As patient-on-staff violence increases, Iowa hospitals look for solutions, up security

When a team of University of Iowa Hospitals and Clinics employees six months ago sat down to negotiate a new contract with the Board of Regents, they asked for more than raises, overtime, and family leave provisions.

They asked for protection.

“We have seen over the last several years a significant increase in the amount and types of violence against hospital staff,” Hannah Bott, organizer with the Service Employees International Union representing thousands of UIHC workers, told regent negotiators in January. “It is a nationwide trend, to which UIHC is not immune. It's alarming. Our staff are concerned. We have people who have been in the field for decades who are scared to go into work.

“And we would really like to work with the hospital to see that be addressed.”

In support of union demands that its contract include “workplace violence prevention” provisions like training, safety plans, reporting systems, time-off allowances for those who’ve been attacked, and extra pay for workers in high-violence units, UIHC’s unionized workers shared personal accounts of harrowing experiences.

“I don't think I've ever gone a week here on my unit for four years without being physically assaulted,” said UIHC registered nurse Alex Kestrel, who works in the geriatric psychiatry unit. “I get punched in the face pretty much every week by my patients.”

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Although some of his patients are old and frail, others are former farmers or athletes and are strong — putting him and his colleagues at risk, considering the close proximity required to provide care.

“A few years ago, I did get a concussion working on my unit,” Kestrel said. “I got punched in the face — that's not a weird day for me — and I didn't think much of it. A couple hours later, I got a headache, I'm nauseous, the lights are too bright.”

Kestrel missed work and stayed home after that incident and said he has colleagues who’ve suffered serious injuries, post-traumatic stress, and long-term disabilities from being attacked on the job.

“The amount and escalation of violence that we're experiencing is disheartening and unfathomable,” said Michele Whaylen, who’s been in health care for 37 years — including 20 as a critical care nurse and now as a physician assistant in the UIHC emergency room. “When people come to you for help, and then they treat you so poorly, it is kind of unbelievable.”

Nationwide issue

The problem isn’t just at UIHC — which treats some of the region’s sickest patients and for years has struggled to address long wait times in its crowded emergency room. Patient-on-staff violence is a nation- and statewide problem, prevalent too at Mercy Medical Center and UnityPoint Health-St. Luke’s in Cedar Rapids, for example.

“Unfortunately, it's becoming more common in terms of violence in our facility,” Casey Greene, vice president and chief operating officer at St. Luke’s, told The Gazette. “And unfortunately, it’s across all different departments. Our busiest area is our (emergency department.) It's no surprise that you're going to see a higher incidence in our emergency room.”

Nationally, health care violence has been surging for more than a decade — jumping from an incidence rate of 6.4 acts of violence against health care workers per 10,000 full-time employees in 2011 to 10.4 per 10,000 workers in 2018, according to the U.S. Bureau of Labor Statistics.

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Of the 20,790 non-fatal workplace injuries and illnesses due to violence recorded across all sectors in 2018, health care workers accounted for 15,230 — or 73 percent, according to the bureau.

And that upward health care violence trajectory was pre-COVID, which added new and unprecedented stressors on health care — cramming emergency rooms, depleting hospital workforces, heightening population-based anger and tensions, and exposing a growing entitlement among patients.

“The pandemic has placed significant stress on the entire health care system, and unfortunately, in some situations, patients, visitors and family members have attacked health care staff and jeopardized our workforce’s ability to provide care,” according to a 2022 report from the American Hospital Association — or the AHA.

In 2020, the labor and statistics bureau reported 78,740 cases of non-fatal workplace injuries and illnesses that resulted in at least one off work among registered nurses in private industry — which marked a 291 percent increase over the 20,150 cases in 2019.

Although much of that spike was the result of COVID infections, violence against nurses increased in that one year 33 percent. And Iowa saw the second-highest spike in non-fatal workplace injuries and illnesses among registered nurses from 2019 to 2020 — coming in behind only Michigan.

With a jump from 80 reported in 2019 to 830 reported in 2020, Iowa’s injured or ill nurse count jumped 938 percent, according to the federal bureau.

Reporting 44 percent of nurses experienced physical violence and 68 percent experienced verbal abuse during the COVID pandemic, the AHA has advocated for a “safety from violence for health care employees act” providing protections in the form of a federal law.

“Not only does violence cause physical and psychological injury for health care workers, workplace violence and intimidation make it more difficult for nurses, doctors and other clinical staff to provide quality patient care,” according to the AHA.

UIHC efforts

UIHC ER physician assistant Whaylen seconded that idea — after she and her fellow union bargainers felt they were met with silence on their contractual requests. After sharing their stories and asking for more training, reporting supports, and UIHC incentives to keep violence low — like higher pay for those in high-risk units more — Whaylen said, “We got met with nothing.”

“It was absolutely as if we were talking to a wall,” she told The Gazette. “There was no response. There was no, ‘Can we sidebar talk about this later? Can I get more info?’ There was not a clarifying question asked. There was nothing.”

Data provided to The Gazette in response to an open records request show UI police calls to UIHC have been increasing since at least 2017 — from 267 that year to 371 in 2022. Those numbers include both assaults and non-violent incidents, according to UI police spokeswoman Hayley Bruce.

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In a statement, UIHC officials said, “Workplace violence is an issue that affects many health systems. It is a problem that has been on the rise in recent years, and there is national data that speaks to this trend.”

Listing efforts UIHC has taken to “maintain a safe and welcoming environment,” officials cited a Workplace Safety Committee that identifies and implements best practices to protect and support employees facing rising threats of violence.

Among other efforts officials cited, UIHC also has:

“Over recent years, we have seen an increase in behavioral emergencies, which is consistent with the trend seen nationally,” UIHC officials said. “At the same time, our workplace safety initiatives have helped us reduce the number of behavioral emergencies that turn violent.”

That is not Whaylen’s experience, telling The Gazette last week that verbal and physical attacks have continued against her and her colleagues.

“You know what the sad part is? Now I don't think of it as much because it's just become part of my job and the fabric of my work — it’s pathetic,” she said. “It's kind of like, six people swore at me today, and it's not even notable.”

Acknowledging efforts UIHC has taken, Whaylen said she hasn’t felt an impact. Addressing the “alarm buttons,” Whaylen said — from the worker view — the rollout was rocky.

“They found many parts of the hospital the Wi-Fi wasn't good enough to support it, particularly in the older sections of the hospital,” she said, noting the hospital also experienced false alarms and collected the alarm buttons all back. “The rollout of the system hasn't been good.”

Since fall 2021, UI police report increasing the public safety presence on UIHC’s campus, improving response times; and holding joint training and compliance requirements, improving communication and collaboration.

“Since the beginning of the COVID-19 pandemic, those who work in the health care field across the country have experienced an increase in workplace violence due to the increased stress the pandemic has placed on the entire health care system,” UIPD spokeswoman Bruce said. “The UI Department of Public Safety has been proactive in partnering with UI Health Care Safety and Security team to address this issue and provide support.”

St. Luke’s, Mercy violence

At St. Luke’s in Cedar Rapids, the hospital from 2015 to 2022 saw a 144 percent increase in “safety and workplace violence reports for our team members,” according to a spokeswoman. Some of that, Vice President Greene said, was due to education and training on the import of reporting incidents.

“But, unfortunately, these types of incidents are up quite a bit,” Greene said. “I look back at our data, and we've seen the rate of these more than double over the last five to seven years.”

St. Luke’s for years has had a “workplace violence committee” and additionally holds daily safety huddles to address local issues and concerns.

“More recently, over the last year, we actually have a daily huddle that involves all regions of UnityPoint Health,” Greene said. “That allows us to raise up safety concerns such as this and learn from other regions to help us put protocols in place.”

When looking at the “why” behind the rise in violence, Greene said, “hospitals are emotional places.”

“We see patients at their extreme,” he said. “So we have seen everything from verbal abuse to injury that has occurred with employees. And everything in between.”

Like at UIHC, St. Luke’s has added security officers to places like the emergency department.

“Sometimes the presence of a security officer alone will help mitigate some of those events,” he said.

At Mercy Medical Center nearby, Claude Howard directs hospital security and leads a security team that’s grown to about 24.

“That’s increased for sure,” he said. “The organization has made a huge commitment to making sure that our security department is well supported.”

When Howard started in the role six years ago, Mercy’s minimum — and sometimes maximum — staffing was two officers per shift. Today that has bumped up to a minimum of three and as many as five.

Through a de-escalation course, Howard also educates workers on how to identify red flags, diffuse a situation, protect themselves in a room, and call for help if they need it.

“And then I just talk about normal approaches to de-escalation,” he said. “Like how we enter a room.”

Howard trains workers to start from a distance and work in “as we get more comfortable or the patient begins to feel more comfortable.”

“I say things like, ‘Whatever you say from two feet away, you can say from six feet away’,” he said. “That creates a kind of bubble around a space where you can see the whole person and not be so close.”

The why?

UIHC workers have been trained to do the same, but Whaylen said she feels some of the protections have affected care — which in turn affects patients.

“It's really changing how we deliver care,” she said. “When I used to go into a room, I used to sit at the patient's bedside, maybe put my hand on their hand, those kinds of things — because the human touch, we were taught when I went to school, was one of the most healing things you can do.”

But years of escalating patient aggravation and aggression has shifted her tactics.

“Now I find I position myself by the door where I have a quick exit,” she said. “I'm always checking that I'm in a safe position.”

Like hospital systems nationwide, Whaylen said she saw aggression surge during COVID — when the mention or suggestion of a COVID test could send a patient into a rage. Today, she said, some of that rhetoric has died down.

But, she said, demand for health care has remained high — creating bottlenecks getting into specialists, forcing patients into the emergency room, which is crammed with patients who can wait for many hours without being seen.

“The ER is full of people who are laying in the hall, we've got people who are being hospitalized who are sitting out in the waiting room who never got an emergency room bed,” she said. “They never laid in an ER bed, and they're being admitted to the hospital.”

Patients, feeling at their worst, can topple over into physical and verbal aggression when they don’t get the care they believe they need.

“That just creates the perfect storm for people,” Whaylen said. “They’re stressed. They don’t feel good. Or their loved ones don’t feel good. And it creates a perfect storm for emotional outbursts — because people finally have to escalate to get attention.”

Plus, she said, where patients used to present with respect for health care professionals at hospitals and clinics, today so many feel entitled to service.

“There’s just so much entitlement,” Whaylen said, and “Googling.”

“Sometimes they Google something,” she said, “so they think their situation is much more dire than it is and they feel very frustrated that you haven't responded.”

Care givers also have seen more mental health concerns and medication addictions and demands. And all the stressors on health care professionals are pushing them out — even as nursing shortages, for example, are among the reasons hospitals and clinics can’t keep up.

“I can tell you, personally, I went to part time just enough to save my benefits so I can get my last two kids to college,” she said. “I can hardly wait to be done, and I have been a person who has loved my job.”

Although some of her peers have left entirely, Whaylen said, “I am barely hanging on.”

When looking at solutions, she suggested metal detectors and a focus on competitive compensation — attracting more health care professionals to keep up with the rise in patients. Expanded ER space and beds could help, and Mercy’s Howard said he thinks more safety and de-escalation education needs to happen at the collegiate level.

“We do the best we can to educate them here,” he said. “But sometimes that can be a step too late.”

Vanessa Miller covers higher education for The Gazette.

Comments: (319) 339-3158; vanessa.miller@thegazette.com