Workplace Violence
A White Paper Developed by the
MNA Practice and Education Committee.

Background
Part I - Violent Patients – How to Cope
Part II - Documentation and Reporting of Violence
Part III - Employee/Co-Worker Violence
Part IV - Employer Responsibilities when Violence Occurs

Part II - Documentation and Reporting of Violence

By Carol A. Distasio, RN, MSN, MPH, C, CS-P, CS-HH

A long term care facility has been experiencing violent, verbally abusive behaviors from several residents over a period of months and the problem has escalated. Nursing staff throughout the facility are experiencing a high level of stress, anxiety, and fear induced by the unrestrained aggression of several patients in the facility. The situation is so out of control that the facility must rotate nursing staff on one unit every two weeks because staff have refused to care for one particularly difficult patient.

The following case history prompted the facility to contract a psychiatric nursing consultant for assistance. The psychiatric nursing consultant evaluated the situation via on-site observations and assessments, e.g. chart reviews, interviews with interdisciplinary administrative and clinical staff, patient interviews. Staff training and education in management of violent/abusive patients based on the facility’s unique needs was then provided, in accordance with Federal and State regulations on chemical and physical restraints, patient abuse and neglect statues of ANA standards of practice.

Case History

Atris, an Afro-American RN Unit Manager, was assigned to care for a Caucasian male biker nicknamed “Bones’, who was admitted to the facility from the hospital following a collision with a tree which left him a paraplegic. Bones is a powerfully built, 53 year old, 6’3” 235 pound man with long hair, a full beard, and a very muscular upper body. He has the words “Fuck you” tattoos on his right upper arm, along with other tattoos on various body parts that convey varying degrees of antisocial sentiments.

As Atris approached the bedside with Bones’ medications, he ordered her to refill his water pitcher and said: “Give me plenty of ice, got that?”. When Atris placed the newly-filled water pitcher on Bones’ bedside stand, he opened the lid and screamed: “You nigger bitch! I told you to give me a lot of ice! You didn’t give me enough ice!”. and hurled the water pitcher at her head. Atris narrowly averted being struck in the head with the water pitcher and Bones continued his tirade as Atris, terrified, cleaned up the wet floor. Atris noted that Bones’ eyes were wide, his teeth bared, and his face flushed as he continued screaming: “Dirty Bitch! You come near me with those pills and I’ll teach you to do what you’re told! I’ll beat the sit out of you!” Visibly shaken, Atris left the room without responding verbally to the patient. She had to take several minutes to collect herself before she could resume administering medications to her patients. She avoided Bones the rest of her shift, yet every time she passed his room he yelled obscenities, racial epithets, and verbal threats at her. Atris notified the shift supervisor, who directed her to document the incident in the chart but who did not come to the unit to evaluate the situation herself, or to provide managerial support to Atris. When Atris arrived home, she was unable to relax or sleep, and dreaded having to return the next day to care for this patient. In the morning, Atris requested an immediate transfer to another unit, saying she was too upset to continue to work on her regular unit. To avoid Atris’ resignation, the facility changed her assignment.

Assessment Findings

Compare the preceding events to the sterile, succinct nursing documentation in the chart. “Patient became angry over insufficient ice in water pitcher; threw pitcher at me; cursed me out and threatened me with bodily hard.” The documentation did not communicate the patient’s rage, impulsivity, emotional volatility, or use of racial epithets. Further chart review indicated that none of the nursing notes included a description of the patient’s many tattoos or the antisocial sentiments expressed by several of those tattoos. The patient’s social history revealed only that Bones was married, had an adult daughter, worked intermittently as a house painter, and took pride in being a long-time biker.

Interviews with hands-on, direct caregiver staff across all shifts revealed that staff were operating in a self-protective, patient avoidance mode, i.e. they limited their contact with Bones. Management interviews revealed that the nurse managers were also experiencing fears, anxieties and stresses similar to those experienced by direct, hands-on caregiver staff regarding management of these types of patients; as well as uncertainty about administrative responsibilities and interventions for bother patients and staff in such situations. Nurse administrators/managers also verbalized concern about regulatory issues related to patient rights, physical and chemical restraints, etc.

Interviews with administration revealed that there was no incident report documenting the patient’s behaviors, and the facility had not addressed the generalized anxiety and apprehensions felt by the unit’s other staff about the patient’s behaviors toward Artis, or staff’s fears about this patient’s potential violence if another staff member inadvertently displeased him.

Interviews with Bones revealed a history of drug and alcohol abuse, incarceration, sporadic employment, wife beating and risk taking behaviors throughout his adult life. These patient data, which are associated with aggression and which are predictors of violence, were not documented in the chart. All of the preceding were only some of the issues involved in this multidimensional case.

Documentation – How To Paint The Picture

Accurate, clear nursing documentation is essential and serves several purposes, including:

• It communicates the patient’s behaviors and emotional volatility to the interdisciplinary team
• It is part of the broader clinical evaluation of the patient’s appropriateness of placement
• It demonstrate the need for psychiatric interventions, chemical restraints, etc.
• It helps identify behavioral patterns by shift, frequency, type, etc. for individual patients as well as for groups of patients over time

Documentation of patients’ threatening, violent or abusive behaviors must communicate the patient’s verbal and nonverbal behaviors, and emotional intensity, volatility, or deliberateness, etc. during the incident. It is essential to paint a clear, accurate, descriptive and vivid picture of the patient’s behaviors for other staff, and so that facility’s administration can grasp the significance of the patient’s behaviors from various administrative perspectives, e.g. staff retention, safety other staff and other residents, quality improvement, risk management, etc.

Language

If the patient uses profanity, racial or cultural epithets, etc., document the patient’s language verbatim in the medical record using quotation marks. Emotional intensity, rage, inappropriateness, social deviance, etc., are best communicated by quoting the patient’s own words. Words are simply that: words. Patients communicate their perceptions, feelings, philosophy, beliefs, values, etc. through words. Words like ‘bitch, nigger, fuck, bastard”, and any other profanities patients may use are the patients’ language, not yours. Chart the language exactly as the patient expressed it. Sometimes nurses will chart a portion of the patient’s profane verbalizations, e.g. “b---h” –“f—k you!”—“n r”—“a—“, and readers must fill in the blanks as they read the notes. This is distracting, and forces the reader to make assumptions about what language a patient actually used. Therefore, regardless of how repelled you may be at a patient’s terminology, the reality is that they are only words, and are part of the patient’s self-expression repertoire (although they may evoke negative emotion in those who hear the language). Also describe the patient’s non-verbal behaviors, e.g. clenched fists, gritted teeth, flushed face, grimacing, flaring nostrils, threatening gestures, tone of voice, etc. Such descriptors, combined with documentation of the patient’s verbal expressions, paint a more comprehensive picture of the patient’s behaviors and events that occurred.

Triggers

Sometimes a patient will demonstrated escalating behaviors in response to certain triggers. In Bones’ case, perceived betrayal by his spouse, who had not only initiated divorce proceedings but who was attempting to sell his house while he was institutionalized in the facility, was one of several potent triggers. For another patient, the trigger was being addressed as “Mrs.” Instead of “Ms.”. Trigger knowledge allows staff to be inserviced on trigger avoidance.

If you become aware of what a patient’s triggers are, document them in the chart, in the interdisciplinary care plan, inform staff across all shifts, inform nursing administration, inform the physician, and flag the patient’s chart in a way that clearly defines and calls attention to the trigger(s). Chart flagging should be routine for potentially violent patients, much the same way as healthcare facilities would flag the chart of a patient with drug allergies. Chart glassing that indicates a potentially violent patient alerts and informs staff and enables a team oriented response to an escalating patient.

Reporting

All too often, nurses and other healthcare professionals, as well as healthcare organizations, are reluctant to report patient violence. Staff who are the victims, and staff who witness violence, may be traumatized physically and/or emotionally, but their physical, psychological and emotional needs can not be met if violence is not reported. Some healthcare organizations tacitly discourage the reporting and recording of violence which further demoralizes an already traumatized, struggling staff.

Violence must be reported, documented and monitored; and healthcare organizations must develop effective systems to identify, respond to, and administratively and clinically manage the violent and/or abusive patient, with consideration of recruitment, retention, staff training and development, quality improvement, risk management, regulatory compliance, and institutional image in the healthcare and larger communities. Failure to report on the part of staff, and failure to deal with the problem realistically and in a timely manner on the part of administration, worsens the problem; leaves staff unprotected and more vulnerable than ever to patient aggression, and increases institutional risks.

Summary

Violence in society is an ever increasing fact of life, and not surprisingly, is increasingly permeating the healthcare sector. Nurses and other healthcare providers must act responsibly in identifying potentially violent patients, in documenting such behaviors, in sharing such information with other staff who must provide healthcare service to such patients, and in working together as a team to recognize, prevent, intervene and evaluate such behaviors in the healthcare workplace. Future articles will address employer responsibilities relative to violence in the healthcare workplace, and employee/co-worker violence.

References:

(1) Distasio, C.A. “The Journey Into Violence”. In P)sychiatric-Mental Health Nursing: The Nurse-Patient Journey. Ed by Verna Carson and Elizabeth Arnold. New York: Saunders and Company. 2 nd Ed. 2000

(2) Distasio, C.A. Violence in Healthcare: Institutional Strategies to Cope with the Phenomenon. The Health Care Supervisor. 12(4), 1994, 1-34.

(3)Violence: A Plague in Our Lane. Waldorf, Maryland: American Nurses Association Publishing Company (1995).

Carol A. Distasio is a Maryland board certified Nurse Psychotherapist who is also a Certified Specialist in Home Health Nursing and is Certified in Gerontological Nursing. She is a member of MNA’s Legislative Committee, Workplace Advocacy Committee, and was Recording Secretary for the Task Force on Safe Patient Care.