POST 255. June 5, 2022. CORONAVIRUS. “More than a year after U.S. health care workers were saluted for saving lives in the COVID-19 outbreak and celebrated with nightly clapping from windows and balconies, some are being issued panic buttons in case of assault and ditching their scrubs before going out in public for fear of harassment.”

“The shooting in Tulsa is an extreme example of a growing trend: violence against doctors, nurses, and other health care workers.”

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“Across the country, doctors and nurses on the front lines against the coronavirus are dealing with hostility, threats and violence from patients angry over safety rules designed to keep the scourge from spreading.

“A year ago, we’re health care heroes and everybody’s clapping for us,” said Dr. Stu Coffman, a Dallas-based emergency room physician. “And now we’re being in some areas harassed and disbelieved and ridiculed for what we’re trying to do, which is just depressing and frustrating.”..

Dr. Ashley Coggins of St. Peter’s Health Regional Medical Center in Helena, Montana, said she recently asked a patient whether he wanted to be vaccinated.

“He said, ‘F, no,’ and I didn’t ask further because I personally don’t want to get yelled at,” Coggins said. “You know, this is a weird time in our world, and the respect that we used to have for each other, the respect that people used to have for caregivers and physicians and nurses — it’s not always there, and it makes this job way harder.”

Coggins said the patient told her that he “wanted to strangle President Biden” for pushing for vaccinations, prompting her to change the subject. She said security guards are now in charge of enforcing mask rules for hospital visitors so that nurses no longer have to be the ones to tell people to leave.

The hostility is making an already stressful job harder. Many places are suffering severe staffing shortages, in part because nurses have become burned out and quit.” (A)

“The San Leandro Hospital emergency department, where nurse Mawata Kamara works, went into lockdown recently when a visitor, agitated about being barred from seeing a patient due to covid-19 restrictions, threatened to bring a gun to the California facility.

It wasn’t the first time the department faced a gun threat during the pandemic. Earlier in the year, a psychiatric patient well known at the department became increasingly violent, spewing racial slurs, spitting toward staffers and lobbing punches before eventually threatening to shoot Kamara in the face.

“Violence has always been a problem,” Kamara said. “This pandemic really just added a magnifying glass.”…

Hospital executives were already attuned to workplace violence before the pandemic struck. But stresses from covid have exacerbated the problem, they say, prompting increased security, de-escalation training and pleas for civility. And while many hospitals work to address the issue on their own, nurses and other workers are pushing federal legislation to create enforceable standards nationwide…

COVID unit nurses also have shouldered extra responsibilities during the pandemic. Duties such as feeding patients, drawing blood and cleaning rooms would typically be conducted by other hospital staffers, but nurses have pitched in on those jobs to minimize the number of workers visiting the negative-pressure rooms where covid patients are treated. While the workload has increased, the number of patients each nurse oversees is unchanged, leaving little time to hear the concerns of visitors scared for the well-being of their loved ones..

“I don’t want to be a hero,” Kamara said. “I want to be a mom and a nurse. I want to be considered a person who chose a career that they love, and they deserve to go to work and do it in peace. And not feel like they’re going to get harmed.” (B)

“The shooting in Tulsa is an extreme example of a growing trend: violence against doctors, nurses, and other health care workers. According to Bureau of Labor Statistics data, health care and social service workers are five times as likely to be injured from violence in their workplace than other workers, and the number of such injuries has risen dramatically over the last decade—from 6.4 incidents per 10,000 workers annually in 2011, to 10.3 per 10,000 in 2020. Healthcare workers say the situation has become even worse during the COVID-19 pandemic; in September, nearly a third of respondents to a National Nurses United survey said they’d experienced an increase in workplace violence.

In part, this is likely because the pandemic has worn people so thin, and left them with less energy to interact politely. Regardless of their political party, tensions are high because many people are tired of the endless partisan back and forth on COVID-19, says Gordon Gillespie, a registered nurse who researches violence against health care workers as a professor at the University of Cincinnati. Many health care workers are exhausted by endless worrying—about personal protective equipment, the risk of getting sick, or having to pick up the slack for ill coworkers. “Everyone is just tired, and their resilience is down. And so when you have things happen, you’re more likely to escalate even faster,” says Gillespie.

The pandemic has exacerbated many of the underlying problems that lead to violence, revealing deep gaps in the American social safety net and health care system. And even more so than before the pandemic, doctors and nurses—and emergency room workers, in particular—must deal with the consequences. For instance, mental health issues, inadequately treated before the crisis, worsened for many people during the pandemic, which in many cases cut people off from support systems and added to daily stress. The change is visible to Murnita Bennett, a psychiatric nurse and DeNisco’s colleague, who says that some of the increase in violence she’s witnessed has been the result of patients not getting the care that they need.

“These patients who are violent, are put back right in the community. We’re keeping violent offenders in the hospital longer, instead of sending them to the state hospital where they could get more help. It’s appalling,” says Bennett. “I’m talking to the patients constantly, and their families, but I’m always [thinking], where’s my escape route? What’s my body language—[making sure] that I’m not showing any aggressiveness…. When you see what’s happened in Tulsa, it’s a reality for us to know that at any moment, someone could come in to harm us.” (C)

“Currently, there are no federal requirements healthcare employers must follow to protect employees from workplace violence, though the Occupational Safety and Health Administration offers voluntary guidance. A handful of states have rules for employers or laws penalizing offenders, putting much of the responsibility on individual hospitals.

Some nurses say the hospitals where they work have protected them effectively during the pandemic, citing measures like ongoing visitor restrictions and workplace violence prevention programs often spearheaded by labor unions or mandated by state law.

Others disagree, and say a lack of security, training and staffing challenges worsened by the pandemic are hindering their ability to provide timely, adequate care to every patient, resulting in patient and family frustrations that sometimes turn violent.

‘Less and less resources to care for patients’

This comes as hospitals deal with unprecedented staffing shortages. They are unlikely to abate anytime soon as widespread stress and burnout spurs healthcare workers — especially nurses — to consider leaving their roles.

A quarter of U.S. hospitals reporting their data to the HHS said they faced critical staffing shortages in early January, according to the agency.

In some states like Utah, lawmakers currently are considering legislation that would enhance penalties for assaulting healthcare workers.

Wisconsin already has a law that makes battery against certain healthcare workers a felony, though a bill moving through its legislature would extend that penalty to anyone threatening violence to a healthcare worker — similar to laws covering police officers and other government workers.

At the same time, there are no federal laws that directly address violence against healthcare workers, though last April the U.S. House of Representatives passed the Workplace Violence Prevention for Health Care and Social Service Workers Act. The Senate hasn’t passed it.

That legislation would mandate healthcare employers to develop and implement comprehensive workplace violence prevention plans based on guidelines that are voluntary from OSHA.

They would also be required to provide employees with annual training, keep detailed records of violent incidents and submit annual summaries to the federal labor department.

Currently, California has a law similar to that with guidance and enforcement coming through the state’s OSHA department.” (D)

“Violence against US health care workers has been on the rise for at least a decade. According to US Bureau of Labor Statistics data, the incidence of violence–related health care worker injuries has increased by 67%, from 6.4 per 10 000 full-time workers in 2011 to 10.7 per 10 000 in 2018. Also in 2018, health care and social service workers were 5 times more likely to experience workplace violence than all workers, comprising a whopping 73% of all nonfatal workplace injuries and illnesses requiring days away from work…

Addressing health care workplace abuse and violence is an undertaking as complex as the problem itself, Kowalenko said. “There is no one silver bullet, it’s multifactorial.”

The first step is to get health care workers to report abuse and violence, Kowalenko said. “We know underreporting is a huge problem. Some studies have shown 60% of violence is not reported in any way, shape or form,” he noted.

Educating workers about what constitutes violence is crucial, Kowalenko explained. Essentially, the rule of thumb is that if you wouldn’t let someone do it on the street you shouldn’t accept it in the clinic, and it should be reported even if perpetrated by people who cannot help themselves. “A lot of violence is underreported because the perpetrators are suffering from dementia or are confused, so people tend to not report it,” he said. “The same thing happens with smaller kids.”

Reporting is key to addressing abuse and violence because it shows when, where, and how incidents take place, Arnetz said. “Reviewing data collected is the best way to learn what went wrong and what we can do to avoid it going forward.” Her studies of workplace violence include the first randomized clinical trial of an intervention aimed at reducing violence by patients against hospital health care workers. One of the findings from the Detroit Medical Center system was that most incidents took place after 8 pm. Enforcing visiting hour limits immediately reduced the incidence and severity of assaults.

The finding also illustrates the importance of having consistent policies and enforcing them uniformly. “If one nurse lets in 5 visitors and another just 2, the inconsistency can escalate people,” Kowalenko said.

Arnetz’s research also revealed that restricting patients in any way such as denying visitors or not letting them get up and walk around, being in pain, transfers, and needles can trigger violence. “Even those who don’t express fear can become surprisingly aggressive when needles are involved.”

Training staff to recognize when patients are likely to become violent and how to deescalate them are other critical skills, Kowalenko noted. A raised voice or aggressive tone, pacing, or aggressive actions are warning signs. Talking calmly about what’s bothering the patient is an effective approach when emotions run high. “The best way to reduce violence is to avoid it altogether,” he said.

What health care personnel see as necessary medical equipment can be viewed by patients or visitors as weapons, said Jimmy Choi, MD, an emergency physician and martial arts trainer who runs San Francisco–based My Occupational Defense, a firm specializing in training health care workers to defend themselves against physical assaults. As a safeguard, wheeled intravenous (IV) poles have been replaced by poles attached to beds in many facilities around the country. Smaller items including oxygen tanks, scissors, scalpels, and IV needles—anything that can be used to strike or pierce—should be stored out of easy reach of patients and visitors when possible.

Furniture arrangement is another strategic element, Choi said. Beds should be positioned so they don’t trap staff inside the room. “Never let the patient get between you and an escape route,” he noted.

Physical self-defense training, such as how to avoid or disengage from being grabbed or choked, as well as simulated active shooter training, which focuses on when and how to run, hide, or fight, can be valuable, Choi said. He recommended finding trainers with health care backgrounds, who understand the specific needs of health care violence control.

Knowing how to safely subdue violent patients is an important skill. “When you have a big scrum is when the most harm occurs,” Choi said. Defending oneself or restraining a patient without injuring the patient requires more skill than simply disabling an attacker without regard to their safety, said Kowalenko, who, like Choi, has extensive experience in martial arts. “They are still our patients, after all,” Choi added.

He also advocated for joint training of security officers and clinical personnel on their respective roles in controlling or restraining violent patients. “It should run like a code,” he said. “Every person on the team should know their role and do it.”

Metal detectors can help avoid weapons being carried into the ED or other hospital areas. However, they’re not effective for patients brought in on gurneys and aren’t always practical, Choi said.

Cameras and panic buttons can provide added security measures, but they must be monitored to be effective. Ranya Habash, MD, medical director for technology innovation and assistant professor of ophthalmology at the University of Miami’s Bascom Palmer Eye Institute, noted a 2019 incident in which a nurse practitioner was beaten and left on the freezing ground for 2 hours before being discovered in the parking garage of a Milwaukee hospital. The initial assault, by a former valet at the garage, was captured on surveillance video. The nurse died of her injuries.

Sophisticated technology can help keep watch, said Habash, also the chief medical officer for Everbridge, a technology firm that offers health care safety systems. Solutions include panic buttons that can be downloaded onto any desktop computer or mobile device, including smart watches. They can be programmed to interface with security, local 911, incident command centers, or anyone with a smartphone.

Some systems include an escort feature that users can activate when they set out for their vehicle and deactivate when they safely reach it. If they don’t, the system asks for confirmation of safe arrival and alerts security to the employee’s location if there’s no answer. In the event of security breaches in progress, software also can warn users to stay clear of endangered areas and provide real-time video and audio intelligence inside active shooter or hostage situations, Habash said….

Arnetz’ research has suggested that in units with more regular episodes of violent behavior, including EDs and locked behavioral units, workers often have skills for dealing with those encounters, although they usually can be improved. “But what about ICUs [intensive care units] and med-surg? They may not have those skills, and they can be very important when situations develop,” she said.” (E)

Strategies to stop workplace violence before it occurs

Engage executives and clinical leaders

Addressing workplace violence requires organisation-wide buy-in. Everyone, from executives to ward managers, must understand the magnitude of the problem. To do this, collect data on point-of-care violence at your organisation and create a monthly report to inform leaders of incidents, including hot spots and trends.

Communicate behaviour expectations to patients and visitors

Clearly define workplace violence and disruptive behaviour, including both verbal and physical aggression. Then, set and communicate expectations for patient and visitor behaviour and enable staff to hold them accountable.

Empower staff to advocate for their safety

Create a reporting culture by implementing systems for staff to easily detail all instances of violent and disruptive behaviour. Escalate instances of persistent disruption to managers and executives to provide support for frontline staff in managing patient and visitor behaviour. (F)

“The reasons people attack and abuse health-care personnel during health emergencies are many, and local contexts vary. In some settings during the COVID-19 pandemic, fear, panic, misinformation about how SARS-CoV-2 can spread, and misplaced anger are likely drivers. A few government leaders have responded by announcing swift and, in some cases, draconian punishment for those who attack health-care workers.9 Yet threats of retribution do not address the causes of such violence and alone are unlikely to curtail these attacks. Effective responses must address the root causes. We recommend that the following actions be taken immediately.

First, collect data on the incidence and types of attacks on health-care personnel, including in the context of the COVID-19 pandemic, in all countries to fully understand the scope of the problem and to design interventions to prevent and respond to the attacks..

Second, attacks against health-care personnel must be prevented and condemned. Partnerships for the prevention of violence must be forged. Local and state governments must partner with civil society, community-based groups, and media organisations to highlight the problem of attacks on health-care workers and engage with the community on prevention, bystander intervention, and reporting…

Third, misinformation and disinformation about COVID-19 must be countered. Widespread misinformation and disinformation about COVID-19, including conspiracy theories, have contributed to the demonisation of certain groups such as health-care workers.14 Governments, international collaborative bodies, and social media companies must further refine and expand effective public information campaigns to keep members of the public informed and educated and to correct misinformation…

Fourth, accountability is needed. We must demand strong yet responsible enforcement actions against perpetrators of attacks by local and national governments. Violence against health-care personnel should be met with swift responses from law enforcement and legal systems. Local law enforcement authorities must fully investigate each reported incident, with an objective, evidence-based process. Full accountability for these crimes must be ensured and perpetrators must be held accountable.

Fifth, state and local governments should invest in health security measures to protect health-care workers as part of COVID-19 emergency budgets. Funding for the protection of health-care personnel and health facilities is needed now.

Finally, health professional associations, societies, and organisations from all specialties and disciplines should unite in speaking out forcefully against all acts of discrimination, intimidation, and violence against health-care workers.15 They must immediately condemn violence when it occurs and participate in initiatives aimed at responding to and eliminating violence.

These actions must be taken now. By protecting health-care personnel, we protect our most valuable assets in the fight against COVID-19: doctors, nurses, emergency medical technicians, medical and respiratory technicians, laboratory workers, and many others on the front lines.” (G)

• A.Health workers once saluted as heroes now get threats, by Heather Hollingsworth, https://www.pbs.org/newshour/nation/health-workers-once-saluted-as-heroes-now-get-threats
• B.Once hailed as heroes, health care workers now face a rash of violence, Tensions from an exhausting pandemic are spilling over into hospitals, By Bram Sable-smith and Andy Miller,  https://abcnews.go.com/Health/hailed-heroes-health-care-workers-now-face-rash/story?id=80476845
• C,The Tulsa Shooting Is a Reminder Health Care Workers Face Violence Every Day, BY TARA LAW,  https://time.com/6183895/tulsa-shooting-health-care-workers-violence/?utm_medium=email&utm_source=sfmc&utm_campaign=newsletter+brief+default+ac&utm_content=+++20220604+++body&et_rid=207402562&lctg=207402562
• D.Threats, obscenities, homicide: Healthcare workers stressed by pandemic face elevated violence, By Hailey Mensik, https://www.healthcaredive.com/news/threats-obscenities-homicide-healthcare-workers-pandemic/619971/
• E.Navigating Attacks Against Health Care Workers in the COVID-19 Era, by Howard Larkin, https://jamanetwork.com/journals/jama/fullarticle/2779310
• F.Strategies to stop workplace violence before it occurs,
• https://advisory-prod.azureedge.net/-/media/project/advisoryboard/shared/research/cbc/infographics/2020/cbc-workplace-violence-infographic/wf1923558-cbc-workplace-violence-infographic.pdf?rev=5b99316b2d6e47d9a5f1e34a68e145a9&hash=72AD87B27AAAC73C17CEFD7017871820
• G.Attacks against health-care personnel must stop, especially as the world fights COVID-19, by Donna McKay et al, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31191-0/fulltext