The Raleigh nurse becomes aware of the cool tile floor on her face, then realizes the red clouding her vision is from blood spreading under her broken nose. The clock reads 3 a.m. on a sultry July night. Gradually, she slips back into unconsciousness.
In a perfect world, the nurse involved in the 2022 incident at Duke Raleigh Hospital would have known that the man who smashed her face with his fist had a violent record, including assaults on women. But it’s an increasing problem affecting hospitals nationally.
Last year, assaults on healthcare workers reached a record level, according to a report from the National Institutes of Health. Reported assaults increased 5% in 2023 compared with the previous year, to an all-time high of 2.59 per 100 personnel. While healthcare workers make up 10% of the U.S. workforce, they experience nearly half of the non-fatal injuries tied to workplace violence, a Bureau of Labor Statistics report notes.
“Unfortunately, hospitals aren’t like airplanes,” says Lorie Rhine, UNC Rex Health’s chief nursing officer and a national expert on helping healthcare workers work safely. “You can’t put patients on a no-treat list like a no-fly list. There’s always the potential you’ll have someone show right back up in the emergency room again.”
Adds Julie Kennedy Oehlert, chief experience officer at ECU Health in Greenville, “It’s important even before you get to that point to create a safe environment all around, before you have to de-escalate.”
ECU Health and an increasing number of Tar Heel hospitals now drill healthcare workers on simple, quasi-psychological techniques that signal when to try to de-escalate potentially violent situations. The Greenville-based system’s 4,000 nurses have mandatory annual training modules on de-escalation, though Oehlert says all healthcare workers face risk. “That’s true whether you are working in the emergency room or the cafeteria,” she says.
In case de-escalation fails, ECU Health pioneered the use of panic buttons in patient rooms, similar to those used by bank tellers, to permit nurses to discreetly summon help.
The NIH report says incidents are concentrated in emergency rooms, psychiatric units, pediatric departments and perioperative units. A Durham mental-health nurse practitioner was killed two years ago when stabbed to death by a patient.
Earlier this year, the national Emergency Nurses Association’s survey of 500 members showed 56% of respondents had been physically or verbally assaulted or faced threats of violence in the prior 30 days.
“This is happening every day, and unfortunately, many healthcare workers have determined this is part of their jobs,” adds Rhine. “We encourage them to report every case, but a lot still aren’t reported.”
Defusing tense situations can occur “through purposeful actions, verbal communications and body language to calm incidents,” says Tatyana Kelly, who heads a task force on worker safety at the N.C. Healthcare Association, which represents most of the state’s 120 hospitals. “Hospitals use a variety of methods to implement this training.”
What’s behind the rise in assaults on healthcare workers? Experts point to a number of factors, including that healthcare has become expensive, unwieldy and taxing for many patients and families. Societal trends also matter.
“We are less civil as a nation, and that is so true in smaller ecosystems like healthcare,” says ECU Health’s Oehlert. “And healthcare can be frustrating. We have a need for instant gratification, and healthcare can be so frustrating.”
While various Tar Heel hospitals use different systems, most focus on reducing some of that frustration.
Novant Health uses “management of aggressive behavior,” which stresses that workers identify warning signs of conflicts and summon help if necessary. At Cone Health and other places, workers are trained in safe, responsible ways to restrain patients.
A common approach is the Broset Violence Checklist, which coaxes healthcare workers to discreetly rate patients on a scale of six, in which upper numbers indicate greater danger. At the lower end, the patient might be disoriented, unaware of time or place. Going upward, a patient might be easily annoyed or “boisterous,” slamming doors and shouting.
Near the danger end, the patient might be physically threatening others, grabbing the healthcare workers’ clothing, or throwing objects or smashing windows.
The failure to de-escalate is costly, says ECU’s Oehlert. “Nurses who have been attacked — and that happens every day, we are just better than most in reporting it — tend to have lingering anxiety and even post-traumatic stress disorders,”
she says.
N.C. hospitals have gained support in their efforts to prevent harm to healthcare staffers through the Hospital Violence Protection Act, passed by state lawmakers this year.
It requires hospitals with emergency rooms to make risk assessments and post a law-enforcement officer on duty unless the hospital and local law-enforcement organizations agree that it is not necessary. The bill introduced by N.C. Rep. Tim Reeder, an emergency room doctor in Greenville, also requires de-escalation training.
The law builds on a 2015 one that made it a felony to assault healthcare workers. That hasn’t had as sufficient impact due to a lack of enforcement, industry leaders say. There’s hope the new effort can turn the tide. ■
