Audit, Compliance and Risk Blog

A recent news headline told the story of two nurses who were involved in a scuffle with the father of a newborn inside a New York hospital--apparently, the father was a high profile member of the Kennedy family. The conflict was triggered when he began to carry his infant son out of the hospital without the usual authorized procedures--at which point one of the nurses attempted to block him from leaving.

"(He said) 'I don't have to listen to you. It's my child’,” one of the nurses later testified to media. Allegedly, what began as a verbal disagreement, turned physical. "I'm standing at the door and he grabs my wrist and turns my hand,” said the nurse.  ”I still have pain in my arm.”

The nurses said they felt emotional and physical pain from the incident. Doubtless, the high profile name of the father in this instance was what made this a headline story. But the nature of the event itself is not uncommon in health care settings.

In another story reported in the media this year, a severely drunk man who was being treated for intoxication at St. Francis Memorial Hospital in San Francisco, allegedly broke the attending nurse’s eye socket while beating her with his fists.

Prevalence of violence in health care

Such incidents of conflict, aggression, and escalating workplace violence between patients, families, and care teams reflect a pervasive problem in health care settings in the US and Canada. According to Statistics Canada, and the National Institute for Occupational Safety and Health (NIOSH) in the US, workplace violence is more common in social service, health care, retail, and educational settings than in other workplaces. The level of violence can range from a mild slap, to hitting, biting, beatings, sexual assault, even murder—in the case of health care workplaces, violence is usually perpetrated by a patient or family member against someone on staff. According to the US Dept. of Labor’s Bureau of Labor Statistics, a sizable proportion of the victims are caregivers in nursing homes and hospitals, and the majority of the victims of nonfatal assaults, are female. (Statistically men are victims less often, but when they are, the results are more likely to be critical, or fatal.) Emergency and psychiatric units are where most violence and aggression occur in a hospital.

However, because most incidents of violence in these settings do not result in serious injury or hospitalization, the number and type of incidents is believed to go unreported. Also, because experiencing abuse by patients and families in the health care workplace is considered to be an unfortunate ‘part of the job,’ it is less likely to result in a report or complaint from staff or workplace violence prevention response.

According to NIOSH research, violence in hospitals often results from patients and occasionally from their family members who feel frustrated, vulnerable and out of control. They can be triggered when service is denied, when a patient is admitted involuntarily, or when a health care worker attempts to set limits on eating, drinking or tobacco or alcohol use. Patients dealing with mental illness and/or substance abuse are also significant factors.

The prevalence of violence in hospitals and other health care settings, though unfortunate, provides an invaluable lesson for understanding the causes and the appropriate measures necessary for effective workplace violence prevention which can be taken by employers.

Workplace violence goes to court

Take the case of one nurse who sued her employer after being attacked by a patient:

In July 2007, the Bellevue Police Department in Nebraska brought an 18-year-old young man (who according to court records was “mentally ill and dangerous toward others”) into emergency protective custody after he had an altercation with his mother, and dropped him into the local Midlands Hospital. Subsequently the patient attacked the attending nurse. The beating left her “seriously injured,” and the nurse then sued the city of Bellevue, arguing that the city’s police department failed to properly restrain the patient, and erred in bringing him to that hospital instead of a nearby mental health facility where he could be treated and managed adequately.

The Sarpy County District Court in Nebraska awarded $350,000 in damages to the nurse after finding, in part, that Bellevue police “had a duty to prevent [the patient] from injuring third persons” while in protective custody. However, the state Supreme Court reversed that decision finding the police took reasonable care to detain the patient, and that the city no longer had custody of the patient when the assault occurred.

The city was undoubtedly relieved by the higher court’s decision, but still would have been well advised to review and reconsider its health care training, assessment and policy procedures before allowing a high-risk volatile suspect with mental health issues into a small general hospital that did not have psychiatric services.

It can be instructive for other employers to review such cases of violence which highlight the potential for both American employers’ liability and Canadian employers' liability in these kinds of cases.

Foreseen consequences

In one case in Ontario, Canada, a tragedy occurred whose circumstances would reverberate through the halls of government, and throw a spotlight on the inadequacies of many hospitals' policies and practices for workplace violence prevention. In 2005, a 37-year-old nurse was murdered while working in a hospital in Windsor, Ontario.  Anesthesiologist Marc Daniel, 50, was a physician with whom the victim Lisa DuPont had had a tumultuous two-year relationship—a relationship which she had ended a few months before she was killed. Daniel tracked the nurse down where she was working in the hospital's recovery room, and stabbed her in the chest multiple times with a military-style dagger before injecting himself with a lethal dose of an anesthetic.

The investigation of the murder uncovered some disturbing, though not unfamiliar circumstances, relating to the lead up to the nurse’s death; namely, that Daniel had previously been disciplined for harassing DuPont at the hospital where she worked, and that he had been diagnosed with a mental illness, having once made a suicide attempt. As his conduct escalated, hospital officials had been confused and indecisive about how to deal with him.

Legislation as a solution

Many fingers pointed blame at the institutions that permitted DuPont’s killer with the opportunity to assault his victim by not dealing with the persistent harassment of his victim prior to the murder.

 “Addressing harassment is important for several reasons,” says Karla Thorpe, Director with the Leadership and Human Resources Research Division of the Conference Board of Canada. ”Harassment often precedes violence, and serves as an early warning that violence can result if workplace issues are not addressed.”

The upshot of the Lisa DuPont tragedy was the introduction of Ontario’s Bill 168, an amendment to the provincial health and safety legislation that now requires employers in all sectors, including health care, to have the policies and detailed procedures to deal with workplace violence and harassment.

Neither Canada nor the U.S. have uniform national approaches to workplace violence, so individual provinces in Canada are developing requirements that apply national (and international) guidance. Also, the federal department of Human Resources and Social Development Canada has issued extensive regulations for employers to develop workplace violence prevention policies.

The province of Manitoba took workplace violence prevention in health settings further, when in 2011 a Workplace Safety and Health Regulation came into effect that requires compliance in healthcare services specifically to include hospitals, personal care homes, psychiatric facilities, medical clinics, community health centres, physician offices, ambulances, residential care facilities for children, youth or adults, places where home care services are provided, and any other workplace where physical or mental health treatment or care is provided.

In the U.S. the Occupational Safety and Health Administration (OSHA), developed recommendations to address workplace violence issues in workplaces, and effective September 8, 2011, issued “Enforcement Procedures for Investigating or Inspecting Workplace Violence Incidents.”[1], which OSHA inspectors are to use when inspecting workplace violence reports, incidents and complaints.

California, Washington, Minnesota, and New York states have workplace violence prevention guidelines, and in 2007 New York made workplace violence prevention a legal requirement for all public sector employees. Violence prevention measures are required at health care facilities in Oregon (for all health care employers) and New Jersey at health care facilities.

Hospitals - microcosms of community

An important aspect of workplace violence prevention is the recognition that the social environment inside a health care setting is a microcosm of the social environment that exists outside the doors of those health care settings. The mental, social, psychological issues that people carry in normal circumstances are transported inside a hospital, a clinic, or a long-term care facility, where those issues can become intensified. But the challenge for managers and executive leaders of these workplaces is to recognize and prepare for the particular circumstances and events that such settings can trigger.  Illness creates a sense of vulnerability and stress, as do the hospital procedures that can confuse and frustrate families and patients. Health care workplaces are by nature demanding, intense and stressful, and add to the tension in a hospital. Even relationship abuse that begins outside the walls of an institution (as in the DuPont case), can bring risks to the workplace. The challenges these workplaces present is reason enough to review and assess policies, guidelines, practices and procedures, and health care training, for reducing the incidents of violence in health care settings. 

Workplace Violence: A Practical Guide to Security on the Job, authored by Jon F. Elliott J.D., MPP, and others, provides thorough examinations of the many levels and types of workplace violence, including sections on health care settings, and how to deal with them systematically. Also available for download is a Workplace Violence Prevention Checklist.

ABOUT THE AUTHOR

Ellen Baragon is a writer, editor, and communications consultant with an extensive background writing for and about health care and environment. She has worked as a Senior Communications Consultant with federal and provincial health and environment departments and ministries, and related Crown corporations. Her educational background includes a Diploma in Journalism, a Diploma in Applied Communications, and a BA in Italian Classical Studies. She is a freelance writer near Vancouver, Canada and can be reached via her website at Ergo Creative Services.