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.
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