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SUNDAY FOCUS: Health care workers often face threats, abuse

When Laura Magstadt was putting herself through nursing school by working as a certified nursing assistant, she was punched and hit by patients.

Violence against health care workers has long been considered part of the job.

Asante is working to change that at its clinics and hospitals in Medford, Ashland and Grants Pass. The regional Providence health care system is tackling the problem as well, including at Providence Medford Medical Center.

Violence against health care workers is a national problem, said Magstad, vice president of nursing for Asante Three Rivers Medical Center in Grants Pass.

“Every health care setting is struggling with issues of violence,” she said.

Violence against health care workers accounts for nearly as many serious injuries as all other industries put together. Many more assaults and threats go unreported, according to the U.S. Department of Labor.

When nurses get punched, kicked or spit on — especially by a patient in crisis — they usually just carry on with their work.

“They don’t necessarily tell anyone what’s happening. They just accept it,” Magstad said.

But there is growing awareness about the problem in the health care industry, she said.

Asante put together a Workplace Violence Prevention Council this year. The 30-member group has representatives from various departments and jobs throughout the Asante system.

Providence has its own multi-disciplinary team to address workplace violence.

Violence doesn’t just happen in obvious places like the emergency department, said Jennifer Nidalmia, clinical practice advisor for behavioral health services for Asante Rogue Regional Medical Center in Medford.

It can happen in a surgery recovery area, for example, when confused, disoriented patients lash out at those providing post-surgical care, Nidalmia said.

Local hospitals are working to better understand and track workplace violence, train employees and deescalate tense situations before they turn violent.

Nationally, research shows violence against health care workers is on the rise.

Magstad said health care workers were seeing that trend even before the added stress of the COVID-19 pandemic. People are under strain because of issues with their personal lives, work and financial struggles, health problems and the stressful pace of modern society, she said.

“People feel like they can say and do things without consequences. People are quick to anger and they’re quick to become agitated,” she said.

Understanding the problem

Health care workers face both intentional and unintentional violence.

People may be delirious, agitated and not fully aware of their surroundings because of an infection or other type of illness, said Karey Westbrook, medical-surgical care clinical practice advisor at Rogue Regional Medical Center.

“We’re poking at you to start an IV. You start flailing to try to get me to stop poking you,” she said.

Those with Alzheimer’s disease, other forms of dementia and brain injuries can also become agitated and defensive. They may sexually harass health care workers or grab and grope body parts — unaware that what they’re doing is inappropriate.

Health care workers have compassion for patients who aren’t aware of their behavior, but that doesn’t mean they aren’t hurt or traumatized by the experience, Westbrook said.

Some patients make racist remarks against workers.

Asante wrote about the issue of workplace violence in an internal newsletter and netted comments from people who work for a range of local and out-of-state health care providers.

A Filipino certified nursing assistant reported an elderly man at a Grants Pass nursing home hit him in the head with a stainless steel shower sprayer, spat on the floor and said, “I hate Filipinos.” Hospital patients have called him Chinese or Mexican while making racist remarks.

A registered nurse said a female with emotional problems grabbed her by the throat and pinned her against a wall.

“Thankfully the security people were able to get her to let go of me, and she was placed in restraints. I had bruising on my neck and probably shook for an hour afterward,” the nurse wrote in her comment.

A registered nurse who worked in a California psychiatric unit said an enraged patient picked up a heavy metal table with four chairs attached to it and pinned her against the wall with it.

“He went from early signs of agitation to a full blown rage within 30 seconds. It was like he became ‘the Incredible Hulk,’” she wrote.

The nurse said she thought he was going to kill her. More people arrived to take him down and she slid away to safety. She was treated in the emergency department, then resumed her night shift job at 2 a.m.

“I never pressed charges, and there was never any follow-up provided for me regarding the incident and its impact,” the nurse said.

Asante is working to better track incidents of violence. The organization is doing internal surveys of workers to understand the extent of a problem that often goes unreported.

Westbrook said while some violence is at the hands of people who are delirious, suffering from dementia or mental illness, some verbal and physical abuse is intentional.

When some people feel they aren’t in control or are being told what to do, they respond by getting angry.

“People get aggressive or yell at us or curse at us,” Westbrook said.

Some people have become combative over COVID-19 safety precautions, such as requirements to wear masks, Magstadt said.

“We’ve had people screaming and swearing at staff about having to wear a mask — to the point where law enforcement had to be engaged. Some community members are taking out their feelings against staff,” she said.

Intoxication can also lead to violence.

“When patients come in under the influence of drugs or alcohol, that has an impact. Sometimes people do terrible things they normally wouldn’t do,” Magstadt said.

Responding to violence

Asante is working to create an environment where violence is no longer tolerated or hidden, Magstadt said.

“We’re standing behind our staff 100%. There’s no reason they should be the victim of violent or abusive acts. It is not part of the job,” she said.

Part of the effort to support workers is offering training on how to improve personal safety and deescalate situations that are spiraling out of control.

Workers are being taught that when they enter a room, they should position themselves so their exit can’t be cut off.

“Have a way out of that room,” Magstadt said.

Asante is looking to see if the physical layout of some sites is contributing to violence.

“For example, is there a nook where no one can see you with a patient?” Westbrook said. The solution could be to improve the sight lines so no one gets trapped alone.

How health care workers respond to agitated patients can make a difference.

If the person is disoriented or delirious, a soothing approach can ease their agitation.

“Sometimes a quieter, slower approach with a patient will work,” Westbrook said.

Using simple phrases can help patients who are having trouble understanding what is happening.

“Use simple words like, ‘Let’s keep you safe right now. I’m here to help you. I’m on your team,’” Nidalmia said.

She said most patients respond better when they feel treatment is a collaborative process, rather than feeling health care workers have power over them.

“You can say, ‘What are your needs right now? How can we do this together?’ There are phrases you can rely on in the heat of the moment. Train yourself to use the same phrases every time. ‘It seems like you’re not OK. How can I help you? Can you help me understand what is happening to you right now?’” Nidalmia said.

Westbrook said health care workers need to recognize they can become angry and agitated, too. It’s important to remain calm and not ramp up the tension.

“Humans have lots of emotions and feelings. Sometimes they spike. Take a deep breath and let things calm down,” Westbrook said.

When situations get too threatening, the hospitals have security on site around the clock.

“They’re of enormous help. They’re amazing and very well trained. They’re unbelievably helpful,” Magstadt said. “We also have great relationships with local law enforcement if it’s a situation where we need to call police.”

At most hospitals, a code gray is an alert about violent or threatening behavior.

Providence added a pre-code gray level for when a patient is showing warning signs of possible violence, said Patrick Rochon, injury prevention coordinator for Providence.

“Health care workers are trained to recognize the risk factors for anxiety escalating,” he said.

Everyone who works on the floor goes through an eight-hour course covering signs a patient’s anxiety is increasing, how to deescalate situations before a patient reaches a crisis stage, improving personal safety at work, calling for help and other topics, Rochon said.

Nurses can sometimes take quick steps to lower a patient’s anxiety, such as reducing noise and light levels. Nurses reassure patients that they are safe, and let patients know nurses are on their team, he said.

Nurses can call for a case manager or a spiritual advisor to provide additional help to patients. Doctors can revise medical treatment plans to better fit patients’ needs, Rochon said.

The security team can intervene if necessary.

Across the regional Providence system, the more often front-line workers use pre-code gray interventions, the more violence goes down, Rochon said.

“I’m really proud of the team that has come together here at Providence to make these interdisciplinary efforts to create a healing environment for patients and reduce anxiety levels,” he said.

Patients themselves can help reduce the chance they’ll respond with verbal or physical abuse against a health care worker.

If you have a planned medical visit, leave yourself plenty of time so you don’t feel rushed and stressed, Magstadt said.

If you are going in for surgery, bring things that will help you feel more comfortable, such as books and music, she said.

Trips to the emergency room can be stressful, especially if there’s a wait for care. Try to remember that all patients at a hospital feel vulnerable, and other people might have to receive care first.

Westbrook said she wants patients to remember that health care workers experience the same stresses as everyone else. Workers understand what people are going through.

“We’re humans, too. We’re also dealing with the presence of COVID-19. We have family members getting sick. We have young kids who aren’t going to school. We have elderly family members who can’t leave the house. When the public comes into the hospital stressed out, we get it. We are empathetic, because we are you,” she said.

The difference for health care employees is they work in hospitals, so they’re comfortable with the facilities and understand different types of medical treatment, Westbrook said.

Patients should never hesitate or be afraid to talk to health care workers about their fears, she said.

“When you’re stressed out and scared, just come out and tell us. ‘I feel stressed out. I’m uncomfortable. I don’t understand what’s going on. What’s the plan?’ The nurse will talk to you. You have every right to ask me for information. I want to make people feel comfortable,” Westbrook said.

Reach Mail Tribune reporter Vickie Aldous at valdous@rosebudmedia.com. Follow her on Twitter @VickieAldous.

Karey Westbrook, left, and Jennifer Nidalmia of Rogue Regional Medical Center are part of an effort to curb violence against Asante workers. (Andy Atkinson / Mail Tribune)