Safe Nursing: Task force agrees—violence is not part of the job

By Evelyn I. Bain, M Ed, RN, COHN-S, Associate Director, Occupational Health and Safety Specialist, and B. Elaine Mauger MS, RN, Associate Director, Dept. of Labor Relations

Since it's inception, the MNA Task Force on Workplace Violence has gathered over 30 members, with varying interests and involvement and has met with local and state police, the Chief Justice of the Trial Court and members of the District Attorney's office. The task force advocates a Zero Tolerance Policy for violence in health care settings. MNA members Leslie Sullivan and Annie Lewis O'Connor are co-chairpersons of this Task Force

The Occupational Safety and Health Administration notes that 106 health care workers had been killed at work between 1980 and 1990. This included 18 RN's, 35 nurse's assistants or other health care workers, 27 pharmacists and 26 physicians. The Bureau of Justice Statistics noted that from 1992 to 1996 non-fatal assaults on nurses, others in health care and mental health settings were similar in frequency to those in law enforcement, well over 200,000 annually. Assaults in healthcare setting annually averaged 69,500 nurses, 24,000 technicians, 56,000 other health care workers and 10,000 physicians. In mental health settings 50,300 assaults were reported on professionals, 43,500 on other workers and 8,700 on workers in custodial positions.

Violence across the health care spectrum

Stories abound from members of the Task Force and others, from all healthcare settings, regarding the episodes of violence where they have been the victim or a witness to such events. Nurses in home care report being assaulted and held at knife point by patients and family members, physical attacks occur in the emergency department and in psychiatric settings. Verbal aggression and threats occur between co-workers as well as from supervisors and managers.

Domestic violence often spills over into the workplace, especially in health care settings. The MNA Domestic Violence Task Force noted that nurses, student nurses and other healthcare workers, accounted for 38% of domestic violence deaths in Massachusetts in 1998. The shock, horror and emotional aftermath of a domestic violence event tears through the victim's workplace leaving sadness, depression, fear and sometimes guilt in the lives of co-workers. The Domestic Violence Task Force recommends that while nurses cannot resolve all issues surrounding domestic violence, once it is suspected, often the simple statement, "no one should be hurting you" or helping someone to develop a safety plan for themselves and their family, could make a valuable difference.

Why nurses don't call the police

There are many learned and long believed myths that nurses adhere to when confronted with violence in their work-setting. One myth is that the perpetrator (patient or family member) is sick or under stress. Or the nurse must have approached the patient (family) inappropriately and provoked the attack. These myths blame the victim and/or relieve the perpetrator from responsibility. Nurses often accept the blame and the role.

The majority of patients know right from wrong and/or have a history of aggressive and assaultive behavior. Patients may be incorrectly placed in a setting that is not designed for the degree of violence that the patient has exhibited. The patient may require a "secure" environment or one on one observation and care. This secure environment may not be available or the staffing levels are so low that one on one observation reduces the staff available to maintain safe levels of care for the other clients. Low staffing levels have also been identified in settings such as the emergency room, where patients and families endure a long waiting time for care and attention. The stress resulting from long waits escalates to frustration and patients and families act out against health care workers. In home care there is seldom an assessment of the emotional or behavioral status of the patient or family before the nurse arrives.

Nurses have been reluctant to involve police in episodes of violence at work and these reports are seldom encouraged by their employers. It should be just as unthinkable and just as criminal to assault the nurse or any healthcare worker as it is to assault a teacher, a policeman or a judge.

Police protection, court intervention

MNA Task Force members have learned from interviews with police officers, representatives of the district attorney's office and the chief justice of the Trial Court that nurses and other health care workers who are assaulted at work, have the same rights as workers assaulted on the job in any other work setting. You can and should involve the police. You are entitled to file a police report to assure that the episode is investigated by police with follow up in the courts when indicated. No one should go to the police or courts alone. Take someone with you when reporting the crime to the police, preferably someone who witnessed the incident.

What to do after an assault

While there is no clearly defined response process for the victims of violence, the Workplace Violence Task Force has identified certain steps that should take place. The sequence of these steps depends on the individual situation.

• Report any impending and actual acts of violence at work to your supervisor, regardless of who is the victim and whether or not there are injuries
• Call the police immediately if necessary, file a police report as soon as possible. It is very important to have co-workers or others with you, for support and corroboration, when you file the police report.
• Seek medical attention even if there are no "obvious injuries", be sure to describe any physical injuries and your emotional state. Follow the health care provider's recommendations for treatment and work restrictions.
• Request a referral for emotional counseling and evaluation of Post Traumatic Stress Disorder (EAP, ASAP or private counseling) and use it.
• Take photographs of all physical injuries, bruises, etc.
• Contact your local bargaining unit chairperson and share information about the incident.
• Check with your employer to be sure that all injury and incident reports and workers' compensation forms have been filed and obtain copies of all.
• Keep a diary of the progress of treatment, discussions related to your injuries and the progress of any claims for workers' compensation
• Ask for and retain copies of all medical, injury and insurance reports that relate to the incident.
  

Injuries resulting from workplace violence are work related injuries

Injuries, both physical and emotional, that result from events of workplace violence should be treated as work related injuries under Workers' Compensation system. Workers who witness these events may also need post-traumatic stress debriefing and counseling. A Workers' Compensation claim should be filed to pay for treatment, counseling and any lost work time expenses.

Post-traumatic emotional stress is often a more debilitating problem for workers following workplace violence than physical injuries. Employers can have programs in place such as the Assaulted Staff Action Program (ASAP) or an Employee Assistance Program (EAP). ASAP is a peer-counseling program, widely utilized and found to be effective within the Massachusetts Department of Mental Health. EAP is a professional counseling service, as are referrals to private counseling. Therapeutic attention to the emotional component of violence has proven extremely effective in relieving the physical and emotional stress following these events and helping people to return to effective lives and productive work.

What is the union's role

Creation and maintenance of a safe work environment as well as the prevention and response for workplace violence are well understood roles of unions.

• Make workplace safety and health a priority and standing item for committee and labor management meetings.
• Maintain union presence on the facility safety committees
• Learn the employers policy and procedure for addressing workplace violence and educate self and members
• Introduce the OSHA Guidelines For Preventing Workplace Violence In Health Care And Social Service Settings , the concept of EAP's and ASAP if they are not in place. The Guidelines include survey tools that you can use to determine the potential for workplace violence in your facility.
• Have a defined support plan and system for colleagues who have become the victims of workplace violence. Use the steps in "What is a nurse to do following an assault" as noted above, as a basis for a system following an assault. Support is simply, someone designated to keep in caring and concerned contact with your injured colleague. ASAP is a formalized support system that can be implemented in a facility.
• File grievances
• Report on activities in local unit newsletters, especially the progress to prevention
  

OSHA Guidelines For Preventing Workplace Violence In Health Care And Social Service Settings

Because of the frequency and severity of assaults in these settings, in 1996 OSHA published Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers to assist employers to develop programs to address and prevent workplace violence. The Guidelines can be downloaded from the OSHA website, www.osha.gov, (enter "workplace violence" and the document will appear in a list of publications).

Among the factors related to workplace violence identified by OSHA are:

• prevalence of handguns as weapons among patients, their families or friends
• increasing use of hospitals by police and the criminal justice system for criminal holds
• care of acutely disturbed, violent individuals
• unrestricted movement of the public in clinics and hospitals
• long waits in emergency or clinic areas
• low staffing levels during times of specific increased activity
• isolated work with clients
• solo work in remote locations
• lack of training in recognizing and managing hostile and assaultive behavior.
  

OSHA identifies four elements in a Violence Prevention Program which include:

(1) management commitment and employee involvement

(2) worksite analysis

(3) hazard prevention and control

(4) safety and health training.

Nurses and other health care workers employed in state facilities are not covered by OSHA standards. Their safety and health advocacy rests in the Massachusetts Division of Occupational Safety in the Department of Labor and Workforce Development. They can be reached at 617.969.7177. This state agency utilizes OSHA Guidelines to address safety and health concerns, including workplace violence, to protect workers in state facilities.

To join the MNA Task Force on Workplace Violence or for more information on this topic, call Evie Bain at 781.821.4625 or at email eviebain@mnarn.org