An Ounce of Prevention
RNs show that organizing to enforce workplace violence prevention standards can make huge improvements
By Chuleenan Svetvilas
National Nurse magazine - Jan | Feb | March 2024 Issue
Nowadays workplace violence injuries rarely occur at Mercy San Juan Medical Center in Carmichael, Calif., a suburb of Sacramento. But this change was no accident: It is the result of nurses organizing and using California’s workplace violence prevention law to make their workplace safer, and provides an excellent example of how nurses can work to prevent violence in the first place instead of healing from its damage after the fact.
From 2019 to 2021 — two or three workplace violence injuries were happening every month, most often in the emergency department, but also on the medical floor where long-term patients awaited placement in the Dignity Health facility where more than 1,000 nurses work. Agitated patients were physically lashing out, resulting in scratches, bites, sprains, and even a separated shoulder and dislocated finger. Some of the injuries were so serious that staff members were unable to work for months.
“We had been having discussions with management on workplace violence issues for years,” said Frank Bartuska, an RN in the ED, a member of the professional practice committee (PPC), and chief nurse representative since October 2023.
After this rash of injuries, nurses decided to take action. Bartuska and Rebecca Ponziano, an RN in the interventional radiology unit and member of the PPC at the time, began talking with their employer about what could be done to prevent such violence from recurring at the hospital. Reporting procedures were in place, but whenever a violent incident occurred, the reports seemed to go into a black hole. Clearly, something had to change.
“There was no mechanism to identify what was going on,” said Bartuska, who has been a nurse for 30 years, including 11 years at Mercy San Juan. “These things would get shuffled under the rug. Someone would get injured, security would report the incident, but HR would say they didn’t know anything about it.”
The state’s workplace violence prevention law for health care workers, which was sponsored by California Nurses Association (CNA), went into full effect in April 2018. The law’s provisions include requiring health care facilities to report violent incidents and threats of violence, to implement unit-specific workplace violence prevention plans, and to have post-incident response procedures in place.
The hospital already had some workplace violence prevention measures in place, such as identifying a patient’s history of violence in the electronic medical record and informing the RN as part of the patient report that the transferred patient is potentially violent, but workplace violence injuries were still occurring. The RNs leaned heavily on California’s law, particularly the section requiring employers to have a debriefing process in place after a violent incident occurs.
Bartuska says that security had an inconsistent and hands-off response to violent incidents, with anywhere from two to five security guards showing up for code gray. The RNs began organizing in the spring of 2021, collecting signatures across the hospital — including ancillary departments, such as lab, registration, radiology, and environmental services — for a petition of “no confidence” in the security manager. They marched on the boss and presented the letter of no confidence to the chief nursing executive. Within a couple of months, the hospital’s leadership structure changed and the security manager’s position was eliminated. That manager moved to another facility. Under the new leadership structure, there is now a director of security who reports to the senior director for facilities.
Bartuska, Ponziano, and management had many meetings about how to prevent workplace violence injuries from recurring. One result was the addition of door identifiers to warn staff members before entering the room that the patient has a potential for violence.
The RNs called out the lack of appropriate response to violent incidents and pointed out management’s obligation under the workplace violence prevention law’s requirements.
“The law was a very important tool,” noted Bartuska. “There were occasions where we identified problems and filed complaints with the state. The state required our employer to respond to the complaints. We got their attention and they realized they needed to do better.”
Their solution was to create a standing workplace violence task force in 2021, to evaluate incidents and address the security gaps. The task force convenes when an incident occurs and includes Bartuska as the union representative, someone from HR, the security director, security supervisor, the facilities director if an incident was facilities related, the manager of the department where the incident occurred, and the individual who experienced the violence.
“The way we held security accountable is through the workplace violence task force meetings,” said Bartuska. “We debrief the situation, review the actions by security, make recommendations and call out shortcomings in the response. The WPV meetings resulted in a more hands-on approach by security when confronting violent patients as well as implementing practices that deescalate situations.”
Bartuska said that the drop in workplace violence injuries is a direct result of new leadership after the RNs’ collective action when they delivered the letter of no confidence in the previous security manager. With the improved relationship with security, nurses were able to work with security through the task force to identify gaps in their response. He also credits the monthly PPC meetings and the local facility council meetings, which both list security as a standing agenda item, for leading to changes in security patrols, increased camera coverage, and additional security measures. The local facility council includes designated nurses from each Dignity Health facility (per the master collective bargaining contract), human resources, employee labor relations, and hospital leadership.
“We are using the local facility council meetings to address issues of security and workplace violence,” said Bartuska. “Most of our victories recently have come from proactive preventative processes with the employer.”
The RNs also identified other problems in the wake of the slew of injuries, such as the lack of a dedicated security guard for the crisis stabilization unit (CSU), a free-standing facility just outside the ED, which had high potential for violent incidents. Since the leadership change, additional security guards were hired and the CSU has a dedicated security guard. Security now takes a more active approach.
Management also implemented a new post-incident procedure with nurses’ input. Now, after an incident is reported, a manager will talk to the employee within a few days and if needed, activate the employee assistance program (EAP). The manager will also ask the staff member if they would like to participate in a workplace violence prevention task force meeting. Some employees decline to meet because it is retraumatizing.
The nurses had also been pushing for years for metal detectors and a bag-screening process. In 2022, they won metal detector wanding of higher-risk patients in the ER and wanding is part of the screening process for CSU patients. In 2023, security began doing bag searches of visitors entering the ED and no longer allows large bags into the waiting room.
Due to the workplace violence task force and the change in leadership, Mercy San Juan has only had one workplace violence-related injury for the first nine months of 2023. Bartuska is still waiting for his employer to send information on the last quarter of 2023. So far this year, Bartuska says there was one minor workplace violence injury in January, where the employee declined a meeting with the task force, and one injury in February.
“We are definitely seeing improvements,” said Bartuska. “It’s a marathon. “We continue working on identifying problems and trying to get them fixed. We will keep bringing them up until we bring it over the finish line.”
Chuleenan Svetvilas is a communications specialist at National Nurses United.