In the Line of Fire
Hospitals and staff take precautions to guard against growing wave of violence in health care settings

By Donna Hemmila
January 30, 2003

The man who attacked her came into the hospital in handcuffs accompanied by seven police officers. That didn't prevent Roseanne Reed, RN, from ending her shift with a battered face and five stitches in her head.

It was about 1 a.m. on a Friday when police escorted the man into the emergency department at Gnaden Huetten Memorial Hospital in northeastern Pennsylvania. The prisoner seemed to be cooperating, and when he asked to use the bathroom, police removed his handcuffs. Reed, who became a nurse in 1973, followed the man and an officer into the bathroom because police asked her to get a urine sample.

When she handed the man a specimen cup, he lashed out.

"He just up and slammed me," Reed said. She still doesn't know why he attacked her.

"When I went down, I hit the wall," Reed said, recounting the incident that occurred in January 2001. "My glasses flew off. I could feel the officers jumping over me to get in. I crawled on my hands and knees to get away."

Later, Reed learned the man had been using cocaine, marijuana and alcohol and had driven through a turnpike tollbooth waving a handgun.

"I didn't know that part of the story," Reed said.

Reed's story could have had a more tragic ending. At Savannas Hospital in Port St. Lucie, Fla., an oak tree planted in the courtyard reminds nurses of colleague Alda Ellington, who was beaten to death by a patient in April 2001.

The man, who fantasized about being a professional wrestler, also killed three elderly patients and injured two others during a violent body-slamming, neck-breaking rampage.

Emergency department and psychiatric nurses have long lived with the possibility of workplace attacks, but they're not the only ones at risk. In October, a student at the University of Arizona College of Nursing in Tucson shot and killed three nursing professors before taking his own life. Less serious but just as frightening incidents of on-the-job violence have many hospitals strengthening security and many nurses wondering why they've become the preferred target when violence erupts.

Easy targets

Between 1993 and 1999, 429,100 nurses were victims of violent crimes in the workplace annually, according to a Bureau of Justice Statistics special report. That's an average of 21.9 attacks for every 1,000 nurses. In comparison, physicians experienced 71,300 attacks, or 16.2 for every 1,000 doctors.

"The most prominent incidents you read about are the deaths, stabbings and shootings," said Donna Nowakowski, MS, RN, executive director of the Emergency Nurses Association. "But there are other forms of violence."

Nurses are easy targets for patients who hit, shove, kick, bite and spit. They are also the caregiver that patients and their relatives are mostly likely to scream at, threaten and verbally harass.

Nurses have the greatest exposure to patients, and they perform the uncomfortable procedures, said Ronald Charles, MD, medical director of the Lyndon B. Johnson General Hospital in Houston and a faculty member of the University of Texas-Houston Health Science Center.

"It's also a respect issue," Charles said. "The patient is more apt to strike out at a nurse because they know if they target the doctor, they're not going to get what they need."

A national survey of registered nurses sponsored by NURSEWEEK and the American Organization of Nurse Executives found that 28 percent of the nurses who responded had experienced episodes of violence in the workplace within the past year.

A study published in the Journal of Emergency Nursing in June 2000 found that 82 percent of emergency department nurses had experienced physical violence sometime in their careers.

Researchers Lisa Erickson and S. Alicia Williams-Evans interviewed 55 emergency nurses in two Tennessee hospitals and found that more than half, 56 percent, had experienced violence in the previous year and 29 percent of those incidents went unreported. Only two of the 55 nurses said they felt safe all the time at work, and 73 percent said being assaulted is part of the job.

While the sample surveyed is small, the results support other anecdotal evidence that nurses have started to view violence as part of the job and that some don't report incidents unless they need medical attention.

"It's sad that the abnormal becomes normal," said Mary Alexander, MSN, RN, director of emergency services at Gnaden Huetten.

Since Reed's attack, she said, everyone has become more cautious. When patients come in who have been using alcohol or drugs or who have been involved in any kind of resistance with police, Alexander recommends they be put into four-point restraints.

When someone is attacked, she said, it's important for a hospital to offer follow-up support with debriefing sessions and the vigorous pursuit of criminal prosecution. Alexander said she has worked in hospitals where people didn't want to prosecute a violent patient because they felt too guilty about sending someone to jail.

Nowakowski encourages nurses to report incidents and document violence. There's no one best way to prevent these outbreaks, she said. Hospitals are using more physical barriers, electronic surveillance, security guards and metal detectors, but, she said, training is the first line of defense.

Defense strategies

Many hospitals now require staff members to attend violence management training, where they learn how to diffuse potentially dangerous situations and, if need be, how to defend themselves.

A training film may have saved Lori Cline, MNSc, RN, from serious injury. Cline, now on the faculty of the University of Arkansas for Medical Sciences College of Nursing, worked 15 years as a psychiatric nurse. Three times, she had been attacked by children with kicks, punches, bites and, once, scratches severe enough to require medical treatment. But she was unprepared when an 80-year-old Alzheimer's patient tried to strangle her.

The woman had no history of violence at her nursing home, but had been agitated. Cline thought she was asleep for the night and leaned over the bed to check her breathing. But the woman wasn't asleep.

"She sat straight up in the bed and put her hands around my neck and started choking me," Cline recalled.

Fortunately, Cline had been through a violence prevention training course and remembered a film that demonstrated how to release yourself from a strangling grasp. Cline slipped both her hands between the woman's hands and applied pressure on the inside of both her attacker's wrists. That move gave her the leverage to break the woman's hold on her throat and call for help.

Cline believes the statistics don't begin to show the extent of violence in the nursing profession today. Threats of violence, verbal abuse or sexual harassment and spitting create a dangerous, stressful work environment. She finds it disturbing to have to tell nursing students what they'll endure.

"I look out at this sea of faces out there, and I have to tell them that no matter where they'll work, there's a possibility of being attacked," Cline said. "It makes me sad."

Cline believes hospitals aren't doing enough to keep staff safe. Nurses need better training and support in the form of security guards and devices. She blames staffing shortages for increasing the risks to nurses.

"If I don't have anyone to call for help on my side of the ward, my chances of getting more serious injuries grow," she said.

A maddened crowd

Others blame the increase in violence on an increasingly violent society.

"If you have a violent patient, you have a violent patient," said Dorel Harms, vice president professional services, California Healthcare Association, a trade group for hospitals. "It doesn't make any difference how many nurses are there."

Paula Eddy, RN, nurse manager of the emergency department at Highland Hospital, part of the Alameda County Medical Center in Oakland, Calif., points to the shortcomings of an overcrowded health care system for the increasing violence. Her department has seen a 10 percent increase in patients this year.

"People are uninsured and their numbers are growing daily," Eddy said. "They use the emergency department as their doctor. People get angry because they have to wait. You can't have family members with you because there's no room for them. I absolutely understand why they're unhappy."

The department has a low turnover rate of nurses, Eddy said, and that means a seasoned staff that understands how to handle the anger. The county hospital also has sheriff's deputies and security guards on the premises.

Beefing up security

Next year, the department, housed in a 6,000-square-foot space originally designed as a clinic, is moving to a new 26,000-square-foot facility. That new location will have many new security features, including a system of surveillance cameras. The doors will have key access cards.

Gone are the days when visitors and patients could easily come and go at a hospital.

As a preventive measure, Kaweah Delta Hospital in Visalia, Calif., like many hospitals nationwide, has been increasing security.

There's zero tolerance for abuse or threats of abuse against any employee, said Kristine Yahn, MBA, RN, senior vice president of patient care and chief nurse executive.

"If a patient is continually acting out, we will have them removed from the facility," Yahn said. "We'll call the police. The boundaries get drawn pretty early if anyone gets out of line."

Security guards are in the emergency department 24 hours a day and, six months ago, the hospital shortened visiting hours.

When they end at 8 p.m., a newly installed locked door closes off access between the emergency department and the rest of the hospital. At one point, Yahn said, the hospital installed glass partitions in the ER, but later removed them.

"Most people who come in the door are not coming to commit violence," Yahn said. "I just don't think we can turn a hospital into a prison."

A nurse can sense when a patient might act out, Yahn said, when the person is being uncooperative and the body language is threatening. Yet, sometimes, there is no way to predict pending violence. Recently, a female patient decided to barricade herself in her room. She slammed the door into a nurse manager and gave her a black eye.

"I hope our staff knows we're going to support them," Yahn said. "Sometimes, I think the staff tries to work things out on their own for too long."

That tendency of nurses to go it alone can be a big mistake. "You never want to do anything alone," said Charles, who gives violence management training seminars.

Nurses and doctors need to learn to act early and decisively to control patients. They need to call for assistance and not be afraid to display force if they can't calm a patient. "When people get hurt is when they waffle," Charles said.

Two years after Reed's attack, she still thinks about being hit, especially if a psych patient has been brought in and people are screaming. She's more cautious now, but she tries not to let her experience change the way she treats people. Her physical injuries healed and her attacker did go to jail.

"He was sentenced to three months," Reed said. "Not long enough."

Contact Donna Hemmila at dhemmila@prodigy.net