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Violence in ER a Growing Problem

BOSTON -- Stephanie Embrey has handled her share of screaming and pushy patients in the emergency room. But the Beverly Hospital ER nurse says an assault in September, when she was belted in the chest by an agitated woman, has left her shaken.

It took four staff members to subdue the woman, who also bit a security guard, said Embry. Hospital officials confirmed the incident.

Embrey - who remains passionate about her job on the front line of healthcare - has joined a growing chorus of nurses statewide who say they are fed up with being punched, kicked, and bitten on the job.

With more patients flocking to emergency rooms and ER waiting times growing, the Massachusetts Nurses Association says its members are fending off an increasing number of aggressive patients, as well as their frustrated family members.

"I've had it," said Sheila Wilson, a registered nurse who has worked in the emergency room at Caritas Carney Hospital in Dorchester for 15 years. She said there were at least three serious assaults by patients on ER staff over the past two months, and those incidents prompted her to speak publicly about the violence problem.

"I am not a political person," she said, "but I can't go to work and worry that I will be assaulted." Caritas Carney officials declined comment on the incidents Wilson cited, which, like the Beverly Hospital assaults, did not result in serious injury.

Nurses say part of the problem is that hospitals have made security guards less conspicuous in an effort to cultivate a more friendly, service-oriented setting. They say the trend comes as ERs are seeing more patients likely to act out because of substance abuse or psychiatric problems; these patients will have fewer treatment options following budget cuts at social service agencies.

Precisely how many assaults take place in emergency rooms is an open question. The Massachusetts Department of Public Health, which regulates hospitals, does not track assaults on healthcare staff members. The state's hospital association also does not track incidents, and the Bureau of Labor Statistics, the federal government's monitor of workplace injuries, counts only assaults resulting in injuries serious enough to miss one or more days of work. That data show there were roughly 200 such assaults a year reported in Massachusetts hospitals between 2004 and 2006, the most recent available figures. The bureau does not detail where in the hospital the incidents occurred.

However, a 2004 nurses association study found that half of all members surveyed reported being punched at least once in the previous two years, and more than 25 percent said they had been frequently pinched, scratched, and spit on, or had hands or wrists twisted.

The nurses association is ramping up a legislative campaign to criminalize assaults on health care workers in the line of duty - similar to a state law that protects ambulance crews, firefighters, and other public employees. It is also pushing a proposal that would require hospitals to identify factors that contribute to violent incidents and minimize them.

For a profession founded on healing, and an industry competing for consumer dollars, the issue is particularly sensitive.

"This is no different than domestic violence was 25 years ago, when it was kept in the home and nobody talked about it," said Evie Bain, a registered nurse and coordinator of the health and safety division of the Massachusetts Nurses Association.

Nurses say hospital violence is substantially under-reported, in part because nurses "are afraid it will show up on their performance evaluation as not being able to handle a patient," said Bain.

Massachusetts Hospital Association spokeswoman Catherine Bromberg said the organization agrees that strong protections are needed to ensure safety for all hospital staffers and patients, and it backs efforts to criminalize assaults on healthcare workers. But, she said, it objects to legislation that would dictate how hospitals should prevent or respond to such incidents because that approach is "too proscriptive."

She said that hospitals are already required to do risk assessments on workplace violence and submit action plans as part of the state's licensing process, and that adding laws to further address the issue could produce "overlapping and redundant regulations."

Caritas Carney officials, while declining to comment on the assaults described by nurses, issued a statement last week saying "workplace violence is an industry-wide hospital problem and not exclusive to any one hospital."

Hospitals are using a variety of approaches to prevent emergency room violence. Caritas, for example, said in February that Caritas Good Samaritan Medical Center received a $25,000 grant from the Department of Industrial Accidents for a pilot program designed to combat workplace violence and enhance employee and patient safety. "This program demonstrates our ongoing commitment to promote workplace safety system-wide," the hospital's statement said.

At Beverly Hospital, Michael Tarmey, a registered nurse and director of clinical operations, said the ER added a specialist in the past year who is available around the clock to simply listen to agitated patients' concerns.

"The number of episodes happening in the emergency department have decreased dramatically ... despite the (patient) volume going up," he said.

At Signature Healthcare Brockton Hospital, officials mandated last year that all ER personnel receive training to manage aggressive behavior after repeated nurse complaints about violence prompted an inspection by federal regulators and recommendations for improvements.

In a written statement, the hospital said it takes "very seriously" the issue of preventing workplace violence, and has also hired a coordinator to manage patients in crisis and has a committee to monitor workplace safety and update policies.

Previous legislative proposals to beef up hospital violence prevention programs statewide and assess criminal penalties for assaults have failed, but nursing leaders say there is new urgency. The state has ordered Massachusetts hospitals by Jan. 1 to stop diverting ambulances to other facilities when their emergency rooms are overcrowded.

"People in pain will be waiting longer for help and, with families watching this, there will be more opportunities for stress," said nurses association spokesman David Schildmeier. "It's going to create a puddle of gasoline in an already explosive situation."

Kay Lazar can be reached atklazar@globe.com

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