Guest Blog by Mathew Keller, RN, JD. Reprinted with Permission from The American Association of Nurse Attorneys (TAANA)
The forcible and violent July 26th, 2017 arrest of Utah nurse Alex Wubbels was a proverbial shot heard around the nursing world, provoking national media attention and a visceral reaction of support for nurses culminating in national campaigns to #EndNurseAbuse (ANA), #STAMP (stop assaults against medical providers, Show Me Your Stethoscope), and initiatives to escalate assaults in medical facilities to felony levels (NNU and other nurse unions).
But how did we get here? Statistics show that anywhere from 13 to 82 percent of nurses experience physical assaults each year, translating to a Department of Labor estimate of 22,250 to 80,710 incidences of physical assault in healthcare facilities in 2011. Indeed, there were several instances of violence in healthcare around the same time as the Wubbels assault that were perhaps also deserving of a national spotlight: In May, a nurse in Illinois was taken hostage at gunpoint and raped/beaten for 3.5 hours; in June, Massachusetts nurse Elise Wilson was brutally stabbed by a patient; and a month before the Wubbels assault, a former employee of a New York hospital gunned down a physician and wounded several others.
Given the frequency with which these instances occur, it’s often not a question of whether or not a nurse will experience an assault, it’s when. So why isn’t more being done?
Perhaps a better question is, what can be done?
A review of the research presents a somewhat cynical view. In a New England Journal of Medicine literature review, James Phillips, M.D. found that:
The most recent critical review of the literature in 2000 identified 137 studies that described strategies to reduce work-place violence. Of these studies, 41 suggested specific interventions, but none provided empirical data showing whether or how such strategies worked.
Phillips goes on to describe the lack of evidence showing the efficacy of metal detectors as well as training programs, two commonly proposed interventions, in reducing workplace violence.
Despite their popularity amongst many in the profession, there is also a lack of evidence showing that felony laws for assaults in healthcare settings are effective in preventing workplace violence, as well as ethical concerns from some corners regarding reporting patients to law enforcement. However, such laws may get at the heart of a perhaps larger issue: a culture that accepts workplace violence as simply “part of the job” or that blames nurses for the violence perpetrated against them.
This culture is reflected in estimates that only 30% of violence incidents against nurses are reported, with nurses relaying that they fear retaliation, a lack of support, or simply that there will be no response from hospital administration; that they have not been trained on the reporting process; or that they are simply too understaffed (often a precipitating factor in workplace violence) and don’t have the time to report. Indeed, administrative support may be one of the larger factors in preventing instances of workplace violence.
Other creative solutions may prove fruitful in the future as well. For example, the VA has implemented a system which flags patient charts if they have perpetrated incidents of violence. Such patients may be put on a remedial plan where they must be escorted by security while on premises, may never be alone in a room with a provider, or can only be seen during certain hours.
As always, more research is needed. But one thing is certain: as nurse Wubbels found out, nobody else is going to take a stand for us. So when the spotlight hits, it’s on us as a profession to act together and seize the initiative to move the ball forward. See the below case study for such an example.
Case Study: Minnesota Passes Violence Prevention Against Healthcare Workers Law
In November 2014, a patient at St. John’s hospital in Minnesota attacked eight nurses with an IV pole, with one nurse suffering a collapsed lung. The incident was caught on surveillance film which was later released, gaining widespread local coverage as well as some national coverage.
Recognizing the opportunity, nurses in Minnesota teamed up with legislators and local law enforcement in an attempt to pass a comprehensive workplace violence prevention law requiring the following:
- Healthcare facility establishment of a Safety Committee that develops incident/preparedness plans
- Incident/preparedness coordinated with and given to local law enforcement
- Annual staff training on violence reporting, de-escalation, violence prevention plan
- Statewide, annual reporting to the Minnesota Nurses Association regarding incidents violence
- NO interference with employees who wish to contact LE to report violence/press charges
Initial efforts were strenuously opposed by the Minnesota Hospital Association on the grounds that legislation would limit local hospital flexibility and cost too much money. The Hospital Association countered with a bill that would raise assault against healthcare workers to a felony level.
Nurses and their allies were able to overcome these objections on the strength of collective and individual efforts at the state capitol (including powerful nurse testimony regarding experiences of violence) as well as the momentum of media coverage. In 2015, the law was codified as MN Statute 144.566.
There continue to be issues with the law, including the following:
- Many nurses, facilities, and managers unaware of requirements
- Definition of incident of violence: “Act of violence” does not technically include verbal assault
- A $250 fine may not be enough to induce compliance
- If facility is not dedicated to a zero-tolerance philosophy, how effective will the law be?
- Media attention on an individual instance of workplace violence goes a long way to raising awareness of the issue and it behooves the profession to take advantage of such opportunities
- Partnering with law enforcement is an effective tool for lobbying as well as key to addressing incidents of violence at the local facility level
- Personal stories were much more persuasive than statistics at the Capitol
- Facility/administration buy-in to zero-tolerance and violence prevention is all-important to true violence prevention efforts