Violence at Seattle Children’s Psychiatry and Behavioral Medicine Unit

Seattle, Nov. 27 -- Nurses at Seattle Children’s Hospital are demanding immediate help from management on the Psychiatry and Behavioral Medicine Unit, according to the Washington State Nurses Association, which represents over 2,000 registered nurses at the hospital.

In the last two weeks, police have been called twice to quell violence – something that is very rare on the unit and a sign of a systemic crisis in pediatric mental health.

“Having 12 officers come in and escort a patient out is a sign we are under resourced and also traumatizing,” said Natasha Vederoff, a nurse on the unit.

On Nov. 7, police intervened after patients turned over carts, used a pole to swing at people, broke windows, and held a nurse in a chokehold.

Almost simultaneously in a different part of the unit, a nurse was isolated with another patient and was choked, struck in the head 16 times, and nearly lost consciousness, nurses said. Several staff were sent to the Emergency Department due to injuries.

Ten days later, police came because patients were throwing ceiling tiles at staff.

These two incidents are just part of a pattern of ongoing and escalating violence that confronts nurses and patients on the unit on a daily basis, several examples of which are listed below.

“I'm exhausted from constantly reacting to dangerous behaviors and trying to prevent serious harm,” said Henry Jones, a nurse on the unit. “In our current state, I feel like I'm functioning more like a bouncer or a prison guard.”

Forty-four nurses — almost every nurse on the unit, not including those who were on a leave of absence due to injuries sustained while at work — signed a letter to Seattle Children’s management on Nov. 17, urging help on the unit.

“Staff work in a persistent state of fear as they come into each shift expecting violence and debilitating abuse,” the nurses wrote. “Patient care has been compromised to an extent that our milieu is no longer therapeutic, but rather dangerous and detrimental for all who enter the PBMU, staff and patients alike. The unfortunate reality of the unit is an exponentially increasing risk of a sentinel event if the PBMU is left to continue operating under its current conditions.”

Nurses asked for three safety officers to be present during the days, and one safety officer overnight. They also asked for three additional nurse roles (break nurse, resource nurse, and safety coach) to provide necessary resources to the nurses working directly with patients, the maximum nurse-to-patient ratio to not exceed 1:8; and double pay during the crisis to encourage nurses to remain on staff.

This problem has been building. Nurses say the acuity and aggression of some patients has increased since the pandemic. The Psychiatry and Behavioral Medicine Unit was set up for short-term crisis stabilization (3-7 days), but some children are staying for months, even a year, because there are not enough residential care beds for children in the state.

“The lack of infrastructure and social supports in the mental healthcare system and lack of funding is the root cause of what’s happening,” said Amy Lamson, a nurse on the unit. “These lashing outs are exacerbated by hospital leadership who are not providing resources to handle the current reality.”

“The reality is we are forced into this situation,” said Brayden Schander, a nurse on the unit. “If the state and nation are not going to change, Seattle Children’s needs to build a residential facility to meet long-term care needs.”

Earlier this year, a workplace violence complaint was filed with the Washington State Department of Labor and Industries (L&I). L&I inspected the unit June 22, 2023, and issued a report on July 10, 2023. While L&I did not cite any violations or assess penalties, inspectors offered three recommendations:

1. Work with the Safety Committee and affected employees to set quantifiable goals to reduce workplace violence.
2. Have management audit reporting of all workplace violence related threats, injuries, and attempted assaults against employee for record keeping and review.
3. Improve management’s follow up with employees who are affected, including notifying them of corrective actions, coping resources, and a recommended timeline for follow up.

Since those recommendations were issued, the volume and severity of safety incidents have increased. Nurses want to see more communication and transparency from hospital management around this crisis.

Nurses’ urgent request to meet with leadership before Thanksgiving was denied. They were told leadership can meet Dec. 13. Meanwhile, the violence escalated over the holiday weekend.

Below are examples of assignments despite objections (known as ADOs) filed by nurses since the Department of Labor & Industries made its recommendations:

11/25/23
Nine staff were mandated to stay after their day shift was over due to short staffing; three of those had received injuries on the job as a result of various patient escalations during the evening. These three staff should have been able to leave the floor immediately due to their injuries, but due to the lack of available staff on for night shift, they could not leave until around 10:30 p.m. One of the barriers preventing the injured staff from leaving the floor was a serious safety issue involving two patients. (One was holding a sharp, large broken piece of a thick plastic soup bowl and was making verbal threats and threatening gestures to stab another patient.)

11/25/23
A patient was engaging in self-injurious behavior by repeatedly slapping themselves in the forehead. Staff attempted to put the patient's helmet on and in the process one of them got bitten. The bite broke skin and led to significant bruising and pain.

11/25/23
Patient pushed over meal cart attempting to break cart into weapons.

11/17/23
I came to the unit and two patients were throwing ceiling tiles at staff and broke computers. Not enough staff to help intervene. Safety support was called, eventually police were called. A few staff were hit that evening.

11/16/23 
Suicide-watch patient assaulted staff by punching her on the right side of her face and hitting her on top of her head. Patient got very combative with staff on unit and is making a threat to hurt more staff and other patients on the unit. Patient has already injured few staff in the past and talks about continuing to do so.

11/13/23
One patient broke a meal lid into multiple pieces. One piece was sharpened to a point, and the patient made multiple motions mimicking stabbing someone and verbally threatened to stab staff. One patient assaulted multiple staff. Four staff injured at work. A nurse was charged at and hit in the head with closed fist.

11/13/23
One of the patients had soiled themselves and three of us were attempting to change the patient. While attempting to change the patient, the patient became agitated and began engaging in self-injurious behavior. As per the patient's plan, this requires arm splints to be applied to the patient to prevent further injury to the patient's head. The patient also began attempting to physically assault staff members, and we went into a physical hold to prevent them from doing so…I had placed the patient in a standing physical hold with another staff and then transitioned to the supine position. During the transition the patient extricated their legs from the hold and kicked me in the head seven times.

11/7/23
Numerous staff sent to Emergency Department with injuries from patients overturning carts, swinging a metal pole, and putting a nurse in a chokehold.

10/29/2023
Multiple staff were injured and had to leave…One staff was bit, several staff were hit in the head by various patients, several staff were kicked in the head and the body by several patients. We had around 20 call outs throughout the day due (most likely) to the unit’s acuity.

At one point, we had four violent restraints going on at the same time…We did not have enough staff to place the patients kicking staff actively involved in violent restraints, so staff were intermittently getting kicked all over their body.

10/22/2023 
We were short a primary nurse resulting in me having a 13-patient assignment and a charge nurse taking patient assignments.

I have sustained more serious injuries in the past year than in my first six years of working on the floor.

The PBMU is broken and is simply put dysfunctional. We cannot keep admitting patients because the rest of the house needs us to. Once these patients are on our unit they are out of sight and out of mind by the institution.

10/13/2023 
Ongoing safety issues that could be mitigated with stronger security presence. Patient severely assaulted a peer unprovoked…Patient later in evening assaulted staff after they were denied a preferred snack.

10/2/2023  
I was floated to the PBMU to be the primary RN when I have not received any training in this area.

Not only is my safety at risk because I am not trained, but also my license since I has not given what my expectations are while I am here. NOT SAFE!!!

9/30/2023  
Entire unit staffed with only two float pool nurses.

Beginning of shift, a patient threatened to stab staff with a nail they found. The same patient later escalated in the middle of the night, not enough staff to do a hold, patient ended up assaulting another staff member.

9/20/2023 
Patient had a sharp item on unit and was holding it in a fist and making verbal threats suggesting that patient might stab staff. Patient continued to show sharp item and pace unit. 
Another patient trapped an RN in a room and would not let the RN leave until code team was called.

Another patient attacked numerous staff in the hallway.

Another patient would not let a staff member leave and attacked that staff in their living zone and that was a dangerous restraint.

Significant property damage occurred with ceiling tiles broken.

9/19/2023  
A patient tried to escape from patio with help from another patient. Both patients chased a RN and tried to attack the nurse. One of the patients twice in one shift dropped a sharpened toothbrush on the patio.

No security staff working all day. There was talk that there is not going to be a regular security presence on the unit anymore.