signed to stay with the neu­ro­science nurse at Keck, was called away be­cause an­other room, which had two pa­tients, needed a sit­ter, Shin said.

Those other pa­tients’ safety was im­por­tant, but it seemed “in­ap­pro­pri­ate” for her sit­ter to be re­as­signed, be­cause the pa­tient who punched and kicked Shin had pre­vi­ously at­tacked three other nurses in sep­a­rate in­ci­dents, Shin said. “I was ex­pect­ing her feet to be tied down and for the sit­ter to ac­tu­ally stay and for there to be more med­i­ca­tion avail­able to help me keep her calm and keep ev­ery­one safe.”

Cal­i­for­nia Nurses As­so­ci­a­tion mem­bers rally to pe­ti­tion OSHA for a for­mal stan­dard on pre­vent­ing work­place vi­o­lence.

Allysha Shin, who was in­jured in an in­ci­dent at Keck Medicine, spoke at an OSHA con­fer­ence on vi­o­lence in the work­place in Wash­ing­ton, D.C., in Jan­uary.

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