Human Bite of a Staff Nurse on a Psychiatric Unit

Abstract

Occupational violence among health care professionals is a cause for concern, although often neglected especially in developing countries like India. Violence undermines the healing mission of the health care organization and interferes with the ability of the health care team to optimally contribute to positive patient outcomes. The authors discuss a case of a human bite of a staff nurse on a psychiatric unit in a tertiary care Indian hospital. The reported violence against this staff nurse lead to her admission for emergency care followed by emotional stress. Issues related to prevention of occupational violence are also discussed.

Occupational violence is a topic of increasing concern around the world, including for workers in the health care sector. Events that may be classified as occupational violence include homicide, assault, threat, verbal abuse, behaviors that create an environment of fear, stalking, bullying among workers or between managers and workers, and behaviors that lead to stress or avoidance in the recipient (National Occupational Health and Safety Commission [NOHSC], 1999). Because of the rising level of concern about violence toward health workers, a joint international program was initiated by the International Labour Office (ILO), the International Council of Nurses, the World Health Organization, and Public Services International (Di Martino, 2002). This body defined occupational violence experienced by health care workers as “incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health” (Di Martino, 2002, p. 9). Nursing has received increasing attention as a profession at high risk for violent attacks (Ferns, 2005; International Council of Nurses, 2002; McPhaul & Lipscomb, 2004). The U.S. National Crime Victimization Survey (U.S. Department of Justice, Bureau of Justice Statistics, 2001) found that the average annual rate for non-fatal violent crime was 21.9 per 1,000 workers for nurses compared with only 12.6 per 1,000 workers for all occupations. According to the U.S. Department of Labor, Bureau of Labor Statistics (2005), 46% of non-fatal assaults and violent acts against health care providers resulting in lost work days were committed against registered nurses.

Case Study

Miss X, a 22-year-old unmarried woman from a middle-class family was hired to work as a staff nurse at a tertiary care hospital in India. She presented for a pre-placement examination at the hospital. On examination, she was found to have a scar and when asked gave a history of a bite by a psychiatric patient. The incident occurred during her nursing education when she was assigned to a psychiatric unit.

The patient had been admitted for alcohol withdrawal syndrome and a history of repeated admissions to the same hospital. On the day of the incident, Miss X was completing rounds with her colleagues when she noted a noisy dispute between the charge nurse and this patient. Miss X and her colleagues attempted to intervene, and during the process the patient became violent, threatening the nures.

Suddenly, Miss X felt an excruciating pain over the dorsal aspect of her right hand just below the thumb and realized the patient had bitten her so severely that she was bleeding profusely. She was taken to the Emergency Department where the wound was dressed and a prophylactic tetanus toxoid injection was given.

Unfortunately, she developed an allergy to the antibiotic that was prescribed and severe swelling of her hands for which she was admitted to the Intensive Care Unit and treated. She became emotionally upset to such an extent she did not work for more than a month before finally resigning her position. Though informally reported, the incident was never documented as a workplace injury.

Discussion

This case study is an example of occupational violence against a staff nurse. The nurse experienced a human bite, an unfortunate allergic reaction to antibiotics, followed by anxiety and fear about working as a staff nurse. She did not formally report the incident to her supervisor. Violent incidents such as this one are often not reported to law enforcement authorities or the employer (May & Grubbs, 2002). In the health care industry, these incidents may be underreported because hospitals may lack institutional reporting policies, nurses may believe that assaults are part of a nurse’s job or that reporting assaults will not benefit them, or employees may be concerned that assaults are evidence of poor job performance or worker negligence. Though presumably quite common, this is the first case report of a staff nurse being bitten by a psychiatric patient in India.

The authors are highlighting that occupational violence takes a significant toll on nurses, their employers, and their patients. In addition to the physical, emotional, and mental effects on the victim, occupational violence can result in financial loss (e.g., insurance claims, loss of productivity, legal expenses, property damage, and staff replacement). Prevention is essential for creating a safe and therapeutic environment for patients and health care workers. Nurses who resign because of assaults and threats of violence also contribute to the shortage of health care workers. It is possible to reduce and mitigate the effects of violence.

As recommended by American Nurses Association (ANA; 2002) guidelines for preventing workplace violence, institutions must provide a safe workplace including written policies, employee training, proper staffing, and root cause analysis of all incidents. Implementation of a comprehensive policy for preventing and managing workplace violence that establishes clear expectations of employee behavior and a course of action for employees and managers when incidents of violence occur is essential. It is also expected that the policy will include a process for confidential reporting as well as freedom from reprisals and disciplinary action for the victim of violence. Institutions should also develop and implement a violence prevention program.

Conclusion

All health care facilities must actively develop a culture in which violence is not tolerated; incidents must be promptly addressed and managed if not prevented. Comprehensive support for workers who experience violence should be initiated. Nurses should also participate in educational training on violence awareness and prevention.