For registered nurse Jessica Berger, it was a "normal" morning shift at the high-risk psychiatric unit in Quincy, Mass., where she worked: just three staff members, including herself, responsible for the entire floor. Once again, Berger found herself assigned to a patient held at the facility after threatening to kill his girlfriend. During previous nights, he had raised a blanket over his head, capelike, mimicking "Dracula." He had also made menacing sexual comments toward Berger, and refused to sleep while she was on shift.
Although Berger told her supervisor she was concerned the patient might attack her, her fears were dismissed. Instead she was told to escort him to a smoking room at the dead end of an isolated corridor.
"I was opening the door when he threw a blanket over my head and bashed me against the wall," Berger recalls. "He had me on the ground, pummeling me and smashing my face into the floor." She screamed, but no help came. The patient began strangling her. "That's when I started to say the Lord's Prayer," says Berger. Just as she was about to lose consciousness, another patient -- a schizophrenic who'd been locked in his room for weeks -- came to her rescue. "Otherwise," Berger says, "I'd be dead."
Berger, a petite woman in her 30s, took weeks to recover. When she finally returned to work, she made a routine request to have a security guard assigned to the high-risk unit. The notion was dismissed: "That's your trauma talking, Jessica," said her supervisor. "You've gone off the deep end."
Bizarre as it was, the assault on Jessica Berger is not an isolated incident. Nationwide, workplace violence is a job hazard increasingly familiar to registered nurses -- from frontline E.R. and surgical nurses to pediatric and home-care workers. According to the National Institute of Occupational Safety and Health, each day more than 9,000 nurses and healthcare workers are injured or verbally or physically attacked on the job.
The American Nurses Association, which has been tracking assaults on R.N.s, says that reports of workplace violence from ANA members have been steadily increasing over the past few years. The Occupational Safety and Health Administration confirms the rising rate of assaults, and says that the risk of job-related violence against healthcare and social workers is presently higher than for any other field.
Hard numbers on the trend are hard to come by. The Bureau of Labor Statistics shows workplace assaults on nurses holding fairly steady over the past decade, but researchers note that those numbers only include nurses who lose work time thanks to an injury and report it to their employer, when many nurses do neither. OSHA's own guidelines on preventing violence against health workers express great "concern" about "the likely underreporting of violence and a persistent perception within the health care industry that assaults are part of the job."
The trend is old news to R.N. Debbie Corning. During 11 years as an intensive care nurse, Corning has been clawed, punched, choked with a stethoscope and threatened with death too many times to count. Twelve weeks ago, at the Crescent City, Calif., hospital where she works, a patient kicked Corning in the spleen and sent her flying across the room. Reeling from the attack, the R.N. wound up being treated in her hospital's own E.R. unit.
"Today, there's road rage, desk rage, office rage," says California Nurses Association president Kay McVay. "The social fabric is breaking down. Healthcare workers are feeling the effect. With our short-staffed units, it's more difficult to face, and control, an attacker. It's no surprise that the assault rate is rising."
Indeed, in a recent seven-state study carried out by the Colorado Nurses Association Task Force on Workplace Violence, over 30 percent of registered nurses surveyed said they had been assaulted on the job -- mostly by patients. These nurses, queried in Alabama, Colorado, Delaware, Hawaii, Illinois, Kansas and Missouri, reported attacks with everything from scissors to chairs, urinals, knives and guns. And while the vast majority of attacks on nurses are not fatal, last April, in front of colleagues, Port Lucie, Fla., nurse Alda Ellington was brutally murdered by a patient admitted for hospital care.
Such violence has at least partly contributed to an exodus of nurses from their chosen calling, compounding what University of Chicago public health experts have warned will soon be a "terrifying" shortage of R.N.s. A recent study sponsored by the National Institutes of Health revealed that one in three nurses under 30 -- and 20 percent overall -- plan to quit their jobs within the next year.
And while workplace violence against doctors is also on the rise, the lion's share of assaults hit R.N.s. A four-year Bureau of Justice Statistics study showed that between 1992 and 1996, 69,500 nurses were assaulted, compared with 10,000 physicians -- nearly seven times as many. And while the legal penalty for harming an M.D. can be stiff, many states offer little deterrent when it comes to attacking nurses. "In the state of Massachusetts, it's a felony to attack an E.R. doctor," workplace violence expert Marilyn Lanza points out, "but only a misdemeanor to assault a nurse."
Despite the epidemic of assaults against the country's 2.5 million R.N.s, hospital violence is still little known to the general public. It's an ugly problem that's unpleasant to confront -- and one that many healthcare institutions would just as soon keep under wraps. "Over 80 percent of all assaults on R.N.s go unreported. It's rampant," says Lanza, whose decade of research on the subject underlies the Occupational Safety and Health Administration's current voluntary safety guidelines.
In general, hospital administrators reportedly have little interest in investigating assaults, which they know will mean high costs in insurance, workers' compensation and public relations, Lanza says. All too often, nurses refrain from reporting assaults for fear of being blamed or losing their livelihood. And although thousands of assaulted R.N.s suffer from nervous flashbacks, terror, insomnia and other symptoms of post-traumatic stress syndrome, they often receive little if any help in dealing with psychological damage. Indeed, those who do report it are often told that violence against them is "part of the job."
"I've changed. I'll never be the person I used to be," said one California nurse whose jaw and leg bone were shattered during an assault. Like many, she has felt stigmatized by hospital management after the attack, considered a "defective" worker. Her psychiatrist, in fact, warned her not to tell management that she sought counseling after the attack if she wished to keep her job. "Don't tell them you were in therapy or on psychiatric medication, because they can fire you for it," he told her. She believes the warning was not unfounded.
Rick Wade of the American Hospital Association concedes that for hospitals, knowing that an employee is getting psychological treatment can be "one of the toughest situations human resources can face." With regard to psychologically injured workers, Wade says, "hospitals are in a funny position. They're there to encourage employees to seek counseling and help for stress and other 'on the job'-related problems. But they also have their own responsibilities about patient safety. An employee can begin taking medication for a legitimate reason, and then become addicted. Let's look at reality. The medication's effect varies from person to person. If the employee goes back to work -- does the hospital know what their employee is really doing?"
"For an assaulted and traumatized nurse, it's a Catch-22 situation," responds the CNA's Allen Fitzpatrick. "Why would you seek help -- or notify your employer that you're getting help -- if you're jeopardizing your job?"
Though most R.N.s who are assaulted are women -- the nursing workforce is itself over 95 percent female -- Lanza's studies show male nurses are hardly immune to assault. In workplaces that employ both male and female nurses, Lanza says, they're being attacked at equal rates.
San Francisco R.N. George Ouellette doesn't need to be convinced. A burly, 25-year veteran psych nurse, Ouellette has been attacked numerous times on his unit. The R.N.'s powerful 6-foot-2 frame and professional track record challenge the myth that nurses are attacked mainly as a result of gender, their own carelessness or their "victimlike" demeanor.
"On our unit, we've had a couple of psychotic ex-professional boxers who were paranoid about being attacked," he recalls. "They saw the biggest person around -- in this case me -- as their most likely attacker." Jumped from behind on three different occasions, Ouellette has suffered cuts, contusions and severe back injuries that have left him incapacitated for six months at a time.
"Like a football player, I got torque injuries, pressure injuries," says Ouellette, adding that he stays with the high-risk unit because he is dedicated to the patients there. Ouellette believes management often sets up a false "us or them" conflict, pitting the safety of health workers against a distorted version of patients' rights. But the consequences of lax protection for nurses -- tension-filled wards, scared and resentful staff -- won't benefit patients.
Psychiatric patients are not the only ones who can pose a violent threat. Stroke or brain tumor patients may lash out. So may those experiencing adverse drug reactions. Elderly and Alzheimer's patients forced to change living environments, or post-surgery patients coming out from under anesthesia, can also become disoriented and belligerent, as can AIDS patients in delirium.
And not all assaults are by patients. Nurses are also attacked by other staff, and by patients' family members. Emergency room nurses endure the greatest number of assaults -- the average E.R. nurse is exposed to physical assaults up to five times a year, with 24 percent of the assailants using weapons. E.R. nurses face patients arriving fresh from crime and accident scenes who are often angry, frightened or desperate for help. E.R. patients and their family members may become demanding, insisting on immediate care or impossible-to-obtain information. Economic, interracial and personal tensions also flare in the E.R., blowing up in the faces of frontline staff.
CNA president McVay recalls being an R.N. on a tense night shift when a group of Hells Angels brought in a young member injured in a motorcycle crash. Distraught, the group's leader warned medical staff that they had better save the patient's life, or "pay the consequences."
"There was nothing we could do," McVay recalls. "The kid's chest was smashed." Shortly thereafter, the young man died, and the Angels rampaged through the unit. Nurses were forced to run for cover as the furious bikers smashed equipment and hurled shelves of supplies to the floor.
When hospitals are forced to investigate causes of workplace violence against R.N.s, says Marilyn Lanza, too often the nurses themselves are held responsible for the incident, in a sort of "blame the victim" response. Lanza and other experts insist that's exactly the wrong place to look: "It's not individual R.N.s that are responsible for the high incidence of assault, it's specific working conditions."
A major source of the violence, experts agree, is the rapidly declining nurse-to-patient ratio at most hospitals. The result of massive healthcare budget cuts, it's one of the most highly charged controversies in nursing care today. "Our unit's down to a skeletal staff," says one Pennsylvania E.R. nurse. "There's no one to stock, no nurses' aides, not even a secretary. When I'm handling those tasks, I can't be at the bedside. I can't do my job." In understaffed units, resentment breeds, and R.N.s may end up turning on one another. Nurses find themselves under pressure to enter into situations they can't handle -- often at their own peril.
"It's pretty simple," says Jessica Berger. "If you've got a patient who's been admitted for homicidal ideation (imagining killing someone), you need to hire a guard on the floor." Both hospital administrators with whom Berger sought to speak after her assault refused or canceled their appointments. Like many other assaulted R.N.s, Berger eventually left the high-risk unit where she was attacked. "I loved working on psych unit and would have stayed -- except for what happened," she says. Instead she retrained as a surgical nurse.
Interestingly, librarians, whose unions have demanded training in how to deal with violent patrons, may have more background in managing workplace violence than nurses do. Such preparation is nearly absent from most R.N. orientation programs, and increasingly nurse-advocacy groups are demanding it.
Ironically, solutions to curb workplace attacks on nurses already exist. "There's no need to reinvent the wheel," says Lanza. "You increase staff. Form rapid response teams. Enforce employee safety training. Put security guards on high-risk units."
Why, then, are so few hospitals choosing to do so? "The fact is, nationwide, hospital management has made staff safety a "nonpriority," says Alan Fitzpatrick, a nurses union negotiator and R.N. A high-ranking official from Catholic Healthcare West hospitals told Fitzpatrick point-blank what scores of U.S. administrators have put into practice: "The bottom line is, it's cheaper to pay workers' compensation for nurses than it is to solve the problems causing the injury." Despite a plethora of attacks on health workers, in many states, including California, only hospital emergency rooms are required to maintain a 24-hour security officer.
"Frankly, I know that management doesn't care if I end up with my neck broken and in a wheelchair," says one disabled Bay Area R.N., who requested anonymity. "The officials who make these decisions know absolutely nothing about what's going on on the floor. They never see any of it."
Not so, says Shareen Salem, chief nurse executive at St. Mary's Hospital in San Francisco. She says administrators are very aware of the need for safety precautions. "Managers and coordinators make rounds all the time. We know exactly what's going on," she says. "We have alarms. They all go through training. Safety issues are well taken care of." Nevertheless, employees in the hospital's high-risk units have been frequently battered by patients, with one permanently disabled and another requiring six months' recovery time.
And while unionized R.N.s, such as those at St. Mary's, have a chance at protection, home-health workers and other nurses not represented by unions are out of luck, says Marilyn McGreer, herself a nonunion per diem R.N. working in the San Francisco Bay Area. McGreer recalls a recent attack by a "Herculean" psychotic patient. "It took 10 staff people to take him down. Someone called for me to grab his leg, but I have to admit," she says with a touch of embarrassment, "I hesitated. Union nurses have someone to advocate for them and back them up if they report an assault. We don't. If anything happens to us, we have to keep our mouths shut. If you don't, your work will dry up."
Administrators have responded to complaints of violence by creating "risk management" committees, currently in vogue at hospitals from San Diego to Savannah, Ga. But they may not be pro-employee. While hospital honchos say the committees are set up to assess and eradicate workplace hazards, some nurses serving on them report otherwise: An East Coast nurse says she was honored, at first, to be asked to serve on her hospital's risk management committee. But she became outraged when the committee chairman labeled a group of battered nurses -- some of whom had suffered multiple assaults -- "repeat offenders" who were "costing the company money." Rather than insisting the units be made safer, he strongly recommended the nurses be fired. "They were just interested in good public relations and the 'risk' of costly litigation," says the R.N., who quit in disgust.
In fact, healthcare administrators are finding that in small but rising numbers, R.N.s assaulted on the job are suing their employers. And nurses unions are also linking up with supportive legislators to push through laws like the 1999 California "whistle-blower" bill, which made it possible for R.N.s to report assaults and not jeopardize their own jobs.
Another California bill signed into law last year will assess safe staffing ratios in acute-care hospitals across the state. Nationwide, nurses unions are striking for safe staffing ratios in contracts. Nurses and their unions are also lobbying on the federal level to make OSHA's now-voluntary workplace safety guidelines mandatory.
Meanwhile, the Massachusetts Nurses Association is lobbying hard for state legislation that would make it a felony to assault nurses on the job. As part of this effort, the MNA produced an "Anti-Assault Yearbook" complete with graphic photos of assaulted R.N.s, and distributed it to lawmakers to jolt them out of their complacency.
"Employers have said that if you're a nurse, getting injured on the job should be expected," said R.N. Leslie Sullivan of the MNA. "Nurses have heard it so much that they have even started to believe it. Well, no, getting beat up isn't part of your job. It doesn't have to be."
But it may be too late for the nurses who've already been driven by workplace violence to abandon the field. "Getting hit in the jaw was one thing; my co-worker being gunned down was another," says a Florida nurse who recently hung up her scrubs to become a bartender, at one-fifth her former salary. "I'm burned out. My patients deserve better than that."
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