In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of AnnMarie Papa, DNP, RN.
This profile was published in the December, 2011 issue of HealthLeaders magazine.
"Yes, we're here to care for patients, but we also have to care for each other."
It wasn't until 2009 that senior hospital administrators really began paying attention to the prevalence of hospital violence, especially that which occurred in the emergency department, says AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, president of the Emergency Nurses Association.
That's the year ENA researchers published their first survey of emergency nurses' reports of violent attacks while on the job. The paper was accepted for publication in the Journal of Nursing Administration, which meant that the C-suite who read it would learn some disturbing statistics.
The survey revealed that of 3,465 registered nurses who work in EDs or trauma centers in every state, one in four had experienced physical violence more than 20 times in the past three years, and almost one in five had experienced verbal abuse more than 200 times during the same period. Violence against nurses was said to be "prevalent."
"It was a landmark study," says Papa, who as ENA president-elect helped generate widespread awareness. "We published in that journal because we wanted to get the attention of the hospital's senior administrators, and it was an eye opener for them. Once they read this, they said, 'Wow, this is something we really need to take a look at.'"
Nurses said they were spit on, hit, pushed or shoved, scratched, and kicked in psych units, EDs, waiting rooms, and even in geriatric units. The perpetrators usually were patients and their family members and visitors. Verbal hostility was common as well. At least 70% of respondents said they had been yelled at, cursed, intimidated, and harassed with sexual language or innuendo.
Reports of such incidents rarely made their way to administrative offices before this, says Papa, who is the clinical director of Emergency Nursing at the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center in Philadelphia.
“Administrators just don’t spend a lot of time down there, and nurses never used to complain; they thought of it as part of their job.”
Additionally, some nurses said they didn't report incidents because of hospital reporting policies that were unclear.
Papa has been working in ED settings for 35 years, and over that time, she says, "I've seen the landscape of the emergency department and the types of patients that we have change. Now we have a lot of issues with flow and overcrowding and patients with behavioral health disorders."
She's even been a victim of violence herself. Once, a patient punched her in the arm. Another patient, who was upset with the care he received, threatened to kill her. It frightened her so much she reported him to police, which sent investigators to the patient's home.
She's also witnessed violence against coworkers. "Once a patient strangled one of our nurses. He grabbed the nurse's shirt and kept twisting."
Another time, she saw a drug-seeking patient hold a knife to a nurse's throat as he demanded narcotics. Papa walked closer, told the man the nurse didn't have the keys to the drug cabinet, but she did. Only if he dropped the knife would she consider helping him. He did and the crisis was averted.
Papa has become a leading voice for this issue, speaking at events internationally and helping format a guideline for hospitals to safeguard their emergency workers.
In 2010, it started to pay off. The Joint Commission published Sentinel Alert #45, Preventing Violence in the Workplace Setting, which called attention to the issue on multiple levels.
Papa's spoken frequently to leaders with the Occupational Safety and Health Administration to help them appreciate the increasing problem of violence in healthcare settings and has helped develop a toolkit for hospital administrators to evaluate the safety of their EDs and trauma centers.
The ENA says hospital leaders can reduce violent incidents if they:
- Create a culture that prompts staff to report violence.
- Train staff to recognize suspect behaviors in potentially violent people.
- Provide personal panic buttons rather than wall units so staff can quickly notify others when they get in trouble.
- Position cameras at better angles.
- Use and monitor metal detectors.
- Partner with hospital security and law enforcement personnel to develop procedures for dealing with violence.
- Post "violence zero tolerance" signs.
"Having a zero tolerance policy is the most important thing a hospital can do," Papa says. "And that means not just having a policy in writing, but really live and learn the policy, and every time there is an act of violence, do a root cause analysis and work to fix it."
Despite the successes, Papa does not see the issue going away. Today, hospital patients are sicker and more stressed out, she says, and they are more demanding of an immediate response from healthcare workers. Acts of violence are gravitating from emergency and trauma settings even to inpatient and intensive care units. Lateral violence—actual physical abuse and verbal intimidation between healthcare workers—is an increasing problem as well.
Those two issues are next on Papa's agenda, and more surveys are planned.
Papa says that the past three years have been very rewarding because she feels she's empowering other ED nurses to speak out, and that has made a big difference. "Yes, we're here to care for patients, but we also have to care for each other," she says.