Conflict at the psych ward
How can the city protect patients' rights – and stop assaults on nurses?

By Julian Foley

San Francisco General Hospital's Unit 7B looks like a nice place to work, especially compared with other public mental hospitals. Natural light spills onto well-polished hardwood floors through a bank of seventh-floor windows. The spacious common rooms are filled with comfy, cushy chairs. All of the doors are painted a rosy pink, and the daily schedule is posted on rainbow construction paper.

But last month Unit 7B was the site of two incidents that left the nurses and psychiatric technicians here – and throughout General – shaken and angry.

First, on the night of July 17, a newly admitted patient carried in a loaded handgun. A day later, a patient brutally beat a female nurse.

The patient "just attacked without provocation," nurse Oscar Bueno, who witnessed both incidents, told us. The attacker "grabbed her hair and started to put her on the floor, hitting her in the face, and then started biting her."

It took three nurses to subdue the patient; the brawl was over by the time the hospital cops made it to the seventh floor. The nurse still hasn't returned to work.

Citing patient confidentiality, hospital administrators refused to disclose any more details about the incidents. However, several nurses backed up Bueno's account.

Violence isn't particularly unusual in psychiatric wards – after all, mental patients have a tendency to behave unpredictably. "Unfortunately, it's a part of the work that we do," said Dr. Mark Leary, deputy chief of psychiatry at the hospital. "I don't know that there is a way to do the kind of work that we do and eliminate the risk of assault."

General's nurses aren't sold on that idea, though, and the attacks have prompted them to file two complaints with the state Occupational Safety and Health Administration (OSHA) accusing hospital management of failing to keep the frontline staff safe.

"It is not part of a nurse's job to be hit or beaten up or assaulted," said Evan Mogan, a nurse and union shop steward for Service Employees International Union, Local 790. "That's like saying those mine workers just took an occupational hazard when they got stuck in those mines."

According to hospital records, there have been 65 patient-on-staff assaults since August 2001. Administrators say it's not an uncommonly high number, but the recent spike (four in just two weeks) is definitely unusual. For everyone involved – hospital bosses, grunt staffers, and patients and their advocates – the situation poses a troubling question: How can the hospital protect nurses and orderlies without returning to the sedate-and-restrain methods of the past? Not surprisingly, there are plenty of suggestions and little consensus.

Some staff in Unit 7B suspect that the recent incidents are the result of increased nighttime admissions, when fewer nurses are on duty, and have asked for them to be reduced. Others blame a chronic lack of nurses. Most want more cops and security guards, more safety gear, more panic buttons.

"We are probably the only public servants that deal with assaultive situations without any protective gear," said Alexander Modenos, a 54-year-old nurse who says he's ready to quit his job.

The most obvious issue is restraint. In what has been a gradual shift from the straitjacket approach to psychiatric care, current hospital policy – and federal law – severely limits the use of restraints on patients unless they are an imminent danger to themselves or to others. While the rules are clearly designed to protect nonviolent patients from being arbitrarily hog-tied and abandoned, many nurses fear the policy has gone too far, limiting their ability to preempt attacks and forcing them to let dangerous patients roam loose.

"They have to actually hurt someone or threaten to hurt someone" before being restrained, complained one psychiatric technician, who asked that his name be withheld. "We can't intervene earlier or put them in seclusion."

The use of medication has changed too. "About 10 to 15 years ago, we began to recognize that we were vastly overmedicating patients, with horrible, irreversible side effects," Leary said. "Since then, there has been a gradual shift towards lower and lower dosages. And in the past five years, Leary noted, new antipsychotics have come out that are considerably more effective and have far fewer side effects.

While the drugs are a boon to doctors and many patients, they can cause problems for the line staff. The new breed of meds are less sedative, too, meaning aggressive patients can be that much more difficult to handle. "Medications have been reduced to ridiculous dosages," another veteran technician said, also on condition of anonymity, "and patients are not getting strong enough doses to be sedated."

After spending decades decriminalizing psychiatric illness, mental health reformers are in no hurry to turn hospitals back into gulags. The nursing staff, said Fancher Larson of San Francisco Mental Health Clients' Rights Advocates, "needs more support. They need more nurses to work with people who are having difficulties." She recommends hiring specially trained staff to handle, and if absolutely necessary, restrain agitated patients.

In the end, what happens at General may depend on what OSHA finds during the course of its probe. Roland Washington, a psychiatric technician and union shop steward, is hoping the agency will force some change. "Management is supposed to protect us, but they have reneged on their part of the contract," he said. "We just want to know that when we go to work we will come home fully intact."