Mission nurses call for management to address workplace violence

by Andrew R. Jones, avlwatchdog.org

Choked. Hit. Kicked. Thrown against walls.

Nurses at HCA Healthcare-owned Mission Hospital face a steady stream of assaults and violence in their workplace and say management needs to do more to prevent their physical injuries and emotional trauma.

The violence is so prevalent that nurses called Asheville police 25 times in 2023 and complained that year to the North Carolina Department of Labor about management’s inaction. The NCDOL closed its investigation but conceded to Asheville Watchdog that it never visited the hospital to look into the matter, citing staff shortages and a heavy workload.

Nurses and other staff also detailed assaults to the U.S. Centers for Medicare & Medicaid Services late last year as it investigated deficiencies in care at the hospital.

Mission emergency department nurse Misty Jackson described a recent assault in which she called security but continued to be attacked during the several minutes it took for help to arrive.

“I’ve got hit in the head multiple times waiting for them to get there,” Jackson said. “Like, I had a headache for three days afterwards.”

Jackson and other employees said Mission isn’t devoting enough resources to address violence. It especially needs to apply more security and add more nursing and auxiliary staff to deter attacks, they said.

Workplace violence in health care, especially in hospital emergency departments and mental health facilities, is widespread. The World Health Organization estimates that as many as 38% of nurses experience violent abuse – physical, psychological or sexual – during their careers.

And when hospitals don’t have adequate staffing in place to prevent abuse, nurses can be even more vulnerable, research shows.

About 20 Mission Hospital union nurses spoke out about violence in the workplace at a recent contract bargaining session, according to several nurses who were present. They testified to Mission and union leadership about how they had been choked, thrown against a wall, cornered in an elevator, and forced to crawl to safety.

Mission nurse and union representative Elle Kruta, who was present during the testimonials, described to The Watchdog a fellow nurse’s violent assault and the trauma she endured.

“[She] had to come back the next day and be on the same unit where the patient was being treated,” said Kruta, adding that the nurse didn’t have a choice about returning to work. “It’s not just physical violence, it’s emotional trauma.”

Mission Health spokesperson Nancy Lindell said the hospital tracks violence, provides training to staff and has different teams who respond to threats of assault.

“Mission Health keeps data on assaults, and colleagues are asked to enter reports of physical and/or verbal assault into our system, both in the patient record and as a staff report,” Lindell said.

The Watchdog asked Lindell how many assaults had occurred in the past 10 years but she did not respond.

Employees who work on behavioral health units and across the hospital wear duress badges, technology meant to provide assistance at the press of a button, Lindell said.

“We recognize that we are seeing patients and their families at a moment in their lives that is often filled with stress and uncertainty,” Lindell said. “That is why we also provide de-escalation training classes for all ER staff, behavioral health staff, security and our Behavioral Emergency Response Team (BERT) members including a Crisis Prevention Institute (CPI) course and a Care of the Behavioral Health Patient class.”

Mission used to have its own security staff but now contracts with Allied Universal for security services. The company, based in California and Pennsylvania, is currently hiring for part-time and full-time security staff at Mission. Allied did not respond to several questions about its work at Mission, including the number of staff it has at the hospital.

The hospital has a CPI coordinator who has taught verbal de-escalation techniques for 30 years, Lindell said. Mission also conducts BERT drills “to provide practice training for colleagues in high acuity areas.”

As an added measure of security, Mission employs sworn law enforcement officers in its emergency room, Lindell said. She did not respond when asked how many officers were on the hospital’s security team.

Members of the nurses union at Mission, more than 1,600 in 2024, currently are negotiating for stronger contract language to protect nurses before and after workplace violence events. The current contract expires July 2. Nurses are recommending more clear policies around violence, including medical benefits for nurses hurt on the job and more consistently functioning duress badges.

Federal report details series of assaults

Several instances of patient violence toward Mission staff were documented in a federal report on deficiencies in care that occurred between 2022 and 2023. In February, CMS placed Mission Hospital in immediate jeopardy, the harshest sanction a health care facility can face, for those violations.

In one case that lasted more than a month, a 21-year-old woman with behavioral health issues came to Mission’s emergency department in the first week of May 2023, according to CMS’ report on the deficiencies, which identified her as Patient #50. She came under involuntary commitment with a history of autism and mild intellectual disability, according to the report.

She’d recently been “going around the neighborhood with a hammer” and pulled her father’s hat over his eyes while he was driving, according to the report.

On May 6, a nurse reported Patient #50 “became unexpectedly agitated this AM (morning), pulled nurse and sitter’s hair after being asked if her ears hurt,” the report said.

Two days later, a hospital employee contacted the patient’s mother, saying she had been “seen by Psychiatrist who is recommending discharge due to concerns of Pt safety on this unit, her aggressive behaviors w/ (with) other (patients).”

On May 29, a nurse reported that Patient #50 had attacked three sitters — employees who watch over people with behavioral health concerns — to date, including one that morning when she “jumped on top of her.”

On June 10, a nurse wrote about a series of traumatic events related to Patient #50.

“Earlier today … had multiple aggressive acts towards me, the first was when she spit on me as I was handing her a snack in the BHU (behavioral health unit),” the nurse wrote, according to the report. “The second aggressive act came hours later when she saw me in the hall and came towards me. I attempted to walk away but she ran towards me, screaming and reaching for my face. She was able to pull the mask off my face but I restrained her hands and took several steps back, when she came after me again screaming and tearing at my head and face. I restrained her hands again and walked her back into her room towards her bed. As I let go and backed up … leaned on her bed and kicked me in the chest with all her force.”

CMS found hospital staff didn’t sufficiently document Patient #50’s aggressive behavior toward nurses and another patient.

As of June this year, Mission is no longer in immediate jeopardy and has corrected all deficiencies, according to CMS.

Reporting violence

Seventy two reports of assaults against Mission nurses were filed between Jan. 1, 2019, to early June this year, according to Asheville police data. Twenty five were filed in 2023 alone.

From 2014 to 2018, years preceding HCA’s purchase of Mission for $1.5 billion, a total of 12 reports of assaults against nurses were filed.

“If staff choose to do so, they can report an assault to law enforcement,” Lindell said.

Mission nurses have also informed the North Carolina Department of Labor’s Occupational Safety and Health division(OSHNC) of violent assaults.

In early November 2023, at least one nurse filed a complaint with the NCDOL, writing that behavioral health unit patients were violently assaulting employees and leadership had done nothing about it.

“Employees are experiencing being violently assaulted by patients,” an employee wrote in the complaint, obtained by The Watchdog through a public records request. “[H]owever, the employer has not taken actions to address the issue.”

On Nov. 6, 2023, NCDOL sent a letter to Mission, instructing it to investigate the complaint.

“We have not determined whether the hazards, as alleged, exist at your workplace; and we are not conducting an inspection, at this time,” an NCDOL district supervisor wrote. “However, since allegations of violations have been made, you should investigate the alleged conditions and make any necessary corrections or modifications.”

On Nov. 14, Mission responded to the NCDOL.

“Unfortunately, violence against our health care workers is a systemic problem faced by most hospitals throughout our country,” a representative in the hospital’s quality department wrote. “Mission Hospital, in collaboration with our employees, are exploring measures of safety that we can implement to decrease the incidents of employee assaults.”

The representative listed improvements she said Mission was making to communication and training, including roundtable discussions between nurses and a new workplace violence committee.

“Mission Hospital is committed to planning and developing systems to intervene and mitigate incidents of violence within the workplace,” the representative said in the letter.

On Nov. 27, NCDOL told the nurse who filed the complaint that it had “conducted an investigation” and closed the case.

“Based on the investigation, the OSH Division feels the case can be closed on the grounds that the hazardous conditions have been corrected (or no longer exist),” NCDOL said.

Asked if NCDOL sent staff to Mission to review the complaint, spokesperson Erin Wilson told The Watchdog it had not.

“The complaint was investigated by letter and closed after a satisfactory response was received from the employer,” Wilson said.

Wilson said the term “investigation” is used to describe a complaint or accident that is handled or addressed by email or letter.

Asked why no personnel were sent, Wilson cited lack of staff and a heavy workload.

“We simply don’t have the resources to inspect every single complaint and accident, especially given how we strive to conduct a significant percentage of proactive inspections in high hazard industries, such as construction, logging, and food manufacturing,” she said.

Lindell did not answer a question about how Mission investigated the November 2023 complaint. She said Mission “takes every complaint seriously and responds accordingly to all government agency inquiries.”

“In the instance of the letter you attached, Mission’s response was deemed sufficient and the matter was closed,” Lindell said.

Wilson said no one has called or tried to appeal the complaint after it was closed.

Mission in 2023 moved its mental health services from Copestone — across the street from Mission’s 509 Biltmore Ave. facilities — to the new Sweeten Creek Mental Health and Wellness Center, a facility HCA promised Attorney General Josh Stein it would build when it bought Mission for $1.5 billion in 2019.

“When designing the new Sweeten Creek Mental Health and Wellness Center, spaces were created specifically for patient de-escalation, and we have subsequently experienced a decrease in the amount of patient violence since moving to Sweeten Creek,” Lindell said when asked whether the change in location affected incidents of violence. She did not respond when The Watchdog asked for details about changes in patient violence since Sweeten Creek opened.

Healthcare violence widespread across U.S.

According to a 2023 survey of nurses by National Nurses United, the largest union and professional association of registered nurses in the U.S., 81.6% of nearly 1,000 nurses working in 48 states had experienced at least one type of workplace violence during that year.

More than 26% of nurses said violence had “increased a lot” in 2023, according to the report.

“Workplace violence, as you know since COVID, it’s just gotten worse,” said Kruta, the Mission nurse and union representative, adding nurses face violence not just in the emergency department and behavioral health areas, but on other floors as well.

Lack of staff leaves hospitals susceptible to workplace violence, according to a 2022 study from the Journal of Clinical and Translational Research, which characterized violence against nurses as “a pandemic.”

“In general, the common causes of [workplace violence] are understaffing, increased stress among nurses, the demanding nature of the job, and prolonged waiting period,” the study said. “These causes eventually end with dissatisfied patients and visitors, causing [workplace violence].”

A recent investigation by The Watchdog found more than 600 registered nurses have left Mission since 2022, prompting the hospital to fill a huge number of vacancies with more than 1,500 short-contract travel nurses.

“No matter whether you’re at bedside, whether you’re an advanced practice nurse, all levels are really suffering,” said Ashley Sholar, a North Carolina Nurses Association at-large board member, and an emergency department director.

Assaults, whether verbal, physical or sexual, are driving nurses from the profession, Sholar said. “People don’t want to work in an environment where they’re scared,” she said. “They want to work in an environment where they feel safe to be able to come to work and they don’t feel like they’re walking on eggshells.”

Hospitals trying to prevent assaults should have management that is engaged with nurses and seeking their input on policy and procedure, which have to be updated often and should go beyond the regulatory minimum, Sholar said.

Sholar also said people who use the hospital need to be vigilant. Assaults are not unique to patients who are having mental health crises. They also are perpetrated by family members, visitors and patients no one expects to behave aggressively.

“We really do need the public awareness of the impact of violence that is taking a toll on the nursing profession,” she said, “It would go a long way in helping us and saying, ‘This is not okay and this is not acceptable.’”

Asheville Watchdog is a nonprofit news team producing stories that matter to Asheville and Buncombe County. Andrew R. Jones is a Watchdog investigative reporter. Email arjones@avlwatchdog.org. The Watchdog’s reporting is made possible by donations from the community. To show your support for this vital public service go to avlwatchdog.org/donate.