Psych Nurses Sound the Alarm on Patient Violence at Pediatric Hospital

Nurses at Seattle Children’s Hospital demanded the hospital intervene after police were twice called to the Psychiatry and Behavioral Medicine Unit (PBMU) over violent incidents during a 2-week period in November, according to the Washington State Nurses Association (WSNA).

On November 7, police were called to intervene after patients began overturning carts, wielding metal poles as weapons, breaking windows, and holding one nurse in a chokehold. Around the same time in a different part of the unit, another nurse was being choked and was punched 16 times in the head. Several staff were sent to the emergency department, according to a WSNA press release.

Just 10 days later, police were called back to the unit after patients began throwing ceiling tiles at staff. The WSNA called the incidents “part of a pattern of ongoing and escalating violence.”

Josh Pickett, RN, a charge nurse at the facility, attributed the incidents to mounting pressures on the unit — having to accept one aggressive patient after another, with no place to send those already in need of residential care.

In an interview with MedPage Today, Pickett likened the unit to a pot ready to boil over, but “you can’t take the pot off the fire” and “you can’t turn down the heat.”

On November 17, the day of the second police call, 44 of the approximately 52 nurses on the unit penned a letter to Seattle Children’s management requesting help and blaming the incidents on “ongoing deficient and inadequate intervention from the hospital.”

“Staff work in a persistent state of fear as they come into each shift expecting violence and debilitating abuse,” they wrote.

The nurses requested a “surge security presence” of three officers during the day and one at night until a safety officer position could be created. They also asked for three additional support staff (a break nurse, resource nurse, and safety coach), a maximum nurse-to-patient ratio of 1:8, double-pay for full-time staff working over a certain number of hours, and holding any admissions that would require increased staffing.

Seattle Children’s responded by providing three security guards for the unit during the day, but nurses who spoke to MedPage Today expressed concern that those positions could be removed once the hospital determines the unit is safe again.

Henry Jones, RN, another charge nurse in the psych unit there, said that over the past year he’s seen “people kicked in the head,” facial bones broken from headbutts, concussions, and “people grabbed by the throat and dragged across the floor.”

The problem is that roughly one-third of the residential beds in the state have closed since the pandemic, and social supports for children have declined, he said.

According to Jones, the Seattle Children’s PBMU staff share a philosophy of empowering children.

“We want to be therapeutic,” he said, adding that kids are coached to use coping skills to get through crises, and that patients are connected to social supports and residential treatment when needed.

But, Jones said, those things haven’t been happening because of conditions in the unit; instead “we are trying to keep kids safe by keeping them behind locked doors in a very sterile environment where they get further and further disconnected from the outside world.”

The PBMU was meant to provide short-term crisis stabilization for 3 to 7 days, but many children have been staying for weeks or months, and some for even longer than a year, Jones said. “The longer that kids stay, the more likely they are to use aggression.”

Most disheartening is the “contagion effect” among patients who are depressed or suicidal but surrounded by others who have oppositional defiant disorder, said Greg Zorn, RN, also a PBMU charge nurse.

“They came in sad, and then they go out … angry and hitting people,” he told MedPage Today.

Zorn cited hospital construction as one factor exacerbating the violence, as it reduced space for the psych unit and resulted in the crowding of patients who struggle with emotional regulation and who already get agitated easily. “It makes sense to me that there would be fights,” Zorn said.

Staff have left in “droves” as the unit has grown more violent, said Jones, making it harder to maintain the kind of experienced workforce needed to provide safe, therapeutic care.

Zorn noted that a majority of the recent group of nurse residents quit. “They didn’t make it through orientation because they felt too unsafe on the unit,” he said.

More social supports are needed from federal, state, and local government, Jones said, including more local residential beds and especially funding for long-term care. Washington state has approximately 109 residential beds for a population of more than 1 million children.

The most important thing the hospital can do is to create a position for a security officer who is trained in the ways of the PBMU and how to interact with patients, Jones said.

On November 30, Pickett and a handful of other staff met with Seattle Children’s management and human resources, which granted approval to recruit travel nurse staff for the PBMU. Two travel nurses have been found to fill day shifts, and there are roughly six night shift slots PBMU leadership is working to fill, according to a summary of management responses WSNA provided to MedPage Today.

However, according to Zorn, management did not agree to the three requested permanent support positions — two nursing positions and one safety coach. And management also did not confirm an appropriate mechanism for ensuring the requested nurse-to-patient staffing ratio — such as staffing a third nurse whenever the census reaches 17 patients — and did not confirm double-pay for full-time equivalents who work above their contracted hours, Zorn said.

According to the WSNA, hospital management has stated that it has a plan to maintain around-the-clock security through the duration of the crisis, while developing a job description for more permanent security staff. Whether PBMU nurses’ preferences will be acknowledged in designing the role of a permanent safety officer remains unclear, Zorn added.

As of this time, Seattle Children’s Hospital did not respond to a request for comment from MedPage Today.

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