Nurse Kristi Dugan demonstrates her medical staff training July 7 to keep herself between a potentially violent patient and a door at St. Mary’s Regional Medical Center in Lewiston. Andree Kehn/Sun Journal

Hospital workers are expected to endure a certain level of abuse that would otherwise not be tolerated outside of health care settings, complicating workers’ ability to seek recourse following violent incidents, doctors, nurses and administrators from area hospitals told the Sun Journal.

Violence against health care workers is a longstanding issue in Maine and nationwide that, for several reasons, became more frequent and oftentimes more acute during the pandemic.

The continued violence and what the hospital workers said is a lack of recourse for them within Maine’s criminal justice system is the focus of a recently formed legislative task force. The task force is co-chaired by two Democrats, Sen. Ned Claxton of Auburn and Rep. Anne Perry from Washington County.

Both are retired health care workers: Claxton, a family medicine physician and Perry, a family nurse practitioner.

The task force will study the process for bringing criminal charges against perpetrators of violence in health care settings. The nine-member committee of legislators, health care professionals, law enforcement officers and members of the state and district judicial branches is expected to submit its findings and recommendations in November.

‘A LEARNED HELPLESSNESS’

“We’re truly the safety net for the community,” said Dr. David Gammons, an attending physician in the Emergency Department at Franklin Memorial Hospital in Farmington.

“I mean, we see people regardless of the situation,” he said. This is by federal mandate and because, as several of the workers noted, it is in their nature as caregivers to provide help for someone in need, they assist  even if the patients are physically or verbally aggressive toward staff.

“We tolerate a level of abuse that is unlike any level of abuse that’s tolerated in any other setting,” said Andrea Patstone, president of Stephens Memorial Hospital in Norway.

Hospital workers do not have the same protections as staff in other public places such as restaurants, for example. If a patron started yelling at staff or groped a waiter, the restaurant would probably kick the individual out or call law enforcement. Unlike in a restaurant, however, hospitals cannot just kick out a patient who is acting abusively toward staff, she said.

And in cases where an assault turns physical, staff are often hesitant to call law enforcement to assist or to pursue charges against the patient.

“I think that it’s frankly difficult to get our care team to press charges because of the milieu in which they work,” Patstone said.

“I think a lot of times our compassion or understanding actually clouds our judgment about that,” said Christina Booth, the Emergency Department nurse director at Stephens Memorial.

It can be very difficult for staff to draw a line between what’s acceptable and not acceptable, especially when the patient has an underlying psychiatric condition.

“Like if you went out and you were manic and you stole a bunch of stuff, you’d probably get prosecuted for shoplifting,” Booth said. “They’re manic here, they throw things all over the place, they may or may not hit somebody, we generally are not going to think about prosecuting them because we’re thinking, ‘Oh, this is their disease process.’”

And even in cases where law enforcement does get involved, the hospital workers told the Sun Journal that law enforcement is typically “hands off” in a situation.

“Law enforcement is really hands off with a patient unless they actually physically see the patient hit a staff member,” said Courtney Ryder, Emergency Department nursing director at Franklin Memorial.

Security officer Mike Ingalls, left, and Lt. Brian Marshall monitor camera feeds July 7 in the security office of St. Mary’s Regional Medical Center in Lewiston. Cameras are positioned throughout the hospital, outside grounds and parking lots. Andree Kehn/Sun Journal

For an individual to be charged with a criminal offense, law enforcement will send a case to the district attorney, who then decides whether to prosecute. And even in instances where a case has been brought to a district attorney, it doesn’t go forward, several of the workers said.

“We have had many nurses press charges against patients and unfortunately, those have not resulted in any form of recourse for the patient,” Ryder said.

Oftentimes, the workers said they have no idea if law enforcement declined to elevate a case to a district attorney or if it was a district attorney who declined to prosecute, and for what reasons.

This contributes to a “learned helplessness” among health care workers, Dr. Michael Kelley, the chief medical officer for behavioral health for St. Mary’s Health System, said. Staff do not want to press charges “because they feel nothing will be done” and because they don’t want their patients “just shoved in jail.”

“I think it’s both: I think there’s the fear that nothing will happen. There’s also the fear the wrong thing will happen and (the patient) won’t get the help they need,” he said.

A SEARCH FOR A BETTER SYSTEM

The hospital workers said they were glad to see that a legislative task force will be addressing this issue of violence and improving the criminal process.

Resoundingly, they said there is a lack of “infrastructure” to support staff and their institutions in pressing charges and transparency of the process.

“We do not have an infrastructure that is geared toward support care team members to press charges. We don’t have an infrastructure that’s geared toward pressing charges as effectively as institutions. And we don’t have a law enforcement system that is used to or accustomed to the situation where a health care provider might press charges,” said Patstone, from Stephens Memorial.

The task force should be able to address these issues that will help put in place “new systems and processes,” such as a “clinical assessment of competency” that will help workers understand when a patient needs to be held accountable for their behavior, she said.

Several said they would like to see more effort put into preventing the violence before it happens. That includes de-escalation techniques, for example, for when a patient is already in a hospital.

But it also means greater community supports that can address the mental and behavioral health needs of these individuals so that they do not get to a point where they do not end up in an emergency room, either on their own accord or because they were brought in by law enforcement, said Heather Nadeau, the nurse leader at St. Mary’s Regional Medical Center in Lewiston.

Teenagers with mental illnesses, in particular, are in dire need of more resources.

“We’ve seen it here in our emergency department: They get stuck here essentially with no real square for them to go for support. And we’re not isolated in that,” Nadeau said. She’s heard from colleagues around the state who have teenagers essentially living in their emergency departments.

“There’s nowhere for them to go,” she said. That’s also why she would like to see more community education and training.

“A lot of hospitals are being utilized as respites,” for individuals with mental illnesses, Nadeau said. “They’re getting dropped off on our front door and we’re not going to discharge them to the street, you know, until they get the appropriate service. So it is challenging.”

VALIDATING EXPERIENCES

Outside of the criminal justice system, hospital leadership can implement programs that help staff work through what can be traumatic and stressful situations.

“As health care workers, when we’re under that duress, we’re also less capable of helping those patients and families who themselves are in crisis,” Dr. John Alexander, the chief medical officer for Central Maine Healthcare, said.

The workers said their hospitals have systems to report incidents and debrief with their colleagues and supervisors. And at Stephens Memorial, the hospital is “working on ways to try and help foster more resiliency in our staff,” said Emergency Department medical director Dr. Jim Gallea.

The program is still in its early stages and is focused on creating a system of peer support and training across all levels of the hospital, not just doctors and nurses, but also housekeeping, central registration, and kitchen staff, for example.

Not all forms of abuse that workers face are prosecutable offenses, Gallea said, so it is important that staff are supported in other ways beyond criminal proceedings.

All three from Stephens Memorial — Gallea, Patstone and Booth — said the simple act of acknowledging and validating that an abusive incident occurred and debriefing what happened can go a long way.

“That actually creates a huge amount of trust,” Booth said. “It makes it so people will come forward and talk to us. And it also gives them some of the tools they need to actually care for themselves after the traumatic event.”

Editor’s note: The first part of this report, “Hospital workers say they experience assault, threats of violence nearly every day,” was published on Sunday, July 10.