Violence at Work

ER (TV series)
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This past week our local public radio station, KUOW, ran a series on workplace safety in Washington state. For those of you not familiar with Pacific NW-specific high-risk jobs, these include loggers and commercial fishermen, including scuba-diver harvesters of geoducks (world’s largest clams/highly priced aphrodisiac in China and Japan—when you see a photograph of one you’ll understand why). Then there are the non region-specific high-risk jobs of police officers, corrections officers and security guards.

But the highest risk job category of all in Washington state is that of nurses’s aid, followed closely by RN. The highest risk place to work is Western State Hospital. Nurse’s aids, nurses, and other frontline workers at Western State Hospital are assaulted on the job 60 times more than the average worker in Washington state. Western State is the largest psychiatric facility west of the Mississippi and houses criminal defendants when they are found mentally incompetent to stand trial.  So it is in effect a combination correctional and psychiatric facility with highly volatile and violence-prone patients.

Nationwide, nurses working in Emergency Departments (EDs) are at high risk for workplace violence, generally in the form of physical violence from patients, family members or other visitors. EDs and urgent care centers are where people go for violence-related injuries stemming from domestic violence or gang violence. EDs and urgent care centers are where people go who are intoxicated or having acute psychiatric emergencies—usually accompanied by police. Waiting room overcrowding, long wait times to be seen by a provider, lack of visible security systems, lack of staff training on de-escalation techniques, and understaffing, all contribute to increased risk of violence. Reports from around the country indicate a steady increase in ED violence, most likely stemming from weakening primary care safety net services, forcing more desperate and frustrated patients into EDs for basic health care needs.

The KUOW episode “Violence in the ER” and the accompanying Seattle Times article “Most violent job in Washington? Nurse’s Aid” highlight ED workplace violence in Tacoma General Hospital in Tacoma, and Harborview Hospital in Seattle—the state’s two biggest hospital EDs. Tacoma General Hospital ED uses a metal detector at all times to screen patients and visitors. Harborview Hospital only uses a metal detector in the ED at night, and at other times security guards use a hand-held metal detector on patients and visitors they deem high risk.  Harborview Hospital administrators, like many for hospitals across the country, have chosen not to install permanent metal detectors for fear of slowing down emergency care. According to the KUOW report, on a recent Saturday night a man got into the Harborview ED with a backpack containing a large knife, two cans of pepper spray, a cap gun, and bullets.

Third behind ED and psychiatric hospital settings for workplace violence for nurses is home care/home hospice. Work in these settings is usually done solo, with possible exposure to domestic violence or drug activity.

The Occupational Safety and Health Administration (OSHA), the federal agency charged with ensuring safe and healthful working environments for US workers, has failed to issue federal standards on workplace violence in health care settings. So far, they have only published voluntary guidelines on this topic. California, Washington, Florida, Illinois, New Jersey, Tennessee, and Nevada have passed state laws requiring further protection for health care workers. For instance, in Washington state, all health care settings are required to develop and implement plans to protect employees from violence. State law now makes it a felony for anyone to attack a health care provider—including verbal threat of assault. Washington state law requires all health care settings to keep records of any violent act (including verbal threats) against an employee, patient or visitor.

According to Jeaux Rinehardt, president of the Washington State Emergency Nurses Association, the felony assault charge is mainly enforced for attacks on doctors—rarely for attacks on nurses or other health care providers. He also echoes many nurses around the country in stating that nurses are actively discouraged from reporting and documenting workplace violence by managers or hospital administrators. (KUOW News: Violence in the ER, 7-13-11)

I worked in home health in Richmond and Baltimore for seven years during the height of the crack cocaine epidemic of the late 1980’s/early 1990’s. I worked in a large downtown Baltimore hospital urgent care center for six years. If you have watched any episodes of “The Wire” that’s what it was like to work and live in Baltimore at that time. The worst thing that happened to me during those years was that an intoxicated patient peed on me during a pelvic examination right when we had a power outage. She got scared she said, so it’s not like she meant any harm. The urgent care center I worked for was well staffed, had excellent relations with the community it served, and had a visible, well-functioning security system. We had panic buttons we carried in our pockets at all times, but I never had to use it. All staff received regular training in violence prevention techniques.

By contrast, working at various community health centers in and around Seattle for 15 years, there were at least ten times when patients seeking narcotics verbally or physically threatened me. These clinics were usually poorly staffed, served large numbers of impoverished people, had no security systems in place, and did not have clear protocols or “pain contracts” for use of narcotics. I remember front desk staff calling for police in several of the cases, but I think in only one case was I encouraged to complete an Incident Report.

An aspect of workplace violence in health care settings I had not even thought of appeared as a spin-off of a KevinMD.com guest blog. In 2007 Patricia Allen, RN wrote “Violence in the Emergency Department and how to promote ER safety.” It is a short blog post, mainly advertising her book. What I found more interesting was a reader’s comment. Steve Parker, MD: “Here in Arizona, hospitals are gun-free zones. Most physician and healthcare providers will not carry their guns into the hospital. Risk of getting caught is too high.” I had to read his comment twice before I understood it, because it never occurred to me that health care providers would carry concealed weapons to work. I thought that was confined to really bad TV shows.

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