Amid Reforms, Staff Still Fears Hospital Climate

Changes underway at Kings County Hospital should improve the psych ward there. But for now, the threat of violence remains part of the work environment.

By: By Emily Feldman

The notorious Behavioral Health Unit at Kings County Hospital Center has experienced a number of major changes in recent months – moving to a shiny new building at the hospital, acquiring new administrators, and implementing a host of reforms required by a U.S. Department of Justice report documenting the facility’s shocking negligence in practically every area of patient care.

The psychiatric ward’s poor reputation sank even lower last June when hospital cameras captured a 49-year-old patient, Esmin Green, dying of a pulmonary embolism on the floor of a staffed waiting area. (On May 27, Green's family won $2 million from the city in the settlement of a wrongful-death lawsuit.) Green’s highly publicized death, along with the DOJ investigation – which exposed a place where inadequately treated patients wandered the halls, violence erupted routinely, hospital police sometimes dealt too aggressively with disruptive patients, and staff even sometimes watched patients fight as a form of amusement – expedited the city’s efforts to open the new facility and implement reforms. While staffers acknowledge that change was needed, they say some new practices actually make their jobs more dangerous. Most hospital police officers have been removed, and physical and chemical restraints for patients are being used less often. In a massive mental health facility that sees some of the city’s most seriously mentally ill patients, staffers say they fear for their own safety, and need ways to protect themselves when violence breaks out among patients.

“The violence I saw was unprecedented,” said a former Kings County Behavioral Health clinician who did not want to be identified for fear of being labeled a whistleblower. “Everybody who works in a mental health hospital has seen people assaulted, but people at Kings County were beaten. … There were days that I didn’t go into the inpatient unit because it was so violent.”

Speaking outside the new “R Building” on Feb. 5, when he announced both progress made and further plans to improve mental health care, NYC Health and Hospitals Corporation President Alan D. Aviles acknowledged the challenge of managing violence at Kings County Hospital. The facility and Brookdale Medical Center are the only two hospitals in Brooklyn equipped to handle “patients who often present in extreme crisis, who often suffer from co-occurring substance abuse that complicates both diagnosis and treatment, patients who too often have records of incarceration, patients who often come here after acting violently towards themselves or others.” The majority are admitted involuntarily because they are a danger to themselves or others.

“Inevitably, we will continue to struggle with the daunting challenge of accurately identifying and most appropriately treating patients who are prone to assaultive behavior,” Aviles said. “Although the measures taken today have reduced the number of incidents of patient-on-patient and patient-on-staff violence in recent months, given the aggressive behavior exhibited by many of our most seriously mentally ill patients, it would be disingenuous of me to suggest that we could prevent all such future incidents, but we can do better.”
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Two weeks before Aviles made his statement, members of the Municipal Hospital Employees Union, Local 420 of DC-37 – which represents many staff members at Kings county – testified before the state Department of Labor in support of proposed workplace violence prevention regulations for public employees. Local 420 Health and Safety Coordinator Carl Jones expressed concern about the prevalence of violence against staff, particularly in the city’s mental health facilities. In testimony at the hearing he said, “Not a day goes by without at least one of [my members] experiencing some form of violence, or threatened violence, in the workplace. The violence takes many forms ranging from patient-on-patient and patient-on-staff violence, especially in the psychiatric units and emergency rooms, to verbal abuse from supervisors who are trying to manage with staff shortages.”

The employee violence prevention regulations were officially adopted last month, but they’re not intended to stand in for other measures at a place like Kings County. Among the reforms Aviles announced was the replacement of police officers in the unit with “behavioral health associates,” known as BHAs, who are non-uniformed crisis intervention specialists. That’s because parties including the DOJ and the Mental Hygiene Legal Service, a patient advocacy agency with charges against Kings County pending in court, have accused some hospital police of acting violently towards patients, and involving themselves in situations that, they say, could have been managed by clinicians.

Mental Hygiene Legal Service deputy director Dennis Feld said that the hospital police in the run-down “G Building” often contributed to the culture of violence at Kings County. “They were nasty. They cursed a lot, they were denigrating to the clients, and they had their metal expandable batons,” Feld said. Whatever violence there may have been against staff “didn’t justify the hospital police’s use of force in their interventions.”

The former police officers were members of HHC's own police contingent, also referred to as peace officers, who did not carry firearms, but had the ability to use physical force, including deadly force, to make an arrest, prevent an escape or disarm individuals carrying unauthorized firearms, as well as having the power to issue summonses.
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Now BHAs are the hospital’s primary defense for patients and staff facing violence. But employees say the problem is they aren’t always immediately accessible. According to the former clinician on the unit, long waits for intervention have resulted in “times when staffers, including highly senior staff, were beaten with furniture, left with lacerations and fractures, and brought to the emergency room on stretchers.”

About BHAs, HHC spokeswoman Pamela McDonnell would say only that they “are used in emergency as well as the inpatient units.” A representative from Local 420 said this new group of employees has not yet joined any union.

Nationally, there is some debate over whether psychiatric hospitals need police, and how they should be trained. “I have seen security guards used very successfully on in-patient units, but these guards were trained very well, communicated with patients in a very therapeutic manner, and their physical presence on the unit was enough to maintain a safe environment without physical intervention,” said Michele Valentino, chair of the American Psychiatric Nurses Association’s workplace violence task force. The nurses’ association released an extensive position paper in 2008 on workplace violence. The paper cited findings that “psychiatric nurses are assaulted more frequently than other members of the interdisciplinary team.”

Harvey Rosenthal, executive director of the New York State Association of Psychiatric Rehabilitation Services, said that cutting out hospital police and restricting use of restraints were steps in the right direction. He referred to Mohawk Valley Psychiatric Center, an upstate facility that sees similar patients to those at Kings County that has successfully reduced the use of restraints since the 1990s. He said it’s not patients who create an atmosphere of violence, but institutions that “treat patients like they’re problems and focus on control instead of treatment and healing.”

Steve Miccio, executive director of the Poughkeepsie-based group Projects to Empower and Organize the Psychiatrically Labeled (PEOPLe), who has been participating in reforming Kings County’s psychiatric ER and visiting there since November, also basically backs the change. Miccio said he can tell that patients and staff who were accustomed to seeing uniformed police are now fearful for their safety, but he’s confident that the transformation from “a uniformed and punitive structure” to “a more humanitarian kind of institution” will result in a safer environment for everyone.

Once the “illness-based model” is replaced with a “wellness-based model,” fear will dissipate, he said.

Whether DOJ’s recommended remedial measures, including the near-elimination of hospital police and reduced use of restraints, are having the intended impact is still unclear. The DOJ continues to monitor the hospital’s progress, and says it’s too early in the process to measure a change in violence.

One thing that is clear and everyone seems to agree on, is that the hospital has a long way to go. The way the former Kings County clinician sees it, progress will only begin when “there’s a healthier relationship between patients and staff, and a culture of trust and respect” – words nearly identical to those found in the DOJ report.

– Emily Feldman