Cayley Winters doesn't remember what the patient wanted, only that it was something she couldn't give her.

That's why the woman had her hand around Winters' neck, trying to strangle her.

"This patient was somebody who was frequently in and out of the hospital... and when she didn't get her way, she became very violent," said Winters, a former certified nurse assistant.

Winters was working a night shift at Bronson Hospital in Battle Creek in December of 2016. Around 1 a.m., she and the nurse aide she was training went into a room to give the patient a hospital gown and put a heart monitor on her.

When she refused the woman's request, "she swung at me. She swung at my orientee, and then she finally got a hand around my throat and tried to choke me." Winters said. "I was able to get away from her pretty easily, luckily. Sometimes people aren't so lucky."

Nurses more likely to see workplace violence than other private-industry employees

Nurses are four times more likely to experience workplace violence than other private-industry employees, according to the Occupational Safety and Health Administration.

Compounding the problem, hospitals are required to provide treatment to anyone seeking medical care and can't turn patients away, even those who have a history of assaulting staff.

Despite the risks, there are few legal protections in place for nurses, and, because their attackers are often patients seeking medical care, their cases often aren't prosecuted.

The Michigan Legislature is considering bills that would increase penalties for assaulting a nurse and require hospitals to have violence-prevention plans in place.

Nurses support it. Some lawmakers aren't sure new laws will stop the violence.

"It's difficult because whenever you get into your scrubs and you step into that role, it's almost expected that you're going to take on some sort of abuse," said Winters, who never had the opportunity to press charges against the woman who tried to choke her. "But for people to think it's OK to choke, scratch, bite, urinate on (a nurse) — and I've had all these things happen to me — it's not OK, and there needs to be some sort of consequence set in place because right now... As much as management might have the best intent, there's not a lot that they can do."

'We have to take care of whoever comes through our doors'

It is a felony to assault police officers, firefighters, EMTs and paramedics.

Despite the high risk for nurses and other health-care professionals, Michigan law provides no specific protection for them.

Nurse advocacy groups, including the Michigan Emergency Nurses Association and the Michigan Nurses Association, are working to pass legislation that would.

In practice, there are often fewer repercussions for people who assault nurses because they are patients and prosecutors often don't bring charges.

Federal law requires hospitals to admit anyone who comes to an emergency room seeking treatment. This means nurses must treat everyone, even if they have a history of violence against hospital staff.

"We have to take care of whoever comes through our doors, so that's why it's so important to really be working to protect our healthcare workers," said Bronson Hospital Vice President of Patient Care and Chief Nursing Officer Dorothy Malcolm. "These are people who went into business to help people, not get hurt on the job."

Malcolm is in charge of patient care services at Bronson in Battle Creek and oversees nursing, the emergency department, surgery and the inpatient unit. She worked as an ER nurse for 15 years.

"We're seeing more and more violence in the emergency department and in the hospitals in general," she said. "We've had employees who have been physically assaulted by someone punching them, kicking them, even biting them, and this can happen with patients or even patient family members."

Expecting violence, many nurses suffer from burnout

Jamie Brown, president of the Michigan Nurses Association and a registered nurse at Ascension Borgess Hospital in Kalamazoo, said the rise in violence is making it harder for nurses to do their jobs.

"It's more of the overdoses, the alcoholics, the families of people that are in car accidents... They are taking out their frustrations on the nursing staff and it's hard to deal with them," she said. "As you walk in, you start looking around and trying to see if anyone looks like they might cause problems."

For many nurses, the expectation of violence is leading to burnout, Brown said.

In 2018, full-time nursing assistants nearly faced as much workplace abuse as police

Violence in hospitals is a growing problem.

For every 10,000 full-time registered nurses, there were 8.7 reported cases of intentional injury caused by another person in 2018, according to the most recent data from the Bureau of Labor Statistics. That's just under the rate for 2017, which was a five-year high at 8.8 cases per 10,000 workers.

The rate of violence against nursing assistants is even worse: 26.3 reported cases for every 10,000 full-time nursing assistants in 2018. That's nearly two-thirds the rate for police officers.

The national average for reported cases of intentional injury caused by another person across all industries in 2018 was 2.1.

Katie Pontifex is a registered nurse at Sparrow Hospital in Lansing and sits on the Board of Directors for the Michigan Nurses Association. She's been a nurse for 11 years and said she sees some sort of violence nearly every day she works.

"You won't find a single nurse or health-care professional who hasn't experienced some form of workplace violence," she said. "We've become a little bit desensitized to it because it's such an everyday occurrence."

Nurses want to see fewer excuses for patient misconduct

Pontifex had a violent interaction with a patient last year that kept her from her regular duties for three months.

The patient was known to be violent but wasn't medically stable enough to be discharged.

Pontifex said she was walking by the patient's room when she heard yelling.

"I responded and caught this patient attempting to stab one of our patient care techs with a pen," she said. "In the process of intervening and attempting to get the object away from the patient, I was deeply scratched on my hand and wrist."

She filled out the proper incident reports and thought the injury wouldn't be a big deal, but a week later her hand was infected and still swollen. In the struggle, her tendon was twisted. She had to undergo occupational therapy to get the use of her wrist back.

"My wrist is still weak, but I get by," she said. "It's not my dominant, and I'm very fortunate."

Pontifex was not able to pursue charges against her assailant because she said the patient had been found incompetent to stand trial in a different assault case involving her coworker.

The Ingham County Prosecutor's Office said that patients can be found incompetent to stand trial based on a recommendation from the state Center for Forensic Psychiatry. In some cases, the defendant can continue to undergo psychiatric treatment with the goal of attaining competency, and if that patient can be found competent, the case can proceed.

Pontifex said that she's heard similar stories from nurses who struggle to get charges brought against people who are under the influence of drugs or alcohol.

"That's where we see it a lot from the prosecutors' side is when we get these explanations, 'Well, it was very stressful, they were in a very stressful situation,'" Pontifex said. "It doesn't excuse it."

Laws aim to reduce violence with more penalties

Thirty-five states have workplace violence laws in place that set stricter penalties for assault of nurses, and nine states require employers to run workplace violence programs, according to the American Nurses Association.

Lawmakers in Michigan have considered such legislation many times in the past. Just last year, four bills were brought before the House. Four have been brought before the Senate since 2013. None were signed into law.

House Bill 4327 and Senate Bill 80 would make it a felony to assault a nurse. Both bills have been in committee since early 2019.

House Bill 5089 and Senate Bill 303, which would require health facilities and local health departments to provide training and report injuries to law enforcement, are also both in committee.

Sen. Peter Lucido, a Republican who represents Michigan's 8th District, is the Senate majority whip and chair of the Senate Judiciary and Public Safety Committee. He's also a cosigner of Senate Bill 80.

Lucido said that he supports nurses, but he isn't sure the legislation would deter people from assaulting them.

"I know there's an obligation in the health-care industry to go ahead and make people well, and you can't turn away people when you have an obligation. But if somebody is also mentally or emotionally or medically unstable and they create the assault ... how do you handle those that don't have the requisite intent to create the crime?" he said. "Where do we stop with the carve-outs? ... How about a customer service representative or a greeter over at Walmart?"

Even if stricter penalties are put in place, Lucido said, that wouldn't guarantee that prosecutors would bring charges against people who assault health-care workers.

"So, me making a law that says it's stricter penalties if you assault a medical professional, my question is: Is that going to make the prosecutors prosecute? And the answer is, I doubt it," he said. "What good is making a law if no one's going to enforce it?"

Rep. Jim Haadsma, a Democrat who represents Michigan's 62nd District, said he was concerned about penalty creep, the continued incremental increase in the state's penalties and sentence lengths.

"I think nurses should be entitled to the same protections as first responders. This kind of mandate, however, does take away a lot of discretion from judges, and what's more significant, the fiscal obligation on the state for incarcerating these alleged criminals."

Does legislation work in other places?

The data on whether having stricter penalties in place leads to lower rates of violence against nurses is inconclusive.

State-level data on occupational injuries is not as detailed as it is at the national level due to changes in Bureau of Labor Statistics survey participation each year and insufficient sample sizes. That means that occupational incidence rates can't be broken down as narrowly by job type, which prevents a direct comparison.

Limited data also prevents a comparison of incidence rates before and after laws went into effect. Data on intentional injury caused by another person isn't available prior to 2012, and some states have had laws in place for longer than that. In other states, stricter penalties only recently went into effect.

Along with stricter penalties for people who assault nurses, some states have also introduced reporting requirements for hospitals, which also prevents a direct comparison.

Pontifex said that, although it may take some time for laws to deter violent behavior, she believes eventually they would.

"You go to a bar, have too much to drink, and you escalate your behavior, you might be inebriated, but ultimately, you're held responsible if you do anything. ... You don't drink and drive because you know there are penalties," she said. "I've seen it compared to a patient who is in a lot of pain or under stress, not the dementia patient... You or I, going in, and we're in pain out of our minds, and we act up, we should be held accountable."

'The patient always comes first'

Brown, the president of the Michigan Nurses Association, said violent interactions with patients happen on a regular basis, about two out of every three days that she works.

"Recently, a pregnant woman did get kicked in the stomach upstairs, and then just this last weekend, I had a patient that was confused and tried to hit, kick and bite the nurses, including myself," she said.

The violence makes it difficult for nurses to do their job, she said.

"You try to make sure the door is always between you and your patient so you can get out and they can't corner you," she said. "Once in a while, the police will get called, but ... the cops can't do anything until they actually touch us."

It's helpful when management is able to stand behind nurses and a police report can be filed, Brown said, but that's a rarity.

"Very rarely do people file police reports, and I do believe I was told it won't go anywhere because it's not a big enough deal to follow up with the legal process," Brown said. "The patient always comes first. It's kind of like the customer-is-always-right type mentality."

In the past year, nine employees at Bronson Hospital have filed police reports for assault, according to Lt. Doug Bagwell of the Battle Creek Police Department. Most of them were non-aggravated assault and many involved an individual who was intoxicated or mentally ill.

Winters said that it's common for nurses to be discouraged from filing a report.

"When health-care providers do get assaulted, you can press charges, but... it takes so long for the courts to do anything, a lot of cases end up getting dropped, and often, this is something I experienced, management didn't want you to," she said. "Just, nothing's done about it. It was exhausting.

"Working 12s and nights is exhausting enough, working three, four days is exhausting enough...," she said, "and then to go to work and to be so discouraged and feel like your dream was a sham because management and the law doesn't stand behind you? It sucks."

Safeguards to protect employees

Many hospitals, like Bronson, are trying to do more to protect their workers, Malcolm said.

Bronson posts signs in its emergency room stating the hospital's expectations for patients' conduct. They have security around the clock.

"We've done a lot of things to further protect our employees over the recent years as violence has escalated, things like offering self-protection and deescalation training, we do that. We've expanded our employee assistance program after traumatic events," she said.

Sparrow Hospital put a visitor management system in place to help with violence prevention. Between 4 p.m. and midnight, all hospital visitors are required to check in with a photo ID and wear a badge that includes their name and where they're going, Pontifex said.

Sparrow also has mandatory violence prevention and deescalation training in place and encourages employees to report workplace violence.

Pontifex said having those systems makes health-care workers feel supported and has created a positive culture change at the hospital.

"I have the resources I need," she said. "If we are having a positive change at our very large hospital, I can only imagine how my colleagues at some of these smaller hospitals would feel."

Not all hospitals provide that kind of training, though.

Brown said that Borgess trains security guards, nursing aides and psychiatric nurses on how to deal with violent patients, but floor nurses, ER nurses and critical care nurses don't receive any training.

"You get really good at dodging," she said.

In a statement, Borgess Hospital said, in part, that "With workplace safety a top priority, all Ascension Borgess associates complete annual required safety education, including mandatory de-escalation training for all nursing staff to help prepare them for addressing any potential violent behavior."

Study shows that 80,000 nurses may leave the field by 2020

The expectation of violence is causing nurses to leave the field.

"You're constantly looking and double-checking your ways out of the room before you ever walk in," Brown said. "That is part of the reason you have nurses leaving bedside nursing ... because of the violence. You get burned out much quicker."

The number of nurses leaving the field each year has grown steadily, from around 40,000 in 2010 to a projected 80,000 by 2020, according to a 2015 study by Montana State University.

#EndNurseAbuse:Here's how you can help

"Every year it seems to be getting worse for the nurses to go into their job," Brown said. "I'm hoping that the policies will be put into place, as well as legislation on how to deal with violent patients. I also hope the legal aspect comes into play where we are considered, if you attempt to assault a nurse, that it is a felony, just like the other emergency service workers."

Contact Elena Durnbaugh at (269) 243-5938 or edurnbaugh@battlecreekenquirer.com. Follow her on Twitter at @ElenaDurnbaugh.