Hurting Healers: Violence in the Hospital

MAY 14, 2019
Kevin Kunzmann
Silent No MoreEditor’s note: The following article contains several instances of graphic violence and assault.

Angela Simpson, RN, was running out of options for her patient. The older man was a frequent admission in her emergency department (ED), having been previously diagnosed with dementia and earning a reputation for being difficult in care.

The man’s blood pressure was spiking—systolic was 210, diastolic was something equally dangerous—and he was belligerent, refusing medication, and growing more irate with his handlers. A second-career nurse 6 months removed from graduation, Simpson was a “baby” in practice but a well-versed mother at home.

As the patient fell asleep and his vitals worsened one night, Simpson made an uncomfortable call. She attempted to administer an intravenous (IV) therapy, but the patient’s vein blew and the sudden pain woke him. He punched Simpson in the head as she still stood leaning over him and cocked his arm to swing again. Simpson jumped back in shock and shouted—less for him and more to catch the attention of anyone on the floor.

The charge nurse rushed in and intervened. The patient was eventually calmed and went back to sleep, having never gotten the treatment. Later that night, Simpson nursed the painful bruise on her head while retelling the story to colleagues. No one offered her support. All shared a similar story.

She realized that being attacked by a patient had connected to her peers more than anything she had done in her half-year as a nurse.

“Reaching this moment where I get christened into the fold by someone punching me was just so bizarre,” Simpson told MD Magazine®.

Every healthcare provider has been exposed to violence at work. Simpson says that fact with resigned assuredness—it’s as certain as something can be in her field. And it seems well-evidenced. An emergency physician told MD Mag that one of the first lessons she received in medical school was to never let a patient get between her and the door. Another, when asked if he had instances to share of a patient attacking him or a colleague, joked that he would have a few more examples at the end of his next double shift.

A survey of 3500-plus ED physicians by the American College of Emergency Physicians (ACEP) last year showed nearly half (47%) have been physically assaulted at work. Even more (51%) reported patients being physically harmed in the ED, and about 70% agreed with the suggestion that violence in the ED is on the rise.

The issue of violence in healthcare—particularly in places of critical care—is so prevalent and so unchecked that it borders on standard practice. Though it affects the majority, it’s the minority of outspoken organizers and solutionists that stop assault from becoming an acceptable outcome of healing people in the United States.


Jimmy Choi, MDThe learning curve

It took a couple of decades for Jimmy Choi, MD, to bridge his 2 jobs together, mostly because they were always separate in his mind. He trained as an emergency physician at Bellevue Hospital Center at NYU Langone Health before heading west to the Kaiser Permanente San Francisco Medical Center. During that time, he also taught self-defense and martial arts courses.

His work in emergency medicine routinely exposed him to violent situations with intoxicated, high, belligerent, or delirious patients. His classes as a martial arts instructor made him realize that the idea of self-defense was popularly misconstrued. In the instances when a colleague or fellow caregiver sought his training, he realized they were seeking help for something they had no answers for.

“When my colleagues enter this class, they have this self-idealized image of what self-defense is—this Hollywood version of it,” Choi told MD Mag. “I don’t think people know what they want, or what they should learn.”

Choi now co-leads My Occupational Defense, a self-defense and security course designed for employees and employers. About half of his business is in healthcare facilities—training hospitals, clinics, ambulatory services to manage violent patients. What he’s seen in his years spent in the ED is evidenced by what he learns from his self-defense clients: healthcare violence is unusual and unspecific, as not every patient that attacks is trying to cause harm.

“I could have a patient high on PCP swinging at me, or a grandmother having an adverse experience to her medication. Autistic children could bite and scratch. Are you going to apply the same response to violence with them as you are with some drunk 35 year old? It’s a complex issue, and no one’s trying to address this spectrum,” he said.

Doctors and nurses are expected to be capable of managing a hostile situation similarly to law enforcement, Choi noted—except they’re armed with no weapons nor tools, and no one even thinks they should be. Their best option is often “taking down” a delirious patient with an injectable sedative, which means at least 1 person still needs to risk their safety to subdue the situation.

An ED will call for police response when the situation has escalated out of hand, and only then will direct force be used for a situation that calls for it. Choi laughed at the memory of previous self-defense courses offered to his colleagues in the past: annual hour-long programs that showed healthcare providers 10 easy steps to maneuver, block, and counter an attack. They might as well have watched a copy of Karate Kid.

“In order for you to execute and learn how to defend yourself, it has to be simple,” Choi said. “You can’t memorize 10 new techniques after an afternoon and expect you learned something.”

Then there’s active shooter training. Though gun violence defense training varies on state-to-state carry laws, the template mantra for healthcare providers is “run, hide, fight”—a self-explained practice that’s fairly common in US employee handbooks. Choi called it an underwhelming strategy delivered in a ridiculous medium: an online course. He’s convinced not one healthcare provider is going to internalize this critical information.

My Occupational Defense has a partnership with San Francisco State Police to create simulated training scenarios for hospitals and EDs—complete with fake shooters and actor patients. What’s real is the jarring sound of a gunshot, heard in the healthcare providers’ place of work.

The greatest disconnect between gun violence training and real-life application is understanding how it plays out, and where it’s happening, Choi said. If doctors and nurses learned how to respond to gun shots while at their desk or in an observation room, they can act with confidence, and help others.

“You have to simulate in the workplace they’re used to—and no one’s doing that,” Choi said. “Everyone’s getting a slideshow on ‘run, hide, fight.’”

Jennifer L'Hommedieu Stankus, MD, JD


A matter of respect

Jennifer L’Hommedieu Stankus, MD, JD, served as a police officer in her early 20s before finishing law school. She spent some time as a hospital attorney in the US Army, then went back to medical school to become an emergency medicine doctor. She’s now a jack-of-all-trades physician in Washington state, a firsthand observer and occasional target of violence in a handful of Tacoma-based EDs.

She is well-equipped to answer the question as to how the healthcare violence cycle can be stopped. The problem is that she’s not sure where to start—in fact, she told MD Mag, no one is. So, how about at the beginning?

Stankus has seen a diminishing rate of respect for physicians. The doctor’s office was once a formal setting, she explained. Patients would dress presentably, and show regard to what their physician had to say—there was a sense of gratitude and admiration between a doctor and a patient.

Most patients have dropped any sense of formality. She recalled a mother and daughter coming into her office with injured ankles from dumpster diving, their feet still reeking of garbage and covered in dirt. The pair expected their feet would be cleaned, as well as treated.

This flippant attitude extends to how caregivers are spoken to by their patients, Stankus said. It would shock her to meet any ED doctor or nurse—especially women—who have never been verbally abused by a patient.

At any of the inner city EDs she’s worked, Stankus has routinely heard drug addicts shout demands for a specific prescription, seen patients restrained to gurneys with spit masks strapped over their mouths, felt an innate fear of turning her back on any patient under her care—whether she were in the lobby, the observation room, the parking garage, anywhere. Like most of her colleagues, she took note of patients who left scorned by her diagnosis or her treatment, wondering if they would be waiting outside when her shift ended in the middle of the night.

Patients believing they have the right to turn on a provider for any reason at all creates a reaction where most providers are ready to be preyed on. This tense dynamic—which is happening most frequently in the most stressful healthcare facilities—is making it more difficult to defuse potential conflicts between physicians and patients.

“It’s fast-paced, there are lots of decisions needed, and when people are being abusive, it’s really easy to have a short-fuse—and rather than de-escalate the situation, escalate it,” Stankus said.

There is an informal protocol set for when a patient is getting out of control. Floor security is called on the spot, and oftentimes male doctors and nurses will lend their help. In the moment, that response is usually enough. But Stankus wants to see more repercussions for patients’ actions. She’s been the arresting officer in instances of patient assault, and it seems that many care providers don’t even believe that’s a possible outcome.

About 70% of ED physicians in the ACEP survey said their hospital reported an instance of violence—but only 3% said they also pressed charges on the attacker. Stankus counts 31 states currently with laws against attacking an ED caregiver. That doesn’t change how few hospitals pursue charges.

“In terms of making changes in general, there needs to be an expectation that you can get kicked out,” she said. “From an administrative standpoint, it just needs to become the culture, rather than the opposite.”

Any instance of physical assault should result in a person being handled by law enforcement, regardless if the facility pursues charges against them, Stankus said. Caregivers are fixed on healing their patients—requiring them to physically subdue someone, even for the sake of other patients, goes against their nature and does nothing to make their facility safer.

Stankus recalled how her husband, a private practice neurologist, once had a colleague who was abused by a patient. They simply fired the patient. Such a resolution isn’t available in EDs, where caregivers are outnumbered and already overburdened at the frontline of healthcare.

If the public is willing to celebrate the sacrifices of emergency doctors and first responders, they’d want to know what kind of abuse they’re subjected to.

“I think people would be pretty horrified to know most emergency room nurses have been assaulted, that most feel scared in their workplace,” Stankus said. “I think they’d be upset to hear that.”


Giving a voice

Well after a patient punching her head had initiated her into the emergency nurse community, Simpson was following the Delnor Hospital hostage crisis with absolute horror. The Chicago-based hospital was in lockdown on a Saturday afternoon in May 2017, after a jail inmate receiving care broke from his restraints, stole a security guard’s gun, and took 2 nurses hostage.

The inmate was shot and killed after an hours-long police standoff, and no other patients nor caregivers were killed in the crisis. It wasn’t until months later, though, that court reports detailed how 1 of the nurses was repeatedly raped and abused at gunpoint for hours on end.

Simpson kept her attention on the victim. She was suffering from post-traumatic stress disorder, and 2 years after the incident has not returned to work. This story finally broke Simpson. The Silent No More Foundation was launched to amplify these stories of unchecked caregiver assault.

“We are just sick of what’s going on,” she said.

The non-profit grassroots organization combats healthcare violence by driving education, advocacy, and awareness campaigns. In 2 years, it has become a prominent platform for healthcare discussion on social media—its Facebook page features 5600-plus active followers, and the #SilentNoMore hashtag on Twitter has become a fixture among nurse accounts.

Simpson defined their following as a diverse crowd of caregivers—though it’s often difficult to identify individuals, as there’s still a fear of institutional backlash for speaking out on the issue. Caregivers’ unwillingness to seek direct help is part of the systemic expectation that they internalize trauma and keep moving.

“We cannot let people see weaknesses, see that we’re crumbling inside,” Simpson said. “Because that implies we’re unfit for the job.”

Silent No More’s legislative efforts vary from state to state, often advocating for the most routine laws of protection for healthcare workers—including felonizing patient assaults, requiring more law enforcement officers in facilities, installing more panic buttons in strategic locations, and improving the process by which an assaulted caregiver could report an incident to law enforcement.

“We’re trying to attack this at every possible angle,” Simpson explained. “Increasing safety isn’t about 1 thing. Individuals have steps they can take—so can departments, so can hospitals and facilities, so can states, and so can the federal government.”

Though she doesn’t wish to discuss “the politics of hospitals,” Simpson said she’s heard from multiple caregivers who have been threatened with losing their jobs over filing a police report or not following hospital procedure when de-escalating a situation—whatever that procedure may be. Hospitals are public health institutions, she said, and it makes sense that administrators wouldn’t want publicity surrounding patient violence. But that has somehow shifted blame onto the same caregivers being put at risk.

“Sometimes people groan inwardly at the idea that hospital management is not listening,” Simpson said. “But I truly believe that if upper management knew what we were dealing with on the floors, they would want to be involved too.”

The plan is to make the conversation too loud to ignore.

While legislation proposing improved workplace violence defense training grows stagnant, Simpson is calling on individual institutions to implement better practices. Debriefings should follow every incident, she said, and caregivers should reopen conversations on worker’s compensation policies and procedures in the event of an assault.

Administrators taking the step to better protect their physicians and nurses at work also need to include them in the conversation as to how that can be done.

Every healthcare provider has been exposed to violence at work. That is both the problem, and the eventual solution. This giant population of victims can be turned into stakeholders of change with the simplest reassurance that someone has their backs.

Simpson has thought about how a patient could steal a used needle from her and stab her, just because the disposal bin is on the other side of the room. She’s also worried patients will strangle colleagues who wear stethoscopes around their necks. Stankus has even wondered, if there was an active shooter, should she stay with her patients?

There must be answers to these questions. It’s time they were asked more loudly, before more healers are hurt.

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