Self defense

September 15, 2006 -- Recent media items have highlighted the high level of abuse nurses face, which affects patient care and the global shortage. One of the most striking pieces was the story of Portland (OR) emergency nurse Susan Kuhnhausen, who arrived home one day to find an armed intruder in her house. As a September 9 Associated Press piece reports, Kuhnhausen managed to disarm the man, and strangled him to death. The police viewed this as self-defense--and they later charged Kuhnhausen's estranged husband with having hired the intruder to kill her, as a followup AP piece reported today. This case seems unrelated to nursing, though Kuhnhausen appeared to present a model of a nurse strongly defending herself from a serious threat. But the media coverage still drew attention to issues of workplace violence against nurses. In part that's because Kuhnhausen (right) has herself been a leader in advocating for legislative measures to protect nurses from such violence, as a good article by Robin Moody in the March 11, 2005 Portland Business Journal showed. In addition, the AP's September 9 story led Portland FNP Tracy Klein to write a letter to the Oregonian noting that, contrary to implications in the story, nurses like Kuhnhausen "are not immune to the impact of such violence just because they may see it in the workplace." Klein noted that one study had found that 20% of ED nurses sampled met symptom criteria for post-traumatic stress disorder. In fact, nurses experience abuse in clinical settings across geographic and subspecialty boundaries. A good September 7, 2006 piece by Alison Ribbon in the Mercury (Australia) reported that two thirds of Tasmanian nurses surveyed had been physically or verbally abused in the preceding month. The abuse affected patient care, and more than 10% of the nurses had "left a post because of aggression." Like the Portland Business Journal article, the Mercury piece pointed to a reluctance to address the abuse, which may relate to the "virtue script" nurses are still expected to follow. We thank the news entities above for their attention to these issues.

The September 9 AP piece was headlined "Female nurse, 51, strangles hammer-carrying intruder." It says that Kuhnhausen found the intruder armed with a hammer, strangled him, and went to her neighbor's house to report it. The intruder reportedly had a number of criminal convictions. Homicide detectives reportedly viewed the case as one of self-defense and did not expect it to reach a grand jury. Kuhnhausen--whom the piece carefully notes may have had "an advantage," at 260 pounds, because of her size--was treated for "minor injuries" and released. The piece also notes that Kuhnhausen is an ED nurse at Providence Portland Medical Center, and it quotes a strongly supportive neighbor as saying of Kuhnhausen: "You didn't need to calm her...She's an emergency-room nurse. She's used to dealing with crisis." To its credit, the piece also quotes Life Flight nurse Paula Derr as saying that Kuhnhausen has been "an advocate for protection of nurses, who sometimes face violence in the workplace."

Today's followup AP story reports that Portland police have charged Kuhnhausen's estranged husband with hiring the intruder to kill her. Police reportedly say her husband, who had previously hired the intruder as a custodian for the Fantasy Adult Video stores, had actually disarmed the security alarm and let the intruder into the house. The piece also gives additional details about the intruder's death, which allegedly followed an extended struggle in which he had hit Kuhnhausen several times in the head with a claw hammer. The intruder had reportedly served prison terms for conspiracy to commit aggravated murder. This report closes by noting that at the time of the report Kuhnhausen was out of town attending an Emergency Nurses Association conference, but that she had placed the following answer on her voicemail:

I'm not able to answer all the calls that I've received. I'm being comforted by your concern and your support. I want you to know that our lives are all at risk for random acts, but more likely random acts of love will come your way than random acts of violence.

The quote by nurse Paula Derr in the September 9 AP piece at least suggests that workplace violence is not all in a day's work for an ED nurse like Kuhnhausen. But Tracy Klein, RN, FNP, rightly notes in her responding letter that the piece's use of the comment from Kuhnhausen's neighbor may suggest that events like this have little impact on ED nurses. Klein cites a 2003 study of ED nurses that found that "12% met formal diagnostic criteria for PTSD and 20% met PTSD symptom criteria." Klein asks why a nurse experiencing a traumatic event would feel any less impact than someone who experiences such an event outside the workplace. She argues that "[a]ssuming that a nurse can handle emotionally traumatic events differently because of [the nurse's] employment depersonalizes and de-emphasizes the seriousness of what occurs in a tragic situation such as this one."

In fact, though Klein does not explicitly make this link, it could be argued that the suggestion that nurses can handle violence because they see so much of it may reflect a larger unwillingness to face the scope and effects of violence nurses face. Nurses commonly argue that they do not receive adequate support for the abuse they suffer at work. And it may well be in part because some may think of nurses less as flesh-and-blood humans than as collection of two-dimensional stereotypes, such as the angel or the noble handmaiden. Of course, violence against women is often discounted. But nurses in particular may be expected to simply "get over it" because they are spiritual beings with a vocation who do not suffer like others do, just as they don't need the resources that other human professionals do to perform their work. Nurses are so noble and virtuous! Angels don't get PTSD.

As the Derr quote indicates, Kuhnhausen is an advocate for greater protection of nurses. Robin's Moody's Portland Business Journal piece from March 2005 explains this. "Lawmakers want to keep nurses safe" reports that Kuhnhausen and the Oregon Nurses Association are "lobbying for the passage of a [state] bill they say would afford nurses more options to protect themselves, require better data collection for assaults and require that employers have procedures in place to deal with violence." The piece notes that nursing is "dangerous," as Kuhnhausen herself has been punched in the face and bitten by patients, not to mention once watching "an enraged motorist drive his car though the wall of the hospital into the emergency department after his girlfriend opted not to leave the hospital with him." The piece also cites 2000 Bureau of Labor statistics figures showing that nurses were 12 times more likely to be assaulted at work than the average private-sector worker. Kuhnhausen makes the following utterly rational request: "We are public servants, and want people to be held to the same standard of behavior as when they are dealing with a fireman, a police officer or a paramedic." To the extent that this is not happening today, we have to consider whether some of the factors discussed above play a role. Indeed, the piece itself reports that nurses say law enforcement has sometimes been reluctant to pursue assaults against nurses--something the bill would require.

The piece also relies heavily on Kuhnhausen for explanation of the bill and the need for it. She reportedly notes that the methamphetamine epidemic and increasing numbers of uninsured patients have made EDs more dangerous. And she assures readers that the bill is carefully targeted to deliberate assaults rather than "the cognitively impaired or the mentally ill." The bill would also provide greater protection for home health nurses who may face threats in their home visits. The piece closes with a good indirect quote from Kuhnhausen, who points out that "[l]ack of protection in the workplace can also stymie efforts to retain and recruit nurses, who are in increasingly short supply."

The role of abuse in the nursing shortage is borne out in the Mercury piece published earlier in September in Australia. In "Heavy toll of abuse," Alison Ribbon reports on the results of a recent survey conducted by the University of Tasmania and supported by the Australian Nursing Federation. The study surveyed more than 2,400 nurses in Tasmania. Of these, 800 reported being bitten, 144 choked, and "up to 20" stabbed--all in one month. Overall about two thirds reported either physical or verbal abuse during that month, with 30% reporting both. The report measured the types of physical abuse suffered, including being struck with a hand, fist, or elbow (69%), being pushed or shoved (49%), and being spat at (38%). Physical abuse generally came from patients or visitors, though small numbers reported experiencing it from other nurses (4%) or physicians (3%). For verbal abuse, which included shouting, "sarcasm," swearing, and threats against homes or families, almost 30% came from nurses or physicians.

In addition to measuring the prevalence of abuse, the study reportedly looked at its effects. The survey found that 265 nurses had "left a post" because of "aggression" and that almost 50 left the profession completely. Of those surveyed, 600--or something like one quarter--were "considering resigning." Report author Gerald A. Farrell is quoted as saying that two thirds of those who "experienced aggression" said that it affected productivity or led to errors. He also notes that 10% of the nurses said it was the most distressing thing about their jobs, though that is far less than the 51% who cited workload--a telling measure of the severity of short-staffing in hospitals today. We commend the piece for pointing out the effect that abuse can have on patient care and nursing itself, including its role in the shortage.

The piece closes with a telling statement from Professor Farrell about the widespread nature of the problem and the reluctance to address it:

Another key finding was that although verbal and physical abuse spreads across every branch of health care -- from pediatrics to psychiatry and community services to critical care -- few staff made their complaints official.

This suggests that many nurses hesitate to advocate for their own interests. Possible reasons include an understanding that little will be done by hospitals or law enforcement, and perhaps that the nurse herself will be blamed for the abuse. There may also be a sense that perhaps it is all part of what's expected of a nurse, which would be a natural result of prevailing attitudes that nurses should follow the "virtue script" and just get over it.

We hope that these press articles will help the public understand the abuse nurses face, and build support for efforts to address the problem.

Contact Robin Moody from the Portland Business Journal at rmoody@bizjournals.com

The Mercury story appears to no longer be available online.

Tracy Klein's letter to the editor appears below:

To the Editor:

The survival story of nurse Susan E. Kuhnhausen confronting and strangling an intruder is compelling and my heart goes out to her for experiencing such a trauma in her own home.

However, as part of the "survival angle" of the story, neighbors and the writer seem to imply that such violence is all in a days work for the registered nurse: "She's an emergency room nurse. She's used to dealing with crisis." While this may be true, and statistics say it is, nurses are not immune to the impact of such violence just because they may see it in the workplace.

A study by Laposa and Alden (2003) looked at nurses who work in the hospital emergency room. Of the sample studied, 12% met formal diagnostic criteria for post traumatic stress disorder (PTSD) and 20% met PTSD symptom criteria.

Given the impact of personal violence experienced by victims of trauma outside the workplace such as rape, natural disaster, or being involved in a life-threatening accident, why would we assume that a nurse, just because she works in the ER, would not experience the impact of such an event? Assuming that nurses can handle emotionally traumatic events differently because of their employment depersonalizes and de-emphasizes the seriousness of what occurs in a tragic situation such as this one.

Sincerely,

Tracy Klein, RN, FNP
Portland, Oregon

Laposa, JM and Alden, LE. Postraumatic stress disorder in the emergency room: exploration of a cognitive model. Behav Res Ther. 2003 Jan; 41(1): 49-65. abstract.