When the Patient Is a Prison Inmate

How Can Hospitals Better Protect Their Staff From Violence?

Troy Brown, RN


August 15, 2017

Nurses React to Report of Rape by Patient

Many nurses read, and commented on, the Medscape article Nurses Sue Over Hostage, Rape Incident at Illinois Hospital. This report highlighted the dangers faced by nurses when caring for prison inmates.

Here's what happened: Tywon Salters, an inmate being treated at Delnor Hospital in Geneva, Illinois, overpowered a corrections officer who was guarding him and grabbed his gun. He took two nurses hostage, beat them, and raped one of them at gunpoint while the corrections officer cowered in another hospital room. Those nurses, their husbands, and two other nurses are suing the corrections officer, the county he works for, and the company that provides security for the hospital.

Numerous security protocol violations occurred in the days leading up to the incident. The first officer from Kane County sheriff's office allegedly fell asleep on the couch during his duty and was replaced.

"The suit alleges other security protocol violations, including that Salters was freely using the hospital phone and that the sheriff's guards were distracted by their own cell phones and laptops," Alicia Ault wrote on Medscape.

"Finally, on May 13, [Kane County corrections officer Shawn] Loomis removed Salters' shackles, allowing him to use the bathroom. Salters requested the restraints stay off in case he needed to go again. One nurse who came into the room questioned why Salters was unrestrained, but Loomis allegedly did nothing. The prisoner was then able to steal Loomis' gun, and Loomis allegedly ran away and locked himself in a room while Salters had free rein in the hospital."

After our story was published, many nurses wrote in to describe their own experiences with violence at the hands of patients, or to describe how their facilities prevent violence arising from the care of custodial patient, or "prison patients." [Note: Some comments have been edited for length and clarity.]

After this incident, every nurse...carried a scalpel in her pocket, and some carried two.

One nurse who works in a busy emergency department told of a patient who grabbed another nurse and held her in a locked room for hours before eventually releasing her unharmed. "The situation could have ended much differently. After this incident, every nurse, including myself, carried a scalpel in her pocket, and some carried two," she revealed.

Nurse Endangerment Far Too Common

From 2011 to 2013, US healthcare workers suffered 15,000-20,000 workplace-violence–related injuries each year that were serious enough to require them to be absent from work.[1] The number of injuries that occur in healthcare is almost as many as in all other industries combined.[2]

Nurses in all specialties are vulnerable. Patients who are intoxicated or withdrawing from drugs can be found throughout a hospital, as can patients with dementia and psychiatric issues. Patients coming out of anesthesia can be combative as well, and nurses can find themselves dealing with distraught relatives, gang members, and intimate partner violence situations. Nurses who work in home health, hospice, and nursing homes are also vulnerable.

Other healthcare providers, including physicians, nurse assistants, lab workers, radiology staff, and social workers, can also be victims.

"We have to have zero tolerance," Susan Y. Swart MS, RN, CAE, executive director, ANA-Illinois and Illinois Nurses Foundation, told Medscape Nurses. "We need to be backed up when nurses report things, and make sure that we have policies in place that handle the situation. We have to make sure that we have policies about when the nurse takes action or what action the hospital will take when an incident occurs, to hold all of the individuals accountable."

Ms Swart has been working with the nurses at Delnor Hospital, and said that the incident has profoundly affected all of them, whether they were directly involved or not. She pointed out that in Illinois, it is a felony for an individual to harm a nurse who is caring for them, and that such laws need to be enforced to the fullest extent possible.

Regulatory Agencies, Professional Organizations Speak Out

Regulatory agencies and professional organizations have published guidelines on violence in healthcare facilities, some of which specifically address active shooter situations. The Joint Commission published a safety advisory on active shooter situations in July 2014 that includes a February 2017 addendum.

The Occupational Safety and Health Administration (OSHA) requires hospitals to protect staff and to provide a safe working environment. OSHA released Preventing Workplace Violence: A Road Map for Healthcare Facilities[1] in December 2015, along with a related document: Guidelines for Prevention of Violence for Healthcare and Social Service Workers.[3]

The California Nurses Association was the primary sponsor of California Senate Bill (SB) 1299—the "Cal/OSHA Workplace Violence Prevention in Health Care standard"—approved on December 8, 2016. "The new California regulations generally require hospitals to develop, adopt, and train employees on comprehensive workplace violence prevention plans, as well as set much stricter reporting requirements," according to a California Nurses Association/National Nurses United news release. The law requires hospitals to report violent incidents involving weapons or injuries to Cal/OSHA within 24 to 72 hours, and to keep written records of those incidents for 5 years.[4]

Ms Swart said that any guidelines related to workplace violence need to be adapted for the various settings where nurses work, including home health. "It cannot be 'one size fits all.'"

"The hospital did not protect its staff, and certainly the 'contractor' safety officer did nothing to guard the prisoner/patient appropriately and he lacked the knowledge, skills, or ability to do the job," one nurse commented.

Identification and Prevention of Potential Hazards Critical

Administrators must make prevention of workplace violence a priority and communicate this to staff and visitors. They should set goals and objectives; give staff adequate resources and support; appoint knowledgeable leaders and give them the authority to make changes; and document performance. Managers should include employees in all aspects of the program and encourage them to communicate ideas and concerns without fear of reprisal.[1]

Risk factors can be related to the patients or visitors, and include the prevalence of weapons; working in high-crime areas; working with patients who have a history of violence, abuse drugs or alcohol, or are gang members; or working with distressed friends or relatives. Risk factors can also include working in a poorly designed facility, such as one with poor lighting or overcrowded or uncomfortable waiting rooms, or where employees' vision or ability to escape from a violent incident are impeded.[1]

Commented one nurse, "Prisoner patient rooms should be set up as (and remain) the same as a psychiatric room for a violent or suicidal psychiatric patient. That should be the hospital protocol."

One nurse said that although the patient technically did not qualify as an intensive care unit patient, the "goldfish bowl" nature of an intensive care unit room would have allowed all staff to observe the patient continuously. That nurse recalled once successfully advocating to have a dangerous patient moved to intensive care for that purpose.

Understaffing, inadequate security, too few mental health personnel, high worker turnover, overcrowding, and long waiting times also elevate risk for violence.[1]

Hospitals should have procedures to identify and correct environmental and patient-specific risk factors and take steps to provide adequate staffing, eliminate sight and communication barriers, and provide surveillance and alarm systems.[4]

Processes and procedures should ensure ongoing identification of workplace hazards and risk evaluation; tracking of progress in implementing controls; formal postincident reevaluation; comprehensive accident review boards; and after-action reviews, according to the OSHA roadmap.[1]

Nurses and other healthcare providers should avoid wearing lanyards, stethoscopes, or jewelry around their necks, which can be used to choke them. Hoop and drop earrings—even small ones—can be pulled through the earlobe. "Wear long hair up, even if in a ponytail. Grabbing it is one of the easiest ways to get physical control over you," one nurse commented. During the incident at Delnor hospital, the inmate held the nurse's hair in one hand and put the gun to her head with the other hand. Wearing a hairnet can also make it more difficult for someone to grab a potential victim's hair.

Staff Training, Clear Expectations

All employees should undergo education or training on hazard recognition and control, their responsibilities under their organization's program, and steps to take during emergency situations.[2] "We do disaster preparedness, but we haven't been as good about preparedness for hostage or those kinds of emergency situations," Ms Swart said.

We do disaster preparedness, but we haven't been as good about preparedness for hostage or those kinds of emergency situations.

Training should include preventive measures, such as how to recognize cues that a patient or situation may become violent, neutralize potentially violent situations, prevent or manage violence, and avoid physical harm.[1]

Nurses should collaborate with law enforcement and other public safety professions to adapt their training on issues including deescalation of potentially violent situations, Ms Swart said. "We don't need to reinvent the wheel."

Active shooter incidents are unpredictable and evolve rapidly, usually ending within 15 minutes, the Joint Commission explains.[2] Although law enforcement is sent immediately, the situation may be over by the time they arrive. For this reason, healthcare organizations and staff must be prepared.[2]

Training should include how to report and respond to active shooter events; what to expect when law enforcement arrives; how to protect patients; awareness of high-risk, security-sensitive areas (such as the emergency department, operating rooms, and pharmacy); and how to implement mitigation strategies," according to the Joint Commission.[2]

Security personnel; "house supervisors"; and others who need to be aware of, or involved in, incident command support during a situation should undergo specific training in this area. Healthcare facilities should conduct periodic drills or "tabletop" exercises to prepare staff for an active shooter situation.[2]

Organizations and their staff must maintain accurate records of injuries, illnesses, incidents, assaults, hazards, corrective actions, patient histories, and training. These records can assist employers to "determine the severity of the problem, identify trends or patterns, evaluate methods of hazard control, identify training needs, and develop solutions for an effective program."[1] The organization should evaluate programs regularly to identify weaknesses and possibilities for improvement.[1]

Hospitals, Law Enforcement Should Work Together

Both hospitals and law enforcement agencies should have policies with input from nursing and security staff. Hospitals should have a plan that assists and provides access to law enforcement personnel, possibly including a "go kit" that contains access badges, the location of the hospital's incident command center, and electronic and hard-copy life safety drawings.

Another nurse commented, "My hospital held seminars and policy reviews that included the warden from our local prison. They clearly laid out the expectations for both correctional officers and hospital staff. We have clear guidelines on how to immediately report any deficits in security or care. We work closely with hospital security and report in daily safety briefings the number and the location of custodial patients. The higher-risk patients have two officers. The officer in closer proximity to the patient does not have a firearm; all doors and curtains are open; and no phones or laptops are allowed."

Shackles: No Exceptions

Patients should be shackled at all times, unless they are in childbirth or the medical caregiver judges it medically appropriate to remove the shackles. Several nurses with experience caring for prisoner patients explained how shackles are used in the hospital setting.

"Shackles are never to be removed, and if they must, it has to be done in a specific order such that the prisoner remains shackled at all times (and secured to the bed frame appropriately). One is removed while another is still in place securing the prisoner patient. At no time should a prisoner patient be allowed to go unshackled just because a guard says it is okay," a nurse wrote.

"If a man is guarding a female patient (or vice versa), then two hospital staff have to be present to provide care behind a curtain, with the guard positioned on other side of the curtain. Patients are given urinals and bedpans rather than bathroom privileges," another nurse explained. "Physical therapy staff are present with the guard when the patient dangles, or stands. Nursing staff check shackled areas for skin breakdown and document this on a special prisoner flow sheet. The guard has to verify shackle security at same time." If a patient must be unshackled for any reason, such as to transport the patient to the radiology department, two guards must be present.

One nurse commented that at her facility, guards were required to remain alert; they must be relieved for break and are not allowed to use their phones or laptops. "No phone calls are allowed, and the patient's name should not be on the hospital's admission list," emphasized another nurse.

Getting Started

Nurses need to take a systematic approach to addressing this issue, Ms Swart said. First, they need to process their own emotions about the incident and others like it. "Part of public policy is losing the emotion, but not the passion, for a situation," she explained.

For example, the ANA-Illinois is gathering data, having conversations with individuals, and assessing the legislation. The next steps are dealing with "low-hanging fruit"—immediate policies that can be addressed within 30 days. If your hospital has a zero-tolerance policy that includes reporting every incident of violence against a healthcare worker, "put a sign up, so that every person entering your facility knows. That seems simple, but for some that's enough," Ms Swart said.

Nurses trying to make changes at their own hospitals should talk with like-minded colleagues throughout their institution and not try to do things alone. Get a "core team of nurses together. We are always better united than alone," she recommended.

Go up the chain of command if your immediate supervisor is unreceptive; for example, perhaps there is a nurse leader responsible for your unit and several others, or a vice president of nursing. The risk management department can be another good source of support. "We don't always appreciate the value of risk management," Ms Swart said.

When trying to pass legislation, nurses should understand how the legislative process works in their state and be sure that hospitals and other stakeholders are willing to abide by new regulations. "The best type of public policy to put forward is one where you have multiple stakeholders' buy-in and support, so that you're more likely to get it passed," Ms Swart concluded.

Web Resources

American Hospital Association. Active Shooter Response Toolkit: Healthcare Staff Training

Department of Health and Human Services' Office of the Assistant Secretary for Preparedness and Response. Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans

New York State Health Emergency Preparedness Coalition

California Hospital Association

Emergency Nurses Association. Workplace Violence Resources


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