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How much more can nurses take when it comes to mental and physical injuries?
Growing up in the nursing field, starting as a nurse’s aid assistant, I fell in love with taking care of patients. It did not matter their background or why they needed help; I was there to help them to not only feel better but to live as close to normal life as possible. As the years progressed, it was apparent that not only I was getting tired, but so were the nurses around me. Achieving every level in nursing, there has only been a progression of increased stress, fewer resources, and more of the same every year. The organizations offer employee assistance programs for nursing staff to discuss their troubles and issues they are facing if they do not feel supported. The EAP is linked to the organization, and employee records have a higher incidence of exposure to reveal issues about the organization. Is this fair? No, of course not. Does it happen? Absolutely.
There have been more incidences than not that are not being reported, due to the fear of the organization penalizing the nurse reporter. Happens all the time and has pushed nurses into feeling helpless, that nothing else will get done about the problem, so why even report it. Then we have nurses that are pushing for legislation and acuity. These are gallant acts of heroism, but the real problem is sinister and reveals itself as overwhelming violence in not only the emergency rooms but trickling to the floors such as medical/surgical units, telemetry, orthopedics, and anywhere there is an observation or emergency holding bed in the hospital. Patients are transferred to these units where nurses are not trained to work with behavior issues that could present.
Is there a hole in the education system? Yes. Being a nursing professor in recent years, I have seen firsthand and created curriculum from the board of nursing approved frameworks. The information that is given is vague and does not offer much to nursing schools that are equally understaffed to create frameworks in a subject that the professor is not familiar with. For example, you may have a nursing professor that was a chemo nurse for about one year and have a total of two years then become a nursing chair for the department and overlooks curriculum. How about a maternity nurse teaching mental health? What do they know about mental health or addiction?
One of the largest failures in nursing is the education system and the lack of administration to be proactive and adhere to the trends in healthcare. Right now, we are in a full-blown opioid epidemic, and nothing is addressed in schools for curriculum modifications or withdraw protocols to assist nurses in determining and preventing patient on nurse attacks. This is what Nurses Against Violence Unite, Inc. which is a 501 c (3) nonprofit geared towards educating, empowering and eliminating violence in the workplace. Other initiatives will be to offer low fee to free third-party therapeutic services to help nurses, and healthcare workers receive care in a safe space without feeling of retaliation.
Join us on FaceBook: #NursesAgainstViolenceUnite Community
We are in a nursing crisis. Working in nursing pretty much all of my life, I have seen a lot of issues from patients spitting, punching, biting, kicking and slamming nurses against walls. Is this behavior acceptable? Absolutely not! It has been my mission to advocate for others and help them to advocate for themselves, so helping nurses is one of my highest passions.
Nearing the end of my DNP (Doctor of Nursing Practice) project and program, I am honored to have had the privilege of working with some of the best healthcare professionals that have helped me navigate through the doctoral process. They have helped me grow my focus instead of patient on nurse abuse but the overall picture. It took me a very long time to get others around me to see the problem and proud that they would look at me like I was insane! Needless to say, it is important to educate everyone about the issues that we face and give support to all nurses and healthcare workers.
Lateral and patient/family on nurse abuse has gotten so out of control that in the news we are reading more and more nurses are committing suicide. We need to really help ourselves as nurses, through education and helping one another or the violence is only going to get worse. Some may agree with what I am about to say, others may really get offended, but as nurses, we need to hold ourselves accountable and fix what we can with this mess we are in. Legislation is what we also need for increased security and mandate hospitals to provide protections, but also education to keep us safe. My goal is to help nurses through education and to hopefully prevent another injury.
So let’s be objective, shall we?
Here is a scenario:
Nurses suffer an enormous amount of abuse —> Nurse has her 5th admission for the day—> Nurse cannot eat or go to the bathroom as they are slammed! —> Nurse files a report about the verbal or physical abuse —> Nurse Manager starts writing the reporter up for things they did wrong —> Reporting Nurse tries to recoup and stops reporting —> Nurse still has not had a break since she started the shift, even yesterday for that matter! —> Nurse sneaks to the bathroom —> Nurse is being paged, bed 8 is screaming —> Patient is punching the nurses’ aid —> Nurse tries to stop the battery, blocks the CNA and gets hit.
…How would you feel? Pleasant? Hardly! Definitely defeated, upset, feeling like you could do more, what did you do, and in pain but afraid to report it because you know that you are under a magnifying glass. Face it, we are human too and have a tough job without a moment or a day to recover, we are forced to get back up and keep going. If the nurse is needing help and asks for help, will she get it? Probably not because all the other nurses are busting tail just as much as the nurse that needs help!
Will the nurse manager step in? Maybe or maybe not, depends on how their boss views teamwork and patient care. If the nurse manager calls into her meeting, will the DON or administration be forgiving? Wait…she just wrote the nurse up, no way is that nurse going to her! The patient is #1 but also, what about the nurse? Staffing is bad, patients are mean, the staff is grouchy, bed 8 just clocked her in the head…and this has the other 6 patients to care for. Smile and keep going is the current culture of nursing and we are losing nurses just as fast as gaining them to an already struggling profession.
As a side note, I decided to look into how much education there is on acute mental illness, addiction in nursing school. Barely any. The Florida professional and practical nurse frameworks have minimal requirements for mental illness and substance abuse. Is there a de-escalation program offered to nurses on med/surg? Probably not! Injuries are not being reported due to retaliation and accepted as “a part of the job” and “nobody will do anything anyway”. So being that nurses are in fact human beings, the nurse may indirectly start behaving like an abuser. Yes…I know I am about to get blacklisted from the unapproving reader but really think about it. How much abuse can 1 person take?
Is this nurse going to be happy or mean? I would have to say appearing to be quite kind and happy but the underlying personal family history and built up pressures or abuse, maybe not. This nurse may be having increased anxiety progressing toward burn-out and post-traumatic stress disorder (PTSD). Some may call it compassion fatigue, to me, that sounds like another fancy name to cover up a huge problem in nursing. Police and first responders get more recovery time than a nurse! The nurse calls off, the floor is short, no fill-in for their spot….so nurses have increased their patient load by 1 patient. Will they be happy? Probably not. Will there be increase patient errors? Unfortunately yes, it puts the patient and nurse at risk.
Education is power and the elimination of violence in the workplace.
The theme of my research is patient violence against nurses…but there are more sources. Nurses have messaged and thanked me for taking the stand against violence in the workplace. When I took on this sensitive topic, it was apparent that this would be a very unpopular topic among employers. I too have been retaliated against throughout my career, but that has not stopped me. I feel that it is important to bring our profession up to speed with the rapidly changing patient population through education and tactics to decrease our nurses from being injured.
Retaliation is when someone returns a perceived attack. The nurse reporting is not attacking the organization but truly trying to bring to light an issue that is occurring on their unit. When looking at the nursing indicators laid out by the American Nurses Association, it was not surprising to see that psychiatric physical assault and nursing turnover were both on the list. I personally have seen and talked with nurses that have been injured, that have stated they have reported a physical attack and have been told that they perpetrated and caused the person to attack them. All the while the nurse stands in their own blood, suspended until an investigation is completed…with no pay. So about underreporting…this is one of the reasons.
Understanding the bottom line and the costs involved in advertising, interviewing, hiring, and training new nurses and nursing staff, is it truly necessary to look for new help when you already have great nurses? Not at all. Playing the advocate role for the nurses that leave their positions, a majority are leaving because they are not being heard, tired of being hurt by patients, while being told that they could have done a better job. When a patient hurts them, the nurse composes themselves trying to brush it off, while smiling and caring for the other 4-6 patients that they are assigned…without a bathroom break…or lunch…or a moment to sit down to rest. If the nurses and nursing staff report a problem, please listen, we are on the front line of patient care.
I love being a nurse, we are a tough bunch that love our patients.
Shouldn’t we be loved too?
The one thing that I have found while educating the staff over the years, is a mix of psychology where most nurses are taught between 2-4 weeks of psych in their rotation and want more understanding about how to treat this population. The next area is negative reinforcement by rewarding the bad behavior, such as ordering more pain medication, giving PRN’s on a timed basis just so they “will have a good shift and not get beat up”. When a nurse understands the importance of why reporting is necessary, I have found they are more receptive. The holes of the computerized system not relaying the “misc” data, which is where WPV is reported, does not label or track the data. The computerized reporting system does not have WPV as an option and if it is charted as miscellaneous, it is not capturable for statistical reasoning. The average time for reporting in the computerized system is 10-15 minutes juggled between the other 4-6 patients that also may not be staffed according to acuity. The nurse simply does not have time.
Another barrier, which is pretty huge, is the fact that when a nurse is hurt and reports the incident, there is no provided light duty so the nurse is forced to out on worker’s compensation and to use their banked time (PTO) to make up the difference. Let me stress…the nurse is not only injured, but they are victimized again by being forced off the floor due to not having provided light duty and a third victimization by losing their hard earned and rewarded PTO time. In some facilities, sick time is PTO. As a result, the injured nurse forces themselves to manage, report it to the next nurse, and keep on moving with a smile as patient satisfaction is #1. The end result, the nurse developing burn-out and possibly Post-Traumatic Stress Disorder.
Mental health can be affected by various environmental agents. Several contributors that enhance and bring about mild to acute mental illness include nutritional deficiencies, injuries, alcoholism, illicit drug use, or victimization (National Institute of Mental Health [NIMH], 2017). Situational stress, such as natural disasters or seasonal affective disorder, can also be a causative agent of an individual’s mental well-being (Heekin & Polivka, 2015). Mental health can also be a genetic factor. In 2016, adults suffering from mental illness reached approximately “44.7 million, where women were the largest population affected at 21.1 percent versus the males at 14.5 percent” of the total amount presented (National Institute of Mental Health, 2017, figure 1). Due to the nature of women having a hormone imbalance, such as serotonin, where levels can be low and be a contributor to developing depression and anxiety (Young, 2018). A combination of “lower socioeconomic status or stressors” that are related to “job loss, financial hardships, and changing schools” are a few additions to increasing mental illness among both females and males (Heekin & Polivka, 2015, p. 5).
Environmental health risk
As we all know and have heard that when you lead a stressful life, you can become ill. There are many outcomes from the environmental exposure to stressors. There is a decrease in life expectancy by “10-25 years”, which could be a result from the development of chronic diseases, such as “heart disease, infectious disease, hypertension, diabetes, and suicide” (World Health Organization [WHO], n.d., para. 1). Nearly “one in five adults in the United States lives with a mental illness”, which equates to “44.7 million individuals in 2016”, with individuals between “18-25 years with two or more races” (NIMH, 2017, para. 4). With a large number of those with mental illness comes with a cost of “$89 million in 2013, and with serious mental illness, $193 million reported in 2008” (Kamal, 2017, figure 27).
While working with acute mental health patients for years in various healthcare environments, the background of those I worked with were from a lower socioeconomic situation, including those that are homeless. However, mental illness can affect anyone. For the purposes of this discussion, when you have someone that is suffering from mental illness, they often do not keep up with their appointments or check-ups with the psychiatrist or with the primary. Not to seem controversial in our discussion, but from my experience, patients that are hard to talk with, such as those with schizophrenia, borderline personality, or bipolar, nurses really have a hard time separating the subjective from the objective data. When a patient says they are fine and ramble off into a tangent, the nurse will get nervous and either end the physical assessment stating that were non-compliant or they take for granted that since the appearance looks normal that they are of sound mind. To fix this issue, effective communication would be the key to help the nurse to complete their thorough assessment and not the issues the patient may be having. More times than not, I have found abscesses and septic patients from my time on the floor which infection can also contribute to behavior issues.
Heekin, K., & Polivka, L. (2015, November). Environmental and economic factors associated with mental illness. The Claude Pepper Center, 1-16. Retrieved from https://coss.fsu.edu/subdomains/claudepeppercenter.fsu.edu_wp/wp-content/uploads/2016/02/Environmental-and-Economic-Factors-Associated-with-Mental-Illness-Manuscript.pdf
Kamal, R. (2017). What are the current costs and outcomes related to mental health and substance abuse disorders [Report]. Retrieved from https://www.healthsystemtracker.org/chart-collection/current-costs-outcomes-related-mental-health-substance-abuse-disorders/#item-eighteen-percent-adults-united-states-mental-behavioral-emotional-disorder
National Institute of Mental Health. (2017). Mental illness. Retrieved from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
Schmidt, C. W. (2007, August). Environmental connections: A deeper look into mental illness. Environmental Health Perspectives, 115, A404-A410. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1940091/
World Health Organization. (n.d.). Premature death among people with severe mental disorders [Report]. Retrieved from http://www.who.int/mental_health/management/info_sheet.pdf
Young, J. L. (2015). Women and mental illness. Retrieved from https://www.psychologytoday.com/us/blog/when-your-adult-child-breaks-your-heart/201504/women-and-mental-illness
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There is an influx of verbal and physical abuse that is affecting nurses throughout that United States and the world. According to the American Nurses Association in the latest survey and response to the Joint Commission sentinel event, is that “62 percent of nurses had experienced verbal or physical abuse” (American Nurses Association [ANA], 2018, para. 4). Working on the floor myself for 26 years, until last year taking a teaching position, verbal and physical abuse is a common occurrence no matter what unit that you worked on. Experiencing first hand the morale of the staff when it came to the effectiveness of reporting incidents to the unit managers or administration, and nothing changes. The rationale given by nurses is that they believe that their patients are not in their right mind when they lash out at the nurse and leaves them unsure of what constitutes as a violent act (The Joint Commission, 2018). The nurses that do report the incident usually give a verbal report of the issue to the supervisor, and since it is not in writing, the incident may not be available to pass along for policy changes (Arnetz et al., 2015).
Strategies for stakeholder participation
Awareness of the problem and formulation of a plan is the first step in the process of creating a policy (Laureate Education, Inc. (Executive Producer), 2011). One of the strategies for stakeholder participation is through implementing an education plan for nursing professionals and practitioners focusing on the barrier to reporting incidents. When analyzing the structure of an organizational policy that is in place, the facility should have reported data in their system, if not then this would be the best place to start. The goal should be finding out why there is no data that reflects patient on nurse injuries. When nurses state that they obtained lasting injuries, then ask them if they reported it, many times they will tell you no due to “nothing being done to fix the problem.” One reason for underreporting can include a “lack of reporting policy, lack of faith in the reporting system, and the fear of retaliation” from the organization (Occupational Safety and Health Administration [OSHA], n.d., p. 2). Many places have a no tolerance policy when it comes to workplace violence. However, the verbiage is mainly geared towards lateral violence and not upheld when the incidents happen. When it comes down to be a patient safety issue, patient on nurse violence is huge. The rationale is, if a nurse is injured, staffing is often reduced, leading to job dissatisfaction, and eventual nursing turnover.
American Nurses Association. (2018, April 18). ANA responds to the Joint Commission sentinel event alert on physical and verbal violence against healthcare workers. Nursing World.
Arnetz, J. E., Hamblin, L., Ager, J., Luborsky, M., Upfal, M. J., Russell, J., & Essenmacher, L. (2015, May). Underreporting of Workplace Violence. Workplace Health & Safety, 200-210. https://doi.org/10.1177/2165079915574684
Laureate Education, Inc. (Executive Producer). (2011). Healthcare policy and advocacy: Agenda setting and the policy process [Video file]. Retrieved from https://class.waldenu.edu/bbcswebdav/institution/USW1/201870_27/DR_NURS/NURS_8100_WC/USW1_NURS_8100_week03.html
Occupational Safety and Health Administration. (n.d.). Workplace violence in healthcare; Understanding the challenge. Retrieved from https://www.osha.gov/Publications/OSHA3826.pdf
The Joint Commission. (2018). Physical and verbal violence against health care workers. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf
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With the increase of drug and alcohol abuse tagged with the large homeless population that we have in society today, the dynamic of a nurse’s assignment. Some people do not understand or know the progression or living options for these individuals. It can be a continuation of the same unless the patient chooses to change and has resources to take the necessary steps to get better.
Where do these people go?
Let’s examine the options:
- Home – The most ideal. Usually at the beginning of the illness, prior to and the beginning of the addiction or the progression of the mental illness. This patient still has a job and functional.
- Move in with friends – The addiction is growing to the substance of their choice to the point they need to downsize due to the cost of the lifestyle. The reason is that the mental illness untreated or treated they had lost their job or need to work part-time due to decompensating. If the patient is treated, will they continue their meds or self-medicate? More times than not, they self-medicate.
- Homeless shelters/Tent cities – The issues (addiction & mental illness) are becoming great. The patient may have exhausted their resources to the point that their friends and family cannot take them in any longer due to stealing, the mental illness progression, or other reasons relating to abuse and illness.
- The streets – Life has completely changed for this patient where they could be committing crimes to support their habit or they aren’t able to work due to the decompensation from their illness.
- Hospitals – In Florida, we have the Baker Act. If you feel that you are a danger to yourself or others you or someone else can Baker Act you for a mandatory 72-hour psychiatric hold. The psychiatric doctor can hold the patient or not and also depends on if the patient takes their medications, and cooperates with meetings or rules of the unit. Often, the patients can refuse the medication so this delays treatment. The other scenario is that the patient forgot to make their appointment due to their illness and ran out of medication.
- Jail – The patient is arrested in the community and they stay there for their sentence and released back into the community. Some with lengthy records, including felonies. When you have a lengthy record or receive a felony, it is difficult to find housing and a job.
- The cycle starts back at #3 unless they get housed in an Assistant Living Facility (ALF), group home, or Skilled Nursing Facility (SNF) as a Traumatic Brain Injury (TBI) staying across the hall from a fragile individual. The patient may sign themselves out of the facility and go back to the streets due to having more freedom and options for continuing the same circle.