09/19/10 — Cherry Hospital - The rest of the story: Nurses speak out

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Cherry Hospital - The rest of the story: Nurses speak out

By Matthew Whittle
Published in News on September 19, 2010 1:50 AM

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After months of reading about patient abuses at Cherry Hospital, those on the floor are speaking out and saying they are getting hurt, too.

Ever since the deaths of two patients at Cherry Hospital, the state's eastern psychiatric facility has struggled with a reputation as a poor place to receive personal mental health care.

Today, however, among at least some of the nurses who work there, Cherry Hospital has a reputation as a place where members of the health care staff take their lives into their own hands when they walk through the doors of a ward.

More than half a dozen nurses explained their concerns with the state psychiatric facility, why they feel persecuted and unsafe, and what they would like to see done to improve things.

The workers spoke on the condition of anonymity because of concerns that they would lose their jobs for violating the hospital's 2009 Code of Conduct, which prohibits speaking out.

The policy, in part, targets disruptive behavior, which is defined as "making degrading, demeaning or belittling comments regarding Cherry Hospital; making negative comments regarding the quality of care being provided, the clinical judgment or professional qualifications of an employee; and inappropriate dialogue in front of hospital employees and non-hospital employees regarding the competency of a member of the hospital staff."

For the nurses who spoke out, many with years of experience in the field, going to work is, simply, dangerous.

"I've never seen anything like Cherry Hospital. It's going to change what I do for a living," said RN No. 1, a traveling nurse employed through a temp agency. "It is the worst job on earth, and yet you're not supposed to respond in any way.

"It's not part of my job to be beat up and abused 24 hours a day. It's not part of my job to be stabbed in the face with a pencil. Cherry is the worst hospital in the U.S. to work for. Cherry has a horrendous


Nurses interviewed described being hit, kicked, scratched, spit on and cussed at by patients; patients picking up and throwing televisions; and patients kicking and beating down both metal and wooden doors.

"It's a very real danger, going in there to work," said RN No. 2, also a traveling nurse.

"Those of us in the trenches, we feel injuries are way up, and that's a huge cost to taxpayers and a huge blow to morale," said RN No. 3, a full-time, permanent staff member for nearly 15 years.

And the numbers back them up -- that Cherry Hospital, especially in recent months, can be a very dangerous place for those staff dealing directly with patient care.

So far this year, according to numbers from the state Department of Health and Human Services, 251 staff members have been injured at Cherry  by patients -- many more than the 48 listed publicly on the state's Cherry Hospital website, and many more when compared to those reported at Central Regional, 175; Broughton, 153; and Dorthea Dix, 102.

Additionally, though the state Department of Health and Human Services would not provide the numbers, according to the nurses who spoke, the hospital's administration has told them in recent months that the number of staff out on worker's compensation from patient attacks has averaged between 60 and 80 people at any given time.

In fact, the North Carolina Department of Labor's Occupational, Safety and Health Division's Raleigh field office was recently contacted by a nurse regarding the number of employees being assaulted by patients. And while there are no specific OSHA rules for workplace violence, a letter of concern was sent to Cherry.

One example of this potentially dangerous environment is an incident that occurred on June 18, when a patient with a long history of assaulting nurses, Earnest Ellis -- identified here because of the criminal charges brought against him by at least 10 staff members -- allegedly attacked a roomful of RNs and health care technicians, seriously injuring one in the process, a licensed practical nurse named Teresa Howell, who had on April 1 sent an e-mail to Gov. Beverly Perdue asking for help.

That e-mail reads, in part, "...I, an LPN, due to the shortage of staff had to escort seven male consumers back to the ward from evening meal. This required me to be on a closed elevator with seven male consumers and ride with them for two floors. Of the seven, five of these were House Bills, meaning they have serious legal charges against them. One of these consumers had been so aggressive, verbally and physically, that he was to be transferred back to our acute building, known as U2, immediately after the meal. We the staff at Cherry feel that no one is listening to us."

Ms. Howell then went on to discuss staffing shortages at Cherry and the problems they are posing for nurses, as well as supervisors.

How these concerns were addressed, however, is unclear. Chrissy Pearson, spokeswoman for the governor, said that the e-mail was forwarded to the state Department of Health and Human Services for handling, though information about that response was not available from department spokesman Mark Van Sciver.

"People who work with the patients -- we feel like we're in much more danger than in other years," said RN No. 3. "The patients feel empowered to assault staff."

That's why some nurses have taken to filing charges against aggressive patients.

"You didn't used to see nurses press charges against patients, but people get desperate," RN No. 3 added.


Physical holds/

restrictive actions

Cherry Hospital, like other state psychiatric facilities in North Carolina and across the country, uses the Crisis Prevention Intervention method of intervening when a patient becomes agitated or aggressive. For Cherry, it's still a relatively new method, having been introduced by hospital Director Philip Cook in April 2009.

The problem, though, the nurses say, is not with CPI itself. Most of them, in fact, agree that it is a good method and one that can and does work.

Rather, they say, the problem at Cherry is with the administration's enforcement of the use of the method.

With cameras watching most areas of Cherry Hospital, except for bathrooms and patient bedrooms, nurses describe something of a "Big Brother" situation, with hospital administrators reviewing videos and passing judgment on how well the nurses and health care technicians perform their maneuvers.

But, the nurses said, even that wouldn't be a problem if the people watching the tapes understood and appreciated the fact that classroom theory doesn't always translate to practice when performing in real-life situations. They also expressed concern about the hospital's definition of abuse -- described as more stringent than other state facilities -- which they said ruled in one instance that a nurse putting her arm up to block a blow was intimidating to a patient because her fist was closed.

The problem, they explained, is that things that go well during a training session don't always come

as easily during an actual confrontation.

"They are micromanaging a criminal assault," said RN No. 4, a full-time, permanent employee with nearly 15 years experience.

The nurses even went as far as to say that by taking such a harsh stance, they felt the administration is looking to make examples out of them when things aren't done perfectly, including reporting them in high numbers to the state Board of Nursing, where only five of the 54 complaints reported to the board have resulted in any disciplinary action since 2005. Officials from the state board, however, said they could not determine if that was an excessively high number of complaints as some could be about the same incident, or could include multiple nurses, or could be the result of "an incident that several people reported, or administrator(s) that are quick to report to the board."

"Administration, no matter what happens, is going to find a way to blame the staff," said RN No. 5, another full-time, permanent employee with nearly 15 years experience. "You cannot pre-control somebody's violent actions. You don't have time to prepare your choreography (like in

practice). You're doing your best to hold the person, and they want it to look like a choreographed dance."

"They're not looking for abuse as much as they are trying to prove staff did something wrong," RN No. 1 agreed.

And that, said RN No. 3, keeps health care staff from effectively doing their jobs caring for their patients.

"They're terrified to touch a patient. They're terrified to intervene, because if they do anything less than perfect, they get in trouble. People are terrified to do the job they're paid to do," RN No. 3 said. "We're calling on people to be superhuman and perfect. If I intervene with anything less than perfect form, with something we're taught only once a year, I could lose my job, my license and go to jail."

Contributing to the problem, they say, is the way they are instructed to deal with patients -- to make every effort not to enter into a physical restriction by just talking to them or offering them juice or a snack or some other type of diversion when they begin to act out. That type of reward, the nurses said, teaches patients that they can demand pretty much whatever they want.

"We don't address negative behaviors," RN No. 4 said.

For example, RN No. 5 described a patient who once threw a chair and hit a staff member in the head, and then calmly sat down to watch television. The staff, she said, was told not to respond because the patient had calmed down.

According to Cherry Hospital's Clinical Care Plan, the goal is to use non-restrictive interventions first, including providing feedback to the patient or talking to the patient, removing stimuli from around the patient or removing the patient from the current environment, offering a diversional activity such as music or a magazine, a snack or beverage, a walk

or a medication "to address the patient's underlying mental illness and designed to help the patient gain


"Ten years ago, we wouldn't have had to give into their demands," RN No. 5 said. "They learn. They see there are no consequences and they do more and more."

Until eventually, RN No. 3 said, the patients come to see the nurses as hated authority figures trying to tell them what to do, whom they don't have to listen to and can even attack to get what they want.


The second leg of the problem, in addition to a discouragement and a fear of physical intervention, nurses say, is the discouragement of the use of PRN medication (short for a Latin term meaning "as needed") -- outside their normal dosages -- to help control patients.

"It's a fine line you walk. You want the least amount of medication to control a patient's symptoms," RN No. 3 said.

But, RN No. 3 said, there are times when extra medication is appropriate to keep a patient from losing control, and that by not making those medications readily available, "at some point that becomes neglect."

"You're also creating a dangerous situation for the other patients," RN No. 3 said.

And while the nurses agreed with the goal of using a minimal amount of medication to treat patients, something that dates back a number of years, they feel the current policy, which has banned the use of any chemical restraints since 2009, goes too far -- that it takes the ability to make decisions out of the hands of the medical professionals.

Before, they said, if a nurse felt extra medication was needed, he or she could call a doctor, have the request reviewed and if necessary, approved. Now, they said their requests are immediately turned down by doctors, who are rarely on the ward, who simply suggest the health care staff find other ways of helping the patient manage his or her behavior safely.

"They see extra meds as punishment," RN No. 5 said.

But, RN No. 4 explained, that's not what the nurses want.

"We don't want a bunch of sedated patients so we don't have to work," RN No. 4 said. "But it seems more humane to medicate a patient than to fight with them."

Rather, RN No. 4 explained, they want to be able to interact safely with patients, and they think that rather than simply limiting needed medications, the hospital should focus on teaching staff how to properly care for properly sedated patients.

"They're taking our skills away from us. More and more, we're not allowed to use our own nursing judgments," RN No. 4 said.

"They backed off medications. Then they told us hands off. And then they throw these violent patients at us. All at once, it paralyzed us for a while," RN No. 5 said.



But, the nurses said, perhaps they could deal with those issues if not for the third leg of the problem -- staffing.

"Staffing is key," RN No. 3 said.

Unfortunately, the nurses said, because of the working conditions at Cherry, there is a fair amount of turnover, especially among agency nurses who are already there to fill in the gaps in the permanent staff.

"They turn over out there like there's no tomorrow," RN No. 4 said.

Often, they said, on a day shift, there are only two or three health care technicians, one licensed nurse practitioner and one registered nurse for anywhere from 18 to 26 patients. At night, there might be only one registered nurse and two health technicians for those same patients.

That, they said, is not enough -- that not only is a higher staff-to-patient ratio safer, it also provides for better patient care.

One example RN No. 3 pointed to was the high-management unit that Cherry had until about eight years ago. Serving the hospital's most aggressive patients, those with the most acute psychiatric problems, the unit "worked because it had a high staff-to-patient ratio," RN No. 3 said.

Unfortunately, RN No. 3 said, when it was shut down, those high-management patients were mixed in with the general population, "and Cherry's been in a downward spiral ever since. But it's a very small percentage that does most of the damage."

The good news, however, is that on Aug. 19, the hospital reopened the eight-member unit, this time calling it a psychiatric intensive care unit, in a newly renovated portion of the hospital.

"That will be very beneficial," RN No. 3 said.

But while the move will pull some of the most dangerous patients out of the general population and put them with some of the hospital's most experienced and capable staff, it won't change the fact that "most of the time (Cherry has) a minimal skeleton staff," RN No. 3 said.

Add to that the number of staff members out injured on worker's compensation claims  -- an average of between 60 to 80 front-line workers at any one time, according to nurses -- and the stresses on staff become even more apparent as mandatory overtime rules are invoked, creating fatigued employees, and staff are pulled from unit to unit to fill in where needed, despite the importance of building relationships with patients.

Also contributing to the problem, the nurses said, is the feeling that nobody in administration wants to hear from them -- that the opinions of front-line staff are not considered when new policies and ways of doing things are rolled out.

"They don't want our suggestions," RN No. 4 said. "We don't get told why we're doing anything. We don't learn from mistakes."


When the problems began and how they can get better

While most of the nurses agree that things have gotten worse since the deaths of Janella Williams in 2006 and Steven Sabock in 2008, the latter of which ultimately resulted in the hospital losing its certification from the federal Centers for Medicare and Medicaid, and therefore its federal funding from September 2008 to July 2009, they also say that conditions at the hospital have been on a downward spiral for the better part of the last decade, with much of that blame placed on a revolving leadership door.

Since 2000, the hospital has had seven directors and interim directors.

With each of those, nurses said, came a new philosophy and a new boss with a desire to make his mark on the


"It's like reinventing the wheel every time we get a new administration in. Everybody wants to implement their changes," RN No. 4 said.

But, they said, the result of those changes has simply been the piling on of more paperwork and more requirements, rather than the actual correction of past problems.

And that, said RN No. 6, anther full-time permanent staff member with nearly 15 years experience, has just created a "snowballing problem" with "more problems having been created than solved."

But the problems of recent years, RN No. 3 said, are what have really made people -- and officials higher up the line in Raleigh --  sit up and take notice of Cherry Hospital.

"Those drew all the attention and made it seem like people were out here hurting people, and because of that we got such scrutiny, such pressure from the top down to run a tight ship," RN No. 3 said.

And while the nurses agree with the need to keep a close eye on things to ensure no patients are being abused or neglected -- even going as far as to say that Cherry did have problems in the past -- they believe the state and the hospital's administration have gone too far.

"That's not why most of us are out here. I didn't get into this to harm people. I'm a nurse," RN No. 3 said. "Zero tolerance is stupid. It says the administrators and the health care staff don't have the sense to look at each incident individually."

And so instead of protecting patients, such policies have instead caused staff to be hesitant about doing their jobs -- creating a situation that's almost as bad, RN No. 3 said.

"Everybody at Cherry is scared to do anything, and if you're not doing anything for your patient, you're neglecting them," RN No. 3 said.

At the end of the day, however, RN No. 3 said, the staff members are not trying to make excuses for themselves, and they're not trying to talk their way into higher salaries. They simply want and need "better working conditions."

"What I want people to understand is we're not just a group of disgruntled employees who have a beef with the hospital. It's companywide," RN No. 6 said. "We have a long ways to go, but I really want to be positive about the future."

What would help, the nurses said, would be a more stable leadership team and administration with a better understanding of the day-to-day life on the wards, and a larger, more stable pool of employees.

In the meantime, the nurses say they will continue to do their best to deal with a difficult situation and to find ways to fix the problems they face.

"I as one person can't make a big change in anything, but at some point I might be able to make a difference," RN No. 6 said. "I work with some really good people and we're all in the same boat. I go back every day just hoping it's going to get better, and I go back to show my co-workers that if we can just all get through this together, things are going to get better."