“Why are they allowed to do it just because I am a nurse?”

Recent press items highlight the violence U.S. hospital nurses face today

The Atlantic posted a piece in December 2016 on the growing threats from nurses’ patients, and the inadequate support from legislators and employers. In September 2017, Montana’s Prairie Populist excoriated a state legislator for claiming nurses had failed to document the problem. And in December 2017, Los Angeles TV station NBC4 reported on a former Cedars-Sinai nurse who is suing a surgeon for assault.

December 14, 2017 – Several recent press items point up the serious problem of violence against U.S. nurses, although they address the issue in wildly different contexts. On December 1, 2016, The Atlantic published a strong piece by Alexia Fernández Campbell headlined “Why Violence Against Nurses Has Spiked in the Last Decade.” Campbell’s piece is short, but it is a dense report on the increase in the already high rate of violence against U.S. hospital nurses by patients, most often those with some kind of altered mental status. Campbell cites several studies documenting the problem. And she describes the well-known lack of support for nurses from their hospital employers. Campbell also discusses possible causes of the recent increase and explores potential solutions. Those range from legislative action to hospital initiatives like enhanced staff training. More recently, on September 8, 2017, the Prairie Populist (Montana) posted “Rep. Manzella Not Sure Nurses Are Getting Attacked.” Sanjay Talwani’s item indignantly refutes the suggestions of one state legislator that nurses are making unsupported claims. The report give examples of the recent rise in attacks, as documented by the Montana Nurses Association as part of efforts to get the legislature to increase applicable penalties. And today NBC4, the network’s Los Angeles television affiliate, posted a short piece titled “Former Cedars Sinai Nurse Sues Surgeon for Alleged Attack.” Mekahlo Medina reports on an alleged attack on nurse Paula Rickey by surgeon Kerry Kourosh Assil that was captured on surveillance video. The hospital says Assil has been disciplined, but Rickey’s attorney says that was just a “slap on the wrist” because Assil is “a big revenue generator.” Rickey says the hospital retaliated against her for reporting the assault. Her comments clearly suggest that the attack was related to her status as a woman. Altogether, these diverse press items paint a revealing portrait of the range of physical threats nurses face in the workplace, and we thank all those responsible.

They didn’t even offer me counseling

Invading the personal space

Apparently, she “likes the abuse”

They didn’t even offer me counseling

The Atlantic article says the rate of reported violence against health workers has risen more than 100% in the last decade, and violent injuries in health care almost outnumber those from all other industries combined. One informal survey found that “as many as one-in-four nurses suggested that they had been attacked at work between 2013 and 2014 alone.” The piece explains that attacks on nurses range from grabbing to killing. It cites a recent Journal of Emergency Nursing study, apparently the same study referenced above, that found altered patients—those who have dementia or Alzheimer’s or are on drugs—are most likely to hurt nurses. Of the 700 nurses surveyed, 76 percent had suffered “physical or verbal abuse from patients and visitors” in the prior year, and about 30 percent had “been physically assaulted.” The article notes that working with patients in pain has always led to risks of violence, but the problem worsened in the wake of the Great Recession, as hospital budgets and mental health services were cut just as people were losing jobs and health insurance. That meant fewer nurses and security staff, but more people with serious problems turning to hospitals where they could not be turned away. The piece quotes nurse Bonnie Castillo, then-health and safety director for the union National Nurses United, who notes that this has made for “volatile, unpredictable situations.” 

The piece also highlights the impunity that exists in too many settings, the sense that abuse is part of a nurse’s job. Castillo says that nurses are discouraged from reporting assaults, noting that she herself was actually punished by an employer for calling 9-1-1 after a patient attack. Thus, in the above study, only 29% of the surveyed nurses who were physically attacked reported it to their supervisors. California nurse Rosa Parma says that during her five years as a nurse, patients have spit on her, slapped her, threatened her life, and in one case, while she was two months pregnant, kicked her so hard she slammed into a wall and fell to the ground. Her manager was unconcerned and told her she would see Parma the following day at work. Parma thought she was going to die during the attack, but “’they didn’t even offer me counseling.’ (Her baby survived.)” 

Finally, the piece briefly explores possible policy responses. It says there are currently no federal rules requiring that hospitals try to protect nurses, although the U.S. Department of Labor is apparently considering adopting safety standards. Some states have required hospitals to develop violence-prevention programs or have increased penalties for those who assault health care workers. And some hospitals have on their own offered training in responding to violent scenarios. But the piece argues that a lack of meaningful legal standards prevails and may be contributing to the U.S. nursing shortage, which is a threat to patients and staff.

This is a strong piece with many helpful elements. They include the descriptions of some of the immediate causes and extent of violence against nurses, including a few helpful anecdotes to bring it home to readers; the critical issue of impunity that results from the perception that it’s just part of the nurse’s job; and the inadequate policy responses to date. The piece also relies heavily on research in a nursing journal and consults two nurses as sources. It might have provided more context about the underlying nature and causes of the problem—the prior research supporting the findings of the recent study on which the piece relies; the longstanding lack of real respect that fuels under-staffing and a general disregard for nurses; the enduring angel stereotype that has presented nurses as virtuous females who can and should bear anything without complaint; and the potential for minimum-nurse-staffing-level legislation to address the issue. But on the whole the report does a very good job of explaining this problem in a short space.

Invading the personal space

Echoing a key point of the Atlantic report, the Prairie Populist piece reports that physical attacks against Montana health workers have doubled in just a few years. It says nurses have “sounded the alarm” with the state legislature and the state in general. But when the legislature considered a bill introduced by Rep. James O’Hara during the preceding winter (presumably early 2017) to make such on-the-job attacks felonies, Rep. Theresa Manzella had a “problem”:

She noted that when the nurses told the committee about the 2,155 workmen’s comp claims paid to workers because of physical attacks over a five-year period (outlined in this study that reviewed thousands of Montana claims), the nurses didn’t also provide the committee with actual police reports for all those claims. “And that is a big problem,” Manzella said. And she went further, blaming the nurses and casting doubt on the severity of the issue. “I really think that the nurses need to provide us with the necessary information that we need to expose the holes in the system should there be holes,” she said. “We may have a problem that we need to address, but they’re not giving us what we need to address it.”

Manzella then moved to table the bill and it died in committee. The reporter mocks the idea that the lack of police reports means assaults did not happen, then sets out to “remind Manzella, and the rest of Montana, of some of the issues that nurses face in their efforts to provide comfort and aid to everyone.” The piece notes that nurses have “raised the alarm” for years about the violence they have endured, often from patients. The item appears to rely mainly in the efforts of the Montana Nurses Association (MNA), noting that its executive director Vicky Byrd told the House Judiciary Committee in January 2017 that “unlike police officers and security guards, nurses are not trained to deflect a physical attacker.” The piece offers a photo of a nurse with a black eye suffered in a 2016 attack, along with more detail about incidents involving two other nurses. In one case, a patient had “tried to strangle the nurse with her own stethoscope.” The patient pursued her into another patient’s room and continued attacking; he also wiped some of his own blood on her and told her she would die from AIDS. That nurse’s statement added: 

Throughout my career, I have been hit, punched, spit on, scratched, belittled and my life threatened more times than I can count. … Healthcare workers do not deserve to just ‘put up’ with this simply because we chose a profession where we care for those who are intoxicated or under the influence of substances that alter their normal behavior. As a colleague of mine stated, “If this person did this to me outside of work, they would be arrested. Why are they allowed to do it just because I am a nurse?”

Another nurse described being “bulldozed” into a concrete wall, suffering physical, emotional, and financial injuries, including difficulties in her personal relationships. The piece offers some analysis from the testimony of the MNA’s Byrd, who explains that nurses’ work in patients’ “personal space” makes them uniquely vulnerable to assault, and after an assault happens, the nurses are expected to continue providing care “and there’s rarely a consequence.” Wrapping up, the report says nurses are trying to change this culture, making safety a part of contract negotiations, getting hospitals to develop safety protocols, and fighting for bills like the one in Montana, to which they will return next session, “invading the personal space of legislators as they try to do their jobs without being assaulted or having to fight for their lives.”

This is another strong report. It does not have as much hard data and research, which would have been helpful, but it does have a powerful tone and the anecdotes about the nature and effects of specific assaults to back it up. And it does rely on a nursing leader. Its quotations also make the point that the attacks often have few consequences, although the piece might have provided more detail about that. In particular, it might have noted that it’s not just that laws are too weak but also the culture of impunity at hospitals, which may discourage or even punish nurses who report attacks. 

Apparently, she “likes the abuse”

The NBC4 piece highlights a related issue, namely the risks of assault that nurses face from their own colleagues. It reports that former Cedars-Sinai charge nurse Paula Rickey was allegedly assaulted by surgeon Kerry Kourosh Assil, and the piece offers surveillance video of her being pushed out an operating room, apparently by him. Now she is suing the hospital. Rickey says that when she reported the alleged attack a month after it happened, she suffered retaliation, being moved to a different floor and having her hours reduced. Rickey says she would like an apology, stressing that “no woman should be treated like that” and that she hopes “some exposure takes place not only on him, but men who are abusive towards their position of power.” In the lawsuit, she says Assil told her she “likes the abuse.” The hospital reportedly issued a statement about the suit, saying Assil had been disciplined and that the safety of patients and employees is paramount. But Rickey’s lawyer says that he believes Assil got only a “slap on the wrist” because he is “a big revenue generator” and “the rules don’t apply to him.”

We commend those responsible for this item for at least bringing the basic elements of this reported abuse to light. However, the report is so short and seems to be so cautious that not everything is clear. First, although only a minority of the physical threats to nurses come from their colleagues, there have been reports about physicians, especially surgeons, assaulting nurses, including by throwing dangerous objects (links below). The piece fails to offer any larger context for this type of threat to nurses. Some have linked the problem to issues that include the overall stress of life-and-death health practice, the sometimes-abusive culture of medicine and medical training, the power imbalance between physicians and nurses, and the excessive deference to physicians that is associated with their social status and economic status as revenue generators, as reflected in the comments by Rickey’s attorney. Of course, one thing the abuse from colleagues has in common with abuse from patients is the view that it is a natural part of nursing. In addition, although persons of different genders have been identified as abusers and victims, it seems pretty clear that the abusive physicians tend to be male and the abused nurses are overwhelmingly female. In this case, there is no direct indication as to why Assil might have singled Rickey out for abuse. But Rickey’s comments—and what she reports Assil said to her—strongly suggest that she sees this at least in part as a gender issue. Indeed, the reported comments would not seem out of place in a sexual harassment scenario. And that type of scenario is certainly another strand in the fabric of troubled nurse-physician relations.

Further reading

Also see a Vox article from 2018 on the introduction of a bill in the U.S. House of Representatives to address violence against health care workers.

See some of our pieces on violence against nurses:

Abusive physicians
https://www.truthaboutnursing.org/news/2009/jun/abuse.html

Many surgeons don’t listen to nurses, say non-nurses
https://www.truthaboutnursing.org/news/2006/may/05_healthday.html

McDrunky
https://www.truthaboutnursing.org/news/2006/mar/09_ap.html

Physician anger management
https://www.truthaboutnursing.org/news/2013/mar/16_out_of_control.html