Cindy Zolnierek, Ph.D., RN, still remembers her first day as a newly minted hospital nurse. She was at the nurses’ station when a patient reached over the counter and swung a fist at her. Zolnierek backed up just in time.
Zolnierek is now CEO of the Texas Nurses Association and sees clearly how she is hardly alone in encountering a violent patient. A 2016 study by the Texas Center for Nursing Workforce Studies Advisory Committee, commissioned by the Texas Legislature with backing from the Texas Hospital Association and TNA, found that nearly half of the state’s nurses had experienced workplace violence, including verbal abuse, sexual harassment and physical abuse. But just 40 percent had reported it.
More than half of American hospitals said last year that they saw an uptick in violent acts against staff over the past 12 months, according to the American Society for Health Care Engineering’s 2018 Hospital Security Survey.
Hospitals face increasing safety and security challenges, including keeping patient data away from hackers; stopping trespassers; ensuring that patients don’t wander off; and preventing campus car thefts and break-ins, according to the 2018 ASHE survey.
Many hospitals are beefing up security, including investments in video surveillance, technology to electronically lock down facilities, panic buttons and visitor management systems that require sign in, an ID and a visitor badge, the survey said.
Creating a safe workplace has become a major priority. Although it’s a felony in Texas and many other states to attack emergency health care workers, hospital workers are four times more likely to experience violence than other private industry employees, according to several studies.
In 2017, the Texas Legislature, with support from THA, passed House Bill 280 by Rep. Donna Howard (D-Austin) providing grants from the Texas Department of State Health Services to hospitals instituting innovative solutions to reduce verbal and physical abuse against nurses.
Administrators have a big stake in proactively addressing the issue, especially at a time of workforce shortages. Nurses, the group most often targeted for violence, and other hospital workers will choose to work where they feel safe and supported — environments that tend to boost morale and, by extension, the quality of care.
Solutions proposed by seven hospitals or hospital systems in the DSHS grant program currently are being tested. Presentations of outcomes for the pilots are due in late 2019 or early 2020.
Needs, Approaches Vary
“The world is not the place it was 20 years ago,” said Gordon Gillespie, Ph.D., RN, a professor and associate dean for research at the University of Cincinnati College of Nursing.
Gillespie once worked as the only male nurse in the emergency department and was asked to handle the disruptive patients, he said. He experienced at least 100 aggressive incidents, including being hit, bit, pinched, spat upon and groped.
Many nurses consider aggressive behavior a part of the job and frequently don’t report it, Gillespie said. That’s starting to change as hospital administrators, lawmakers and others focus on ways to create a safer health care workplace.
Texas hospitals are partnering with law enforcement agencies, employing security contractors and working with regional trauma organizations to enhance their safety and security.
“I’m a real advocate of preventing the violence,” Zolnierek said.
There is no one-size-fits-all approach, she added. “I’ve worked in hospitals that have police officers and police dogs in the ER. But there are different needs and resources,” depending on the facility and the community.
Smaller hospitals might contract with a local security firm or hire off-duty peace officers; larger facilities might have an in-house police department.
Not only has health care worker violence been a topic in recent Texas legislative sessions, it also emerged again this year. Rep. Howard, an Austin nurse, also sponsored House Bill 1146 this session as a way to prevent violence. It would require health care facilities to develop a violence prevention plan, workplace safety training and a system to investigate violent acts, but the legislation died in committee in early May.
“THA member hospitals have made the prevention of workplace violence a priority in their facilities and THA has proudly supported continuing those efforts in the legislative and regulatory arena. We’ve worked to enhance penalties on violence in an emergency room, support collection of data to assess the extent of the workplace violence and engaged with the legislature on solutions like those proposed in Rep. Howard’s HB 1146,” said Jennifer Banda, J.D., THA vice president of advocacy and public policy. “We look forward to continuing those efforts over the interim and next session.”
One thing that hospitals agree on, regardless of their size, is the need to report aggressive or harassing behavior, including bullying and inappropriate touching.
A Big Hospital Model
Parkland Health & Hospital System, the name for the Dallas County Hospital District, was one of the first in Texas to employ an in-house police force, 35 years ago. Having a 24/7 law enforcement presence in the sprawling 870-bed public hospital is a key security tool.
“What we’ve seen here at Parkland is an increased number of psych patients because of the closing of psychiatric hospitals,” said Dallas County Hospital District Police Chief Marlin Suell. The influx is the result of the recent loss of more than 400 inpatient psychiatric beds in North Texas, Suell said.
In May 2018, Parkland responded to the crisis. It expanded its police presence to include a Law Enforcement Intervention for Environmental/Patient Safety, or LIFE, team to provide immediate assistance to clinical staff treating behavioral health patients “who may come in aggressive or have aggressive tendencies,” said Capt. Anetta Linson, who briefly supervised the LIFE officers.
LIFE officers are specially trained in crisis intervention, mental health conditions and managing aggression. They seek to be a calming, reassuring presence to patients and visitors as they try to pinpoint what’s agitating them.
“I treat them like I would my own loved one. I just listen,” said Linson, who has been at Parkland for 15 years. “A lot of times, they just want to … know they’re actually being heard and not being brushed off. I will talk to them like a cousin or a sister … and say, ‘Let’s slow down a little bit. I’m just here to listen to you.’”
LIFE team members don’t wear traditional police uniforms; instead they wear khaki pants and black polo shirts. The goal of the team is to build rapport with the individual. One of the LIFE officers is a gifted singer who will sometimes sing to patients to soothe them, Suell said.
“The ultimate goal is to help the patient,” he said.
The team has had an immediate impact. The number of psychiatric patients taken from Parkland to jail dropped 28 percent from May to September 2018, Suell said.
On any given shift, Parkland typically has 12 to 14 officers on duty, with one or two from the LIFE team. The police force also provides two officers per shift to nearby Children’s Health, Dallas.
Officers at Parkland respond to more than 300 calls a day for service. The officers closely work with the human resources department, but getting employees to report attacks is challenging, Suell said.
“We preach and teach to the nursing and medical staff — if you see something, say something,” he said. Employees can do it anonymously, but Suell said odds are 50-50 they’ll report.
It’s also difficult to get employees to report patient violence when the person is impaired by drugs, mental illness or dementia. The staff member may think that because the patient didn’t intend to strike out, it’s OK. It’s not.
“They shouldn’t be abused by anyone,” Suell said.
In April, Parkland became one of seven Texas hospitals to receive a Texas Center for Nursing Workforce Studies grant to support innovative approaches for reducing verbal and physical violence against nurses. Parkland received the largest award, $325,000, and will use it to raise community awareness, train staff, enhance peer support programs and develop best practices, among other initiatives.
“If You See It, Report It”
CHRISTUS Santa Rosa Health System, which operates five hospitals in the San Antonio area, conducts active-shooter tabletop drills and presentations to hospital departments. Live drills can be intimidating or frightening for some staff, visitors and patients said Mark Hart, the system’s regional director of security.
CHRISTUS promotes an ongoing culture that a hospital safe environment is a shared role. “Safety and security is everyone’s responsibility, not just security’s,” Hart said. “If you see it, report it.”
As a community partner, The Children’s Hospital of San Antonio, which is part of CHRISTUS, facilitates the Downtown Security Network coalition comprised of the lodging, financial, retail and health care industry. This coalition also includes the San Antonio Police Department and local city council districts in the downtown San Antonio area which meets every two months. The primary benefit of this coalition is to promote and share safety and security “best practices” and to mitigate issues and concerns shared with the group. Guest speakers provide beneficial presentations to help members better manage their safety and security programs. The San Antonio Police Department conducts sessions on work environment and personal safety, Hart said.
In addition, CHRISTUS partners with STRAC (South Texas Regional Advisory Council for Trauma)to provide and support health care system communities in South Central Texas with valuable training, preparation and response related to disaster events and community support.
Each month, Hart said, various disciplines of the CHRISTUS Santa Rosa Health System Safety and Emergency Management Committees take turns to share safety tips, and each year, hospital staff are assigned online education to address workplace violence, with reminders to report incidents. Like Parkland, there’s an anonymous hotline.
“Our organization has “zero tolerance” for any form of threatening behavior or violence in the work place,” Hart said.
His team trains staff on how to deal with tense situations by using de-escalation techniques. If security is called, Hart’s officers are trained to de-escalate the situation and calm the individuals, using some of the same techniques as Parkland’s LIFE team.
Other Prevention Tools
Son Chae Kim, Ph.D., RN, a Texas State University professor at St. David’s School of Nursing in Round Rock, has developed a tool for identifying patients who could become violent. Studies in a U.S. hospital and 25 long-term care homes in Canada found that her Aggressive Behavior Risk Assessment Tool, or ABRAT, was reliable, useful, and easy-to-use.
Hospitals can assess arriving patients using ABRAT and obtain a violence risk score based on such factors as whether they’ve previously been violent, are confused, agitated, anxious or shouting.
Kim, who serves on a state task force on workplace violence against nurses, believes such preventive strategies can reduce most aggressive acts. Patient violence cannot be eliminated entirely, but Kim hopes that focusing on high-risk patients proactively may prevent violent acts as well as reduce violence-associated injuries.
She hopes to see the tool become part of the electronic health record and be used regularly, especially in one of a hospital’s most violence-prone places: the emergency department.
Gillespie, the Cincinnati nursing professor, is a fan of involving registration clerks and triage staff in identifying patients who could become violent. Those staff also can communicate early with clients and “have them become part of the solution,” he said.
“The registration personnel are the perfect people to pick out who’s going to act out,” Gillespie said. For example, registration staff can read a script that says something like, “‘Thank you for coming in. We are committed to a culture of safety, so if you see anything that’s not safe or anything that’s abusive or loud, let us know.’ When people hear that message they will think, ‘If I act out, someone may be reporting me.’”
Some hospitals will designate patient gowns of a certain color to subtly identify potential aggressors.
To change outdated thinking that “snitches get stiches,” Gillespie suggests rewarding staff for reporting incidents. Some hospitals tie raises to reporting or provide a thank you note or other small forms of recognition, he said.
In addition, he suggested having “awareness days” to remind staff of best practices. Having workers sign a poster, saying they are committed to treating everyone with respect, is a good reminder, he said.
When dealing with an aggressive patient, he suggests saying something like, “I want to help you, but I can’t help you and feel safe when you’re yelling.” Having the person move to another space can help because “their brain isn’t focusing on yelling” any longer, Gillespie said.
“If you’re the only one there, you need to get help. You may need an intervention,” he said. “It’s not about winning the argument. It’s about going home alive.”