“You know the sound a bowling ball makes, when it strikes the pins? That crash happened inside my head.”

Maureen Holder is describing the July 13, 2012 punch by a patient that, 20 years into her career as an ER nurse, changed her entire life. While waiting for a CT scan, Holder’s patient, a professional boxer with possible head trauma, needed a urinal. Radiology staff was delayed, security was busy handling a different patient, and her facility, St. Francis Memorial Hospital in San Francisco, had made staffing cuts the previous year, leaving her alone without the tech who might otherwise have been by her side.

Concerned with making her patient more comfortable, she quickly ran across the hall for the urinal. When she returned, her patient was off the gurney, with his back turned, falling. Holder reached out to help catch him, and with all the force of a pro boxer, he turned around and swung.

“I thought I had ruptured my eyeball,” she said. Holder turned out to have an orbital floor fracture underneath her eye, a nasal fracture, fractures in her cheek, a concussion, and a traumatic brain injury, all of which required two eye surgeries, one nose surgery, physical therapy, and chiropractic treatments. And the psychological wounds ran deep.

“I had counseling for about two years. I didn’t want to leave my house,” says Holder. Acupuncture and weekly cognitive behavioral therapy worked to curb residual trauma, but Holder still had lingering double vision, ringing in her ears, difficulty lifting, and post-traumatic stress disorder. She was unable to return to ER nursing. Her workers’ comp payments, a fraction of her original salary, eventually ran out, and she was essentially forced, for lack of funds, to move to Florida to live with one of her daughters and her family. Now, still experiencing vision and hearing issues as well as “a significant number of headaches every week,” she has returned to school at age 59 in an attempt to qualify for an office job.

“I am keeping a positive attitude and refuse to allow this to define me going forward,” said Holder. “But this has been life-changing, and I feel let down by the system.”

No job comes without some degree of risk. But for registered nurses, the dangers of being hurt by workplace violence while doing their jobs have not only reached unprecedentedly high levels, but are also now much more frequent. The U.S. Bureau of Labor Statistics reports that violence against hospital workers is almost five times greater than the average worker in all other industries combined, and the rates appear to be rising.

For too long, nurses have simply put up with the violence. Or, worse yet, they actually assimilated and normalized the violence as a routine part of their jobs.

Hospitals must be held accountable for having violence prevention plans and for practices, such as unsafe staffing levels, that directly contribute to the inability to stave off violent incidents, say RNs. They must also be prepared to deal with increasingly mentally unstable patients, and even their family members, due to the abandonment of psychological services across both the public and private health sectors. The healthcare industry’s plans to maximize profits by shifting the burden of care onto the patient’s family members at home may also be putting undue stress on both patients and relatives. By having a plan to prevent violence, employers will not only be protecting RN and other healthcare staff, but also other patients, families, and visitors.

Across the country, RNs are now demanding that hospitals and clinics take responsibility for creating and maintaining safe work environments – as employers across all sectors are required to do. Nurses in California in 2014 passed a law directing their state Occupational Health and Safety Administration to draft tougher workplace violence rules for hospitals and spell out what is required of them. Nurses in Minnesota, Florida, Texas, and Massachusetts are also trying to pass legislation requiring similar safeguards.

Holder said RNs understand that with the confusion and fear brought on by illness, medication, old age, and mental illness, there is some amount of risk that a patient will occasionally become agitated or lash out. She’s been bitten, hit, and scratched by “little old ladies,” but the scenarios RNs face now are wholly different. Today, nurses are constantly put in risky situations that should have been avoided in the first place had the hospital had better protections and policies in place. No staff should have been left alone with a boxer suspected to suffer from a head injury.

“We feel like we’re putting our life on the line for no reason,” said Holder. “Now I have a permanent injury. As far as having any kind of light at the end of the tunnel after all this, or [the hospital saying], ‘Here, we’re going to make up for your lost wages.’ There have been no phone calls [from administration], no card. They forget about you.”

Nurses rallying for workplace violence prevention

Ask a convention hall packed full of thousands of registered nurses, “Who has suffered violence at work?” and almost all will raise their hands. Violence comes in many forms, whether physical, verbal, or psychological, and can be committed by patients, their friends and family members, and even doctors, hospital management, and administrators.

“We’ve always considered workplace violence a critical issue,” said Karen Higgins, a Massachusetts RN and a copresident of National Nurses United. “Now, the concern is that the violence seems to be escalating.”

According to the Bureau of Labor statistics, violence against healthcare workers is, indeed, on the rise. In 2013, thirteen percent of the injuries and illnesses requiring health care and social assistance workers to miss workdays were the result of violence. That’s an increase, for the second year in a row, of 16.2 cases per 10,000 workers, up from 15.1 in 2012, according to the BLS. Again, these rates are almost five times greater than typical workers.

And those are just the recorded figures. According to the U.S. Department of Justice, Federal Bureau of Investigation, actual statistics regarding violence committed against healthcare workers may be even higher, due to a “likely under-reporting of violence and a persistent perception within the healthcare industry that assaults are part of the job. Under-reporting may reflect a lack of institutional reporting policies, employee beliefs that reporting will not benefit them, or employee fears that employers may deem assaults the result of employee negligence or poor job performance.”

In her 40 years as a nurse, Kathy Britten, RN, of Sanford Thief River Falls Medical Center, in Thief River Falls, Minn., has seen violence go unreported, due, she believes, to factors such as worries about getting fired and not wanting to be reprimanded. “I keep telling my younger coworkers, you need to fill things out,” she said, stressing that it’s critical to report and document violence in order to establish patterns and hold management accountable.

In the face of escalating workplace violence, possibly even more widespread than the reported numbers, nurses have been mobilizing to call for greater protections. The California Nurses Association, for example, shepherded passage of the 2014 Healthcare Workplace Violence Prevention Act. This landmark bill requires California hospitals to adopt comprehensive workplace violence prevention plans and also forces hospitals to document and report incidents of violence to the California Occupational Safety and Health Association (Cal/OSHA).

At a National Nurses Organizing Committee conference in January, around 100 RNs from Florida, Texas, Missouri, Kansas, and Nevada, echoed California’s call for stepped-up action to reduce hospital violence. They gathered in Tampa for a rally piggybacking on proposed Florida legislation geared, much like California’s, to standardizing and formalizing workplace violence prevention.

“Such a large percentage of us are assaulted at work,” said rally attendee Kim Scott, an intensive care unit RN at Oakhill Hospital in Brooksville, Fla. Her own violent experiences range from verbal assaults, to watching a coworker get kicked “hard in the chest.” She joined RNs holding signs that read “Assaulted” and “Physically Assaulted,” while Bonnie Castillo, RN and director of National Nurses United’s Registered Nurse Response Network, read statistics from the Journal of Emergency Nursing citing that 76 percent of nurses with at least 10 years of experience had experienced some form of workplace assault in 2013.

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There are a multitude of reasons why violence against healthcare workers is on the rise. But in discussion with registered nurses across the country, several key factors attributable to the hospitals and healthcare industry’s prioritization of profits over its staff and patients are most prominent.

One main way hospitals can prevent workplace violence, agreed nurses, is to simply increase staffing. More staff means more sets of eyes on the patients, more hands and bodies to step in if a patient or family member acts out. Better care also means patients and families are less likely to become agitated. This applies across all levels to not just registered nurses, but techs, aids, and sitters to watch potentially volatile patients. California’s recent legislation, for example, involves safe staffing protocols written into its standards for healthcare facilities.

Holder points out that not being left alone may have prevented the patient from slugging her. “The hospital is always trying to save money, downsizing, making staff cuts,” she said. “We used to have a person on every shift who would help nurses with transporting, drawing blood, getting people undressed or helping us with agitated patients. They cut those positions, so we didn’t have help at all. It really made a difference.”

A second is that patients today tend to be sicker and more likely to present with emotional and psychological volatility – if not outright untreated mental illnesses. Millions of people lost their jobs and, subsequently, their health insurance during the Great Recession and have had to go long periods without primary healthcare, therapy, or needed prescription medication. Private and public services for patients suffering from mental health issues have been cut, cut, cut.

According to a 2014 report by the National Association on Mental Illness (NAMI), the lack of acute inpatient or crisis stabilization services for patients who are experiencing psychiatric emergencies has “contributed to the problems with ‘psychiatric boarding’ in emergency rooms.”

“There’s a serious problem throughout the country with ERs housing psych patients because there aren’t enough psych beds,” said Judy Lerma, an RN of the Center for Healthcare Services (CHS) Crisis Care Center in San Antonio, Texas and an active member of NNOC-Texas. Lerma’s facility assesses adult patients having a psychiatric emergency, and accomplishes a 48-hour crisis observation in order to keep these patients “out of jail — or the hospital.”

“The idea is that [our facility] will stabilize them, and they won’t need to end up sitting in the ER, waiting in a bed there.” But many psychiatric patients across the country still wind up in the emergency room, nonetheless.

Last, nurses point to changes in hospital visitor policies intended to maximize hospital profits that result in many more people besides just patients and hospital personnel to be present on a unit.

When Scott became an ICU nurse 27 years ago, RNs had to buzz visitors in. Today, she said, there is minimal security and few rules about who and when someone can be on the unit.

Hospitals will never admit it, but they actually need and want patients’ families and friends to stay and do the work – helping patients to the toilet, feeding them, refilling their water – that was once performed by paid staff they’ve now eliminated.

As the industry has continued to commodify healthcare as a “product” and pushed the concept of patients and their families as “customers,” hospitals have further relaxed visitor policies for family members who, understandably, would like unrestricted access to be with their loved ones. Some nurses reported that they felt visitor policies were geared more toward encouraging higher scores on patient satisfaction surveys, rather than facilitating care. Sadly, payments to hospitals today are tied to patient satisfaction scores and reward the patient’s perception of care instead of the reality of care they receive. “The hospital cares more about patient and family satisfaction because it impacts their bottom line,” said Scott.

The two drivers are, in fact, interrelated. Instead of spending money on increased hospital staffing and services, which would naturally improve actual patient care, outcomes, and satisfaction, the hospitals have a calculated strategy to shift the burden, cost, and responsibility for care onto unpaid family members. If relatives and friends were not available to step in to fill that void, that would surely lead to greater suffering and upset by patients. Hence the current situation where many more people are on the unit, introducing potentially violent variables into the work equation.

Scott understands the calming effect friends and family can have on patients and always encourages them to ask questions and advocate for the best care for their loved ones. But she noted that RNs sometimes have to perform job duties or procedures where, even under the most ideal circumstances, it would be best if visitors were not present. For example, when an RN asks a post-operative patient to turn and cough, the patient will likely feel pain – something that worried relatives don’t understand and could further upset them. “Families will be angry at us, yelling at us,” said Gwynn Pepin, an RN at St. John’s Hospital in Maplewood, Minn., where a brutal Nov. 2, 2014 attack by a patient stunned the country. “There are times we don’t even think about it as verbal harassment, and we just try to deal with it, to do our best.”

Even living on the edge of violence, via verbal threats, can take its toll. A recent study by the Manitoba Nurses Union, on the prevalence of PTSD among nurses, revealed that nurses who did not sustain any injuries, but just “anticipated some sort of violence at work, reported higher levels of stress than nurses with minor injuries.”

And when an RN’s best isn’t enough to deescalate visitors, with hospital policies barring nurses from controlling which “customers” are on their unit, the threat of violence looms.

This attack had no prelude. Through security camera footage, you can see nurses calmly working and charting at their nurses’ station; one RN even had her hands relaxed and folded behind her head. Seconds later, around 2 a.m., RNs at St. John’s Hospital in Maplewood, Minn. were blindsided when 68-year-old patient Charles Logan rushed into the med-surg station, wielding a metal bar he had stripped from his bed, and began striking nurses.

Surveillance video of the assault exploded across both mainstream and social media. Reports focused on the shocking footage and subsequent injuries to four nurses (including a collapsed lung and a fractured wrist), and also on Logan’s apprehension by police, several blocks from the hospital, where he collapsed while resisting arrest and ultimately died.

What’s not obvious in the video, according to Pepin, is that even in the midst of panic, there was also strategy. The pattern of movement, on the part of RNs, purposely led Logan away from other patients. RNs also pressed a panic button that notified a trained team of respondents, including hospital security. In the aftermath, RNs were provided with workers’ comp and ongoing counseling, all as part of the facility’s workplace violence plan, dubbed “Code Green.”

Every hospital must have a plan, say NNU nurses, not only for how to prevent workplace violence but how to handle any incidents that arise on any unit and the subsequent trauma.

Any workplace violence prevention training RNs have received has traditionally focused on ER nurses in emergency and psychiatric departments, since they were often dealing with patients in crisis. However, Higgins points out that these units cannot be the only areas of the hospital prepared for violence. All units, she said, in all communities, also need access to a plan.

“You don’t know where violence is going to show up,” she emphasizes. “It has spread through all areas of the hospital. You can never assume just because RNs are in a certain area of the hospital or in a sleepy community, that they’re safe. We should always make sure we have training in place — everywhere.”

Public health nurse Laarni San Juan, RN, of California’s San Mateo County takes the call for training a step further, advocating for plans extending beyond the hospital walls, into the community.

“Public health nurses go out and visit the most vulnerable and marginalized patients, the most unlikely to have health insurance,” said San Juan. “We are aware of the inherent risk, but that’s why we chose this work: to help those who are vulnerable.”

In her 17 years with the county, San Juan has been in homes with evidence of abuse, had a drug dealer jump in her car, and navigated a number of situations where her facility’s basic guidelines, such as “lock your car door” or “trust your gut,” did not feel sufficient.

“I cannot even recall the last training we’ve had,” San Juan said. “It’s one thing to have a general guideline, but what’s missing is: If I were to get into a situation where law enforcement was involved and I needed medical attention, I don’t know what the protocols are. There’s nothing in place. It’s scary to think an [institution] that employs nurses who are at most risk, going in their cars into the community, does not have that in place.” 

Jon Tollefson, who handles governmental affairs for the Minnesota Nurses Association, explained that an upcoming Minnesota bill seeks to guarantee hospital staff is fully trained for violent scenarios.

“Not just training for RNs in ER or psych,” Tollefson said, “but for all healthcare workers employed or contracted. We have some hospitals where they have a contractor, and who knows what kind of training they get? They have to get the same as in-house staff.”

RNs want change. Last year, before moving to Florida, Holder lobbied for passage of California’s Healthcare Workplace Violence Prevention Act. She was encouraged to do so by her friend Nicole van Stijgeren, an ER nurse at San Mateo Medical Center, in San Mateo, Calif., who also participated.

“I asked her to go because I thought it would be cathartic. She was a powerful speaker; she had such a powerful personal story,” said van Stijgeren, who was “devastated” to witness the impact of workplace violence on Holder. In fact, while van Stijgeren had encountered violence in her own career, it was seeing her friend in so much physical and emotional pain that motivated van Stijgeren to take collective action through her union.

“This turned me into an activist for the violence that I was seeing and experiencing myself. It really made me want to speak out,” said van Stijgeren. And she is not alone in her activism; nurses across the country are increasingly rallying, lobbying, and saying they have had enough of hospital workplace violence. The unions of National Nurses United are providing nurses an avenue by which to fight to protect workers and communities.

“Maureen’s experience gave me a voice and [so did] meeting my CNA rep, who is an activist,” said van Stijgeren. “It inspired me to fight to better protect nurses.”

In a system where violence is both normalized and on the rise, Holder’s story and others like it are fueling a movement to ensure that no more RNs will feel that their lives and careers are considered expendable before the hospital industry is held accountable for change.