TAN Issue: January/February 2001: Features: Illinois RNs Win Workplace Safety Measures

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by Susan Trossman, RN

Zero tolerance

What a difference a year can make. Just ask the nurses at Zeller Mental Health Center.

Last year, nurses at the central Illinois facility feared for their safety and that of their patients every time they stepped onto their units. And why not? One of their own, long-time registered nurse Mary Grimes, was lying in a coma after being slammed into a metal door frame by a patient who had a documented history of violence. Nurses were convinced that despite all their efforts, they could never change management's view that workplace violence just came with the territory.

But change has come to Zeller -- in terms of both new policy and management's attitude, and members of the Illinois Nurses Association (INA) local have been instrumental in creating that safer workplace. Further, nurses are hopeful that more workplace improvements are on the way.

"I'd say one of the biggest changes is that management no longer sees violence as 'part of the job,'" said Brooke Beal, RN, a Zeller bargaining unit member. "Before Mary's injury, our administration never tried to prevent injuries."

Now, management is focusing on prevention and advocating a "zero tolerance" policy when it comes to workplace violence, according to Beal, chair of an ongoing labor-management committee responsible for developing policies and procedures that address workplace safety.

"We really have come a long way in just one year," said Debbi Reed, RN, president of the Zeller bargaining unit and chair of RC-23, the bargaining unit that represents all state-employed nurses. "Now when we tell management that something is not working, they believe us."

One major catalyst behind management's new attitude was the hiring of a new medical director and director of nursing in March 2000 who shared staff concerns about worker and patient safety. The other catalyst was the efforts of bargaining unit members who waged a public awareness campaign aimed at ending workplace violence in their facility following the November 1999 attack on Grimes (See story, Jan./Feb. 2000 The American Nurse).

"We as nurses stepped forward and kept on speaking out loudly," Reed said. And when the nurses spoke, legislators, the media and eventually management listened. Their efforts -- in conjunction with INA and other INA-represented mental health nurses -- sparked a state legislative hearing on violence in health care settings.

The testimony of the Zeller nurses and others then led to a House Committee on Mental Health and Patient Abuse directive requiring the state Department of Human Services (DHS) to gather information on state health care facilities' safety and medication protocols and other related workplace policies, as well as to track episodes of violence against workers. Further, the committee asked the DHS to look into management's seeming acceptance of violence as part of a staff nurse's job.

At Zeller, nurses and management formed several joint committees aimed at tackling different aspects of workplace safety. Some of the committees' recommendations have been implemented over the course of the past year, while other safety measures still are being hashed out.

Among the reforms already implemented are:

* Nurses have greater freedom to use their professional judgment when it comes to placing violent patients in restraints or seclusion, and no longer face criticism when they choose to use these methods. Further, nurses now have emergency medication ordered on admission for patients who are violent or who have a strong tendency to become violent.

* A patient care monitoring team has been formed to deal with patients who are identified as "problematic." The team reviews those patients' histories, treatment plan and medications, and then devises a plan to help staff better work with them.

* All staff are armed with personal safety alarm devices they can trigger when endangered.

* Two-way radios are readily available on all units to contact security.

* Security staff have been freed from tasks that previously took them off-site much of the time, so they can respond to on-site emergencies.

Other policies are still in the works. One proposed policy would require staff to inform patients on admission that violence will not be tolerated and spell out the consequences of violent actions against staff or other patients. (It was unusual that Grimes' attacker was formally charged.)

Another would require nurses to continually rate all patients on specific indicators, such as violence potential, physical aggression and suicidal ideation.

On another front, Zeller staff has participated in formal training on workplace violence prevention and other targeted safety strategies.

"All staff members -- social workers, techs, nurses and physicians -- were required to attend a two-day workshop on the theory of violence and violence prevention," Reed said. During the workshops, which were held from August to October 2000, staff and administrators addressed topics ranging from the overall plan to move toward a "zero tolerance" policy on violence to efforts to educate the state's attorney and law enforcement about the need for legal intervention.

Reed and some of her co-workers also participated in a November 2000 training for staff interested in participating on an 11-member "debriefing team." This team is available to provide support and follow-up to any staff member who experiences a workplace violence-related injury or a close call. Previously, no formal support was given to staff who were attacked.

And yet another training focused on a new policy that requires staff to check all new admits for contraband, which includes any item that can be used as weapon, as well as alcohol and drugs.

"All these changes occurred as the result of a concerted effort between nurses and management and because of mutual respect," Reed said. "That's not to say we always agree, but we respect each other and no (topic) is off limits."

As for workplace issues that still need to be addressed, Reed would like nurses to make greater strides in the area of professional autonomy. And staffing levels still have not increased.

"The main thing is, nurses feel safe. And so do the patients," Reed said.

Beal agreed, saying, "There's still a fear of injury, and injuries still occur. But I think people do feel safer now that we're working as a team. Everyone is watching for each other's back now."

And there has been less of a need to place patients in restraints or seclusion since many of the safety strategies were implemented, Reed reported.

As for Bruce Perona, the patient who attacked Grimes, he recently was sentenced to 30 months' probation after pleading guilty to one count of aggravated battery. He currently is confined to a maximum security mental health care facility for several months until he is reevaluated. Perona, a diagnosed schizophrenic, also was ordered to take medication as a condition of his probation, according to the Nov. 21, 2000, Peoria Journal-Star.

Grimes, who had been in a coma for several weeks due to a severe head injury, is still recovering.

She was present at Perona's hearing, where she "extended a gesture of friendship" to his family, the Journal-Star reported.

"Mary had a miraculous recovery and has made great strides," Beal said. "But her life is forever changed."

Susan Trossman is the senior reporter for The American Nurse.

Workplace Violence Resources

ANA's brochure "Workplace Violence: Can You Close the Door?" -- Call (800) 274-4ANA or go to www.NursingWorld.org.

"The Epidemic of Violence in Health Care Settings: An Industry in Denial" -- a 73-minute video produced by ANA and the Foundation of the National Student Nurses Association. Call (212) 581-2211.

"Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers" -- U.S. Department of Labor, OSHA 3148-1996. Go to www.osha-slc.gov/SLTC/WorkplaceViolence