Violence prevention for mental health workers--and others

While health professionals working in mental health facilities try to make sure their patients don't suffer as a result of staff downsizing and understaffing (see the May-June 2000 issue of Healthwire), the flip side is that mental health professionals themselves may be suffering in the sometimes violent, volatile and chaotic environment of overcrowded facilities. In fact, nurses and health professionals in all settings are finding that they are becoming the focus for patients and family members increasingly frustrated and dissatisfied with today's health care system.

• New York State Public Employees Federation (PEF) member and psychiatric center intensive case manager Judi Scanlon was murdered while making a home visit to a patient/client. (Nov. 1998)
• At the Zeller Mental Health Center in Peoria, Ill., RN Mary Grimes is shoved backward into a metal door frame by a patient, knocking her unconscious and into a coma. (Nov. 1999)
• In Girard, Kan., visiting nurse Waneta Boatright is shot and killed by a patient's son when making a home visit. (Feb. 2000)
• PEF member Rhonda Bedow, a nurse at the Buffalo Psychiatric Center, was brutally beaten by a patient at the center, suffering massive bruising, a concussion and dislocation of her jaw. (Sept. 1997)

Figures from a recent Bureau of Labor Statistics survey on occupational injuries show that about 118,000 or 4.6 percent of the nation's 2.6 million nurses and nurses' aides suffered sprains, fractures, bruises and cuts on the job in 1997. While the specific causes of those injuries are not delineated, FNHP/AFT health and safety specialist Darryl Alexander says, "We can say with a great deal of certainty that at least half of our members' injuries in our mental health institutions are suffered as a result of mental health patients' action and behavior. The anecdotal information we get from our members has been substantiated by at least two studies from mental health hospitals."

But mental health hospitals aren't the only settings for violence against our members, says Alexander. In hospitals and nursing homes, our nurses' aides and other health care workers are suffering injuries that are related to unpredictable behavior on the part of their patients and sometimes patients' families, she adds.

The bigger issue in health care facilities, says Alexander, is that what constitutes violence is very complex. "We need qualitative studies to define the violence that goes on in our health care facilities." What about the surgeon who gets angry in the operating room and throws a scalpel? What about a push or a shove from a co-worker or a doctor? Alexander says she had heard stories involving all those incidents. "Those are acts of violence or harassment that aren't even acknowledged as such."

Systems and environments have to be examined for their conduciveness to violence, says PEF health and safety director Jonathan Rosen, who is overseeing a three-year program to implement the Occupational Safety and Health Administration guidelines on violence prevention in four state mental health hospitals. For example, says Rosen, in one of the state mental health facilities in Buffalo, the smoking policy was such that if a patient [with a history of violence] was caught smoking, they were not allowed to get privileges for two days. "So who would they beat up? Not the people who made up the policy, but the nurses and aides who had to implement the policy," said Rosen.

One of the keys to implementing a violence prevention program is to get management commitment and employee involvement. "The hospital hierarchies have to agree to consensus... managers have to free people up to come to the meetings," said Rosen. "Management has to be reasonable in considering the recommendations and in implementing them."

In their FNHP professional issues conference workshop "Violence in the Health Care Workplace: Stop It Before It Starts," presenters Victor Vignola and Burt Thelander explained that in addition to management commitment and staff involvement, a comprehensive plan should include:

• a commitment to a safe work environment;
• ongoing development and support of recommendations;
• prompt reporting of violent incidents; and
• continuing education related to violence prevention.

They also emphasized that violence has to be defined by your facility or organization and it has to say, up front, that violence is not acceptable.

You must analyze the causes of violence in your facility, said Vignola, who is a National Institute for Occupational Safety and Health (NIOSH) project coordinator for the New York State Office of Mental Health. This could include reviewing accident and injury records to identify patterns, analyzing episodes of violence, workplace security and coming up with recommendations for changes to policies, procedures and work site design.

Risk factors should also be assessed. "Each facility has its own culture and thus its own risk factors," said Vignola. For instance, is there a prevalence of weapons in the community? Are there an increasing number of acutely or chronically mentally ill patients being released from hospitals without follow-up evaluations?

Developing skills is key, said Thelander, a psychiatric nurse and director of nursing at Middletown Psychiatric Center in Middletown, N.Y. Learning how to talk to clients, how to talk "physically" with clients, learning not to work alone, are all skills to learn, he said.

Long-term systemic changes must be made--not just crisis management alone--to become a crisis-prepared organization. That involves:

• setting up and maintaining effective reporting systems;
• collecting and analyzing data related to crisis;
• cultivating all the "stakeholders" (labor, management and patients/clients);
• developing and disseminating a policy of dealing with violence and crisis (including what happens prior to an incident, as well as the incident itself);
• encouraging a climate of communication and responsiveness;
• engaging in problem solving;
• evaluating risks "proactively."

"If you have a policy that your organization is not going to accept violence, then you must have a response to it," said Vignola.

For more information about the OSHA guidelines on violence prevention, go to: www.osha-slc.gov/SLTC/workplaceviolence/guideline.html.

Another helpful web site is: www.cdc.gov/niosh/violence.html (Centers for Disease Control and Prevention).