Rise in violent incidents and injuries force staff to quit at NYC psychiatric ward

Editor's note: This story describes a reported sexual assault.

Psychiatric staff at one of New York City’s public hospitals are growing increasingly alarmed about high numbers of workplace injuries amid what they describe as an overall atmosphere of combativeness and violence that has only worsened since the pandemic began. Many of these injuries have been debilitating for staff, who say patient safety is also at risk.

Documents obtained by Gothamist and interviews with nine current and former employees at Harlem’s Metropolitan Hospital show that workplace injuries have caused employees to miss thousands of work days over the past four years and have led many psychiatric staff to leave altogether. The medical center is run by NYC Health + Hospitals, whose facilities treat a large share of the city’s psychiatric patients.

The employees, including nurses and support staff such as behavioral health associates, describe the psychiatric department at Metropolitan as an often understaffed, volatile environment that lacks the resources to accommodate the range of acute needs patients have and offers little in the way of therapeutic care. Some NYC Health + Hospitals staff say they are now afraid to speak out about workplace violence themselves because they believe a union representative was fired for repeatedly flagging workers’ concerns.

“When you don't have the support that you need and then you run into another crisis, it's always in the back of your head, like, ‘I don't want to get hurt again,’” said Humberto Garcia, a former inpatient psychiatric nurse at Metropolitan Hospital.

On the day Garcia was injured last July, he said he first noticed one of his patients getting increasingly agitated around lunchtime. At first, he said the patient was complaining about the food and the staff not paying attention to him before repeatedly demanding to be discharged. The patient finally got so frustrated that he started throwing chairs and food, according to Garcia. An altercation ensued while staff tried to subdue the patient with medication. Garcia ended up with a black eye, and an injured shoulder that forced him off work for a month, according to a doctor’s evaluation reviewed by Gothamist.

Most of the employees who spoke to Gothamist said they had been injured multiple times during violent incidents, which are reported to the New York State Department of Labor along with other workplace injuries.

In response to Gothamist’s findings, Stephanie Buhle, a spokesperson for NYC Health + Hospitals, said, “We know that there has been an increase in violence nationally since the start of the pandemic, coupled with an increased need for emergency behavioral health care.” She added that the health system is aware of safety concerns at Metropolitan and already working to address them.

The troubles in Metropolitan’s psych department got worse over the past couple of years, state Labor Department records show. There were at least 21 violent incidents involving behavioral health patients in 2018, keeping employees out of work for 866 days overall. This figure remained somewhat steady in 2019 with at least another 21 incidents resulting in 826 missed work days. That’s about 40 missed work days per incident, on average, over those years.

By 2020, the number of workdays missed per incident shot up 68% — with at least 36 violent incidents resulting in 2,375 days out of work. A year later, staff working with Metropolitan’s behavioral health patients missed at least 2,840 days of work due to 27 incidents of violence — or 100 days per episode.

These include injuries incurred while breaking up a fight, while restraining a patient, or from a patient attacking an employee. Such incidents accounted for more than half of all the days staff were out due to workplace injury at the hospital that year.

Meanwhile, the New York State Nurses Association, a union representing staff at the hospital, said this year behavioral health staff are filing more “protests of assignment.” That’s a formal complaint filed by nurses when their job feels unsafe, in part to protect themselves from liability if something bad happens such as a patient getting injured.

About one in five protests filed this year at Metropolitan Hospital came from the behavioral health units, with the majority mentioning “assaultive behavior in addition to understaffing,” according to the union. During 2021 and 2020, their share was less than 6%. The number of psychiatric nurses already signing onto protests of assignment halfway through 2022 currently stands at 31, which is larger than recent annual totals.

The city said 248 behavioral health staff are currently employed at NYC Health + Hospitals/Metropolitan, which includes psychiatrists, registered nurses, residents, social workers, behavioral health associates and clerical staff.

Concerns over the situation at Metropolitan Hospital come at a time when state and city leaders are trying to ensure that people experiencing mental health emergencies are placed in psychiatric care. Increasing access to inpatient psychiatric care and making it easier to involuntarily commit people is a well-known priority for both Gov. Kathy Hochul and Mayor Eric Adams.

This month, Adams appointed Brian Stettin as the city’s senior adviser for severe mental illness. Stettin helped draft Kendra’s Law, a 1999 statute that made it possible for New York courts to mandate outpatient treatment for people with mental illness and for them to be involuntarily hospitalized if they don’t comply. He has since helped implement similar programs across the country. Hochul also approved measures this year to expand Kendra’s Law and committed funding in the state budget to restore psychiatric beds that were taken offline during the pandemic.

The city is also working to create alternatives to hospitals such as the Bronx Support and Connection Center that Adams announced last week as a destination for people who are picked up as part of the city’s B-HEARD initiative, in which teams of NYPD officers and mental health professionals respond to mental health crises instead of just police.

But there has been less public discussion about the environment within inpatient facilities — and whether they are designed to keep people safe. Those sounding the alarm about the conditions at Metropolitan Hospital say the facility demonstrates what can happen when inpatient psychiatric units are overloaded and under-resourced.

Jannete Marin, who became Metropolitan Hospital’s local bargaining unit president for the New York State Nurses Association in 2019, has attempted to keep a tally of staff injuries — some of which she says go unreported in official records — and bring employees’ safety concerns to the attention of management. She was fired in May, following a disciplinary hearing citing workplace misconduct, according to documentation shared with Gothamist. But some staff believe she was let go because of her advocacy, and have since petitioned for Marin to be rehired.

“This subject about staffing safety in the psych units is brought to each meeting [with management],” Marin said of her experience trying to advocate for change at Metropolitan. “Supposedly, in every meeting they're going to address it … and the numbers keep on adding up, and nothing has been done.”

NYC Health + Hospitals declined to comment on Marin’s firing but added that Metropolitan Hospital “has taken several proactive measures” in recent months to address safety concerns and improve patient care.

According to spokesperson Buhle, that includes daily huddles on the behavioral health units, more frequent check-ins from hospital police, more therapeutic activities for patients, and a higher plexiglass barrier on the nurses station — something staff requested to make it harder for patients to enter. The health system said they are also “offering more therapeutic medication options to patients earlier in the treatment process to manage and mitigate potential safety issues.”

“As the largest and most experienced provider of behavioral health services in the city, we are committed to providing high-quality, compassionate and safe care for our patients and a safe working environment for our staff,” Buhle said in a statement.

She also touted the recent formation of a training program to bring on more behavioral health associates across the system who “are trained in prompt therapeutic interventions to de-escalate and address behavioral health crises.” But Gothamist’s investigation found that, for all their training, behavioral health associates are often the ones getting injured.

Resorting to restraint

Protest of assignment documents filed by nurses – and backed by interviews with current and former employees – describe situations in which there were too few staff available to monitor patients who posed a safety risk to others. Myriad incidents of patients assaulting staff members and other patients are outlined in letters from employees to management, workplace injury and violence logs, and a January 2022 report to the hospital’s Behavioral Health Special Incident Review Committee.

In Garcia’s case, he said staff might have been able to talk the patient down if they had the capacity to give him more attention and intervene sooner. But by the time staff responded, “we were past the point of verbally redirecting his negative behavior,” he said. Instead, Garcia opted to medicate the patient with an antipsychotic and a sedative — a practice he said is “usually” done involuntarily.

Expecting a struggle, Garcia said he called for the hospital’s behavioral emergency response team to help him hold the patient down. When they took too long to arrive, he called the hospital police instead — but staff said these officers are not typically authorized to intervene. So the police stood by while Garcia and two colleagues — women he described as much smaller in stature than the man they were medicating — successfully convinced the patient to take the shot.

“Then when I'm getting ready to give the injection, he sucker punches me,” Garcia recalled. “He grabs me, and then he just starts beating me.”

According to documents and interviews, staff at Metropolitan sometimes physically restrain patients or use medication to subdue them, which is considered another form of restraint when it’s not specifically used to treat a patient’s condition. Such restraints have been recognized for years as both physically dangerous and psychologically traumatizing for patients, while also creating a high risk of injury for staff.

Garcia said his forced leave of absence depleted his cache of sick days as he waited for his application for Worker’s Compensation benefits to go through. Others who spoke to Gothamist also said they were concerned about taking too much time off after injuries while Worker’s Comp applications were pending.

“I couldn't raise my arm above my shoulder,” Garcia said. He ultimately left his job of four years in May to become a travel nurse.

The hazardous conditions have also forced others on Metropolitan’s psychiatric unit to go on extended leave to recover from injuries incurred on the job, in some cases for months at a time. Some said they have become disillusioned about psychiatric inpatient care, citing concerns that it is more focused on medicating and restraining patients than treating people in need.

The U.S. Substance Abuse and Mental Health Services Administration set a goal of reducing and ultimately eliminating the use of seclusion and restraints in behavioral health in 2003. The agency has pointed to a range of strategies such as thoroughly screening patients for potential triggers upon admission and creating safety plans where necessary; training staff in trauma-informed care; making sure patients aren’t waiting too long to have their needs addressed; creating “comfort” rooms with less stimulation; and offering treatment activities that help patients better manage their emotions. Some psychiatric facilities have reported progress toward this goal, although there’s limited data on long-term progress overall.

According to NYC Health + Hospitals, all behavioral health staff are trained in how to verbally de-escalate situations involving patients who are being aggressive, so that restraint is only used as a last resort.

“Additional training is focused on restraining patients … in a safe manner,” spokesperson Buhle said.

Current and former staffers who spoke to Gothamist said the issue was often having not enough staff on hand to restrain a patient without getting injured.

Buhle also noted that the health system is developing enhanced behavioral health emergency response teams that will not only respond to incidents — but will also proactively assess patients “for more intensive interventions to ensure their clinical success and the safety of staff.”

But those who have worked in both Metropolitan and other psychiatric hospitals in the city said the Harlem medical center lacks the basic safety precautions and resources of some other facilities. Those who spoke to Gothamist described the environment as a free-for-all where there was a constant power struggle between patients and staff. Official reports describe multiple incidents of patients punching or otherwise assaulting staff members “unprovoked” (although they also don’t include patients’ accounts of events).

Adewunmi Ogunbiyi, a former Metropolitan nurse who transferred out of inpatient psychiatric care at the hospital in 2020 and left the hospital permanently to become a travel nurse last year, said in addition to lacking any kind of therapeutic activities to keep patients busy, the hospital’s psych units also often lacked such basics as sufficient heating at night and bedding for all the beds. He also alleged that patients were underfed and said he used to bring peanut butter and jelly sandwiches and other food for patients during every shift he worked.

“[If] they’re extremely cold and we don't have enough blankets, they're gonna react to us,” Ogunbiyi said.

In response to these allegations, Buhle said, “All NYC Health + Hospitals facilities have the resources they need to deliver high quality care for our patients, and all patients receive the nutritional and dietary meals required by their clinicians.”

Why violence is rising at Metro Psych

One of the most consistent issues current and former Metropolitan employees raised was not just the lack of staff overall, but the lack of appropriate staff for the specific patient population.

Beyond just maintaining an acceptable patient-to-employee ratio, staffing in the psychiatric department is complicated by the fact that some patients require one-to-one care, which can pull a staffer away from other duties.

Those who spoke to Gothamist said gender – and sometimes, physical size – also matter.

One nurse who was injured trying to break up a fight described herself as “mini” in stature, especially compared to one of the patients involved, who she said was over 6 feet tall. The nurse asked to remain anonymous because she still works for Metropolitan and fears retaliation by management.

In some cases, patients are “sexually preoccupied” — meaning they have compulsive sexual behavior – and are abusive toward female staff, in particular, or only respond to men, according to current and former employees at Metropolitan.

“When it's mostly females [on-duty] and they're sexually preoccupied, it's a rough environment,” said a nurse who transferred to another public hospital after sustaining multiple injuries at Metropolitan. The nurse also asked not to be identified because they still work for NYC Health + Hospitals.

A September 2020 report to the state Department of Labor indicated that while a nurse was monitoring a patient one-on-one because he was a fall risk, he “grabbed both of her wrists trying to pull her on him.” A coworker then came to her rescue “after hearing her screams for help,” according to the description of the incident. Citing “anxiety due to sexual assualt,” the report notes that the nurse was out of work for more than three months.

One “protest of assignment” filed by a nurse on an inpatient psych unit at Metropolitan in December 2020 noted that three out of five support staff on duty that day were floated to other units to address their staffing needs, leaving their own unit understaffed as a result. The nurse said it created “an acutely dangerous situation … Also, 2 highly sexual patients who need constant supervision, and 3 potentially dangerous patients. Not enough support staff to safely manage patients.”

Each protest of assignment form has a space for a manager’s signature and comments. In this case, the manager who signed the document denied the request for additional staffing, saying that none was available and that a behavioral health associate was “required for 1:1 on medical surgical floor.”

A protest of assignment filed by a different nurse in August 2021 specifically cited “lack of male staff” as the reason for the complaint. It noted that that there was “only one male nurse on unit with numerous sexually preoccupied patients, and verbally aggressive towards female staff.” A note on the form says a manager was notified but didn’t visit the unit to sign the protest of assignment.

Another filed in April of this year noted that one “aggressive female patient” required two dedicated staff members to watch her, while another patient required one, leaving fewer staff to tend to the other 15 patients in the unit at the time. With many other patients also presenting serious issues, “Patient’s safety and staff safety is in high jeopardy & DANGER,” the nurse wrote (emphasis theirs). The manager’s response on the form cited staff calling out sick.

While there were reports of violence and injuries at Metropolitan before the pandemic, some who spoke to Gothamist said staffing had gotten worse and the severity of patients’ needs had increased over the past two years.

“So many people with serious mental illness have gone untreated during the past two years,” said Dr. Lloyd Sederer, the former chief medical officer of New York’s state Office of Mental Health, who is an adjunct professor of epidemiology at Columbia University’s Mailman School of Public Health. “When they come into the hospital, they're more deteriorated than they might otherwise have been.”

The staff pushes back

In addition to more robust staffing, current and former Metropolitan employees said they wanted to see other changes to help ensure their safety, such as higher plexiglass barriers on the nurse’s station that could prevent patients from entering — something they said is standard at other hospitals.

“We have had multiple meetings with management to discuss safety issues in the psych units,” read a petition from September 2021 that was signed by about 65 nurses, behavioral health associates and other psych department staff at Metropolitan. It went on to say that the number of staff injuries in the department was mounting and that additional safety measures requested had yet to be put in place.

“We the staff from Metropolitan Hospital is requesting a solution to this problem in an urgent matter,” the letter said. “We can not keep waiting for more staff members to be injured before safety measures are implemented. We need an URGENT INTERVENTION FROM MANAGEMENT NOW” (emphasis theirs).

Marin forwarded the petition to Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals.

In a brief response to Marin on September 13th, 2021, Katz offered one theory as to why the violence seemed to be getting worse.

“I appreciate your sending this to me,” he wrote. “We are working hard to improve the safety conditions of our psych wards. No question the increase in drug use has made psych care significantly more difficult and we need to evolve to deal with these issues.”

Sederer said the theory has some merit, noting that people who experience psychosis are more likely to be violent if they’re using substances, and that particular substances such as K2 and alcohol can make people more prone to aggression.

In recent years, Metropolitan Hospital has closed its detox unit and integrated those services with inpatient care. NYC Health + Hospitals says this is an evidence-based model that has made people more likely to engage in addiction treatment. But some current and former Metropolitan staffers said mixing people who were coming down off of substances into the traditional psych units was making the situation more volatile.

“Half the time you’re breaking up fights,” said the nurse who transferred to another public hospital.

That nurse and others who spoke to Gothamist also noted that Metropolitan recently began accepting psych patients directly from the Rikers Island jail complex without having the resources to do so.

“They're used to that rough and tumble environment,” the nurse said of those coming from the notoriously violent jail.

Buhle of NYC Health + Hospitals said Metropolitan does not admit patients who are under arrest. But she added that “the hospital will provide immediate emergency care to anyone who needs it, and that includes patients in custody in need of emergency psychiatric evaluation.”

Dr. Katz acknowledged broader staffing issues in behavioral health during a recent panel on health care hosted by WNYC in June.

He said it’s getting harder to recruit psychiatrists and psychologists, in particular, because they can now more easily work in telehealth, which became increasingly popular during the pandemic.

“They’re doing their work by Zoom and suddenly the idea of being on a hospital ward is less appealing to them,” he said, adding that the need for psychiatric care has increased. “You have high demand and decreased ability for people to be able to respond to it.”

In response to questions about understaffing, Buhle said, “There is a nationwide shortage for behavioral health workers, and this affects everyone. However, all NYC Health + Hospitals facilities have the resources they need to deliver high-quality care for our patients and a safe environment for our patients and staff.”

Some current and former staffers also said they wanted hospital police to have a greater presence in the psychiatric units – something they reported seeing at other hospitals.

It’s a stance one former nurse said management had pushed back on, as it could agitate patients who have faced trauma because of their previous interactions with the police.

“While hospital police are onsite for security purposes, use of specially trained staff to both de-escalate and address behavioral health crises has improved therapeutic outcomes for patients and is considered as best practice to ensure safety of both patients and staff,” NYC Health + Hospitals said in a statement.

Permanent damage

The violence at Metropolitan raises questions about the toll inpatient psychiatric settings take on patients and staff — an environment that Bronx resident Arvind Sooknanan, who has schizophrenia, described to Gothamist as “health jail.”

In the period of a few years, Sooknanan said he was admitted upwards of 20 times to different New York City hospitals — both private and public — for symptoms of his schizophrenia. He declined to discuss a specific facility, but said they have a lot in common.

“I've been to a lot of different psychiatric inpatients and their ERs, and they're all bad,” said Sooknanan, who is a board member at the community-based mental health organization Fountain House. “They're all not places anyone wants to be at, whether they're staff or patient.”

He said at most hospitals, the typical protocols for responding to patients who get upset — for instance, about wanting to be discharged — only serve to make the situation worse. He said staff can be dismissive of patient complaints, which only makes them more frustrated.

“When it escalates, they send out a code, and so immediately people would rush over,” Sooknanan said. “Hospital police would respond and so would a group of mental health workers, standing there and trying to hold down the patient, restrain the patient. That's always the protocol.”

Sooknanan said the punitive approach to hospital psychiatric care is misguided in both private and public settings — but he said he has specifically told his care team not to send him to a city hospital if he has a mental health emergency.

Garcia and others who spoke to Gothamist said they had worked in other inpatient psych units in the city and on Long Island that employ more treatment and social therapy options — both of which they found severely lacking at Metropolitan. Activities such as nurses leading educational sessions on antipsychotic medications, therapists going over different coping mechanisms for dealing with stress, art therapy or even trips to a gym are available at some other facilities, Garcia said.

“They have designated rooms where patients are able to reroute their frustrations into an activity,” he added. “It's not like that at Metropolitan.”

Buhle of NYC Health + Hospitals said Metropolitan is in the process of addressing this. “We are increasing recreational activities by adding more activity therapists, music therapy options, including the use of wireless headphones, and televisions,” she said. “Additionally, there is a peer who runs sessions with patients.”

Sederer said that at state psychiatric hospitals, where the goal was also to minimize the use of restraints, they had had success with “quiet rooms” with softer lighting where patients were told they could go voluntarily to “get away from the stimulation they need to get away from, or the battle that they're in with somebody about the TV station.”

For some staff at Metropolitan, conflicts with patients have been life-altering. Tamila Glaze said her experience working as a behavioral health associate at the hospital not only left her disabled but also led her to swear off inpatient psychiatric care altogether, after being certified as a clinical mental health counselor and behavior analyst.

She is one of several current and former employees who told Gothamist about ongoing physical ailments, trauma or both that resulted from working at Metropolitan.

Documents show Glaze, 32, was injured on Mother’s Day 2019 while trying to de-escalate a fight in her unit that, by her account, involved about a dozen patients. It didn’t work. “My foot was slammed in the metal door, trying to run away from the patient that tried to jump over the nurse’s station,” Glaze said.

She was initially out for six weeks but said, even if she could get more paid time off, she was eager to go back to the hospital at the time. “That's where you do your overtime,” said Glaze, who has a 5-year-old daughter. “That's where you feed your family.”

By the following year, however, she realized her ankle injury was only getting worse. Glaze has been living off of worker’s compensation and help from her family since September 2020 and finally resigned in January. She says she now has trouble walking long distances or standing for too long, and can’t run at all.

At one point, she was getting upwards of $500 per week from worker’s comp but in a recent decision at a hearing of the state Worker’s Compensation Board, the amount was reduced to $150.

She said she’s still passionate about working in behavioral health, but won’t be returning to a psychiatric inpatient unit.

“That’s not mental health,” she said. “That's not care. That's just medication. That's babysitting.”

Do you have experience with psychiatric inpatient or emergency room care in the New York City area as a patient, family member of a patient, or hospital employee? We want to hear from you. Was it an environment that felt safe and therapeutic? Were there issues you want to highlight? Is there a specific incident you want to share?

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