REPORT: September 2006

Preventing workplace violence

Faced with the constant threat of violence, RNs at some hospitals are taking action to protect themselves and their patients

by Mark Genovese

• Related article: Pressure by RNs wins policy at Shore Memorial

Assault leads to plan at Mount Sinai

In May 2005, an RN working in an adult psychiatric unit at Mount Sinai Hospital was assaulted by a patient for the second time in less than a year.

Although the patient was discharged the next day, the RN was left to recover from wounds that were emotional as well as physical. This incident prompted labor and management to begin a joint effort to improve protection of the unit’s staff and develop a more effective means of response for the injured.

Better preparation

“Patients on the Mount Sinai unit suffer from variety of chronic psychiatric diagnoses and are admitted because they pose a threat to themselves or others,” said Lucille Sollazzo, NYSNA nursing representative. “Such a potential for danger makes it crucial that staff be aware of potential for violence.”

The joint labor/management Safety Committee discussed how to respond to this need at its July 2005 meeting. The committee includes NYSNA members and representatives, nursing management, physicians, aides, and personnel from housekeeping, security, risk management, and employee assistance.

“The question before us was: How do we make our unit safer?” said Ida Bowman-Kelly, a clinical nurse working on the unit who is studying the case as part of her doctoral work and volunteered to take part in the project. A task force was formed to focus on the need for better planning, preparation, and training to reduce and manage such incidents in this unit.

“We enlisted a facilitator who conducted focus groups with the staff. We received several suggestions for environmental improvements.”

Suggestions included:

• Installing a partial unbreakable-glass wall at the nurses’ station.
• Providing RNs with personal warning devices that emit a loud sound when a pin is pulled.
• Replacing hard, metal wastebaskets with soft, plastic ones that won’t hurt anyone if thrown and
• Replacing bulky computer monitors with flat-screens, which are less likely to break.
• Installing mirrors near corners so staff can see if someone is hiding on the other side.

“We were very thorough. We tried not to overlook any detail,” Bowman-Kelly said. “We had security assess our furniture, as well as the patient rooms, for safety. If we found anything that was unsafe, management agreed to make the changes. It was a positive experience.”

There were also suggestions for operational changes:

• A safety manual was developed to help make risk assessment a daily part of the staff’s duties.
• All patients will be assessed for potential violence under physician supervision, starting in the emergency room and from admission to discharge.
• Staff were trained to listen for verbal cues, such as threats and challenges to staff authority. They also watch for non-verbal cues such as pacing, staring, and agitation.

Better response

Next, the task force developed a detailed plan on appropriate interventions to take when confronted.

“Staff was told to trust their ‘gut feelings,’ and to be proactive,” Sollazzo said. “They were told to not turn their back on an agitated patient, not approach the patient alone, and to be aware of a way out, making sure the patient was not between the nurses and the exit.”

According to the plan:

• Staff first apply verbal de-escalation techniques. If this fails, they use a personal safety alarm and call for help.
• Each employee has a role when an alarm is activated. Staff nearest the nurses’ station first call security, and then alert the rest of the staff.
• One staff member moves other patients away from the crisis area while other staff attend to injuries.
• The injured are accompanied to the emergency room by a clinical nurse manager.
• Documentation of the patient’s behavior is included in the incident reports.
• Arrangements are made for counseling for staff and patients.

Group training is an important part of the preparation. Management gave unit staff paid time off to attend an eight-hour crisis intervention training program and hired temporary staff to handle their shifts. “Management made a big commitment to this project and financed it,” Bowman-Kelly said.

The process of evaluating the unit’s safety procedures is ongoing, as is the training.

The broader picture

Adding to the frustration of the Mount Sinai RN’s second attack was the uncooperative response he received from the local New York City Police precinct. Officers refused his request over the phone to file a report.

“As has been the case for many other RNs over the years, police agencies often consider assaults on hospital personnel to be routine — just a regular hazard of the job,” said Patricia Kane, chair of the Legislative Committee of NYSNA’s Delegate Assembly. “This incident gave us further verification that the laws and the way they are enforced need to be changed.”

The Delegate Assembly this past spring approved a legislative agenda that would make it a felony to assault a nurse in the workplace.