After many years of nurses advocating for change, on August 13, 2010, with the approval of the Governor, and the legislature, subdivisions 3 and 11 of section 120.05 of the Penal Law was amended by adding Registered Nurses and Licensed Practical Nurses to the occupations protected under the law. Cases that were previously charged as misdemeanors will now be charged as Class D felonies, which carry a sentence of 2 1/3 to 7 years in prison. All cases will be evaluated, and applies only to those tried in adult court. Obviously thinking that nurses of New York State are now protected under the law, nurses continue to be assaulted while caring for their patients. Dealing with workplace violence not only hinders the care of our patients but those surrounding them.

Over the past two years we had heard of many difficulties of the members of the New York State ENA concerning workplace violence, enforcement of the law and lack of support of hospital administrations. After attending the Chicago Advocacy Intensives program we were inspired to seek out solutions for this country wide problem in our own state.  When returning from Chicago it was obvious and clear this was not an easy problem to solve but the NYS ENA's Professional Issues Committee was looking to address the issues of workplace violence. Trying to find proactive solutions to have the law enforced we looked to find why there had been so many problems with the enforcement of the law. Was it an educational problem that nurses and law enforcement agents are not aware of the law? Why in some cases, nurses were afraid to report an individual who might later become a threat to them? Why some hospitals failed to be supportive of the injured worker? Why were police failing to take the complaint? Why district attorneys did not always present the case and judges did not always sentence, or could not due to other issues concerning the patient, such as a mental health diagnosis? Realizing this issue was prevalent here in New York State the Professional Issue Committee decided to look for answers. Our plan was twofold, increasing the knowledge about the law and to seek out the answers to our questions.

Thinking there was a potential educational component, the committees choose to develop a resource tool for emergency nurses that would be available for the membership and distributed it at the 2013 April "Setting the Pace" conference. At the conference the Professional Issues Committee acquired a vendor table to reach out to the attendees to discuss the issues surrounding workplace violence. We distributed a questionnaire about workplace violence and distributed the resource tools. Over two hundred resource tools were distributed to the attendees at the conference.

Secondly, we wanted to seek out organizations of law enforcement agencies, the criminal justice system and the hospital organizations.   We looked to the New York State District Attorney's 'Association for our first contact. We, the New York State ENA Council decided to seek assistance from the members of the NYS District Attorney's Association.. On April 13 we held our quarterly meeting in Tarrytown at the Double Tree Inn. The NYS Council of ENA met with several of their members to look at these difficulties of enforcing the law. Six representatives from the surrounding counties of Westchester, Rockland, Manhattan, Bronx, Brooklyn, and Kings County met with the council and in an informal forum. A short power point presentation was presented by Sandi Tetler, which gave focus for the discussion. We asked questions surrounding the issue of the law, it's enforcement and the problems we were facing with workplace violence. Enforcing the law is not just a clear cut situation in the interpretation of the law. Each case is evaluated on several aspects. What was the intent of the assailant, were there certain aspects of the situation that alter the validity of the case. And we looked at the definitions; " intent "of the assailant, "severe injury" to the victim and those incidents involving an assailant with mental illness also. It is not an easy situation at all. Every aspect of each situation is looked at when there is a complaint made.

Through our discussion, we found that most of our difficulties may not lie with the criminal justice system but with individual law enforcement agencies. District Attorney Leroy Fraser, who acts as the coordinator of the NYS Law Enforcement Council offered us an invitation to the council's next meeting in the fall to explore and speak with it members in an effort to advocate for enforcement of the law. The New York State Law Enforcement Council was formed in 1982 as a legislative advocate for New York's law enforcement community. The Council's members represent the leading law enforcement professionals throughout the State, including the Attorney General of the State of New York, the District Attorneys Association of the State of New York, the New York State Association of Chiefs of Police, the New York State Sheriffs' Association, the New York City Criminal Justice Coordinator, and the Citizens Crime Commission of New York City. Since its inception, the Council has been an active voice and participant in improving the quality of justice and in the continuing effort to provide for a safer New York. By speaking with the council we can raise our concerns and facilitate education about the 2010 law that was enacted to protect nurses against assaults in the state of New York.

We look forward to meeting with the council in the fall as well as looking to meet with the NYS hospital organizations to discuss our concerns and get their support with enforcing the law. A nurse may be more inclined to report an incident if law enforcement agents and the hospital for which they work are committed to enforcing the law. Only through support of zero tolerance policies can we make a difference with respect to workplace violence. In the survey that was conducted by ENA in 2009-2010, it was concluded that a lower rate of incidents were noted with those hospitals with a zero tolerance policy. It was also with these hospitals were nurses were supported to file a complaint due to the support of their employment. If the hospitals' administration teams were committed to criminal mitigation, nurses were less likely to experience workplace violence. Cooperation between nurses and their employer is necessary for a safe work environment. Post incident evaluation is crucial. Nurses need to work with their employer and those assaulted to assess the events that have occurred. Nurses are less likely to experience workplace violence in facilities where hospital administration and ED management are committed to active prevention programs. Also, it is a JACHO initiative for a safe work environment (Sentinel Alert Issue #45), and, is also stipulated by 2006 NYS Public Employer Workplace Violence Prevention Law. Every facility is required to have a written workplace violence prevention program that details how these assessments will be conducted.  With hope this may lead to a public understanding that assaulting a nurse while on duty is not acceptable and it is the law, a law that will be supported by nurses, law enforcement agents, hospitals and the criminal justice system. Our fight did not end with the passing of the law it only began. There is still work to be done, change takes time and we will continue our fight until every nurse feels safe when caring for their patients and their families. We do not want to be injured while providing care to our patients, after all that is what we are called to do. It is our passion. It is our life's work and we only want to do our best for all.  

By Tammy A. Davis, RN, BSN, CEN, CCRN

Why can't patients have their pain assessed in the Emergency Department?  It seems like a simple thing to do while assessing your patient; you ask them if they are in pain.  We as nurses cannot accept a simple yes/no answer to the question though.  What do we need to ask to properly assess our patient for pain?  First, we need to establish if the pain is acute or chronic.  The intensity is assessed using an appropriate scale for the patient such as the numeric 0-10 scale, PAINAD for dementia patients, FACES pain scale, and FLACC, NIPS, and N-PASS for pediatrics.  Included also in the assessment is the type of pain, location, radiation, duration, precipitating and/or alleviating factors, and if the level of current pain is acceptable to the patient.

What causes patients to be assessed inadequately for pain management?  Pain is considered the 5th vital sign and it is still frequently missed by clinicians during patient assessments (NPC, 2012).  One of the largest reasons that a patient visits the emergency department is for pain management (Motov & Khan, 2009).  Problems that occur for pain management is that staff fails to acknowledge the patient's pain, assess their pain, document pain, implement pain management guidelines for the emergency department, and fail to meet the patient's needs for pain management (Motov & Khan, 2009).  Patients often wait hours for and then when they receive pain medications, they receive less than optimal doses (Motov & Khan, 2009).

What are some of the barriers to pain management?  The physicians are skeptical of the patient in pain, they fail to believe the patient's self-report of pain, and there is also racial, ethnic, age, and gender bias (Motov & Khan, 2009).  What nurses and providers fail to remember is that pain is subjective and the clinician needs to accept the patient's report of pain (NPC, 2012).  Observations of the patient's behavior or potential physiological signs should not replace a patient's self-report for pain and pain tolerance varies between individuals (NPC, 2012).  Specifically nurses can feel overwhelmed in the emergency department setting and when it comes to prioritizing tasks, pain is usually not a priority (Bergman, 2012).  Nurses have also felt dissatisfied with nursing administration's understanding of bedside nurses tasks and also feel pressured with non-patient care tasks such as chart audits, in-services and meetings and feel patient care is neglected in lieu of administrative requirements (Bergman, 2012).  Nurses can feel frustration because the emergency department is an ideal place for drug abuse and can feel like a drug-pusher because the doctors are too quick to give narcotics, or the opposite, and they are frustrated because the doctors do not place orders in a timely fashion (Bergman, 2012)

What can we do as nurses?  Speak up for our patients.  Speak to the doctors to get medications ordered in a more timely fashion.  Establish trust and respect between yourself, the patients, and the doctors for better pain management.  Ask for an education program for the doctors and the nurses in the emergency department about proper pain management and non-pharmacological pain management techniques. Believe your patient's self-report of pain (unless there are strong indications to believe otherwise) and do not let their physiological signs or behavior deter what maybe their real pain level. Lastly, don't forget the turkey sandwich!

Bergman, C. (2012). Emergency nurses' perceived barriers to demonstrating caring when

   managing adult patients' pain. Journal of Emergency Nursing 38(3):218-225.

Motov, S. & Khan, A. (2009). Problems and barriers of pain management in the

   emergency department: are we ever going to get better? Journal of Pain Research

   2:5-11.

National Pharmaceutical Council. (2012). Pain: current understanding of assessment,

   Management and treatments. National Pharmaceutical Council, Inc. Retrieved from

   the American Pain Society website on April 29, 2013

   http://www.americanpainsociety.org/education/content/enduringmaterials.html.