A call bell summons her. When she steps into the room, the patient tells her he thinks his roommate may have urinated on the floor. The roommate, a 70-year-old man with metastatic cancer, stands at the windowsill and scoops beach sand with a child-size shovel from a pail, a gift from his grandchildren. As E. approaches and speaks, Mr. R. turns and begins to punch her in the abdomen with the shovel. She reaches for the call button.

“I need help in here,” she says to the voice that answers.

While she tries to contain Mr. R., he grabs at her pocket and pulls out a straight Kelly clamp. He wrenches it apart at the hinge and lunges at her with the single pointed end. With every ounce of her strength, she pushes his arms back, but he’s strong. The tip of the clamp is just a few inches from her neck.

Finally a nurse arrives, and Mr. R. turns and drops the clamp. He yanks out his central line and collapses on his roommate’s bed. A second nurse arrives, and E. leaves the room shaking. The nurses return Mr. R to his own bed. Two hours later, he dies.

Although the incident happened more than four years ago, E. says, “Being pinned up against the wall and thinking I was going to be stabbed is still vivid in my mind. This was the most afraid I have ever been for my personal safety.

”What occurred afterwards could only have compounded the trauma, according to literature on debriefing and follow-up after a violent incident.1-3 The supervisor, charge nurse, and her coworkers expressed concern, and E. says she felt supported at the time. They suggested that she might want to go home, but E. decided to stay for the rest of the night. However, she says that no one asked her to document the event or complete an incident report.

No one followed up at all. “I wondered why I never was spoken to by my nurse manager. I never got a phone call the next day or at any point.”

Unfortunately, E.’s experience is all too common. Few healthcare facilities offer comprehensive debriefing and follow-up services for staff after a violent incident, according to Marilyn Lewis Lanza, RN, DNSc, CS, FAAN, associate chief of nursing service for research at Edith Nourse Veterans Administration (VA) Hospital in Bedford, MA. Lanza, who is known as the foremost authority on the psychological effects of workplace violence on nurses, has conducted research at the VA Hospital and collected hundreds of vignettes from nurses across the country.

Debriefing

Right after a violent incident, Lanza counsels victims to go home and ask a trusted person to stay with them. The VA program offers victims access to a counselor they can call or meet, as desired.

Debriefing is a first step in the follow-up process. Another specialist in the field, Susan R. Braverman, LICSW, defines it as “a process to structure a way for people to talk about an experience in a way that feels safe and helps them begin to integrate the experience.” Braverman is cofounder and consultant at CMG Associates, Inc. in Newton, MA, a crisis management group that serves all types of organizations, including healthcare facilities.

Braverman says she usually starts initial sessions after a traumatic incident with a short explanation of the common responses. Even though people may still be feeling numb and shocked, they often begin to talk spontaneously about the event.4 As group facilitator, she encourages them to describe what they experienced at the time. “The more people verbalize [their experiences], the more they’ll be able to integrate the event,” says Braverman. Debriefing, however, doesn’t go far enough, according to both Lanza and Braverman. They agree that comprehensive follow-up with the victim and staff can strongly influence recovery after a violent incident.

Follow-up

In Lanza’s experience, nurses typically seek out counseling about a week or so after the assault. They may have had troubling reactions, such as disturbed sleep, flashbacks, or episodes of crying. Braverman notes that it is also important to follow up with anyone within the “circle of impact” who could have been affected by the event, including coworkers, family members, ancillary staff, and staff on other units.

In follow-up sessions, Braverman offers staff the opportunity to reflect on the incident and its meaning in their life, taking an active role in their healing. Recovery depends on the severity of the incident, the individual’s resilience, and a number of other factors, but support and understanding can play a major role.

Braverman says that her company also works with management staff after a traumatic incident. “People are looking for leadership in a crisis. They want to know that their managers are in control and know what to do,” she says.

Likewise, family members may need help in providing necessary support. “The family may often trigger a reaction that’s not therapeutic,” says Lanza. They may ask, Why are you working in that hospital? Why don’t you leave? E.’s husband and three sons questioned why she had not defended herself more vigorously. To this day, she wonders if she could respond were she threatened again.

A good follow-up program needs administrators who support it wholeheartedly. Braverman says that an organization’s failure to provide good follow-up can be seen by affected employees as a “secondary injury.” But the organization will benefit by providing follow-up care, since people who feel cared for don’ t burn out as fast. Despite that, Lanza says that although she sees progress in the workplace toward preventing violence, follow-up efforts are still lacking. Unfortunately, the consequences can be life-altering. Some victims develop symptoms of posttraumatic stress disorder that can persist for months or years.

Nonetheless, nurses are resilient and heal despite lack of support, but they may suffer unnecessarily. E. feels like a case in point. Although she is much more aware of potential threats to her personal safety, she no longer thinks about the assault unless someone brings it up. However, she admits, “if I do sit down and think about it, I still cry.” This event has left its mark on her life.